cardiology PT 1 2016

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• Patients who present after 48 hours will need 4–6 weeks of full anticoagulation (INRs > 2.0 if using warfarin)

before synchronised DCCV. Alternatively, earlier DCCV can be performed if a transoesophageal echocardiogram

(TOE) can be done to exclude clot in the left atrial appendage

• Intravenous flecainide may be considered for chemical cardioversion in the absence of a history of ischaemic heartdisease; amiodarone is an acceptable alternative

• Longterm prophylaxis with agents such as sotalol may be required

Atrial flutter (Option A) is incorrect. Atrial flutter is less associated with alcohol and is more likely to cause a regular

tachycardia

Sicksinus syndrome (Option C) is incorrect. Sicksinus syndrome is less associated with alcohol and is more likely tocause a regular tachycardia

Sinus tachycardia (Option D) is incorrect. Sinus tachycardia is less associated with alcohol and is more likely to cause aregular tachycardia

Ventricular tachycardia (Option E) is incorrect. Ventricular tachycardia is less associated with alcohol and is more likely tocause a regular tachycardia

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Question 2 of 295

A previously fit 25yearold man with a history of heavy smoking comes to the Emergency Department complaining ofbreathlessness and pleuritic pain occurring suddenly in the middle of a pub team football match. On examination, a

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Myocardial infarction (Option D) is incorrect. The clinical history and physical signs are not classical for a myocardialinfarction

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Question 3 of 295

A 40yearold man is referred by his GP for advice with regard to primary prevention of cardiovascular disease. He is asmoker with a strong family history of premature death from ischaemic heart disease. Following a period of lifestyle

modification, his fasting cholesterol concentration is 7.2 mmol/litre. On consultation of the local guidelines you find thathis estimated 10year risk of a coronary heart disease event is > 30%

• Nonfasting blood samples should be taken to measure total cholesterol (TC) and HDLcholesterol. In the past, fastLDLc was used, but a more pragmatic approach of measuring nonHDLc is now being proposed (determined by TCminus HDLc = nonHDLc)

• All highrisk people should receive professional lifestyle support to reduce total and LDLc, raise HDLc and lowertriglycerides to reduce their CVD risk

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Cholestyramine (Option A) is incorrect. Cholestryamine is used in truly statinintolerant patients and therefore is not thecorrect answer

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Hypertrophic obstructive cardiomyopathy (Option C) is incorrect. Hypertrophic cardiomyopathy also creates an ejectionsystolic mumur, but this is due to assymetrical hypertrophy of the septum and systolic movement of the anterior mitralvalve leaflet to create a dynamic obstruction to flow. The aortic valve itself is normal

Rheumatoid arthritis (Option D) is incorrect. Rheumatoid arthritis is not associated with aortic stenosis; patients may

develop aortic root dilatation, as seen in many connective tissue disorders, and this would cause aortic regurgitation. Thequestion is also an additional trick – the candidate may misread it as rheumatic fever and select it as an answer. Even

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rheumatic fever itself is not a cause of aortic stenosis; rather, the exposure to the streptococcal illness triggers an

autoimmune response that damages the heart valves to cause rheumatic heart disease. Any valve could be affected by thiscondition

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Inpatient exercise stress test (Option D) is incorrect. Historically, such patients will have been risk stratified with an inpatient exercise test when the barrier to angiography was higher, but this patient has higher risk features.

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The ECG shows characteristic, tall, peaked T waves with widened QRS complexes: the ECG becomes progressivelywider and more sinusoidal with bradycardia and loss of all typical QRS features. There is a progressive diminution inthe amplitude of the P wave, which eventually disappears. Asystole usually results shortly after. The presence of tall,peaked Twaves is highly characteristic and therefore is the correct answer

Narrow QRS complexes (Option A) is incorrect. The QRS complexes are widened in hyperkalaemia

Prolonged QT intervals (Option C) is incorrect. Prolonged QT intervals are not the characteristic feature in hyperkalaemia;prolonged QT can be seen in

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artery may be seen on chest Xray in persistent ductus, but the presence of pulmonary plethora is more suggestive of atrialseptal defect. Note that the term plethora suggests there are increased lung vessel markings throughout the lung field andthis is a feature of ASD; upperlobe diversion can appear similar, but is mostly in the upper lung fields and can occur withany cause of pulmonary oedema

Right ventricular hypertrophy on ECG (Option E) is incorrect. The continuous shunting into the pulmonary artery causesincreased pulmonary venous return to the left heart and an increased left ventricular volume load, which then manifestswith LA and LV dilatation. The right heart is not affected until late into the disease and would not be present in a 2yearold

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Question 15 of 295

A 67yearold man comes to the clinic for review. He has suffered episodes of central chest pain on 3 occasions over thepast year, which have occured twice when he went out on a cold morning in the winter, and once when he was carrying atree trunk which had been chopped down in his garden. On all of the occasions the pain lasted for a few minutes and thensubsided spontaneously when he rested. He smokes 5 cigarettes per day and has a history of hypertension managed withRamipril 10mg daily. He is also taking Aspirin 75mg for primary prevention. On examination his BP is 135/72 mmHg,pulse is 72/min and regular. His BMI is 25

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correct answer here. Clopidogrel is used in combination with aspirin in the management of ACS and post coronary arterystenting

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In those diagnosed after the age of 35 years, survival to age 50 is only 20%, whereas diagnosis and treatment as achild is associated with a survival above 90%

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Explanation

The answer is Auatomatic supraventricular tachyarrhythmias –

Automatic supraventricular arrhythmias characteristically show a warmup phenomenon; that is, the rate acceleratesafter its initiation. In the scenario, the arrhythmia is seen to speed up after initiation, making this the correct answer

AV nodal reentrant tachycardia (Option B) is incorrect. AV nodal reentrant tachycardia, bypass tractmediated

macroentrant tachycardia and intraatrial reentry are all types of reentrant supraventricular arrhythmias; in AV nodal reentrant tachycardia, P waves are usually of abnormal morphology (inverted); since the question states the P waves are

normal, the answer cannot be AV nodal reentrant tachycardia

Bypass tractmediated macroentrant tachycardia (Option C) is incorrect. The normal P waves rule this option out here asdescribed

Intraatrial reentry (Option D) is incorrect. In intraatrial reentry SVTs there are discrete P waves, but there is no warm

up phenomenon and so this cannot be the answer here

Ventricular tachycardia (Option E) is incorrect. The normal QRS width rules out a ventricular tachycardia – which aretypically very broad due to abnormal conduction in the myocardium rather than through specialised conducting tissues

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Question 18 of 295

A 55yearold obese woman presents to the Emergency Department with worsening dyspnoea and ankle swelling due toendstage heart failure. Her BP in the department is measured at 135/72 mmHg, her pulse is 79/min and regular. There arecrackles up to the midzones bilaterally on auscultation of her chest, and bilateral pitting oedema to the knees

Ramipril, amlodipine and bendrofluazide (Option A) is incorrect. This option does not include all of the recommendedtherapies

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Ramipril, amiloride, furosemide and atenolol (Option B) is incorrect. This option does not include all of the recommendedtherapies

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Question 19 of 295

A 32yearold man presents to the clinic with shortness of breath, which is particularly bad when he goes jogging. He hasrecently increased his exercise to try and reduce his weight. On a couple of occasions he has also noticed some chest

discomfort, which has caused him to stop exercising. On examination his BP is 150/88 mmHg, and he has a double apicalimpulse. On auscultation there is a harsh midsystolic murmur, which is loudest between the apex and the left sternal

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Question 20 of 295

A patient presents with shortness of breath and ankle swelling. An echocardiogram has been ordered to determine the leftventricular ejection fraction

These data are interpretable when one knows which structure each line represents, and the technique has excellentspatial resolution

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