Mock Cardiology Module 1

A 78-year-old man is reviewed in the cardiology clinic four months after radiofrequency catheter ablation for symptomatic paroxysmal atrial fibrillation.

Over the preceding 12 months he has had three admissions with per-rectal bleeding; colonoscopy identified caecal angiodysplasia treated with argon plasma coagulation.

His medications include apixaban 5 mg twice daily, bisoprolol 2.5 mg daily and atorvastatin 40 mg daily.

Investigations:

Haemoglobin 96 g/L (135–175)
MCV 74 fL (80–100)
Ferritin 12 µg/L (30–300)
Creatinine 88 µmol/L (60–110), eGFR >60 mL/min/1.73m²
CHA₂DS₂-VASc score 5; HAS-BLED score 4
Transthoracic echocardiogram: LVEF 55%, left atrial volume index 42 mL/m², no thrombus visualised; transoesophageal echocardiogram confirms a suitable left atrial appendage morphology

Which of the following statements regarding left atrial appendage closure (LAAC) in this patient is most accurate?

LAAC was non-inferior to oral anticoagulation and reduced major bleeding in patients following AF ablation

Correct Incorrect Correct answer

LAAC has demonstrated superiority to oral anticoagulation for ischaemic stroke prevention

Correct Incorrect Correct answer

LAAC eliminates the need for any antithrombotic therapy immediately post-procedure

Correct Incorrect Correct answer

LAAC is only indicated in patients with valvular atrial fibrillation

Correct Incorrect Correct answer

LAAC significantly increases all-cause mortality compared with anticoagulation

Correct Incorrect Correct answer

A 72-year-old woman with permanent atrial fibrillation (CHA₂DS₂-VASc 4) taking rivaroxaban 20 mg daily attends for review of persistent palpitations.

Six weeks ago a rate-control agent was added by her general practitioner. She now reports recurrent epistaxis, spontaneous bruising and dark stools.

Investigations:

Haemoglobin 108 g/L (115–160), down from 134 g/L three months ago
Platelets 245 × 10⁹/L (150–400)
Creatinine 82 µmol/L (45–90), eGFR 78 mL/min/1.73m²
Prothrombin time mildly prolonged; anti-Xa (rivaroxaban) level markedly elevated
Faecal occult blood positive

ECG confirms atrial fibrillation with a ventricular rate of 78 bpm.

Which agent added six weeks ago most likely precipitated this presentation through a pharmacokinetic interaction?

Diltiazem

Correct Incorrect Correct answer

Metoprolol

Correct Incorrect Correct answer

Digoxin

Correct Incorrect Correct answer

Bisoprolol

Correct Incorrect Correct answer

Atenolol

Correct Incorrect Correct answer

A 58-year-old woman presents with acute severe dyspnoea developing over two hours. She has no prior cardiac history.

On examination she is tachypnoeic and diaphoretic; blood pressure 148/92 mmHg, heart rate 118 bpm, SpO₂ 87% on room air. Auscultation reveals crackles concentrated over the right lung field and a soft apical systolic murmur.

Investigations:

Chest radiograph: dense right-sided perihilar and mid-zone airspace opacification with a relatively clear left lung
Troponin I 45 ng/L (<16), stable on repeat
BNP 820 ng/L (<100)
ECG: sinus tachycardia, no ST changes
Bedside transthoracic echocardiogram: hyperdynamic LVEF, difficult mitral assessment
Transoesophageal echocardiogram: flail posterior mitral leaflet with a severe, anteriorly directed eccentric regurgitant jet; ruptured chordae identified

Which mechanism best explains the radiographic distribution?

Eccentric regurgitant jet directed preferentially into the right upper pulmonary vein

Correct Incorrect Correct answer

Right ventricular failure causing selective right-sided congestion

Correct Incorrect Correct answer

Compression of the left main bronchus by an enlarged left atrium

Correct Incorrect Correct answer

Concomitant right lower lobe pneumonia

Correct Incorrect Correct answer

Primary pulmonary arterial hypertension

Correct Incorrect Correct answer

A 64-year-old man with hypertension and type 2 diabetes presents with an NSTEMI (troponin I 780 ng/L, ECG showing lateral T-wave inversion).

He proceeds to coronary angiography via the right radial artery, with successful drug-eluting stent placement in the circumflex. The interventional fellow discusses the evidence supporting the chosen access route.

Investigations:

Creatinine 96 µmol/L (60–110), eGFR 74 mL/min/1.73m²
Haemoglobin 142 g/L (135–175)

Compared with femoral access, radial access has been shown in randomised trials to improve all of the following outcomes EXCEPT:

Contrast-induced nephropathy

Correct Incorrect Correct answer

Major (non-CABG) bleeding

Correct Incorrect Correct answer

Vascular access-site complications

Correct Incorrect Correct answer

All-cause mortality

Correct Incorrect Correct answer

Net adverse clinical events

Correct Incorrect Correct answer

A 70-year-old man with hyperlipidaemia and a 40-pack-year smoking history presents with 40 minutes of crushing central chest pain radiating to the left arm, associated with diaphoresis and hypotension (BP 92/58 mmHg, HR 104 bpm). He appears grey and clammy.

Investigations:

ECG: 3–4 mm ST elevation in V1–V6, I and aVL with reciprocal ST depression in II, III and aVF; new right bundle branch block
Troponin pending
Lactate 3.2 mmol/L (0.5–2.2)

Which culprit lesion best explains this pattern?

Left main coronary artery

Correct Incorrect Correct answer

Right coronary artery

Correct Incorrect Correct answer

Proximal circumflex artery

Correct Incorrect Correct answer

Distal LAD after the diagonal branches

Correct Incorrect Correct answer

Posterior descending artery

Correct Incorrect Correct answer

A 62-year-old man with dilated cardiomyopathy is examined during a ward round. His JVP is elevated at 6 cm above the sternal angle.

The registrar times the venous waveform against the carotid pulse and identifies a distinct trough occurring during ventricular systole.

Echocardiography demonstrates LVEF 35% with no significant tricuspid regurgitation.

Which component of the jugular venous pressure waveform corresponds to the fall in atrial pressure as the tricuspid annulus descends during ventricular systole?

x descent

Correct Incorrect Correct answer

a wave

Correct Incorrect Correct answer

c wave

Correct Incorrect Correct answer

v wave

Correct Incorrect Correct answer

y descent

Correct Incorrect Correct answer

A 66-year-old man with stable angina undergoes elective PCI to a proximal left anterior descending artery lesion.

During the procedure there is transient loss of flow in a large first diagonal side branch, which is subsequently restored.

He is asymptomatic afterwards and haemodynamically stable, with no ongoing chest pain.

Investigations:

Baseline high-sensitivity troponin T 12 ng/L (<14)
Twelve-hour post-procedure troponin T 98 ng/L (i.e. approximately 7× the upper reference limit)
ECG at 12 hours: new T-wave inversion in V2–V4, no ST elevation
Angiographic report: transient occlusion of the first diagonal branch with subsequent restoration of TIMI 2 flow; the main LAD stent is patent with good flow
Blood pressure 128/78 mmHg, heart rate 76 bpm

Which of the following is the most appropriate next step in management?

Continue guideline-directed medical therapy with dual antiplatelet therapy and serial monitoring, without repeat intervention

Correct Incorrect Correct answer

Emergency repeat coronary angiography with a view to reintervention

Correct Incorrect Correct answer

Administer intravenous fibrinolysis

Correct Incorrect Correct answer

Cease dual antiplatelet therapy given the troponin rise

Correct Incorrect Correct answer

Urgent referral for coronary artery bypass grafting

Correct Incorrect Correct answer

A 56-year-old man presents with an anterior STEMI to a rural centre and receives fibrinolysis. Transferred for angiography, he is found to have an 80% distal left main stenosis. He is a company director who strongly wishes to avoid sternotomy and prolonged recovery.

Investigations:

SYNTAX score 5 (low anatomical complexity)
Transthoracic echocardiogram: LVEF 52%, no significant valvular disease
Creatinine 78 µmol/L (60–110)
HbA1c 5.6% (non-diabetic)

Compared with CABG, PCI with a second-generation drug-eluting stent in this patient at 3 years is best described as:

Non-inferior for the composite of death, MI or stroke

Correct Incorrect Correct answer

Superior for the composite of death, MI or stroke

Correct Incorrect Correct answer

Associated with lower rates of repeat revascularisation

Correct Incorrect Correct answer

Contraindicated regardless of anatomical complexity

Correct Incorrect Correct answer

Associated with significantly higher periprocedural MI at 30 days

Correct Incorrect Correct answer

A 68-year-old woman presents with 3 hours of chest pain. The admitting team calculates a GRACE score to guide the timing of invasive management.

Investigations:

Heart rate 96 bpm, systolic blood pressure 128 mmHg
Creatinine 118 µmol/L (45–90)
Killip class I (no signs of heart failure)
ECG: 1 mm ST depression in V4–V6
High-sensitivity troponin T 210 ng/L (<14)
Chest radiograph: mild upper-lobe diversion, no consolidation

Which of the following variables is NOT incorporated into the GRACE risk score?

Chest radiograph findings

Correct Incorrect Correct answer

Age

Correct Incorrect Correct answer

Serum creatinine

Correct Incorrect Correct answer

Killip class (signs of heart failure)

Correct Incorrect Correct answer

Cardiac arrest at admission

Correct Incorrect Correct answer

A 50-year-old man presents with 2 hours of chest discomfort that has now resolved. He is haemodynamically stable and pain-free.

Investigations:

Heart rate 72 bpm, systolic blood pressure 122 mmHg, Killip class I
Creatinine 90 µmol/L (60–110)
High-sensitivity troponin T 300 ng/L (<14), rising on serial testing
ECG: 1 mm ST depression in V2–V6
Calculated GRACE score 96 (predicting ~3% 6-month mortality)

He is referred for angiography, performed within 24 hours.

Compared with a delayed strategy, early invasive intervention in this patient is most likely to provide:

No clear additional benefit

Correct Incorrect Correct answer

Reduction in 6-month mortality

Correct Incorrect Correct answer

Reduction in 6-month reinfarction

Correct Incorrect Correct answer

Reduction in 6-month stroke

Correct Incorrect Correct answer

Reduction in major bleeding

Correct Incorrect Correct answer

A 67-year-old man undergoes successful primary PCI with a drug-eluting stent to a culprit lesion in the circumflex artery for an inferolateral STEMI. He is haemodynamically stable throughout.

Investigations:

Post-procedure ECG: resolving ST elevation, TIMI 3 flow in the treated vessel
Angiography also demonstrates a 75% stenosis in the mid-LAD (non-culprit)
LVEF on echocardiogram 48%
Creatinine 84 µmol/L (60–110)

The team plans a staged procedure.

Compared with culprit-only PCI, staged complete revascularisation of the non-culprit LAD lesion is most strongly supported to:

Reduce cardiovascular death or new MI

Correct Incorrect Correct answer

Reduce contrast nephropathy

Correct Incorrect Correct answer

Reduce stroke

Correct Incorrect Correct answer

Reduce major bleeding

Correct Incorrect Correct answer

Eliminate the need for antiplatelet therapy

Correct Incorrect Correct answer

A 50-year-old man presents to a rural hospital 90 minutes from the nearest catheterisation laboratory with 1 hour of chest pain.

Investigations:

ECG: 3 mm ST elevation in V2–V6
Heart rate 92 bpm, systolic blood pressure 120 mmHg, Killip class I
Troponin I 20 ng/L (<16) initially
Creatinine 90 µmol/L (60–110)

He receives fibrinolysis with tenecteplase and dual antiplatelet therapy, with ST-segment resolution of >50%, and is transferred for angiography within 6 hours.

Compared with a standard ischaemia-guided approach, this pharmaco-invasive strategy most likely provides:

Lower risk of recurrent ischaemia/reinfarction

Correct Incorrect Correct answer

Lower risk of stroke

Correct Incorrect Correct answer

Lower risk of major bleeding

Correct Incorrect Correct answer

Reduced transfusion requirement

Correct Incorrect Correct answer

No clear benefit

Correct Incorrect Correct answer

A 54-year-old man with paroxysmal atrial fibrillation (CHA₂DS₂-VASc 3) presents with an NSTEMI and undergoes PCI with a drug-eluting stent to the LAD.

Investigations:

Haemoglobin 148 g/L (135–175)
Platelets 260 × 10⁹/L (150–400)
Creatinine 76 µmol/L (60–110), eGFR >60 mL/min/1.73m²
HAS-BLED score 1 (low bleeding risk)
Troponin peak 4200 ng/L

Given his low bleeding risk relative to his thrombotic risk, which antithrombotic regimen is most appropriate?

Triple therapy (DOAC + aspirin + clopidogrel) up to 1 month, then DOAC + clopidogrel to 12 months

Correct Incorrect Correct answer

Lifelong triple therapy with aspirin, clopidogrel and warfarin

Correct Incorrect Correct answer

Dual therapy with aspirin and warfarin for 6 months

Correct Incorrect Correct answer

Dual therapy with clopidogrel and warfarin for 12 months

Correct Incorrect Correct answer

Aspirin monotherapy for 12 months

Correct Incorrect Correct answer

A 75-year-old man with non-valvular atrial fibrillation (CHA₂DS₂-VASc 4) on long-term warfarin undergoes single-stent PCI to the circumflex for stable angina.

Investigations:

INR 2.4 on admission (target 2–3)
Haemoglobin 128 g/L (135–175)
Creatinine 92 µmol/L (60–110), eGFR 68 mL/min/1.73m²
Recent history of a gastric ulcer, now healed on proton pump inhibitor

Which post-PCI regimen offers the most favourable bleeding profile while maintaining anti-ischaemic efficacy?

Dabigatran plus single antiplatelet therapy

Correct Incorrect Correct answer

Warfarin plus dual antiplatelet therapy

Correct Incorrect Correct answer

Warfarin plus prasugrel

Correct Incorrect Correct answer

Full-dose rivaroxaban plus dual antiplatelet therapy

Correct Incorrect Correct answer

Apixaban plus dual antiplatelet therapy indefinitely

Correct Incorrect Correct answer

A 45-year-old man with idiopathic dilated cardiomyopathy is admitted with his third episode of decompensated heart failure in 12 months, despite maximally tolerated sacubitril/valsartan, carvedilol, spironolactone and dapagliflozin.

Investigations:

LVEF 15% on echocardiography, severe global hypokinesis
Cardiac index 1.8 L/min/m² (2.5–4.0) on right heart catheterisation
NYHA class IV
Peak VO₂ 11 mL/kg/min on cardiopulmonary exercise testing (severely reduced)
eGFR 55 mL/min/1.73m²
BNP 2200 ng/L (<100)
Coronary angiography: unobstructed coronary arteries

Which factor most appropriately supports referral for cardiac transplant evaluation?

Refractory advanced heart failure with poor 1-year prognosis despite optimal therapy

Correct Incorrect Correct answer

Presence of a mechanical aortic valve

Correct Incorrect Correct answer

Recent single episode of non-sustained VT

Correct Incorrect Correct answer

Concomitant stable coronary artery disease

Correct Incorrect Correct answer

Age under 50 alone

Correct Incorrect Correct answer

A 62-year-old man with type 2 diabetes underwent coronary angiography two weeks ago for known three-vessel disease. He now presents with malaise and diffuse abdominal pain.

On examination there is livedo reticularis over both lower limbs and cyanotic discolouration of several toes with intact pedal pulses.

Investigations:

Creatinine 450 µmol/L (60–110), up from 140 µmol/L pre-angiography
Eosinophils 0.9 × 10⁹/L (0.0–0.5)
C3 and C4 reduced
Urinalysis: bland sediment, minimal proteinuria
No recovery in renal function over 10 days

Which is the most likely diagnosis?

Cholesterol embolisation syndrome

Correct Incorrect Correct answer

Contrast-induced nephropathy

Correct Incorrect Correct answer

ACE-inhibitor nephropathy

Correct Incorrect Correct answer

Bilateral renovascular disease

Correct Incorrect Correct answer

Aortic dissection

Correct Incorrect Correct answer

A 74-year-old woman with newly diagnosed non-valvular atrial fibrillation is counselled on anticoagulation options.

Investigations:

CHA₂DS₂-VASc score 4; HAS-BLED score 2
Creatinine 88 µmol/L (45–90), eGFR 62 mL/min/1.73m²
Weight 68 kg
Haemoglobin 132 g/L (115–160)
Echocardiogram: no significant valvular disease, normal LV function

She asks how apixaban compares with warfarin. Which statement most accurately describes the advantage demonstrated in the ARISTOTLE trial?

Reduced rates of stroke or systemic embolism with lower major bleeding and lower mortality

Correct Incorrect Correct answer

Complete absence of bleeding risk

Correct Incorrect Correct answer

Safe use in severe chronic kidney disease and dialysis

Correct Incorrect Correct answer

No requirement for any dose adjustment in any patient

Correct Incorrect Correct answer

Superior efficacy only when combined with aspirin

Correct Incorrect Correct answer

A 78-year-old woman presents following two episodes of syncope. On examination her pulse is regular at 38 bpm with a wide pulse pressure.

The first heart sound varies in intensity from beat to beat, and intermittent large pulsations are visible in the neck.

Investigations:

ECG: atrial rate 88 bpm and ventricular rate 38 bpm with complete AV dissociation; broad QRS escape rhythm
Troponin negative
Potassium 4.2 mmol/L (3.5–5.2)
TSH normal

Which of the following examination findings would be INCONSISTENT with her diagnosis?

Soft second heart sound (S2)

Correct Incorrect Correct answer

Variable intensity of S1

Correct Incorrect Correct answer

Wide pulse pressure

Correct Incorrect Correct answer

Cannon a waves in the JVP

Correct Incorrect Correct answer

Regular bradycardia at 30–50 bpm

Correct Incorrect Correct answer

A 55-year-old woman who migrated from a region with endemic rheumatic heart disease presents with progressive exertional dyspnoea and haemoptysis.

On examination she has a tapping apex beat, a loud first heart sound and a low-pitched apical mid-diastolic murmur with presystolic accentuation.

Investigations:

ECG: atrial fibrillation, P mitrale absent (in AF), signs of right ventricular hypertrophy
Transthoracic echocardiogram: mitral valve area 0.9 cm² (normal 4–6), mean transmitral gradient 12 mmHg, doming anterior leaflet, estimated pulmonary artery systolic pressure 60 mmHg
Chest radiograph: straightening of the left heart border, splayed carina

Which physical finding would be INCONSISTENT with severe mitral stenosis?

Prominent v wave in the JVP due to the mitral lesion itself

Correct Incorrect Correct answer

Loud P2

Correct Incorrect Correct answer

Right ventricular heave

Correct Incorrect Correct answer

A shorter interval between S2 and the opening snap

Correct Incorrect Correct answer

Mid-diastolic rumbling murmur

Correct Incorrect Correct answer

A 64-year-old man with hypertension, type 2 diabetes and hyperlipidaemia presents with stable exertional angina (CCS class II) occurring after two blocks of walking, relieved by rest. H

e has no rest pain and remains functionally active. He is established on aspirin, atorvastatin 80 mg, metoprolol and perindopril, with good adherence.

Investigations:

ECG: normal sinus rhythm, no acute ischaemic changes
Exercise stress echocardiogram: extensive reversible inferolateral wall-motion abnormality, consistent with moderate-to-severe ischaemia
LVEF 58% on transthoracic echocardiography
HbA1c 6.8%; LDL cholesterol 1.5 mmol/L (target <1.8 for high-risk)
eGFR 72 mL/min/1.73m²
CT coronary angiography excludes left main disease

Based on the best available evidence, which management strategy is most appropriate as the initial approach?

Continue and optimise guideline-directed medical therapy, reserving invasive management for refractory symptoms

Correct Incorrect Correct answer

Urgent coronary angiography with a view to revascularisation to reduce mortality

Correct Incorrect Correct answer

Immediate referral for coronary artery bypass grafting

Correct Incorrect Correct answer

PCI of all ischaemic territories to reduce future myocardial infarction

Correct Incorrect Correct answer

Cease beta-blockade and commence long-acting nitrate monotherapy

Correct Incorrect Correct answer

A 60-year-old man with poorly controlled hypertension presents with sudden tearing interscapular chest pain radiating to the abdomen, followed by presyncope.

Investigations:

Blood pressure 88/54 mmHg right arm, 122/70 mmHg left arm
ECG: 2 mm ST elevation in II, III and aVF with complete heart block, ventricular rate 40 bpm
Chest radiograph: widened mediastinum
CT aortogram: intimal flap extending from the aortic root into the ascending aorta (Stanford type A) with extension towards the right coronary ostium
Troponin I 320 ng/L (<16)

Which coronary artery is most commonly compromised in this setting?

Right coronary artery

Correct Incorrect Correct answer

Left anterior descending

Correct Incorrect Correct answer

Left circumflex

Correct Incorrect Correct answer

Left main stem

Correct Incorrect Correct answer

Posterior descending artery

Correct Incorrect Correct answer

A 58-year-old man undergoes primary PCI for an anterior ST-elevation myocardial infarction. After successful stent deployment in the proximal-to-mid left anterior descending artery, the operator observes that contrast reaches and completely fills the distal vessel, but opacification is visibly delayed compared with an adjacent normally perfused artery.

There is no residual stenosis, dissection, distal embolus or vessel closure on angiography.

His blood pressure 118/72 mmHg, heart rate 84 bpm, patient haemodynamically stable and pain-free.

Post-procedure ECG shows only partial (<50%) resolution of the anterior ST-segment elevation.

Which of the following is the most appropriate next step in management?

Administer an intracoronary vasodilator (e.g. adenosine, verapamil, or nicorandil)

Correct Incorrect Correct answer

Deploy a further overlapping drug-eluting stent across the treated segment

Correct Incorrect Correct answer

Perform emergency coronary artery bypass grafting

Correct Incorrect Correct answer

Commence intravenous fibrinolysis

Correct Incorrect Correct answer

Withdraw all antiplatelet therapy and observe

Correct Incorrect Correct answer

A 65-year-old woman with obesity, hypertension, a prior transient ischaemic attack and permanent atrial fibrillation is scheduled for CABG for triple-vessel disease.

Investigations:

CHA₂DS₂-VASc score 5
Transthoracic echocardiogram: mild mitral regurgitation, normal LVEF
eGFR 70 mL/min/1.73m²
Currently on dabigatran 150 mg twice daily
Coronary angiography: significant proximal LAD, circumflex and RCA disease

Which concomitant intervention at the time of surgery reduces her future stroke risk?

Surgical left atrial appendage occlusion during CABG

Correct Incorrect Correct answer

Elective mitral valve replacement

Correct Incorrect Correct answer

Switching dabigatran to rivaroxaban post-operatively

Correct Incorrect Correct answer

Carotid endarterectomy

Correct Incorrect Correct answer

Adding clopidogrel indefinitely

Correct Incorrect Correct answer

A 68-year-old man with ischaemic cardiomyopathy remains breathless (NYHA class III) despite maximally tolerated sacubitril/valsartan, carvedilol, spironolactone and dapagliflozin, plus an appropriately functioning CRT-D device.

He has had two heart failure admissions in the past six months.

Investigations:

LVEF 30% on transthoracic echocardiography
Transoesophageal echocardiography: severe secondary (functional) mitral regurgitation; effective regurgitant orifice area 0.35 cm², regurgitant volume 55 mL; left ventricular end-systolic dimension 55 mm (i.e. MR severity disproportionate to the degree of LV dilatation)
NT-proBNP 3200 ng/L (<125)
eGFR 48 mL/min/1.73m²
Coronary angiography: previously stented, no new revascularisable lesions

Which intervention is most likely to reduce both heart failure hospitalisation and mortality in this patient?

Transcatheter edge-to-edge mitral valve repair (MitraClip)

Correct Incorrect Correct answer

Further up-titration of diuretics alone

Correct Incorrect Correct answer

Surgical mitral valve replacement

Correct Incorrect Correct answer

Addition of digoxin

Correct Incorrect Correct answer

Referral for orthotopic cardiac transplantation as first-line

Correct Incorrect Correct answer

A 58-year-old man with symptomatic paroxysmal atrial fibrillation and heart failure with reduced ejection fraction remains breathless (NYHA class II–III) despite adequate rate control and optimal medical therapy.

Investigations:

LVEF 30% on echocardiography
Holter monitor: frequent paroxysms of AF with rapid ventricular response
eGFR 65 mL/min/1.73m²
Thyroid function normal
NT-proBNP 1600 ng/L (<125)

Which strategy is most likely to improve survival and reduce heart failure hospitalisations?

Catheter ablation for AF

Correct Incorrect Correct answer

Continued rate control alone

Correct Incorrect Correct answer

Amiodarone monotherapy indefinitely

Correct Incorrect Correct answer

AV node ablation without pacing

Correct Incorrect Correct answer

Digoxin uptitration

Correct Incorrect Correct answer

A 40-year-old woman with metastatic breast cancer presents with progressive dyspnoea and presyncope.

On examination she is tachycardic, hypotensive (BP 92/70 mmHg) with muffled heart sounds and a JVP elevated to the angle of the jaw.

Investigations:

ECG: sinus tachycardia, low QRS voltages, electrical alternans
Chest radiograph: enlarged globular cardiac silhouette
Echocardiogram: large circumferential pericardial effusion with diastolic right atrial and early diastolic right ventricular collapse, and >25% respiratory variation in mitral inflow
Measured inspiratory fall in systolic blood pressure 18 mmHg

Which haemodynamic sign is most characteristic of her diagnosis?

Pulsus paradoxus >10 mmHg

Correct Incorrect Correct answer

Prominent y descent in the JVP

Correct Incorrect Correct answer

Kussmaul's sign

Correct Incorrect Correct answer

Wide pulse pressure

Correct Incorrect Correct answer

Loud S3 gallop

Correct Incorrect Correct answer

A 66-year-old woman with hypertension and type 2 diabetes presents with palpitations and mild breathlessness. Atrial fibrillation was first documented three months ago. She has no prior stroke and is otherwise well.

Investigations:

ECG: atrial fibrillation, ventricular rate 96 bpm
CHA₂DS₂-VASc score 4
Transthoracic echocardiogram: LVEF 55%, left atrial volume index 34 mL/m², no significant valvular disease
Thyroid function normal
eGFR 68 mL/min/1.73m²

She is anticoagulated with apixaban.

In addition to anticoagulation and rate control, which strategy is most likely to reduce cardiovascular death, stroke, and hospitalisation for heart failure or acute coronary syndrome?

Early rhythm control with antiarrhythmic drugs or catheter ablation

Correct Incorrect Correct answer

Rate control alone with a target resting heart rate <110 bpm

Correct Incorrect Correct answer

Aspirin in addition to apixaban

Correct Incorrect Correct answer

Digoxin monotherapy for rate control

Correct Incorrect Correct answer

Deferral of any rhythm intervention until symptoms become intolerable

Correct Incorrect Correct answer

A 79-year-old woman presents with exertional syncope and progressive dyspnoea.

Investigations:

Transthoracic echocardiogram: aortic valve area 0.8 cm² (normal 3–4), mean transaortic gradient 48 mmHg, LVEF 55%, calcified trileaflet aortic valve
CT aortic annular assessment: suitable annular dimensions and peripheral access for a transcatheter valve
STS predicted risk of mortality 5% (intermediate)
eGFR 62 mL/min/1.73m²
Frailty assessment: mildly frail but independent

Which intervention is most appropriate?

Transcatheter aortic valve implantation (TAVI)

Correct Incorrect Correct answer

Balloon aortic valvuloplasty alone

Correct Incorrect Correct answer

Medical therapy with diuretics

Correct Incorrect Correct answer

Watchful waiting until symptoms worsen

Correct Incorrect Correct answer

Percutaneous coronary intervention

Correct Incorrect Correct answer

A 62-year-old man with type 2 diabetes and a strong family history of coronary disease presents with worsening angina.

Angiography reveals significant three-vessel coronary artery disease.

Investigations:

Coronary angiography: 80% proximal LAD, 75% mid-circumflex, and 85% proximal RCA stenoses
SYNTAX score 28 (intermediate-to-high anatomical complexity)
Fractional flow reserve (FFR): LAD 0.68, circumflex 0.72, RCA 0.70 (all functionally significant, ≤0.80)
LVEF 52% on echocardiography
HbA1c 7.4%; eGFR 66 mL/min/1.73m²
Heart Team assessment: acceptable surgical candidate

Which statement most accurately guides revascularisation in this patient based on the FAME-3 trial?

FFR-guided PCI did not meet non-inferiority compared with CABG for the composite outcome at one year

Correct Incorrect Correct answer

FFR-guided PCI is superior to CABG for the composite of death, MI, stroke or repeat revascularisation

Correct Incorrect Correct answer

FFR guidance renders PCI equivalent to CABG regardless of anatomical complexity

Correct Incorrect Correct answer

CABG is contraindicated once all lesions are FFR-positive

Correct Incorrect Correct answer

Medical therapy alone is preferred over both PCI and CABG in this scenario

Correct Incorrect Correct answer

A 58-year-old man is admitted with acute decompensated heart failure and treated with intravenous diuretics, with resolution of congestion. He is a new diagnosis of dilated cardiomyopathy.

He is haemodynamically stable and euvolaemic, and is being planned for discharge.

Investigations:

LVEF 32% on echocardiography
Blood pressure 118/74 mmHg, heart rate 78 bpm
Potassium 4.4 mmol/L (3.5–5.2)
eGFR 62 mL/min/1.73m²
NT-proBNP 4800 ng/L on admission, now falling
He is currently on low-dose ramipril and furosemide only

Which post-discharge strategy is most likely to reduce 180-day mortality and heart failure readmission?

Rapid, protocolised up-titration of guideline-directed medical therapy with close early follow-up

Correct Incorrect Correct answer

Discharge on current therapy with routine GP review in three months

Correct Incorrect Correct answer

Deferral of beta-blocker and MRA initiation until the outpatient clinic in eight weeks

Correct Incorrect Correct answer

Maintenance of diuretic monotherapy until symptoms recur

Correct Incorrect Correct answer

Immediate referral for cardiac transplantation assessment

Correct Incorrect Correct answer

Mock Cardiology Module 1

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