This document contains multiple medical case summaries and questions. It provides explanations for answers to questions about various cardiac conditions including: - Digoxin is the most appropriate treatment for atrial fibrillation in a patient with asthma and cardiomegaly. - Echocardiography can confirm aortic stenosis as the cause of an elderly patient's worsening angina and heart failure. - Tricuspid regurgitation is the most likely diagnosis for a patient who develops a murmur after a STEMI.

1. B type natriuretic peptide is likely to be normal in which of the following?
Unstable angina
Acute STEMI
Pulmonary Embolus
Acute mitral regurgitation correct answer
LVF
------------------
A 68 year old asthmatic presents with shortness of breath. She also has a PMH of hypertension
for which she is prescribed ramipril. On examination she is found to have a BP of 130/80mmHg,
pulse of 90 irregularly, irregular and bilateral wheeze and normal heart sounds. A CXR reveals
cardiomegaly. What is the most appropriate treatment of her AF?
Digoxin correct answer
Verapamil
Amiodarone
Atenolol
Flecainide
Explanation:
Rate control is the most appropriate in this case. Digoxin should be utilised due to the
cardiomegaly and history of asthma which means verapamil and atenolol should be avoided due
to potential of precipitating heart failure and worsening asthma respectively.
---------------
Which of the following suggests the presence of mitral regurgitation as well as mitral stenosis?
Your answer was Displaced apex beat which is correct
Displaced apex beat correct answer
Raised JVP
Atrial fibrillation
Loud P2
Localised tapping apex beat
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A 81 year old male with a history of hypertension and inferior MI is seen in the cardiology clinic
due to worsening angina and heart failure and 2 syncopal episodes. He is found to have an
ejection systolic murmur loudest at the apex. Which investigation will confirm the most likely
diagnosis?
Your answer was Echocardiography which is correct
Echocardiography correct answer
ECG
Exercise tolerance test
Coronary angiography
Blood cultures
Explanation:

2. Aortic Stenosis explains all of the symptoms of worsening angina and heart failure and the 2
episodes of syncope. Although the murmur is loudest at the apex mitral regurgitation is less
likely to explain the syncopal episodes.An Echocardiograph will confirm the diagnosis. Coronary
angiography should be performed but is not used for the diagnosis.
-----------------
Which of the following antibodies present in the maternal circulation may lead to congenital
heart block?
Your answer was Anti Ro which is correct
Anti Ro correct answer
Anti Jo1
Anti dsDNA
Rheumatoid factor
ANCA
------------------
A 62 year old has had two syncopal episodes. She complains of intermittent palpitations. There
is nil of note on examination and her bloods are normal. What is a useful first investigation?
Your answer was EEG which is incorrect
24 hour ECG correct answer
Echocardiogram
EEG
Exercise tolerance test
Nil required
---------------------
Which of the following suggests more severe mitral regurgitation?
Your answer was Length of murmur which is incorrect
Displacement of apex beat and systolic thrill correct answer
Soft S1
Split S2
Length of murmur
Loudness of murmur
-----------------------
A 65 year old gentleman with type 2 diabetes mellitus is found incidentally to have left bundle
branch block on his ECG. It had not been present on previous ECGs. An ECHO reveals no
structural abnormality. You want to exclude a myocardial infarct. What investigation should be
performed in the first instance?
Your answer was Thallium perfusion scan which is incorrect
Exercise tolerance test correct answer
Thallium perfusion scan
Coronary angiography
CT angiography
Repeat ECG
--------------------
An echocardiogram is performed on a patient prior to surgery and reveals a very small
pericardial effusion but no other abnormalities. He is asymptomatic. What should be done

3. regarding this prior to surgery?
Your answer was Proceed with surgery, nil required which is correct
Proceed with surgery, nil required correct answer
NSAIDs
Pericardial drain
Postpone surgery and perform further investigations
Troponin
---------------------
A 40 year old male presents with shortness of breath and a headache. He is found to have a
blood pressure of 200/115mmHg and on fundoscopy has retinal haemorrhages and
papilledema. An ECG shows LVH. Heart sounds normal and chest is clear. What is the most
appropriate management?
Your answer was IV Labetalol which is incorrect
Ramipril
Atenolol correct answer
IV Labetalol
IV Sodium Nitroprusside
Methyldopa
Explanation:
Atenolol is the most appropriate as blood pressure in malignant hypertension should be lowered
gradually. Aims are lowering diastolic to 100 105mmHg over a few days. Blood pressure should
be monitored 4 hourly and should not drop initially more than 25 per cent of presenting. First
line therapy are beta blockers or calcium antagonist such as nifedipine (sublingual should be
avoided as it can lead to dramatic falls).
---------------
A 45 year old male presents with palpitations. He had been drinking heavily the night before. His
heart rate is about 140 bpm and is irregularly irregular. What is the most likely diagnosis?
Your answer was Atrial flutter which is incorrect
Atrial flutter
Supraventricular tachycardia
Ventricular tachycardia
Paroxysmal atrial fibrillation correct answer
Torsades de pointes
--------------
A 50 year old female presents with shortness of breath, fatigue and peripheral oedema. On
examination she has a raised JVP, pitting oedema, hepatomegaly and ascites. An echo is
organised and reveals globally thickened walls oncluding the interatrial septa with atrial
dilatation but the ventricles are not dilated. There is an increased scintillation pattern (granular
speckling). There is a normal ejection fraction. An ECG shows low voltage complexes. Given the
most likely diagnosis, how else might it present?
Your answer was Renal failure which is incorrect
Embolic symptoms correct answer

4. Cardiac tamponade
Myocardial infacrtion
Liver failure
Renal failure
--------------
A 35 year old female with rheumatoid arthritis presents with pain and tightness behind of the
left leg. On examination there is evidence of a swelling in the popliteal fossa of the left knee.
What investigation should be organised?
Your answer was D dimers which is incorrect
Ultrasound of popliteal fossa correct answer
D dimers
MRI of knee
Arthroscopy
Routine bloods
Explanation:
The most likely diagnosis is a Baker's cyst and an ultrasound should be performed to confirm
this. A d-dimer should only be measured if you suspect a DVT and according to the appropriate
Well's score.
-----------------
You are asked to review a 52 year old gentleman who has become suddenly unwell and
hypotensive. He had an STEMI 2 days previously. On examination he has a pansystolic murmur
lowest at the lower left sternal border and a raised JVP. Further investigation reveals a high right
atrial pressure and low left atrial pressure. What is the most likely diagnosis?
Your answer was VSD which is incorrect
Tricuspid regurgitation correct answer
Aortic Stenosis
VSD
Mitral regurgitation
Aortic regurgitation
Explanation:
The history and findings of high right atrial pressure suggests tricuspid regurgitation which can
occur post MI and is more commonly seen in those with chronic lung disease, endocarditis,
rheumatic heart disease and congenital abnormalities. It leads to a pansystolic murmur at the
LLSE, raised JVP and pulsatile liver and sometimes a RV impulse.
-----------------
A 58 year old gentleman has severe central crushing chest pain for about half an hour which is
finally relieved by GTN. There is evidence of ST depression in the anterolateral leads and his
troponin is elevated. He is treated with aspirin, clopidogrel and LMWH. What is the next
appropriate management?
Your answer was Coronary Angiography as an outpatient which is incorrect

5. Urgent coronary angiography as an inpatient correct answer
Discharged with Outpatient cardiac clinic follow up
Coronary Angiography as an outpatient
Cardiac Rehabilitation
Exercise Tolerance Test
--------------------
Which of the following is a risk factor for the development of Torsades de pointes?
Your answer was Hypermagnesaemia which is incorrect
Hypothermia correct answer
Hyperkalaemia
Hypercalcaemia
Hypermagnesaemia
Hyponatraemia
-------------------
A temporary single chamber pacing wire is being inserted for a patient with complete heart
block. Where should the lead be positioned?
Your answer was Right Ventricle Apex which is correct
Right Ventricle Apex correct answer
Right Atrium
Left Ventricular Apex
Left Atrium
Bundle of HIS
----------------
A 72 year old man has had several episodes of collapse and TIAs. He had suffered from an
extensive Myocardial Infarction previously. The only finding on clinical examination is a
displaced apex beat. An ECG revealed anterior ST elevation although he is currently pain free.
What further investigation is the most appropriate for diagnosis of the underlying diagnosis?
Your answer was Transoesophageal echocragiogram which is incorrect
CT head
Echocardiogram
Transoesophageal echocragiogram
Cardiac MRI correct answer
Coronary Angiography
Explanation:
A left ventricular aneurysm is a likely possibility due to the persistence of the ST elevation with
no chest pain and history of previous MI. The aneurysm would provide an environment for a
thrombus to form and lead to an embolic source causing TIAs. The preferred initial imaging is a
cardiac MRI.
--------------------
A 40 year gentleman is concerned as his brother died whilst playing football following a sudden
cardiac arrest. It was discovered that he had Hypertrophic Obstructive Cardiomyopathy on post
mortem. How would you screen this gentleman?

6. Your answer was Trans oesophageal ECHO which is correct
Trans oesophageal ECHO correct answer
ECG at rest
Exercise Tolerance test
Cardiac MRI
Dobutamine Stress Echo
--------------------
A 60 year old woman has a history of PAF for which she is on warfarin and amiodarone,
hypercholesterolaemia for which she takes simvastatin and hypertension on
bendroflumethiazide and ramipril. She is suffering from recurrent UTIs and has been advised
to drink cranberry juice. What is cranberry juice likely to interact with?
Your answer was Warfarin which is correct
Warfarin correct answer
Simvastatin
Amiodarone
Bendroflumethiazide
Ramipril
Explanation:
Cranberry juice can cause inhibition of cytochrome P450 and thus should avoided with warfarin.
---------------------
A 78 year old man has a PMH of MI, Angina and Hypertension. He attends for pre op assessment
for a hip replacement. He remains relatively fit and an ETT 2 years earlier had been negative.
What other investigation would you organise for preoperative assessment?
Your answer was Repeat ETT which is incorrect
Echocardiogram correct answer
Repeat ETT
Dobutamine Stress ECHO
Coronary Angiography
CXR
Explanation:
Echocardiogram is the most suitable to exclude Left ventricular impairment and valvular disease.
His recent ETT and no history of worsening angina would make a repeat ETT, angiography and
dobutamine stress echo would not be appropriate.
-----------------
A 40 year old man is referred to the cardiology clinic due to increased SOB and several TIAs with
left sided weakness and slurred speech. He has no significant PMH, is a non smoker and drinks
10units of alcohol per week. On examination blood pressure is 145/98 and his pulse was 80 and
regular. Although his chest clear there is evidence of a diastolic murmur with postural changes.
Bloods are normal. What is the likely diagnosis?
Your answer was Left atrial myxoma which is correct

7. Left atrial myxoma correct answer
Mitral Valve Prolapse
Aortic stenosis
Mitral stenosis
Aortic Regurgitation
----------------
In pregnany, which antiarrhythmic should be utilised as prophylaxsis for paroxysmal SVT?
Your answer was Metoprolol which is correct
Metoprolol correct answer
Amiodarone
Adenosine
Flecainide
Verapamil
---------------------
A 70 year old woman has had 34 syncopal episodes in the last 4 months. She has recently been
prescribed enalapril for hypertension. On examination her blood pressure is 165/120 mmHg, she
has aloud ejection systolic murmur and heaving apex beat and bibasal crackles. Which
investigation will provide the diagnosis?
Your answer was Echocardiogram which is incorrect
Cardiac catheterisation correct answer
CXR
ECG
Echocardiogram
ETT
-------------
A 20 year old has been admitted with chest pain. He admitted to using cocaine and is found to
have a STEMI. What do you do next?
Your answer was Aspirin and clopidogrel and LMWH which is incorrect
Percutaneous coronary intervention correct answer
Thrombolysis
IV heparin
Aspirin and clopidogrel and LMWH
Glycoprotein IIb/IIIa inhibitors
---------------
A 60 year old gentleman with angina is having increased shortness of breath on exertion. An
ECHO shows normal LVF however an ETT is positive. What is the most appropriate
management?
Your answer was Atenolol which is correct
Atenolol correct answer
Nicorandil
Isosorbide mononitrate
Perindopril
Amlodipine
-------------------

8. What characteristic when described with chest pain is most indicative of myocardial ischaemia?
Your answer was Relief with GTN which is incorrect
Radiation to jaw correct answer
Shortness of Breath
Light Headed
Palpitations
Relief with GTN
-----------------
What effect do class 1c agents have on the heart?
Your answer was Little effect on the action potential which is correct
Slow transmission at the AV node
Affect the SA node
Lengthen the action potential
Shorten the action potential
Little effect on the action potential
-------------------
An 80 year old female collapsed whilst out shopping. A first aider was on the scene who stated
he could not find a pulse for the first few seconds. On examination there was nil of note and an
ECG is normal. A 24 hour tape is organised and is normal except for a few ectopics. What is the
most likely diagnosis?
Your answer was Complete heart block which is incorrect
Complete heart block
Carotid Sinus Hypersensitivity correct answer
Vasovagal episode
Sick sinus syndrome
Transient Tachyarrhythmia
----------------
A 50 year old gentleman is on warfarin for AF with an INR of 2.0. He is planning to undergo a
tooth extraction, how would you manage his warfarin?
Your answer was Maintain warfarin at the therapeutic dose which is correct
Maintain warfarin at the therapeutic dose correct answer
Stop warfarin and convert to UFH until after procedure
Stop warfarin and convert to LMWH until after procedure
Convert to aspirin
Stop warfarin for 5 days before
Explanation:
As long as the INR is 2.0 or below then the British Haematological Society guidelines suggest the
procedure can be performed.
---------------------------
A 60 year old woman is brought into A and E, she looks unwell. She had had been complaining
of a sudden onset of palpitation and then collapsed. On examination she looks pale and
sweaty, is drowsy and her blood pressure is 80/50mmHg. An ECG is performed and shows

9. Torsades de Pointes. What following drug is not known to be associated with Torsades de
Pointes?
Your answer was Digoxin which is incorrect
Verapamil correct answer
Erythromycin
Sotalol
Risperidone
Digoxin
Explanation:
Verapamil is not associated with Torsades de Pointes due to its suppression of after
depolarisations. Risperidone, erythromycin and sotalol can lead to prolonged QT interval.
---------------------
A 55 year old gentleman presents to A and E following a collapse at work. He has a past medical
history of hypertension managed with perindopril and is a smoker of 30 a day. On examination
he has a left sided hemiplegia. Other examination findings and blood results are unremarkable.
A CT head is organised and no intracerebral haemorrhage is seen. How long after presentation is
thrombolysis appropriate to?
Your answer was 4 1/2 hours which is correct
4 1/2 hours correct answer
3 hours
6 hours
12 hours
24 hours
--------------------
A 20 year old female is referred to the clinic due to palpitations which sometimes occur on
exertion and are associated with nausea and light headedness. Her examination is unremarkable
as are her blood results. What is the next most appropriate investigation for diagnosis?
Your answer was 24 hour ECG which is incorrect
12 lead ECG
Continuous loop recorder correct answer
TFTs
24 hour ECG
Tilt Table Test
Explanation:
Due to the intermittent nature of her symptoms then continuous monitoring is the most
appropriate for diagnosis as a 12 hour ECG is unlikely to rule out arrhythmias although may
show features of some conditions such as WPW.
--------------------
A 73 year old woman has a history of myocardial infarction and poor exercise tolerance due to
SOB attends for preoperative assessment for a hip replacement. Her current medication is

10. aspirin, ramipril and simvastatin. There is nil of note on examination and her HR and BP are
within normal parameters. Blood results are normal. How would you assess her cardiovascular
status further for suitability for surgery?
Your answer was Echocardiogram which is incorrect
ECG
Dobutamine stress echo correct answer
Exercise Tolerance Test
Echocardiogram
Cardiac angiography
Explanation:
An exercise tolerance test would be the most appropriate but due to her requirement for a hip
replacement and poor exercise tolerance test then a Dobutamine stress echo is the most
appropriate as it does not require the patient to exercise but provides a similar stress via IV
infusion of dobutamine. ECG monitoring and ECHO are undertaken during this test.
------------------------
A 62 year old male is brought to A and E following a collapse. A first aider was on the scene and
stated he was pulseless for a few seconds. He states he has been suffering from intermittent
palpitations. What is the most likely diagnosis?
Your answer was Ventricular cardia which is incorrect
Vasovagal episodes
Sick sinus syndrome correct answer
Paroxysmal atrial fibrillation
Supra ventricular Tachycardia
Ventricular cardia
Explanation:
The history reveals episodes of tachycardia, when the patient is aware of palpitations and
bradycardia where he has collapsed and is pulseless. Thus it is indicative of Sick sinus syndrome
where there is sinoatrial node dysfunction with periods of sinus bradycardia, sometimes
asystole, conduction defects and SVT/atrial tachyarrhythmias. It can present with syncope,
dizziness, palpitations, angina, CCF or stroke due to embolic events.(tachy-brady syn)
--------------------
What investigation should be utilised to confirm an intraventricular thrombus following an
Echo?
Your answer was Transthoracic echo which is correct
Transthoracic echo correct answer
Cardiac MRI
Cardiac CT
Persistent ST elevation on ECG
Transesophageal echo

11. Explanation:
Transthoracic echo is much more useful for assessing ventricles than transesophageal.
Persistence of ST elevation on an ECG suggests development of a ventricular aneurysm post MI
and although there may be a thrombus formed within this it is definitive.
-----------------------
A 67 year old male presents to his GP with a cold right hand. He has had a previous coronary
artery bypass graft 3 years ago. Over the last few months he has noticed his hand being cold and
painful. It occurs at rest and is not worsened by any particular movements. On examination his
capillary refill time is slowed to about 3 seconds. The hand is cold and the radial pulse is
impalpable. The rest of the examination is normal. He has not had an angina attack for some
time. What is the most likely cause?
Your answer was Embolism which is incorrect
Radial artery trauma correct answer
Atherosclerosis of the radial artery
Embolism
Raynaud's Phenomenon
Ulnar artery trauma
Explanation:
This patient has had a CABG in the past. This means the radial artery may have been utilised for
catheterisation. This can cause trauma to the radial artery and if this does not recanalise and
there is significant athersclerosis to the ulnar artery this can lead to a compromised blood
supply to the hand. In some patients the radial artery can be used for grafting. Subclavian
stenosis can occur following CABG when the internal mammary artery is utilised however this
does not typical present in this fashion as there is intermittent arm claudication worsened with
arm raised above the head and there can be a steal syndrome leading to angina.
-------------------------
A 29 year old female who was on methadone dies suddenly whilst out running. Which of the
following is the most likely cause?
Your answer was VF which is incorrect
Prolonged QT correct answer
Intracranial Haemorrhage
SVT
VF
Methadone overdose
Explanation:
Methadone can lead to a prolonged QT interval. Torsades de point is therefore a risk.
--------------------------
What is the most likely cause from the following to lead to cyanosis in the newborn within the
first 24 hours?

12. Patent Ductus Arteriosus
Tetralogy of Fallot
ASD
Transposition of the great vessels correct answer
Eisenmenger syndrome
------------------
After cardioversion for AF, which of the following suggests there is a good chance of maintaining
sinus rhythm?
Your answer was Duration of AF less than 6 months which is correct
Left ventricular dysfunction
Previous successful cardioversions
Left atrium enlarged
Young age
Duration of AF less than 6 months correct answer
-----------------------
After cardioversion for AF, which of the following suggests there is a good chance of maintaining
sinus rhythm?
Your answer was Duration of AF less than 6 months which is correct
Left ventricular dysfunction
Previous successful cardioversions
Left atrium enlarged
Young age
Duration of AF less than 6 months correct answer
-------------------
Which of the following cardiac abnormalities is most susceptible to the development of
infective endocarditis?
Aortic regurgitation correct answer
Atrial septal defect
Aortic Stenosis
Mitral Valve Prolapse
Mitral Stenosis
Explanation:
Of the options here the highest risk is aortic regurgitation. Aortic stenosis is also at high risk as
are prosthetic valves. ASD and mitral stenosis is at low risk as is MVP without regurgitation.
------------------------
Which of the following is not useful in differentiating ventricular tachycardia from
supraventricular tachycardia with aberrant conduction?
Your answer was Very irregular rhythm which is correct
Very irregular rhythm correct answer
Capture and fusion beats
QRS width >160 ms
RBBB with left axis deviation on ECG

13. Concordance of QRS in chest leads
----------------------
A 68 year old male presents with severe central chest pain. He is found to have ST elevation in
the anterolateral leads. A primary PCI is performed and a stent inserted. He is then found to be
hypotensive at 70/40 with a few bibasal crepitations. Heart sounds are pure. A central line is
inserted and his pulmonary artery wedge pressure is 12 mmHg. Which of the following is the
most appropriate management?
Your answer was Inotropes which is incorrect
IV fluids correct answer
IV furosemide
Repeat PCI
Fluid Restriction
Inotropes
Explanation:
Hypotension can occur following an MI for numerous reasons. These include hypovolaemia,
decreased left ventricular filling secondary to right ventricular failure, GTN therpay leading to
vasodilatation and mechanical failure due to for example large infarcts. There is a low PCWP
suggesting the patient may be underfilled and it is appropriate to give IV fluid challenges to
optimise this before treating other potential causes and before inotropes can be commenced if
appropriate.
----------------------
A 50 year old gentleman presents with central chest pain with associated autonomic features.
He looks grey and clammy and on auscultation his heart sounds are normal but there is bibasal
crackles. His heart rate is 80 bpm and his blood pressure is 103/60 mm Hg. His ECG revealed ST
elevation V1 to V4 and ST depression II, II and aVF. He is referred for Primary PCI. What is likely
to be found at angiography?
Your answer was 70 per cent stenosis of left anterior descending artery which is incorrect
Complete occlusion of left anterior descending artery correct answer
Vasospasm
70 per cent stenosis of left anterior descending artery
80 per cent stenosis of left circumflex artery
Complete occlusion of right coronary artery
-------------------------
A 68 year old female has recently had a mitral valve replacement. She presents feeling
generally unwell, feverish with night sweats and weight loss. On examination she is pyrexial
and there is a murmur in the aortic area and inflammatory markers are raised. Blood cultures
are taken. What other investigation is most likely to confirm the diagnosis?
Transoesophageal Echocardiogram correct answer
Transthoracic Echocardiogram
ESR
ECG
Troponin

14. Explanation:
The diagnosis you would be suspecting is infective endocarditis. The major criteria in Dukes
criteria require two positive blood cultures and echocardiogram findings. TOE has been shown
to be more sensitive and is more useful for visualising mitral valve lesions as in this case.
---------------
A 39 year old female who is being treated for hypertension and has recently commenced
ramipril presents with sudden onset shortness of breath. His is has a regular pulse but is
tachycardic and his heart sounds are pure. On auscultation of the chest there is bibasal
crackles. What is the most likely underlying cause?
Your answer was Ischaemic heart disease which is incorrect
Renal artery stenosis correct answer
Hypertension
Silent STEMI
Ischaemic heart disease
Atrial Fibrillation
Explanation:
This patient is likely to have renal artery stenosis and the ACE-I may have precipitated ARF and
flash pulmonary oedema secondary to this. His pulse is regular thus this excludes AF. IHD and
STEMI are much less likely considering the patients age and there is nothing indicative of this in
the history.
------------------------
An ETT shows J point ST depression of approximately 1 mm. What treatment should be
initiated?
Your answer was Nil which is correct
Commence aspirin
Repeat ETT
Commence beta blockers
Nil correct answer
Referral for Angiography
-------------------
A 30 year old woman presents with palpitations. She is found to have a regular tachycardia of
200 bpm. She is normally fit and healthy and has no past medical history however drinks 5 mugs
of coffee per day and uses alcohol excessively. She is not compromised with a blood pressure of
130/80mmHg with no chest pain and no signs of heart failure. Her bloods are all within normal
parameters however the ECG confirms a narrow complex tachycardia of 200 bpm. If after giving
IV adenosine 3mg and then 6mg this fails what should be the next management step?
Your answer was IV 12mg adenosine which is correct
IV 12mg adenosine correct answer
IV Atenolol
IV amiodarone 900mg
DC Cardioversion
IV verapamil

15. --------------------
A 72 year old female has a permanent pacemaker for complete heart block. She then presents
with palpitations and shortness of breath and is found to be in fast atrial fibrillation. She is rate
controlled and warfarin is commenced. It is decided that she should have DC cardioversion. In
regards to this, which of the following is true?
During cardioversion pads placed 12-15cm away from permanent pacemaker, pacemaker and
lead function check immediately following procedure and 4-6 weeks after correct answer
Cardioversion is contraindicated
During cardioversion pads placed 12-15cm away from permanent pacemaker, nil else required
No extra precautions required
Removal of pacemaker, then reinsertion following cardioversion
Explanation:
A permanent pacemaker or ICD is not a contraindication to DC cardioversion, however DC
cardioversion can alter the settings of these devices. There is therefore certain precautions
which must be taken including placing pads 12-15cm away from device and an immediate check
of pacemaker and lead function and a further check at 4-6 weeks
------------------
A 42 year old female with rheumatoid arthritis presents with dyspnoea, fatigue and ankle
swelling. An ECG reveals 2:1 heart block and an echo is performed and reveals ventricular wall
thickening with granular sparkling of left ventricle and dilated atria. What is the most likely
diagnosis?
Dilated cardiomyopathy
Restrictive cardiomyopathy
Hypertrophic cardiomyopathy
Cardiac amyloid correct answer
Pericarditis
-------------------
A 25 year old female is referred due to palpitations. On examination her heart rate and blood
pressure are normal, chest is clear however there is splitting of the first heart sound. On an ECG
what is the first heart sound associated with?
R Wave correct answer
P wave
Q wave
S wave
T wave
----------------
A patient is diagnosed with infective endocarditis. Which of the following requires urgent
surgical intervention?
Your answer was Prolonged PR interval which is correct
Prolonged PR interval correct answer
Pyrexia and raised ESR despite antibiotic therapy
Mobile vegetation

16. Systolic murmur
Shortened PR interval
------------
A 60 year old who is on Lithium for bipolar disorder is found to be hypertensive by her GP is to
be commenced on anti hypertensive therapy. What anti hypertensive would you prescribe to
limit the risk of lithium toxicity?
Your answer was Bendroflumethiazide which is incorrect
Atenolol correct answer
Amlodipine
Bendroflumethiazide
Ramipril
Losartan
-------------------
A 50 year old man was admitted with central crushing chest pain. He is a smoker and is on
ramipril fro hypertension which has not been well controlled. He is found to have ST
depression in leads I, II, aVL, V4 V6 and his 12 hour troponin was 1.0. He underwent
angiography and stent insertion. Three days later he is complaining of the same crushing
central chest pain. A repeat ECG showed the same ST depression. Which enzyme should be
measured to assess if there is further damage to the myocardium?
Your answer was LDH which is incorrect
CKMB correct answer
Troponin I
LDH
AST
Troponin T
Explanation:
In this example CKMB would be useful if there has been a baseline value as it increase shortly
after onset of chest pain and an increase again would indicate a new event as the levels
decrease quickly. Troponin is not indicative as it does not reach its peak until 24-48 hours after
onset of chest pain and remains elevated for up to 2 weeks following chest pain. LDH has a later
peak at 3-6 days.
---------------
A 22 year old female has been suffering from intermittent palpitations. She states these occur
about four times a year and she is finding them increasingly troublesome. A 24 hour ECG is
organised and she is found to have paroxysmal atrial fibrillation. She is fit and well otherwise.
She was commenced on a beta blocker however could not tolerate the side effects as she was
having vivid dreams which were disturbing her sleep. Which of the following could be utilised as
an alternative?
Your answer was Verapamil which is incorrect
Flecainide correct answer
Amiodarone
Digoxin
Sotalol

17. Verapamil
Explanation:
This patient due to the infrequency of the episodes may be suitable for a "pill in the pocket"
approach. Flecainide can be utilised PRN with the patient only taking it when they are suffering
from an episode of AF. This is useful for infrequent episodes and can be used in patients with no
past history of structural heart disease, LVF or unstable AF. Sotalol is another option. A regular
betablocker can also be tried. If there is LV dysfunction or the others fail. Amiodarone can be
considered. Surgery is also an option where pharmacological therapy has failed or there is
evidence of WPW. Digoxin and verapamil are used in rate control.
---------------
A 55 year old man with poor dentition, has infective endocarditis. He presents with night sweats
and lethargy to his e GP. Blood cultures are taken and grow Strep Viridans. Examination reveals
splinter haemorrhages and a pyrexia of 37.8 C. On auscultation his chest is clear however there
is evidence of a systolic murmur. Investigations revealed a Hb of 10.1 g/dL, WCC of 15.0 x109, an
ESR of 101 and Acute Renal Failure. His ECG reveals a PR interval of 140 and an ECHO reveals
vegetations on the mitral valve and mitral regurgitation. After 12 days of antibiotics
intravenously, urgent surgical intervention is required for?
Your answer was Systolic Murmur which is incorrect
Prolonged PR Interval correct answer
Continually high ESR
Systolic Murmur
Pyrexia
Large mobile vegetation on mitral valve
Explanation:
The correct answer is the prolongation of PR interval as this implies that the myocardium has
been affected and there may be formation of an abscess. If there is evidence of regurgitation
with heart failure or obstruction of the valve this is another indication for surgery. If there is
rupture into the pericardium immediate referral is required. Neither continued pyrexia or raised
ESR are indications for surgical intervention.
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What s the best indicator of the severity of aortic stenosis?
Your answer was Character of second heart sound which is correct
Character of second heart sound correct answer
Character of apex beat
ECG changes
Intensity of murmur
Co Existence of AR
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In heart failure, what leads to a shift to the right of the pressure volume curve?
Reduced compliance secondary to volume overload

18. Reduced afterload
Increased preload
Increased contractibility of the chamber
Increased Compliance secondary to volume overload correct answer
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A patient has taken an amitriptyline overdose. She is tachycardic and hypotensive and is having
short runs of non sustained ventricular tachcardia. Her blood gases reveal a metabolic acidosis.
In terms of the non sustained Ventricular tachycardia, what is the most appropriate
management?
Your answer was IV Magnesium which is incorrect
IV Sodium bicarbonate correct answer
Implantable Defibrillator
IV Amiodarone 900mg
IV Magnesium
IV Adenosine 6mg
Explanation:
In amitriptyline overdose Sodium bicarbonate is the treatment of choice. It has been shown to
stabilise arrhythmias and increase blood pressure. Magnesium is useful in the management of
VT not secondary to TCA overdose however is not the treatment of choice here. Adenosine is
utilised for SVT.
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A 30 year old male presents to his GP due to shortness of breath and chest discomfort whilst
exercising. On examination there is a double apical impulse and a harsh mid systolic murmur
loudest between the apex and the left sternal border. His ECG shows LVH and widespread Q
waves. You suspect HOCM, which of the following is associated with increased risk of sudden
death?
Your answer was Family history of sudden death which is incorrect
Degree of left ventricular hypertrophy correct answer
Asymmetrical septal hypertrophy
Loudness of murmur
Family history of sudden death
Age
Explanation:
The most strongly correlated is the degree of LVH. Previously documented VT is also a risk
factor.
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The existence of atrial fibrillation with mitral stenosis results in which of the following?
Your answer was Disappearance of a wave and large V wave which is correct
Disappearance of a wave and large V wave correct answer
Large a wave

19. Large a wave and v wave
Deep x and y descents
Nil
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A 42 year old male is found to be hypertensive with a blood pressure of 190/100 mmHg. He is
otherwise fit and well and there is nil of note on examination. Bloods reveal normal renal
function however there is evidence of hypokalaemia, elevated bicarbonate and both renin and
aldosterone levels are increased. A 24 hour urinary cortisol fell within the normal range. What is
the most likely diagnosis?
Your answer was Conn's syndrome which is incorrect
Renal artery fibromuscular dysplasia correct answer
Conn's syndrome
Cushing's syndrome
Phaeochromocytoma
Glomerulonephritis
Explanation:
This patient most likely is suffering from renal artery stenosis. The underlying pathology is
fibromuscular dysplasia of the renal artery. It leads to hypoperfusion and thus leads to
activation of the renin-angiotensin-aldosterone system leading to elevated renin and
aldosterone levels and thus hypokalaemia. Conn's syndrome would lead to elevated aldosterone
levels and suppressed renin levels. There is a normal cortisol and nil of note on examination thus
Cushing's syndrome is unlikely. There is no symptoms to suggest phaeochromocytoma.
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A patient presents bradycardic and she is haemodynamically unstable. It is thought to be related
to a beta blocker overdose. She is given IV fluids and atropine with no response. Which of the
following should be utilised?
Your answer was Temporary cardiac pacing which is incorrect
Glucagon correct answer
Haemodialysis
Insulin
Temporary cardiac pacing
Adenosine
Explanation:
Glucagon can increase myocardial contraction, heart rate and AV conduction and many feel it is
the drug of choice. Cardiac pacing is reserved for those who feel medical management.
Haemodialysis may be useful for atenolol overdoses. High dose insulin has been shown to be
useful in a few case reports but should always be discussed with a specialist. Adenosine is used
in the management of SVTs and must be avoided.
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How long should you advise a patient not to drive after pacemaker insertion?

20. One week correct answer
One day
One month
Can drive immediately
One year
Explanation:
After permanent pacemaker insertion patient's should be advised not to drive for one week.
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A 50 year old woman presents with left arm and leg weakness of 5 hours duration. She is known
to have AF. She is hypertensive but her AF is rate controlled with a HR of 80. Neurological exam
confirms 4/5 weakness but there is nil else remarkable, bloods are normal and CT head shows
no evidence of haemorrhage. As there is no evidence of haemorrhage on CT, what anti platelet
or anticoagulant are yo going to prescribe?
Your answer was Warfarin to be commenced covered by LMWH which is incorrect
Aspirin correct answer
Warfarin to be commenced covered by LMWH
IV Heparin
None
Thrombolysis
Explanation:
As the symptoms have been present for 5 hours then thrombolysis is not appropriate as it it only
recommended for up to 4 hours. Due to her AF she will need to be anticoagulated and it is
recommended this should be delayed until 2 weeks later although this varies as there is early
risk of haemorrhagic transformation. Aspirin should be commenced in the meantime.
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