MRCP(UK) and MRCP(I) Part I Best of Fives: Volume I

By Osama Shukir Muhammed Amin

"MRCP(UK) and MRCP(I) Part I Best of Fives: Volume I" by associate professor Dr. Osama Shukir Muhammed Amin MRCP, MD, FRCP(Edin), FRCP(Glasg), FRCP(Ire), FRCP(Lond), FACP, FAHA. Dr. Amin is a senior consultant neurologist and formerly a clinical associate professor at the International Medical University, Kuala Lumpur, Malaysia as well a former director of the Kurdistan Board of Neurology Sulaymaniyah. In writing this book, I have tried to focus on the most important updates in medicine that have been emerging during the past decade; novel diseases, novel investigations, and newly approved medications. Needless to say, COVID-19 and its SARS-CoV-2 will be encountered in each chapter, in addition to occupying a unique position in the chapter on infectious diseases. The other aspect that I think is very crucial to tackle is women’s health and pregnancy. Once again, such a topic has been addressed in each and every chapter. There are no separate chapters for geriatrics, clinical sciences, and pharmacology (including therapeutics and toxicology); their questions have been distributed throughout the book’s chapters. Each answer is followed by an explanation and a reference (source) and/or additional (further) reading. In this way, you can go there; skim the whole subject if you are interested to get more information. I did my best to avoid regurgitated subjects and themes (which have been encompassed by many books, including me, during the past 20 years). Although many questions appear to be difficult and may fit part II examinations, I believe these questions (and their explanation) will strengthen your background and help you prepare well for part II. Remember, the goal is to find and fill in the gaps in your knowledge. This is volume I, which assesses the candidates’ knowledge in cardiology, pulmonology, renal medicine (as well as acid-base balance, electrolytes, and urology), gastrointestinal medicine and hepatology, and finally neurology (as well as stroke medicine, medical ophthalmology, and psychiatry); there are 732 bests of fives in this volume. Volume II will be available in the 2nd half of the year 2023.

• Language: English
• Publisher: Lulu.com
• Release date: Jan 20, 2023
• ISBN: 9781447878872

Book preview

MRCP(UK) and MRCP(I) Part I

Best of Fives

MRCP(UK) and MRCP(I) Part I

Best of Fives

Volume I

(Cardiovascular Medicine, Respiratory Medicine, Nephrology, Acid-Base and Electrolytes Disturbances, Urology, Gastroenterology and Hepatology, Neurology, Stroke Medicine, Medical Ophthalmology, and Psychiatry)

Osama Shukir Muhammed Amin

MBChB, MD, MRCP, FRCP(Edin), FRCP(Glasg), FRCP(Ire), FRCP(Lond), FACP, FAHA, FCCP(USA), FRSA

- Senior Consultant Neurologist

- Formerly, Director of the Kurdistan Board of Neurology, Sulaymaniyah

- Formerly, Clinical Associate Professor

International Medical University

Kuala Lumpur, Malaysia

©2022 Osama Shukir Muhammed Amin

Copyright Notice:

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior permission of the copyright owner in writing:

Email: [e-mail]

First Edition: 2022. Re-edited and reprinted 2023.

ISBN: 978-1-4583-4964-4

Disclaimer:

This book was written depending on reliable sources. However, while every effort has been made to ensure its accuracy, no responsibility for loss, damage, or injury occasioned on any person acting or refraining from action as a result of information contained herein can be accepted by the author or publisher.

Published and distributed by Lulu Press, Inc. Northern Carolina, USA.

Copyright © 2022. Osama Shukir Muhammed Amin.

Dedication

To my lovely family

Sarah, Awan, and Naz

Acknowledgments

I would like to sincerely thank my dear patients; their clinical scenarios were used to formulate and generate these questions.

Special gratitude goes to my wife, Sarah, for her endless support and encouragement, and of course, her extreme patience.

Preface

"Listen to your patient – he is telling you the diagnosis.", Sir William Osler (b. 1849, d. 1919)

Medicine is an ever-changing branch. The COVID-19 global crisis has reformatted our concepts and perspectives on the understanding of novel diseases and their treatment, including vaccinations. During the last decade, there has been a robust revolution in smartphones and the internet access industry, and accordingly, both have been reflected in the ways in which postgraduate trainees get their information and study.

My previous books, "Get Through MRCP Part I; BOFs (published by the Royal Society of Medicine Press in London, 2008), Mock Papers for MRCPI part I, 2nd Edition (published by Lulu Press, Inc., USA, 2016), and Self-Assessment: 650 BOFs for MRCP(UK) and MRCP(I) Part I" (published by Lulu Press, Inc., USA, 2017) have already covered most of the classical examination scenarios and themes. Combined, they create a question bank of approximately 1600 questions.

In writing this book, I have tried to focus on the most important updates in medicine that have been emerging during the past decade; novel diseases, novel investigations, and newly approved medications. Needless to say, COVID-19 and its SARS-CoV-2 will be encountered in each chapter, in addition to occupying a unique position in the chapter on infectious diseases.

The other aspect that I think is very crucial to tackle is women’s health and pregnancy. Once again, such a topic has been addressed in each and every chapter. There are no separate chapters for geriatrics, clinical sciences, and pharmacology (including therapeutics and toxicology); their questions have been distributed throughout the book’s chapters. Each answer is followed by an explanation and a reference (source) and/or additional (further) reading. In this way, you can go there; skim the whole subject if you are interested to get more information.

I did my best to avoid regurgitated subjects and themes (which have been encompassed by many books, including mine, during the past 20 years). Although many questions appear to be difficult and may fit part II examinations, I believe these questions (and their explanation) will strengthen your background and help you prepare well for part II. Remember, the goal is to find and fill in the gaps in your knowledge.

Still, after 27 years, I find Sir Davidson’s textbook, "Davidson’s Principles and Practice of Medicine" (by Elsevier Health Sciences) is the best source to build up your solid foundations. In addition, Medscape (https://emedicine.medscape.com/, by WebMD LLC.), and StatPearls [Internet] (https://www.ncbi.nlm.nih.gov/books/NBK430685/, by StatPearls Publishing, Treasure Island) are the best-updated sources of information.

This is volume I and assesses the candidate’s knowledge in cardiology, pulmonology, nephrology (as well as acid-base balance, electrolytes, and urology), gastrointestinal medicine and hepatology, and finally neurology (as well as stroke medicine, medical ophthalmology, and psychiatry); there 732 bests of fives in this volume. 

Undoubtedly, if you are well-prepared, you will pass the examination very easily. No need to panic when you hear about your colleagues’ past [bad] experiences. Lack of preparation is the single most common reason for failure. Remember, practice makes perfect. Read and self-assess; that’s it!

Volume II (rheumatology, infectious diseases, endocrinology, etc.) was supposed to be published in the 2nd half of the year 2022. For certain reasons, I stopped drafting it. I apologize for any inconvenience this may cause. I still believe that this volume (volume I), which has been re-edited (with some updates in 2023), is quite helpful; it will highlight and fill in several gaps in your knowledge. Good luck with your career and exams!

Osama S. M. Amin

February 2023

Table of Contents:

Chapter 1: Cardiovascular Medicine

Chapter 2: Respiratory Medicine

Chapter 3: Nephrology, Acid-Base & Electrolytes Disturbances, & Urology

Chapter 4: Gastroenterology & Hepatology

Chapter 5: Neurology, Stroke Medicine, Medical Ophthalmology, & Psychiatry

Chapter One - Cardiovascular Medicine Questions

1) Because of exertional breathlessness and palpitations, a 69-year-old woman visits the physician’s office. There is tachycardia, raised JVP, bi-pedal pitting edema, and bi-basal crepitations. The patient’s serum TSH is <0.05 miU/L. Which one of the following mechanisms is responsible for this woman’s heart failure?

2) A 62-year-old man says that he develops a slight limitation of physical activity upon mild exertion that is associated with fatigue and palpitations. He is comfortable at rest. Your preliminary diagnosis is heart failure. The patient’s NYHA (New York Heart Association) classification of heart failure symptom severity is:

3) A 71-year-old man visits the Accident and Emergency because of palpitations that developed suddenly an hour ago. He has breathlessness and polyuria. You detect a rapid pulse. You do carotid sinus messages and the patient’s heart rate becomes slower but still rapid at more than 100 beats per minute. Which one of the following is suggestive of paroxysmal atrial fibrillation rather than supraventricular tachycardia?

4) A 58-year-old man has been found to have an irregularly irregular pulse. Which one of the following is not a potential cause of this heart rate abnormality?

5) While examining a 59-year-old woman, you find a pulse rate of 38 beats per minute. Which one of the following is not responsible for this woman’s bradycardia?

6) You have checked the blood pressure of this 52-year-old woman on separate occasions, and it turns out to be 170/85 mmHg. She is on no medications. Which one of the following best describes her blood pressure?

7) You have examined the neck of a 40-year-old obese woman, and you have some difficulty differentiating between arterial pulsation and jugular pulsation. Which one of the following is suggestive of carotid pulsation rather than jugular pulsation?

8) A patient has recently been diagnosed with Fabry’s disease. While examining the cardiovascular system, you notice regular cannon a waves of the jugular venous pulsation. Which does the patient have?

9) You auscultate the precordium of a 64-year-old man and hear a variable intensity of the first heart sound. Which one of the following is the cause of this abnormal heart sound?

10) A 45-year-old man displays wide splitting of the second heart sound when you auscultate his precordium. Which one of the following is not a potential etiology of this finding?

11) A 67-year-old woman has been diagnosed with a left anterior fascicular block. Her ECG would not display which one of the following?

12) A 61-year-old man presents to the Accident and Emergency with severe central chest pain. He is diabetic and hypertensive. You do a 12-lead ECG and find ST-segment elevation in leads I and aVL. Which one of the following arteries has been occluded?

13) A 65-year-old man has been referred to the cardiology outpatient department for further evaluation of bigeminal rhythm. Which one of the following is not a cause of this cardiac rhythm?

14) You interpret the 12-lead ECG of a 70-year-old man who has visited the Accident and Emergency. You find a tall symmetrical T-wave in the precordial leads. Which one of the following is not a cause of this ECG abnormality?

15) A 34-year-old man has been evaluated for absent P-waves on a 12-lead ECG assessment. Which one of the following is not an etiology of this ECG sign?

16)  You are interpreting the ECG abnormalities of a cyanosed infant with tricuspid atresia. Which one of the following is not a recognized ECG finding in this condition?

17) A 63-year-old woman has been experiencing progressive shortness of breath, exercise intolerance, orthopnea, and fatigue over the past several months. After running some investigations, you diagnose restrictive cardiomyopathy. Which one of the following is the correct statement about this illness?

18) A 54-year-old man presents with prominent bipedal pitting edema and ascites. You do transesophageal echocardiography and diagnose chronic constrictive pericarditis. Which one of the following is the correct statement about this disease?

19) A 67-year-old man develops substernal chest pain and profuse sweating. He is brought to the Accident and Emergency by his son within one hour of the onset of the symptoms. 12-lead ECG reveals ST-segment elevation in V1-V4, and serum cardiac troponin is elevated. Your hospital has a cardiac catheterization lab. After doing the ABC (airway, breathing, circulation) and patient stabilization, which one of the following is the best next step?

20) A 72-year-old woman has been admitted to the Accident and Emergency after developing symptoms of unstable angina. Which one of the following is not a bad prognostic indicator in unstable angina?

21) A 22-year-old woman was diagnosed with rheumatic mitral stenosis 3 years ago. She has been referred to you for further evaluation. You suggest doing percutaneous mitral balloon commissurotomy (PMBC). Which one of the following is a contraindication to this form of therapy?

22) A 63-year-old woman visits the Accident and Emergency because of acute shortness of breath. She takes no medications. A preliminary diagnosis of left ventricular failure is made. 12-lead ECG shows rapid atrial fibrillation. You run a battery of investigations and find serum Na of 129 mEq/L, serum K of 3.2 mEq/L, blood urea of 24 mg/dl, serum creatinine of 0.7 mg/dL, and serum AlT of 75 IU/L. Which one of the following is the correct statement regarding heart failure?

23) A 57-year-old man has been diagnosed with NYHA class III congestive heart failure. He receives optimal doses of valsartan, frusemide, and carvedilol. He is symptomatic on minimal exertion. Which one of the following is the best next step?

24) A 67-year-old woman visits the physician’s office for a scheduled follow-up. She was diagnosed with idiopathic dilated cardiomyopathy NYHA class III, one year ago.

Her current medications are maximally tolerated doses of bisoprolol, ramipril, and bumetanide. Resting 12-lead ECG shows a regular heart rate of 96 beats/minute. Echocardiography reveals an ejection fraction of 31%. What would you do?

25) A 61-year-old woman develops congestive heart failure. Her functional status is consistent with NYHA class III. Resting 12-lead ECG shows a regular sinus rate of 64 beats per minute, a left bundle branch block pattern, and a QRS interval of 190 milliseconds. The ejection fraction is 30%. The man’s daily medications are optimal doses of metoprolol, enalapril, atorvastatin, aspirin, and furosemide. What is the best next step?

26) A 45-year-old man has been evaluated for cardiac transplantation. He has intractable congestive heart failure with an NYHA class of IV. Which one of the following is a contraindication to this form of transplantation?

27) A 54-year-old man develops short-lived but troublesome paroxysmal atrial fibrillation every few months. He has no coronary artery disease. The patient's left ventricular ejection fraction is 61%. Flecainide is prescribed to prevent further episodes. The patient develops an attack of atrial flutter after 2 weeks of starting flecainide. What would you do?

28) A 77-year-old man develops ischemic stroke in the territory of the posterior-inferior branch of the right middle cerebral artery. He has congestive heart failure and slow permanent atrial fibrillation. Echocardiography shows mild mitral and tricuspid regurgitations. Creatinine clearance is 20 ml/minute. You consider starting rivaroxaban. Which one of the following is the correct statement?

29) A 78-year-old woman develops non-valvular permanent atrial fibrillation. She has congestive heart failure and hypertension. There is no history of embolic stroke or transient ischemic attack. How much is this woman’s CHA2DS2-VASc score?

30) You have prescribed warfarin for a 69-year-old woman to prevent embolic stroke. She was diagnosed with hypertension, congestive heart failure, and permanent atrial fibrillation 2 months ago. She takes daily aspirin. The blood pressure in your clinic is 170/90 mmHg. Serum ALT is 24 IU/L and serum creatinine is 2.6 mg/dl. She has no history of major bleeding. The patient’s HAS-BLED bleeding risk score is?

31) A 68-year-old man develops central chest pain and palpitations followed by a lapse of consciousness. You do ECG and find wide QRS complex tachycardia of 160 beats/minute. Which one of the following is suggestive of supraventricular tachycardia with aberrant conduction rather than ventricular tachycardia?

32) A 65-year-old woman demonstrates prolonged ventricular repolarization of 0.52 seconds upon doing a 12-lead rest ECG. A few weeks later, she develops non-sustained ventricular tachycardia. Which one of the following is not a potential cause?

33) A 24-year-old man presents with recurrent syncope at rest. He reports frequent nightmares and thrashing at night. Resting 12-lead ECG reveals incomplete right bundle branch block and ST-segment elevation in V1 and V2. The QTc interval is 0.41 seconds. These ECG changes disappear on stress testing. Serum calcium and potassium are within their normal reference range. Which one of the following is the correct statement about this condition?

34) A 66-year-old woman develops recurrent syncope because of a cardiac problem. You consider implanting a permanent pacemaker. Which one of the following is the correct statement about permanent pacemakers?

35) A 66-year-old man develops extensive ST-segment elevation myocardial infarction. No ventricular arrhythmia develops. The left ventricular ejection fraction is 28%. The man’s daily medications are lisinopril, rosuvastatin, metoprolol, furosemide, and clopidogrel. Which one of the following is the best next step to prolong his survival?

36) A 65-year-old man develops angina. He is hypertensive and diabetic. He develops substernal pain during vigorous physical activities with a slight limitation of these everyday activities. Which one of the following indicates high-risk angina?

37) A 68-year-old man has been diagnosed with chronic stable angina. He has hypertension, hypercholesterolemia, and diabetes. The patient’s Canadian Cardiovascular Society (CCS) angina grading scale is Class III. The resting heart is 58 beats per minute. The left ventricular ejection fraction is 58%. The man’s current daily medications are telmisartan, bisoprolol, aspirin, simvastatin, and a long-acting oral nitrate. What is the best next step?

38) A 67-year-old woman has been diagnosed with angina pectoris. She is on a maximally tolerated anti-anginal regimen but is still symptomatic on minimal exertion. You consider percutaneous coronary intervention (PCI). Which one of the following is the correct statement about the role of PCI in chronic stable angina?

39) A 66-year-old man develops central chest pain and shortness of breath during rest. He is a known case of type II diabetes and hypertriglyceridemia. The patient’s blood pressure on admission is 180/110 mmHg. The JVP is elevated, and you hear bibasal crackles. 12-lead ECG shows ST-segment elevation in V3 and V4. No dysrhythmia is detected. Serum creatinine is 210 μmol/L and serum cardiac troponin is elevated. You calculate the GRACE score. Which one of the following is a parameter of the GRACE score?

40) A 70-year-old man develops acute ST-segment elevation myocardial infarction. He has been admitted to the coronary care unit. You observe the monitor and find a variety of cardiac rhythm disorders. Which one of the following is the correct statement about acute coronary syndrome-induced arrhythmias?

41) A 69-year-old man develops acute ST-segment myocardial infarction because of posterior descending artery occlusion. On day 6, the patient develops sudden cardiogenic shock and severe pulmonary edema. A late systolic murmur is heard. ECG does not reveal tachyarrhythmia. Which one of the following is the correct statement about this complication?

42) A 72-year-old woman presents with recurrent syncope because of ventricular dysrhythmia. She developed ST-segment elevation myocardial infarction 3 months ago. Her resting 12-lead ECG reveals a tall R-wave in lead aVR and persistent ST-segment elevation with T-wave inversion in the infarct area. Which one of the following is the correct statement about this complication?

43) A 75-year-old man develops severe substernal pain and chest tightness. Serum CK-MB and cardiac troponins are elevated. ECG shows ST-segment elevation in leads V1-V2. The patient receives intravenous alteplase. After one day, the serum CK-MB becomes very high while the ST-segment elevation starts to normalize. What is the reason for this increment in this cardiac enzyme?

44) A 67-year-old woman visits the Accident and Emergency after developing severe central chest pain, sweating, and nausea. The symptoms started 3 hours ago. 12-lead ECG shows 5 mm ST-segment elevation in leads V5-V6, I, and aVL. The patient has received aspirin, ticagrelor, intravenous metoprolol, and intravenous morphine. You consider reperfusion therapy (RT) of percutaneous coronary intervention (PCI) or thrombolytic therapy. Which one of the following is the correct statement about RT in ST-segment elevation myocardial infarction?

45) A 68-year-old woman received intravenous alteplase 3 hours after developing central chest pain and fatigue because of ST-segment elevation myocardial infarction. After 4 hours, the patient develops frequent and repetitive accelerated idioventricular rhythm with a regular heart rate of 52 beats/minute. Why has she developed this rhythm?

46) A 61-year-old woman is referred to you for further evaluation. She will undergo biliary tract surgery under general anesthesia. Her records reveal a cardiac problem. Which one of the following is a major risk factor for cardiac complications of non-cardiac surgery?

47) A 71-year-old man presents with intermittent claudication (IC) involving both calves. He is diabetic and hypertensive. He has a 30-pack-year smoking history. Which one of the following is the correct statement about peripheral arterial disease (PAD)?

48) A 73-year-old heavy-smoker man has been experiencing rest pain in left the forefoot over the past 4 months. The patient takes daily morphine for pain relief. You find multiple toes ulcerations. The ankle blood pressure is 40 mmHg, and the ankle/brachial pressure index is 0.3. What does the man have?

49) A 74-year-old man has been diagnosed with critical leg ischemia one month ago. He is diabetic and was diagnosed with chronic stable angina 3 years ago. The patient’s daily medications are aspirin, metformin, and atorvastatin. You think of adding another medication to lessen the incidence of thrombotic events. Which one of the following would you choose?

50) A 30-year-old smoker man presents with rest pain in the forefeet and hands. You find multiple skin ulcerations in the distal limbs in addition to red and tender streaks along the superficial veins of the lower limbs. What does the man have?

51) A 70-year-old man undergoes a contrast-enhanced abdominal CT scan because of right loin pain and hematuria. He smokes cigarettes daily and he is hypertensive.

A 5-mm stone in the right kidney is detected in addition to an abdominal aortic aneurysm (AAA) of 4.2 cm in maximum diameter. Which one of the following is the correct statement about AAA?

52) A 67-year-old man presents with low back and abdominal pain. Abdominal ultrasonography reveals dilatation of the abdominal aorta. Contrast CT angiography shows vessel wall thickening and non-smooth soft tissue thickening around the aorta. Serum IG4 is very high. What is your preliminary diagnosis?

53) A 32-year-old man presents with palpitations. Echocardiography reveals mitral valve prolapse with moderate regurgitation in addition to aortic root dilatation. He has Marfan’s syndrome. Which one of the following is the correct statement about aortic involvement in Marfan’s syndrome?

54) A 28-year-old man has been referred to the cardiology outpatient department for further evaluation of palpitations and shortness of breath. He has Marfan’s syndrome. Which one of the following is not a recognized cardiovascular manifestation of Marfan’s syndrome?

55) A 19-year-old man presents with severe hypertension. Resting 12-lead ECG reveals prominent voltage criteria of left ventricular hypertrophy.

A further evaluation shows aortic constriction distal to the origin of the left subclavian artery. Which one of the following is the correct statement about this condition?

56) An 18-year-old female is found to have a blood pressure of 190/120 mmHg on more than one occasion. There is a family history of systemic hypertension. You find hypokalemia, metabolic alkalosis, low serum aldosterone, and low plasma renin activity. Which one of the following is the cause of this hypertension?

57) You check the blood pressure of a 39-year-old African American man, and it turns out to be 160/100 mmHg. The patient takes maximally tolerated doses of valsartan, bisoprolol, prazosin, chlorthalidone, and spironolactone. He is fully compliant with his medications. He neither smokes cigarettes nor drinks alcohol. What definition of hypertension this man has?

58) A 17-year-old English female has been diagnosed with acute rheumatic fever. Which one of the following is not a major diagnostic criterion in low-risk populations?

59) A 25-year-old woman presents with exertional breathlessness and palpitations. Transthoracic echocardiography reveals a mitral valve area of 1.3 cm², a mean trans-mitral valvular gradient of 7 mmHg, and a pulmonary artery pressure of 40 mmHg. What does the woman have developed?

60) A 25-year-old woman presents with recurrent palpitations and atypical chest pain.

Transthoracic echocardiography reveals mitral valve leaflets of 7 mm in thickness with a symmetrical displacement of 4 mm above the mitral annulus; a mild regurgitation is present. Which one of the following is the false statement about this condition?

61) A 69-year-old man is found to have a systolic ejection murmur in the aortic area. Transthoracic echocardiography reveals mobile but thickened and calcified aortic cusps and a peak trans-aortic Doppler velocity of 1.7 meters/second. What does the man have?

62) You hear a systolic ejection murmur in a 69-year-old man. You do transthoracic echocardiography and find an aortic valve area of 1.3 cm², a maximum transaortic Doppler velocity of 3.5 meters/second, and a mean transaortic valvular gradient of 35 mmHg. Which of the following is the correct statement about this condition?

63) A 67-year-old man develops a fever, malaise, anorexia, shortness of breath, and palpitations. Serum CRP and ESR are high.

Transthoracic echocardiography reveals vegetations on the mitral valve leaflets and severe mitral regurgitation. Which one of the following is the correct statement about this condition?

64) A 74-year-old man presents with fever, drowsiness, malaise, and weight loss. He did a colonoscopy a few weeks ago because of chronic constipation that turned out to be due to colonic cancer. Transesophageal echocardiography reveals vegetations on the aortic valve. Which one of the following organisms is responsible for this deterioration?

65) A 68-year-old man has had fever, chills, malaise, and breathlessness over the past week. He underwent surgical aortic valve replacement (SAVR) 6 weeks ago because of severe calcific aortic stenosis. Which of the following is the correct statement about this type of infective endocarditis?

66) A 28-year-old man presents with fever, rigor, and malaise. You find bipedal pitting edema and raised JVP. He is an intravenous drug abuser of heroin. Which one of the following is the correct statement about this man’s presentation?

67) A 46-year-old woman has been admitted to the hospital for further evaluation and management of infective endocarditis (IE). You run a battery of investigations. Which one of the following is the incorrect statement about IE?

68) A 36-year-old woman develops infective endocarditis. You do blood cultures and detect fully sensitive streptococci. You consider using a short 2-week treatment regimen. Which one of the following should be present in this case to use this regimen?

69) A 20-year-old man develops a fever, shortness of breath, chest pain, and palpitations. You find bilateral ankle edema. He was otherwise healthy and enjoyed an independent life. These symptoms started to appear several days after being vaccinated with the 2nd dose of the Pfizer-BioNTech COVID-19 vaccine. What does the man have?

70) A 19-year-old man develops a fever, malaise, and anorexia. A few days later, he develops a dry cough and shortness of breath. Further evaluation reveals Coronavirus disease 2019 (COVID-19). On day 4 of hospitalization, he complains of severe substernal chest pain. ECG shows ST-segment elevation in leads V1-V4. Which one of the following is not a recognized cardiovascular complication of COVID-19?

71) A 21-year-old cheerleader female presents with recurrent palpitations and infrequent short-lived lapses of consciousness. Her older brother died at the age of 29 years. You do a resting 12-lead ECG and find T-wave inversion in V1-V3 but no features of the right bundle branch block. Echocardiography reveals right ventricular posterior wall dilatation underneath the tricuspid valve. What is your provisional diagnosis?

72) A 25-year-old man presents with recurrent syncope. Resting 12-lead ECG shows non-specific ST-T wave abnormalities. Echocardiography reveals asymmetric septal hypertrophy and abnormal systolic anterior leaflet motion of the mitral valve. Which one of the following is the correct statement about this condition?

73) A 29-year-old man has been experiencing exertional breathlessness and syncope on effort over the past year. His older sister died suddenly 2 years ago. You suspect hypertrophic cardiomyopathy. Which one of the following is inconsistent with your preliminary diagnosis?

74) A 21-year-old man has been diagnosed with hypertrophic cardiomyopathy. Which one of the following medications should be avoided in this man?

75) A 41-year-old woman presents with central chest pain a few hours after her husband’s death. She has been admitted to the Accident and Emergency. Her past medical histories are unremarkable. Serum troponins are elevated. 12-lead ECG shows ST-segment elevation in the chest leads. You do cardiac catheterization and find that the coronary arteries are intact and are not blocked, and you see ballooning of the left ventricular apex. What does the woman have developed?

76) A 23-year-woman has been referred from the obstetrics department for further evaluation. She is 36 weeks pregnant. Which one of the following is not a normal physiological sign in pregnancy?

77) Because of palpitations, a 34-year-old pregnant woman visits the cardiology outpatient department. She is 34 weeks pregnant. You do 12-lead rest ECG. Which one of the following is not a normal ECG finding in pregnancy?

78) A 29-year-old pregnant woman, in her 2nd trimester, is brought to the Accident and Emergency because of palpitations. The heart is regular at a rate of 180 beats/minute and her blood pressure is 70/30 mmHg. She is drowsy and dyspneic. Her records reveal infrequent AV nodal re-entrant tachycardia before pregnancy. What is the best next step?

79) A 38-year-old pregnant woman has frequent cardiac dysrhythmia. Which one of the following medications is contraindicated in this woman?

80) A 41-year-old woman demonstrates a blood pressure of 150/95 mmHg on 3 occasions while visiting the antenatal care clinic. She is 17 weeks pregnant. No history of hypertension before pregnancy was obtained. 12-lead ECG and echocardiography are unremarkable. What does her blood pressure reading represent?

81) A 43-year-old woman is 6 weeks pregnant. Before pregnancy, she was diagnosed with stage I essential hypertension, but she has erratically ingested her medications. Which one of the following antihypertensive medications is contraindicated?

82) A 41-year-old woman develops orthopnea, palpitations, and exercise intolerance. She is 36 weeks pregnant. You find bipedal pitting edema, raised JVP, and bibasal crackles. Serum BNP and NT-proBNP are elevated. 12-lead rest ECG reveals intraventricular delay. Echocardiography shows left ventricular (LV) dilatation and an LV systolic function of 38%. Which one of the following is the correct statement about this woman’s condition?

83) A 25-year-old woman presents with palpitations and mild exertional breathlessness. She is 12 weeks pregnant. Echocardiography reveals moderate mitral stenosis. Which one of the following is the correct statement about mitral valve stenosis in pregnancy?

84) A 42-year-old woman presents with severe substernal pain and shortness of breath. She is 34 weeks pregnant. You suspect acute coronary syndrome. Which one of the following is the correct statement about myocardial infarction in pregnancy?

85) A 32-year-old woman is 37 weeks pregnant. She has severe symptomatic aortic stenosis. Her water breaks. She is on no medication. The obstetrician consults you about her labor and what to do. What is your reply concerning her labor?

86) A 65-year-old man undergoes an electrophysiological study of the heart because of unexplained recurrent syncope. You think of dysrhythmia.

The patient asks you some questions about the electricity of the heart. Which one of the following is the incorrect statement about the action potential of the sinoatrial node (SAN)?

87) A 71-year-old man has been prescribed an antiarrhythmic medication that affects the cardiomyocyte action potential. Regarding the action potential of the contractile cells of the heart, which one of the following is the correct statement?

88) Because of troublesome arrhythmia, you prescribe a class I antiarrhythmic medication to a 54-year-old man. Which one of the following is the incorrect statement about class I antiarrhythmic medications?

89) A 61-year-old man takes a daily antiarrhythmic medication. You do a resting 12-lead ECG and find a short QT interval. Which one of the following medications does he ingest?

90) You assess the effective refractory period (ERP) in a 67-year-old man who uses an antiarrhythmic medication. Which one of the following antiarrhythmics does not affect (neither increases nor decreases) the ERP?

Chapter One - Cardiovascular Medicine Answers

1) c

Objective: Different mechanisms behind developing heart failure.

Heart failure resulting from thyrotoxicosis is due to a tachycardia-mediated mechanism leading to an increased level of cytosolic calcium during diastole with reduced ventricular contractility and diastolic dysfunction, often with tricuspid regurgitation.

Ralston, Stuart H., et al., editors. Davidson's Principles and Practice of Medicine. 23rd ed., Elsevier Health Sciences, 2018.

2) b

Objective: New York Heart Association (NYHA) classification of heart failure symptom severity.

The patient’s symptoms are consistent with NYHA II. Such patients are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or angina pectoris. The patient has symptomatically mild heart failure. There is no category V.

Ralston, Stuart H., et al., editors. Davidson's Principles and Practice of Medicine. 23rd ed., Elsevier Health Sciences, 2018.

3) d

Objective: Clinical presentation of tachyarrhythmias.

Without doing electrocardiography, it’s usually impossible to differentiate between various tachyarrhythmias. However, some clues may be helpful. Paroxysmal atrial fibrillation has a sudden onset and may be induced by exercise or alcohol; sometimes entirely asymptomatic and even slow in rate in elderly people. Polyuria and dyspnea are common while syncope is not. Vagal maneuvers may slow the heart rate but never abort the attack. Patients may develop supraventricular tachycardia during rest or upon doing minimal physical activity (e.g., bending), while vagal maneuvers can abort the episode. The palpitation is usually moderate to severe; lightheadedness, chest tightness, and polyuria are common.

Ralston, Stuart H., et al., editors. Davidson's Principles and Practice of Medicine. 23rd ed., Elsevier Health Sciences, 2018.

4) e

Objective: Review the causes of irregular heart rate and/or rhythm.

The heart rate can be irregular in rate and/or rhythm. First-degree AV block is abnormally slow conduction through the AV node. It is defined by ECG changes that include a PR interval of greater than 200 milliseconds without disruption of atrial to ventricular conduction (no changes in the rate).

Frank G. Yanowitz. Outline of ECG interpretation. Updated 2018. ECG Learning Center. ecg.utah.edu/. Accessed January 24, 2022. 

Schamroth C. An Introduction to Electrocardiography, 7th edition. New Jersy; Wiley-Blackwell: 2000. 

5) d

Objective: Review the etiologies of bradycardia.

Cocaine imparts a multitude of deleterious cardiovascular effects. Catecholamine surge results in sinus tachycardia (very common), reentrant supraventricular tachycardia, and atrial fibrillation.

Wide QRS complex (QRS duration >120 milliseconds) tachycardia is related to its sodium channel blockade and reentry ventricular tachycardia may ensue. A Brugada-like ECG pattern has been noted. A reentrant rhythm and monomorphic ventricular tachycardia or torsades de pointes can result from cocaine-induced potassium channel blockade and prolonged QT interval. Digitalis intoxication can result in a variety of cardiac dysrhythmia; extrasystoles, non-paroxysmal junctional tachycardia, ventricular fibrillation, premature ventricular contractions, atrial fibrillation, atrial flutter, bi-directional ventricular tachycardia, as well as SA block and AV node block.

A slow regular ventricular rhythm might be due to:

Sinus bradycardia.

Complete AV block with idioventricular rhythm

Normal sinus rhythm with 2:1 AV block

Normal sinus rhythm with 2:1 SA block (very rare)

Atrial flutter with high grade 4:1 AV block.

Sinus default with idionodal escape rhythm

Sinus default with idioventricular escape rhythm

Frank G. Yanowitz. Outline of ECG interpretation. Updated 2018. ECG Learning Center. ecg.utah.edu/. Accessed January 24, 2022. 

Schamroth C. An Introduction to Electrocardiography, 7th edition. New Jersy; Wiley-Blackwell: 2000. 

6) d

Objective: British Hypertension Society classification of blood pressure levels.

This patient has Grade 2 isolated systolic hypertension. Grade 3 (severe) hypertension is defined as a blood pressure of >180 mmHg (systolic) and >110 mmHg (diastolic).

Ralston, Stuart H., et al., editors. Davidson's Principles and Practice of Medicine. 23rd ed., Elsevier Health Sciences, 2018.

7) b

Objective: Differences between carotid artery pulsation and jugular venous pulsation.

The presence of two peaks per heart rate (in sinus rhythm) is consistent with a jugular venous pulsation. The jugular venous pulsation is impalpable and rises with abdominal pressure. The carotid artery pulsation displays a rapid outward movement, is palpable, and is independent of respiration, the patient’s posture, or abdominal pressure. It’s unaffected by pressure at the neck’s root.

Ralston, Stuart H., et al., editors. Davidson's Principles and Practice of Medicine. 23rd ed., Elsevier Health Sciences, 2018.

Innes, J. Alastair, et al, editors. Macleod's Clinical Examination 14th ed., Elsevier Health Sciences, 2018.

8) d

Objective: Abnormalities of the jugular venous pulse.

Absent a waves are encountered with atrial fibrillation. Cannon a waves can be regular (tricuspid stenosis) or irregular (complete heart block). Giant c or cv waves are seen in tricuspid regurgitation. Pericardial effusion results in rapid y descent.

Fabry’s disease can result in a multitude of cardiac manifestations: heart failure, valvular stenosis or regurgitation (mitral and aortic valves are more affected than the right-sided valves), conduction defects, complete heart block, and a variety of dysrhythmias. 

Ralston, Stuart H., et al., editors. Davidson's Principles and Practice of Medicine. 23rd ed., Elsevier Health Sciences, 2018.

Innes, J. Alastair, et al, editors. Macleod's Clinical Examination 14th ed., Elsevier Health Sciences, 2018.

9) e

Objective: Abnormalities of the intensity of the first heart sound.

The variable intensity of the first heart sound is encountered with complete heart block, multiple extrasystoles, and atrial fibrillation. LV systolic dysfunction, low cardiac output states, first-degree AV block (prolonged PR interval), and rheumatic mitral regurgitation result in a quiet first heart sound. Large stroke volumes, increased cardiac output states, mitral stenosis, atrial myxoma, and short PR interval (sinus tachycardia) would result in a loud first heart sound.

Ralston, Stuart H., et al., editors. Davidson's Principles and Practice of Medicine. 23rd ed., Elsevier Health Sciences, 2018.

Innes, J. Alastair, et al, editors. Macleod's Clinical Examination 14th ed., Elsevier Health Sciences, 2018.

10) e

Objective: Abnormalities of the second heart sound.

The second heart sound widens in expiration (reversed splitting) in ventricular pacing, aortic stenosis, left bundle branch block, and hypertrophic cardiomyopathy. Fixed splitting is heard in the atrial septal defects. Pulmonary hypertension results in loud and widely split (in inspiration; enhanced physiological splitting) second heart sound. The second heart sound becomes quiet in calcified aortic stenosis and aortic regurgitation. The second heart sound becomes loud in systemic hypertension.

Ralston, Stuart H., et al., editors. Davidson's Principles and Practice of Medicine. 23rd ed., Elsevier Health Sciences, 2018.

Innes, J. Alastair, et al, editors. Macleod's Clinical Examination 14th ed., Elsevier Health Sciences, 2018.

11) e

Objective: Left anterior fascicular block versus left posterior fascicular block.

The first 4 stems are features of the left anterior fascicular block. Left posterior fascicular block results in QRS duration equal or more than 0.10 second, right axis deviation (+90 degree or greater), qR pattern in lead II, III, and aVF, and finally rS pattern in lead I and aVL.  You should exclude other causes of right axis deviation (chronic obstructive airway disease, right ventricular hypertrophy, and lateral myocardial infarction).

Frank G. Yanowitz. Outline of ECG interpretation. Updated 2018. ECG Learning Center. ecg.utah.edu/. Accessed January 24, 2022. 

Schamroth C. An Introduction to Electrocardiography, 7th edition. New Jersy; Wiley-Blackwell: 2000.

12) d

Objective: Localization of myocardial infarction via 12-lead ECG changes.

Inferior (II, III, aVF) – right coronary artery

Septal (V1-V2) – left anterior descending artery

Anterior (V3-V4) – left anterior descending artery

Antero-septal (V1-V4) – left anterior descending artery

Extensive anterior (I, aVL, V1-V6) – left anterior descending artery

Lateral (I, aVL, V5-V6) – left circumflex artery

High Lateral (I, aVL) – left circumflex artery

Posterior, usually occurs in association with inferior or lateral infarctions, (Prominent R in lead V1) – right coronary artery (80%) or left circumflex artery (20%)

Right ventricular, usually in association with inferior infarction, (ST elevation in lead V1, and more specifically, V4R in the setting of inferior infarction) – right coronary artery

Frank G. Yanowitz. Outline of ECG interpretation. Updated 2018. ECG Learning Center. ecg.utah.edu/. Accessed January 24, 2022. 

Schamroth C. An Introduction to Electrocardiography, 7th edition. New Jersy; Wiley-Blackwell: 2000.

13) e

Objective: Review the causes of bigeminal rhythm.

Alternate ventricular extrasystoles are the commonest cause in clinical practice. Atrial fibrillation causes an irregularly irregular rhythm.

Frank G. Yanowitz. Outline of ECG interpretation. Updated 2018. ECG Learning Center. ecg.utah.edu/. Accessed January 24, 2022. 

Schamroth C. An Introduction to Electrocardiography, 7th edition. New Jersy; Wiley-Blackwell: 2000.

14) b

Objective: Review the causes of tall peaked symmetrical T-wave in the precordial chest leads.

Hyperkalemia, as well as the hyperacute phase of anterior wall myocardial infarction, can result in tall symmetrical T-waves in the precordial leads.

Frank G. Yanowitz. Outline of ECG interpretation. Updated 2018. ECG Learning Center. ecg.utah.edu/. Accessed January 24, 2022. 

Schamroth C. An Introduction to Electrocardiography, 7th edition. New Jersy; Wiley-Blackwell: 2000.

15) e

Objective: Review the causes of absent P-wave.

In atrioventricular nodal rhythm, the P-wave might be hidden within the QRS complex. In pulmonic stenosis, there is P-pulmonale (reflecting right atrial abnormality) which is a big, as well as tall and peaked P-wave on the ECG.

Frank G. Yanowitz. Outline of ECG interpretation. Updated 2018. ECG Learning Center. ecg.utah.edu/. Accessed January 24, 2022. 

Schamroth C. An Introduction to Electrocardiography, 7th edition. New Jersy; Wiley-Blackwell: 2000.

16) b

Objective: ECG changes in congenital heart disease.

Tricuspid atresia is the 3rd commonest cause of cyanotic congenital heart disease (after transposition of great vessels and tetralogy of Fallot). In an infant with cyanosis, electrocardiographic findings are virtually diagnostic of tricuspid atresia. Most cases of cyanotic congenital heart disease are associated with right ventricular dominance and right axis deviation; tricuspid atresia is a notable exception. In the latter, there is prominent left ventricular hypertrophy and left axis deviation.

Frank G. Yanowitz. Outline of ECG interpretation. Updated 2018. ECG Learning Center. ecg.utah.edu/. Accessed January 24, 2022. 

Schamroth C. An Introduction to Electrocardiography, 7th edition. New Jersy; Wiley-Blackwell: 2000.

17) e

Objective: Review restrictive cardiomyopathy and differentiate it from chronic constrictive pericarditis.

Of all cardiomyopathies, restrictive cardiomyopathy is the rarest type; it constitutes approximately 5% of cardiomyopathies. Characteristically, there is diastolic dysfunction with restrictive ventricular physiology while the ventricular systolic function often remains unaffected. The primary (idiopathic) variety may be caused by endomyocardial fibrosis or Loeffler eosinophilic endomyocardial disease. However, secondary etiologies are much more common (e.g., amyloidosis, sarcoidosis, carcinoid disease, and progressive systemic sclerosis). The overall clinical presentation may be chronic constrictive pericarditis-like. Myocardial biopsy is usually diagnostic. Digoxin should be used with caution; it is potentially arrhythmogenic, especially in patients with amyloidosis.

Reardon L, McKenna P, Viccellio AW. Restrictive Cardiomyopathy.Medscape. Updated August 30, 2017. Available at: https://emedicine.medscape.com/article/153062-overview 

18) d

Objective: Review chronic constrictive pericarditis and its novel treatment.

The commonest cause of chronic restrictive pericarditis in the Western World is the idiopathic variety (probably viral) while the tuberculous variety is more common in the Developing Countries as an etiology. Cardiac surgery and radiation therapy rank 2nd and 3rd, respectively. The parietal pericardium is predominantly involved (the visceral pericardium is rarely involved resulting in the so-called constrictive-effusive pericarditis). A cardiac murmur is typically not present unless concomitant valvular heart disease or a fibrous band that constricts the right ventricular outflow tract is present. The cornerstone of cure is surgery; medical treatment relieves symptoms and is a bridge toward surgery. Although many non-specific ST-segment and/or T-wave changes may be observed, there is no single diagnostic ECG sign. Rilonacept (Arcalyst®), an interleukin-1 cytokine trap, was approved in March 2021 to treat pericarditis.

Edwards W. Constrictive Pericarditis. Medscape. Updated March 23, 2021. Available at: https://emedicine.medscape.com/article/157096-overview

19) d

Objective: Review the emergency department and inpatient care of patients with acute coronary syndrome and differentiate between STEMI and NSTEMI.

Although all stems appear reasonable and are part of the management plan, primary percutaneous coronary intervention (PCI) is the best modality in this patient with STEMI (ST-segment elevation myocardial infarction). If STEMI is diagnosed and the patient is within 90 minutes of reaching a PCI-capable hospital, he/she should undergo emergent coronary angiography and primary PCI. If the patient is longer than 120 minutes from such facilities, intravenous fibrinolysis should be considered. Although patients presenting without ST-segment elevation (so-called NSTEMI) are not candidates for immediate administration of intravenous thrombolytic medications, they should receive anti-ischemic therapy; in addition, they may be candidates for PCI urgently or during admission. In December 2017, the PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitor (evolocumab; Repatha®) was approved for the prevention of strokes, heart attacks, and coronary revascularizations in adults with established cardiovascular disease. The other approved PCSK9 inhibitor is alirocumab (Praluent®); this was approved in 2021 as a second-line medication for the treatment of familial homozygous hypercholesterolemia. PCSK9 inhibitors are monoclonal antibodies that block the LDL receptors. 

Maziar Zafari AM, Abdou MH. Myocardial Infarction. Medscape. Updated May 07, 2019. Available at: https://emedicine.medscape.com/article/155919-overview

20) d

Objective: Prognosis of unstable angina.

The following are significant prognosticators for poor outcomes in patients with unstable angina:

Ongoing congestive heart failure

Presence or history of poor left ventricular ejection fraction

Hemodynamic instability

Recurrent angina despite intensive anti-ischemic therapy

New or worsening mitral regurgitation

Sustained ventricular tachycardia

Ralston, Stuart H., et al., editors. Davidson’s Principles and Practice of Medicine. 23rd ed., Elsevier Health Sciences, 2018.

21) e

Objective: Indications of and contraindications to percutaneous mitral balloon commissurotomy (PMBC) and mitral valve replacement.

The progression of mitral stenosis (MS) can be classified into 4 stages (A to D) as follows:

Stage A: At risk of MS

Stage B: Asymptomatic with progressive MS (mild to moderate)

Stage C: Asymptomatic with severe MS

Stage D: Symptomatic with severe MS

PMBC is recommended for all patients with Stage D disease (symptomatic with severe MS; mitral valve area ≤1.5 cm²), who display no contraindications to surgery, and exhibit a favorable valve morphology. Surgical intervention is recommended in patients with severe MS (Stage D) with NYHA functional class III-IV who are not at high risk for surgery and who are not candidates for PMBC (this includes patients with a history of PMBC failed attempts). The contraindications to PMBC include a mitral valve area >1.5 cm², presence of a left atrial thrombus, more than mild mitral reflux, severe or bi-commissural calcification, absence of commissural fusion, severe concomitant aortic valve disease (or severe combined tricuspid stenosis and reflux) and coexisting ischemic heart disease that should be treated by bypass surgery.

Dima C. Mitral Stenosis. Medscape. Updated December 08, 2021. Available at: https://emedicine.medscape.com/article/155724-overview

22) e

Objective: Review the complications of heart failure.

Hypokalemia can be caused by potassium-losing diuretics or secondary hyperaldosteronism due to the activation of the renin-angiotensin system and impaired aldosterone metabolism because of chronic hepatic congestion. Hyponatremia reflects severe heart failure and portends a poor outcome. It may be caused by excessive diuretic therapy, syndrome of inappropriate secretion of ADH (hypervolemia), or failure of the cell membrane ion pumping system. Renal impairment is common in advanced heart failure and results from poor renal perfusion (due to low cardiac output) and may be exacerbated by diuretic therapy, ACE inhibitors, and angiotensin receptor blockers. Atrial and ventricular arrhythmias are very common and may be induced by electrolyte disturbances (e.g., hypokalemia and hypomagnesemia), the underlying cardiac disease itself, and the pro-arrhythmic effects of sympathetic system activation. Atrial fibrillation occurs in 20% of patients and further impairs the already comprised cardiac function. Sudden death occurs in up to 50% of patients and is probably due to ventricular fibrillation.

Ralston, Stuart H., et al., editors. Davidson’s Principles and Practice of Medicine. 23rd ed., Elsevier Health Sciences, 2018.

23) e

Objective: Review the role of neprilysin inhibitors in the treatment of heart failure.

Sacubitril is a neprilysin inhibitor and is responsible for the breakdown of the endogenous diuretics atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP). When combined with valsartan (sacubitril-valsartan; Entresto®), it has been shown to produce additional symptomatic and mortality benefits over ACE inhibition alone and is now recommended in the management of resistant heart failure.

Ralston, Stuart H., et al., editors. Davidson’s Principles and Practice of Medicine. 23rd ed., Elsevier Health Sciences, 2018.

24) d

Objective: Review the role of ivabradine in the management of heart failure.

Ivabradine (Procoralan® or Corlanor®) is an If inhibitor; it inhibits the If inward current in the sinoatrial (SA) node and results in the reduction of heart rate. It has been shown to reduce the risk of hospitalization for worsening heart failure in patients with stable, symptomatic chronic heart failure with LVEF ≤35%, who are in sinus rhythm with resting heart rate ≥70 beats per minute, and either are on maximally tolerated doses of beta-blockers or have a contraindication to beta-blocker use.

Ralston, Stuart H., et al., editors. Davidson’s Principles and Practice of Medicine. 23rd ed., Elsevier Health Sciences, 2018.

25) e

Objective: Review the role of cardiac resynchronization therapy (CRT) in patients with congestive heart failure.

Mechanical dyssynchrony, i.e., nonsynchronous contraction of the wall segments of the left ventricle (intraventricular) or between the left and right ventricles (interventricular), impairs the cardiac systolic function and ventricular filling, increases wall stress and worsens mitral regurgitation. It is most readily defined by the presence of QRS widening and left bundle branch block (LBBB) configuration on the electrocardiogram. Biventricular pacing by atrial-synchronized pacing of the right ventricle and left ventricle via the coronary sinus to the basal or midventricular left ventricle region accomplishes reverse remodeling of the left ventricle. LBBB and QRS >150 milliseconds, female gender, and a non-ischemic etiology are established predictors of response. The best evidence-based candidates are patients who display sinus rhythm, left ventricular ejection fraction of ≤35 %, LBBB, QRS ≥150 milliseconds, and NYHA class III/IV.

Ralston, Stuart H., et al., editors. Davidson’s Principles and Practice of Medicine. 23rd ed., Elsevier Health Sciences, 2018.

26) b

Objective: Review the contraindications of cardiac transplantation in the recipient.

The contraindications are:

Irreversible pulmonary hypertension/elevated pulmonary vascular resistance

Pretransplant body mass index >35 kg/m² 

Active alcohol or illicit drug ingestion

Active systemic infection

Active malignancy or history of malignancy with a probability of recurrence

Inability to comply with complex medical regimen

Severe peripheral or cerebrovascular disease

Irreversible dysfunction of another organ, including diseases that may limit prognosis after heart transplantation

Active neoplasm from origins other than the skin is an absolute contraindication to heart transplantation due to the limited survival rates. Patients with a history of malignancy can be considered for heart transplantation when the risk of tumor recurrence is low, preferably after a reasonable time of complete remission, depending on the tumor type, response to therapy, and negative metastatic workup. On the other hand, donor selection is very critical. For heart donation, the upper age limit is 65 years. The only absolute specific cardiac contraindication for heart donation is the presence of important heart diseases, such as angina pectoris, myocardial infarction, prior coronary bypass surgery, moderate to severe valvular disease, cardiomyopathy, and important arrhythmias. General contraindications for all donations are, for example, untreated sepsis, malignancies, and active infections.

Bhangra et al. Cardiac transplantation: indications, eligibility and current outcomes. Heart. 2019;105(3):252-60. Available at: https://pubmed.ncbi.nlm.nih.gov/30209127/

27) c

Objective: Review the treatment options for paroxysmal atrial fibrillation.

Infrequent not problematic episodes do not necessarily need anti-arrhythmic therapy. Beta-blockers are excellent options in patients with heart failure or coronary artery disease. Class Ic anti-arrhythmic medications (e.g., flecainide) are effective but contraindicated in left ventricular systolic dysfunction and ischemic heart disease. Flecainide is rarely used alone and is usually combined with a rate-limiting beta-blocker because the former may precipitate atrial flutter. Digoxin and verapamil are rate-limiting only; they don’t prevent future attacks. Ablation is an excellent prophylactic option when medications are ineffective or poorly tolerated. However, it may be complicated by cardiac tamponade, stroke, phrenic nerve injury, and, rarely, pulmonary vein stenosis.

Ralston, Stuart H., et al., editors. Davidson’s Principles and Practice of Medicine. 23rd ed., Elsevier Health Sciences, 2018.

28) a

Objective: Anticoagulation therapy in patients with permanent atrial fibrillation and chronic renal failure.

Warfarin remains the first-line treatment in end-stage renal disease. Rivaroxaban dose is reduced from 20 mg once daily to 15 mg once daily if creatinine clearance is 30-49 mL/min and is contraindicated below 30 mL/min. Directly acting oral anticoagulants do not require blood monitoring and they display fewer (than warfarin) drug-drug interactions. In addition, their fixed daily dosing enhances patients’ compliance.

Ralston, Stuart H., et al., editors. Davidson’s Principles and Practice of Medicine. 23rd ed., Elsevier Health Sciences, 2018.

29) c

Objective: CHA2DS2-VASc stroke risk scoring system for non-valvular atrial fibrillation.

This woman has a score of 5 (the range is 0 to 9). This is a high CHA2DS2-VASc score. The annual stroke risk is >2.2% in patients who have a score of 2+ points. Therefore, oral anticoagulants are recommended to prevent embolic events. Aspirin has little or no effect on this patient and should not be used.

Ajam T, Mehdirad AA. CHADS2 Score for Stroke Risk Assessment in Atrial Fibrillation. Medscape. Updated February 27, 2020. Available at: https://emedicine.medscape.com/article/2172597-overview

30) c

Objective: Review the HAS-BLED bleeding risk scoring system for patients receiving oral anticoagulation.

This woman has a score of 4 (ranging from 0 to 9). The HAS-BLED score can be used to estimate the bleeding risk; patients with a HAS-BLED score of 3 or more points may require more careful monitoring if anticoagulated. A score of 4 is translated to 8.7 bleeds per 100 patient-years.

Zhu et al. The HAS-BLED Score for Predicting Major Bleeding Risk in Anticoagulated Patients With Atrial Fibrillation: A Systematic Review and Meta-analysis. Clin Cardiol. 2015;38(9):555-61. Available at: https://pubmed.ncbi.nlm.nih.gov/26418409/ 

31) b

Objective: Causes of wide QRS complex tachycardia and their diagnostic features.

It may be difficult to distinguish ventricular tachycardia (VT) from supraventricular tachycardia (SVT) with aberrant conduction (bundle branch block) or pre-excitation (Wolff-Parkinson-White syndrome) on the 12-lead ECG. However, features in favor of VT are:

History of myocardial infarction

Atrioventricular dissociation (pathognomonic)

Capture/fusion beats (pathognomonic)

Extreme left axis deviation

Very broad QRS complexes (>140 milliseconds)

No response to carotid sinus massage or intravenous adenosine

Ralston, Stuart H., et al., editors. Davidson’s Principles and Practice of Medicine. 23rd ed., Elsevier Health Sciences, 2018.

32) a

Objective: Causes of the prolonged QT interval and torsades de pointes ventricular tachycardia.

Prolonged ventricular repolarization