1 >>A 66-year-old woman with a past medical history of hypertension undergoes DC cardioversion for atrial fibrillation. Immediately following the procedure, transient ST elevation is seen. The patient is asymptomatic post-procedure but cardiac enzymes are taken 12 hours later. These show a normal troponin I but a raised CK. The SHO calls you to advise him on the significance of the ECG and blood tests. What do you advise? ?
- (A) The ST elevation and raised CK are probably not abnormal
- (B) A rise in troponin I, but not in troponin T, is sometimes seen following AF cardioversion
- (C) A rise in troponin T, but not in troponin I, is sometimes seen following AF cardioversion
- (D) Both troponin I and T are usually raised post-cardioversion
2 >>A 40-year-old man presents to A&E with a 12-hour history of sudden-onset palpitations. He has no previous medical history of note and the clinical examination is unremarkable. His troponin is negative. His ECG shows atrial fibrillation with a ventricular rate of 130 bpm, his BP is 110/70 mmHg, and his oxygen saturation is 98%. He has no symptoms associated with his palpitations. What is the best management? ?
- (A) Amiodarone 300 mg IV loading followed by 900 mg over 24 hours
- (B) Flecainide 2 mg/kg over 10 minutes followed by oral dose
- (C) Digoxin 500 micrograms IV followed by 500 micrograms after 6 hours
- (D) Anticoagulate, rate control, and perform DC cardioversion in 6 weeks
3 >>A 72-year-old man with symptomatic persistent atrial fibrillation is admitted for pulmonary vein isolation. Which one of the following statements is most likely to be true? ?
- (A) The risk of stroke is around 5%
- (B) The chance of successful ablation of the arrhythmia is around 90% at 1 year
- (C) The chance of successful ablation is higher for persistent AF than for paroxysmal AF
- (D) The risk of cardiac tamponade is around 5%
4 >>A patient is admitted for a DC cardioversion for their persistent atrial fibrillation. Which one of the following statements is true? ?
- (A) M onophasic waveforms are more effective than biphasic waveforms at cardioverting patients
- (B) Increased left atrial size is associated with an increased risk of AF recurrence
- (C) The initial success rate is around 50%
- (D) Patients do not require anticoagulation prior to cardioversion if their CHADS2 score is ?1
5 >>A 75-year-old man with a previous history of persistent AF, peptic ulceration, and renal failure (creatinine 220 ?mol/L) undergoes elective PCI to his LAD with a bare metal stent (BMS). He was on warfarin for AF prior to his PCI. What is the best combination of drugs immediately following the procedure? ?
- (A) Aspirin, clopidogrel, and warfarin
- (B) Aspirin and clopidogrel
- (C) Aspirin and warfarin
- (D) Clopidogrel and warfarin
6 >>A 35-year-old man with no past medical history of note and on no regular medication presents to clinic with palpitations. Holter monitoring reveals short-lasting episodes of atrial fibrillation during which he has noted ‘a fluttering sensation’ in his patient diary. What is the best initial management plan? ?
- (A) Warfarin and atenolol
- (B) Amiodarone and aspirin
- (C) R efer for pulmonary vein isolation
- (D) Flecainide and atenolol
7 >>An 80-year-old woman with permanent atrial fibrillation and palpitations attends clinic. She has been in AF for over 10 years and has a left atrial diameter of 5.5 cm. She has high ventricular rates despite being on digoxin 125 micrograms od and atenolol 50 mg od. She has dizzy episodes when she has high ventricular rates and had a pre-syncopal episode 1 month ago. She is keen to consider an AV node ablation. What do you advise? ?
- (A) There is no evidence that this will improve her symptoms
- (B) The mortality of the procedure is about the same as for medical treatment of AF
- (C) The procedure is contraindicated in patients with heart failure
- (D) PVI ablation should be attempted first
8 >>A 50-year-old man with a history of hypertension, diabetes, and persistent atrial fibrillation, for which he is warfarinized, is admitted with an NSTEMI. He undergoes PCI to his proximal LAD with a drug-eluting stent (DES). What is the best combination of drugs following his intervention? ?
- (A) Aspirin, clopidogrel, and warfarin for 1 month; then warfarin alone thereafter
- (B) Aspirin, clopidogrel and warfarin for 1 month; then warfarin and clopidogrel for 12 months followed by warfarin alone
- (C) Aspirin, clopidogrel, and warfarin for 6 months; then warfarin and clopidogrel for 6 months followed by warfarin alone
- (D) Aspirin, clopidogrel and warfarin for 12 months; then warfarin alone
9 >>An 85-year-old woman is referred to your cardiology clinic because of an incidental finding of atrial fibrillation at a routine check-up. The patient is asymptomatic from a cardiovascular perspective, but a 24-hour tape organized by the GP shows atrial fibrillation throughout with rates varying between 60 and 110 bpm. The patient has a history of hypertension and stable angina. Coronary angiography performed several years ago showed minor atheroma in the LAD, circumflex, and RCA. Echocardiography shows good biventricular systolic function with a left atrial diameter of 5.2 cm. The patient is on aspirin 75 mg od, ramipril 10 mg od, simvastatin 20 mg od, and atenolol 50 mg od. What thromboprophylactic treatment do you recommend? ?
- (A) Warfarinization with a target INR of 2.0�3.0
- (B) Warfarinization with a target INR of 1.8�2.5
- (C) Continue with aspirin 75 mg od
- (D) Aspirin and warfarin with a target INR of 2.0�3.0
10 >>An 18-year-old woman attends the ED with palpitations and dizziness. An ECG shows a broad complex tachycardia with an irregularly irregular rhythm and a ventricular rate of 160 bpm. Her BP is 88/60 mmHg but she has no chest pain or dyspnoea. She had been told several years earlier that she had a ‘Wolff� Parkinson�White ECG’ and offered ‘a procedure’ for this but declined. She has had no previous admissions to hospital and is on no regular medication. What is the best treatment? ?
- (A) Adenosine IV
- (B) Verapamil IV
- (C) Amiodarone IV
- (D) DC cardioversion
11 >>A 60-year-old hypertensive patient presents to the ED with chest pain. The pain came on very suddenly in the left chest whilst he was lifting a heavy plant pot. The pain is difficult to localize. The intensity has been constant and remains persistent. En route to hospital it has changed location to the left side of the lower thoracic back. He has recently had treatment for thoracic back pain from a chiropractor. He is sweating (looks unwell) and anxious but has no shortness of breath. Blood pressure is 160/90 mmHg, heart rate is 100 bpm and saturations are 99% on room air. The ECG does not show acute ST change. D-dimer is 1700 ng/mL (normal < 500 ng/mL), and troponin is awaited. Based on the information available, what is the most likely diagnosis? ?
- (A) Acute coronary syndrome
- (B) Pulmonary embolism
- (C) Acute aortic syndrome
- (D) Musculoskeletal pain
12 >>You review a 65-year-old male on the post-take ward round who has been referred by his GP with a 2-week history of exertional chest pain. There have been no episodes at rest and he has improved since the GP started him on bisoprolol 2.5 mg od. His resting ECG shows no ischaemia and troponin tests are negative. He has a family history of ischaemic heart disease but no other risk factors. Which investigation would you recommend? ?
- (A) CT coronary angiogram
- (B) Invasive coronary angiogram
- (C) Exercise treadmill test
- (D) Stress echo
13 >>A 45-year-old woman presents with ongoing chest pain. Immediate observations reveal BP 140/80 mmHg, heart rate 90 bpm, and saturations 99% on room air. What should you do next? ?
- (A) Administer oxygen
- (B) Administer analgesia
- (C) Give aspirin 300 mg
- (D) Perform a 12-lead ECG
14 >>You review a 55-year-old woman in clinic who has been referred by her GP with recent chest pains. You feel that the nature of the pains is atypical for ischaemia although they are reproduced with exertion. She has no identifiable risk factors for ischaemic heart disease and the resting ECG is normal. What would you recommend? ?
- (A) CT coronary angiogram
- (B) R eassure-no further tests required
- (C) Invasive coronary angiogram
- (D) Exercise treadmill test
15 >>You are referred a 40-year-old lady with left arm pain. She had a single episode after running for a bus with shopping, which subsided after 5 minutes. She has never previously had exertional chest discomfort. Resting ECG is normal and 8 hours high-sensitivity troponin is negative. She has a BMI of 33 and diet-controlled type 2 diabetes mellitus but is not hypertensive. What do you recommend? ?
- (A) R eassure and discharge
- (B) Inpatient invasive coronary angiogram
- (C) Outpatient stress echo
- (D) Discharge-dependent exercise treadmill test
16 >>A 25-year-old male developed sharp central chest pain and palpitations after drinking three cans of energy drink whilst revising for exams. The symptoms were ongoing when he initially attended the ED, and an ECG showed a sinus tachycardia with no ST change. The pain subsided shortly afterwards. He is normally fit and well. His father recently had a myocardial infarction at the age of 62. All observations and examination are normal. Troponin and D-dimer tests were negative. What would you recommend? ?
- (A) Admit for observations
- (B) Exercise treadmill test
- (C) Stress echocardiogram
- (D) No further investigation
17 >>O ne of your patients has small vessel coronary disease which is not suitable for revascularization. They are still experiencing class 2 angina particularly in the evening despite bisoprolol 10 mg od. Blood pressure is 135/90 mmHg. What would you recommend next? ?
- (A) Amlodipine
- (B) Ivabradine
- (C) Nicorandil
- (D) Bisoprolol 5 mg bd
18 >>O ne of your patients has discrete angiographically significant lesions in the mid right coronary artery and the mid left anterior descending coronary artery. He is 60 years old and is not diabetic. He has ongoing class 2 anginal symptoms despite optimal dose of a beta-blocker and a long-acting nitrate. What do you recommend? ?
- (A) CABG will be associated with a greater mortality benefit compared with PCI
- (B) The risk of stroke will be significantly lower with PCI
- (C) Add a third oral antianginal and then reconsider revascularization
- (D) The likelihood of repeat revascularization is higher with PCI
19 >>A 45-year-old diabetic male patient has returned to clinic following a recent angiogram. He has stable class 2 angina and is currently on aspirin 75 mg od, atorvastatin 40 mg nocte, and bisoprolol 2.5 mg as antianginal treatment. His symptoms have improved since starting the beta-blocker. The angiogram showed severe plaque in the proximal left anterior descending artery and discrete simple lesions in the mid circumflex and right coronary arteries. The echocardiogram has shown moderate LV impairment. What do you recommend? ?
- (A) Titrate the beta-blocker and add a calcium-channel blocker or long-acting nitrate-reassess symptoms
- (B) Titrate the beta-blocker and add an ACE inhibitor-reassess symptoms and LV function
- (C) CABG for prognostic and symptomatic improvement
- (D) PCI guided by ischaemia via a functional imaging test
20 >>Which one of the following is true of atherosclerotic plaque formation? ?
- (A) It is an acute inflammatory disease of the vascular intima
- (B) It is characterized by the accumulation and modification of cholesterol esters on the luminal surface of the endothelium
- (C) Macrophages bind and phagocytose oxidized LDL to form foam cells
- (D) Typically form away from branch points