1 >>A 30-year-old man had a cardiac transplant 5 years previously because of dilated cardiomyopathy. He initially did very well post-transplant. However, he has noticed that he is progressively short of breath on exertion. His TTE shows mid and apical anterior hypokinesia. What is the most likely diagnosis? ?
- (A) Acute T-cell rejection
- (B) Non-Hodgkin’s lymphoma
- (C) Coronary vasculopathy
- (D) Sarcoidosis
2 >>A 55-year-old man presents with pulmonary oedema following an episode of chest pain a week previously. What does his CMR show (z Video 4.1)? ?
- (A) Normal
- (B) Global mild LV systolic dysfunction
- (C) RWMA in the RCA territory with severe LVSD
- (D) RWMA in the LAD territory with severe LVSD
3 >>Which one of the following is not a contraindication to an ACE inhibitor? ?
- (A) History of angioedema
- (B) Known renal artery stenosis
- (C) TTE showing AVA 1.2 cm2
- (D) Serum creatinine 250 ?mol/L
4 >>A 40-year-old man with known hypertrophic cardiomyopathy presents to the outpatient clinic with a history of increased breathlessness. He has noted a marked reduction in his exercise tolerance over the last 6 months and it is now limited to 100 yards despite his being commenced on bisoprolol. Clinical examination demonstrates a forceful apex and a mid-systolic murmur. There is no evidence of fluid overload. Echocardiography demonstrates asymmetric left ventricular hypertrophy with a septal thickness of 20 mm. There is a resting left ventricular outflow tract gradient of 60 mmHg. What is the most appropriate management for this patient? ?
- (A) Dual-chamber pacing
- (B) ICD implantation
- (C) Referral for exercise stress echocardiography to assess for arrhythmia and increase in LVOT gradient
- (D) Referral to a specialist centre for septal ablation
5 >>A 25-year-old woman is referred with a mid-systolic murmur. Echocardiography demonstrates asymmetric left ventricular hypertrophy with good left ventricular systolic function. The septal thickness is 17 mm with a small left ventricular outflow tract gradient. She is symptom free. Which one of the following statements is not true? ?
- (A) A blood pressure response of <20 mmHg on standard exercise testing is a risk factor for sudden cardiac death
- (B) First-degree relatives who have had normal screening echocardiograms should have repeat studies every 5 years
- (C) The patient should be advised that future pregnancy is high risk
- (D) She is at higher than normal risk of developing atrial fibrillation
6 >>A 53-year-old man presents to the outpatient clinic with symptoms of lethargy and tiredness. Clinical examination reveals him to be pale with a blood pressure of 110/70 mmHg, a JVP of +8 cmH2O, and oedema to his mid-calf. His 12-lead ECG demonstrates a PR interval of 200 ms, a QRS duration of 145 ms, and poor R-wave progression. A subsequent echocardiogram was technically challenging, but demonstrated a thickened ventricle with a septal thickness of 15 mm. Overall systolic function is reported as normal. An E/A ratio was estimated to be 1.4 with tissue Doppler giving an E/E’ ratio of 12. Which one of the following investigations is most likely to help make the diagnosis? ?
- (A) Myocardial biopsy
- (B) Contrast-enhanced transthoracic echocardiogram
- (C) U rine and serum electrophoresis for monoclonal protein
- (D) Myocardial perfusion scan
7 >>A 73-year-old man well known to the ED with alcohol excess presented with acute pulmonary oedema requiring CPAP. His presenting ECG demonstrated sinus rhythm with a broad left bundle branch block with QRS duration of 173 ms. A subsequent coronary angiogram demonstrates the following: LMS normal LAD 50% mid vessel stenosis LCx 60% distal stenosis RCA recessive vessel, 75% proximal disease A subsequent echocardiogram demonstrated a left ventricular diastolic dimension of 7 cm. There is global impairment of left ventricular systolic function with EF estimated at 30%. There was severe mitral regurgitation due to annular dilatation. He was successfully commenced on ramipril and bisoprolol. What is the most appropriate management at this stage? ?
- (A) Referral for CRT-D
- (B) Referral for revascularization
- (C) Commence warfarin therapy for a dilated left ventricle
- (D) Commence spironalactone
8 >>A 74-year-old patient presents to hospital with a VF arrest. She is successfully resuscitated and a subsequent ECG demonstrates a clear-cut anterior myocardial infarction with >2 mm ST elevation in leads V2�V6. Coronary angiography demonstrates a suboccluded proximal LAD, with a small unobstructed circumflex artery and a 70% stenosis in the proximal RCA. She undergoes successful coronary intervention to her proximal LAD and has an uncomplicated recovery from her infarct. Her echocardiogram demonstrates akinesia of the apex, but an overall EF estimated at 35�40%. She is established on dual anti-platelet therapy, ramipril, bisoprolol, and a statin. What other therapy should she have? ?
- (A) Spironalactone
- (B) Epleronone
- (C) ICD insertion
- (D) CRT insertion
9 >>A 45-year-old patient with a known diagnosis of AL amyloid presents to cardiology outpatient clinic. He is under the haematologists receiving chemotherapy for myeloma. Which one of the following statements is true when there is cardiac involvement with amyloid? ?
- (A) ACE inhibitor therapy is the cornerstone of treatment with cardiac involvement
- (B) In endstage disease, cardiac transplantation in AL amyloid is relatively contraindicated
- (C) Beta-blockers are used routinely
- (D) With adjunctive chemotherapy, the prognosis for AL amyloid is good
10 >>A 50-year-old man with sarcoidosis is referred to the outpatient clinic from the respiratory clinic. Which one of the following features would suggest cardiac involvement? ?
- (A) First-degree heart block
- (B) Dilated cardiomyopathy
- (C) All of the above
- (D) E/A reversal on mitral inflow Doppler with an elevated E/E’ on tissue Doppler imaging
11 >>A patient is not achieving target LDL-C on high-dose statin alone. Which combination with statin is not recommended? ?
- (A) Gemfibrozil
- (B) Ezetimibe
- (C) Colesevelam
- (D) Nicotinic acid
12 >>Which one of the following agents will have the greatest LDL-C-lowering effect? ?
- (A) A torvastatin 40 mg od
- (B) P ravastatin 40 mg od
- (C) S imvastatin 40 mg od
- (D) C holestyramine 8 mg od
13 >>A 52-year-old patient presents with breathlessness. He has had hypertension for many years but has been non-compliant with his medication. His echocardiogram demonstrates an EF of 70%, with marked concentric hypertrophy. Which one of the following therapies is not appropriate? ?
- (A) Ramipril
- (B) Atenolol
- (C) Irbesartan
- (D) Amlodipine
14 >>A 42-year-old Caucasian woman presents to the outpatient clinic when she is 10 weeks pregnant. This is her second pregnancy and was unplanned. Her first pregnancy was complicated by peripartum cardiomyopathy with moderate impairment of left ventricular systolic function. However, she did have complete resolution of systolic function 6 months after the birth of her first child. Which one of the following statements is true? ?
- (A) Her risk of death during this pregnancy is significantly increased
- (B) Her risk of developing heart failure during the pregnancy is around 20%
- (C) If she develops cardiomyopathy during this pregnancy, the likelihood of resolution of LV function after pregnancy is high
- (D) Prophylactic use of ACE inhibitors is mandatory
15 >>You are reviewing a 27-year-old male in clinic for the first time. On a routine health check 12 months previously he was found to have a restrictive perimembranous VSD on his echocardiogram. The jet velocity was measured at 5 m/s. There was no evidence of left ventricular dilatation and pulmonary pressures are not raised. He is asymptomatic. The rest of his echocardiogram confirmed a structurally normal heart apart from mild aortic regurgitation. You repeat the echocardiogram in clinic and there has been no change.What is the most appropriate follow-up? ?
- (A) Advise him that this is an incidental finding which should not cause any problems and discharge him from clinic
- (B) Advise that there is an increased risk of endocarditis but based on the current guidance there is no role for antibiotic prophylaxis and discharge him from clinic
- (C) Arrange for follow-up with echocardiography in 12 months
- (D) Advise him that although there are no problems at the moment it is advisable to close the VSD to reduce the risk of progressive haemodynamic change and risk of endocarditis. This can usually be done transcatheter
16 >>You are asked to review and explain the terminology on an echocardiogram report for a patient who has just returned to the ward having been admitted with stable but symptomatic AV block. The report states that there is A�V and V�A discordance. What is the underlying diagnosis? ?
- (A) Congenitally corrected transposition of the great arteries (ccTGA)
- (B) Transposition of the great arteries
- (C) An atrioventricular defect with lack of AV valve offset
- (D) Truncus arteriosus
17 >>You receive a letter from a GP asking if a patient requires follow-up in clinic. She is 35 years old and has not been seen since discharge from the paediatric cardiology services. She had a coarctation repair in childhood with no associated lesions. You have the surgical information, which documents a Dacron patch aortoplasty technique with excellent result and no residual stenosis. She is otherwise well with BP 120/80 mmHg. She has normal peripheral pulses and no murmurs. She has had two successful pregnancies. What should you advise the GP? ?
- (A) She should have an echocardiogram and if this demonstrates normal structure and velocities in the descending aorta, based on normal blood pressure and clinical examination she does not require regular follow-up
- (B) She does not require follow-up but should be referred to the pregnancy clinic if she decides to have more children
- (C) She does not require any follow-up as surgical repair of coarctation has excellent long-term results
- (D) She will require long-term follow-up in a specialist clinic; an MRI will be the investigation of choice to document the previous repair and any associated problems
18 >>A 33-year-old male has been admitted under the stroke physicians with an episode of transient left upper limb weakness, which lasted 1 hour after exercising at the gym. He has no prior medical history. He is a lifelong non-smoker with no important family history. He is very fit and plays competitive basketball. Blood tests reveal total cholesterol of 4.3 mmol/L. BP is 110/70 mmHg and ECG shows sinus rhythm with normal morphology. The stroke physicians arrange a CT head and echocardiogram. The CT head returns normal. You are asked to comment on the echocardiogram report which documents a structurally normal heart with no thrombus in the LA. The only finding is of an ‘aneurysmal’ intra-atrial septum. What should you advise the stroke team? ?
- (A) The patient should have a TOE as transthoracic echocardiography cannot rule out a cardiac source of thrombus
- (B) Aneurysmal intra-atrial septum is a common and benign finding in young adults and the rest of the echocardiogram is reassuring. No further cardiac investigations are required
- (C) They should arrange a Holter monitor to exclude a paroxysmal atrial arrhythmia which may have precipitated thrombus
- (D) A bubble contrast echocardiogram would be the next investigation of choice
19 >>Which one of the following statements regarding the Fontan operation is correct? ?
- (A) I t is a palliative procedure in patients with congenital cyanotic heart disease when a biventricular repair is not possible; the result is univentricular physiology with diversion of systemic venous return to the pulmonary arteries
- (B) P atients should have a near-normal life expectancy as chronic cyanosis is corrected and the pulmonary vasculature is protected from systemic pressures
- (C) I t is one potential solution for transposition of the great arteries; systemic venous blood is diverted to the subpulmonary ventricle via an atrial baffle and pulmonary venous return is redirected to the systemic ventricle
- (D) I t is a corrective procedure for patients with functionally univentricular cyanotic heart disease; the end result is a biventricular repair
20 >>You are asked to review a 27-year-old female with complex congenital heart disease. She is normally managed at another centre, and limited information is available. She has had a number of operations in early life but has recently been well. Her parents tell you that she has ‘one main pumping chamber’. The history is of deterioration over the last week with fevers and headache. On examination the patient is cyanosed (baseline saturations 85% on room air) and agitated with GCS 13�15. Temperature is 38.4�C, BP is 120/80 mmHg, and heart rate is 100 bpm (regular). A bedside echocardiogram is attempted but the image quality is very poor. The ED team have initiated supportive treatment with high-flow O2 and IV fluids. Blood cultures have been taken. The chest X-ray is suspicious for right basal consolidation. What would you advise? ?
- (A) There is evidence of severe sepsis with compromise; in view of the complex congenital heart disease there is a risk of rapid decompensation and the patient should be moved to the ITU with a view to intubation if the hypoxia deteriorates
- (B) The patient requires an immediate TOE as she is in a high-risk category for concomitant endocarditis and TTE is non-diagnostic
- (C) I n view of the temperature and reduced GCS she should have an urgent CT head
- (D) After adequate blood cultures have been taken, initiate empirical antibiotics for pneumonia and move to CCU for supportive treatment; involve the ITU team in case of deterioration; aim for saturations >93% and plan for TOE when stabilized to rule out endocarditis