PM 23 from 1 to 100 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
41
A 55-year-old man is reviewed in the rapid access chest pain clinic with a history of central chest
pain on exertion, relieved by rest. He is currently taking no regular medications and has no drug
allergies.
Which of the following therapies should he be prescribed to reduce the frequency of his
symptoms?
Bisoprolol
42
A 68-year-old man presents to you with intermittent left-sided crushing chest pain which is
brought on by walking his dog on an incline. The pain settles within a couple of minutes of rest
and glyceryl trinitrate (GTN) spray. The pain is not associated with shortness of breath or
lightheadedness.
He first presented to you with these same symptoms six months ago, at this time you gave him
lifestyle advice and prescribed bisoprolol, aspirin, GTN and atorvastatin. He has noted only
minimal improvement of his symptoms over the last six months.
On examination he is comfortable at rest, with blood pressure 124/73 mmHg, heart rate 63
beats/minute, oxygen saturation 99%, respiratory rate 18 breaths/minute and he is afebrile. His
chest is clear, and heart sounds are normal. ECG shows normal sinus rhythm, with no ischaemic
changes. He is also awaiting a CT coronary angiography.
What would be the next stage of treatment for this patient?
Add nifedipine
43
A 48-year-old man with known stable angina is reviewed in the cardiac clinic. He takes aspirin and
a statin and is established on a maximum dose calcium channel and beta-blocker however he is
still experiencing chest discomfort on exertions requiring the use of his sublingual glyceryl
trinitrate spray.
He is to be started on a third medication however due to the potential of tolerance with the
standard-release form of this medication, an asymmetrical dosing regime is required. The regime
and potential side effects are explained to the patient.
What medication is the patient due to be started on?
Isosorbide mononitrate
44
A 56-year-old male is seen in the cardiology clinic after experiencing episodes of chest tightness
on exertion. After appropriate investigation, his GP diagnosed angina and initially provided
lifestyle advice and started him on aspirin, a statin and a sublingual glyceryl trinitrate spray.
The patient otherwise well with no other past medical history and is not on any other regular
medications.
On review in the clinic today the patient, unfortunately, reports ongoing episodes of angina.
His examination and observations are normal and an ECG performed displays normal sinus
rhythm.
What is the most appropriate next course of action?
Commence on verapamil
45
A 52-year-old man is seen in the clinic after originally being referred with progressively increasing
central chest pain but base level investigations, including ECGs and troponin level return within
normal range.
The pain is exercise dependent with it occurring when the patient carries out activities such as
climbing stairs and resolving on rest. As such the patient was started on atenolol 100mg OD along
with a GTN spray and aspirin.
On review today the patient still reports symptoms of chest pain on exertion despite good
compliance.
What alteration should be made to this patientâs management?
Add nifedipine
46
A 72-year-old man is investigated for exertional chest pain and has a positive exercise tolerance
test. He declines an angiogram and is discharged on a combination of aspirin 75mg od,
simvastatin 40mg on, atenolol 50mg od and a GTN spray prn. Examination reveals a pulse of 72
bpm and a blood pressure of 130/80 mmHg. On review he is still regularly using his GTN spray.
What is the most appropriate next step in management?
Increase atenolol to 100mg od
47
An 82-year-old man is reviewed. He is known to have ischaemic heart disease and is still getting
regular attacks of angina despite taking atenolol 100mg od. Examination of his cardiovascular
system is unremarkable with a pulse of 72 bpm and a blood pressure of 148/92 mmHg. What is
the most appropriate next step in management?
Add nifedipine MR 30mg od
48
A 54-year-old man with atypical chest pain is referred to cardiology. An exercise ECG shows nonspecific ST and T wave changes. Following this an coronary angiogram is performed which
demonstrates no evidence of atherosclerosis. A diagnosis of Prinzmetal's angina is suspected.
What is the most appropriate first-line treatment?
Felodipine
49
A 60-year-old man who is investigated for exertional chest pain is diagnosed as having angina
pectoris. Which one of the following drugs is most likely to improve his long-term prognosis?
Aspirin
50
A 60-year-old man is referred to the cardiology clinic with recurrent exertional chest pain
associated with dyspnoea. It improves with rest. He has a history of ischaemic heart disease and
underwent PCI to the right coronary artery five years ago. A coronary angiogram six weeks ago
showed widely patent stents. His current medications include aspirin, ramipril, bisoprolol,
eplerenone, and atorvastatin. Recently, his GP started him on sildenafil for erectile dysfunction. On
assessment, his BP is 142/88 mmHg, and his heart rate is 70 bpm.
What medication should be added to improve his symptoms?
Nifedipine
51
A 64-year-old man presents to his general practitioner with chest tightness, worse on exertion. It
occurs after approximately 200m and then quickly subsides if he stops walking. He has a past
medical history of angina, hypertension and gastro-oesophageal reflux disease. He is currently
taking atenolol, lansoprazole, aspirin and atorvastatin.
The examination is unremarkable.
Given the likely diagnosis, what is the most appropriate management?
Add amlodipine
52
A 59-year-old woman is seen in clinic, with a history of chest pain upon exertion, relieved by rest.
Her pain never occurs at rest. She takes aspirin, atorvastatin and the maximum dose of atenolol,
but she is still persistently experiencing exertional chest pain. She has tolerated all medicines since
commencement.
What would be the best recommendation for the next step in her management?
Commence nifedipine
53
A 55-year-old man presents to the cardiology clinic with chest pain. He has a history of previous
ST-elevation myocardial infarction and angioplasty.
He describes periods of worsening stable angina limiting his exercise tolerance. His resting heart
rate is 60bpm. Recent echocardiography shows a left ventricular ejection fraction of 50-55%.
Current medications include amlodipine 10mg OD and bisoprolol 10mg OD.
What is the most appropriate medication to initiate while awaiting further investigation?
Isosorbide mononitrate (immediate release) BD at 0800 and 1400
54
An 87-year-old man with mild dementia presents to your GP practice.
He has a documented drug allergy to calcium channel blockers and has hypertension confirmed
on ambulatory blood pressure monitoring. He has developed an intolerable cough whilst trialling
ramipril.
He is otherwise fit and well and takes only donepezil. He is interested in taking anti-hypertensives
and you have a discussion with him regarding the anti-hypertensive most commonly used in this
scenario.
What is the mechanism of action of the next-line antihypertensive for this patient?
It prevents angiotensin 2 acting on AT1 receptors
55
You are the ST1 working on cardiology. The nurses have asked you to review a 56-year-old man
complaining of dyspnoea which is limiting his mobility.
He presented three days ago with an inferior STEMI. He was loaded with 300mg aspirin and
180mg ticagrelor before being taken to the cath-lab where he underwent primary PCI with a drug
eluting stent for a sub-total occlusion of the right coronary artery. He was subsequently
commenced on aspirin 100mg od, ticagrelor 90mg bd, atorvastatin 80mg od, bisoprolol 5mg od
and perindopril 5mg od. His echo demonstrated only mildly reduced LV systolic function (LVEF
50%).
His vital signs are stable with a blood pressure 125/70mmHg, heart rate 64bpm, oxygen
saturations 98% on room air and temperature 36.5ºC. Examination reveals dual heart sounds with
no murmurs and his chest is clear on auscultation with no wheeze. JVP is +2cm and there is no
peripheral oedema. His calves are soft and non tender. A Chest X-Ray shows mild atelectasis at
the bases. His bloods are unremarkable. His ecg shows normal sinus rhythm with inferior q waves.
With respect to his dyspnoea, what would be the next best step in his management?
Substitute ticagrelor for clopidogrel
56
A 75-year-old female presents diaphoretic and distressed with new onset sternal chest pain
radiating through to the back. She has a past history of hypertension on lercanidipine. On
examination her blood pressure is 190/70 mmHg and there is an early diastolic murmur heard
best at the left sternal edge. Her ECG is unremarkable. What is the next best course of action?
CT chest with contrast
57
Which one of the following conditions is most associated with aortic dissection?
Bicuspid aortic valve
58
Each one of the following is associated with aortic dissection, except:
Ventricular septal defect
59
A 79-year-old man is referred to the acute medical unit following a fall. He is unsure why he
collapsed but is now fully alert. He is complaining of abdominal pain but his bowel habits are
unchanged.
He has a past medical history of prostatism and hypertension. He tells you he doesn't take any
medication.
On examination he has a Glasgow coma scale score of 15, a blood pressure of 98/46 mmHg and a
heart rate of 98beats per minute
...
...
Which of the following is the next most appropriate step in this man's management?
CT aortic angiogram
60
A 63-year-old man presents to the Emergency Department with sudden chest pain. He describes
the pain as 'tearing'. He has a history of hypertension, for which he normally takes amlodipine.
On examination, he has a tachycardia of 112 beats per minute, his blood pressure is 135/80 in the
left arm and 85/65 in the right arm. Pulses are diminished in the legs.
Initially, the doctors request a CT angiogram to confirm the suspected diagnosis, but the patient is
too unstable for this.
Which alternative investigation would be most useful instead, as per guidance?
Transoesophageal echocardiography (TOE)
61
A 57-year-old man presents with sudden-onset, tearing chest pain. He has a history of Marfan
syndrome and hypertension. On examination, he is visibly shocked and observations are as
follows:
Blood pressure of 78/65 mmHg
Heart rate of 161 beats/minute
Respiratory rate of 42 breaths/minute
Oxygen saturation of 95% on 8L/minute oxygen flow
What is the most appropriate diagnostic investigation?
Transoesophageal echo
62
A 64-year-old man is admitted to the Emergency Department with chest pain radiating through to
his back. On examination pulse 90 regular, BP 140/90. A CXR shows mediastinal widening. A CT
shows dissection of the descending aorta. What is the most suitable initial management?
IV labetalol
63
A 72-year-old man presents to the emergency department with left-sided tearing chest pain. He
has a past medical history of hypertension and hypercholesterolemia. He is on regular amlodipine,
ramipril and indapamide. She smokes 30 cigarettes per day and drinks 3-4 beers each night. He
lives alone and is usually independent of all activities of daily living.
His observations are heart rate 101 beats per minute, blood pressure 182/97 mmHg, respiratory
rate 21/minute, oxygen saturations 97% on room air and he is apyrexial.
On clinical examination, chest auscultation demonstrates equal air entry bilaterally. Both heart
sounds are audible and there is a diastolic murmur audible at the lower left sternal edge in endexpiration. Abdominal and neurological examinations are normal.
An ECG demonstrates sinus tachycardia.
A plain radiograph of the chest is normal.
Blood tests:
...
...
CT angiography of the chest is organized, which demonstrates an intimal flap proximal to the
brachiocephalic vessels.
Given the diagnosis, what is the appropriate management?
Control blood pressure (IV labetalol) + surgery
64
A 69-year-old man has been brought to the emergency department by ambulance with sudden
onset tearing chest pain.
Cross-sectional imaging has confirmed a thoracic aortic dissection, involving the descending aorta
only. There is no evidence of malperfusion.
He is currently alert and orientated. His pulse rate is 100bpm and his blood pressure is
156/98mmHg.
What is the most appropriate treatment strategy for this patient?
Intravenous labetalol
65
A 65-year-old man is referred to the hospital by his GP with a 2-week history of worsening
shortness of breath. He reports sleeping in a chair due to breathlessness when lying flat and
awakens several times at night, struggling to breathe. He has a history of well-controlled
hypertension and childhood rheumatic fever. His medications are ramipril and amlodipine.
Observations:
Heart rate: 98bpm
Blood pressure: 170/56mmHg
Temperature: 36.7 C
Respiratory rate: 18/min
Saturations: 98% on room air
On examination, you notice pulsation in the patient's nail bed.
What murmur would you expect to hear on auscultation?
Early diastolic murmur
66
Which one of the following is least associated with aortic regurgitation?
William's syndrome
67
Which of the following conditions is not associated with the development of aortic regurgitation?
Dilated cardiomyopathy
68
A 72-year-old man presents to his general practitioner with shortness of breath. He has no past
medical history.
On examination, abrupt distension and collapse of the carotid arteries are noted along with
visualization of capillary pulsations with light compression applied to the fingernail bed.
What type of murmur is likely to be heard on auscultation?
Early diastolic
69
Which one of the following clinical signs would best indicate severe calcified aortic stenosis?
Displaced apex beat
70
A 68-year-old man with a past history of aortic stenosis is reviewed in clinic. Which one of the
following features would most guide the timing of surgery?
Symptomatology of patient
71
Which one of the following features would best indicate severe aortic stenosis?
Fourth heart sound
72
Which one of the following clinical signs would best indicate severe aortic stenosis?
Soft second heart sound
73
A 53-year-old man is reviewed in the cardiology clinic with a history of chest pain and syncope.
On examination he has an ejection systolic murmur radiating to the carotid area. What is the most
likely cause of his symptoms?
Bicuspid aortic valve
74
An elderly man with aortic stenosis is assessed. Which one of the following would make the
ejection systolic murmur quieter?
Left ventricular systolic dysfunction
75
An 82-year-old man is referred to cardiology by his GP with increasing dyspnoea on exertion and
a systolic murmur. Examination demonstrates a blood pressure of 100/80 mmHg and a slow rising
pulse. What is the most likely cause of his underlying condition?
Calcification of the aortic valve
76
A 62-year-old man comes for review. In the past month he has had two episodes of 'passing out'.
The first occurred whilst going upstairs. The second occurred last week whilst he was getting out
of a swimming pool. There were no warning signs prior to these episodes. He was told by people
who witnessed the episode last week that he was only 'out' for around 15 seconds. He reports
feeling 'groggy' for only a few seconds after the episode. On examination pulse is 90 / minute,
blood pressure 110/86 mmHg, his lungs are clear and there is a systolic murmur which radiates to
the carotid area. Which one of the following investigations should be arranged first?
Echocardiogram
77
A 65-year-old man is found to have an ejection systolic murmur and narrow pulse pressure on
examination. He has experienced no chest pain, breathlessness or syncope. An echo confirms
aortic stenosis and shows an aortic valve gradient of 36 mmHg. How should this patient be
managed?
Regular cardiology outpatient review
78
A 72-year-old woman has presented to the emergency department with severe breathlessness.
On examination, she is breathless at rest with a slow-rising pulse and a raised jugular venous
pressure. She has significant pitting oedema to her thighs with a degree of sacral oedema.
Observations show that her pulse is 78beats per minute, blood pressure 98/52mmHg, oxygen
saturations 95% on 40% inspired oxygen and respiratory rate 32 breaths per minute.
On auscultation there are absent breath sounds to bilateral lower zones with crepitations
throughout both upper lung fields. Her heart sounds demonstrate a murmur with S4 heart sound.
Which valvular pathology is most likely to be seen on echocardiogram?
Aortic stenosis
79
You are reviewing a 78-year-old man who has been admitted via the emergency department with
chest pain. History reveals that he has been struggling with shortness of breath, and that his wife
is worried as he briefly lost consciousness on one occasion.
Echocardiogram reveals aortic stenosis.
What examination finding would suggest that his condition is severe?
Fourth heart sound
80
A 22-year-old man was out with his friends when he suddenly reported not feeling well. He
reported he could feel his heart beating very fast and then collapsed. A bystander started CPR and
an ambulance was called. Resuscitation attempts continued for an hour but were unsuccessful. A
post mortem was carried out to ascertain the cause of death as the young man had no medical
problems. During post mortem, the right ventricle was noticed to be thin-walled and histology of
the right ventricle revealed fibro-fatty infiltration.
What is the most likely cause of death in this case?
Arrhythmogenic right ventricular cardiomyopathy
81
A 44-year-old man is seen in the cardiology clinic. For the past 6 months he has been
experiencing episodes of palpitations associated with pre-syncopal symptoms. An ECG taken in
clinic shows T wave inversion in leads V1-3 associated with a notch at the end of the QRS
complex. He is known to have a family history of sudden cardiac death. What is the most likely
diagnosis?
Arrhythmogenic right ventricular cardiomyopathy
82
Which one of the following statements regarding arrhythmogenic right ventricular
cardiomyopathy is correct?
It is characterised by fibrofatty infiltration of the right ventricular myocardium
83
A 24-year-old man presents to the emergency department with palpitations and pre-syncope. He
has no past medical history.
Observations:
Heart rate 82 beats per minute
Blood pressure 131/74 mmHg
Respiratory rate 18/minute
Oxygen saturations 97% on room air
The examination is unremarkable.
An ECG demonstrates T wave inversion and an epsilon wave in leads V1-V3
.
NT-proBNP
182 pg/ml
(<400)
Given the likely diagnosis, what is the expected pathological finding in this condition?
Right ventricular myocardium replaced by fatty and fibrofatty tissue
84
A 29-year-old woman presents to the cardiology clinic with frequent palpitations and episodes of
dizziness on exertion. She has no prior medical history. Her father passed away at age 33 by
sudden cardiac death.
Her 12-lead ECG at rest shows sinus rhythm with T wave inversion in V1-3, with a small positive
deflection at the end of the QRS complexes in V1-3.
A 24-hour Holter monitor shows evidence of frequent premature ventricular complexes and runs
of non-sustained ventricular tachycardia.
What is the most likely underlying pathological process?
Replacement of right ventricular free wall myocardium with fibrous and fatty tissue
85
A 66-year-old lady presented to the emergency department with a 5-minute history of right upper
limb weakness which spontaneously resolved. She had a past medical history of hypertension, for
which she is taking amlodipine 10mg once daily. She is not diabetic. She currently smokes 10
cigarettes a day. Her examination was remarkable for an irregularly irregular heartbeat.
Electrocardiogram confirms a diagnosis of atrial fibrillation. CT head showed no evidence of
intracranial haemorrhage. She is otherwise well with a normal renal function. What is the most
appropriate next step?
Commence the patient on anticoagulation
86
A usually fit and well 24-year-old man presented with palpitations in the early hours of the
morning after consuming a large amount of alcohol. He denied any chest pain or breathlessness.
On examination his pulse was 120 beats per minute and irregularly irregular. His blood pressure
was 124/70 mmHg. On auscultation his chest was clear.
An ECG showed atrial fibrillation with a ventricular rate of 118.
What is the most appropriate initial management?
Intravenous fluids
87
A 58-year-old man presents to the Emergency Department following an episode of transient
right-sided weakness which lasted approximately 20 minutes. He has had two previous episodes
of a similar nature. On examination he is found to be in atrial fibrillation at a rate of 80 bpm.
CT head
normal
He is started on aspirin 300mg od. Two days later he has a carotid doppler which is normal. What
is the most appropriate management?
Start a direct oral anticoagulant
88
A 76-year-old man is reviewed. He was recently admitted after being found to be in atrial
fibrillation. This was his second episode of atrial fibrillation. He also takes ramipril for hypertension
and has a history of mitral stenosis but has no other history of note. During admission, he was
warfarinised and discharged with planned follow-up in the cardiology clinic. However, on review
today he is found to be in sinus rhythm. What should happen regarding anticoagulation?
Continue lifelong warfarin
89
A 71-year-old man who is known to have atrial fibrillation comes for review. He had a transient
ischaemic attack two weeks ago and takes bendroflumethiazide for hypertension but is otherwise
well. His latest blood pressure is 124/76 mmHg. You are discussing management options to try
and reduce his future risk of having a stroke. What is his CHA DS -VASc score?
4
90
A 54-year-old male with no past medical history is found to be in atrial fibrillation during a
consultation regarding a sprained ankle. He reports no history of palpitations or dyspnoea. After
discussing treatment options he elects not to be cardioverted. Examination of the cardiovascular
system is otherwise unremarkable with a blood pressure of 118/76 mmHg. According to the latest
NICE guidelines, if the patient remains in chronic atrial fibrillation what is the most suitable
treatment to offer?
No treatment
91
A 51-year-old female presents to the Emergency Department following an episode of transient
right sided weakness lasting 10-15 minutes. Examination reveals the patient to be in atrial
fibrillation. If the patient remains in chronic atrial fibrillation what is the most suitable form of
anticoagulation?
Direct oral anticoagulant
92
A 75-year-old woman was admitted to the Acute Medical Unit with pneumonia. Her only past
medical history of note is transient ischaemic attack 2 months previously. On initial assessment,
ECG revealed atrial fibrillation with a ventricular rate of 103. She was treated with intravenous
fluids and antibiotics. She improved significantly. Two further ECGs overnight revealed normal
sinus rhythm. The following day, she was deemed medically fit for discharge.
What is the single most appropriate management option regarding her episode of atrial
fibrillation?
Oral anticoagulation
93
A 70-year-old man presented to the emergency department following a fall and head injury. This
is his third fall in the past 12 months. He has a background of persistent atrial fibrillation, type 2
diabetes mellitus and Parkinson's disease. He is taking apixaban 5mg BD, bisoprolol 5mg OD, cobeneldopa 100mg QDS, and metformin 1g BD.
CT head reveals no acute findings.
What is the most appropriate management regarding his anticoagulation?
Continue apixaban
94
A 35-year-old female has paroxysmal atrial fibrillation and was successfully treated with DC
cardioversion 1 week ago. She is now resultantly on warfarin. A subsequent post-cardioversion
echocardiogram shows no structural abnormalities.
How long should the warfarin be continued?
4 weeks
95
A 62-year-old man is reviewed two hours after a successful elective DC cardioversion for atrial
fibrillation. Six weeks ago he presented in fast atrial fibrillation. A decision was made at the time to
warfarinise him for six weeks after which he was to be cardioverted. During this time he had a
normal transthoracic echocardiogram. He has no past medical history of note other than
treatment for a basal cell carcinoma. What is the most appropriate plan regarding
anticoagulation?
Continue warfarinisation for 4 weeks then review
96
A 58-year-old woman with paroxysmal atrial fibrillation was admitted to a cardiology ward
overnight as she developed palpitations. A diagnosis of atrial fibrillation was made 6 months ago,
where apixaban was commenced. Subsequently, she had a successful elective cardioversion 6
weeks later. She has been taking her apixaban regularly and hasn't missed any doses. She had
been symptom-free until last night.
The consultant plans for the patient to be treated with a direct current cardioversion on the
theatre list today.
During which part of the electrocardiogram trace should a direct current cardioversion be
delivered on for this patient given her arrhythmia?
R wave
97
A 67-year-old man with a history of hypertension presents to the emergency department with a
24hr history of dyspnoea and palpitations. He also complains of mild chest discomfort. On
examination, you note an irregularly irregular pulse of 115 beats per minute, blood pressure 95 /
70 mmHg and a respiratory rate of 20 breaths/min. He denies any regular medication and insists
he has never experienced anything like this before. An ECG shows absent P waves with QRS
complexes irregularly irregular intervals.
What is the most appropriate management?
Direct current cardioversion
98
A 48-year-old gentleman presents with a 3-day history of palpitations. This is on a background of
recurrent atrial fibrillation with previous failed cardioversion attempts but had successful electrical
cardioversion 8 months previously. An ECG confirms that he is in atrial fibrillation with a rate of 80
beats per minute. He currently takes bisoprolol and apixaban. The cardiology consultant reviews
and has planned electrical cardioversion for 4 weeks time.
Until he is cardioverted, which of the following should be given in addition to his current
medications?
Amiodarone
99
You receive an emergency bleep to a 52-year-old woman who was admitted 6 hours ago with
atrial fibrillation with a fast ventricular response.
On arrival, you find her sweaty, tachypnoeic, and hypotensive. You note bibasal crepitations on
auscultation of the chest with irregular tachycardia. Cardiac monitoring shows atrial fibrillation at a
rate of 140-170 bpm.
A decision is made to perform emergency DC cardioversion. The on-call anaesthetist is in
attendance to support with sedation and airway.
Synchronised DC cardioversion takes place as per the tachyarrhythmia advanced life support
algorithm.
Which part of the QRS complex is used for synchronisation?
R wave
100
A 55-year-old man with a history of ischaemic heart disease presents to the Emergency
Department with palpitations for the past 10 days. Examination of his pulse reveals a rate of 130
bpm which is irregularly irregular. He has had one previous episode of atrial fibrillation 3 months
ago which was terminated by elective cardioversion following warfarinisation. What term best
describes his arrhythmia?
Persistent atrial fibrillation
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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
41
A 55-year-old man is reviewed in the rapid access chest pain clinic with a history of central chest
pain on exertion, relieved by rest. He is currently taking no regular medications and has no drug
allergies.
Which of the following therapies should he be prescribed to reduce the frequency of his
symptoms?
Bisoprolol
42
A 68-year-old man presents to you with intermittent left-sided crushing chest pain which is
brought on by walking his dog on an incline. The pain settles within a couple of minutes of rest
and glyceryl trinitrate (GTN) spray. The pain is not associated with shortness of breath or
lightheadedness.
He first presented to you with these same symptoms six months ago, at this time you gave him
lifestyle advice and prescribed bisoprolol, aspirin, GTN and atorvastatin. He has noted only
minimal improvement of his symptoms over the last six months.
On examination he is comfortable at rest, with blood pressure 124/73 mmHg, heart rate 63
beats/minute, oxygen saturation 99%, respiratory rate 18 breaths/minute and he is afebrile. His
chest is clear, and heart sounds are normal. ECG shows normal sinus rhythm, with no ischaemic
changes. He is also awaiting a CT coronary angiography.
What would be the next stage of treatment for this patient?
Add nifedipine
43
A 48-year-old man with known stable angina is reviewed in the cardiac clinic. He takes aspirin and
a statin and is established on a maximum dose calcium channel and beta-blocker however he is
still experiencing chest discomfort on exertions requiring the use of his sublingual glyceryl
trinitrate spray.
He is to be started on a third medication however due to the potential of tolerance with the
standard-release form of this medication, an asymmetrical dosing regime is required. The regime
and potential side effects are explained to the patient.
What medication is the patient due to be started on?
Isosorbide mononitrate
44
A 56-year-old male is seen in the cardiology clinic after experiencing episodes of chest tightness
on exertion. After appropriate investigation, his GP diagnosed angina and initially provided
lifestyle advice and started him on aspirin, a statin and a sublingual glyceryl trinitrate spray.
The patient otherwise well with no other past medical history and is not on any other regular
medications.
On review in the clinic today the patient, unfortunately, reports ongoing episodes of angina.
His examination and observations are normal and an ECG performed displays normal sinus
rhythm.
What is the most appropriate next course of action?
Commence on verapamil
45
A 52-year-old man is seen in the clinic after originally being referred with progressively increasing
central chest pain but base level investigations, including ECGs and troponin level return within
normal range.
The pain is exercise dependent with it occurring when the patient carries out activities such as
climbing stairs and resolving on rest. As such the patient was started on atenolol 100mg OD along
with a GTN spray and aspirin.
On review today the patient still reports symptoms of chest pain on exertion despite good
compliance.
What alteration should be made to this patientâs management?
Add nifedipine
46
A 72-year-old man is investigated for exertional chest pain and has a positive exercise tolerance
test. He declines an angiogram and is discharged on a combination of aspirin 75mg od,
simvastatin 40mg on, atenolol 50mg od and a GTN spray prn. Examination reveals a pulse of 72
bpm and a blood pressure of 130/80 mmHg. On review he is still regularly using his GTN spray.
What is the most appropriate next step in management?
Increase atenolol to 100mg od
47
An 82-year-old man is reviewed. He is known to have ischaemic heart disease and is still getting
regular attacks of angina despite taking atenolol 100mg od. Examination of his cardiovascular
system is unremarkable with a pulse of 72 bpm and a blood pressure of 148/92 mmHg. What is
the most appropriate next step in management?
Add nifedipine MR 30mg od
48
A 54-year-old man with atypical chest pain is referred to cardiology. An exercise ECG shows nonspecific ST and T wave changes. Following this an coronary angiogram is performed which
demonstrates no evidence of atherosclerosis. A diagnosis of Prinzmetal's angina is suspected.
What is the most appropriate first-line treatment?
Felodipine
49
A 60-year-old man who is investigated for exertional chest pain is diagnosed as having angina
pectoris. Which one of the following drugs is most likely to improve his long-term prognosis?
Aspirin
50
A 60-year-old man is referred to the cardiology clinic with recurrent exertional chest pain
associated with dyspnoea. It improves with rest. He has a history of ischaemic heart disease and
underwent PCI to the right coronary artery five years ago. A coronary angiogram six weeks ago
showed widely patent stents. His current medications include aspirin, ramipril, bisoprolol,
eplerenone, and atorvastatin. Recently, his GP started him on sildenafil for erectile dysfunction. On
assessment, his BP is 142/88 mmHg, and his heart rate is 70 bpm.
What medication should be added to improve his symptoms?
Nifedipine
51
A 64-year-old man presents to his general practitioner with chest tightness, worse on exertion. It
occurs after approximately 200m and then quickly subsides if he stops walking. He has a past
medical history of angina, hypertension and gastro-oesophageal reflux disease. He is currently
taking atenolol, lansoprazole, aspirin and atorvastatin.
The examination is unremarkable.
Given the likely diagnosis, what is the most appropriate management?
Add amlodipine
52
A 59-year-old woman is seen in clinic, with a history of chest pain upon exertion, relieved by rest.
Her pain never occurs at rest. She takes aspirin, atorvastatin and the maximum dose of atenolol,
but she is still persistently experiencing exertional chest pain. She has tolerated all medicines since
commencement.
What would be the best recommendation for the next step in her management?
Commence nifedipine
53
A 55-year-old man presents to the cardiology clinic with chest pain. He has a history of previous
ST-elevation myocardial infarction and angioplasty.
He describes periods of worsening stable angina limiting his exercise tolerance. His resting heart
rate is 60bpm. Recent echocardiography shows a left ventricular ejection fraction of 50-55%.
Current medications include amlodipine 10mg OD and bisoprolol 10mg OD.
What is the most appropriate medication to initiate while awaiting further investigation?
Isosorbide mononitrate (immediate release) BD at 0800 and 1400
54
An 87-year-old man with mild dementia presents to your GP practice.
He has a documented drug allergy to calcium channel blockers and has hypertension confirmed
on ambulatory blood pressure monitoring. He has developed an intolerable cough whilst trialling
ramipril.
He is otherwise fit and well and takes only donepezil. He is interested in taking anti-hypertensives
and you have a discussion with him regarding the anti-hypertensive most commonly used in this
scenario.
What is the mechanism of action of the next-line antihypertensive for this patient?
It prevents angiotensin 2 acting on AT1 receptors
55
You are the ST1 working on cardiology. The nurses have asked you to review a 56-year-old man
complaining of dyspnoea which is limiting his mobility.
He presented three days ago with an inferior STEMI. He was loaded with 300mg aspirin and
180mg ticagrelor before being taken to the cath-lab where he underwent primary PCI with a drug
eluting stent for a sub-total occlusion of the right coronary artery. He was subsequently
commenced on aspirin 100mg od, ticagrelor 90mg bd, atorvastatin 80mg od, bisoprolol 5mg od
and perindopril 5mg od. His echo demonstrated only mildly reduced LV systolic function (LVEF
50%).
His vital signs are stable with a blood pressure 125/70mmHg, heart rate 64bpm, oxygen
saturations 98% on room air and temperature 36.5ºC. Examination reveals dual heart sounds with
no murmurs and his chest is clear on auscultation with no wheeze. JVP is +2cm and there is no
peripheral oedema. His calves are soft and non tender. A Chest X-Ray shows mild atelectasis at
the bases. His bloods are unremarkable. His ecg shows normal sinus rhythm with inferior q waves.
With respect to his dyspnoea, what would be the next best step in his management?
Substitute ticagrelor for clopidogrel
56
A 75-year-old female presents diaphoretic and distressed with new onset sternal chest pain
radiating through to the back. She has a past history of hypertension on lercanidipine. On
examination her blood pressure is 190/70 mmHg and there is an early diastolic murmur heard
best at the left sternal edge. Her ECG is unremarkable. What is the next best course of action?
CT chest with contrast
57
Which one of the following conditions is most associated with aortic dissection?
Bicuspid aortic valve
58
Each one of the following is associated with aortic dissection, except:
Ventricular septal defect
59
A 79-year-old man is referred to the acute medical unit following a fall. He is unsure why he
collapsed but is now fully alert. He is complaining of abdominal pain but his bowel habits are
unchanged.
He has a past medical history of prostatism and hypertension. He tells you he doesn't take any
medication.
On examination he has a Glasgow coma scale score of 15, a blood pressure of 98/46 mmHg and a
heart rate of 98beats per minute
...
...
Which of the following is the next most appropriate step in this man's management?
CT aortic angiogram
60
A 63-year-old man presents to the Emergency Department with sudden chest pain. He describes
the pain as 'tearing'. He has a history of hypertension, for which he normally takes amlodipine.
On examination, he has a tachycardia of 112 beats per minute, his blood pressure is 135/80 in the
left arm and 85/65 in the right arm. Pulses are diminished in the legs.
Initially, the doctors request a CT angiogram to confirm the suspected diagnosis, but the patient is
too unstable for this.
Which alternative investigation would be most useful instead, as per guidance?
Transoesophageal echocardiography (TOE)
61
A 57-year-old man presents with sudden-onset, tearing chest pain. He has a history of Marfan
syndrome and hypertension. On examination, he is visibly shocked and observations are as
follows:
Blood pressure of 78/65 mmHg
Heart rate of 161 beats/minute
Respiratory rate of 42 breaths/minute
Oxygen saturation of 95% on 8L/minute oxygen flow
What is the most appropriate diagnostic investigation?
Transoesophageal echo
62
A 64-year-old man is admitted to the Emergency Department with chest pain radiating through to
his back. On examination pulse 90 regular, BP 140/90. A CXR shows mediastinal widening. A CT
shows dissection of the descending aorta. What is the most suitable initial management?
IV labetalol
63
A 72-year-old man presents to the emergency department with left-sided tearing chest pain. He
has a past medical history of hypertension and hypercholesterolemia. He is on regular amlodipine,
ramipril and indapamide. She smokes 30 cigarettes per day and drinks 3-4 beers each night. He
lives alone and is usually independent of all activities of daily living.
His observations are heart rate 101 beats per minute, blood pressure 182/97 mmHg, respiratory
rate 21/minute, oxygen saturations 97% on room air and he is apyrexial.
On clinical examination, chest auscultation demonstrates equal air entry bilaterally. Both heart
sounds are audible and there is a diastolic murmur audible at the lower left sternal edge in endexpiration. Abdominal and neurological examinations are normal.
An ECG demonstrates sinus tachycardia.
A plain radiograph of the chest is normal.
Blood tests:
...
...
CT angiography of the chest is organized, which demonstrates an intimal flap proximal to the
brachiocephalic vessels.
Given the diagnosis, what is the appropriate management?
Control blood pressure (IV labetalol) + surgery
64
A 69-year-old man has been brought to the emergency department by ambulance with sudden
onset tearing chest pain.
Cross-sectional imaging has confirmed a thoracic aortic dissection, involving the descending aorta
only. There is no evidence of malperfusion.
He is currently alert and orientated. His pulse rate is 100bpm and his blood pressure is
156/98mmHg.
What is the most appropriate treatment strategy for this patient?
Intravenous labetalol
65
A 65-year-old man is referred to the hospital by his GP with a 2-week history of worsening
shortness of breath. He reports sleeping in a chair due to breathlessness when lying flat and
awakens several times at night, struggling to breathe. He has a history of well-controlled
hypertension and childhood rheumatic fever. His medications are ramipril and amlodipine.
Observations:
Heart rate: 98bpm
Blood pressure: 170/56mmHg
Temperature: 36.7 C
Respiratory rate: 18/min
Saturations: 98% on room air
On examination, you notice pulsation in the patient's nail bed.
What murmur would you expect to hear on auscultation?
Early diastolic murmur
66
Which one of the following is least associated with aortic regurgitation?
William's syndrome
67
Which of the following conditions is not associated with the development of aortic regurgitation?
Dilated cardiomyopathy
68
A 72-year-old man presents to his general practitioner with shortness of breath. He has no past
medical history.
On examination, abrupt distension and collapse of the carotid arteries are noted along with
visualization of capillary pulsations with light compression applied to the fingernail bed.
What type of murmur is likely to be heard on auscultation?
Early diastolic
69
Which one of the following clinical signs would best indicate severe calcified aortic stenosis?
Displaced apex beat
70
A 68-year-old man with a past history of aortic stenosis is reviewed in clinic. Which one of the
following features would most guide the timing of surgery?
Symptomatology of patient
71
Which one of the following features would best indicate severe aortic stenosis?
Fourth heart sound
72
Which one of the following clinical signs would best indicate severe aortic stenosis?
Soft second heart sound
73
A 53-year-old man is reviewed in the cardiology clinic with a history of chest pain and syncope.
On examination he has an ejection systolic murmur radiating to the carotid area. What is the most
likely cause of his symptoms?
Bicuspid aortic valve
74
An elderly man with aortic stenosis is assessed. Which one of the following would make the
ejection systolic murmur quieter?
Left ventricular systolic dysfunction
75
An 82-year-old man is referred to cardiology by his GP with increasing dyspnoea on exertion and
a systolic murmur. Examination demonstrates a blood pressure of 100/80 mmHg and a slow rising
pulse. What is the most likely cause of his underlying condition?
Calcification of the aortic valve
76
A 62-year-old man comes for review. In the past month he has had two episodes of 'passing out'.
The first occurred whilst going upstairs. The second occurred last week whilst he was getting out
of a swimming pool. There were no warning signs prior to these episodes. He was told by people
who witnessed the episode last week that he was only 'out' for around 15 seconds. He reports
feeling 'groggy' for only a few seconds after the episode. On examination pulse is 90 / minute,
blood pressure 110/86 mmHg, his lungs are clear and there is a systolic murmur which radiates to
the carotid area. Which one of the following investigations should be arranged first?
Echocardiogram
77
A 65-year-old man is found to have an ejection systolic murmur and narrow pulse pressure on
examination. He has experienced no chest pain, breathlessness or syncope. An echo confirms
aortic stenosis and shows an aortic valve gradient of 36 mmHg. How should this patient be
managed?
Regular cardiology outpatient review
78
A 72-year-old woman has presented to the emergency department with severe breathlessness.
On examination, she is breathless at rest with a slow-rising pulse and a raised jugular venous
pressure. She has significant pitting oedema to her thighs with a degree of sacral oedema.
Observations show that her pulse is 78beats per minute, blood pressure 98/52mmHg, oxygen
saturations 95% on 40% inspired oxygen and respiratory rate 32 breaths per minute.
On auscultation there are absent breath sounds to bilateral lower zones with crepitations
throughout both upper lung fields. Her heart sounds demonstrate a murmur with S4 heart sound.
Which valvular pathology is most likely to be seen on echocardiogram?
Aortic stenosis
79
You are reviewing a 78-year-old man who has been admitted via the emergency department with
chest pain. History reveals that he has been struggling with shortness of breath, and that his wife
is worried as he briefly lost consciousness on one occasion.
Echocardiogram reveals aortic stenosis.
What examination finding would suggest that his condition is severe?
Fourth heart sound
80
A 22-year-old man was out with his friends when he suddenly reported not feeling well. He
reported he could feel his heart beating very fast and then collapsed. A bystander started CPR and
an ambulance was called. Resuscitation attempts continued for an hour but were unsuccessful. A
post mortem was carried out to ascertain the cause of death as the young man had no medical
problems. During post mortem, the right ventricle was noticed to be thin-walled and histology of
the right ventricle revealed fibro-fatty infiltration.
What is the most likely cause of death in this case?
Arrhythmogenic right ventricular cardiomyopathy
81
A 44-year-old man is seen in the cardiology clinic. For the past 6 months he has been
experiencing episodes of palpitations associated with pre-syncopal symptoms. An ECG taken in
clinic shows T wave inversion in leads V1-3 associated with a notch at the end of the QRS
complex. He is known to have a family history of sudden cardiac death. What is the most likely
diagnosis?
Arrhythmogenic right ventricular cardiomyopathy
82
Which one of the following statements regarding arrhythmogenic right ventricular
cardiomyopathy is correct?
It is characterised by fibrofatty infiltration of the right ventricular myocardium
83
A 24-year-old man presents to the emergency department with palpitations and pre-syncope. He
has no past medical history.
Observations:
Heart rate 82 beats per minute
Blood pressure 131/74 mmHg
Respiratory rate 18/minute
Oxygen saturations 97% on room air
The examination is unremarkable.
An ECG demonstrates T wave inversion and an epsilon wave in leads V1-V3
.
NT-proBNP
182 pg/ml
(<400)
Given the likely diagnosis, what is the expected pathological finding in this condition?
Right ventricular myocardium replaced by fatty and fibrofatty tissue
84
A 29-year-old woman presents to the cardiology clinic with frequent palpitations and episodes of
dizziness on exertion. She has no prior medical history. Her father passed away at age 33 by
sudden cardiac death.
Her 12-lead ECG at rest shows sinus rhythm with T wave inversion in V1-3, with a small positive
deflection at the end of the QRS complexes in V1-3.
A 24-hour Holter monitor shows evidence of frequent premature ventricular complexes and runs
of non-sustained ventricular tachycardia.
What is the most likely underlying pathological process?
Replacement of right ventricular free wall myocardium with fibrous and fatty tissue
85
A 66-year-old lady presented to the emergency department with a 5-minute history of right upper
limb weakness which spontaneously resolved. She had a past medical history of hypertension, for
which she is taking amlodipine 10mg once daily. She is not diabetic. She currently smokes 10
cigarettes a day. Her examination was remarkable for an irregularly irregular heartbeat.
Electrocardiogram confirms a diagnosis of atrial fibrillation. CT head showed no evidence of
intracranial haemorrhage. She is otherwise well with a normal renal function. What is the most
appropriate next step?
Commence the patient on anticoagulation
86
A usually fit and well 24-year-old man presented with palpitations in the early hours of the
morning after consuming a large amount of alcohol. He denied any chest pain or breathlessness.
On examination his pulse was 120 beats per minute and irregularly irregular. His blood pressure
was 124/70 mmHg. On auscultation his chest was clear.
An ECG showed atrial fibrillation with a ventricular rate of 118.
What is the most appropriate initial management?
Intravenous fluids
87
A 58-year-old man presents to the Emergency Department following an episode of transient
right-sided weakness which lasted approximately 20 minutes. He has had two previous episodes
of a similar nature. On examination he is found to be in atrial fibrillation at a rate of 80 bpm.
CT head
normal
He is started on aspirin 300mg od. Two days later he has a carotid doppler which is normal. What
is the most appropriate management?
Start a direct oral anticoagulant
88
A 76-year-old man is reviewed. He was recently admitted after being found to be in atrial
fibrillation. This was his second episode of atrial fibrillation. He also takes ramipril for hypertension
and has a history of mitral stenosis but has no other history of note. During admission, he was
warfarinised and discharged with planned follow-up in the cardiology clinic. However, on review
today he is found to be in sinus rhythm. What should happen regarding anticoagulation?
Continue lifelong warfarin
89
A 71-year-old man who is known to have atrial fibrillation comes for review. He had a transient
ischaemic attack two weeks ago and takes bendroflumethiazide for hypertension but is otherwise
well. His latest blood pressure is 124/76 mmHg. You are discussing management options to try
and reduce his future risk of having a stroke. What is his CHA DS -VASc score?
4
90
A 54-year-old male with no past medical history is found to be in atrial fibrillation during a
consultation regarding a sprained ankle. He reports no history of palpitations or dyspnoea. After
discussing treatment options he elects not to be cardioverted. Examination of the cardiovascular
system is otherwise unremarkable with a blood pressure of 118/76 mmHg. According to the latest
NICE guidelines, if the patient remains in chronic atrial fibrillation what is the most suitable
treatment to offer?
No treatment
91
A 51-year-old female presents to the Emergency Department following an episode of transient
right sided weakness lasting 10-15 minutes. Examination reveals the patient to be in atrial
fibrillation. If the patient remains in chronic atrial fibrillation what is the most suitable form of
anticoagulation?
Direct oral anticoagulant
92
A 75-year-old woman was admitted to the Acute Medical Unit with pneumonia. Her only past
medical history of note is transient ischaemic attack 2 months previously. On initial assessment,
ECG revealed atrial fibrillation with a ventricular rate of 103. She was treated with intravenous
fluids and antibiotics. She improved significantly. Two further ECGs overnight revealed normal
sinus rhythm. The following day, she was deemed medically fit for discharge.
What is the single most appropriate management option regarding her episode of atrial
fibrillation?
Oral anticoagulation
93
A 70-year-old man presented to the emergency department following a fall and head injury. This
is his third fall in the past 12 months. He has a background of persistent atrial fibrillation, type 2
diabetes mellitus and Parkinson's disease. He is taking apixaban 5mg BD, bisoprolol 5mg OD, cobeneldopa 100mg QDS, and metformin 1g BD.
CT head reveals no acute findings.
What is the most appropriate management regarding his anticoagulation?
Continue apixaban
94
A 35-year-old female has paroxysmal atrial fibrillation and was successfully treated with DC
cardioversion 1 week ago. She is now resultantly on warfarin. A subsequent post-cardioversion
echocardiogram shows no structural abnormalities.
How long should the warfarin be continued?
4 weeks
95
A 62-year-old man is reviewed two hours after a successful elective DC cardioversion for atrial
fibrillation. Six weeks ago he presented in fast atrial fibrillation. A decision was made at the time to
warfarinise him for six weeks after which he was to be cardioverted. During this time he had a
normal transthoracic echocardiogram. He has no past medical history of note other than
treatment for a basal cell carcinoma. What is the most appropriate plan regarding
anticoagulation?
Continue warfarinisation for 4 weeks then review
96
A 58-year-old woman with paroxysmal atrial fibrillation was admitted to a cardiology ward
overnight as she developed palpitations. A diagnosis of atrial fibrillation was made 6 months ago,
where apixaban was commenced. Subsequently, she had a successful elective cardioversion 6
weeks later. She has been taking her apixaban regularly and hasn't missed any doses. She had
been symptom-free until last night.
The consultant plans for the patient to be treated with a direct current cardioversion on the
theatre list today.
During which part of the electrocardiogram trace should a direct current cardioversion be
delivered on for this patient given her arrhythmia?
R wave
97
A 67-year-old man with a history of hypertension presents to the emergency department with a
24hr history of dyspnoea and palpitations. He also complains of mild chest discomfort. On
examination, you note an irregularly irregular pulse of 115 beats per minute, blood pressure 95 /
70 mmHg and a respiratory rate of 20 breaths/min. He denies any regular medication and insists
he has never experienced anything like this before. An ECG shows absent P waves with QRS
complexes irregularly irregular intervals.
What is the most appropriate management?
Direct current cardioversion
98
A 48-year-old gentleman presents with a 3-day history of palpitations. This is on a background of
recurrent atrial fibrillation with previous failed cardioversion attempts but had successful electrical
cardioversion 8 months previously. An ECG confirms that he is in atrial fibrillation with a rate of 80
beats per minute. He currently takes bisoprolol and apixaban. The cardiology consultant reviews
and has planned electrical cardioversion for 4 weeks time.
Until he is cardioverted, which of the following should be given in addition to his current
medications?
Amiodarone
99
You receive an emergency bleep to a 52-year-old woman who was admitted 6 hours ago with
atrial fibrillation with a fast ventricular response.
On arrival, you find her sweaty, tachypnoeic, and hypotensive. You note bibasal crepitations on
auscultation of the chest with irregular tachycardia. Cardiac monitoring shows atrial fibrillation at a
rate of 140-170 bpm.
A decision is made to perform emergency DC cardioversion. The on-call anaesthetist is in
attendance to support with sedation and airway.
Synchronised DC cardioversion takes place as per the tachyarrhythmia advanced life support
algorithm.
Which part of the QRS complex is used for synchronisation?
R wave
100
A 55-year-old man with a history of ischaemic heart disease presents to the Emergency
Department with palpitations for the past 10 days. Examination of his pulse reveals a rate of 130
bpm which is irregularly irregular. He has had one previous episode of atrial fibrillation 3 months
ago which was terminated by elective cardioversion following warfarinisation. What term best
describes his arrhythmia?
Persistent atrial fibrillation