PM 23 from 81 to 100 ð«
åé¡äžèŠ§
1
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
2
Which one of the following statements regarding arrhythmogenic right ventricular
cardiomyopathy is correct?
It is characterised by fibrofatty infiltration of the right ventricular myocardium
3
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
4
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
5
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
6
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
7
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
8
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
9
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
10
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
11
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
12
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
13
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
14
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
15
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
16
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
17
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
18
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
19
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
20
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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Mohamed Ahmed · 40å · 1幎åPM 23 from 1 to 40 ð«
PM 23 from 1 to 40 ð«
40å ⢠1幎ååé¡äžèŠ§
1
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
2
Which one of the following statements regarding arrhythmogenic right ventricular
cardiomyopathy is correct?
It is characterised by fibrofatty infiltration of the right ventricular myocardium
3
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
4
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
5
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
6
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
7
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
8
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
9
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
10
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
11
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
12
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
13
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
14
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
15
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
16
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
17
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
18
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
19
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
20
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