Cardiology Module 1

A 75-year-old patient with chronic atrial fibrillation (AF) recently underwent catheter ablation for his atrial fibrillation and was advised to remain on long-term anticoagulation post-ablation.

However, he has a history of recurrent gastrointestinal bleeding that has required urgent hospitalization. The patient’s HAS-BLED score is 4, indicating a high risk of bleeding with anticoagulation.

What treatment option could be offered to this patient as an alternative to long-term anticoagulation for stroke prevention?

A 68-year-old man with a history of atrial fibrillation and recent diagnosis of deep vein thrombosis is being managed with rivaroxaban. He is currently evaluated for additional rate control medication to manage his atrial fibrillation symptoms better.

Given his current medication regimen, the healthcare team is cautious about potential drug interactions, particularly those that could increase his risk of bleeding.

Which of the following rate control medications, if prescribed alongside Rivaroxaban, is most likely to increase his risk of bleeding?

A 55-year-old woman presents to the emergency department with sudden onset of shortness of breath and right-sided chest pain. She has a history of mitral valve prolapse and was recently diagnosed with hypertension. On examination, she has bilateral crackles with a notable decrease in breath sounds at the right lung base. Her oxygen saturation is 89% on room air.

A chest X-ray reveals unilateral right pulmonary edema, while initial bedside ultrasound does not show clear signs of mitral regurgitation (MR). Subsequent echocardiography by a senior radiologist confirms posterior mitral valve leaflet prolapse with chordae tendineae rupture.

What is the most likely pathophysiological mechanism leading to unilateral right pulmonary edema (UPE) in this patient?

Among patients with acute coronary syndromes (ACS) undergoing coronary angiography, radial access appears to be more superior compared to femoral access in terms of the following outcome except?

A 70-year-old man presents with severe, crushing chest pain radiating to his left arm. He has a background history of hypertension, hyperlipidemia, type 2 diabetes, and is a smoker.

An ECG is obtained on presentation, and this shows 3-4mm ST elevation over leads V1-V6, I, and aVL, with reciprocal ST depression over leads II, III, and aVF.

Where is the likely site of the lesion responsible for the changes seen on his ECG?

Which part of the jugular venous waveform is associated with the fall in atrial pressure during ventricular systole?

Which of the following is not a contraindication to percutaneous mitral balloon valvotomy for moderate to severe mitral stenosis?

Acute myocardial infarction can be classified on the basis of presence or absence of ST segment elevation on the ECG and is further classified into 5 types.

When an AMI is due to infarction related to a percutaneous coronary intervention, which Type of MI is this?

What type of murmur is heard in aortic sclerosis?

A 50 year old man from a rural hospital presents to the Emergency Department with chest pain. He is subsequently diagnosed with an anterior STEMI. Following stabilization with thrombolysis and antiplatelet medications, he is transferred to a tertiary hospital for an angiogram.

His angiogram showed an 80% stenosis in the left main coronary artery with SYNTAX score of 5 (ie: low anatomic complexity). He is offered a coronary artery bypass graft but refused to have this done.

Which of the following intervention is likely to provide a similar outcome in terms of mortality and risk of future myocardial infarction in 3 years time?

The GRACE Score is a prospectively studied scoring system that risk stratifies patients with acute coronary syndrome to estimate their inhospital, 6-month to 3-year mortality. It involves all of the following variables EXCEPT?

A 50-year-old man presents with acute central chest pain. On examination, his pulse is 90 and regular, blood pressure is 120/80, and JVP is +1cm. The chest is clear, and there is no pedal edema. His serum creatinine level is 90.

The serum troponin level is 300. The chest X-ray (CXR) is normal. The ECG shows 1mm ST depression over leads V2-V6. You decide to treat him as a NSTEMI and subsequently refer him to cardiology for a coronary angiogram. The angiogram is performed within 24 hours of his presentation.

Which of the following is the likely benefit from early invasive intervention in this man?

A 67-year-old man is referred to the cath lab following an acute coronary syndrome (STEMI). The angiogram reveals that the culprit lesion is in the left circumflex artery, so a drug-eluting stent is placed successfully. However, this man is also noted to have multi-vessel disease on his angiography.

Which of the following interventions would lead to the best long-term outcome?

A 50-year-old man presents to a rural hospital with acute central chest pain. On examination, his pulse is 90 and regular, blood pressure is 120/80, and JVP is +1cm. The chest is clear, and there is no pedal edema. His serum creatinine level is 90. The serum troponin level is 20. The chest X-ray (CXR) is normal. The ECG shows 3mm ST elevation over leads V2-V6.

You diagnose him as having an anterior STEMI, and he is immediately thrombolysed. He is then subsequently referred to cardiology for a coronary angiogram. The angiogram is performed within 6 hours of his presentation.

Which of the following is the likely benefit from early invasive intervention in this man?

Which of the following statement regarding Dabigatran is incorrect?

A 54 year old man with a background of atrial fibrillation presents with a Non-STEMI. He then undergoes a PCI and receives a second generation drug eluting stent. His bleeding risk is low when compared to the risk of stent thrombosis.

Which of the following is the most appropriate therapy following his PCI?

A 75 year old man with a background of non-valvular atrial fibrillation (CHADS2 score of 3) on warfarin with normal renal function had just undergone a PCI with single stent placement in his left circumflex artery.

Which of the following drug combination post-PCI would be the safest in terms of future bleeding risk?

In addition to statin, which of the following medication has been proven to cause a significant reduction of LDL cholesterol by approximately 60 percent?

What is the mechanism by which inclisiran reduces serum LDL levels?

A 50 year old man has been admitted with an acute coronary syndrome. He has been started on aspirin, clopidogrel, metoprolol, simvastatin and cilazapril. His measured LDL is 3.2 mmol/L. In view of this result, which of the following medication could be added to help reduce his cardiovascular mortality?

A 62-year-old man with type 2 diabetes and hypertension is on long-term aspirin, quinapril, metoprolol, and insulin. He presents with two hours of central chest pain, and a diagnosis of non-ST elevation myocardial infarction is made. He proceeds to have coronary angiography, which demonstrates diffuse three-vessel coronary artery disease. He is discharged home with the introduction of a long-acting nitrate to await elective coronary artery surgery.

Two weeks later, he represents with malaise and abdominal pain, and his serum creatinine has increased to 450 mg/dL from 140 mg/dL on his previous admission.

What is the most likely cause of the deterioration in his renal function?

Apixaban is a novel oral direct factor Xa inhibitor and is recommended for use in patients with non-valvular atrial fibrillation.

What superior advantage does this medication have over warfarin?

Which of the following is not consistent with the diagnosis of complete heart block?

Angiopoietin-like 3 (ANGPTL3) plays an important role in which bodily mechanism?

What is the recommended daily salt intake that has been proven to be beneficial in reducing cardiovascular events in normotensive adults?

Which of the following physical findings is not consistent with severe mitral stenosis?

A 30 year old patient with a history of rheumatic fever as a child develops increasing dyspnea on exertion. ECHO shows mitral stenosis with valve area of 1.0cm2, mean gradient of 15mmHg and PASP of 60mmHg.

What is the best intervention?

Ticagrelor has been proven in a recent study to be more effective than clopidogrel in reducing the rate of cardiovascular death, MI or stroke when used in patients with acute coronary syndrome.

In this randomized controlled trial, which of the following was not part of the observed adverse events of this drug?

The continuous wave doppler flow signal shown below is most consistent with which of the following?

A 35 year old man with a history of rheumatic heart disease presents with increasing dyspnea. An urgent bedside ECHO performed shows severe mitral stenosis with a left ventricular ejection fraction of 30 percent. He also has a left atrial thrombus that persists despite anticoagulation.

What should be the next step in management?

A patient with an ascending aortic dissection may present with an acute myocardial ischaemia due to coronary artery occlusion.

Which artery is most commonly involved in this situation?

The TIMI Grade Flow is a scoring system which grades the level of coronary blood flow assessed during a percutaneous coronary angioplasty. What does a TIMI 2 flow signify?

A 65 year old lady with a background of obesity, chronic atrial fibrillation, hypertension and previous TIA has been referred to the cardiothoracic surgeon for a triple bypass graft following the diagnosis of triple vessel disease on her recent angiogram. Her echocardiogram shows mild MR with normal left ventricular ejection fraction. She is currently on oral dabigatran for her chronic AF.

Which of the following intervention is likely to be helpful in reducing her risk of a future stroke?