1 >> Atherosclerotic plaque rupture is the most common event leading to clinically relevant ischaemia. Which one of the following statements regarding this process is not true? ?
- (A) Thin-capped fibroatheromas are most prone to cap disruption and thrombus formation
- (B) Fracture of the fibrous cap allows platelets, clotting factors, and inflammatory cells to come into contact with the thrombogenic necrotic lipid core, leading to thrombus
- (C) Disrupted plaques can be accurately identified by optical coherence tomography
- (D) Plaque rupture will always result in some degree of clinical ischaemia (ACS)
2 >>Which one of the following statements regarding the new generation of antiplatelet drugs is not true? ?
- (A) Clopidogrel, prasugrel, and ticagrelor all inhibit the same receptor (P2Y12 ADP receptor)
- (B) Clopidogrel and prasugrel are irreversible inhibitors, whereas ticagrelor is reversible
- (C) Clopidogrel and prasugrel are both prodrugs which are metabolized to the active form, whereas ticagrelor acts directly
- (D) All are converted to the active metabolite by the hepatic cytochrome enzyme (CYP3A4) Pathway
3 >>You are called by the CCU nurses. They are concerned that one of a post primary angioplasty patient’s blood results has returned with platelets of 12 � 109/L. Bloods taken at the time of procedure revealed platelets of 179 � 109/L. The patient has no signs of bleeding and all other blood results, including haemoglobin, are stable and consistent. They have been loaded with aspirin 300 mg, prasugrel 60 mg, heparin 8000 units, and abciximab as a weight-adjusted bolus and current infusion for 12 hours. They had not previously received these agents. GP 2b/3a was recommended as the patient had a highly thrombotic right coronary artery occlusion with evidence of microvascular distal embolization and required a long length of drug-eluting stent. What do you advise? ?
- (A) This is likely to be a spurious result; continue with the current treatments but repeat the blood result urgently and watch for bleeding
- (B) This degree of platelet inhibition is to be expected with the current regime; reassure but watch for bleeding and repeat the bloods
- (C) This is a sign of early heparin-induced thrombocytopenia; stop the abciximab and replace platelets until >50 � 109/L
- (D) This may represent an immune-mediated thrombocytopenic reaction to abciximab; stop the infusion and repeat the bloods
4 >>A patient arrives directly in the catheterization laboratory for primary angioplasty. They volunteer a previous serious allergic reaction to heparin called ‘HIT’ as you are consenting them. What would be your anticoagulation strategy? ?
- (A) A single administration of unfractionated heparin in this situation should be safe
- (B) Avoid all anticoagulants as a precaution and complete the procedure with Gb2b/3a cover
- (C) Bivalarudin is safe and effective in this situation
- (D) A single administration of fondaparinux in this situation should be safe and effective
5 >>You review a patient in clinic who has previously had bypass surgery and a recurrence of angina. They have three grafts (LIMA to LAD, vein graft to OM, and vein graft to RCA). You recommend a coronary angiogram. The patient asks you if the procedure will be carried out from the wrist or the leg as they have had vascular procedure to both groins. You can see bilateral inguinal scars, but the procedures were carried out at another hospital. What do you advise? ?
- (A) The left wrist would be the preferred route here
- (B) The right wrist would be the preferred route here
- (C) The left leg would be the preferred route, but you will need to obtain further information regarding the vascular procedures
- (D) The right leg would be the preferred route, but you will need to obtain further information regarding the vascular procedures
6 >>Which of the following statements is true regarding non-ST elevation acute coronary syndromes (NSTE-ACS) compared with ST elevation myocardial infarctions (STEMI)? ?
- (A) Initial mortality of NSTE-ACS is higher
- (B) Six-month mortality of STEMI is higher
- (C) Long-term mortality of NSTE-ACS is higher
- (D) STEMI patients are older with more comorbity
7 >>O n your ward round you review a patient who is 48 hours post anterior STEMI treated successfully with primary angioplasty. He has type 2 diabetes and hypertension. He is gradually improving, having initially suffered with heart failure. He still feels ‘chesty’ and auscultation reveals minimal basal crepitations. Echocardiography has revealed an ejection fraction of 40%. Blood pressure is 110/70 mmHg with heart rate 55 bpm at rest. Ramipril has been titrated to 2.5 mg bd with bisoprolol 2.5mg od. U&Es have remained normal. How would you improve his medical treatment? ?
- (A) Add furosemide 40 mg od
- (B) R educe the bisoprolol
- (C) Further titrate the ramipril
- (D) Add Eplerenone 25 mg od
8 >>Which of the following should not be used as a procedural antiacoagulant for primary angioplasty? ?
- (A) Unfractionated heparin (GP 2b/3a)
- (B) Enoxaparin (GP 2b/3a)
- (C) Fondaparinux
- (D) Bivalarudin
9 >>You review a patient in the CCU who was admitted earlier with a large anterior myocardial infarction treated with primary angioplasty. He has no bystander disease but the presentation was late. The echocardiogram shows severe LV impairment. There is pulmonary oedema which you have been treating with furosemide boluses and continuous positive airway pressure non-invasive ventilation. Blood pressure is now 85/50 mmHg and urine output in the last hour is 10 mL. Oxygen saturations are maintained at 94% with high-flow oxygen. He remains alert. What treatment should you consider next? ?
- (A) Call an anaesthetist to consider ventilation
- (B) Start a dopamine infusion
- (C) Give a fluid challenge
- (D) Start a nitrate infusion
10 >>You are completing the discharge summary for a patient who has undergone primary angioplasty with a bare metal stent for an anterior myocardial infarction. The pharmacist questions you regarding the duration of antiplatelets. What do you advise? ?
- (A) Dual antiplatelets for 12 months and then aspirin long term
- (B) Ticagrelor for 1 month and aspirin long term
- (C) Aspirin for 1 month and ticagrelor long term
- (D) Ticagrelor alone is adequate long term
11 >>You review a 59-year-old man with long-standing hypertension in clinic. He has no other comorbidities. He complains of some breathlessness, but this does not limit his physical activity. A transthoracic echocardiogram demonstrates aortic root dilatation and severe aortic regurgitation. Which one of the following is not an indication for surgery? ?
- (A) NYHA class II breathlessness
- (B) Aortic root disease with maximal diameter 49 mm
- (C) Patients undergoing CABG, valve surgery, or surgery of the ascending aorta
- (D) Asymptomatic with resting LVEF ?50%
12 >>You are asked to review the echocardiogram of a 74-year-old woman with a loud pansystolic murmur The following statements are all true, except: ?
- (A) The jet of regurgitation is anteriorly directed
- (B) The regurgitation is likely to be chronic
- (C) Using PISA to assess the severity of the regurgitant jet is more accurate than measuring the vena contracta
- (D) The MV inflow E-wave velocity is 1.6 m/s; this suggests severe MR
13 >>You are reviewing a 65-year-old farmer in the post-PCI clinic. He had primary angioplasty to his RCA for an inferior STEMI 3 months previously. He reports exertional breathlessness but no chest pain. His current medications are aspirin 75 mg od, clopidogrel 75 mg od, ramipril 5 mg bd, bisoprolol 5 mg od, and atorvastatin 80 mg od. On examination his BP is 110/70 mmHg and his heart rate is 60 bpm. You hear a soft pan-systolic murmur at his apex. His chest is clear and there is no pedal oedema. His ECG shows atrial fibrillation. He manages only 3 minutes on the treadmill with no chest pain or ECG changes, stopping due to breathlessness. You request an urgent echocardiogram, which demonstrates mild LV systolic dysfunction. The inferior wall is akinetic, there is some tethering of the posterior mitral valve leaflet, and as a result some mitral regurgitation (ERO = 0.2 cm2). What is the next appropriate step in his management? ?
- (A) Start dabigatran
- (B) Start eplerenone
- (C) Urgent repeat coronary angiography
- (D) Stress echocardiography
14 >>An 82-year-old retired solicitor presents to the ED with chest pain radiating to his jaw. He has hypertension treated with ramipril 5 mg bd but is otherwise normally fit and well. His admission ECG shows atrial fibrillation with a ventricular rate of 90 bpm, LVH, and widespread ST segment depression. His peak troponin is 110 ng/L (normal <30 ng/L). He is started on treatment for an acute coronary syndrome and listed for an inpatient angiogram. You are asked to perform a bedside echocardiogram as a systolic murmur is heard on the post-take ward round. Calculate the aortic valve area (using the continuity equation) from ?
- (A) 0.76 cm2
- (B) 0.80 cm2
- (C) 0.92 cm2
- (D) 1.02 cm2
15 >>The patient in Question 4 goes on to have a coronary angiogram. It shows: � LMS: mild atheroma � LAD: severe (90%) proximal stenosis; good distal target � LCx: small vessel with diffuse distal atheroma � RCA: dominant; moderate (50�60%) mid-vessel focal stenosis. Which one of the following statements is correct? ?
- (A) The patient should be referred for AVR and LIMA to LAD
- (B) His operative mortality is about 3%
- (C) Surgical ablation for AF may be considered
- (D) The patient should have PCI to LAD followed by TAVI
16 >>A 68-year-old man is referred for assessment of an ejection systolic murmur after presenting with worsening breathlessness. measurements were obtained during transthoracic echo: � mean gradient across aortic valve, 30 mmHg � aortic valve area (by continuity equation), 1.0 cm2 Coronary angiography demonstrated mild atheroma without any significant disease. Which one of the following would be the most useful next investigation? ?
- (A) Repeat transthoracic echocardiogram in 6 months
- (B) Transoesophageal echocardiography
- (C) Dobutamine stress echocardiography
- (D) Exercise tolerance test for risk stratification
17 >>A 79-year-old retired farmer with known aortic stenosis (AS) returns for his annual surveillance echocardiogram. He remains physically active with no symptoms. His BP is 180/110 mmHg. The following summary is obtained: � Severe AS-peak velocity has increased from 3.8 m/s a year ago to 4.0 m/s today � Mean gradient, 40 mmHg � Aortic valve area, 1.0 cm2 � Mild LVH � Good overall LV systolic function Which one of the following statements is correct? ?
- (A) A statin should be prescribed to reduce the rate of AS progression
- (B) An antihypertensive drug should be prescribed
- (C) The increase in peak velocity of ?0.2 m/s/year suggests that surgery should be considered
- (D) An exercise tolerance test (ETT) is unsafe in asymptomatic severe AS
18 >>Three years later, the patient in question 5 is admitted to hospital with chest pain. A repeat echocardiogram shows a heavily calcified aortic valve with a peak velocity of 4.8 m/s, valve area of 0.8 cm2, and moderately impaired LV systolic function. Two years ago he had a right upper lobe lung lobectomy with chemoradiotherapy for a localized primary bronchogenic carcinoma. Your consultant has asked you to write a referral letter to the ‘heart team’ at the regional tertiary centre to consider this patient for a transcatheter aortic valve implantation (TAVI). Which one of the following is a contraindication for TAVI? ?
- (A) Plaques with mobile thrombi in the ascending aorta or arch
- (B) Porcelain aorta
- (C) Home oxygen therapy
- (D) Severe peripheral vascular disease
19 >>You are asked to review an echocardiogram of a 82-year-old woman who has both severe aortic stenosis (AS) and severe mitral regurgitation (MR). All the following statements are true in patients with combined or multiple valve lesions except: ?
- (A) Associated MR may lead to underestimation of the severity of AS
- (B) Severe AS may lead to overestimation of coexisting MR
- (C) Significant aortic regurgitation (AR) lengthens the Doppler pressure half-time (PHT) in mitral stenosis (MS)
- (D) The presence of significant AR may overestimate the gradient across the aortic valve
20 >>A 24-year-old IV drug user presents to hospital with a 6-week history of fever, rigors, and general malaise. On admission his temperature is 38�C. His venous pressure is elevated to the angle of the jaw with prominent V waves. You hear a loud systolic murmur at the lower left sternal edge, which is louder on inspiration. There is mild pedal oedema. Blood cultures grow Staphylococcus aureus in all six bottles. An initial transthoracic echocardiogram followed by a transoesophageal echocardiogram show no obvious vegetation and severe tricuspid regurgitation (TR). Nonetheless, he has 6 weeks of intravenous antibiotics withresolution of his sepsis. There are no embolic complications. He is now asymptomatic. The following are all appropriate considerations for tricuspid valve surgery except: ?
- (A) Persistent symptoms with reasonable right ventricular dysfunction
- (B) No symptoms-TAPSE 12 mm
- (C) No symptoms-tricuspid annulus systolic velocity 13 cm/s
- (D) No symptoms-RV end-systolic area 30 cm2