Cardiology Module 3

A 55-year-old male patient with a history of type 2 diabetes mellitus and hypertension presents for a routine check-up. His LDL cholesterol (LDL-C) level is high at 9.1 mmol/L (<2.0 mmol/L). He has no history of cardiovascular disease, but his 10-year ASCVD risk score is calculated at 12%.

What is the most appropriate lipid-lowering strategy for this patient?

Initiate high-intensity statin therapy to reduce LDL-C by ≥50%

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Initiate low-intensity statin therapy to reduce LDL-C by 20-30%

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Initiate moderate-intensity statin therapy to reduce LDL-C by 30-49%

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Initiate ezetimibe as first line without initiating statin therapy

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Recommend lifestyle modifications only without statin therapy

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In a patient with acute cardiogenic pulmonary oedema, what is the primary reason for using Continuous Positive Airway Pressure (CPAP)?

To increase intrathoracic pressure, reducing preload and afterload, while recruiting collapsed alveoli to improve oxygenation

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To increase oxygen delivery to the tissues by directly increasing the partial pressure of oxygen in arterial blood.

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To decrease venous return to the heart, thereby reducing preload and cardiac workload.

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To redistribute lung water from the alveolar space to the interstitial space, improving gas exchange.

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To increase the rate of diuresis by directly stimulating renal blood flow.

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A 30-year-old Filipino man presents to the emergency department following an episode of syncope. He is usually fit and well and takes no regular medication. He has a family history of sudden cardiac death. His ECG is consistent with Brugada syndrome Type 1.

What is the most appropriate management?

Implantable cardiac defibrillator

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Amiodarone

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Sotalol

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A permanent pacemaker

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Warfarin

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A 70-year-old man presents with symptomatic congestive heart failure (NYHA Class III) without chest pain. He is fluid-overloaded. ECG shows sinus rhythm; chest X-ray shows cardiomegaly with small bilateral effusions and fluid in the fissures. Echocardiography shows moderate-to-severe LV dysfunction with an ejection fraction of 35%. He is started on intravenous furosemide.

Which medication is least helpful for his heart condition?

Isosorbide mononitrate

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Spironolactone

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Valsartan/sacubitril

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Empagliflozin

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Angiotensin II receptor blocker

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What type of murmur usually accompanies obstructive HCM?

Mitral regurgitation

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Mitral stenosis

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Aortic stenosis

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Aortic regugitation

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Tricuspid regurgitation

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Which medication is least useful in the treatment of Hypertrophic Cardiomyopathy?

Digoxin

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Verapamil

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Disopyramide

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Beta blockers

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Mavacamten

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A 20-year-old man with hypertrophic cardiomyopathy develops atrial fibrillation within the last 24 hours. His heart rate is 150 bpm and blood pressure is 90/50 mmHg.

What is the most appropriate management?

Urgent DC cardioversion

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Digoxin

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Pacemaker insertion

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Beta blockers

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AV node ablation

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A 30 year old man presents with dyspnoea, syncope and mild fever. On examination, there is a loud first heart sound, a loud third heart sound and a mid-diastolic murmur. Blood test shows a raised ESR.

What is the most likely diagnosis?

Atrial myxoma

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Aortic regurgitation

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Aortic stenosis

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Mitral regurgitation

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Ruptured myocardial papilla

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The continuous-wave Doppler flow signal shown is most consistent with which of the following?

Mitral stenosis

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Mitral regurgitation

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Aortic stenosis

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Aortic regurgitation

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Pulmonary hypertension

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In a haemodynamically unstable patient with suspected acute aortic dissection, which imaging modality is most useful for rapid bedside assessment of cardiac complications such as aortic regurgitation and pericardial tamponade?

Transthoracic ECHO (TTE)

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Transoesophageal ECHO (TOE)

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MRI

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Spiral CT

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Chest X ray

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What is the imaging modality of choice for surveillance of a patient with chronic, haemodynamically stable aortic dissection presenting with chronic chest pain?

MR Angiography

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Spiral CT

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Transesophageal ECHO

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Transthoracic ECHO

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CXR

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Which clinical feature is NOT consistent with an acute Stanford Type A aortic dissection?

Murmur best heard over the left sternal border

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Non specific ST-T wave changes on the ECG

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Severe pain

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Aortic regurgitation

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Blood pressure difference in both arms.

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Which medication should be avoided in acute aortic dissection?

Hydralazine

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Diltiazem

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Verapamil

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Sodium nitroprusside

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Labetolol

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A patient with acute aortic dissection is markedly hypertensive (systolic BP 190 mmHg). IV labetalol is commenced but systolic BP remains above 160 mmHg. GCS is 15 and renal function is normal.

What is the next step?

Start IV sodium nitroprusside

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Start IV Digoxin

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Start IV Diltiazem

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Start IV Hydralazine

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Start cilazapril

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All of the following are indications for intervention in Type B aortic dissection EXCEPT:

Persistence of a patent false lumen alone

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Presence of dissection within an aortic aneurysm

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Evidence of aortic rupture

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Recurrent pain

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Occlusion of a major aortic branch

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Which of the following is the most important contraindication for percutaneous mitral balloon valvotomy in the treatment of moderate to severe mitral stenosis?

Presence of left atrial thrombus

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Presence of moderate mitral regurgitation

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Mitral valve morphology not favourable for valvotomy.

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Calcified mitral valve

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Presence of severe mitral regurgitation

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A 60-year-old man with aortic stenosis attends for routine review. Echocardiography shows an aortic valve area of 0.9 cm² with an ejection fraction of 60%. He remains asymptomatic and physically active.

What is the next appropriate step?

Exercise stress test

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Re-evaluate in 6 months.

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Proceed with surgery

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Commence carvedilol

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Commence warfarin

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A 20-year-old footballer is referred for a pre-participation medical assessment. Which finding is most suggestive of underlying cardiac disease?

T wave inversion in V1-V5

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Wenkebach phenomenon

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Junctional rhythm at rest of 50 beats per minute

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Voltage criteria for left ventricular hypertrophy

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Dominant R wave in lead V1

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A 55-year-old diabetic man has acute, severe mid-sternal chest discomfort waking him from sleep. He is diaphoretic. Heart rate 58/min; BP 88/62 mmHg (right arm) and 92/60 mmHg (left arm); respiratory rate 20/min. There is marked elevation of the jugular venous pressure. Auscultation reveals no murmur but an S4 gallop; the lungs are clear. There is no peripheral oedema.

ECG shows 4 mm ST elevation in II, III, and aVF with 2 mm ST depression in I and aVL.

What is the most likely diagnosis?

Right ventricular infarction.

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Acute pericarditis.

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Aortic dissection.

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Acute pulmonary embolism.

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Acute pericardial tamponade

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A 25-year-old Indigenous woman with a history of rheumatic fever presents with increasing dyspnoea, paroxysmal nocturnal dyspnoea, and pedal oedema. BP is 95/60 mmHg. JVP is elevated. S1 is loud, S2 normal. There is an early diastolic sound after S2 with a mid-diastolic rumble at the apex, accentuated on expiration. There is hepatomegaly and pitting oedema to mid-shin.

What is the most likely diagnosis?

Mitral stenosis and aortic regurgitation

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Mitral stenosis and pulmonary stenosis

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Mitral stenosis (with secondary pulmonary hypertension and right heart failure)

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Mitral stenosis and tricuspid regurgitation

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Mitral stenosis and tricuspid stenosis

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A 65-year-old man presents with a 3-day history of severe epigastric “indigestion” with nausea and vomiting. He has paroxysmal atrial fibrillation treated with digoxin. He is 170 cm, 97 kg, BP 110/70 mmHg, pulse 85/min and regular, with slight epigastric tenderness. His ECG is shown.

What is the most likely diagnosis?

Posterior myocardial infarction

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Non-Q wave anterior myocardial infarction

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Digoxin toxicity.

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Oesophageal spasm

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Hypertrophic cardiomyopathy

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An 89-year-old man attends for follow-up of persistent AF. He was successfully cardioverted a month ago but reverted to AF two weeks ago. He takes warfarin, digoxin, and diltiazem; metoprolol was stopped because of side effects. He is asymptomatic but rate control is inadequate, and he does not wish to add medications.

BP 140/80 mmHg; pulse 147/min, irregularly irregular, with a grade 2/6 pansystolic murmur. Lungs clear; no oedema. TSH normal.

A 24-hour Holter shows a mean heart rate 137/min (minimum 70/min, maximum 170/min).

What is the most appropriate management?

Atrioventricular node ablation with permanent pacemaker placement

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Amiodarone

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Maze surgical procedure

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Radiofrequency ablation

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Observation

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A 65-year-old man with stable angina (diagnosed 2 years ago) presents after 30 minutes of severe chest pain following heavy exertion. He took three glyceryl trinitrate (GTN) tablets at home without relief. In the ED, oxygen gave some relief. Over the preceding six months his angina had been stable on atenolol 50 mg daily, aspirin, and isosorbide mononitrate 60 mg daily, with only two infrequent angina episodes and no recent GTN use.

What is the most appropriate immediate concern?

reduced drug potency

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poor absorption due to dry mouth.

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Onset of an acute coronary syndrome (unstable angina/NSTEMI)

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nitrate tolerance

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paroxysmal atrial fibrillation

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Several randomised trials have compared anticoagulation with placebo in non-rheumatic atrial fibrillation. Based on this and subsequent observational data, the annual stroke risk in an untreated patient with AF and a CHA₂DS₂-VASc score of 0 is closest to:

Less than 1%

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5%

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8%

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12%

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15%

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A 72-year-old woman presents after a simple fall. She has AF and takes warfarin. She has a few minor leg bruises but is otherwise well. Pulse 68/min irregular; BP 175/90 mmHg. Full blood count is normal; serum creatinine is elevated at 170 µmol/L (50–100) and INR is 7.1.

What is the best management of her elevated INR?

Withhold warfarin and continue to monitor INR

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Withhold warfarin ± administer low-dose oral Vitamin K1, and monitor INR

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Withhold warfarin and administer Vitamin K1 and prothrombin complex concentrate.

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Withhold warfarin and administer Vitamin K1, prothrombin complex concentrate with fresh plasma.

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Withhold warfarin and administer prothrombin complex concentrate with fresh plasma

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A 70-year-old man with newly diagnosed AF on ECG. In terms of stroke prevention, which factor is the strongest indication for long-term oral anticoagulation?

Moderate-to-severe (rheumatic) mitral stenosis

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The patient's age.

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Hypertension

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Diabetes.

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Dyslipidaemia.

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A 67-year-old diabetic man with non-valvular AF takes warfarin for stroke prophylaxis and is scheduled for elective inguinal hernia repair. Echocardiography shows no structural abnormality. INR is 2.9.

Which preoperative anticoagulation strategy is most appropriate?

Withhold warfarin for up to one week pre-operatively and allow the INR to normalise, without bridging heparin

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Withhold warfarin therapy for four days before surgery and administer lowmolecular-weight heparin (LMWH) for these four days, ceasing 24 hours prior to surgery

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Withhold warfarin for two days prior to surgery.

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Continue warfarin up until the time of surgery then administer prothrombin complex concentrate on the day of surgery.

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Withhold warfarin therapy for four days before surgery. Commence intravenous infusion of unfractionated heparin two days prior to surgery, ceasing four hours prior to surgery.

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The ECG shown was performed on an asymptomatic 27-year-old man. What is the underlying atrial rhythm?

atrial flutter.

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atrial fibrillation

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complete heart block

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premature atrial contractions

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sinus arrhythmia.

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A 70-year-old woman is admitted with several days of intermittent dizziness. There is no chest pain, dyspnoea, palpitation, syncope, orthopnoea, or oedema. She had CABG six years ago following a myocardial infarction.

Background: hypertension, hyperlipidaemia, and paroxysmal AF with rapid ventricular response.

Medications: metoprolol, simvastatin, cilazapril, warfarin.

BP 135/88 mmHg; pulse 52/min. Auscultation: bradycardia with regular S1/S2 and an S4; grade 2/6 early systolic murmur at the left upper sternal border; lungs clear; no oedema.

Telemetry shows sinus bradycardia (40–50/min) with two symptomatic sinus pauses of 3–5 seconds.

What is the most appropriate management?

Permanent pacemaker implantation

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Add amiodarone

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Discontinue metoprolol

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Echocardiography

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Observation

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A 55-year-old man presents with recurrent arrhythmia. He had rapid atrial flutter six weeks ago requiring urgent cardioversion and was started on oral metoprolol. Three days ago the arrhythmia recurred with worsening fatigue and now exertional dyspnoea; no chest pain, lightheadedness, or palpitation. He is otherwise well, taking only aspirin and metoprolol. BP 120/60 mmHg; pulse 50/min; BMI 23. Cardiac exam: bradycardia, irregular rhythm, normal S1/S2, no murmurs; lungs clear. ECG: atrial flutter with high-grade AV block and a ventricular rate of ~50/min.

What is the most appropriate management?

Radiofrequency (cavotricuspid isthmus) ablation

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Add Amiodarone

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Add Digoxin

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Stop metoprolol and change to flecainide

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Observation only.

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A 60-year-old man has newly diagnosed symptomatic paroxysmal atrial fibrillation and is on no medication.

Which first-line treatment is most appropriate to achieve and maintain sinus rhythm?

Catheter ablation (pulmonary vein isolation)

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Flecainide

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Sotalol

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Amiodarone

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Propafenone

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In patients with type 2 diabetes and recent worsening heart failure, the addition of sotagliflozin is most likely to reduce which outcome?

The total number of hospitalisations and urgent visits for heart failure (plus cardiovascular death)

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The change in the estimated glomerular filtration rate

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The incidence of death from any cause

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The incidence of death from cardiovascular causes

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The incidence of death from renal causes

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A 45-year-old man has an InterHeart risk score of 15 (intermediate cardiovascular risk) and no known cardiovascular disease.

If a “polypill plus aspirin” strategy is considered, which combination is most likely to lower his future cardiovascular event risk?

Simvastatin, atenolol and hydrochlorothiazide

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Simvastatin, atenolol, hydrochlorothiazide, ramipril plus aspirin.

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Simvastatin, hydrochlorothiazide plus aspirin

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Atenolol, hydrochlorothiazide and aspirin

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Atenolol, hydrochlorothiazide, ramipril plus aspirin

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Which medication may benefit obese patients with heart failure with preserved ejection fraction (HFpEF)?

Semaglutide

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Liraglutide

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Digoxin

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Spironolactone

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Sacubitril/Valsartan

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Which lifestyle modification, when implemented between ages 55 and 60, has the strongest association with increased overall life expectancy?

Quitting smoking

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Controlling hypertension

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Lowering non-HDL cholesterol

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Maintaining a healthy BMI

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Managing diabetes

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Average score
Your score

Cardiology Module 3

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