1 >>Which one of the following transthoracic echocardiographic parameters does not suggest severe aortic regurgitation? ?
- (A) Vena contracta 0.50 cm
- (B) Central jet width 70% of LVOT
- (C) Holodiastolic aortic flow reversal in descending aorta
- (D) Pressure half-time 190 ms
2 >>During your CCU ward round you review a 72-year-old man with known aortic stenosis who presented with angina. He has been referred for aortic valve replacement. He has heard that there are different types of valve replacement and asks which is best. Which one of the following statements is false? ?
- (A) A mechanical prosthesis is preferred for patients with hyperparathyroidism
- (B) Patient lifestyle is an important factor in decision-making
- (C) A bioprosthetic valve is preferred for patients with limited life expectancy
- (D) Bioprosthetic valves are preferred for patients who have previously undergone CABG
3 >>A 23-year-old man with transposition of the great arteries underwent a Mustard operation during childhood. Three months previously he had a stent for a baffle stenosis. He attends outpatient clinic. He is undergoing a root canal procedure the following week and his dental surgeon has asked whether he needs prophylaxis for infective endocarditis (IE) before the procedure. He has a history of penicillin allergy. What would you recommend? ?
- (A) No antibiotic prophylaxis required
- (B) IV/oral clindamycin 600 mg 30 minutes before the procedure
- (C) O ral amoxicillin 1 g 30 minutes before the procedure with steroid and antihistamine
- (D) IV cephalexin 2 g 60 minutes before the procedure
4 >>A 38-year-old IV drug abuser presents with a 1-week history of malaise, fatigue, and rigors. His temperature on admission was 38.5�C. Examination revealed a pan-systolic murmur which was loudest at the left sternal edge. Three sets of blood cultures were taken. Transthoracic echocardiography (TTE) showed vegetation on the tricuspid valve with moderate TR. Which one of the following organisms is most likely to be positive in blood cultures? ?
- (A) Streptococcus sanguis
- (B) Enterococcus faecium
- (C) Coxiella burnetii
- (D) Staphylococcus aureus
5 >>A 76-year-old man presents to the ED with a 2-week history of fever, chills, poor appetite, and weight loss. He had a bovine aortic valve replacement 5 years previously for severe aortic stenosis. He was pyrexial. Admission bloods revealed a white cell count of 16.0 � 109/L and C-reactive protein (CRP) 120 mg/dL. What is the abnormality shown on the echocardiogram? ?
- (A) Vegetation on the aortic valve
- (B) Aortic root abscess
- (C) Vegetation on the anterior mitral leaflet
- (D) Severe central mitral regurgitation
6 >>A 59-year-old man with a bicuspid aortic valve and a background of benign prostatic hypertrophy presents with a 1-week history of fever and lethargy. He had been treated by his GP with oral antibiotics for a urinary tract infection (UTI) a week prior to admission. On examination, an ejection systolic murmur was audible on auscultation. As part of his initial investigations routine bloods and blood and urine cultures were taken. His urine culture sent by his GP has grown Escherichia coli. The admitting team suspects endocarditis. What is the next step of management? ?
- (A) Treat UTI with different antibiotics than those used previously
- (B) Arrange a transthoracic echocardiogram (TTE).
- (C) Arrange a transoesophageal echocardiogram (TOE) as aortic valve vegetations are poorly visualized on TTE
- (D) Repeat urine culture
7 >>Which one of the following is a predictor of poor outcome in patients with infective endocarditis? ?
- (A) Insulin-dependent diabetes mellitus
- (B) Renal failure
- (C) All the above
- (D) Staphylococcus aureus in blood cultures
8 >>An 80-year-old woman with a background of moderate aortic stenosis presents with a 2-week history of fatigue, weight loss, and night sweats. She has a history of nausea and altered bowel habit. Bloods revealed Hb 9.9 g/dL, white cell count 16.0 � 109/L, and CRP 187 mg/L. Blood cultures were taken on admission and she was commenced on empirical antibiotics. TTE demonstrated an aortic valve vegetation. The presence of which one of the following organisms would prompt ?
- (A) gastrointestinal investigations?
- (B) Haemophilus para-influenzae
- (C) Cardiobacterium hominis
- (D) Streptococcus bovis
9 >>A 71-year-old man presents 10 months after aortic valve replacement with fatigue, weight loss, and fever. Six weeks previously he had had treatment for a dental abscess. Whilst results from blood culture were awaited, a transthoracic echocardiogram revealed an aortic valve vegetation. Which of the following is the most appropriate next step? ?
- (A) Start vancomycin with gentamicin and rifampicin
- (B) Arrange urgent TEE
- (C) Wait for identification and sensitivities of cultures
- (D) Repeat TTE in 1 week
10 >>A 51-year-old farmer presents with low-grade fever and a recent history of weight loss. He has been investigated by his GP and general physicians but no cause has been identified for his symptoms. His inflammatory markers are raised and a TTE shows a 0.5 � 0.3 cm echogenic mass attached to the non-coronary cusp of the aortic valve. Endocarditis is suspected, although multiple blood cultures are negative. Which one of the following organisms is the most likely cause of persistently negative cultures? ?
- (A) Streptococcus constellatus
- (B) Coagulase-negative staphylococci
- (C) Cardiobacterium hominis
- (D) Coxiella burnetii
11 >>Which one of the following statements regarding outpatient parenteral antibiotic therapy (OPAT) for infective endocarditis is true? ?
- (A) O PAT can be considered in oral-streptococci-positive endocarditis in stable patients with no complications in the critical phase (0�2 weeks)
- (B) Complications are rare in the first 2 weeks
- (C) O PAT in patients who have received inpatient therapy for 3 weeks can be considered despite the presence of heart failure
- (D) Daily post-discharge evaluation physician review is necessary for OPAT
12 >>A 55-year-old man with known heart failure and LVEF of 37% is reviewed in the outpatient clinic with breathlessness. He is NYHA class III with no signs of fluid overload on examination. His BP is 110/60 mmHg, and his heart rate is 55 bpm. He is on bisoprolol 5 mg od and ramipril 10 mg od. His U&E tests reveal Na 137 mmol/L, K 4.5 mmol/L, urea 7 mmol/L, and creatinine 85 ?mol/L. Which one of the following medications will you chose next? ?
- (A) Furosemide 40 mg od
- (B) Spironolactone 25 mg od
- (C) Digoxin 62.5 micrograms od
- (D) Hydralazine 37.5 mg and isosorbide dinitrate 20 mg od
13 >>An 80-year-old woman is admitted with acute pulmonary oedema on a background of progressive shortness of breath with exertional chest pain for 6 months. She has a history of renal impairment with an eGFR of 40 mL/min. She is initially commenced on IV furosemide with good effect. An echocardiogram reveals LVEF 40% with severe aortic stenosis (AS) with an estimated valve area of 0.7 cm2. What would you do next? ?
- (A) Add a beta-blocker
- (B) Perform angiography with a view to aortic valve replacement (AVR)/transcatheter aortic valve implantation
- (C) Add an ACE inhibitor
- (D) A and B
14 >>You review a 60-year-old man with NHYA class II heart failure in clinic. He has LVEF 35%, BP 110/50 mmHg, and heart rate 80 bpm (sinus rhythm). Current medications are bisoprolol 1.25 mg and ramipril 7.5mg. What medication alteration would you recommend to the GP? ?
- (A) Add ivabradine
- (B) Add spironolactone 25 mg od
- (C) Add digoxin 62.5 micrograms od
- (D) Titrate up bisoprolol
15 >>A 35-year-old man presents to the medical take with acute heart failure. He has a 2-week history of progressive breathlessness. Past medical history includes type II diabetes mellitus. An echocardiogram subsequently shows an EF of 25% with anterior, septal, and lateral wall motion defects. He is stabilized on medication with furosemide, spironolactone, bisoprolol, and ramipril. What would be your next course of investigation? ?
- (A) Endomyocardial biopsy
- (B) Angiogram
- (C) Viral titres
- (D) Exercise tolerance test
16 >>A 65-year-old woman with ischaemic cardiomyopathy and LVEF30% comes for review in the outpatient clinic. She is NYHA class II and has been optimally revascularized. Her current heart failure medications are bisoprolol 10 mg od, ramipril 10 mg od, ivabradine 7.5 mg bd, and spironolactone 25 mg. Her ECG shows sinus rhythm, left bundle branch block (QRS duration 135 ms), left axis deviation, and PR interval 180 ms. Which one of the following managements would you recommend next? ?
- (A) Refer for transplant assessment
- (B) Refer for ICD
- (C) Refer for CRT-D
- (D) Refer for CRT-P
17 >>A 65-year-old man presents to the chest pain clinic with a 2-month history of exertional chest pain. He has no past medical history of note. On examination his BP is 130/70 mmHg and his heart rate is 65 bpm in sinus rhythm with a 3/6 pansystolic murmur. He has a positive ETT with inferolateral ST segment depression at 5 minutes Bruce protocol. Coronary angiography reveals severe distal left main stem disease, severe mid-LAD disease, severe mid-circumflex disease, and severe distal RCA disease. An echocardiogram shows severe mitral regurgitation with moderate LV systolic dysfunction. CMR confirms viability in all territories. What should you do next? ?
- (A) Continue medical management
- (B) Refer for CABG
- (C) Refer for mitral valve repair/replacement
- (D) B and C
18 >>You get a phone call from the heart failure nurse specialist regarding a patient followed up in clinic for titration of medication. He has dilated cardiomyopathy with an EF of 30%. His most recent BP is 110/60 mmHg with heart rate 60 bpm. He is currently on bisoprolol 7.5 mg od and ramipril 5 mg od. His renal function test results have been phoned through to the specialist nurse: Na 136 mmol/L, K 5.5 mmol/L, urea 13 mmol/L, creatinine 270 ?mol/L. (Baseline before titration of ACE inhibitor: Na 138 mmol/L, K 4.8 mmol/L, urea 8 mmol/L, creatinine 180 ?mol/L.) What would be your advice? ?
- (A) Continue current medication and recheck U&E at 1 week
- (B) Stop ramipril and recheck U&E at 1 week
- (C) Add spironolactone and recheck U&E at 1 week
- (D) Halve dose of ramipril and recheck U&E at 1 week
19 >>A 36-year-old woman with known idiopathic dilated cardiomyopathy (confirmed by TTE and angiography) is reviewed in the heart failure clinic. She is NYHA class III. Her current medication is bisoprolol 10 mg od, ramipril 7.5 mg od, spironolactone 25 mg od, digoxin 62.5 micrograms od, furosemide 40 mg bd. She has CRT-D in situ. Her heart rate is 70 bpm and her BP is 85/40 mmHg. She has mild peripheral oedema and a raised JVP. What is your next step? ?
- (A) Add candesartan 8 mg od
- (B) Perform CMR
- (C) Refer for transplant assessment
- (D) Increase ramipril
20 >>A 57-year-old woman with known heart failure and EF 42% is reviewed in clinic. She is breathless on walking up one flight of stairs or half a mile on the flat. On examination, her BP is 130/90 mmHg and her heart rate is 75 bpm (SR, ECG QRS < 120 ms). Her chest is clear to auscultation. There are no signs of fluid overload. Her current medication is carvedilol 25 mg bd, furosemide 40 mg od, and digoxin 62.5 micrograms od. Her recent renal function tests are Na 141 mmol/L, K 5.1 mmol/L, urea 13.5 mmol/L, and creatinine 236 ?mol/L. She has not previously tolerated an ACE inhibitor or spironolactone because of deteriorating renal function and hyperkalaemia. What would you do next? ?
- (A) Add hydralazine and isosorbide dinitrate (H-ISDN)
- (B) Add candesartan
- (C) Add eplerenone
- (D) Add furosemide