Medicine Malaysia Cardiology 1 Page: 1/40 A 60-year-old man with a past history of controlled hypertension presents with acute

onset weakness of his left arm, that resolved over 12 hours. He had suffered two similar episodes over the last three months. Examination reveals a blood pressure of 132/82 mmHg and he is in atrial fibrillation with a ventricular rate of 85 per minute. CT brain scan is normal. What is the most appropriate management? 1 2 3 4 5 ) ) ) ) ) amiodarone aspirin digoxin dipyridamole warfarin

Page: 2/40 Answer is 5 This patient has had three transient ischaemic attacks due to atrial fibrillation. The most appropriate therapeutic strategy for this patient would be warfarin. Studies reveal that warfarin would be therapeutically superior than aspirin in such a patient's case. Page: 3/40 A 35-year-old healthy woman has a faint systolic murmur on physical examination. An echocardiogram is performed, and she is found to have a bicuspid aortic valve. In explaining the meaning of this finding to her, the most appropriate statement is that? 1 ) An aortic valve replacement is eventually likely to be required. 2 ) Other family members are likely to have the same condition 3 ) She should be treated with a cholesterol-lowering agent 4 ) The problem resulted from past injection drug usage 5 ) This is one manifestation of an underlying autoimmune disease process

Page: 4/40 Answer is 1. Bicuspid aortic valve is perhaps the most common form of congenital heart disease in adults (1-2% of population). Bicuspid valves have a propensity to wear out and calcify with aging. Bicuspid aortic valve tends to be a sporadic although there is a reported familial incidence of approx 9%. From a review of several sources in the literature, the Aeromedical Consultation Service (ACS) at Brooks AFB calculated a 1.2% per year incidence of aortic valve surgery in individuals with BAV, although the vast majority occur in the 5th and 6th decades of life. Page: 5/40 A 28-year-old man who is known to have Hypertrophic Cardiomyopathy has an out of hospital cardiac arrest and is successfully resuscitated. What is the most appropriate mode of treatment? 1 2 3 4 5 ) ) ) ) ) Alcohol Septal Ablation Amiodarone Beta Blocker Implantable Defibrillator Myomectomy

Page: 6/40 Answer is 4. Patients with HCM are at increased risk of sudden cardiac death due to VF/VT. Implantable Cardio Defibrillators (ICD) are superior to Amiodarone or Beta Blockers for preventing this. Reducing outflow tract obstruction with myomectomy or Alcohol Septal Ablation does not reduce the risk of SCD. Other indications for ICD implantation include 1. Cardiac arrest due to VF/VT 2. Sustained VT causing haemodynamic compromise 3. Chronic Heart Failure, LVEF<40% and associated syncopal episodes due to Non Sustained VT 4. Post-MI Non Sustained VT with LVEF<40% 5. Arrythmogenic right ventricular cardiomyopathy causing cardiac arrest 6. Congenital Long QT with family history of sudden cardiac death at young age. For European Society of Cardiology guidelines on ICD

implantation visit: http://medc.unimuenster.de/medc/dienstleistungen/public/PDF/icd-esc-guidelines2001.pdf Page: 7/40 A 27 year old woman complained of palpitations, breathlessness and chest pain, radiating to the left arm. These symptoms had developed six weeks previously, after she had witnessed her father dying from a myocardial infarction. In the past 10 years she had been investigated for abdominal pain, headaches, joint pains, and dyspareunia, without serious cause being found for these symptoms. What is the most likely diagnosis? 1 2 3 4 5 ) ) ) ) ) Depressive episode Factitious disorder Generalized anxiety disorder Hypochondriasis Somatization disorder

Page: 8/40 Answer is 5. Although the brief scenario does not have quite enough criteria to fulfill a diagnosis there is enough to make somatization disorder the most likely answer. Somatization disorder is characterized by multiple recurring pains and gastrointestinal, sexual, and pseudo-neurologic symptoms that occur over a period of years. To meet the diagnostic criteria for somatization disorder, the patients' physical complaints must not be intentionally induced and must result in medical attention or significant impairment in social, occupational, or other important areas of functioning. By definition, the first symptoms appear in adolescence and the full criteria are met by 30 years of age. Of all the other disorders "factitious disorder" would seem the least likely. The other three are possible explanations but not as likely as somatization. Page: 9/40 A 65 year old male with left ventricular systolic dysfunction was dyspnoeic on climbing stairs but not at rest. The patient was commenced on Ramipril and Furosemide. Which one of the following drugs would improve the patients prognosis further? 1 ) Amiodarone 2 ) Digoxin

3 ) Diltiazem 4 ) Metoprolol 5 ) Isosorbide Mononitrate Page: 10/40 Answer is 4. This patient has NYHA grade II heart failure and is already receiving ACE-Inhibitors and diuretics. Studies such as CIBIS, MERIT HF and COPERNICUS clearly demonstrate the advantage of beta blockers even with severe heart failure. Page: 11/40 Primary prevention trials for the treatment of hypercholesterolaemia reveal a reduction in all cause mortality following treatment with which of the following? 1 2 3 4 5 ) ) ) ) ) Fibrates Fish Oils Nicotinic acid Resins Statins

Page: 12/40 Answer is 5. Primary prevention refers to the prevention of cardiovascular disease in subjects without pre-existent IHD. Although many lipid lowering agents have demonstrated reductions in cardiovascular mortality, the question refers to all cause mortality. WOSCOPS (pravastatin) and AFCAPSTexCAPS (lovastatin) demonstrated reductions in overall mortality not just cardiovascular mortality following treatment with statins. None of the other agents are proven to reduce all cause mortality in primary prevention. Fibrates are however well proven in secondary prevention trials (BECAIT, VA-HIT). Page: 13/40 A 69 year old man is treated for chest infection. He has been on a stable dose of warfarin for the last six months as a treatment for atrial fibrillation, with INR recordings between 2-2.5. However, his most recent INR was 5. Which one of the following drugs that has recently been started is likely to be responsible for the increased INR?

1 2 3 4 5

) ) ) ) )

Clarithromycin Co-dydramol Digoxin Rifampicin Temazepam

Page: 14/40 Answer is 1. Clarithromycin induces the anticoagulant effect of warfarin whereas, rifampicin would reduce the anticoagulant effect. Ciprofloxacin and sulphonamides will also increase the anticoagulant effect of warfarin. Temazepam, digoxin and codeine have no appreciable effect. Study list of liver enzyme inducers and inhibitors Inducers (PC BRAS) P henytoin C Carbamazepine B Barbiturates R ifampicin A lcohol (chronic excess) S ulphonylureas Inhibitors (ODEVICES) O meprazole D isulfiram E rthromycin V alproate I soniazid C imetidine / Ciprofloxacin E thanol intoxication S ulphonamides Page: 15/40 A 74-year-old man presented with acute pain, pallor and absent pulses in his right leg. Investigations revealed an embolus in his femoral artery. What is the most likely source of this embolus? 1 ) marantic endocarditis 2 ) paradoxical emboli 3 ) rheumatic endocardial vegetations

4 ) right ventricular thrombi 5 ) thrombi from an atheromatous aorta Page: 16/40 Answer is 5. Ulceration of an atheromatous plaque of the abdominal aorta is the most common source of emboli in this situation. Right ventricular thrombi would embolise to the lung. The others are possible but less likely causes. Page: 17/40 A 72-year-old man presents with an episode of collapse. He has had two similar episodes recently, each lasting about one minute. Four years ago he suffered an anterior myocardial infarction. On examination he was orientated and symptom-free with a regular pulse rate of 80 bpm, BP 140/80 mmHg and the apex beat was displaced to the left. There was an apical systolic murmur. There were no signs of trauma. ECG showed sinus rhythm, Q waves and ST segment elevation anteriorly without reciprocal depression. What is the diagnosis? 1 2 3 4 5 ) ) ) ) ) acute anterior myocardial infarction cerebrocasvular acciden epileptic seizure pulmonary embolism ventricular tachycardia

Page: 18/40 Answer is 5. The ECG is suggestive of a left ventricular aneurysm, which has a tendency for both an malignant arrhythmogenic focus and also for left ventricular thrombus. The brief episode of loss of consciousness with no residual neurology makes the diagnosis for cerebral embolism unlikely. The story is more suggestive of a ventricular tachycardia and would suggest further investigations. Prolonged heart rhythm monitoring and an echo are recommended. If VT is proven then he should be on amiodarone and the indication for an automated implantable cardioverter/defibrillator strongly considered if the overall LV function is reduced. Page: 19/40

Left atrial myxoma may be associated with all except1 2 3 4 5 ) ) ) ) ) Sudden death A mid systolic click Systemic emboli Left atrial dilatation Adrenal hyperplasia

Page: 20/40 Answer is 2. Atrial myxoma in the heart make up 50% of primary cardiac tumours. They are most common in the left atrium arising from a pedicle on the fossa ovalis. On third present with emboli, a third with systemic inflammation (ESR elevated in 1/3) and a third are asymptomatic when detected. The can intermittently flop through the mitral valve, and cause a mid-diastolic click (tumour plop) when they stop moving. Elevated left atrial pressures cause dilatation. Syncope can occur due to obstruction. They are more common in women. Page: 21/40 Which one of the following is the most likely mechanism by which Aspirin exerts its beneficial effects in patients with coronary artery disease? 1 ) anti-inflammatory action 2 ) cyclo-oxygenase inhibitation 3 ) glycoprotein IIB/IIIA receptor inhibitation 4 ) inhibitation of binding of adenosine diphosphonate to its platelet receptor 5 ) structural changes in platelets Page: 22/40 Answer is 2. It inhibits platelet aggregation through inhibition on both COX I and II. Clopidogrel inhibits ADP binding to platelet receptors. Page: 23/40 A 57-year-old female school cleaner is undergoing investigation for breathlessness. All the following would be in keeping with a diagnosis of constrictive pericarditis except

1 2 3 4 5

) ) ) ) )

Elevated JVP with absent y descent Peripheral oedema Orthopnoea Ascites Previous cardiac surgery

Page: 24/40 Answer is 1. Constrictive pericarditis produces an elevated JVP, with prominent x and y descent. Pulsus paradoxus occurs less frequently than in tamponade. Other signs include oedema, ascites, hepatomegaly, orthopnoea and dyspnoea. Constriction can be a subtle cause of dyspnoea after cardiac surgery. Distinguishing features contrictive pericarditis vs restrictive cardiomyopathy 1. absence of LVH in constrictive pericarditis 2. absent calcification on CXR, prominent apical impulse and conduction abnormalities on ECG which are features of restrictive cardiomyopathy. Page: 25/40 A study reveals an immediate rise in blood pressure following infusion of a hormone in normal volunteers. Which of the following is the most likely hormone used in this study? 1 2 3 4 5 ) ) ) ) ) angiotensin I angiotensin II atrial natriuretic peptide (ANP) brain natriuretic peptide (BNP) prolactin

Page: 26/40 Answer is 2. Angiotensin II when infused intravenously produces an immediate rise in blood pressure being a potent vasoconstrictor. Both BNF and ANF result in natriuresis and lowering of blood pressure. Prolactin has no specific effect. Page: 27/40 A 55-year-old woman has had worsening shortness of breath for several years. She now has to sleep sitting up on two pillows.

She has difficulty swallowing. There is no history of chest pain. She is afebrile. Recently, she suffered a stroke with left hemiparesis. A chest X-ray reveals a near-normal left ventricular size with a prominent left atrial border. Which of the following conditions is most likely to account for these findings? 1 2 3 4 5 ) ) ) ) ) Aortic coarctation Cardiomyopathy Essential hypertension Left renal artery stenosis Mitral valve stenosis

Page: 28/40 Answer is 5. Mitral valve stenosis leads to left atrial enlargement, but the left ventricle is usually small. An enlarged left atrium may lead to pressure posteriorly on the oesophagus. Most mitral valvular disease in adults results from rheumatic heart disease. Page: 29/40 A 72 year old man noted to have a systolic murmur undergoes an echocardiogram which demonstrates aortic stenosis. Which of the following is associated with a poor prognosis in this patient? 1 2 3 4 5 ) ) ) ) ) Aortic regurgitation Cardiomegaly on chest X-ray Clinical features of left ventricular failure ECG evidence of left ventricular hypertrophy severe valvular calcification on echocardiogram

Page: 30/40 Answer is 3. Aortic stenosis is associated with a worse prognosis when accompanied by left ventricular dysfunction. Other predictors of a poorer prognosis include increasing gradient across the valve (above 70 mmHg), Age of patient and symptomatology. Although the severity of valvular calcification is prognostically important in an asymptomatic patient the most important predictor is LV function. Page: 31/40

A 42 year old male admitted with dyspnoea is noted to have a murmur suggestive of mitral stenosis. The presence of which of the following clinical signs suggests that the mitral valve is mobile? 1 2 3 4 5 ) ) ) ) ) fourth heart sound loud second heart sound opening snap a soft first heart sound a third heart sound

Page: 32/40 Answer is 3. Features of Mitral stenosis include the loud first heart sound, opening snap and if in sinus rhythm, a pre-systolic accentuation. Calcification of the valve results in immobility and loss of the opening snap. Page: 33/40 A 44-year-old man has had no major medical problems throughout his life, except for arthritis pain involving all extremities for the past couple of years. He has had worsening orthopnoea and ankle oedema in the past six months. He is afebrile. There is no chest pain. A chest X-ray shows cardiomegaly with both enlarged left and right heart borders, along with pulmonary oedema. Laboratory test findings include sodium 139 mmol/L, potassium 4.3 mmol/L, urea 7 mmol/L creatinine 95 mol/L, and glucose 8.6 mmol/L. Which of the following additional laboratory test findings is he most likely to have? 1 2 3 4 5 ) ) ) ) ) Anti-centromere antibody titer of 1:320 Erythrocyte sedimentation rate of 79 mm/Hr Haemoglobin of 10.7 g/dL with MCV of 72 fL Serum ferritin of 3400 pmol/L Spherocytes in his peripheral blood smear

Page: 34/40 Answer is 4. He has findings of a cardiomyopathy with right and left heart failure. Hereditary haemochromatosis (HHC) is suspected with a serum ferritin > 1000 and confirmed by genetic testing. It is characterised by diabetes, CCF, pseudogout and slate-grey skin. "HHC is an autosomal recessive condition and in 90% of cases in the United Kingdom (UK) the condition is owing to homozygosity for the C282Y mutation in the HFE gene.2 A second mutation in the HFE gene, H63D, can cause the disease when in the presence of a single C282Y mutation (the so-called 'compound heterozygote' state). These mutations are common in people of Northern European origin with a carrier frequency of the C282Y mutation of one in 1017, in the UK, suggesting a prevalence of people homozygous for the C282Y mutation of between one in 100 and one in 280.3 If HHC becomes symptomatic by mid-life, a general practitioner (GP) with a list size of 2000 patients should have approximately four cases. In our experience most GPs claim to have never seen a case. Herein lies the conundrum: is HHC far more common than is currently recorded in clinical records and death registers because it is not being diagnosed, or does significant disease not develop in a large proportion of C282Y homozygotes and compound heterozygotes?" Page: 35/40 Which ONE of the following statements is true about the diastolic Austin Flint murmur? 1 ) It is associated with a loud first heart sound. 2 ) It is an early sign of aortic regurgitation 3 ) It can be distinguished from the murmur of mitral stenosis by absence of presystolic accentuation 4 ) It is due to partial closure of the anterior leaflet of the mitral valve 5 ) It does not occur in aortic incompetence secondary to an aortitis Page: 36/40 Answer is 4. The Austin Flint murmur is a low frequency mid/late diastolic murmur which may show pre-systolic accentuation which is virtually indistinguishable from that of mitral stenosis. There is no correlation between presence of murmur and severity of AR, or aetiology. The first heart sound is normal but in severe cases, it may be absent

Page: 37/40 Which ONE of the following is a contraindication to thrombolysis? 1 2 3 4 5 ) ) ) ) ) age over 75 years the presence of atrial fibrillation asthma pregnancy background diabetic retinopathy

Page: 38/40 Answer is 4. Those over 75 years benefit as much or more than younger MI patients from thrombolysis. Proliferative diabetic retinopathy is a relative contraindication.Important contraindications to thrombolysis include pregnancy, bleeding (gut, menstrual), recent stroke or surgery, uncontrolled severe hypertension, GI malignancy and prolonged CPR (more than half an hour). Page: 39/40 Cyanosis is a typical feature of which of the following conditions: 1 2 3 4 5 ) ) ) ) ) Patent ductus arteriosus. Ventricular septal defect. Total anomalous pulmonary venous drainage. Atrial septal defect Mitral atresia.

Page: 40/40 Answer is 3. PDA, ASD and VSD are left to right shunts. Tricuspid atresia is typically associated with cyanosis rather than Mitral.