Cardiology Module Three

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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Which of the following is the primary reason for the use of Continuous Positive Airway Pressure (CPAP) in the management of pulmonary edema?

To mechanically open collapsed airways, thereby reducing the work of breathing and improving ventilation.

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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 increase venous return to the heart, thereby increasing the cardiac afterload.

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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 Asian male from the Philippines presents to the emergency department after an episode of syncope. He is usually fit and well and is not currently taking any medication.

He has a family history of sudden cardiac death. ECG taken is consistent with Brugada syndrome Type 1.

What is the most appropriate management for this patient?

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 to ED with symptomatic congestive heart failure with NYHA Class III symptoms. He denies any chest pain.

On examination, he appears clinically to be in fluid overload. ECG shows normal sinus rhythm. Chest x-ray shows cardiomegaly with small bilateral effusions and fluid in the fissures.

His echo shows moderate to severe LV dysfunction with an ejection fraction of 35 percent.

He is started on intravenous frusemide.

Which of the following 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 Hypertrophic Obstructive Cardiomyopathy (HOCM)?

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 of the following 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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A 20 year man with a background of Hypertrophic cardiomyopathy develops atrial fibrillation in last 24 hours.

His heart rate is 150 bpm with a blood pressure of 90/50.

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 below 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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Which of the following imaging modality is the most useful for assessment of cardiac complications of dissection such as aortic insufficiency and 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 of choice for patients with chronic aortic dissection who presents with chronic chest pain and is hemodynamically stable.

MRI

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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 of the following clinical feature is not consistent with an acute aortic dissection (Type 1)?

Murmur is best heard over 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 of the following medication should be avoided in an 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 an acute aortic dissection is noted to be very hypertensive with systolic blood pressure of 190. Labetalol is commenced but his blood pressure remains above 160 systolic.

GCS remains 15 and renal function is normal.

What should be 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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The following are indications for surgery in patients with Type B aortic dissection except?

Persistence of false lumen.

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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 male patient with aortic stenosis presents for a routine clinic review. His recent echocardiogram showed an aortic valve area of 0.9cm2 with an ejection fraction of 60%.The valves are not calcified. However patient is asymptomatic and is physically active.

What is the next appropriate step?

Exercise 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 football player is referred for a medical assessment.

Which of the following finding is suggestive of an 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 male diabetic patient has a history of acute onset of severe mid-sternal chest discomfort during sleep. The patient is diaphoretic. The heart rate is 58 beats/minutes. The blood pressure is 88/62 mmHg in the right arm and 92/60 mmHg in the left arm. The respiratory rate is 20 breaths/minute and there is marked jugular venous pressure elevation. Auscultation reveals no murmurs but there is an S4 gallop rhythm heard. The lungs are clear on auscultation. There is no peripheral oedema.

His ECG shows 4mm ST elevation over lead II,III and aVF with 2mm ST depression over 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 female indigenous patient has a history of rheumatic fever. She presents with increasing shortness of breath. She describes paroxysmal nocturnal dyspnoea and pedal oedema.

On examination her blood pressure is 95/60 mmHg. The jugular venous pressure is elevated with a prominent a wave. The S1 is loud, S2 is normal. There is an early diastolic sound after S2 with a diastolic rumble at the apex. There is also an early diastolic murmur which is accentuated with expiration. There is hepatomegaly and pitting oedema to the 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

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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 epigastric discomfort which he describes as severe indigestion associated with nausea and vomiting. He has a history of paroxysmal atrial fibrillation and takes digoxin for this. On examination, his height is 170 cm and weight 97 kg. His blood pressure is 110/70 mmHg and pulse 85/minute and regular. He has slight epigastric tenderness. His ECG is shown below:

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 male presents for follow up of his persistent AF.

Successful cardioversion a month ago but recently reverted back to AF two weeks ago. Have been managed by warfarin, digoxin and diltiazem. He was previously prescribed metoprolol but had to stop due to side effects. He is entirely asymptomatic despite the inadequate rate control. He is not keen to take on more medications.

On physical examination, his blood pressure is 140/80 mm Hg and his pulse is 147/min. Cardiac auscultation reveals an irregularly irregular rhythm and a grade 2/6 pansystolic murmur. The lungs are clear to auscultation and there is no edema. Serum TSH is normal. A 24-hour ambulatory monitor demonstrates a mean heart rate of 137/min, with a minimum rate of 70/min and a maximum rate of 170/min.

Which of the following is the most appropriate management?

Atrioventricular node ablation and 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 has a background of mild angina diagnosed a couple of years ago. He presents to the emergency department after 30 minutes of severe chest pain following some heavy physical activity. He has taken three glyceryl trinitrate tablet at home without relief. On arrival to the emergency department, he is given oxygen which gave him some relief. Over the last 6 months, his angina symptoms had been stable on atenolol 50 mg/day, aspirin and isosorbide mononitrate 60 mg/day. He has only experienced angina twice, and has not used his glyceryl trinitrate over this period.

What would be the most likely explanation for the failure of the glyceryl trinitrate to relieve his angina?

reduced drug potency

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poor absorption due to dry mouth.

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onset of unstable angina

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nitrate tolerance

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paroxysmal atrial fibrillation

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There has been several randomized controlled studies comparing the use of anticoagulation compared with placebo in patients with nonrheumatic atrial fibrillation. These trials suggest that the annual risk of stroke in untreated patients with atrial fibrillation with a CHADs score of zero would be nearest 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 to the emergency department following a simple fall. She has a background of atrial fibrillation on warfarin.
On examination she has a few small bruises on her legs but is otherwise well. Her pulse is 68 bpm and irregular and her blood pressure is 175/90 mmHg. Her full blood examination is normal however her serum creatinine is elevated at 170 mcg/L [50-100 mcg/L] and her INR is elevated at 7.1.

Which of the following is the best management strategy for her elevated international normalised ratio (INR)?

Withhold warfarin and continue to monitor INR

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Withhold warfarin and administer Vitamin K1

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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 male presents with an irregular heart beat and the ECG confirms atrial fibrillation. In terms of stroke prevention, which of the following is the strongest indication for recommending long term oral anticoagulation in this patient?

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 atrial fibrillation is taking warfarin for primary prophylaxis and is scheduled for inguinal hernia repair. His echocardiogram shows no structural abnormality. His international normalised ratio (INR) is 2.9.

Which of the following preoperative anticoagulant management strategies is most appropriate?

Withhold warfarin therapy for up to 1 week and allow the INR to normalize without substituting UFH.

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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 electrocardiogram (ECG) shown above was performed on an asymptomatic 27 year old male.

What is the underlying 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 to the hospital for intermittent dizziness over several days. There is no chest discomfort, dyspnea, palpitations, syncope, orthopnea, or edema. Had a CABG 6 years ago after a myocardial infarction. Background history includes hypertension, hyperlipidemia, and PAF with a history of rapid ventricular response. Her medications include metoprolol, simvastatin, cilazapril and warfarin.

On physical examination, her blood pressure is 135/88 mm Hg and her pulse is 52/min. Cardiac auscultation reveals bradycardia with regular S1 and S2, as well as an S4. A grade 2/6 early systolic murmur is heard at the left upper sternal border. The lungs are clear to auscultation. no pedal edema.
On telemetry, she has sinus bradycardia with rates between 40/min and 50/min, with two symptomatic sinus pauses of 3 to 5 seconds each.

Which of the following is the most appropriate management for this patient?

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 went into rapid atrial flutter 6 weeks ago and underwent urgent cardioversion. He was later commenced on oral metoprolol.

Three days ago, he had a recurrence of his arrhythmia with worsening fatigue and has now begun experiencing dyspnea on exertion. There is no history of chest pain, lightheadedness, and palpitation.

He is otherwise fit and well and is only on aspirin and metoprolol.

On physical examination, his blood pressure is 120/60 mm Hg and his pulse is 50/min. BMI is 23. Cardiac examination reveals bradycardia with an irregular rhythm, normal S1 and S2, and no murmurs or gallops. Lungs are clear to auscultation.

The electrocardiogram shows atrial flutter with a 6:1 block and a ventricular rate of 50/min.

Which of the following is the most appropriate management for this patient?

Radiofrequency 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 recently been diagnosed by his GP with symptomatic paroxysmal atrial fibrillation but is currently not on any medication.

Which of the following first line treatment should be offered to help him achieve and maintain sinus rhythm?

Catheter ablation

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Flecainide

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Sotalol

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Amiodarone

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Propafenone

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The addition of Sotagliflozin in patients with diabetes and worsening heart failure symptoms will likely cause a reduction in the following outcome:

The total number of hospitalizations and urgent visits for heart failure

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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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You have just evaluated a 45 year old male in your clinic who appears to have an InterHeart risk score of 15 (intermediate cardiovascular risk) but with no known cardiovascular disease.

Which of the following treatment is likely to lower his risk of developing a cardiovascular event in the future if a ‘polypill’ approach is being considered?

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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Cardiology Module Three

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