PM 23 from 1 to 40 ð«
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1
A 51-year-old man presents four weeks after being discharged from hospital. He had been
admitted with chest pain and thrombolysed for a myocardial infarction. This morning he
developed marked tongue and facial swelling. Which one of the following drugs is most likely to
be responsible?
Ramipril
2
A 51-year-old man is started on lisinopril after being found to have an average blood pressure of
154/93 on ambulatory blood pressure monitoring. Around two weeks after starting treatment he
represents with a persistent dry cough. Accumulation of which one of the following proteins is
responsible for this?
Bradykinin
3
A 64-year-old man attends his GP for an annual health check. He was found to be hypertensive
and his GP started ramipril 2.5mg OD. His other medications include lansoprazole 30mg OD,
furosemide 20mg OD and atorvastatin 40mg ON
An ECG is normal.
Which of the following represents the most appropriate management plan, in addition to rechecking the U+E's?
Swap ramipril for another anti-hypertensive
4
A 79-year-old female, newly diagnosed as hypertensive is taken to the emergency department
with collapse. She recalls feeling 'giddy' moments before. She had just started a new medication
from her GP.
Her past medical history includes: type II diabetes mellitus, glaucoma, diverticular disease.
Which of the following medications is she most likely to have just started?
Ramipril
5
A 57-year-old man comes to the emergency department with severe, central, crushing chest pain.
By the time he arrives on the medical admissions unit he is pain-free.
He had a myocardial infarction (MI) two years ago; additionally he has type 2 diabetes mellitus,
hypertension and hypercholesterolaemia. His brother died of a MI at a similar age. His repeat
prescriptions include aspirin, metformin, ramipril, amlodipine and atorvastatin.
On examination he looks pale and sweaty. On auscultation he has vesicular breathing and normal
heart sounds. He is overweight.
His oxygen saturations are 98% on air; respiratory rate 14 breaths per minute; blood pressure
150/88 mmHg, heart rate 90 beats per minute. His blood sugar (BM) is 22.5.
There are no ischaemic changes on his ECG; however a 12 hour troponin is elevated. The
admitting doctor has already given aspirin, clopidogrel and fondaparinux.
What is the next step in the management of this patient?
Angiography within 72 hours
6
A 55-year-old man is admitted with central chest pain. His ECG shows ST depression in the inferior
leads and the chest pain requires intravenous morphine to settle. Past medical history includes a
thrombolysed myocardial infarction 2 years ago, asthma and type 2 diabetes mellitus. Treatment
with aspirin, clopidogrel and unfractionated heparin is commenced. Which one of the following
factors should determine if an intravenous glycoprotein IIb/IIIa receptor antagonist is to be given?
High GRACE (Global Registry of Acute Cardiac Events) risk score + whether a percutaneous coronary intervention is to be performed
7
You review a patient who has been admitted with a non-ST elevation myocardial infarction in the
Emergency Department. They have so far been treated with aspirin 300mg stat and glyceryl
trinitrate spray (2 puffs). Following recent NICE guidance, which patients should receive ticagrelor?
All patients
8
You are an SHO working at district general hospital in Cornwall. A 56-year-old man presents to the
emergency department with crushing central chest pain that started 30 minutes ago. His ECG
demonstrates ST elevation in the anterior leads and he is treated for an ST-elevation myocardial
infarction (STEMI). So far he has been given aspirin, clopidogrel, low-molecular weight heparin
(LMWH) and his chest pain has significantly improved with sublingual GTN and IV morphine +
metoclopramide. There is no cath-lab on site and and the nearest percutaneous coronary
intervention (PCI) centre in Truro is approximately 2 œ hours away. Which of the following is the
most appropriate course of action?
Give alteplase
9
A 74-year-old man is admitted with chest pain associated with ECG changes. A troponin T taken
12 hours after admission indicates an acute myocardial infarction. Which one of the following is
most likely to predict a poor prognosis?
Left ventricular ejection fraction of 40%
10
A 36-year-old male presents with chest pain, the chest pain is left-sided and dull in nature. It has
been present for a period of five days. There is no associated shortness of breath, cough, collapse
or pleuritic nature of the chest pain. He describes a recent sore throat and headache last week
which has since resolved. There is no family history in a first-degree relative of sudden cardiac
death and the patient has never smoked.
Blood pressure 125/89 mmHg, heart rate 95/min, temperature 37.3ºC, oxygen saturations 97% on
room air. Pulsus paradoxus is not present.
Blood results reveal:
...
Electrocardiogram (ECG): ST-segment elevation in lead I, II, III, aVL, V5 and V6. PR segment
elevation in aVR.
What is the most likely diagnosis in this patient?
Pericarditis
11
A 30-year-old man presents to the Emergency Department with several days of progressive chest
pain, pleuritic in nature and worse on lying down. He achieves some relief from the pain by sitting
forward.
On examination, a pericardial rub is noted when leaning forward.
Given the most likely diagnosis, which of the following electrocardiogram (ECG) findings is most
specific?
PR depression
12
A 45-year-old man presents with pleuritic central chest pain and flu-like symptoms to the
Emergency Department. The pain started yesterday and is worse at night when he lies flat. Which
one of the following ECG findings is most specific for the likely diagnosis?
PR depression
13
A 41-year-old man is admitted with left-sided pleuritic chest pain. He has a dry cough and reports
that the pain is relieved by sitting forward. For the past three days he has been experiencing flulike symptoms. Given the likely diagnosis, what is the most likely finding on ECG?
Widespread ST elevation
14
A 30-year-old woman presents to the Emergency Department with a one-day history of central
chest pain. The pain is described as severe, non-radiating and eases on expiration. Clinical
examination of her cardiorespiratory system is unremarkable other than a heart rate of 96 / min.
An ECG shows widespread ST elevation in the anterior, inferior and lateral leads. Bloods show the
following:
....
...
What is the most likely diagnosis?
Acute pericarditis
15
A 65-year-old man is admitted to the Emergency Department with chest pain, nausea and feeling
lethargic. He has a history of type 1 diabetes mellitus and is known to have chronic kidney disease
stage 4 secondary to diabetic nephropathy. An ECG taken on admission shows widespread ST
elevation. Bloods tests show the following:
...
...
An echocardiogram shows a small effusion. What is the most appropriate next step in
management?
Haemodialysis
16
A 26-year-old female is referred to the acute medical unit with chest pain. The pain is sharp, leftsided, worse on inspiration and worsened by lying flat. She has no significant past medical history
and is on no regular medications except the combined oral contraceptive pill. She does not drink
or smoke.
Her observations are heart rate 91 beats per minute, blood pressure 128/84 mmHg, respiratory
rate 18/minute, oxygen saturations 98% on room air and temperature 37.4ºC.
Clinical examination is unremarkable.
An ECG demonstrates widespread ST elevation and PR depression in all leads.
Blood tests:
...
...
A transthoracic echocardiogram demonstrates a 0.9cm pericardial effusion.
What is the most appropriate immediate management?
Non-steroidal anti-inflammatory (NSAID) and colchicine
17
Which one of the following may reduce the effects of adenosine?
Aminophylline
18
A 36-year-old man has presented to the emergency department with palpitations. His heart rate
was 138 beats per minute and an ECG showed a likely supraventricular tachycardia. The registrar
asks you to draw up 6mg of adenosine.
Which of the following drugs may reduce the action of adenosine?
Aminophylline
19
A 66-year-old man with no past medical history of note presents with central chest pain to the
Emergency Department. An ECG shows ST elevation in the anterior leads. He is given aspirin and
ticagrelor before going for a percutaneous coronary intervention. What is the mechanism of
action of ticagrelor?
Inhibits ADP binding to its platelet receptor
20
A 56-year-old man presented with central chest pain at rest and associated difficulty in breathing.
He has a background of hypertension, type-2 diabetes mellitus and hypercholesterolaemia. He is a
non-smoker. His ECG showed inferior and lateral T-wave inversion with a significant positive
troponin rise in his blood test. As a result he was commenced on treatment for acute coronary
syndrome with aspirin, ticagrelor and fondaparinux. He had a normal echo-cardiogram and is
discharged from hospital a few days later as his symptoms improved with a diagnosis of a non-ST
segment elevation myocardial infarction (NSTEMI). He presents to his general practitioner towards
the end of the week with multiple short-lived episodes of difficulty in breathing.
What is the most likely cause for this patient's dyspnoea?
Ticagrelor-associated side effect
21
A 56-year-old Asian man presented with chest pain to the emergency department. He was
diagnosed with a non-ST elevation myocardial infarction following initial investigations. He was
treated with dual anti-platelet therapy, with both aspirin and ticagrelor, as well as subcutaneous
fondaparinux. A few days after starting the treatment he reported feeling short of breath.
What is the mechanism of the action of the offending drug in this case?
Inhibits ADP binding to platelet receptors
22
A 70-year-old man comes to the emergency department with sudden onset chest pain that is
radiating to his left shoulder. He had a past medical history of a previous transient ischaemic
attack two years ago for which he is taking aspirin 75mg OD.
An initial ECG was performed.
..
..
He was managed with percutaneous coronary intervention with a drug-eluting stent and was
haemodynamically stable after the procedure. He is given ramipril, ticagrelor, simvastatin and
atenolol as part of further management.
Which of the following best describes the mechanism of action of the newly prescribed
antiplatelet medication?
Inhibit the binding of ADP to platelets
23
A 68-year-old man has recently been discharged from hospital following a non-ST-elevation
myocardial infarction (NSTEMI).
He has a history of angina, hypertension and hypercholesterolaemia and was already taking
aspirin, atorvastatin, bisoprolol and ramipril prior to his NSTEMI.
Following his hospital discharge, he has been instructed to also take ticagrelor for the next 12
months.
What is the mechanism of action of this newly-started drug?
P2Y12 receptor antagonist
24
You are part of the cardiac arrest team and are called to see a 72-year-old man who was admitted
to the care of the elderly ward. He presented with shortness of breath, productive cough and
hypoxia. He was being treated for community-acquired pneumonia with IV antibiotics. His early
warning score has continued to worsen throughout the day and then he became unresponsive.
There were no signs of life, therefore, chest compressions were commenced by the ward staff and
the crash call was put out. The first rhythm check shows the patient is in ventricular fibrillation.
Apart from restarting chest compressions, what should be the next step taken as part of the
advance life support algorithm?
1 shock
25
The cardiac arrest team is called to the bedside of a 67-year-old male patient, 2 days postmyocardial infarction. Two nurses are currently performing chest compressions and a manual
defibrillator has just been attached. Chest compressions are paused briefly so that the rhythm can
be analysed: pulseless electrical activity is observed.
Given the above, which of the following should happen in this scenario?
Adrenaline should be commenced immediately
26
A 64-year-old patient is admitted to the hospital for an ST-elevation myocardial infarction and is
promptly transferred to the catheter lab for percutaneous coronary intervention. During the
procedure, whilst connected to monitoring, he is witnessed as having a cardiac arrest and the
rhythm is noted to be ventricular tachycardia.
Which of the following is the most appropriate immediate action?
Deliver three successive shocks
27
A 62-year-old male with a recent myocardial infarction goes into ventricular fibrillation on the
coronary care unit. This is recorded on his heart monitor.
An emergency call is put out and a defibrillator is immediately brought over.
What is the most appropriate course of action?
Administer three successive shocks, then commence CPR
28
A 55-year-old man with chest pain collapsed in the emergency department while waiting to be
seen. The triage nurse assessed him and could not feel the carotid pulse, so started chest
compressions immediately. After moving to the resuscitation bay, the patient was connected to
the defibrillator using adult pads. Once the monitor was turned on, chest compressions were
interrupted for rhythm analysis. The monitor showed wide complex polymorphic ventricular
tachycardia at 150 bpm. There was no palpable carotid pulse.
What is the immediate course of action to resuscitate this patient?
Deliver unsynchronized shock at 200 J
29
Nursing staff report that a 65-year-old with a past medical history of ischaemic heart disease
appears unwell on the ward.
Upon the arrival of the medical team, the patient is unresponsive. A broad complex tachycardia is
noted on telemetry at a rate of 150 beats per minute. A pulse is not palpable.
What is the appropriate treatment?
Defibrillation
30
You are working a medical ward cover shift when a crash call is put out for a 64-year-old man
arrested on the ward. He was admitted this morning with acute breathlessness and pleuritic chest
pain and is being treated as a likely pulmonary embolus with treatment-dose dalteparin whilst he
awaits his CT pulmonary angiogram.
When you arrive, the first cycle of cardiopulmonary resuscitation is underway. He has a laryngeal
mask airway in situ with good effect. After 2 minutes of chest compressions, the defibrillator
shows normal sinus rhythm. He does not have a palpable central pulse.
What is the most appropriate immediate treatment?
Adrenaline 1mg 1:10000
31
An elderly patient on the oncology ward has a cardiac arrest. You start compressions and the
resuscitation team are contacted. Assessment of the rhythm shows ventricular tachycardia (VT).
Three cycles of CPR are performed and successive shocks given.
After the third shock which two medications are indicated in the ALS protocol?
Amiodarone 300mg and adrenaline 1mg
32
You are a doctor on the evening cardiac arrest team.
An emergency bleep has occurred stating the need for immediate attendance on the colorectal
ward.
You are the first doctor to arrive and find chest compressions being performed by the nursing
staff.
On assessment, there is no response from the patient and an absent carotid pulse.
You ask for chest compressions to continue whilst defibrillator pads are applied to the patient's
chest.
After asking for a pause in chest compressions the defibrillator monitor shows a monomorphic,
broad complex tachycardia.
What is the most appropriate next step in management?
Immediately give 1 defibrillator shock followed by CPR
33
A 54-year-old man with known ischaemic heart disease presents with acute onset palpitations and
shortness of breath.
He is found to be in a tachyarrhythmia with evidence of instability and therefore electrocardioversion is attempted. Unfortunately, this fails to restore sinus rhythm and so amiodarone is
given IV whilst a cardiology opinion is sought.
Due to its half-life time an initial loading dose is required followed by a continuous infusion over
24 hours which, once started, reverts the patient into sinus rhythm.
How long is the half-life of this antiarrhythmic agent?
Approximately 20-100 days
34
A patient develops a broad complex tachycardia two days following a myocardial infarction.
Intravenous amiodarone is given.
Which one of the following best describes the primary mechanism of action of amiodarone?
Blocks voltage-gated potassium channels
35
What is the main reason for checking the urea and electrolytes prior to commencing a patient on
amiodarone?
To detect hypokalaemia
36
A 75-year-old man is admitted after feeling faint and complaining of palpitations. An ECG taken in
the department shows a ventricular tachyarrhythmia. His blood pressure is stable. Treatment with
IV amiodarone is commenced, with a loading dose being given initially.
What is the reason for the loading dose being given?
Long half-life of amiodarone
37
A 65-year-old man has been started on amiodarone. He has been told he must first take higher
doses and then continue on a lower maintenance dose long-term.
What is the reasoning behind this initial dose regime?
Slow metabolism of amiodarone due to extensive lipid binding
38
A 58-year-old man with a background history of hypertension presents to the emergency
department with palpitations. The symptoms started suddenly, six hours prior to his attendance.
There was no chest pain, dizziness or shortness of breath.
His observations were heart rate 163/min, blood pressure 155/92 mmHg, respiratory rate 17/min,
oxygen saturations 98% on air and temperature 36.2ºC. On examination, his pulse was irregularly
irregular. There was no clinical evidence of pulmonary oedema. His Glasgow coma scale was 15.
An ECG demonstrated atrial fibrillation with a fast ventricular response.
Despite treatment with IV fluids, IV metoprolol and IV digoxin, he remained tachycardic at 162
beats per minute.
Given the onset of symptoms was less than 48 hours ago, a decision was made to attempt
chemical cardioversion with amiodarone. A loading dose is administered initially, followed by an
infusion.
What pharmacological feature of amiodarone make a loading dose necessary?
Long half-life
39
A 63-year-old woman was successfully cardioverted for an unstable broad complex tachycardia.
The cardiologist decides to commence oral amiodarone at 200mg three times a day, and wean at
weekly intervals until a maintenance dose of 200mg once daily.
What is the reason for this dosing strategy?
Amiodarone has a very long half-life
40
A 54-year-old man is reviewed in the cardiology clinic. He has a diagnosis of stable angina and
was started on isosorbide mononitrate 20mg twice daily at his last appointment. His other
medication includes low dose aspirin, atorvastatin, bisoprolol, nifedipine and glyceryl trinitrate
sublingual spray as required.
During the consultation he complains that at first his isosorbide mononitrate helped control his
angina, however shortly after starting the medication he noticed his anginal symptoms began to
recur.
What is the most appropriate next step in managing this patient's symptoms?
Recommend asymmetric dosing regimen of isosorbide mononitrate
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1
A 51-year-old man presents four weeks after being discharged from hospital. He had been
admitted with chest pain and thrombolysed for a myocardial infarction. This morning he
developed marked tongue and facial swelling. Which one of the following drugs is most likely to
be responsible?
Ramipril
2
A 51-year-old man is started on lisinopril after being found to have an average blood pressure of
154/93 on ambulatory blood pressure monitoring. Around two weeks after starting treatment he
represents with a persistent dry cough. Accumulation of which one of the following proteins is
responsible for this?
Bradykinin
3
A 64-year-old man attends his GP for an annual health check. He was found to be hypertensive
and his GP started ramipril 2.5mg OD. His other medications include lansoprazole 30mg OD,
furosemide 20mg OD and atorvastatin 40mg ON
An ECG is normal.
Which of the following represents the most appropriate management plan, in addition to rechecking the U+E's?
Swap ramipril for another anti-hypertensive
4
A 79-year-old female, newly diagnosed as hypertensive is taken to the emergency department
with collapse. She recalls feeling 'giddy' moments before. She had just started a new medication
from her GP.
Her past medical history includes: type II diabetes mellitus, glaucoma, diverticular disease.
Which of the following medications is she most likely to have just started?
Ramipril
5
A 57-year-old man comes to the emergency department with severe, central, crushing chest pain.
By the time he arrives on the medical admissions unit he is pain-free.
He had a myocardial infarction (MI) two years ago; additionally he has type 2 diabetes mellitus,
hypertension and hypercholesterolaemia. His brother died of a MI at a similar age. His repeat
prescriptions include aspirin, metformin, ramipril, amlodipine and atorvastatin.
On examination he looks pale and sweaty. On auscultation he has vesicular breathing and normal
heart sounds. He is overweight.
His oxygen saturations are 98% on air; respiratory rate 14 breaths per minute; blood pressure
150/88 mmHg, heart rate 90 beats per minute. His blood sugar (BM) is 22.5.
There are no ischaemic changes on his ECG; however a 12 hour troponin is elevated. The
admitting doctor has already given aspirin, clopidogrel and fondaparinux.
What is the next step in the management of this patient?
Angiography within 72 hours
6
A 55-year-old man is admitted with central chest pain. His ECG shows ST depression in the inferior
leads and the chest pain requires intravenous morphine to settle. Past medical history includes a
thrombolysed myocardial infarction 2 years ago, asthma and type 2 diabetes mellitus. Treatment
with aspirin, clopidogrel and unfractionated heparin is commenced. Which one of the following
factors should determine if an intravenous glycoprotein IIb/IIIa receptor antagonist is to be given?
High GRACE (Global Registry of Acute Cardiac Events) risk score + whether a percutaneous coronary intervention is to be performed
7
You review a patient who has been admitted with a non-ST elevation myocardial infarction in the
Emergency Department. They have so far been treated with aspirin 300mg stat and glyceryl
trinitrate spray (2 puffs). Following recent NICE guidance, which patients should receive ticagrelor?
All patients
8
You are an SHO working at district general hospital in Cornwall. A 56-year-old man presents to the
emergency department with crushing central chest pain that started 30 minutes ago. His ECG
demonstrates ST elevation in the anterior leads and he is treated for an ST-elevation myocardial
infarction (STEMI). So far he has been given aspirin, clopidogrel, low-molecular weight heparin
(LMWH) and his chest pain has significantly improved with sublingual GTN and IV morphine +
metoclopramide. There is no cath-lab on site and and the nearest percutaneous coronary
intervention (PCI) centre in Truro is approximately 2 œ hours away. Which of the following is the
most appropriate course of action?
Give alteplase
9
A 74-year-old man is admitted with chest pain associated with ECG changes. A troponin T taken
12 hours after admission indicates an acute myocardial infarction. Which one of the following is
most likely to predict a poor prognosis?
Left ventricular ejection fraction of 40%
10
A 36-year-old male presents with chest pain, the chest pain is left-sided and dull in nature. It has
been present for a period of five days. There is no associated shortness of breath, cough, collapse
or pleuritic nature of the chest pain. He describes a recent sore throat and headache last week
which has since resolved. There is no family history in a first-degree relative of sudden cardiac
death and the patient has never smoked.
Blood pressure 125/89 mmHg, heart rate 95/min, temperature 37.3ºC, oxygen saturations 97% on
room air. Pulsus paradoxus is not present.
Blood results reveal:
...
Electrocardiogram (ECG): ST-segment elevation in lead I, II, III, aVL, V5 and V6. PR segment
elevation in aVR.
What is the most likely diagnosis in this patient?
Pericarditis
11
A 30-year-old man presents to the Emergency Department with several days of progressive chest
pain, pleuritic in nature and worse on lying down. He achieves some relief from the pain by sitting
forward.
On examination, a pericardial rub is noted when leaning forward.
Given the most likely diagnosis, which of the following electrocardiogram (ECG) findings is most
specific?
PR depression
12
A 45-year-old man presents with pleuritic central chest pain and flu-like symptoms to the
Emergency Department. The pain started yesterday and is worse at night when he lies flat. Which
one of the following ECG findings is most specific for the likely diagnosis?
PR depression
13
A 41-year-old man is admitted with left-sided pleuritic chest pain. He has a dry cough and reports
that the pain is relieved by sitting forward. For the past three days he has been experiencing flulike symptoms. Given the likely diagnosis, what is the most likely finding on ECG?
Widespread ST elevation
14
A 30-year-old woman presents to the Emergency Department with a one-day history of central
chest pain. The pain is described as severe, non-radiating and eases on expiration. Clinical
examination of her cardiorespiratory system is unremarkable other than a heart rate of 96 / min.
An ECG shows widespread ST elevation in the anterior, inferior and lateral leads. Bloods show the
following:
....
...
What is the most likely diagnosis?
Acute pericarditis
15
A 65-year-old man is admitted to the Emergency Department with chest pain, nausea and feeling
lethargic. He has a history of type 1 diabetes mellitus and is known to have chronic kidney disease
stage 4 secondary to diabetic nephropathy. An ECG taken on admission shows widespread ST
elevation. Bloods tests show the following:
...
...
An echocardiogram shows a small effusion. What is the most appropriate next step in
management?
Haemodialysis
16
A 26-year-old female is referred to the acute medical unit with chest pain. The pain is sharp, leftsided, worse on inspiration and worsened by lying flat. She has no significant past medical history
and is on no regular medications except the combined oral contraceptive pill. She does not drink
or smoke.
Her observations are heart rate 91 beats per minute, blood pressure 128/84 mmHg, respiratory
rate 18/minute, oxygen saturations 98% on room air and temperature 37.4ºC.
Clinical examination is unremarkable.
An ECG demonstrates widespread ST elevation and PR depression in all leads.
Blood tests:
...
...
A transthoracic echocardiogram demonstrates a 0.9cm pericardial effusion.
What is the most appropriate immediate management?
Non-steroidal anti-inflammatory (NSAID) and colchicine
17
Which one of the following may reduce the effects of adenosine?
Aminophylline
18
A 36-year-old man has presented to the emergency department with palpitations. His heart rate
was 138 beats per minute and an ECG showed a likely supraventricular tachycardia. The registrar
asks you to draw up 6mg of adenosine.
Which of the following drugs may reduce the action of adenosine?
Aminophylline
19
A 66-year-old man with no past medical history of note presents with central chest pain to the
Emergency Department. An ECG shows ST elevation in the anterior leads. He is given aspirin and
ticagrelor before going for a percutaneous coronary intervention. What is the mechanism of
action of ticagrelor?
Inhibits ADP binding to its platelet receptor
20
A 56-year-old man presented with central chest pain at rest and associated difficulty in breathing.
He has a background of hypertension, type-2 diabetes mellitus and hypercholesterolaemia. He is a
non-smoker. His ECG showed inferior and lateral T-wave inversion with a significant positive
troponin rise in his blood test. As a result he was commenced on treatment for acute coronary
syndrome with aspirin, ticagrelor and fondaparinux. He had a normal echo-cardiogram and is
discharged from hospital a few days later as his symptoms improved with a diagnosis of a non-ST
segment elevation myocardial infarction (NSTEMI). He presents to his general practitioner towards
the end of the week with multiple short-lived episodes of difficulty in breathing.
What is the most likely cause for this patient's dyspnoea?
Ticagrelor-associated side effect
21
A 56-year-old Asian man presented with chest pain to the emergency department. He was
diagnosed with a non-ST elevation myocardial infarction following initial investigations. He was
treated with dual anti-platelet therapy, with both aspirin and ticagrelor, as well as subcutaneous
fondaparinux. A few days after starting the treatment he reported feeling short of breath.
What is the mechanism of the action of the offending drug in this case?
Inhibits ADP binding to platelet receptors
22
A 70-year-old man comes to the emergency department with sudden onset chest pain that is
radiating to his left shoulder. He had a past medical history of a previous transient ischaemic
attack two years ago for which he is taking aspirin 75mg OD.
An initial ECG was performed.
..
..
He was managed with percutaneous coronary intervention with a drug-eluting stent and was
haemodynamically stable after the procedure. He is given ramipril, ticagrelor, simvastatin and
atenolol as part of further management.
Which of the following best describes the mechanism of action of the newly prescribed
antiplatelet medication?
Inhibit the binding of ADP to platelets
23
A 68-year-old man has recently been discharged from hospital following a non-ST-elevation
myocardial infarction (NSTEMI).
He has a history of angina, hypertension and hypercholesterolaemia and was already taking
aspirin, atorvastatin, bisoprolol and ramipril prior to his NSTEMI.
Following his hospital discharge, he has been instructed to also take ticagrelor for the next 12
months.
What is the mechanism of action of this newly-started drug?
P2Y12 receptor antagonist
24
You are part of the cardiac arrest team and are called to see a 72-year-old man who was admitted
to the care of the elderly ward. He presented with shortness of breath, productive cough and
hypoxia. He was being treated for community-acquired pneumonia with IV antibiotics. His early
warning score has continued to worsen throughout the day and then he became unresponsive.
There were no signs of life, therefore, chest compressions were commenced by the ward staff and
the crash call was put out. The first rhythm check shows the patient is in ventricular fibrillation.
Apart from restarting chest compressions, what should be the next step taken as part of the
advance life support algorithm?
1 shock
25
The cardiac arrest team is called to the bedside of a 67-year-old male patient, 2 days postmyocardial infarction. Two nurses are currently performing chest compressions and a manual
defibrillator has just been attached. Chest compressions are paused briefly so that the rhythm can
be analysed: pulseless electrical activity is observed.
Given the above, which of the following should happen in this scenario?
Adrenaline should be commenced immediately
26
A 64-year-old patient is admitted to the hospital for an ST-elevation myocardial infarction and is
promptly transferred to the catheter lab for percutaneous coronary intervention. During the
procedure, whilst connected to monitoring, he is witnessed as having a cardiac arrest and the
rhythm is noted to be ventricular tachycardia.
Which of the following is the most appropriate immediate action?
Deliver three successive shocks
27
A 62-year-old male with a recent myocardial infarction goes into ventricular fibrillation on the
coronary care unit. This is recorded on his heart monitor.
An emergency call is put out and a defibrillator is immediately brought over.
What is the most appropriate course of action?
Administer three successive shocks, then commence CPR
28
A 55-year-old man with chest pain collapsed in the emergency department while waiting to be
seen. The triage nurse assessed him and could not feel the carotid pulse, so started chest
compressions immediately. After moving to the resuscitation bay, the patient was connected to
the defibrillator using adult pads. Once the monitor was turned on, chest compressions were
interrupted for rhythm analysis. The monitor showed wide complex polymorphic ventricular
tachycardia at 150 bpm. There was no palpable carotid pulse.
What is the immediate course of action to resuscitate this patient?
Deliver unsynchronized shock at 200 J
29
Nursing staff report that a 65-year-old with a past medical history of ischaemic heart disease
appears unwell on the ward.
Upon the arrival of the medical team, the patient is unresponsive. A broad complex tachycardia is
noted on telemetry at a rate of 150 beats per minute. A pulse is not palpable.
What is the appropriate treatment?
Defibrillation
30
You are working a medical ward cover shift when a crash call is put out for a 64-year-old man
arrested on the ward. He was admitted this morning with acute breathlessness and pleuritic chest
pain and is being treated as a likely pulmonary embolus with treatment-dose dalteparin whilst he
awaits his CT pulmonary angiogram.
When you arrive, the first cycle of cardiopulmonary resuscitation is underway. He has a laryngeal
mask airway in situ with good effect. After 2 minutes of chest compressions, the defibrillator
shows normal sinus rhythm. He does not have a palpable central pulse.
What is the most appropriate immediate treatment?
Adrenaline 1mg 1:10000
31
An elderly patient on the oncology ward has a cardiac arrest. You start compressions and the
resuscitation team are contacted. Assessment of the rhythm shows ventricular tachycardia (VT).
Three cycles of CPR are performed and successive shocks given.
After the third shock which two medications are indicated in the ALS protocol?
Amiodarone 300mg and adrenaline 1mg
32
You are a doctor on the evening cardiac arrest team.
An emergency bleep has occurred stating the need for immediate attendance on the colorectal
ward.
You are the first doctor to arrive and find chest compressions being performed by the nursing
staff.
On assessment, there is no response from the patient and an absent carotid pulse.
You ask for chest compressions to continue whilst defibrillator pads are applied to the patient's
chest.
After asking for a pause in chest compressions the defibrillator monitor shows a monomorphic,
broad complex tachycardia.
What is the most appropriate next step in management?
Immediately give 1 defibrillator shock followed by CPR
33
A 54-year-old man with known ischaemic heart disease presents with acute onset palpitations and
shortness of breath.
He is found to be in a tachyarrhythmia with evidence of instability and therefore electrocardioversion is attempted. Unfortunately, this fails to restore sinus rhythm and so amiodarone is
given IV whilst a cardiology opinion is sought.
Due to its half-life time an initial loading dose is required followed by a continuous infusion over
24 hours which, once started, reverts the patient into sinus rhythm.
How long is the half-life of this antiarrhythmic agent?
Approximately 20-100 days
34
A patient develops a broad complex tachycardia two days following a myocardial infarction.
Intravenous amiodarone is given.
Which one of the following best describes the primary mechanism of action of amiodarone?
Blocks voltage-gated potassium channels
35
What is the main reason for checking the urea and electrolytes prior to commencing a patient on
amiodarone?
To detect hypokalaemia
36
A 75-year-old man is admitted after feeling faint and complaining of palpitations. An ECG taken in
the department shows a ventricular tachyarrhythmia. His blood pressure is stable. Treatment with
IV amiodarone is commenced, with a loading dose being given initially.
What is the reason for the loading dose being given?
Long half-life of amiodarone
37
A 65-year-old man has been started on amiodarone. He has been told he must first take higher
doses and then continue on a lower maintenance dose long-term.
What is the reasoning behind this initial dose regime?
Slow metabolism of amiodarone due to extensive lipid binding
38
A 58-year-old man with a background history of hypertension presents to the emergency
department with palpitations. The symptoms started suddenly, six hours prior to his attendance.
There was no chest pain, dizziness or shortness of breath.
His observations were heart rate 163/min, blood pressure 155/92 mmHg, respiratory rate 17/min,
oxygen saturations 98% on air and temperature 36.2ºC. On examination, his pulse was irregularly
irregular. There was no clinical evidence of pulmonary oedema. His Glasgow coma scale was 15.
An ECG demonstrated atrial fibrillation with a fast ventricular response.
Despite treatment with IV fluids, IV metoprolol and IV digoxin, he remained tachycardic at 162
beats per minute.
Given the onset of symptoms was less than 48 hours ago, a decision was made to attempt
chemical cardioversion with amiodarone. A loading dose is administered initially, followed by an
infusion.
What pharmacological feature of amiodarone make a loading dose necessary?
Long half-life
39
A 63-year-old woman was successfully cardioverted for an unstable broad complex tachycardia.
The cardiologist decides to commence oral amiodarone at 200mg three times a day, and wean at
weekly intervals until a maintenance dose of 200mg once daily.
What is the reason for this dosing strategy?
Amiodarone has a very long half-life
40
A 54-year-old man is reviewed in the cardiology clinic. He has a diagnosis of stable angina and
was started on isosorbide mononitrate 20mg twice daily at his last appointment. His other
medication includes low dose aspirin, atorvastatin, bisoprolol, nifedipine and glyceryl trinitrate
sublingual spray as required.
During the consultation he complains that at first his isosorbide mononitrate helped control his
angina, however shortly after starting the medication he noticed his anginal symptoms began to
recur.
What is the most appropriate next step in managing this patient's symptoms?
Recommend asymmetric dosing regimen of isosorbide mononitrate