Clinical SBAs
Clinical Cardiology: (32 questions)

Questions

• 1
  A 46-year old man presents with headache and a blood pressure of 216/122mmHg. Which of the following is least consistent with the diagnosis?
  Difficulty: Medium     Topic: Headache and hypertension
  a

  A-V nipping on fundoscopy

  b

  Acute renal failure

  c

  Confusion

  d

  Adrenocortical atrophy

  e

  Pulmonary oedema
  Explanation: End-organ dysfunction (headache, in this case) with greatly raised blood pressure diagnoses malignant hypertension. It can also cause acute renal failure, seizures, pulmonary oedema and intravascular haemolysis resulting in anaemia. Confusion occurs in hypertensive encephalopathy. A-V nipping is a feature of grade 2 hypertensive retinopathy. Addison's disease results in dehydration and postural hypotension. Conn's syndrome can cause marked hypertension.
• 2
  A 46-year old man has been diagnosed with angina is given sublingual GTN to take for symptomatic relief. Which of the following medications should he be advised not to use with GTN?
  Difficulty: Easy     Topic: GTN drug interactions
  a

  Bisoprolol

  b

  Sildenafil

  c

  Lisinopril

  d

  Furosemide

  e

  Amiodarone
  Explanation: GTN is a nitrate vasodilator that relieves the symptoms of angina by reducing cardiac preload and dilating the coronary vasculature. Sildenafil is a phosphodiesterase inhibitor used for treatment of impotence. Sildenafil has been shown to potentate the effects of GTN, which can result in severe hypotension therefore co-administration of sildenafil with GTN is contraindicated. Beta-blockers (bisoprolol), ACE-inhibitors (lisinopril), loop diuretics (furosemide) and amiodarone can be used with GTN.
• 3
  A 39-year diabetic old woman presents with central crushing chest pain that has lasted 45minutes and is being considered for treatment with alteplase. Which of the following conditions is it least important to ask about in the history?
  Difficulty: Easy     Topic: Chest pain history
  a

  Current menstruation

  b

  Recent head injury

  c

  Aortic dissection

  d

  Use of warfarin

  e

  Previous haemorrhagic stroke
  Explanation: Patients presenting with ischaemic chest pain should be considered for thrombolysis and in order to do this contraindications should be assessed. These include those listed plus: an ischaemic stroke <3m, intracranial neoplasm or known arterio-venous malformation. Menstruation is not a contraindication to thrombolysis, though it may be part of systems review it is unlikely to affect management.
• 4
  A 56-year old woman presents to the cardiology clinic with syncope. She has a regular bradycardia and ECG shows complete dissociation of P-waves and QRS-complexes. Which of the following features is most likely to be present?
  Difficulty: Easy     Topic: Jugular venous pulse features
  a

  Fixed raised JVP

  b

  Canon a-waves

  c

  Giant v-waves

  d

  Absent a-wave

  e

  Raised JVP with normal waveform
  Explanation: Canon a-waves occur due to contraction the right atrium against a closed tricuspid valve, which happens to patients with complete heart block if ventricular and atrial contraction take place simultaneously. Dissociation of atrial and ventricular depolarisation on ECG is characteristic of third degree atrio-ventricular block. Fixed raised JVP is a sign of SVC obstruction, which often occurs due to invasion by apical lung tumours. Giant v-waves are generated by ventricular contraction with an incompetent tricuspid valve that allows regurgitation of blood up the internal jugular vein. The a-wave is caused by atrial contraction therefore it is absent in atrial fibrillation. A raised JVP with normal waveform suggests raised central venous pressure, which may be due to right heart failure or hypervolaemia.
• 5
  A 37-year old Marfanoid man is found to have aortic regurgitation with preserved left ventricular function on echocardiogram. Which of the following physical signs is least likely to be present?
  Difficulty: Easy     Topic: Aortic regurgitation signs
  a

  Wide pulse pressure

  b

  Collapsing pulse

  c

  Early diastolic murmur at the left sternal edge

  d

  A pulsatile right upper quadrant mass

  e

  Quincke's sign.
  Explanation: Aortic regurgitation is associated with a number of conditions, including: Marfan's & Ehlers-Danlos syndromes, spondyloarthritidies, pseudoxanthoma elasticum and syphilitic aortitis. A pulsatile RUQ mass is a sign of tricuspid regurgitation, due to regurgitation of blood into the liver during systole. A wide pulse pressure, causing a 'collapsing' pulse occurs in aortic regurgitation. The murmur is typically early diastolic and best heard in expiration at the left sternal edge as the regurgitant jet travels towards the chest wall. Quincke's sign is pulsation of the capillary bed under the finger nails however it is non-specific and can occur in other causes of high-cardiac output states.
• 6
  A 70-year old man presents to the GP with headache after starting a new medication. Which of the following is most likely to be responsible?
  Difficulty: Easy     Topic: Side-effects of cardiac drugs 2
  a

  Lisinopril

  b

  Clopidogrel

  c

  Digoxin

  d

  Aspirin

  e

  Amlodipine
  Explanation: Headaches may occur due to vasodilatation of cerebral vessels, which is an effect of calcium channel blockers such as amlodipine. They also causes flushes, diuretic unresponsive pedal oedema and (rarely) gingival hypertrophy. Lisinopril, an ACEi, is the only other vasodilator (by reduction in Ang-2 levels) given however it more commonly causes hypotension, cough, hyperkalaemia and renal impairment. Clopidogrel is an ADP-receptor blocker that reduces platelet aggregation. Its most common side-effects are GI bleeds and skin rashes. Digoxin is a cardiac glycoside and is used for rate-control in patients with chronic atrial fibrillation. It causes nausea, arrhythmias, xanthopsia and gynaecomastia. Aspirin is an irreversible-COX inhibitor and its main side-effects are bleeding and exacerbation of symptoms in some asthmatics.
• 7
  A 61-year old man presents to the clinic with breathlessness on exertion. He has a third heart sound and an ejection systolic murmur that radiates to the carotids. CXR is normal and ECG shows left ventricular hypertrophy. What is the most appropriate initial investigation?
  Difficulty: Easy     Topic: Investigation of breathlessness
  a

  Exercise tolerance test

  b

  Cardiac magnetic resonance imaging

  c

  Transthoracic echocardiogram (TTE)

  d

  Transoesophageal echocardiogram (TOE)

  e

  Dobutamine-stress echocardiogram
  Explanation: It is most likely that this man has cardiac failure due to aortic stenosis. An ejection systolic murmur with radiation to carotids is most likely to come from the aortic valve and radiation is a sign of significant disease. (Radiation is absent in absent in aortic sclerosis.) Echocardiogram is the investigation of choice to diagnose heart failure. A TTE is most appropriate first because TOE are invasive and used for pre-operative assessment, or for patients with previous valve replacements. An exercise tolerance test is an investigation used for risk stratification in coronary artery disease. It may be used in pre-operative assessment but is not required initially. Cardiac MR imaging and dobutamine-stress echocardiography are other techniques that look for evidence of ischaemic damage. They are most often used for patients who are unable to exercise, for example due to osteoarthritis.
• 8
  A 42-year old man presents with 2-hours of chest pain and nausea. He is later found to have occlusion of his right coronary artery. In which leads are ECG changes most likely to have been seen?
  Difficulty: Easy     Topic: MI localisation
  a

  V1-V2

  b

  II, III & aVF

  c

  V5-V6

  d

  I & aVL

  e

  I, aVL & V3-V6
  Explanation: The right coronary artery supplies the right ventricle, which forms the inferior aspect of the heart as it sits in the thorax. The ECG leads that measure the right ventricle's activity most closely are II, III and aVF. The left anterior descending artery supplies the interventricular septum and part of the left ventricular wall. A septal infarction causes changes in leads V1-2. An anterior infarction of the left ventricle causes changes in leads V3-4. The left circumflex also supplies the left ventricle and occlusion causes lateral infarction with changes most seen in I, aVL, V5 and V6. The posterior aspect of the heart is supplied by the posterior descending artery, which is formed from anastamosis of the right and left coronary arteries. Posterior MI causes deep ST-depression in V1-3 with a tall R-wave in V1.
• 9
  A 68-year old man with severe congestive cardiac failure from ischaemic cardiomyopathy is being treated with lisinopril, furosemide, digoxin, bisoprolol and aspirin. Which of the following medications is most likely to give him prognostic benefit?
  Difficulty: Easy     Topic: Heart failure treatment
  a

  Diltiazem

  b

  Verapamil

  c

  Abciximab

  d

  Metformin

  e

  Spironolactone
  Explanation: All patients with chronic heart failure should be treated with several medications. An ACE-inhibitor reduces ventricular remodelling and gives prognostic benefit. A diuretic, which reduces the symptoms of volume overload. A cardiac-specific beta-blocker, which limits ventricular work and gives survival benefit. Aspirin or warfarin to reduce the chance of thrombotic events. Digoxin gives symptomatic benefit to patients otherwise on maximum therapy. Spironolactone (an aldosterone antagonist) gives both symptomatic and prognostic benefit for those with NYHA III-IV heart failure who are already on maximum therapy. Diltiazem & verapamil are negatively inotropic therefore are not used in heart failure. Abciximab is a GpIIb/IIIa inhibitor that may be used for NSTEMI. There is no history to suggest this man has diabetes.
• 10
  A 43-year old woman presents with progressive breathlessness, cough and recurrent chest infections. She has an irregularly, irregular pulse, a tapping apex beat and a mid-diastolic murmur best heard over the apex. What is the most common cause for this condition?
  Difficulty: Medium     Topic: Progressive breathlessness and chest infection
  a

  Carcinoid syndrome

  b

  Floppy mitral valve

  c

  Degenerative calcification of a bicuspid valve

  d

  Rheumatic fever

  e

  Infective endocarditis
  Explanation: This woman has mitral stenosis, which often presents with a picture similar to that of chronic bronchitis due to the severe pulmonary hypertension that develops. She is in AF, which is a common finding as the left atria dilates from increased pressure. 95% of mitral stenosis occurs due to previous rheumatic fever. Carcinoid syndrome and certain congenital conditions are much more rare causes. Floppy mitral valve results in a prolapsing mitral valve that can cause mitral regurgitation. 'C' refers to the process that underlies early onset aortic stenosis in patients with a bicuspid aortic valve. Infective endocarditis causes regurgitant murmurs from erosion of the valves.
• 11
  A 42-year old man is involved in a RTA. He has severe chest pain and is distress. His blood pressure is 72/54mmHg, heart rate is 124bpm, his heart sounds are to hear and his apex beat cannot be felt. Chest examination is normal. Which other feature is most consistent with the diagnosis?
  Difficulty: Medium     Topic: Hypotension following RTA
  a

  Alternating strong and weak pulses

  b

  JVP rises on inspiration

  c

  Giant v-waves in JVP

  d

  Different blood pressure in each arm

  e

  Tracheal deviation
  Explanation: This man has cardiac tamponade and is displaying signs of Beck's triad: falling blood pressure, muffled heart sounds and Kussmaul's sign (JVP that rises during inspiration). Pulsus paradoxus may also be found, where the pulse is weaker during inspiration. Tamponade is a frequent cause of cardiovascular distress following trauma to the chest. It results in ventricular fibrillation or pulseless electronic activity. Pulsus alternans, alternating strong and weak beats, is a sign of left ventricular failure. Tricuspid regurgitation causes giant v-waves in the JVP. Different would be consistent with aortic dissection, which is an important differential following trauma but only rarely does it cause tamponade therefore tamponade as the underlying diagnosis is more likely. Massive haemothorax or tension pneumothorax would cause tracheal deviation, but respiratory examination was normal in this case.
• 12
  An asymptomatic 22-year old man is shown to have a P-R interval that gets progressively longer until a QRS complex is missed. Heart rate 42bpm. What is the most likely diagnosis?
  Difficulty: Medium     Topic: Asymptomatic bradycardia
  a

  Sinus arrhythmia

  b

  1st degree atrio-ventricular block

  c

  Mobitz type I atrio-ventricular block

  d

  Mobitz type II atrio-ventricular block

  e

  3rd degree atrio-ventricular block
  Explanation: This man has Mobitz type I AV-block, also know as 'Wenckebach'. In young, fit individuals this is normal variant and can be left if the patient is asymptomatic. In older patients it may be due to ischaemic damage to the conduction system however it is associated with a relatively low chance of progression to complete (3rd degree) heart block, unlike Mobitz type II. In Mobitz II there is a dropped QRS complex one out of every 2-4. 1st degree heart block is an elongated PR-interval and this is usually asymptomatic. Complete heart block shows dissociation between p-waves and QRS complexes, which are usually broad.
• 13
  Which of the following associations is incorrect?
  Difficulty: Hard     Topic: Congenital cardiac defects
  a

  Noonan's syndrome - pulmonary stenosis

  b

  Down's syndrome - atrioventricular septal defect

  c

  William's syndrome - sub-valvular aortic stenosis

  d

  Turner's syndrome - bicuspid aortic valve

  e

  Marfan's syndrome - aortic root dilatation
  Explanation: William's syndrome is characterised by supra-valvular aortic stenosis. All the other associations are correct. Aortic dilatation in Marfan's develops during early adulthood. Turner's syndrome is also associated with coarctation of the aorta.
• 14
  A 26-year old woman presents with 1 day of palpitations. ECG shows an irregular R-R interval and an absence of P-waves. She is haemodynamically stable What is the most appropriate management?
  Difficulty: Medium     Topic: New onset palpitation
  a

  Oral metoprolol rate control

  b

  IV amiodarone cardioversion

  c

  Oral digoxin rate control

  d

  LMWH and DC cardioversion

  e

  Warfarin and DC cardioversion
  Explanation: This woman has new onset AF. If it presents within 48hrs, the best treatment is anticoagulation with LMWH and DC cardioversion. If presenting >48hrs then cardioversion with amiodarone is usually preferred. DC cardioversion can be performed >48hrs by either: fully anticoagulating with warfarin, or a TOE to check for thrombi and giving LMWH if no thrombi are present. Metoprolol is 1st line rate control, and digoxin/amiodarone is 2nd line.
• 15
  A 81-year old man is recovering from a myocardial infarction when he loses consciousness. The ECG monitor shows an irregular broad complex tachycardia. What is the most appropriate first treatment?
  Difficulty: Easy     Topic: Arrhythmia following MI
  a

  Unsynchronised DC cardioversion

  b

  Assess for signs of life

  c

  Cardio-pulmonary resuscitation

  d

  1:10,000 adrenaline IM

  e

  1:1,000 adrenaline IM
  Explanation: An irregular broad complex tachycardia is assumed to be ventricular fibrillation, especially following MI patients are at highest risk. First the patient must be assessed for signs of life: breathing and presence of a pulse. If these are absent then treatment should continue in accordance with Adult-Life Support guidelines. Airway control should be the priority, followed by commencing CPR. Treatment of VF is with unsynchronised DC cardioversion, for shockable rhythms (VF and VT) adrenaline can be given each 3-5min after the 3rd shock. IM adrenaline is given at 1:1,000 and IV adrenaline is given at 1:10,000. Continue to re-evaluate and look for signs of life.
• 16
  A 27-year old IVDU presents with pyrexia, shortness of breath, pulsatile RUQ mass, clubbing and microscopic haematuria. Which finding would be least consistent with the diagnosis?
  Difficulty: Medium     Topic: Pyrexia in IVDU
  a

  Giant V-waves

  b

  Boat-shaped retinal haemorrhages

  c

  Dullness in Traube's space

  d

  Painful, erythematous lesions in finger pulp

  e

  Pan-systolic murmur that radiates to the axilla
  Explanation: IVDU are at high risk of right-sided endocarditis. This patient has tricuspid regurgitation, which would cause giant V-waves in the JVP and pulsatile hepatomegaly. Retinal haemorrhages in IE are known as Roth's spots. Painful lesions in the finger pulp are Osler's nodes (Janeway lesions are painless). Dullness in Traube's space is a sign of splenomegaly, which occurs in IE. A pan-systolic murmur audible in the axilla suggests mitral regurgitation.
• 17
  A 72-year old diabetic man presents with chest pain and vomiting. His blood pressure is 92/65mmHg, has a regular pulse of 44bpm and canon a-waves in the JVP. What is the most likely diagnosis?
  Difficulty: Hard     Topic: Chest pain and canon a-waves
  a

  Posterior MI

  b

  Raised intracranial pressure

  c

  Inferior MI

  d

  Cardiac tamponade

  e

  Digoxin toxicity
  Explanation: This man has complete heart block as a complication of MI. A regular bradycardia with canon a-waves is highly suggestive of complete heart block. A rate of 30-50 is typical of intrinsic ventricular rhythm. The history suggests a MI as the cause rather than digoxin toxicity. Raised ICP causes Cushing's reflex which sees bradycardia, irregularly respiration and increased pulse pressure, unlike in this patient. Cardiac tamponade presents with tachycardia, muffled heart sounds and a JVP that rises on inspiration (Beck's triad). Anterior and inferior MI can cause conduction defects, but it would be unusual for a posterior infarct.
• 18
  A 43-year old woman with previous rheumatic fever and TB presents with a 3 week history of fever and weight loss. A new pan-systolic murmur is noted at the apex. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Fever and systolic murmur
  a

  Miliary TB

  b

  Infective endocarditis

  c

  Atrial myxoma

  d

  Ventricular septal defect

  e

  Libbman-Sachs endocarditis
  Explanation: Rheumatic fever can result in valvular damage, which is a risk factor for endocarditis. Libbman-Sachs endocarditis is a non-infective condition that occurs in SLE. Endocardial involvement is very rare in miliary TB and would usually be associated with other features of organ-dysfunction. Atrial myxoma most often mimics mitral stenosis. Most VSD are congenital or occur post-MI and aren't associated with fever.
• 19
  A 52-year old man presents with recurrent intermittent dull chest pain. The GP prescribes sublingual GTN, which relieves the pain after 10-15min of taking it. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Intermittent dull chest pain
  a

  Prinzmetal's angina

  b

  Atheromatous angina

  c

  Recurrent pulmonary emboli

  d

  Oesophageal reflux

  e

  Oesophageal spasm
  Explanation: All of these can cause recurrent intermittent chest pain. GTN acts to relax smooth muscle by release of nitric oxide. This dilates coronary arteries and venous vessels, which gives relief from angina (both Prinzmetal's & atheromatous) rapidly. It can also relieve oesophageal spasm however much more slowly. 'C' & 'D' are unlikely to get an analgesic effect from GTN.
• 20
  A 73-year old diabetic woman presents with 1hr of sudden onset breathlessness and nausea. She has known renal artery stenosis. Examination is normal. There are inverted T-waves in II and III. What is the most likely diagnosis?
  Difficulty: Medium     Topic: Sudden breathlessness with nausea
  a

  Acute pulmonary oedema

  b

  Angina

  c

  Myocardial infarction

  d

  Pulmonary embolism

  e

  Pneumonia
  Explanation: Diabetic patients often present with 'silent' MI (breathlessness, pulmonary oedema, syncope, asymptomatic) due to autonomic neuropathy. This is not angina due to a 1 hour duration. Renal artery stenosis can cause 'flash' pulmonary oedema, but this would cause bilateral fine crackles. PE is an important differential but given the risk factors for arterial disease (and absence for VTE), MI is more likely. PE may cause right ventricular strain with inverted T-waves however in this case they indicated inferior ischaemia from a NSTEMI. 'E' is unlikely to have a sudden onset and absence of physical signs.
• 21
  A 54-year old Afro-Caribbean man is starting medical treatment for newly diagnosed hypertension. Which of the following medications should be begun initially?
  Difficulty: Easy     Topic: Hypertension in primary care
  a

  Bendroflumethiazide

  b

  Chlortalidone

  c

  Lisinopril

  d

  Lorsartan

  e

  Nifedipine
  Explanation: Primary hypertension in those over 55 years old or black of any age should initially be treated with a calcium-channel blocker (e.g. nifedipine). ACEi (e.g. lisinopril) are used 1st line for non-black patients under 55 years. These two classes of medication are then used in combination for both patient groups. Chlortalidone is the preferred form of thiazide-type diuretic (instead of bendroflumethiazide) for hypertension, being used 3rd line. Lorsartan is an angiotensin-II-receptor blocker, which is used for patients who are intolerant of ACEi.
• 22
  A 54-year old lady is being treated with atorvastatin, nifedipine and lisinopril. Which of the following side-effects is least likely to be caused directly by her medications?
  Difficulty: Easy     Topic: Cardiovascular drug side-effects
  a

  Hyperkalaemia

  b

  Myositis

  c

  Gum hyperplasia

  d

  Lethargy

  e

  Pedal oedema
  Explanation: Lethargy most commonly occurs with beta-blockers. Atorvastatin can cause raised LFT, myalgia, myositis and rarely rhabdomyolysis. Nifedipine causes gum hyperplasia, flushing, headaches and pedal oedema not responsive to diuretics. Lisinopril causes dry cough, reduced GFR and raised potassium (especially with renal artery stenosis).
• 23
  A 55-year old man is being investigated for congestive cardiac failure. There are no ischaemic changes on ECG. CXR demonstrates areas of calcification around the heart. Echocardiogram shows a non-dilated left ventricle and a small pericardial effusion. What is the most likely diagnosis?
  Difficulty: Medium     Topic: Cardiac failure with calcification on CXR
  a

  Cardiac tamponade

  b

  Constrictive pericarditis

  c

  Ischaemic cardiomyopathy

  d

  Viral cardiomyopathy

  e

  Alcoholic cardiomyopathy
  Explanation: Constrictive pericarditis can present with congestive cardiac failure and is the most likely diagnosis here by exclusion. Viral and alcoholic cardiomyopathy cause marked dilatation of the left ventricle. Ischaemic cardiomyopathy occurs following a history of MI/angina, which show ECG findings. Tamponade requires a pericardial effusion large enough to impair ventricular filling.
• 24
  A 56-year old woman presents with intermittent blackouts that occur once every 2-3 months without preceding symptoms and there is rapid recovery. What is the most appropriate investigation?
  Difficulty: Medium     Topic: Intermittent, sudden blackouts
  a

  Electroencephalogram (EEG)

  b

  Tilt-table test

  c

  24-hour ambulatory ECG

  d

  7-day ambulatory ECG

  e

  Implantable loop recorder (ILR)
  Explanation: This woman's syncope is likely to be arrhythmic in origin due to the intermittent nature, rapid recovery and absence of preceding symptoms (which may suggest vasovagal syncope). EEG is not indicated if cardiac causes are suspected. If blackouts occur less than once every 2 weeks an ILR is the 1st line investigation because it is most likely to give symptom-ECG correlation, unlike 7-day or 24-hour tapes.
• 25
  A previously well 22-year old woman presents with confusion and papilloedema. Her blood pressure is 210/116mmHg. Blood tests are normal. Renal ultrasound Doppler gives the diagnosis. What is the most likely underlying cause?
  Difficulty: Hard     Topic: Confusion, papilloedema and hypertension
  a

  Kawasaki disease

  b

  Fibromuscular dysplasia

  c

  Atherogenic renal artery stenosis

  d

  Phaeochromocytoma

  e

  Polycystic kidney disease (PCKD)
  Explanation: This woman has hypertensive encephalopathy, a medical emergency treated with IV labetalol. Renal ultrasound Doppler can be used to diagnose renal artery stenosis, which is most commonly due to atherosclerosis, however in a previously well young patient fibromusclar dysplasia (FD) is more likely to be the cause. FD is autosomal dominantly inherited and causes multiple stenoses in the renal arteries. Phaemochromocytoma or PCKD both cause hypertension but neither require Doppler for diagnosis.
• 26
  A fit and well 45-year old man is found to have a blood pressure of 172/106mmHg in clinic. Examination is otherwise normal as are blood tests. 24-hour ambulatory monitoring gives an average of 156/98mmHg. What is the most likely diagnosis?
  Difficulty: Medium     Topic: Hypertension with normal exam
  a

  Acromegaly

  b

  Cushing's syndrome

  c

  Conn's syndrome

  d

  Primary hypertension

  e

  White-coat hypertension
  Explanation: Primary hypertension is defined as either >140/>90mmHg on 3 separate occasions over 3 months, supported by ambulatory blood pressure monitoring. NICE guidelines (CG127) would class this man as having Stage 2 hypertension due to a ambulatory pressure of over 150/95mmHg. White-coat hypertension would give normal-range blood pressure on ambulatory monitoring. Cushing's, Conn's and acromegaly are unlikely given normal examination and bloods. In a middle-aged population the most common cause of hypertension is primary hypertension.
• 27
  Which of the following is not a common feature of vasovagal syncope?
  Difficulty: Easy     Topic: Vasovagal syncope features
  a

  Chest pain

  b

  Rapid regaining of consciousness

  c

  Dizziness

  d

  Occurring with prolonged standing

  e

  Dry mouth
  Explanation: Vasovagal syncope occurs due to excessive vagal activity that results in cerebral hypoperfusion. Prolonged standing causes pooling of blood in the legs and activation of ventricular afferents that stimulate the Vagus. Dizziness and dry mouth are typical features of symptoms preceding vasovagal syncope. Rapid recovery of full consciousness is a feature common to cardiac causes of syncope, in contrast with epilepsy. Chest pain suggests an arrhythmic or ischaemic rather than a 'simple' vasovagal syncope.
• 28
  Which of the following is true about Wolff-Parkinson-White syndrome (WPW)?
  Difficulty: Medium     Topic: Wolff-Parkinson-White syndrome
  a

  It is an atrio-ventricular node re-entrant tachycardia

  b

  The Q-T interval is short

  c

  The P-R interval is long

  d

  The QRS complex may be prolonged

  e

  Adenosine will safely terminate tachyarrhythmias
  Explanation: WPW is a cause of atrio-ventricular re-entrant tachycardias due to the presence of a low-resistance pathway between the atria and ventricles. Resting ECG shows a delta-wave, which is an upsloping R-wave. This acts to reduce the P-R interval and increase the QRS duration. Adenosine causes transient AVN block, which may safely terminate the WPW tachycardias but it can also increase the rate of conduction through the accessory pathway, increasing the ventricular rate.
• 29
  A 14-year old boy with a known large VSD presents to A&E with fever that has lasted 1 month, with increased breathlessness and weight loss. He is clubbed and has splenomegaly. What is the most likely diagnosis?
  Difficulty: Easy     Topic: 14-year old with VSD and fever
  a

  Congestive cardiac failure

  b

  Eisenmenger's syndrome

  c

  Atrial myxoma

  d

  Rheumatic fever

  e

  Infective endocarditis
  Explanation: This boy has infective endocarditis (IE). Large VSD are a risk factor for endocarditis and patients should receive antibiotic prophylaxis for procedures. Congestive cardiac failure and rheumatic fever do not cause clubbing. Atrial myxomas can mimic IE but are very rare and are unlikely to cause splenomegaly. Eisenmenger's syndrome would cause cyanosis and not fever or splenomegaly.
• 30
  Which of the following is not a cause of clubbing?
  Difficulty: Medium     Topic: Causes of clubbing
  a

  Fallot's tetralogy

  b

  Transposition of the great vessels

  c

  Ventricular septal defect (VSD)

  d

  Eisenmenger's syndrome

  e

  Patent truncus arteriosus (PTA)
  Explanation: The cardiac causes of clubbing are: infective endocarditis, atrial myxoma and cyanotic heart disease. Only R-to-L shunts cause cyanosis. Fallot's tetralogy (VSD, over-riding aorta, RVH, pulmonary stenosis) is the most common congenital cyanotic heart disease. Transposition of the great vessels and PTA are also congenital R-to-L shunts. Eisenmenger's is an acquired R-to-L shunt from reversal of a L-to-R shunt due to right sided hypertrophy. VSD is a L-to-R shunt that does not cause clubbing.
• 31
  A 48-year old man who is treated for hypertension with Lisinopril is referred for eyelid swelling. Anti-histamines have not helped. He also describes abdominal pain and cough that occur at the same time. What is the most likely cause?
  Difficulty: Medium     Topic: ACEi side-effects
  a

  Inappropriate release of histamine

  b

  A medication side-effect

  c

  A hereditary immunological defect

  d

  Infectious disease

  e

  A systemic inflammatory disorder
  Explanation: Angio-oedema is one of the side effects of ACEi, when it occurs in the bowel it can cause abdominal pain. The co-incidence with cough suggests that it takes places when lisinopril levels are highest. An anaphylactoid reaction is caused by inappropriate histamine release. Hereditary angio-oedema is a genetic condition, which is less likely given the medication history. Systemic infection or inflammation are unlikely to cause this presentation.