(A) atrial myxoma
(B) carotid artery stenosis
(C) embolus from paroxysmal atrial fibrillation
(D) patent foramen ovale
2 A 51yearold woman has had several syncopal episodes over the past year. Each episode is characterized by sudden but brief loss of consciousness. She has no chest pain. She has no ankle edema. On brain MRI there is a 1.5 cm cystic area in the left parietal cortex. A chest Xray shows no cardiac enlargement, and her lung fields are normal. Her serum total cholesterol is 6.5 mmol/L. Which of the following cardiac lesions is she most likely to have?
(A) Cardiac amyloidosis
(B) Ischemic cardiomyopathy
(C) Left atrial myxoma
(D) Mitral valve prolapse
3 A 66yearold man has developed chronic renal failure with a serum urea of 60 mmol/L and creatinine of 650 micromol/L. Auscultation of the chest reveals a friction rub over the cardiac apex. He is most likley to have a pericarditis that is termed?
(A) Constrictive
(B) Fibrinous
(C) Hemorrhagic
(D) Purulent
4 Which ONE of the following is a contraindication to thrombolysis?
(A) age over 75 years
(B) the presence of atrial fibrillation
(C) asthma
(D) pregnancy
5 Which of the following antimicrobials is associated with prolongation of the QT interval?
(A) Coamoxiclav
(B) Gentamicin
(C) Cefuroxime
(D) Isoniazid
6 A 60yearold man presents with an inferior MI and receives thrombolysis. 4 hours following initial presentation he becomes acutely breathless. His ECG demonstrates sinus tachycardia (rate 108bpm) with T wave inversion inferiorly. His ST segments are normal. On examination his JVP is elevated at 5 cm. Chest was clear to auscultation. Following 80 mg of Frusemide he deteriorates. His BP is now 80/60 and his urine output over the last 2 hours is 5 mls. What is the best investigative measure?
(A) Arterial Blood Gases
(B) Central Venous Pressure Monitoring
(C) Chest XRay
(D) Pulmonary Capillary Wedge Pressure Monitoring
7 Which of the following is a recognised feature of massive pulmonary embolism?
(A) reduced plasma lactate levels
(B) an increase in serum troponin levels
(C) an arterial pH less than 7.2
(D) blood gases show increased pCO2 on air
8 A 60yearold man has worsening congestive heart failure with increasing pulmonary oedema. His blood pressure is normal. He has been healthy all his life with no major illnesses. A serum glucose is 5.6 mmol/L. His total serum cholesterol is 4.8 mmol/L. The serum creatine kinase is not elevated. The most likely explanation for these findings is?
(A) Alcoholic cardiomyopathy
(B) Aortic dissection
(C) Calcified bicuspid aortic valve
(D) Mitral valve annulus calcification
9 During auscultation of the heart you discover a wide fixed splitting of the second heart sound. In which of the following conditions does this occur?
(A) an uncomplicated ASD
(B) Fallot's tetralogy
(C) aortic stenosis
(D) Right Bundle Branch Block
10 A 62 year old man has experienced substernal chest pain upon exertion with increasing frequency over the past 1 year. An electrocardiogram shows T wave inversion in the anterolateral leads at rest. He has a total serum cholesterol of 7.0 mmol/l. On angiography, he has an 85% narrowing of the left anterior descending artery. Which of the following events is most likely to occur in this patient?
(A) A systemic artery embolus from thrombosis in a peripheral vein.
(B) A systemic artery embolus from a left atrial mural thrombus.
(C) Pulmonary embolism from a left ventricular mural thrombus
(D) A systemic artery embolus from a left ventricular mural thrombus.
11 A 17 year old girl was found collapsed and drowsy. Her 12lead ECG showed a sinus tachycardia of 120 beats per minute with a corrected QT interval of 500 ms (normal <470). Which of the following is the most likely cause of her presentation?
(A) Amphetamine
(B) Diphenhydramine
(C) Glue sniffing
(D) Methadone
(E) Methanol
12 A randomised doubleblind placebo controlled study of a cholesterollowering drug for the primary prevention of coronary heart disease was conducted. It had a fiveyear follow up period. The results showed an absolute risk of myocardial infarction in the groupreceiving placebo during was 10 percent. The relative risk of those given the cholesterol lowering medication was 0.8 What number of patients will need to be treated with the drug for five years to prevent one myocardial infarction?
(A) 20
(B) 40
(C) 50
(D) 80
(E) 100
13 Which ONE of the following is true regarding acute pulmonary embolism?
(A) a normal ECG excludes the diagnosis
(B) embolectomy is more effective than thrombolysis in improving survival
(C) Heparin is as effective as thrombolytic therapy
(D) the presence of hypoxaemia is an indication for thrombolysis
(E) thrombolysis administered through a peripheral vein is as effective as through a pulmonary artery catheter
14 A 70yearold woman has a history of dyspnoea and palpitations for six months. An ECG at that time showed atrial fibrillation. She was given digoxin, diuretics and aspirin. She now presents with two shortlived episodes of altered sensation in the left face, left arm and leg. There is poor coordination of the left hand. ECHO was normal as was a CT head scan. What is the most appropriate next step in management?
(A) anticoagulation
(B) carotid endarterectomy
(C) clopidogrel
(D) corticosteroid treatment
(E) no action
15 A 21 year old man with Hypertrophic Cardiomyopathy presents in clinic with dizzy spells but has not had any syncopal episodes. Which of the following, if present, would be indicate an increased risk of sudden cardiac death?
(A) Asymmetric septal hypertrophy with maximum wall thickness of 2.1 cm
(B) Blood Pressure drop of 20mmHg during peak exercise tolerance testing
(C) Left Ventricular Outflow Tract Gradient of 80 mmHg
(D) Systolic Anterior Movement of the mitral valve on echocardiography
(E) Worsening exertional angina
16 Whilst attending the cardiology clinic, the staff nurse measures the blood pressure of a 61yearold man, and finds that it is 183/100 mmHg sitting and 190/105 standing. He has a heart rate of 81/minute, with an irregularly irregular rhythm. On auscultation of the heart, there are no murmurs, but he has bibasilar crackles on chest examination. Which of the following pathological findings is most likely to be present?
(A) Left ventricular hypertrophy
(B) Left atrial myxoma
(C) Occlusive coronary atherosclerosis
(D) Cor pulmonale
(E) Mitral regurgitation
17 A 24yearold woman develops infective endocarditis involving the aortic valve. She receives a porcine bioprosthesis because of her desire to have children and not to take anticoagulant medication. After ten years, she must have this prosthetic valve replaced. Which of the following pathologic findings in the bioprosthesis has most likely led to the need for replacement?
(A) Calcification with stenosis
(B) Dehiscence
(C) Infective endocarditis
(D) Strut failure
(E) Thrombosis
The bioprosthesis has the advantage of not requiring anticoagulation, but it does not wear well with time, and typically must be replaced within 5 to 10 years
18 A randomised, doubleblind, placebo controlled trial of a cholesterol lowering drug in the primary prevention of coronary heart disease is reported. 1000 subjects are treated with the active drug, and 1000 are given placebo. They are followed up over a five year period and 100 individuals in the placebo group and 80 in the treatment group suffer a myocardial infarction. What is the annual percentage risk of myocardial infarction in the group treated with placebo?
(A) 0.5%
(B) 2%
(C) 5%
(D) 8%
(E) 10%
19 A 25yearold previously healthy woman has worsening fatigue with dyspnoea, palpitations, and fever over the past one week. Her vital signs on admission to the hospital show Temperature 38.9°C Respiratory rate 30/min Pulse 105 bpm and BP 95/65 mmHg. Her heart rate is irregular. An ECG shows diffuse STT segment changes. A Chest Xray shows mild cardiomegaly. An echocardiogram shows slight mitral and tricuspid regurgitation but no valvular vegetations. Her troponin I is 12 ng/mL. She recovers over the next two weeks with no apparent sequelae. Which of the following laboratory test findings best explains the underlying etiology for these events?
(A) ANCA titer of 1:80
(B) Antistreptolysin O titer of 1:512
(C) Blood culture positive for Streptococcus, viridans group
(D) Coxsackie B serologic titer of 1:160
(E) Total serum cholesterol of 9.6 mmol/l
20 A 74yearold 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?
(A) marantic endocarditis
(B) paradoxical emboli
(C) rheumatic endocardial vegetations
(D) right ventricular thrombi
(E) thrombi from an atheromatous aorta
21 Which of the following concerning congenital heart disease is correct?
(A) ASD is the commonest malformation at birth
(B) congenital complete heart block is usually associated with AntiRo antibodies in the mother
(C) Ebstein's anomaly is associated with maternal exposure to lithium carbonate
(D) Hypoplastic left heart syndrome is characterised by a large, dilated left ventricle
(E) Osteogenesis imperfecta is associated with aortic stenosis
22 Which of the following regarding the anatomy of the heart is true?
(A) The aortic valve is tricuspid.
(B) The ascending aorta is entirely outside the pericardial sac.
(C) The left atrial appendage is identified readily by transthoracic echocardiography.
(D) The pulmonary trunk lies anterior to the ascending aorta.
(E) The right atrium is posterior to the left atrium.
23 A patient presents with atrial fibrillation and later they revert to sinus rhythm. Under which of the following circumstances is the patient more likely to remain in sinus rhythm?
(A) age > 75 years old
(B) been commenced on warfarin
(C) left atrium size > 6 cm on ECHO
(D) short history of AF
(E) ventricular rate on presentation of 130 bpm
24 A 68yearold man has been very ill for months following the onset of chronic liver disease with hepatitis C infection. He experiences a sudden loss of consciousness and then exhibits paraplegia on the right. A cerebral angiogram reveals lack of perfusion in the left middle cerebral artery istribution. The most likely cardiac lesion to be associated with this finding is?
(A) Acute rheumatic fever
(B) Left atrial myxoma
(C) LibmanSacks endocarditis
(D) Nonbacterial thrombotic endocarditis
(E) Paradoxical thromboembolus
25 A 65 year old man presents with severe central crushing chest pain. ECG shows evidence of an inferior myocardial infarction. He receives TPA, Heparin and Aspirin. Four hours after initial presentation, he starts feeling dizzy and breathless. His pulse is 40 bpm regular, BP 80/50. Heart sounds are soft and chest clear to auscultation. ECG shows 2:1 AV block with T wave inversion inferiorly. IV atropine was administered but had no effect. What is the next most important treatment?
(A) IV Dopamine.
(B) IV Isoprenaline.
(C) Insert a permanent pacemaker.
(D) Insert a temporary pacemaker.
(E) Monitor his progress.
26 A 70yearold male is referred by his GP for management of recently diagnosed congestive heart failure. The patient has a history of poorly controlled hypertension. Over the last three months he has been aware of deteriorating shortness of breath, fatigue, and orthopnea. Over the last month he had been commenced on Digoxin (62.5 micrograms daily), Frusemide (80 mg daily), and amiloride 10 mg. On examination he has a pulse of 96 bpm regular, a blood pressure of 132/88 mmHg. His JVP was not raised, he had some scattered bibasal crackles on auscultation with a displaced apex beat in the anterior axillary line, 6th intercostal space. Auscultation of the heart revealed no murmurs and he had peripheral oedema to the mid tibia. Investigations
showed: electrolytes normal serum urea concentration 17 mmol/l (NR 28 mmol/l) creatinine 175 micromol/l (NR 55110) Serum digoxin 0.7 ng/mL {therapeutic: 1.02.0} One month previously his urea had been 11 mmol/l and creatinine 110 micromol/l. An ECG reveals left ventricur hypertrophy and Chest Xray shows cardiomegaly and calcified aorta. What is the most appropriate next step in management?
(A) Add an ACE inhibitor to the current regimen
(B) Add atenolol at a dose of 25mg daily
(C) Increase digoxin to 0.25 mg daily
(D) Increase frusemide to 80 mg twice daily
(E) Maintain on current therapy.
27 A 14yearold boy presents with hypertension. Which of the following statements concerning hypertension in the young is true?
(A) Sodium nitroprusside is useful for the longterm treatment of severe cases.
(B) Headache is the usual presenting feature.
(C) It is defined as systolic blood pressure above the 99th centile for age.
(D) Abnormalities are frequently seen on DMSA scan.
(E) Aortic coarctation is the commonest secondary cause.
28 A 23 year old male presents with a deep vein thrombosis. He has no past medical history but his mother has suffered from deep vein thromboses. Which of the following is likely to be found on haematological assessment?
(A) Factor V Leiden mutation
(B) Protein S deficiency
(C) Protein C deficiency
(D) Antithrombin deficiency
(E) Lupus anticoagulant
29 In a normal heart, the oxygen saturation of a sample of blood taken from a catheter in the pulmonary capillary wedge position should be equal to a sample from which of the following?
(A) coronary sinus
(B) femoral artery
(C) pulmonary artery
(D) right atrium
(E) right ventricle
30 A 60yearold 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?
(A) amiodarone
(B) aspirin
(C) digoxin
(D) dipyridamole
(E) warfarin
31 In a patient presenting with aortic stenosis, which of the following findings would be most helpful in establishing a diagnosis of congenital bicuspid valve as the etiology?
(A) age
(B) calcified leaflets
(C) commissural fusion on ECHO
(D) negative history for rheumatic fever
(E) systolic ejection click
32 A 55yearold woman was found to have ++ glycosuria and had a maternal history of Type II diabetes mellitus. She was a smoker of 20 cigarettes per day. Examination reveals no specific abnormalities apart from a BMI of 30. Blood pressure was 132/88 mmHg. Investigations reveal: serum creatinine 80 µmol/L (60 – 110) plasma glucose (fasting) 11.3 mmol/L (3.0 – 6.0) total serum cholesterol 5.5 mmol/L (<5.(B) HDL cholesterol 1.4 mmol/L (>1.5(E) What is most likely to improve her life expectancy?
(A) Metformin 500 mg bd
(B) Ramipril 10 mg daily
(C) Simvastatin 10 mg daily
(D) Stopping smoking
(E) Weight loss to achieve a BMI of 25
33 Which of the following concerning the use of intravenous bicarbonate in cardiorespiratory arrest is correct?
(A) exacerbates intracellular acidosis
(B) has a positive inotropic effect on ischaemic myocardium
(C) improves oxygen release to the tissues
(D) increases cerebral blood flow
(E) reduces preexistent hyperkalemia
34 Primary prevention trials for the treatment of hypercholesterolaemia reveal a reduction in all cause mortality following treatment with which of the following?
(A) Fibrates
(B) Fish Oils
(C) Nicotinic acid
(D) Resins
(E) Statins
35 A 30yearold man presents with a history of transient loss of consciousness and palpitations. His ECG shows ventricular tachycardia. Which of the following treatments should be avoided?
(A) adenosine
(B) amiodarone
(C) DC cardioversion
(D) flecainide
(E) verapamil
36 A 56 year old male with left ventricular systolic dysfunction was dyspnoeic on climbing stairs but not at rest. The patient was commenced on ramipril and frusemide. Which one of the following drugs would improve the patient's prognosis?
(A) Amiodarone
(B) Amlodipine
(C) Bisoprolol
(D) Digoxin
(E) Nitrate therapy
37 A 44yearold 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 Xray 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 µmol/L, and glucose 8.6 mmol/L. Which of the following additional laboratory test findings is he most likely to have?
(A) Anticentromere antibody titer of 1:320
(B) Erythrocyte sedimentation rate of 79 mm/Hr
(C) Haemoglobin of 10.7 g/dL with MCV of 72 fL
(D) Serum ferritin of 3400 pmol/L
(E) Spherocytes in his peripheral blood smear
38 Which of the following is a recognised feature of abetalipoproteinaemia?
(A) a high serum cholesterol
(B) palmar xanthomas
(C) advanced atherosclerotic vascular disease
(D) abnormal red blood cell morphology
(E) severe mental retardation
39 Which of the following infections is least likely to cause myocarditis?
(A) Coxsackie virus
(B) Diphtheria
(C) Chagas Disease
(D) Syphillis
(E) Toxoplasmosis
40 A 68 year old woman was admitted to hospital with evidence of biventricular cardiac failure. On examination her pulse was 100 beats per minute (sinus rhythm), and her blood pressure was 140/60 mmHg. She had haemorrhages in both fundi. Her condition improved after intravenous diuretics. Investigations revealed: haemoglobin 5.6 g/dl (11.5 – 16.(E) haematocrit 0.19 (0.36 – 0.47) MCV 118 fl (80 – 96) MCH 33.0 pg (28 – 3(B) WCC 3.4 x 109/L (4 – 1(A) platelet count 95 x 109/L (150 – 400) What is the next most appropriatestep in management?
(A) blood transfusion
(B) bone marrow aspiration
(C) intramuscular vitamin B12 alone
(D) intramuscular vitamin B12 and oral folic acid together
(E) oral folic acid alone
41 Which of the following compounds has a vasodilating effect?
(A) Antidiuretic hormone
(B) Calcitonin
(C) Endothelin
(D) Renin
(E) Somatostatin
42 Which of the following may be responsible for a hypokalaemic hypertension ?
(A) Nonclassical congenital adrenal hyperplasia
(B) Barter's syndrome
(C) Diabetic nephropathy
(D) Liddle's syndrome
(E) Type IV renal tubular acidosis
43 A 52 year old sales representative is admitted with an inferior myocardial infarction. He receives thrombolysis and makes an uneventful recovery. He is discharged on atenolol, aspirin and orvastatin. He enquires how long after his MI must he wait before he is able to drive?
(A) One week
(B) Two weeks
(C) Four weeks
(D) Three months
(E) Six months
44 A 35 year old woman presented with a history of intermittent lightheadedness. Clinical examination and 12lead ECG were normal. Which of the following, if present on a 24 hour Holter ECG tracing, would be the most clinically important?
(A) Atrial premature beats.
(B) Profound sleepassociated bradycardia.
(C) Supraventricular tachycardia.
(D) Transient Mobitz type 1 atrioventricular block.
(E) Vertricular premature beats.
45 A 57yearold man develops deep venous thrombosis during a hospitalization for prostatectomy. He exhibits decreased mental status with right hemiplegia, and a CT scan of the head suggests an acute cerebral infarction in the distribution of the left middle cerebral artery. A chest Xray reveals cardiac enlargement and prominence of the main pulmonary arteries that suggests pulmonary hypertension. His serum troponin I is <0.4 ng/mL. Which of the following lesions is most likely to be present on echocardiography?
(A) Coarctation of the aorta
(B) Dextrocardia
(C) Pulmonary stenosis
(D) Tetralogy of Fallot
(E) Ventricular septal defect
46 A 60 year old man had a myocardial infarction 6 weeks ago. He is taking aspirin 75 mg/day and metoprolol 50mg 2/day. During a routine followup Exercise Test he has a 20 beat run of nonsustained VT. He achieved stage 4 of the Bruce protocol and 92 % of his target heart rate. The nonsustained VT occurred halfway through Stage 2. ST segments were normal during the study. What is the definitive investigation?
(A) Coronary angiography.
(B) Echocardiogram.
(C) Electrophysiological study.
(D) Thallium exercise scan.
(E) 24 hour Holter monitor.
47 A 55yearold 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 Xray reveals a nearnormal left ventricular size with a prominent left atrial border. Which of the following conditions is most likely to account for these findings?
(A) Aortic coarctation
(B) Cardiomyopathy
(C) Essential hypertension
(D) Left renal artery stenosis
(E) Mitral valve stenosis
48 Which of the following antiarrhythmic drugs may be used in the treatment of long QT syndrome?
(A) Amiodarone
(B) Atenolol
(C) Flecainide
(D) Propofanone
(E) Sotalol
49 A 70 year old male was receiving amiodarone 200 mg daily for intermittent atrial fibrillation. However, he was aware of tiredness and lethargy. He appeared clinically euthyroid with no palpable goitre. Investigations revealed: Serum free T4 23pmol/L (926) Serum total T3 0.8 nmol/L (0.92.8) Serum TSH 8.2 mU/L (<(E) Which of the following statements would explain these results?
(A) Abnormal thyroxine binding globulin
(B) Amiodaroneinduced hypothyroidism
(C) 'sick euthyroid' syndrome
(D) Spontaneous hypothyroidism
(E) TSH secreting pituitary adenoma
50 A 65yearold woman, a heavy smoker for many years, has had worsening dyspnoea for the past 5 years, without a significant cough. A chest Xray shows increased lung size along with flattening of the diaphragms, consistent with emphysema. Over the next several years she develops worsening peripheral oedema. BP 115/70 mmHg. Which of the following cardiac findings is most likely to be present?
(A) Constrictive pericarditis
(B) Left ventricular aneurysm
(C) Mitral valve stenosis
(D) Nonbacterial thrombotic endocarditis
(E) Right ventricular hypertrophy
51 An elderly man with a history of asthma, congestive heart failure, and peptic ulcer disease is admitted with bronchospasm and rapid atrial fibrillation. He recieves frequent nebulised salbutamol and IV digoxin loading, his regular medications are continued. 24 hours after admission his serum potassium is noted to be 2.8 mmol/l. Which of his medications is most likely to have caused this abnormality.
(A) Digoxin
(B) ACE inhibitor
(C) Salbutamol
(D) Ranitidine
(E) Spironolactone
52 In the diagnosis of rheumatic fever, which of the following may be helpful?
(A) A generalised macularpapular rash.
(B) ASO titre of less than 1:200.
(C) Polyarthritis.
(D) Staphylococcus aureus grown on throat culture.
(E) Splinter haemorrhages.
53 A 55 year old man presents with gynaecomastia while receiving treatment for Heart failure. Which of the following drugs is most likely to be the cause of his gynaecomastia
(A) Amiloride
(B) Carvedilol
(C) Frusemide
(D) Omeprazole
(E) Ramipril
54 A 78 year old female is referred by her GP with high blood pressure. Over the last three months her blood pressure is noted to be around 180/80 mmHg. She has a body mass index of 25.5kg/m2, is a nonsmoker. There are no features to suggest a secondary cause for her hypertension. Which of the following is the most appropriate treatment for her blood pressure?
(A) AlphaBlocker
(B) Angiotensin Converting Enzyme (ACE) Inhibitor
(C) Angiotensin Blocker
(D) Betablocker
(E) Calcium channel blocker
55 A 17yearold woman loses consciousness while out jogging one afternoon, as she has done for many years. She is taken to Accident and Emergency, where a chest Xray, CT brain scan, FBC, and biochemistry are all normal. Over the next year, she develops mild dyspnea and fatigue. There are several episodes of presyncope. After another syncopal episode, she is referred to a cardiologist who orders and ECG that shows changes of left ventricular hypertrophy and broad Q waves. An echocardiogram reveals left ventricular and septal hypertrophy, small left ventricle, and reduced septal excursion. The septum has a "ground glass" appearance. She then dies suddenly and unexpectedly. The microscopic appearance of the septum with trichrome stain reveals myofiber disarray. Which of the following conditions is she most likely to have had?
(A) Diabetes mellitus
(B) Hypertrophic cardiomyopathy
(C) Rheumatic heart disease
(D) Systemic lupus erythematosus
(E) Viral myocarditis
56 Which of the following is true regarding the coronary circulation?
(A) Adenosine is the most important mediator of metabolic vasodilation.
(B) Coronary blood flow is independent of myocardial oxygen consumption due to autoregulation.
(C) Coronary blood flow within a normal range of blood pressure is primarily determined by perfusion pressure.
(D) Increased myocardial O2 demand is met primarily by increasing O2 extraction.
(E) The vasodilatory reserve of the epicardium and endocardium is equivalent under normal physiologic conditions.
57 A 54 year old man presents with central crushing chest pain. Examination is normal. 12lead ECG shows ST segment elevation in leads II, III, aVF and ST depression in V1, V2 and V3. Which coronary artery is occluded?
(A) Circumflex
(B) Left Anterior Descending
(C) Left Main Stem
(D) Obtuse Marginal
(E) Right Coronary Artery
58 Which of the following is true regarding mitral stenosis?
(A) it is tolerated well in pregnancy
(B) there is characteristically a low wedge pressure
(C) in AF, the opening snap disappears
(D) The opening snap is not heard when the mitral valve is heavily calcified
(E) Doppler U/S is usually inaccurate in determining severity
59 A 26yearold man is noted to have cyanosis of the lower limbs and clubbing of the toes but not the fingers. Which of the following statements is true?
(A) He has Eisenmenger's syndrome.
(B) He has coarctation of the aorta.
(C) He is likely to have a loud continuous 'machinery' murmur below the left clavicle.
(D) He is likely to need urgent surgery.
(E) He has had a Blalock shunt operation.
60 A 74yearold man has had increasingly severe, throbbing headaches for several months, centered on the right. There is a palpable tender cordlike area over his right temple. His heart rate is regular with no murmurs, gallops, or rubs. Pulses are equal and full in all extremities, BP is 110/85 mmHg. A biopsy of this lesion is obtained, and histologic examination reveals a muscular artery with lumenal narrowing and medial inflammation with lymphocytes, macrophages, and occasional giant cells. He improves with a course of highdose corticosteroid therapy. Which of the following laboratory test findings is most likely to be present with this disease?
(A) Antidouble stranded DNA titer of 1:1024
(B) Erythrocyte sedimentation rate of 110 mm/hr
(C) HDL cholesterol of 0.6 mmol/L
(D) pANCA titer of 1:160
(E) Rheumatoid factor titer of 80 IU/mL
61 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?
(A) Depressive episode
(B) Factitious disorder
(C) Generalized anxiety disorder
(D) Hypochondriasis
(E) Somatization disorder
62 A 35yearold 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?
(A) An aortic valve prosthesis may eventually need to be placed
(B) Other family members may have the same condition
(C) She should be treated with a cholesterollowering agent
(D) The problem resulted from past injection drug usage
(E) This is one manifestation of an underlying autoimmune disease process
63 Which of the following findings is the most specific for a diagnosis of myocardial infarction?
(A) an akinetic area of LV wall motion on ECHO
(B) elevated cardiac enzymes
(C) evolution of Q waves on ECG
(D) history of severe chest pain
(E) ST elevation on ECG
64 A 15 year old female presents following a sore throat with chest pain, fever, and a skin rash. Examination reveals a diastolic murmur. Her ASO titre is elevated. Which of the following is a major criterion for the diagnosis of Rheumatic fever?
(A) Fever
(B) Raised ESR
(C) Polyarthritis
(D) Migratory erythema
(E) Prolonged PR interval
65 A 55yearold man with Type 2 Diabetes Mellitus and Ischaemic Heart Disease has been researching the Internet! He asks your opinion on Laser Transmyocardial Revascularisation. Which of the following statements about this technique is true?
(A) avoids the need for major surgery
(B) damages the endocardium
(C) involves destruction of coronary stenoses
(D) is of particular use in severe proximal coronary artery disease
(E) stimulates collateral vessel formation
66 On auscultation of the heart of a 30 year old female a loud first heart sound is heard. Which of the following may be responsible for thsi auscultatory feature?
(A) a long preceding diastolic interval
(B) Atrial premature beat
(C) increrased pulmonary arterial pressure
(D) increased systemic arterial pressure
(E) rupture of a papillary muscle
67 A 64yearold man is admitted with a right femoral neck fracture following a fall. Also seen in the radiograph of the pelvis are several prominent calcified vessels. What is the most appropriate next step in management of this finding?
(A) anticoagulate with heparin
(B) Ignore it
(C) Order a pulmonary ventilationperfusion scan
(D) Request a serum troponin test
(E) Start the patient on a nitrate infusion
68 A 59yearold man who was active all his life develops sudden severe anterior chest pain that radiates to his back. Within minutes, he is unconscious. He has a history of hypertension, but a recent treadmill test had revealed no evidence for cardiac disease. Which of the following is the most likely diagnosis?
(A) Acute myocardial infarction
(B) Group A streptococcal infection
(C) Pulmonary embolus
(D) Right middle cerebral artery embolus
(E) Tear in the aortic intima
69 Which ONE of the following statements is true about the diastolic Austin Flint murmur?
(A) It is associated with a loud first heart sound.
(B) It is an early sign of aortic regurgitation
(C) It can be distinguished from the murmur of mitral stenosis by absence of presystolic accentuation
(D) It is due to partial closure of the anterior leaflet of the mitral valve
(E) It does not occur in aortic incompetence secondary to an aortitis
70 A 28yearold 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?
(A) Alcohol Septal Ablation
(B) Amiodarone
(C) Beta Blocker
(D) Implantable Defibrillator
(E) Myomectomy
71 A 14 year old boy presents with fever. Which of the following might contribute to a diagnosis of rheumatic fever?
(A) The finding of target lesions on the hands.
(B) The finding of tender nodules in the fingertips.
(C) A prolonged PR interval on ECG.
(D) A CRP of 10.
(E) Positive Romberg's sign.
72 A 40yearold man attending a routing screening has a blood pressure of 166/100 mmHg. Two weeks later his blood pressure was 150/90 mmHg. He does not smoke. He drinks 35 units alcohol / week. His body mass index (BMI) is 30 kg/m2 (20 2(E). What is the best management strategy?
(A) amlodipine
(B) atenolol
(C) bendrofluazide
(D) enalapril
(E) lifestyle advice
73 A 19yearold woman is found to have a cardiac murmur characterized by a midsystolic click. An echocardiogram reveals mitral insufficiency with upward displacement of one leaflet. There is also aortic root dilation to 4 cm. She has a dislocated right ocular crystalline lens. She dies suddenly and unexpectedly. The medical examiner finds a prolapsed mitral valve with elongation, thinning, and rupture of chordae tendineae. A mutation involving which of the following genes is most likely have be present in this patient?
(A) Betamyosin
(B) CFTR
(C) FGFR
(D) Fibrillin
(E) Spectrin
74 A 51 year old businessman complains of dyspnoea on exertion. He recently returned from a business trip to the USA. He has distant heart sounds on auscultation of the chest. A chest radiograph reveals that there is a thin rim of calcification surrounding the cardiac outline. Which of the following conditions is most likely responsible for these findings?
(A) Uraemia
(B) Tuberculosis
(C) Group B coxsackie virus
(D) Sarcoidosis
(E) Metastatic carcinoma
75 A 60yearold woman is admitted with sudden onset of chest pain and is diagnosed with an acute myocardial infarction. Her acute illness is complicated by low blood pressure and poor tissue perfusion for several days. Her serum lactate becomes elevated. Her serum urea and creatinine are noted to be increasing. Day 1 Day 2 Day 3 urea (mmol/L) 8 22 30 creatinine (µmol/L) 116 140 200 Granular and hyaline casts are present on microscopic urinalysis. The renal lesion that is most likely to be present in this situation is?
(A) Acute tubular necrosis
(B) Minimal change disease
(C) Nodular glomeruloscerosis
(D) Pyelonephritis
(E) Renal vein thrombosis
76 A 45 year old male type 1 diabetic with a number of complex diabetic gastrointestinal complications is noted to have a PR interval of 0.18s, a QRS duration of 0.1s and a QT interval of 0.48s on routine ECG. Which of the following drugs may be responsible?
(A) Cisapride
(B) Octreotide
(C) Cotrimoxazole
(D) Domperidone
(E) Cimetidine
77 You are asked to see a patient in the Intensive Care Unit who is short of breath and tachycardic to rule out a cardiac cause of her symptoms. A right heart catheter reveals that the mixed venous O2 saturation is 70%; the pulmonary capillary wedge O2 saturation is 97%. The haemoglobin is normal and the patient is afebrile. You are able to state which of the following?
(A) her cardiac output is decreased
(B) her cardiac output is normal
(C) her heart is normal
(D) she has highoutput failure
(E) she is in shock due to a noncardiac cause
78 A 59yearold man who was active all his life develops sudden severe anterior chest pain that radiates to his back. Within minutes, he is unconscious. He has a history of hypertension, but a recent treadmill test had revealed no evidence of cardiac disease. Which of the following do you suspect?
(A) Acute viral myocarditis
(B) Group A streptococcal infection
(C) Pulmonary embolus
(D) Right middle cerebral artery embolus
(E) Tear in the aortic intima
79 Concerning complete atrioventricular septal defects which of the following statements is true?
(A) are seen frequently in patients with trisomy 21
(B) frequently have aortic valve insufficiency
(C) have a normal mitral valve structure
(D) include a coronary sinus atrial septal defect
(E) include a perimembranous ventricular septal defect
80 21 yearold woman has a history of palpitations and light headedness. ECG shows short PR interval and inferior Q waves. Her symptoms improve with atenolol 25 mg/day but she has had two short episodes of similar symptoms in the previous 24 hours. What is the longterm management of choice?
(A) Anticoagulation.
(B) Oral amiodarone.
(C) Oral digoxin.
(D) Increase the dose of atenolol.
(E) Radiofrequency ablation.
81 A 60yearold man's echocardiogram shows a dilated left ventricular cavity with the remainder of the other chamber sizes normal. The most likely diagnosis is which of the following?
(A) aortic regurgitation
(B) aortic stenosis
(C) hypertensive heart disease
(D) mitral regurgitation
(E) mitral stenosis
82 Left axis deviation is seen on the ECG in which of the following conditions?
(A) atrioventricular canal defects.
(B) Ebstein's anomaly.
(C) large ventricular septal defect.
(D) patent ductus arteriosus.
(E) tetralogy of Fallot.
83 Which of the following is true regarding the action of Clopidogrel?
(A) It inhibits cyclooxygenase
(B) It is an ADP receptor antagonist
(C) It is a glycoprotein IIb/IIIa inhibitor
(D) It is a selective factor Xa inhibitor
(E) It is Hydroxymethyl Coenzyme A inhibitor
84 Which ONE of the following is associated with Marfan's syndrome?
(A) Autosomal recessive inheritance
(B) increased upper : lower body ratio
(C) Mental retardation
(D) Pulmonary stenosis
(E) Retinal detachment
85 A 30yearold intravenous drug abuser develops acute aortic regurgitation due to infective endocarditis. Which of the following is least likely to be found on clinical examination?
(A) decreased cardiac output
(B) decrescendo diastolic murmur
(C) hypotension
(D) mitral valve preclosure
(E) peripheral vasodilatation
86 A 67 year old man presents with sudden onset atrial fibrillation (ventricular rate of 150/minute). His serum creatinine concentration was 250 umol/L (70110). What is the main factor that determines the choice of loading dose of digoxin in this patient?
(A) Absorption
(B) Apparent volume of distribution
(C) Lipid solubility
(D) Plasma halflife
(E) Renal clearance
87 A 17yearold girl is short in stature for her age. She has not shown any changes of puberty. She has a webbed neck. Her vital signs include Temperature 36.6°C Respiratory rate 18/min Pulse 75 bpm and BP 165/85 mmHg. On physical examination, she has a continuous murmur heard over both the front of the chest as well as her back. Her lower extremities are cool with poor capillary filling. A chest radiograph reveals a prominent left heart border, no oedema or effusions, and rib notching. Which of the following pathologic lesions best explains these findings?
(A) Constriction of the aorta past the ductus arteriosus
(B) Lack of development of the spiral septum and partial absence of conus musculature
(C) Shortening and thickening of chordae tendineae of the mitral valve
(D) Single large atrioventricular valve
(E) Supravalvular narrowing in the aortic root
88 Elevation of the jugular venous pressure during inspiration is most likely to be found in which of the following situations?
(A) a normal physical exam
(B) cardiac tamponade
(C) constrictive pericarditis
(D) dilated cardiomyopathy
(E) myocarditis
89 75 yearold man with a history of anterior MI is taking amiodarone 400mg/day for history of VT. He has a prolonged QT interval on his ECG.What is the most appropriate management?
(A) Admit to hospital for monitoring.
(B) Atenolol.
(C) Change amiodarone to flecainide.
(D) Continue with amiodarone.
(E) Discontinue amiodarone immediately.
90 A 58yearold man has had an enlarging abdomen for several months. He has experienced no abdominal or chest pain. On physical examination he has a nontender abdomen with no masses palpable, but there is a fluid thrill. An abdominal Ultrasound Scan shows a large abdominal fluid collection with a small cirrhotic liver. A chest Xray shows a globally enlarged heart. Which of the following conditions is most likely to be present?
(A) Dilated cardiomyopathy
(B) Lymphocytic myocarditis
(C) Myocardial amyloid deposition
(D) Nonbacterial thrombotic endocarditis
(E) Severe occlusive coronary atherosclerosis
91 Angina due to an imbalance between O2 supply and demand without atherosclerosis would most likely be seen in which of the following circumstances?
(A) aortic regurgitation
(B) cardiac tamponade
(C) pulmonary regurgitation
(D) right heart failure
(E) tricuspid regurgitation
92 An 18 year old man had repeated episodes of breathlessness and palpitations, lasting about 20 minutes and resolving gradually. There were no abnormal physical signs. What is the most likely cause of these features?
(A) Drug abuse
(B) Panic disorder
(C) Paroxysmal supraventricular tachycardia
(D) Personality disorder
(E) Thyrotoxicosis
93 A previously well 60 year old lady is admitted with an Acute Anterior Myocardial Infarction. A random blood glucose concentration was found to be 12.1 mmol/L (<6.7). What is the optimal management of her blood sugar?
(A) Diet
(B) Gliclazide
(C) Intravenous insulin plus dextrose
(D) Metformin
(E) Subcutaneous insulin
94 A 65yearold was advised to start oral digoxin at a dose of 250 µg daily. His physician explained that the full effect of this treatment would not be apparent for at least a week. Which one of the following pharmacokinetic variables did the physician use to give this explanation?
(A) bioavailablity
(B) halflife
(C) plasma protein binding
(D) renal clearance
(E) volume of distribution
95 A 75 yearold lady presents with sudden breathlessness and palpitations. On examination, she was observed to have an irregular heart beat with rate of 140 bpm, BP 150/84 and normal heart sounds. On auscultation of the chest, Fine basal crepitations are heard. An ECG confirms AF and an old inferior MI. She is anticoagulated with heparin and given diuretics. Her heart rate remains rapid. What is the most appropriate management of the lady's AF?
(A) DCCV.
(B) IV amiodarone.
(C) IV betablocker.
(D) IV digoxin.
(E) Oral quinidine therapy.
96 A 45 year old female presents with a two day history of fever and joint pains. She has a past history of hypertension for which she is receiving antihypertensives. On examination she has a temperature of 38 Celsius, a facial rash and slight swelling with tenderness of the wrist and ankle joints. Which of the following antihypertensives may be responsible for her presentation.
(A) Minoxidil
(B) Phenoxybenzamine
(C) Hydrallazine
(D) Alphamethyldopa
(E) Bendrofluazide
97 A 70yearold man with dilated cardiomyopathy remains symptomatic in NYHA class 2 due to chronic heart failure. On examination his pulse is 90 regular, BP 140/90, heart sounds normal, chest auscultation did not reveal any abnormalities. He is currently taking Lisinopril 30 mg OD and Frusemide 80 mg OD. What is the best treatment option?
(A) Amiodarone
(B) Carvedilol
(C) Digoxin
(D) Spironolactone
(E) Valsartan
98 A 40yearold man received an orthotopic cardiac transplant 7 years ago to treat a dilated cardiomyopathy. Since that time he has been healthy, with no episodes of rejection or infection. Over the next year, however, he develops fatigue with exercise. He has worsening pedal edema and orthopnea. On physical examination, his vital signs are Temperature 36.3°C, Pulse 78, Respiratory rate 16, and BP 130/70 mm Hg. There are no murmurs, rubs, or gallops audible. Bibasilar crackles in the lungs are audible. Which of the following conditions is most likely to account for these findings?
(A) Angiosarcoma
(B) Coronary arteriopathy
(C) Mitral valvular stenosis
(D) Myocarditis
(E) Pulmonary hypertension
99 Which of the following statements concering the treatment of acute myocardial infarction is correct?
(A) A pansystolic murmur developing within the first 24 hours does not require further investigation.
(B) Dipyridamole therapy reduces reinfarction within the first year.
(C) Heparin is beneficial if given with streptokinase.
(D) Prophylactic lignocaine given in the first 48 hours is effective in preventing ventricular fibrillation
(E) Treatment with a dihydropyridine calcium antagonist is associated with increased cardiovascular mortality.
100 A 70yearold man is admitted with an acute Qwave inferior Myocardial Infarction. On day 5, he suddenly develops pulmonary oedema and a loud systolic murmur. Which of the following would be the most useful in establishing a diagnosis?
(A) chest Xray
(B) coronary arteriography
(C) ECG
(D) right heart catheterisation and oximetry
(E) serum cardiac enzymes
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