Mock Cardiology Module 2

A 55-year-old Māori male, Mr. T, is admitted to the hospital with a diagnosis of acute coronary syndrome. He is prescribed clopidogrel as part of his treatment plan. However, his cardiologist notes that Mr. T’s platelet aggregation studies show a reduced response to clopidogrel.

Which of the following genetic variations is most likely responsible for this reduced response in Mr. T?

CYP2C19*2 polymorphism

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ABCB1 gene variant

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PON1 Q192R polymorphism

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COX-1 gene mutation

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SLCO1B1 gene variant

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A 50 year old woman presents with acute onset left sided chest pain radiating to her neck and down her left arm. Her ECG shows 2mm ST elevation in V2-V4.

An urgent angiography subsequently shows a spontaneous coronary artery dissection involving her left anterior descending artery.

Which of the following intervention is least likely to be helpful?

Statins

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Beta-blocker

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Calcium channel blocker

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Aspirin

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Angiotensin receptor blocker

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Which of the following risk factor has the highest odds ratio for myocardial infarction?

Stress

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Dyslipidemia

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Diabetes

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Hypertension

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Regular alcohol consumption

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A 52-year-old man presents to the emergency department with acute chest pain.

Coronary angiography reveals an acute thrombotic occlusion of the proximal left anterior descending artery.

He undergoes successful percutaneous coronary intervention.

His post-procedural lipid profile on high-intensity atorvastatin 80 mg daily shows:

Total cholesterol 4.8 mmol/L (reference: <5.5 mmol/L)
LDL-C 2.1 mmol/L (reference: <2.0 mmol/L)
HDL-C 1.1 mmol/L (reference: >1.0 mmol/L)
Triglycerides 1.3 mmol/L (reference: <1.7 mmol/L)

Which of the following is the most appropriate LDL-C target for this patient?

50% reduction from baseline and LDL-C less than 1.4 mmol/L

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LDL-C less than 2.6 mmol/L

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LDL-C less than 1.8 mmol/L

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50% reduction from baseline and LDL-C less than 1.0 mmol/L

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LDL-C less than 3.0 mmol/L

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A 48-year-old woman is referred for assessment of hypercholesterolaemia. She has no personal history of cardiovascular disease. Her father had a myocardial infarction at age 50.

On examination, she has bilateral Achilles tendon xanthomata.

Her fasting lipid profile shows:

total cholesterol 9.2 mmol/L (reference: <5.5 mmol/L)
LDL-C 7.0 mmol/L (reference: <3.5 mmol/L)
HDL-C 1.3 mmol/L (reference: >1.0 mmol/L)
triglycerides 1.8 mmol/L (reference: <1.7 mmol/L)

Using the Dutch Lipid Clinic Network Score, what is this patient’s classification?

Definite familial hypercholesterolaemia

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Unlikely familial hypercholesterolaemia

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Possible familial hypercholesterolaemia

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Probable familial hypercholesterolaemia

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Homozygous familial hypercholesterolaemia

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A 55-year-old man with a history of coronary artery bypass grafting is commenced on atorvastatin 40 mg daily.

After six weeks he reports bilateral thigh myalgia that interferes with daily activities.

His creatine kinase is 280 U/L (reference: 30–200 U/L), ALT 32 U/L (reference: <45 U/L), and TSH is normal. His LDL-C is 2.8 mmol/L (reference: <2.0 mmol/L).

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

Switch to low-dose rosuvastatin with alternate day dosing and add ezetimibe

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Increase atorvastatin to 80 mg daily

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Switch to rosuvastatin 40 mg daily

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Cease the statin and commence ezetimibe 10 mg daily as monotherapy

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Commence coenzyme Q10 supplementation and continue atorvastatin

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A 62-year-old woman with established atherosclerotic cardiovascular disease is on rosuvastatin 20 mg daily and ezetimibe 10 mg daily.

Her LDL-C is 2.0 mmol/L (reference: <2.0 mmol/L).

She reports severe bilateral lower limb muscle symptoms on any statin dose increase. Bempedoic acid is being considered as add-on therapy.

Which of the following best describes the mechanism of action of bempedoic acid?

Inhibition of ATP-citrate lyase in the liver, upstream of HMG-CoA reductase

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Inhibition of HMG-CoA reductase in both hepatocytes and skeletal muscle

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Inhibition of Niemann-Pick C1-like 1 protein in the small intestine

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Inhibition of PCSK9 binding to the LDL receptor extracellularly

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Silencing of PCSK9 mRNA synthesis via small interfering RNA

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A 58-year-old man with heterozygous familial hypercholesterolaemia and previous myocardial infarction is on maximally tolerated rosuvastatin 40 mg daily and ezetimibe 10 mg daily.

His LDL-C is 2.4 mmol/L (reference: <2.0 mmol/L). A PCSK9 inhibitor is commenced.

After 12 weeks, his LDL-C is 1.1 mmol/L.

Which of the following best describes the mechanism by which PCSK9 inhibitors lower LDL-C?

Prevention of PCSK9-mediated lysosomal degradation of LDL receptors, increasing receptor recycling and LDL-C clearance

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Increased hepatic cholesterol synthesis leading to feedback upregulation of LDL receptors

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Direct inhibition of intestinal cholesterol absorption via Niemann-Pick C1-like 1 protein

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Inhibition of VLDL secretion from the liver

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Enhanced biliary excretion of cholesterol

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A 45-year-old woman with type 2 diabetes mellitus, BMI 33 kg/m², and hypertriglyceridaemia presents for cardiovascular risk assessment.

Her fasting lipid profile shows:

total cholesterol 5.8 mmol/L (reference: <5.5 mmol/L)
LDL-C 2.9 mmol/L (reference: <3.5 mmol/L)
HDL-C 0.8 mmol/L (reference: >1.0 mmol/L)
triglycerides 4.8 mmol/L (reference: <1.7 mmol/L)

She is on atorvastatin 40 mg daily. Her HbA1c is 8.2% (reference: <7.0%).

Which of the following is the most appropriate next step in managing her dyslipidaemia after achieving her LDL-C goal?

Add fenofibrate 145 mg daily

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Add ezetimibe 10 mg daily

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Switch statin to rosuvastatin 40 mg daily

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Add omega-3 fatty acid ethyl esters 4 g daily

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Add nicotinic acid 1 g daily

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A 50-year-old man with recurrent cardiovascular events despite optimal statin and ezetimibe therapy has the following lipid profile:

Lp(a) level of 180 nmol/L (reference: <75 nmol/L)
His LDL-C is 1.6 mmol/L (reference: <2.0 mmol/L)
HDL-C 1.2 mmol/L (reference: >1.0 mmol/L)
triglycerides 1.4 mmol/L (reference: <1.7 mmol/L)

Which of the following therapies has the greatest potential to reduce Lp(a) levels?

Apo(a) antisense oligonucleotide (RNA-targeted therapy)

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High-intensity statin therapy

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PCSK9 monoclonal antibody inhibitors

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Ezetimibe

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Fenofibrate

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A 64-year-old man with a history of peripheral arterial disease and ischaemic stroke is commenced on inclisiran after failing to achieve LDL-C targets on maximally tolerated statin and ezetimibe therapy.

His baseline LDL-C is 2.5 mmol/L (reference: <2.0 mmol/L).

Which of the following best describes the dosing schedule of inclisiran?

Subcutaneous injection at baseline, three months, then every six months

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Oral tablet taken daily

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Subcutaneous injection every two weeks

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Intravenous infusion every four weeks

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Oral tablets taken twice daily

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A 57-year-old man presents to the cardiology outpatient clinic eight weeks after an acute coronary syndrome. He was commenced on atorvastatin 40 mg daily at discharge.

His current LDL-C is 2.3 mmol/L (reference: <2.0 mmol/L).

He tolerates his medications well.

Which of the following strategies is most likely to help him achieve an LDL-C target of less than 1.8 mmol/L?

Add ezetimibe 10 mg daily to atorvastatin 40 mg daily

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Increase atorvastatin to 80 mg daily

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Switch to rosuvastatin 10 mg daily

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Add a bile acid sequestrant

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Add plant sterols to his diet

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A 58-year-old man presents to the emergency department with 3 hours of central chest heaviness radiating to the left arm. He has a history of type 2 diabetes mellitus and hypertension.

His initial ECG shows T-wave inversion in leads V3-V6.

His initial high-sensitivity cardiac troponin I (hs-cTnI) is 85 ng/L (upper reference limit 26 ng/L). A repeat hs-cTnI at 2 hours is 320 ng/L.

Which of the following best describes the significance of these troponin results?

The absolute level exceeds 5-fold the upper reference limit on repeat testing, giving a positive predictive value greater than 90% for acute type 1 myocardial infarction

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The troponin rise is likely a false positive related to his diabetes mellitus and requires further investigation before treatment

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The rising pattern is consistent with chronic myocardial injury and should prompt investigation for heart failure

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A third troponin sample at 6 hours is mandatory before the diagnosis of NSTEMI can be confirmed

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The initial value is less than 3-fold the upper reference limit so this represents a low-risk presentation suitable for outpatient follow-up

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A 72-year-old woman is admitted to the intensive care unit with community-acquired pneumonia and sepsis. She has a history of stable coronary artery disease managed with aspirin and a statin.

On day 2, she develops new chest discomfort. Her heart rate is 130 bpm, blood pressure 85/50 mmHg, and SpO2 88% on 6 L/min nasal prong oxygen.

ECG shows sinus tachycardia with no new ST-segment changes.

Her hs-cTnT is 150 ng/L (upper reference limit 14 ng/L), rising from 25 ng/L on admission.

What is the most likely classification of her myocardial injury?

Type 2 myocardial infarction due to oxygen supply-demand mismatch

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Type 1 myocardial infarction due to plaque rupture

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Type 3 myocardial infarction

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Chronic myocardial injury from underlying stable coronary artery disease

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Stress cardiomyopathy (Takotsubo syndrome)

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A 65-year-old man presents with 4 hours of crescendo chest pain at rest. His past history includes prior percutaneous coronary intervention 3 years ago, type 2 diabetes mellitus, and chronic kidney disease (eGFR 42 mL/min/1.73m2).

On examination, his blood pressure is 145/85 mmHg, heart rate is 95 bpm, and there are bibasal crepitations on auscultation.

ECG shows 2 mm ST-segment depression in leads V4-V6 and I and aVL.

His initial hs-cTnI is 1,200 ng/L (upper reference limit 26 ng/L). His GRACE risk score is calculated at 168.

What is the most appropriate timing for invasive coronary angiography?

Early invasive strategy (within 24 hours)

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Immediate invasive strategy (within 2 hours)

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Selective invasive strategy based on results of non-invasive stress testing

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Delayed invasive strategy (within 72 hours)

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Conservative management with medical therapy alone given his renal impairment

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A 62-year-old man presents to the emergency department with 90 minutes of central crushing chest pain. His ECG shows 3 mm ST-segment elevation in leads II, III, and aVF.

He has a background of chronic obstructive pulmonary disease (COPD).

His observations are: blood pressure 130/80 mmHg, heart rate 72 bpm, respiratory rate 18 breaths/min, SpO2 95% on room air, and temperature 36.8°C.

Which of the following is the most appropriate oxygen management strategy?

Withhold supplemental oxygen as SpO2 is above 93%

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Administer high-flow oxygen at 15 L/min via non-rebreather mask immediately

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Administer supplemental oxygen to maintain SpO2 above 98%

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Administer supplemental oxygen to maintain SpO2 88-92% given his COPD

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Administer oxygen at 2 L/min via nasal prongs to all patients with STEMI regardless of saturation

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A 55-year-old man is diagnosed with NSTEMI after presenting with 2 hours of chest pain at rest.

His ECG shows T-wave inversion in leads V1-V4 and his hs-cTnT is 450 ng/L (upper reference limit 14 ng/L).

He has no history of stroke or transient ischaemic attack. His renal function is normal. He is planned for early invasive coronary angiography within 24 hours.

He has no contraindications to antiplatelet therapy and is not on any anticoagulant.

In addition to aspirin and unfractionated heparin, which of the following is the most appropriate P2Y12 inhibitor?

Ticagrelor 180 mg loading dose

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Clopidogrel 300 mg loading dose

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Prasugrel 60 mg loading dose prior to angiography

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Cangrelor intravenous infusion

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Ticagrelor 90 mg twice daily without a loading dose

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A 48-year-old man develops sudden onset severe crushing chest pain while working on a rural property. Paramedics arrive 30 minutes later.

A 12-lead ECG shows 4 mm ST-segment elevation in leads V1-V4 with reciprocal changes in leads II, III, and aVF.

His blood pressure is 120/75 mmHg, heart rate is 90 bpm, and SpO2 is 97% on room air.

The nearest percutaneous coronary intervention (PCI)-capable hospital is 3 hours away by road.

What is the most appropriate reperfusion strategy?

Administer fibrinolysis immediately and arrange urgent transfer for rescue PCI if reperfusion fails

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Arrange emergency helicopter transfer for primary PCI without administering fibrinolysis

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Administer aspirin and heparin only and transfer for PCI the following morning

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Administer fibrinolysis only if the patient develops cardiogenic shock during transfer

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Commence intravenous glycoprotein IIb/IIIa inhibitor and transfer for primary PCI

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A 70-year-old woman presents to a rural emergency department with 2 hours of chest pain and an ECG showing ST-segment elevation in leads II, III, and aVF. The nearest PCI-capable hospital is 4 hours away.

The emergency physician prepares to administer fibrinolysis. On reviewing her history, she reports a fall 5 days ago resulting in a head injury requiring 4 sutures but no loss of consciousness.

Her CT brain at the time was normal. She also reports that she takes warfarin for atrial fibrillation, and her INR today is 3.2 (therapeutic range 2.0-3.0). She had an ischaemic stroke 8 months ago. Her blood pressure is 155/90 mmHg.

Which of the following is the strongest contraindication to fibrinolytic therapy in this patient?

Ischaemic stroke 8 months ago

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Blood pressure of 155/90 mmHg

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Head injury 5 days ago with normal CT brain

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INR of 3.2 on warfarin therapy

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Age of 70 years

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A 42-year-old woman presents with acute onset chest pain and is diagnosed with NSTEMI based on ischaemic ECG changes and elevated troponin.

She has no traditional cardiovascular risk factors. She proceeds to coronary angiography which demonstrates no obstructive coronary artery disease.

Echocardiography shows a regional wall motion abnormality in the mid-anterior wall with a left ventricular ejection fraction of 48%.

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

Cardiac MRI to further characterise the underlying aetiology

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Discharge with reassurance as normal coronary arteries exclude a significant cardiac event

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Repeat coronary angiography with intravascular ultrasound within 48 hours

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Initiate triple antithrombotic therapy with aspirin, ticagrelor, and rivaroxaban

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Commence high-dose colchicine for presumed pericarditis

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A 60-year-old man is recovering from an anterior NSTEMI treated with PCI and drug-eluting stent to the left anterior descending artery.

His echocardiogram on day 2 shows a left ventricular ejection fraction of 35% with anterior wall hypokinesis.

He has a history of type 2 diabetes mellitus (HbA1c 7.8%) and stage 3 chronic kidney disease (eGFR 38 mL/min/1.73m2). His blood pressure is 125/78 mmHg and heart rate is 68 bpm in sinus rhythm.

He has no symptoms of heart failure.

Which combination of secondary prevention medications is most appropriate at discharge?

Aspirin, ticagrelor, statin, ACE inhibitor, beta-blocker, proton pump inhibitor

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Aspirin, clopidogrel, statin, ACE inhibitor, beta-blocker, proton pump inhibitor

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Aspirin, ticagrelor, statin, calcium channel blocker, proton pump inhibitor

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Aspirin, ticagrelor, statin, angiotensin receptor blocker, ivabradine

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Aspirin, prasugrel, statin, ACE inhibitor, eplerenone

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A 38-year-old woman presents to the emergency department with 1 hour of sharp left-sided chest pain that worsens with inspiration. She has no past medical history and takes no regular medications. She is a non-smoker with no family history of premature coronary disease.

On examination, her vital signs are normal and cardiac examination is unremarkable.

Her ECG shows normal sinus rhythm with no ST-segment or T-wave changes.

Her initial hs-cTnI is 4 ng/L (upper reference limit 26 ng/L) and a repeat at 2 hours is 3 ng/L.

What is the most appropriate next step in management?

Discharge with outpatient follow-up, as she meets criteria for safe discharge under an accelerated diagnostic pathway

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Admit for continuous cardiac monitoring and repeat troponin at 6 hours

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Proceed to urgent coronary angiography within 24 hours

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Commence aspirin, ticagrelor, and heparin while awaiting further investigation

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Obtain CT coronary angiography before discharge as it is mandatory in all patients under 40 with chest pain

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A 58-year-old man with a history of percutaneous coronary intervention (PCI) with drug-eluting stent placement 18 months ago for stable angina presents for routine review.

He has type 2 diabetes mellitus (HbA1c 7.8%, reference range <6.5%), hypertension, and a body mass index (BMI) of 31 kg/m2.

His current medications include aspirin 100 mg daily, atorvastatin 40 mg daily, metformin 1 g twice daily, and perindopril 5 mg daily.

His fasting lipid profile shows LDL-cholesterol 2.1 mmol/L (reference range <2.0 mmol/L), HDL-cholesterol 1.0 mmol/L (reference range >1.0 mmol/L), and triglycerides 1.8 mmol/L (reference range <1.7 mmol/L).

His echocardiogram shows a left ventricular ejection fraction of 35%.

Which of the following is the most appropriate addition to his current management?

Empagliflozin 10 mg daily

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Ezetimibe 10 mg daily

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Evolocumab 140 mg fortnightly

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Fenofibrate 145 mg daily

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Icosapent ethyl 2 g twice daily

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A 67-year-old woman underwent PCI with a drug-eluting stent to the proximal left anterior descending artery 14 months ago for an acute coronary syndrome.

She has well-controlled hypertension and dyslipidaemia. She has no history of bleeding complications.

She is currently taking aspirin 100 mg daily, clopidogrel 75 mg daily, rosuvastatin 20 mg daily, and amlodipine 5 mg daily.

She presents for routine review and asks about her ongoing antiplatelet therapy.

Based on current guidelines, which of the following is the most appropriate antiplatelet strategy?

Continue dual antiplatelet therapy with aspirin and clopidogrel for a total of 36 months

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Cease clopidogrel and continue aspirin alone indefinitely

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Switch to ticagrelor 60 mg twice daily in addition to aspirin

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Cease aspirin and continue clopidogrel alone indefinitely

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Cease both antiplatelet agents and commence rivaroxaban 2.5 mg twice daily

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A 55-year-old man with Canadian Cardiovascular Society (CCS) class II angina is found to have moderate ischaemia on myocardial perfusion imaging.

A coronary CT angiogram excludes significant left main disease.

His echocardiogram shows an ejection fraction of 55%.

He is commenced on optimal medical therapy including aspirin, metoprolol, ramipril, and atorvastatin.

Which of the following statements best describes the expected outcomes of an initial invasive strategy compared with an initial conservative strategy in this patient?

An initial invasive strategy provides superior angina relief at 3 months but no significant reduction in the primary composite outcome at median follow-up

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An initial invasive strategy reduces the composite of cardiovascular death, myocardial infarction, hospitalisation for unstable angina, heart failure, or resuscitated cardiac arrest at 4 years

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An initial invasive strategy reduces all-cause mortality compared to a conservative strategy

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An initial conservative strategy is superior to an invasive strategy for all endpoints including angina relief

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The results of the ISCHEMIA trial apply equally to patients with left main coronary artery disease

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A 70-year-old man with a history of anterior myocardial infarction presents with CCS class II angina.

His echocardiogram shows a left ventricular ejection fraction of 30% with anteroapical akinesis.

His resting heart rate is 72 beats per minute and blood pressure is 118/70 mmHg.

He is currently taking aspirin, atorvastatin, ramipril, and sacubitril/valsartan.

His angina is not adequately controlled.

Which of the following is the most appropriate first-step anti-ischaemic agent for this patient?

Bisoprolol

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Diltiazem

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Amlodipine

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Ivabradine

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Ranolazine

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A 63-year-old woman with type 2 diabetes mellitus, hypertension, and chronic kidney disease (eGFR 45 mL/min/1.73m2) presents with CCS class III angina despite optimal medical therapy.

Coronary angiography reveals severe three-vessel coronary disease with a SYNTAX score of 34. Her left ventricular ejection fraction is 45%.

Based on current evidence and guidelines, which of the following revascularisation strategies is most appropriate?

Coronary artery bypass grafting

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PCI to the most severe lesion only

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PCI with drug-eluting stents to all three vessels

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Continued medical therapy with referral for cardiac rehabilitation

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Hybrid revascularisation with LIMA to LAD and PCI to other vessels

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A 52-year-old woman presents with chest discomfort described as a burning sensation in the epigastric region radiating to the left arm. She reports that the discomfort occurs when walking up two flights of stairs and resolves after approximately 3 minutes of rest. She has no symptoms at rest.

Her risk factors include hypertension and a family history of premature coronary artery disease.

Which of the following best describes her presentation?

Atypical angina, CCS class II

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Typical angina, CCS class I

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Typical angina, CCS class II

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Non-anginal chest pain, CCS class III

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Atypical angina, CCS class III

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A 59-year-old man with stable angina (CCS class II) and a single severe stenosis in the mid-left anterior descending artery is being considered for PCI. He is on optimal medical therapy.

He asks about the evidence for PCI improving his angina symptoms beyond a placebo effect.

Which of the following best describes the findings of the ORBITA-2 trial?

PCI resulted in lower angina symptom scores compared to a placebo procedure at 12 weeks

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PCI was not superior to a placebo procedure for angina symptom improvement

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PCI reduced cardiovascular mortality compared to placebo at 12 months

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PCI was associated with increased adverse events compared to a placebo procedure

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PCI was only superior to placebo in patients with multivessel disease

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A 60-year-old man with three-vessel coronary artery disease is being considered for coronary artery bypass grafting.

He has a severe proximal left anterior descending artery stenosis, moderate circumflex disease, and moderate right coronary artery disease.

The cardiothoracic surgeon discusses graft options with him.

Which of the following statements regarding conduit selection in CABG is most accurate based on long-term outcome data?

Use of internal mammary artery grafting is associated with improved 20-year survival

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Saphenous vein grafts have 90% patency at 10 years

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Internal mammary artery grafts have 40-50% patency at 10 years

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There is no significant difference in survival between IMA and saphenous vein grafts at 20 years

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Saphenous vein grafts are preferred for the left anterior descending artery due to superior size matching

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Mock Cardiology Module 2

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