Back up copy of original Cardiology Module 3

A 40-year-old Filipino man presents to the cardiology clinic for evaluation of an abnormal ECG found during a routine pre-employment medical examination. He reports occasional atypical chest discomfort but denies syncope, palpitations, or exertional dyspnea. There is no family history of sudden cardiac death.

His ECG demonstrates giant negative T-wave inversions (>10 mm) in the precordial leads (V3–V6) with high QRS voltages.

A transthoracic echocardiogram (TTE) is performed suggests possible increased wall thickness at the left ventricular apex, but the apical segments are not clearly visualized and the diagnosis remains equivocal.

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

Cardiac magnetic resonance (CMR) imaging

Correct Incorrect Correct answer

Coronary angiography

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Endomyocardial biopsy

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Exercise treadmill stress test

Correct Incorrect Correct answer

24-hour ambulatory Holter monitoring

Correct Incorrect Correct answer

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%

Correct Incorrect Correct answer

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%

Correct Incorrect Correct answer

Initiate ezetimibe as first line without initiating statin therapy

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Recommend lifestyle modifications only without statin therapy

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

Amiodarone

Correct Incorrect Correct answer

Sotalol

Correct Incorrect Correct answer

A permanent pacemaker

Correct Incorrect Correct answer

Warfarin

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

Spironolactone

Correct Incorrect Correct answer

Valsartan/sacubitril

Correct Incorrect Correct answer

Empagliflozin

Correct Incorrect Correct answer

Angiotensin II receptor blocker

Correct Incorrect Correct answer

What type of murmur usually accompanies obstructive HCM?

Mitral regurgitation

Correct Incorrect Correct answer

Mitral stenosis

Correct Incorrect Correct answer

Aortic stenosis

Correct Incorrect Correct answer

Aortic regugitation

Correct Incorrect Correct answer

Tricuspid regurgitation

Correct Incorrect Correct answer

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

Digoxin

Correct Incorrect Correct answer

Verapamil

Correct Incorrect Correct answer

Disopyramide

Correct Incorrect Correct answer

Beta blockers

Correct Incorrect Correct answer

Mavacamten

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

Digoxin

Correct Incorrect Correct answer

Pacemaker insertion

Correct Incorrect Correct answer

Beta blockers

Correct Incorrect Correct answer

AV node ablation

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

Aortic regurgitation

Correct Incorrect Correct answer

Aortic stenosis

Correct Incorrect Correct answer

Mitral regurgitation

Correct Incorrect Correct answer

Ruptured myocardial papilla

Correct Incorrect Correct answer

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

Mitral stenosis

Correct Incorrect Correct answer

Mitral regurgitation

Correct Incorrect Correct answer

Aortic stenosis

Correct Incorrect Correct answer

Aortic regurgitation

Correct Incorrect Correct answer

Pulmonary hypertension

Correct Incorrect Correct answer

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)

Correct Incorrect Correct answer

Transoesophageal ECHO (TOE)

Correct Incorrect Correct answer

MRI

Correct Incorrect Correct answer

Spiral CT

Correct Incorrect Correct answer

Chest X ray

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

Spiral CT

Correct Incorrect Correct answer

Transesophageal ECHO

Correct Incorrect Correct answer

Transthoracic ECHO

Correct Incorrect Correct answer

CXR

Correct Incorrect Correct answer

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

Murmur best heard over the left sternal border

Correct Incorrect Correct answer

Non specific ST-T wave changes on the ECG

Correct Incorrect Correct answer

Severe pain

Correct Incorrect Correct answer

Aortic regurgitation

Correct Incorrect Correct answer

Blood pressure difference in both arms.

Correct Incorrect Correct answer

Which medication should be avoided in acute aortic dissection?

Hydralazine

Correct Incorrect Correct answer

Diltiazem

Correct Incorrect Correct answer

Verapamil

Correct Incorrect Correct answer

Sodium nitroprusside

Correct Incorrect Correct answer

Labetolol

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

Start IV Digoxin

Correct Incorrect Correct answer

Start IV Diltiazem

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Start IV Hydralazine

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Start cilazapril

Correct Incorrect Correct answer

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

Persistence of a patent false lumen alone

Correct Incorrect Correct answer

Presence of dissection within an aortic aneurysm

Correct Incorrect Correct answer

Evidence of aortic rupture

Correct Incorrect Correct answer

Recurrent pain

Correct Incorrect Correct answer

Occlusion of a major aortic branch

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

Presence of moderate mitral regurgitation

Correct Incorrect Correct answer

Mitral valve morphology not favourable for valvotomy.

Correct Incorrect Correct answer

Calcified mitral valve

Correct Incorrect Correct answer

Presence of severe mitral regurgitation

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

Re-evaluate in 6 months.

Correct Incorrect Correct answer

Proceed with surgery

Correct Incorrect Correct answer

Commence carvedilol

Correct Incorrect Correct answer

Commence warfarin

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

Wenkebach phenomenon

Correct Incorrect Correct answer

Junctional rhythm at rest of 50 beats per minute

Correct Incorrect Correct answer

Voltage criteria for left ventricular hypertrophy

Correct Incorrect Correct answer

Dominant R wave in lead V1

Correct Incorrect Correct answer

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.

Correct Incorrect Correct answer

Acute pericarditis.

Correct Incorrect Correct answer

Aortic dissection.

Correct Incorrect Correct answer

Acute pulmonary embolism.

Correct Incorrect Correct answer

Acute pericardial tamponade

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

Mitral stenosis and pulmonary stenosis

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

Mitral stenosis and tricuspid regurgitation

Correct Incorrect Correct answer

Mitral stenosis and tricuspid stenosis

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

Non-Q wave anterior myocardial infarction

Correct Incorrect Correct answer

Digoxin toxicity.

Correct Incorrect Correct answer

Oesophageal spasm

Correct Incorrect Correct answer

Hypertrophic cardiomyopathy

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

Amiodarone

Correct Incorrect Correct answer

Maze surgical procedure

Correct Incorrect Correct answer

Radiofrequency ablation

Correct Incorrect Correct answer

Observation

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

poor absorption due to dry mouth.

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

nitrate tolerance

Correct Incorrect Correct answer

paroxysmal atrial fibrillation

Correct Incorrect Correct answer

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%

Correct Incorrect Correct answer

5%

Correct Incorrect Correct answer

8%

Correct Incorrect Correct answer

12%

Correct Incorrect Correct answer

15%

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

Withhold warfarin and administer Vitamin K1 and prothrombin complex concentrate.

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

Withhold warfarin and administer prothrombin complex concentrate with fresh plasma

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

The patient's age.

Correct Incorrect Correct answer

Hypertension

Correct Incorrect Correct answer

Diabetes.

Correct Incorrect Correct answer

Dyslipidaemia.

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

Withhold warfarin for two days prior to surgery.

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

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.

Correct Incorrect Correct answer

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

atrial flutter.

Correct Incorrect Correct answer

atrial fibrillation

Correct Incorrect Correct answer

complete heart block

Correct Incorrect Correct answer

premature atrial contractions

Correct Incorrect Correct answer

sinus arrhythmia.

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

Add amiodarone

Correct Incorrect Correct answer

Discontinue metoprolol

Correct Incorrect Correct answer

Echocardiography

Correct Incorrect Correct answer

Observation

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

Add Amiodarone

Correct Incorrect Correct answer

Add Digoxin

Correct Incorrect Correct answer

Stop metoprolol and change to flecainide

Correct Incorrect Correct answer

Observation only.

Correct Incorrect Correct answer

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)

Correct Incorrect Correct answer

Flecainide

Correct Incorrect Correct answer

Sotalol

Correct Incorrect Correct answer

Amiodarone

Correct Incorrect Correct answer

Propafenone

Correct Incorrect Correct answer

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)

Correct Incorrect Correct answer

The change in the estimated glomerular filtration rate

Correct Incorrect Correct answer

The incidence of death from any cause

Correct Incorrect Correct answer

The incidence of death from cardiovascular causes

Correct Incorrect Correct answer

The incidence of death from renal causes

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

Simvastatin, atenolol, hydrochlorothiazide, ramipril plus aspirin.

Correct Incorrect Correct answer

Simvastatin, hydrochlorothiazide plus aspirin

Correct Incorrect Correct answer

Atenolol, hydrochlorothiazide and aspirin

Correct Incorrect Correct answer

Atenolol, hydrochlorothiazide, ramipril plus aspirin

Correct Incorrect Correct answer

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

Semaglutide

Correct Incorrect Correct answer

Liraglutide

Correct Incorrect Correct answer

Digoxin

Correct Incorrect Correct answer

Spironolactone

Correct Incorrect Correct answer

Sacubitril/Valsartan

Correct Incorrect Correct answer

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

Quitting smoking

Correct Incorrect Correct answer

Controlling hypertension

Correct Incorrect Correct answer

Lowering non-HDL cholesterol

Correct Incorrect Correct answer

Maintaining a healthy BMI

Correct Incorrect Correct answer

Managing diabetes

Correct Incorrect Correct answer

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Your score

Back up copy of original Cardiology Module 3

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