Cardiology Module 4

Which of the following cardiac mechanisms primarily contributes to the development of right ventricular failure?

Increase in right ventricular afterload

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Decrease in right ventricular contractility

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Increase in right ventricular preload

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Impairment of right ventricular lusitropy

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Decrease in right ventricular afterload

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Based on the REDUCE-AMI trial, which statement best reflects beta-blocker use in post-MI patients with preserved ejection fraction (LVEF ≥50%) and no heart failure?

Beta-blockers are not associated with a reduction in death or new MI and are not mandatory in this group

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Beta-blockers should be used routinely to improve long-term survival in all post-MI patients with HFpEF.

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Beta-blockers are indicated primarily to control symptoms of heart failure in post-MI patients with HFpEF.

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ACE inhibitors should be avoided in post-MI patients with HFpEF as they increase mortality.

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Diuretics should be the first-line treatment to enhance ejection fraction in post-MI HFpEF patients.

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A 58-year-old man with hypertension and type 2 diabetes has exertional chest pain, nonspecific resting ST-T changes, and good exercise capacity.

What is the most appropriate next investigation?

CT Coronary Angiography (CTCA)

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Dobutamine Stress Echocardiography (DSE)

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Myocardial Perfusion Scan (MPS)

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Immediate Coronary Angiography

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Exercise Stress Test

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Which is NOT an indication for permanent pacemaker insertion?

Asymptomatic second-degree AV block, Mobitz I (Wenckebach)

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Symptomatic sinus node dysfunction

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Asymptomatic Mobitz II second degree AV block with a narrow QRS interval

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Transient advanced infranodal AV block with associated bundle branch block following a ST elevation myocardial infarction (STEMI)

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Recurrent syncope caused by spontaneously occurring carotid sinus stimulation

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Which of the following is an indication for permanent pacemaker insertion following an ST elevation myocardial infarction?

Transient 2nd degree AV block or 3rd degree block and associated bundle branch block

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Transient AV block in presence of isolated left anterior fascicular block.

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Transient AV block in absence of intraventricular conduction defects.

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New bundle branch block in absence of AV block.

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Persistent asymptomic 1st degree AV block in presence of bundle branch or fascicular block.

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Which outcome is least likely following a Cardiac Resynchronisation Therapy (CRT)?

Reversion of atrial fibrillation to sinus rhythm

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Improvement in 6 minutes walking distance

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Improvement in quality of life

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Reduction in NYHA class score

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Decreased mortality

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The main reason troponin T and I are preferred biomarkers for myocardial injury is that they are:

specific for cardiac muscle origin.

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not elevated in strenuous exercise.

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not affected by renal failure

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more sensitive than creatine kinase-MB levels.

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elevated for days after myocardial infarction.

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Which of the following is the most common acquired valve disease in Australasian patients aged over 75 years?

Aortic stenosis

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Aortic regurgitation

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Mitral stenosis

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Tricuspid stenosis

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Mitral regurgitation

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A 72-year-old man with a background of coronary artery disease, hyperlipidemia and type 2 diabetes mellitus presents with symptoms of increasing fatigue and dyspnea for the last several months to a year.

Most recently, he noticed that he is increasingly becoming short of breath and fatigue just walking from across a room of less than 50 meters and is only comfortable at rest.

His current medications include aspirin, carvedilol, cilazapril, digoxin, spironolactone, furosemide, simvastatin, and glipizide.

On examination, his blood pressure is 95/60 mm Hg, pulse is 57/min, and respiration rate is 12/min. Cardiovascular examination reveals a displaced apex beat. Rhythm is regular and bradycardic. S1 and S2 are normal, with a grade 3/6 pan-systolic murmur at the apex. An S3 is present. There is no hepatojugular reflux. The lungs are clear. There is no ascites. The liver edge is palpable 1 cm below the right costal margin. The lower extremities are warm with decreased distal pulses bilaterally. There is no ankle edema.

Electrocardiogram shows sinus rhythm with a rate of 55/min. PR interval is 180 msec, QRS width is 180 msec, and QT interval is 380 msec. Left bundle branch block is seen.

A dobutamine stress echocardiogram reveals a left ventricular ejection fraction of 33% with a large antero-apical area of akinesis and no ischemia.

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

Biventricular pacemaker-defibrillator (CRT-D)

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Add Amiodarone

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Increase dose of Digoxin

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Dual chamber pacemaker

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Implantable cardioverter

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What is the mechanism of action of aspirin?

Irreversibly inhibits COX-1 and COX-2, suppressing prostaglandin/thromboxane synthesis

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Reversibly inhibits COX1 and COX2 enzymes thereby suppressing the production of prostaglandins and thromboxanes

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ADP receptor blocker

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Reversible direct thrombin inhibitor

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Factor Xa inhibitor

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What is the mechanism of action of clopidogrel?

ADP (P2Y12) receptor blocker

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GP IIb/IIIa inhbitor

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Irreversibly inhibits COX1 and COX2 enzymes thereby suppressing the production of prostaglandins and thromboxanes

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Reversible direct thrombin inhibitor

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Factor Xa inhibitor

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What is the mechanism of action of Fondaparinux?

Factor Xa inhibitor (indirect, antithrombin-mediated)

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Direct thrombin inhibitor

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Indirect thrombin inhibitor

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ADP receptor blocker

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GP IIb/IIIa receptor blocker

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What is the mechanism of action of enoxaparin (LMWH)?

Potentiates antithrombin III, predominantly inhibiting factor Xa (with some anti-IIa)

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ADP receptor blocker

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COX inhibitor

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GP IIb,IIIa receptor blocker

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Direct thrombin inhibitor

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In systolic LV dysfunction, which medication should be started regardless of symptoms?

ACE inhibitor (or ARNI)

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Spironolactone

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Digoxin

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Frusemide

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Hydralazine

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What is the mechanism of action of carvedilol?

Beta-1, Beta-2 and Alpha-1 antagonist

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Beta-1 antagonist.

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Beta-2 antagonist.

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Alpha-1 antagonist.

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Beta-1 and alpha-1 antagonist.

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A patient presents with sudden onset severe retrosternal chest pain associated with shortness of breath and diaphoresis. ECG shows 2mm ST elevation over lead V1 and V2.

Which myocardial wall is most likely affected?

Septal

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Anterolateral

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Anteroseptal

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Inferior

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Posterior

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What is the most likely diagnosis?

Pericarditis

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Acute myocardial infarction

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Pulmonary embolism

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Hyperkalemia

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Cardiac tamponade

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What is the most likely diagnosis?

Lown-Ganong-Levine syndrome

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Wolff Parkinson White syndrome

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Brugada syndrome

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Atrial fibrillation

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AV nodal re-entrant tachycardia

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An 18-year-old woman is evaluated for recurrent syncope. She has experienced four syncopal episodes in her lifetime, all of which occurred during activity. The most recent was last week, when she dove into a pool and had a brief loss of consciousness. Episodes have no prodrome, and she has had no dizziness.

She is healthy and active, without cardiopulmonary complaints, and takes no medications. Her maternal cousin drowned at age 10 years, and her mother has been diagnosed with a seizure disorder.

On physical examination, her blood pressure is 112/65 mm Hg and her pulse is 67/min and regular. The cardiopulmonary and general physical examinations are normal.

Her electrocardiogram is shown below:

Which of the following is the most likely diagnosis?

Long QT syndrome

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Brugada syndrome

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Short QT syndrome

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Wolff-Parkinson-White syndrome

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Arrhythmogenic right ventricular dysplasia

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Which of the following medication should be avoided in this rhythm?

Amiodarone

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Isoproterenol

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Magnesium sulfate

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Potassium chloride

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Esmolol

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In a patient who presents with this ECG finding, where is the most likely location of the block?

At the level of the AV node

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Below the AV node

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Right bundle branch

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Left bundle branch

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Below the bundle of his

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A 65 year old lady presents with 3 episodes of syncope over the last 5 months.Each episode has been associated with exertion and has been preceded by palpitations.Episodes of syncope has been brief only lasting a few seconds.No urinary incontinence.No tongue biting. Holter monitor was reported as normal. Her ECG shows normal sinus rhythm with a right bundle branch block.
Which of the following is the most appropriate investigation?

Implantable loop recorder

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Carotid sinus massage

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Echocardiography

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External event recorder

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Tilt table test

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A 50 year old man presents to his GP with atypical chest pain. He has a background of hypertension but is otherwise well with no other cardiac risk factors. Resting ECG shows left bundle branch block.

What is the most appropriate step?

CT coronary angiography OR pharmacological stress imaging (e.g., dobutamine stress echo / vasodilator stress CMR)

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Coronary angiography

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Holter monitor

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Treadmill stress ECG

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No further evaluation required.

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Which of the following contributes the greatest population attributes risk for myocardial infarction?

Dyslipidemia

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Hypertension

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Hyperuricemia

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Lack of exercise

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Lack of fruit and vegetables in diet

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If a patient presents to hospital with chest pain and has the following ECG, which ECG feature would predict the highest risk of in-hospital mortality?

ST depression in II,III,aVF, V4-V6

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New onset atrial fibrillation

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Non sustained VT lasting 3 beats

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ST elevation of 3mm in V2-V4.

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T wave inversion in I,II,aVL,V1-V6.

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The following constitutes a positive stress ECG except?

Exercise induced left bundle branch block

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1 mm horizontal or downsloping ST depression

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Ventricular fibrillation during exercise

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4 sequential beats of ventricular tachycardia

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2 mm downsloping ST depression with T wave inversion

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The following are indications for exercise stress ECG except?

Patients with symptomatic severe aortic stenosis.

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Atypical chest pain in a patient with 1 or 2 cardiac risk factors

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Patients with IHD following an uncomplicated MI

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Patients with recurrent exercise induced cardiac arrhythmia.

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Patients who are considered for heart transplant.

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A 22-year-old man collapses immediately after being hit in the chest with a ball while playing lacrosse. Emergency medical personnel were present during the game and noted the initial rhythm to be ventricular fibrillation.

The patient underwent prompt defibrillation within 3 min, and normal sinus rhythm was restored.

The patient has been transported to the emergency room and is stable with a blood pressure of 128/76 mmHg and heart rate of 112 beats/min.

He has no prior history of syncope and no family history of sudden cardiac death. His electrocardiogram (ECG) is normal. There is no evidence of broken ribs or sternum by x-ray.

What is the most likely diagnosis?

Commotio cordis

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Brugada syndrome

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Cardiac contusion

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Hypertrophic cardiomyopathy

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Right ventricular dysplasia

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All of the following statements regarding sudden cardiac death are true except?

70–75% who die of SCD show acute MI, only 20–30% have healed MI

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A strong parental history of sudden cardiac death as a presenting history of coronary artery disease increases the likelihood of a similar presentation in an offspring.

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An estimated 50% of all cardiac deaths are sudden and unexpected.

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By 5 min after sudden cardiac arrest, the estimated survival rates are no better than 25-30% in the out of-hospital setting.

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Brugada syndrome is a known cause of sudden cardiac death in the young population.

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The loss-of-function single nucleotide polymorphism of cytochrome P450 family 2 subfamily C member 19 enzyme (CYP2C19) would render this medication to be ineffective:

Aspirin

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Clopidogrel

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Ticagrelor

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Prasugrel

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Dabigatran

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Among patients with heart failure and a reduced ejection fraction, which of the following medication has been shown to reduce the risk of worsening heart failure?

Dapagliflozin

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Ivabradine

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Spironolactone

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Hydralazine

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Canagliflozin

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A 60 year old man with a background of advanced renal cell cancer presents with symptoms of chest pain and dyspnea, 20 days after receiving his first cycle of combination ipilimumab/nivolumab therapy.

Clinically, he appeared to be in gross fluid overload and was hypotensive. Chest x-ray shows cardiomegaly with interstitial edema. He had non-specific ST changes on ECG with a raised Hs-troponin T of 500.

Echocardiogram shows moderate to severe LV dysfunction with an estimated LV ejection fraction of 35 percent but with no regional wall motion abnormalities.

Which of the following would be the most appropriate next step?

Cease immunotherapy permanently and start intravenous methylprednisone and diuretic therapy.

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Temporarily hold his immunotherapy for next cycle and start intravenous methylprednisone.

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Repeat a second Hs-troponin and if remains elevated then refer for urgent cardiac angiography.

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Arrange an urgent cardiac MRI and immediately commence intravenous immunoglobulins.

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In patients with stable angina who are not on regular anti-anginal medications, what is the likely benefit of percutaneous coronary intervention (PCI) on the daily number of angina episodes?

PCI resulted in a lower daily number of angina episodes.

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No significant impact on symptoms

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PCI and placebo showed similar effects on angina episodes.

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PCI resulted in a higher daily number of angina episodes.

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A 16-year-old teenager is referred for hypertension noted during a routine physical examination. The blood pressure in the upper limbs is significantly higher than in the lower limbs. A murmur is heard on the left back and inter-scapular area.

What is the most likely diagnosis?

Coarctation of aorta

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Patent Ductus Arteriosus

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Pulmonary Hypertension

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Transposition of great vessels

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Aortic stenosis

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Which medication may benefit obese patients with 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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A child with a congenital heart defect presents with chronic hypoxia. As a compensatory mechanism, the body responds by increasing the production of red blood cells. This response is known as secondary erythrocytosis.

Which of the following best explains the underlying physiological process leading to this condition?

The kidneys produce more erythropoietin in response to hypoxia, stimulating the bone marrow to increase red blood cell production.

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The liver releases increased amounts of hepcidin, leading to enhanced iron absorption and red blood cell production.

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The spleen decreases the destruction of red blood cells, leading to an increased number in circulation.

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The heart secretes a special hormone that directly stimulates the bone marrow to produce more red blood cells.

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Cardiology Module 4

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