02-04-2024

Which of the following is true of Eisenmenger's syndrome?

A. Breathlessness and fatigue are uncommon symptoms

B. It occurs in patients with patent foramen ovate
C. Left to right shunting occurs because of pulmonary hypertension
D. Life expectancy is markedly reduced
E. Patients are peripherally but not centrally cyanosed
Answer: D.
• Eisenmenger's syndrome occurs in patients with untreated intracardiac shunts such as
atrial or ventricular septal defects. Initially shuntil')g is from the left to the right side of
the heart, ~nd central cyanosis does not occur. The resl)ionse to increased pulmonary
blood flow is pul~onary vasoconstriction, which leads to permanent sclerotic changes in
the pulmonary microvasculature. This causes right heart pressure to increase to the point
it exceeds left heart pressure.
• Shunt reversal and central (and peripheral) cyanosis then occur. Breathlessness and
fatigue are common symptoms. Patients with Eisenmenger's syndrome have markedly
reduced life expectancy because of cardiac failure and cardiac arrhythmias. Patent
foramen ovale is not a cause of Eisenmenger's syndrome and it does not cause
significant intracardiac shunting.
A 48 year old woman registers with a new family physician. She tells the doctor she had a small
hole in her heart from birth but that it did not require. any treatment. On examination, pulse is
70peats/min and regular; BP 122/76 mmHg. You detect a loud, high-pitched systolic murmur at
the left sternal border, accompanied by a thrill. Which of thefollowing conditions would explain
the history and physical findings?

A. Anterior mitral leaflet prolapse

B. Atrial septal defect
C. Patent foramen ovale
D. Persistent ductus arteriosus
E. Ventricular septal defect
Answer: E.
• Ventricular septal defect (VSD) causes a harsh systolic murmur that may radiate to
the right side of the sternum. Small VSDs do not cause significant shunting but can
produce a loud murmur. Atrial septE,~I defect might cause a quiet systolic flow
murmur. Persistent ductus arteriosus causes a continuous murmur throughout systole
and diastole. Patent foramen ovale produces no abnormal auscultatory findings.
Mitral valve prolapsed causes a late systolic murmur and is not referred to as a 'hole'
in the heart.
A 21 year old man presents with a recent history of an influenza-like illness initially
characterised by fever, myalgia and headache. He develops pleuritic-type chest discomfort and
breathlessness. On examination, pulse is 105 beats/min and regular; BP 105/60 mmHg. The JVP
is not elevated. Heart sounds 1 and 2 are present with a loud to-and-fro harsh sound present in
systole and diastole. Which of the following conditions explains this clinical presentation?

A. Acute viral pericarditis

B. Aortic valve endocarditis
C. Mitral valve endocarditis
D. Persistent ductus arteriosus
E. Pulmonary embolism
Answer: A.
• Pericarditis is associated with friction between the epicardial surface of the heart and the
pericardia! sac. This causes a scratchy to-and-fro sound in time with the cardiac cycle,
which is distinct from a murmur. It is associated with pleuritic chest pain, which may be
affected by sitting forward or backward. Heart sounds are either normal or, if there is a
large pericardia! effusion, diminished. It may occur in the context of flu-like illness and a
viral aetiology is common. Endocarditis is not associated with pleuritic chest pain.
Persistent ductus arteriosus is a congenital (rather than acute) condition, which is
associated with a continuous murmur.
What is the appropriate initial treatment for the symptoms of acute pericarditis?

A. Intravenous glucocorticoids
B. Intravenous morphine
C. Oral amiodarone
D. Oral aspirin
E. Rectal diclofenac
Answer: D.
• Aspirin, through its anti-inflammatory effects, is a very effective symptomatic
treatment for pericarditis. Non-steroidal anti-inflammatory drugs such as diclofenac
can also be used orally. Steroids are rarely required. Amiodarone is an anti-
arrhythmic drug and has no role in the management of acute pericarditis.
Which of the following best describes dilated cardiomyopathy?

A. A disease of the myocardium characterised by chamber enlargement and thinning of the left and right
ventricular walls
B. A disease of the myocardium characterised by disproportionate thickening of the interventricular septum
C. A disease of the myocardium characterised by infiltration of myocardial tissue resulting in restricted
contraction and relaxation
D. Isolated dilatation of the atria, causing atrial fibrillation
E. Isolated dilatation of the right ventricle, causing ventricular tachycardia
Answer: A.
• Dilated cardiomyopathy is characterised by dilatation of the atria and ventricles, and
thinning of ventricular walls. Hypertrophic cardiomyopathy causes disproportionate
thickening of myocardium, particularly the interventricular septum. Myocardial
infiltration (e.g. with amyloid protein) can cause restrictive cardiomyopathy, which
does not cause cardiac dilatation but does restrict myocardial contraction and
relaxation.