Mock Cardiology Module 5

A 65-year-old woman with a history of dyslipidaemia and a 40-pack-year smoking history presents with exertional chest tightness.

She undergoes a pharmacological stress myocardial perfusion scan (MPS) with single-photon emission computed tomography (SPECT).

The images demonstrate homogeneous tracer uptake at stress and rest with no reversible or fixed perfusion defects. Her pre-test probability of obstructive coronary artery disease is high.

Which of the following best explains a potential false-negative result in this clinical scenario?

Balanced reduction in myocardial perfusion across all coronary territories

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MPS cannot detect subendocardial ischaemia

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Pharmacological stress agents are unable to provoke coronary steal

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SPECT imaging has insufficient spatial resolution to detect any perfusion abnormality

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MPS is unreliable in female patients due to breast attenuation artefact alone

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A 72-year-old man with ischaemic cardiomyopathy and a left ventricular ejection fraction of 25% presents with worsening peripheral oedema, weight gain of 4 kg over 2 weeks, and serum sodium of 128 mmol/L (reference range: 135–145 mmol/L).

His serum potassium is 4.8 mmol/L (reference range: 3.5–5.0 mmol/L).

He is currently taking ramipril 10 mg daily, carvedilol 25 mg twice daily, and frusemide 80 mg daily.

Which neurohormone is most directly responsible for the sodium and water retention contributing to this patient’s clinical deterioration?

Aldosterone

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Brain natriuretic peptide (BNP)

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Bradykinin

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Nitric oxide

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Atrial natriuretic peptide (ANP)

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A 74-year-old woman with a 20-year history of hypertension, type 2 diabetes mellitus, and obesity (BMI 36 kg/m2) presents with progressive exertional dyspnoea over 6 months.

Examination reveals bibasal crackles, elevated jugular venous pressure, and peripheral oedema.

Her transthoracic echocardiogram shows a left ventricular ejection fraction of 62%, concentric left ventricular hypertrophy, an E/e’ ratio of 16, a left atrial volume index of 40 mL/m2, and a tricuspid regurgitation velocity of 3.0 m/s.

Her NT-proBNP is 450 pg/mL (reference range: <125 pg/mL for age-adjusted).

Which underlying condition is the most common contributor to this patient’s type of heart failure?

Systemic hypertension

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Cardiac amyloidosis

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Hypertrophic cardiomyopathy

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Coronary artery disease

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Constrictive pericarditis

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A 62-year-old man with non-ischaemic dilated cardiomyopathy and a left ventricular ejection fraction of 28% is being managed with ramipril 10 mg daily, spironolactone 25 mg daily, and frusemide 40 mg daily.

He is NYHA class II. His resting heart rate is 78 beats per minute in sinus rhythm, and his blood pressure is 118/72 mmHg.

Which additional medication has the strongest evidence for reducing the risk of sudden cardiac death in this patient?

Carvedilol

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Digoxin

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Diltiazem

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Amiodarone

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Ivabradine

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A 64-year-old man with heart failure with reduced ejection fraction (LVEF 32%) is already receiving maximum tolerated doses of ramipril, carvedilol, and spironolactone.

Despite this, his resting heart rate remains 82 beats per minute in sinus rhythm. His cardiologist commences ivabradine 5 mg twice daily.

Two weeks later, his resting heart rate is 68 beats per minute. His blood pressure is unchanged, and his echocardiogram shows no change in left ventricular contractility.

Which mechanism best explains the isolated heart rate reduction observed with this medication?

Selective inhibition of the hyperpolarisation-activated cyclic nucleotide-gated (HCN) channel current (If) in the sinoatrial node

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Blockade of beta-1 adrenergic receptors

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Inhibition of the L-type calcium current in the atrioventricular node

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Blockade of muscarinic receptors in the sinoatrial node

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Inhibition of the rapid component of the delayed rectifier potassium current (IKr)

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A 58-year-old man with heart failure with reduced ejection fraction (LVEF 30%) has been clinically stable on optimal guideline-directed medical therapy for 3 months. He is NYHA class II with no recent hospitalisations.

He asks about lifestyle modifications to improve his functional capacity and quality of life.

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

Structured, supervised exercise training including aerobic and resistance components

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Avoidance of all physical activity to reduce cardiac workload

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Unrestricted fluid intake to maintain hydration

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Ad libitum sodium intake as there is no evidence for restriction

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Prolonged sauna bathing to improve peripheral vasodilation

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A 72-year-old man with acute decompensated heart failure (LVEF 18%) is admitted to the coronary care unit.

Despite intravenous frusemide and non-invasive ventilation, he remains hypotensive (systolic BP 85 mmHg) and has evidence of end-organ hypoperfusion.

The cardiology team considers initiating inotropic support but is concerned about the risk of ventricular arrhythmias, given his markedly impaired left ventricular function.

Which of the following inotropic agents has the lowest arrhythmogenic potential?

Levosimendan

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Dobutamine

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Milrinone

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Adrenaline

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Dopamine

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A public health researcher is analysing sudden cardiac death (SCD) data across different population groups to determine optimal resource allocation for community defibrillator programs.

In which population group does the greatest absolute number of sudden cardiac deaths occur annually?

General adult population

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Cardiac arrest survivors

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Patients with heart failure and LVEF <35%

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High-risk post-myocardial infarction subgroups

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Patients with inherited channelopathies

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A 58-year-old man is recovering on the coronary care unit following a large anterior ST-elevation myocardial infarction treated with primary PCI to a proximal LAD occlusion three days ago.

His echocardiogram reveals a left ventricular ejection fraction of 28% with anterior wall akinesis.

He has been commenced on aspirin, ticagrelor, atorvastatin, ramipril, and bisoprolol.

He has had no sustained ventricular arrhythmias. The electrophysiology team is consulted regarding the appropriateness of ICD implantation for primary prevention.

Which of the following best reflects current evidence regarding the timing of ICD implantation in this patient?

ICD implantation should be deferred for at least 40 days post-MI, as early implantation has not been shown to reduce overall mortality

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ICD should be implanted before hospital discharge to prevent early sudden cardiac death

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ICD implantation is indicated only if the patient develops sustained ventricular tachycardia within the first week

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ICD should be implanted within 7 days in all patients with LVEF below 30% post-MI

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ICD implantation can be considered at any time post-MI provided the LVEF is below 35%

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A 62-year-old man with a history of ischaemic cardiomyopathy presents for routine cardiology review. His left ventricular ejection fraction (LVEF) is 30%.

He is currently taking ramipril 10 mg daily, bisoprolol 10 mg daily, and spironolactone 25 mg daily. His heart rate is 64 bpm in sinus rhythm.

Blood pressure is 118/72 mmHg. He reports NYHA class II symptoms.

His eGFR is 45 mL/min/1.73m² and HbA1c is 5.4% (reference range: 4.0–6.0%).

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

Add dapagliflozin 10 mg once daily

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Add ivabradine 5 mg twice daily

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Switch ramipril to sacubitril/valsartan

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Add digoxin 125 mcg daily

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Add vericiguat 2.5 mg daily

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A 72-year-old woman presents to the emergency department with progressive dyspnoea on exertion and bilateral ankle oedema over six weeks. She has a history of hypertension and type 2 diabetes mellitus.

On examination, her blood pressure is 148/88 mmHg, heart rate is 88 bpm, oxygen saturation is 95% on room air, and she has bilateral basal crepitations and elevated jugular venous pressure.

A chest X-ray shows interstitial pulmonary oedema. Her NT-proBNP is 520 ng/L (pg/mL).

Given her age, which of the following is the most accurate interpretation of her NT-proBNP result?

The result falls in the diagnostic grey zone, requiring echocardiography for further assessment

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The result is above the rule-in threshold for heart failure for her age group

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The result is below the exclusion threshold for heart failure

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The result confirms HFpEF and no further imaging is required

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The result is consistent with pulmonary embolism rather than heart failure

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A 58-year-old man with non-ischaemic dilated cardiomyopathy (LVEF 28%) is currently managed with enalapril 10 mg twice daily, carvedilol 25 mg twice daily, eplerenone 50 mg daily, and dapagliflozin 10 mg daily.

He remains NYHA class II-III symptomatic.

His blood pressure is 112/68 mmHg, serum creatinine is 95 µmol/L (reference range: 60–110 µmol/L), potassium is 4.6 mmol/L (reference range: 3.5–5.2 mmol/L), and eGFR is 72 mL/min/1.73m².

The decision is made to switch to sacubitril/valsartan.

Which of the following is the most important safety consideration when initiating this switch?

A minimum 36-hour washout period from enalapril before commencing sacubitril/valsartan

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Concurrent administration of enalapril and sacubitril/valsartan for 2 weeks during cross-titration

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Discontinuation of eplerenone before starting sacubitril/valsartan

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A minimum 72-hour washout period from enalapril before commencing sacubitril/valsartan

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Reduction of carvedilol dose by 50% before initiating sacubitril/valsartan

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A 64-year-old woman with ischaemic cardiomyopathy (LVEF 32%) presents for outpatient review. She is on sacubitril/valsartan 97/103 mg twice daily, bisoprolol 10 mg daily (maximum tolerated dose), eplerenone 50 mg daily, and empagliflozin 10 mg daily. She has NYHA class II symptoms.

Her blood pressure is 106/64 mmHg, heart rate is 78 bpm in sinus rhythm, and her ECG confirms normal sinus rhythm.

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

Add ivabradine 5 mg twice daily

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Add digoxin 125 mcg daily

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Add hydralazine and isosorbide dinitrate

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Add vericiguat 2.5 mg daily

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Add omega-3 polyunsaturated fatty acids

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A 68-year-old man with HFrEF (LVEF 25%) presents with persistent NYHA class III symptoms despite optimal medical therapy including sacubitril/valsartan, bisoprolol, spironolactone, and dapagliflozin.

His haemoglobin is 128 g/L (reference range: 130–180 g/L), ferritin is 80 µg/L (reference range: 30–300 µg/L), and transferrin saturation is 15% (reference range: 16–45%).

Which of the following is the most appropriate management of his iron status?

Intravenous ferric carboxymaltose

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Oral iron supplementation with ferrous sulphate 325 mg three times daily

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No treatment as haemoglobin is near normal

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Subcutaneous erythropoietin

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Blood transfusion of packed red blood cells

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A 74-year-old woman with a history of hypertension, obesity (BMI 34 kg/m²), and atrial fibrillation presents with progressive exertional dyspnoea (NYHA class III) and lower limb oedema.

Echocardiography reveals an LVEF of 62%, moderate left atrial enlargement, left ventricular hypertrophy, and an E/e’ ratio of 18. NT-proBNP is 1,200 ng/L.

According to current evidence and guidelines, which of the following pharmacological therapies has Class I evidence for improving outcomes in this patient?

Empagliflozin

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Sacubitril/valsartan

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Spironolactone

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Carvedilol

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Irbesartan

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A 70-year-old man is admitted to the emergency department with acute decompensated heart failure. He is dyspnoeic at rest, respiratory rate is 32 breaths/min, blood pressure is 82/50 mmHg, heart rate is 110 bpm, and oxygen saturation is 88% on room air.

On examination, he has cool peripheries, delayed capillary refill, bilateral pulmonary crepitations, and elevated jugular venous pressure. He has been given high-flow oxygen and intravenous furosemide 80 mg with minimal improvement.

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

Intravenous inotropic therapy

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Intravenous glyceryl trinitrate infusion

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Non-invasive ventilation with CPAP

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Oral captopril 6.25 mg

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Intravenous morphine 2.5 mg

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A 52-year-old woman was diagnosed with non-ischaemic dilated cardiomyopathy two years ago, when her LVEF was 22%. She was commenced on ramipril, carvedilol, spironolactone, and dapagliflozin with subsequent uptitration to target doses.

A repeat echocardiogram now shows an LVEF of 52%. She is asymptomatic (NYHA class I). No reversible cause was identified.

What is the most appropriate management regarding her heart failure medications?

Continue all neurohormonal antagonists at current doses indefinitely

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Cease all neurohormonal antagonists as LVEF has normalised

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Wean beta-blocker first, then ACE inhibitor over 6 months

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Halve the doses of all medications and monitor

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Cease spironolactone and continue the other medications

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A 28-year-old man presents after a witnessed syncopal episode during a football match. He recovered spontaneously within 30 seconds. His family history is significant for the sudden death of his father at age 35 during exercise.

Echocardiography reveals asymmetric septal hypertrophy with a maximal wall thickness of 32 mm, a resting left ventricular outflow tract gradient of 45 mmHg, and a normal left ventricular ejection fraction.

Cardiac MRI demonstrates late gadolinium enhancement involving 18% of the left ventricular mass.

Ambulatory ECG monitoring reveals a 6-beat run of non-sustained ventricular tachycardia.

What is the single most effective intervention for preventing sudden cardiac death in this patient?

Implantable cardioverter-defibrillator

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Disopyramide

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Surgical myectomy

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Amiodarone

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High-dose beta-blocker therapy

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A 58-year-old woman presents with a 3-month history of exertional chest tightness that is retrosternal, radiates to her left shoulder, and is relieved by rest within 5 minutes. She has hypertension, dyslipidaemia, and type 2 diabetes mellitus. Her resting ECG shows no ST-segment changes. Resting echocardiography demonstrates normal left ventricular systolic function with no regional wall motion abnormalities. Her estimated risk factor-weighted clinical likelihood of obstructive coronary artery disease is 55%.

Which of the following is the most appropriate first-line investigation?

Coronary CT angiography or functional imaging

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Exercise ECG

Correct Incorrect Correct answer

Coronary artery calcium score

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Invasive coronary angiography

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CT-derived fractional flow reserve (FFR-CT)

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A 65-year-old man with known risk factors for coronary artery disease undergoes exercise stress testing for investigation of exertional chest discomfort.

He exercises for 8 minutes on a Bruce protocol, achieves 90% of his maximum predicted heart rate, and develops 1.5 mm horizontal ST depression in leads V4-V6 at peak exercise.

He does not experience chest pain during the test. His blood pressure response is appropriate.

Based on the ischaemic cascade, which of the following abnormalities occurs earliest during progressive myocardial ischaemia?

Perfusion abnormality

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Angina pectoris

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ST-segment depression on ECG

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Regional systolic wall motion abnormality

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Regional diastolic dysfunction

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A 55-year-old man presents with atypical chest pain. His cardiovascular risk factors include smoking and a family history of premature coronary artery disease. His risk factor-weighted clinical likelihood of obstructive coronary artery disease is estimated at 30%.

A coronary CT angiography (CCTA) is performed and demonstrates a non-calcified plaque in the proximal left anterior descending artery with 40% luminal stenosis.

The plaque has the following features: positive remodeling, low Hounsfield unit attenuation, a napkin-ring sign, and spotty calcification.

Which of the following statements best reflects the clinical significance of these plaque characteristics?

These are high-risk plaque features associated with significantly increased risk of future acute coronary syndromes

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The stenosis is less than 50% and therefore the patient can be reassured and discharged without further follow-up

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These plaque features are associated with plaque stability and low risk of future acute coronary events

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FFR-CT should be performed immediately as the stenosis is functionally significant

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These features are only clinically significant if the coronary artery calcium score is greater than 400

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A 62-year-old man with stable exertional angina (Canadian Cardiovascular Society Class II) undergoes stress myocardial perfusion imaging (SPECT) which demonstrates moderate ischaemia involving the anterior wall and apex.

His left ventricular ejection fraction is 55%. His eGFR is 75 mL/min/1.73m2.

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

Based on the findings of the ISCHEMIA trial, which of the following statements is most accurate regarding the management of this patient?

Approximately 20% of patients with moderate-to-severe ischaemia on functional testing have no obstructive coronary artery disease on CCTA

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Immediate invasive coronary angiography and revascularisation will reduce his risk of cardiovascular death and myocardial infarction over 3 years compared with optimal medical therapy alone

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Revascularisation is the standard of care for all patients with moderate-to-severe ischaemia regardless of symptom control

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Patients with moderate ischaemia on SPECT do not require further anatomical assessment as the functional test has confirmed significant coronary artery disease

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The trial demonstrated that revascularisation significantly reduces the risk of heart failure hospitalisation at 3 years

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A 60-year-old woman with a BMI of 38 kg/m2, type 2 diabetes mellitus, and hypertension presents with exertional dyspnoea and atypical chest pain. She has a moderate clinical likelihood of obstructive coronary artery disease.

Her resting ECG shows left bundle branch block. Her cardiologist decides to refer her for functional imaging.

Which of the following imaging modalities would provide the most accurate assessment of myocardial ischaemia in this patient?

Adenosine stress cardiac MRI with quantitative perfusion mapping

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Exercise ECG

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Exercise stress echocardiography

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Myocardial perfusion SPECT (single-photon emission computed tomography)

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Dobutamine stress echocardiography

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A 46-year-old woman presents with recurrent exertional chest pain and dyspnoea over 6 months. She has no traditional cardiovascular risk factors. Resting ECG and echocardiography are normal.

She has had two emergency department presentations with troponin elevations to 44 ng/L (reference range: <14 ng/L) that normalise, with normal coronary CT angiography showing no obstructive coronary artery disease and no significant plaque.

Stress echocardiography demonstrates no regional wall motion abnormalities.

Despite optimal antianginal therapy with a beta-blocker and long-acting nitrate, her symptoms persist and her quality of life is significantly impaired.

What is the most appropriate next step in her management?

Invasive coronary angiography with coronary functional testing including acetylcholine provocation

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Repeat coronary CT angiography in 12 months

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Initiation of a proton pump inhibitor trial for presumed gastro-oesophageal reflux disease

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Discharge from cardiology with reassurance as coronary anatomy is normal

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Cardiac PET scan for assessment of left ventricular ejection fraction

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A 68-year-old man with a history of anterior ST-elevation myocardial infarction 6 weeks ago is referred for assessment of myocardial viability.

His left ventricular ejection fraction is 30% on echocardiography, with akinesis of the anterior wall, septum, and apex. Invasive coronary angiography demonstrates a chronic total occlusion of the proximal left anterior descending artery with good distal vessel suitable for bypass grafting.

A cardiac MRI with late gadolinium enhancement (LGE) is performed.

Which of the following LGE findings would most strongly predict recovery of function following revascularisation?

Less than 25% transmural extent of late gadolinium enhancement in the anterior wall, septum, and apex

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50-75% transmural extent of late gadolinium enhancement in the anterior wall, septum, and apex

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Transmural (>75%) late gadolinium enhancement in the anterior wall, septum, and apex

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No late gadolinium enhancement but global thinning of the anterior wall to 4 mm

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Transmural late gadolinium enhancement with associated microvascular obstruction

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A 58-year-old man undergoes coronary CT angiography for investigation of atypical chest pain.

The CCTA demonstrates a non-obstructive plaque (<50% stenosis) in the proximal left anterior descending artery.

In addition, automated analysis reveals elevated pericoronary adipose tissue (PCAT) attenuation of -65 HU around the proximal LAD (threshold for abnormality: greater than or equal to -70.5 HU) and a low-attenuation plaque (LAP) burden of 6%.

Which of the following best describes the clinical significance of these combined findings?

These findings indicate complementary markers of coronary inflammation and plaque vulnerability, associated with increased risk of future myocardial infarction

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These findings are normal variants and do not require any change in management

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Elevated PCAT attenuation reflects coronary arterial calcification and is equivalent to a high calcium score

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PCAT attenuation is only significant in the setting of obstructive coronary artery disease (>70% stenosis)

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These findings are only relevant in patients who have already had a myocardial infarction

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A 50-year-old woman with hypertension and a 20-pack-year smoking history presents with recurrent intermittent ischaemic-sounding chest pain.

She has had multiple hospital admissions, some with mild troponin elevations (peak 30 ng/L; reference range: <14 ng/L).

Resting echocardiography and coronary CT angiography are unremarkable, with no obstructive coronary disease or significant plaque.

She undergoes stress cardiac MRI with quantitative pixel-wise myocardial perfusion mapping, which demonstrates heterogeneous perfusion in a non-coronary distribution with a global stress myocardial blood flow (MBF) of 2.11 mL/g/min.

Based on the quantitative perfusion data, which of the following is the most likely diagnosis?

Coronary microvascular dysfunction

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Obstructive three-vessel coronary artery disease

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Normal coronary physiology

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Takotsubo cardiomyopathy

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Hypertrophic cardiomyopathy

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Mock Cardiology Module 5

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