PM ð« 121 to 160
åé¡äžèŠ§
1
An 82-year-old attends her GP with breathlessness. She has a past medical history of chronic
kidney disease stage 4, high cholesterol, a previous TIA and osteoarthritis. Her medications are
clopidogrel, simvastatin and as required codeine.
On examination, heart sounds are normal and regular, the chest is clear with no added sounds
and there is no peripheral oedema. Heart rate is 72 beats/minute, blood pressure is 134/75mmHg,
oxygen saturations are 97% and respiratory rate is 24 breaths/minute.
Some blood tests are done:
..
..
What is the most likely cause of her raised BNP?
Chronic kidney disease
2
A 68-year-old woman presents with progressive shortness of breath. She has been feeling
increasingly out of breath when doing jobs around the house over the past few months, to the
point where she is now breathless on walking 5m. She denies any chest pain, cough, fevers or
weight loss - if anything, she's put weight on! She has a background of hypertension and chronic
kidney disease.
On examination, she has fine crepitations at both bases on auscultation, her JVP (jugular venous
pressure) is raised to 4 cm above her clavicle, and she has some mild pitting oedema at her
ankles. She has a regular pulse at around 70bpm, a central capillary refill time of less than 2
seconds, and moist oral mucosa.
An echocardiogram finds an ejection fraction of 40%, yet her NT-pro-BNP (N-terminal pro B-type
natriuretic peptide) is within the normal range at 240.
What could be the cause of this spurious result?
She is obese
3
You are seeing John, a 50-year-old man who is complaining of central constricting chest pain.
Walking up the stairs triggers the pain. The pain goes away with resting. He experiences some
shortness of breath but denies any syncope or palpitations. He suffers from hypertension and
diabetes. He takes verapamil for migraine prophylaxis. His other medications include GTN spray,
aspirin, atorvastatin, Ramipril and metformin. On examination, his rhythm seems to be irregular.
There is no murmur on auscultation of the heart. There is no tenderness on chest wall palpation.
He is asking for a medication that would be helpful to prevent the chest pain from occurring.
What is the most appropriate treatment?
Nicorandil
4
Which of the following congenital heart defects is associated with a bicuspid aortic valve
Coarctation of the aorta
5
A 42-year-old man has his blood pressure measured as part of a routine medical exam. His blood
pressure is recorded as 155/95 mmHg. This is unexpected as it has been normal for the past 5
annual medical exams.
Which one of the following factors may account for this finding?
An undersized blood pressure cuff
6
An 82-year-old female is admitted with palpitations.
..
..
The patient reports no chest pain or pre-syncope. The initial ECG shows a regular broad complex
tachycardia (QRS 152) with a rate of 110. P-waves are visible and appear associated with QRS
complexes. RS waves are seen in the precordial leads. The RS duration is less than 100ms. There is
an RSR' pattern in V1 and V2.
What is the most appropriate initial management for this patient?
Vagal manoeuvres
7
A 76-year-old woman is admitted to the resus department after collapsing whilst shopping. The
paramedics report she is hypotensive and tachycardia. Initial observations include a heart rate of
160 bpm and a blood pressure of 98 / 60 mmHg. A 12 lead ECG shows a broad complex
tachycardia. Which one of the following features on the ECG would suggest a ventricular
tachycardia rather than a supraventricular tachycardia with aberrant conduction?
Atrioventricular dissociation
8
A 72-year-old man presents to the Emergency Department with a broad complex tachycardia.
Which of the following features would make it more likely that this was due to a supraventricular
tachycardia rather than a ventricular tachycardia?
Absence of QRS concordance in chest leads
9
A 28-year-old woman presents with palpitations. Her heart rate is 160/min and irregular. Her
blood pressure is 123/65 mmHg, and her oxygen saturation is 97% on breathing room air. Her
chest is clear on auscultation. Her ECG shows irregular broad complex monomorphic tachycardia
with a stable axis. She has no previous medical history and has never been to a hospital before.
What is the most appropriate treatment?
Amiodarone
10
A 23-year-old man presents to the emergency department after an episode of feeling faint. He
has no significant medical history, nor does he take any medications.
Among other investigations, an ECG is performed which shows convex ST-segment elevation in
leads V1-V3 followed by a negative T-wave. A partial right bundle branch block is also identified.
The cardiologist on-call is asked to review the patient, and administers flecainide, before
repeating an ECG - the changes become more apparent.
Given the likely diagnosis, a mutation in which gene is the probable cause?
SCN5A
11
A 34-year-old man is investigated following an unexplained collapse whilst at work. A resting ECG
shows convex ST elevation in V1-V3 with a partial right bundle branch block pattern. What is the
most likely diagnosis?
Brugada syndrome
12
Which one of the following statements regarding Brugada syndrome is correct?
More common in Asians
13
A 34-year-old woman is referred to cardiology as her primary care doctor has identified a systolic
murmur. As part of the investigations she undergoes cardiac catherisation. The following results
are obtained from the right side of the heart:
..
..
What is the most likely diagnosis?
Ventricular septal defect
14
A 54-year-old man is admitted to the Emergency Department with a 15 minute history of crushing
central chest pain. Which one of the following rises first following a myocardial infarction?
Myoglobin
15
A 62-year-old man is admitted to hospital following a myocardial infarction. Four days after
admission he develops a further episode of central crushing chest pain. Which is the best cardiac
marker to investigate his chest pain?
CK-MB
16
What does troponin T bind to?
Tropomyosin
17
What is the role of troponin in cardiac muscle?
Component of the thin filaments
18
Which one of the following radiotracers is used during cardiac Positron Emission Tomography
(PET) scans?
Fluorodeoxyglucose
19
A 64-year-old man who is known to have ischaemic heart disease is due to start a chemotherapy
regime which includes doxorubicin. His cardiologist wants to accurately assess his left ventricular
function as he is concerned the doxorubicin may damage his myocardium. Which one of the
following is the most accurate method to determine his left ventricular function?
MUGA scan
20
Which one of the following non-invasive methods provides the most accurate assessment of
whether a patient has coronary artery disease?
Contrast enhanced cardiac CT
21
A 65-year-old male presents to the emergency department with increased shortness of breath
and a light-headed feeling. He reports some left shoulder pain and some ongoing mild chest pain,
which improved when sitting up. The patient reports that the breathlessness has been increasing
over the last 7 days, but has been significantly worse over the last 24 hours.
The patient reports having had a STEMI (ST elevation myocardial infarction) 5 weeks ago with a
stent inserted into the left anterior descending artery. The patient has a past medical history of
type II diabetes mellitus.
On examination, the patient is found to have a raised jugular venous pressure. Peripheral pulses
are weak and the patient is tachycardic with a regular rhythm. The chest is clear on examination
with good air entry throughout, and the heart sounds are muffled.
Observations:
..
..
There is no discrepancy between the blood pressures in each arm. An ECG is done which shows Q
waves in V1-V3 with no ST change. The complexes are small amplitude.
What is the most likely diagnosis for the patient's symptoms?
Cardiac tamponade
22
Which one of the following features would indicate cardiac tamponade rather than constrictive
pericarditis?
No Y descent on JVP
23
A 55-year-old woman with hypertension and hypercholesterolaemia complains of acute
breathlessness one hour after a primary percutaneous intervention for an anterior ST-elevation
myocardial infarction. She was successfully revascularized and access was gained using a radial
approach. She appeared well immediately post-procedure and a beside trans-thoracic
echocardiogram demonstrated preserved left ventricular function.
On examination, she appears unwell. She is diaphoretic and clammy with a respiratory rate of
33/min, blood pressure of 80/42mmHg, heart rate of 111/minute, oxygen saturation of 96% on air
and temperature of 36.2ºC. Chest auscultation demonstrates good air entry bilaterally.
Cardiovascular examination demonstrates a regular pulse, elevated jugular venous pulse (JVP) and
quiet heart sounds. She has cool extremities. There are no murmurs or peripheral oedema. There
is no clinical evidence of deep venous thrombosis in the lower limbs.
What intervention is most likely to be life-saving?
Pericardiocentesis
24
Which one of the following statements regarding catecholaminergic polymorphic ventricular
tachycardia (CPVT) is correct?
Symptoms generally develop before the age of 20 years
25
Which one of the following is an example of a centrally acting antihypertensive?
Moxonidine
26
A 58-year-old man is seen in a cardiology clinic. His general practitioner referred him for a threemonth history of exertional chest pain that relieves upon rest. He has a history of type 2 diabetes
and hypertension, both of which he is receiving treatment for. A previous ECG with the general
practitioner was normal but he has had no further investigation for his pain.
What is the most appropriate imaging for this man?
CT coronary angiogram with contrast
27
A 71-year-old man with a four-month history of exertional chest pain is reviewed. The pain
typically comes on when he is walking up a hill, is centrally located and radiates to the left arm. It
then settles with rest after about 2-3 minutes. Clinical examination and a resting 12 lead ECG are
normal. Following NICE guidelines, what is the most appropriate diagnostic strategy?
CT coronary angiography
28
A 79-year-old female presents to the low-risk chest pain clinic with intermittent substernal chest
pains. The pain typically comes on with exertion and improves with rest. A trial of GTN has been
given by her GP which helps with her pain. She is a known ex-smoker of 30 pack-years. She has no
diabetes, hyperlipidaemia, hypertension, and no family history of coronary artery disease.
On examination her observations are stable. On auscultations of her chest, her first and second
heart sounds are audible with no added sounds and her lungs are clear.
What is the most important investigation to pursue given her risk for coronary artery disease?
Contrast-enhanced coronary CT angiography
29
A 52-year-old female with an acute presentation of chest pain undergoes an angiogram to look
for coronary artery disease. During the procedure, she has a run of ventricular tachycardia which
self-resolves.
The report of the angiogram revealed normal coronary arteries. All other cardiac investigations
were normal. What is the most likely follow-up plan?
Discharge from cardiology when medically fit
30
A 61-year-old man with a history of hypertension presents with central chest pain. Acute coronary
syndrome is diagnosed and conventional management is given. A few days later a diagnostic
coronary angiogram is performed. The following week a deteriorating of renal function is noted
associated with a purpuric rash on his feet. What is the most likely diagnosis?
Cholesterol embolisation
31
A 70-year-old man with a background of ischaemic heart disease and peripheral arterial disease
presents to the Emergency Department. He has been feeling generally unwell for the past two
days with fever and myalgia but this morning developed a purple, cold left middle toe. On
examination there are signs of early ischaemia to the toe and a faint livedo reticularis rash is seen
on the foot. A diagnosis of cholesterol embolisation is suspected. Which of the following features
would be most supportive of this diagnosis?
Eosinophilia
32
A 72-year-old female is admitted for an elective abdominal aortic aneurysm repair. She has a past
medical history of long-standing asthma and an undiagnosed peripheral neuropathy. On day 4
post-op, she develops a net-like rash over her torso with fevers, myalgias and discolouration of
her toes.
Blood tests reveal:
..
..
What is the most likely diagnosis?
Cholesterol emboli
33
You have ordered a B-type natriuretic peptide (BNP) test on a patient with suspected heart failure.
It has come back as being slightly elevated. Which one of the following factors may account for a
falsely elevated BNP?
COPD
34
Eugene is a 56-year-old man who was admitted with a 3-day history of worsening shortness of
breath. On his last admission 3 months ago, he was treated for a ST-elevation myocardial
infarction (STEMI).
He does not experience any significant chest pain. A chest X-ray shows minor bibasal
consolidation suggestive of mild pulmonary oedema. His blood tests are as follow:
..
..
A 12-lead electrocardiogram shows sinus rhythm. An echocardiogram shows reduced left
ventricular (LV) contraction with an LV ejection fraction of 40%.
Which of the following treatments should be prescribed to reduce mortality?
Ramipril
35
A 65-year-old female with a known history of heart failure presents for an annual check-up. She is
found to have a blood pressure of 170/100 mmHg. Her current medications are furosemide and
aspirin. What is the most appropriate medication to add?
Enalapril
36
A 57-year-old man with NYHA class III heart failure is currently treated with furosemide and
ramipril. What is the most suitable beta-blocker to add to improve his long-term prognosis?
Bisoprolol
37
A 72-year-old man with a history of chronic heart failure secondary to ischaemic cardiomyopathy
is reviewed. He was discharged two weeks ago from hospital following a myocardial infarction. An
echocardiogram done during his admission showed a left ventricular ejection fraction of 40% but
did not demonstrate any valvular problems.
Despite his current treatment with furosemide, ramipril, carvedilol, aspirin and simvastatin he
remains short of breath on minimal exertion such as walking 30 metres. On examination his chest
is clear and there is minimal peripheral oedema. What is the most appropriate next step in
management?
Add an aldosterone antagonist
38
You review a 62-year-old man who has recently been discharged from hospital in Hungary
following a myocardial infarction. He brings a copy of an echocardiogram report which shows his
left ventricular ejection fraction is 38%. On examination his pulse is 78 / min and regular, blood
pressure is 124 / 72 mmHg and his chest is clear. His current medications include aspirin,
simvastatin and lisinopril. What is the most appropriate next step in terms of his medication?
Add bisoprolol
39
Which one of the following treatments have not been shown to improve mortality in patients with
chronic heart failure?
Furosemide
40
The neprilysin inhibitor, sacubitril, in combination with the angiotensin II receptor blocker,
valsartan, has been shown to reduce mortality, reduce hospitalisations and improve symptoms in
comparison to enalapril in the treatment of heart failure with reduced ejection fraction. What is its
mechanism of action in heart failure?
Prevents the degradation of natriuretic peptides such as BNP and ANP
PM 23 from 1 to 100 ð«
PM 23 from 1 to 100 ð«
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20å ⢠1幎åPM 23 from 101 to 120 ð«
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Mohamed Ahmed · 20å · 1幎åPM 23 from 101 to 120 ð«
PM 23 from 101 to 120 ð«
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PM ð« 161 TO 200
Mohamed Ahmed · 40å · 1幎åPM ð« 161 TO 200
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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
An 82-year-old attends her GP with breathlessness. She has a past medical history of chronic
kidney disease stage 4, high cholesterol, a previous TIA and osteoarthritis. Her medications are
clopidogrel, simvastatin and as required codeine.
On examination, heart sounds are normal and regular, the chest is clear with no added sounds
and there is no peripheral oedema. Heart rate is 72 beats/minute, blood pressure is 134/75mmHg,
oxygen saturations are 97% and respiratory rate is 24 breaths/minute.
Some blood tests are done:
..
..
What is the most likely cause of her raised BNP?
Chronic kidney disease
2
A 68-year-old woman presents with progressive shortness of breath. She has been feeling
increasingly out of breath when doing jobs around the house over the past few months, to the
point where she is now breathless on walking 5m. She denies any chest pain, cough, fevers or
weight loss - if anything, she's put weight on! She has a background of hypertension and chronic
kidney disease.
On examination, she has fine crepitations at both bases on auscultation, her JVP (jugular venous
pressure) is raised to 4 cm above her clavicle, and she has some mild pitting oedema at her
ankles. She has a regular pulse at around 70bpm, a central capillary refill time of less than 2
seconds, and moist oral mucosa.
An echocardiogram finds an ejection fraction of 40%, yet her NT-pro-BNP (N-terminal pro B-type
natriuretic peptide) is within the normal range at 240.
What could be the cause of this spurious result?
She is obese
3
You are seeing John, a 50-year-old man who is complaining of central constricting chest pain.
Walking up the stairs triggers the pain. The pain goes away with resting. He experiences some
shortness of breath but denies any syncope or palpitations. He suffers from hypertension and
diabetes. He takes verapamil for migraine prophylaxis. His other medications include GTN spray,
aspirin, atorvastatin, Ramipril and metformin. On examination, his rhythm seems to be irregular.
There is no murmur on auscultation of the heart. There is no tenderness on chest wall palpation.
He is asking for a medication that would be helpful to prevent the chest pain from occurring.
What is the most appropriate treatment?
Nicorandil
4
Which of the following congenital heart defects is associated with a bicuspid aortic valve
Coarctation of the aorta
5
A 42-year-old man has his blood pressure measured as part of a routine medical exam. His blood
pressure is recorded as 155/95 mmHg. This is unexpected as it has been normal for the past 5
annual medical exams.
Which one of the following factors may account for this finding?
An undersized blood pressure cuff
6
An 82-year-old female is admitted with palpitations.
..
..
The patient reports no chest pain or pre-syncope. The initial ECG shows a regular broad complex
tachycardia (QRS 152) with a rate of 110. P-waves are visible and appear associated with QRS
complexes. RS waves are seen in the precordial leads. The RS duration is less than 100ms. There is
an RSR' pattern in V1 and V2.
What is the most appropriate initial management for this patient?
Vagal manoeuvres
7
A 76-year-old woman is admitted to the resus department after collapsing whilst shopping. The
paramedics report she is hypotensive and tachycardia. Initial observations include a heart rate of
160 bpm and a blood pressure of 98 / 60 mmHg. A 12 lead ECG shows a broad complex
tachycardia. Which one of the following features on the ECG would suggest a ventricular
tachycardia rather than a supraventricular tachycardia with aberrant conduction?
Atrioventricular dissociation
8
A 72-year-old man presents to the Emergency Department with a broad complex tachycardia.
Which of the following features would make it more likely that this was due to a supraventricular
tachycardia rather than a ventricular tachycardia?
Absence of QRS concordance in chest leads
9
A 28-year-old woman presents with palpitations. Her heart rate is 160/min and irregular. Her
blood pressure is 123/65 mmHg, and her oxygen saturation is 97% on breathing room air. Her
chest is clear on auscultation. Her ECG shows irregular broad complex monomorphic tachycardia
with a stable axis. She has no previous medical history and has never been to a hospital before.
What is the most appropriate treatment?
Amiodarone
10
A 23-year-old man presents to the emergency department after an episode of feeling faint. He
has no significant medical history, nor does he take any medications.
Among other investigations, an ECG is performed which shows convex ST-segment elevation in
leads V1-V3 followed by a negative T-wave. A partial right bundle branch block is also identified.
The cardiologist on-call is asked to review the patient, and administers flecainide, before
repeating an ECG - the changes become more apparent.
Given the likely diagnosis, a mutation in which gene is the probable cause?
SCN5A
11
A 34-year-old man is investigated following an unexplained collapse whilst at work. A resting ECG
shows convex ST elevation in V1-V3 with a partial right bundle branch block pattern. What is the
most likely diagnosis?
Brugada syndrome
12
Which one of the following statements regarding Brugada syndrome is correct?
More common in Asians
13
A 34-year-old woman is referred to cardiology as her primary care doctor has identified a systolic
murmur. As part of the investigations she undergoes cardiac catherisation. The following results
are obtained from the right side of the heart:
..
..
What is the most likely diagnosis?
Ventricular septal defect
14
A 54-year-old man is admitted to the Emergency Department with a 15 minute history of crushing
central chest pain. Which one of the following rises first following a myocardial infarction?
Myoglobin
15
A 62-year-old man is admitted to hospital following a myocardial infarction. Four days after
admission he develops a further episode of central crushing chest pain. Which is the best cardiac
marker to investigate his chest pain?
CK-MB
16
What does troponin T bind to?
Tropomyosin
17
What is the role of troponin in cardiac muscle?
Component of the thin filaments
18
Which one of the following radiotracers is used during cardiac Positron Emission Tomography
(PET) scans?
Fluorodeoxyglucose
19
A 64-year-old man who is known to have ischaemic heart disease is due to start a chemotherapy
regime which includes doxorubicin. His cardiologist wants to accurately assess his left ventricular
function as he is concerned the doxorubicin may damage his myocardium. Which one of the
following is the most accurate method to determine his left ventricular function?
MUGA scan
20
Which one of the following non-invasive methods provides the most accurate assessment of
whether a patient has coronary artery disease?
Contrast enhanced cardiac CT
21
A 65-year-old male presents to the emergency department with increased shortness of breath
and a light-headed feeling. He reports some left shoulder pain and some ongoing mild chest pain,
which improved when sitting up. The patient reports that the breathlessness has been increasing
over the last 7 days, but has been significantly worse over the last 24 hours.
The patient reports having had a STEMI (ST elevation myocardial infarction) 5 weeks ago with a
stent inserted into the left anterior descending artery. The patient has a past medical history of
type II diabetes mellitus.
On examination, the patient is found to have a raised jugular venous pressure. Peripheral pulses
are weak and the patient is tachycardic with a regular rhythm. The chest is clear on examination
with good air entry throughout, and the heart sounds are muffled.
Observations:
..
..
There is no discrepancy between the blood pressures in each arm. An ECG is done which shows Q
waves in V1-V3 with no ST change. The complexes are small amplitude.
What is the most likely diagnosis for the patient's symptoms?
Cardiac tamponade
22
Which one of the following features would indicate cardiac tamponade rather than constrictive
pericarditis?
No Y descent on JVP
23
A 55-year-old woman with hypertension and hypercholesterolaemia complains of acute
breathlessness one hour after a primary percutaneous intervention for an anterior ST-elevation
myocardial infarction. She was successfully revascularized and access was gained using a radial
approach. She appeared well immediately post-procedure and a beside trans-thoracic
echocardiogram demonstrated preserved left ventricular function.
On examination, she appears unwell. She is diaphoretic and clammy with a respiratory rate of
33/min, blood pressure of 80/42mmHg, heart rate of 111/minute, oxygen saturation of 96% on air
and temperature of 36.2ºC. Chest auscultation demonstrates good air entry bilaterally.
Cardiovascular examination demonstrates a regular pulse, elevated jugular venous pulse (JVP) and
quiet heart sounds. She has cool extremities. There are no murmurs or peripheral oedema. There
is no clinical evidence of deep venous thrombosis in the lower limbs.
What intervention is most likely to be life-saving?
Pericardiocentesis
24
Which one of the following statements regarding catecholaminergic polymorphic ventricular
tachycardia (CPVT) is correct?
Symptoms generally develop before the age of 20 years
25
Which one of the following is an example of a centrally acting antihypertensive?
Moxonidine
26
A 58-year-old man is seen in a cardiology clinic. His general practitioner referred him for a threemonth history of exertional chest pain that relieves upon rest. He has a history of type 2 diabetes
and hypertension, both of which he is receiving treatment for. A previous ECG with the general
practitioner was normal but he has had no further investigation for his pain.
What is the most appropriate imaging for this man?
CT coronary angiogram with contrast
27
A 71-year-old man with a four-month history of exertional chest pain is reviewed. The pain
typically comes on when he is walking up a hill, is centrally located and radiates to the left arm. It
then settles with rest after about 2-3 minutes. Clinical examination and a resting 12 lead ECG are
normal. Following NICE guidelines, what is the most appropriate diagnostic strategy?
CT coronary angiography
28
A 79-year-old female presents to the low-risk chest pain clinic with intermittent substernal chest
pains. The pain typically comes on with exertion and improves with rest. A trial of GTN has been
given by her GP which helps with her pain. She is a known ex-smoker of 30 pack-years. She has no
diabetes, hyperlipidaemia, hypertension, and no family history of coronary artery disease.
On examination her observations are stable. On auscultations of her chest, her first and second
heart sounds are audible with no added sounds and her lungs are clear.
What is the most important investigation to pursue given her risk for coronary artery disease?
Contrast-enhanced coronary CT angiography
29
A 52-year-old female with an acute presentation of chest pain undergoes an angiogram to look
for coronary artery disease. During the procedure, she has a run of ventricular tachycardia which
self-resolves.
The report of the angiogram revealed normal coronary arteries. All other cardiac investigations
were normal. What is the most likely follow-up plan?
Discharge from cardiology when medically fit
30
A 61-year-old man with a history of hypertension presents with central chest pain. Acute coronary
syndrome is diagnosed and conventional management is given. A few days later a diagnostic
coronary angiogram is performed. The following week a deteriorating of renal function is noted
associated with a purpuric rash on his feet. What is the most likely diagnosis?
Cholesterol embolisation
31
A 70-year-old man with a background of ischaemic heart disease and peripheral arterial disease
presents to the Emergency Department. He has been feeling generally unwell for the past two
days with fever and myalgia but this morning developed a purple, cold left middle toe. On
examination there are signs of early ischaemia to the toe and a faint livedo reticularis rash is seen
on the foot. A diagnosis of cholesterol embolisation is suspected. Which of the following features
would be most supportive of this diagnosis?
Eosinophilia
32
A 72-year-old female is admitted for an elective abdominal aortic aneurysm repair. She has a past
medical history of long-standing asthma and an undiagnosed peripheral neuropathy. On day 4
post-op, she develops a net-like rash over her torso with fevers, myalgias and discolouration of
her toes.
Blood tests reveal:
..
..
What is the most likely diagnosis?
Cholesterol emboli
33
You have ordered a B-type natriuretic peptide (BNP) test on a patient with suspected heart failure.
It has come back as being slightly elevated. Which one of the following factors may account for a
falsely elevated BNP?
COPD
34
Eugene is a 56-year-old man who was admitted with a 3-day history of worsening shortness of
breath. On his last admission 3 months ago, he was treated for a ST-elevation myocardial
infarction (STEMI).
He does not experience any significant chest pain. A chest X-ray shows minor bibasal
consolidation suggestive of mild pulmonary oedema. His blood tests are as follow:
..
..
A 12-lead electrocardiogram shows sinus rhythm. An echocardiogram shows reduced left
ventricular (LV) contraction with an LV ejection fraction of 40%.
Which of the following treatments should be prescribed to reduce mortality?
Ramipril
35
A 65-year-old female with a known history of heart failure presents for an annual check-up. She is
found to have a blood pressure of 170/100 mmHg. Her current medications are furosemide and
aspirin. What is the most appropriate medication to add?
Enalapril
36
A 57-year-old man with NYHA class III heart failure is currently treated with furosemide and
ramipril. What is the most suitable beta-blocker to add to improve his long-term prognosis?
Bisoprolol
37
A 72-year-old man with a history of chronic heart failure secondary to ischaemic cardiomyopathy
is reviewed. He was discharged two weeks ago from hospital following a myocardial infarction. An
echocardiogram done during his admission showed a left ventricular ejection fraction of 40% but
did not demonstrate any valvular problems.
Despite his current treatment with furosemide, ramipril, carvedilol, aspirin and simvastatin he
remains short of breath on minimal exertion such as walking 30 metres. On examination his chest
is clear and there is minimal peripheral oedema. What is the most appropriate next step in
management?
Add an aldosterone antagonist
38
You review a 62-year-old man who has recently been discharged from hospital in Hungary
following a myocardial infarction. He brings a copy of an echocardiogram report which shows his
left ventricular ejection fraction is 38%. On examination his pulse is 78 / min and regular, blood
pressure is 124 / 72 mmHg and his chest is clear. His current medications include aspirin,
simvastatin and lisinopril. What is the most appropriate next step in terms of his medication?
Add bisoprolol
39
Which one of the following treatments have not been shown to improve mortality in patients with
chronic heart failure?
Furosemide
40
The neprilysin inhibitor, sacubitril, in combination with the angiotensin II receptor blocker,
valsartan, has been shown to reduce mortality, reduce hospitalisations and improve symptoms in
comparison to enalapril in the treatment of heart failure with reduced ejection fraction. What is its
mechanism of action in heart failure?
Prevents the degradation of natriuretic peptides such as BNP and ANP