Читать книгу How to Pass the FRACP Written Examination - Jonathan Gleadle - Страница 11

Answers can be found in the Cardiology Answers section at the end of this chapter.

1 1. A 65‐year‐old accountant undergoes an abdominal ultrasound because of mildly abnormal liver function tests. The ultrasound reveals a few mobile gallstones and a 5 cm abdominal aortic aneurysm. He drinks three to four standard drinks of alcohol every day and is an ex‐smoker. He is known to have hypertension and is taking irbesartan 150 mg daily. Blood pressure control is satisfactory with mean systolic BP of 130 mmHg.What is your most appropriate course of action?Abdominal CT with contrast immediately and suspension of driver's license.Endovascular aneurysm repair immediately.Follow up ultrasound in 6 months and continue driving.Open surgical aneurysm repair immediately.

2 2. A 39‐year‐old man with a known atrial septal defect presents to emergency department with a 6‐hour history of palpitations. His ECG is shown below:Which one of the following signs is UNLIKELY to be present?Fixed splitting of second heart sound.Fourth heart sound.Loud first heart sound.Third heart sound.

3 3. Which of the following patient characteristics is LEAST LIKELY to increase an individual's susceptibility to anthracycline cardiomyopathy?Age of 70 years.Male sex.Mediastinal radiotherapy.Positive carrier status for C282Y HFE gene.

4  4. A 65‐year‐old‐man presents with a three‐month history of exertional dyspnoea. He is found to have aortic stenosis with a valve area of 0.9 cm2 and a mean transvalvular pressure gradient of 15 mmHg. His left ventricle ejection fraction (LVEF) is 35%. A Dobutamine Stress Echocardiography (DSE) has been arranged which will provide all of the following information, EXCEPT:Confirming the suitability for valve replacement.Deciding the need for cardiac resynchronisation therapy.Predicting prognosis post valve replacement.Diagnosing low‐flow, low‐gradient aortic stenosis.

5 5. An 84‐year‐old man with severe aortic stenosis complains of shortness of breath after walking for 20 metres and a couple of episodes of unexplained collapse. He is independent with activities of daily living. His medical history includes hypertension, hyperlipidaemia, cholecystectomy, and hernia repair.What is the most appropriate management approach?Aortic valve balloon valvuloplasty.Implantable cardioverter–defibrillator (ICD).Surgical aortic valve replacement (SAVR).Transcatheter aortic valve implantation (TAVI).

6 6. You see a 75‐year‐old woman with a new diagnosis of atrial fibrillation. Her CHA2DS2‐VASc score is 4. She has a history of myocardial infarction four years ago, treated with percutaneous coronary intervention and a bare‐metal stent inserted in the right coronary artery, and is currently on aspirin.Which of the following options is the most appropriate regarding ongoing anti‐thrombotic therapy?Coronary angiogram to guide further therapy.Rivaroxaban and clopidogrel.Rivaroxaban and aspirin.Rivaroxaban monotherapy.

7 7. Beta‐blockers are recommended as first line therapy for stable angina. Their main mechanism of action is explained by:Increased coronary artery blood flow.Plaque stabilisation.Reduction in blood pressure.Reduction in myocardial oxygen demand.

8 8. What is the management strategy for a patient with the following ECG?Amiodarone.Beta‐blocker.Implantable cardioverter–defibrillator (ICD).Pacemaker.

9 9. A 54‐year‐old man is admitted to hospital because of syncope. This is his third presentation with syncope due to severe postural hypotension over the past six months. He has developed chronic diarrhoea and lost 6 kg of body weight in the past six months. He has no significant past medical history. On examination, BP is 90/50 mmHg. HR is 86 bpm. There are no murmurs. Urinary analysis shows ++++ protein but no RBCs nor RBC casts. His investigation results are shown below. ECG shows sinus rhythm and low voltage in all leads. Echocardiogram reports moderate left ventricular hypertrophy, biatrial dilatation and grade 2 diastolic dysfunction.TestsResultsNormal valuesHaemoglobin108 g/L135–175White blood cell5.48 x 109/L4.0–11.0Platelet206 x 109/L150–450Sodium133 mmol/L135–145Potassium4.3 mmol/L3.5–5.2Creatinine156 μmol/L60–110Albumin22 g/L34–48Globulin42 g/L21–41Liver function testsnormalTroponin<29 ng/L0–29N‐terminal pro b‐type Natriuretic Peptide (NT‐proBNP)1800 ng/L0–124What would you consider the most appropriate next investigation?Cardiac MRI.Coronary artery angiogram.Holter monitor.Implantable loop recorder.

10 10. Which one of the following increases cardiac output?Atropine.Acidosis.Beta‐blockers.Hypertension.

11 11. A 72‐year‐old woman presents to emergency department after an episode of loss of consciousness. Which of the following clinical features, if present, DO NOT increase the likelihood that her loss of consciousness was due to cardiac syncope?Breathlessness prior to the episode.Cyanosis during the episode.History of atrial fibrillation.Significant injury as a result of loss of consciousness.

12 12. An 80‐year‐old man presents to emergency department with sudden onset of left‐sided weakness two hours ago. His medical history includes hypertension, hypercholesterolaemia, and atrial fibrillation for which he is taking aspirin only. CT head shows acute right middle cerebral artery territory infarction. He is treated with thrombolysis followed by bridging low molecular weight heparin then a direct thrombin inhibitor. Two weeks later while in rehabilitation, he develops low grade fever, myalgia, painful feet (shown below), anaemia, and AKI.The most likely diagnosis is:Acute allergic reaction to direct thrombin inhibitor.Antiphospholipid syndrome.Cholesterol embolisation.Multiple emboli due to inappropriate use of an oral direct thrombin inhibitor.

13 13. Which one of the following patients can be investigated appropriately with a computed tomography coronary angiography (CTCA)?An asymptomatic patient with history of type 2 diabetes and normal renal function.A patient with previous coronary stents presenting with chest pain and possible in‐stent restenosis.A patient presenting with central chest pain and rapid atrial fibrillation.A patient with chest pain but with a low pre‐test probability of coronary artery disease.

14 14. A 75‐year‐old man presents with transient weakness of his left arm. He is diagnosed with a transient ischaemic attack. He is known to have hypertension, type 2 diabetes, alcohol dependence, recent weight loss, and a low‐grade fever. He undergoes a transthoracic echocardiogram which reveals a 12 mm mitral‐valve vegetation.Which one of the following statements is true?Blood culture is negative in over 20% of cases of infectious endocarditis.Cerebral complications are the most frequent extracardiac complications.Majority (80%) of cases of infectious endocarditis develop in patients with known valvular disease.Streptococci in the most common pathogen isolated.

15 15. A 75‐year‐old man presents with increasing dyspnoea. You note that he had four admissions in the past year due to decompensated CCF. He is known to have ischaemic heart disease with a drug eluting stent in two coronary arteries, insulin dependent type 2 diabetes, hypertension, stage 4 CKD with an eGFR of 26 ml/min/1.73 m2 and severe smoking related COPD. His medications include aspirin, clopidogrel, perindopril, gliclazide, frusemide, digoxin, spironolactone, atorvastatin, formoterol/,budesonide inhaler, and tiotropium inhaler. Physical examination findings are consistent with decompensated CCF. His ECG is shown below. A dobutamine stress echocardiogram demonstrates no reversible ischaemic change but a large antero‐apical area of akinesia. The ejection fraction is 30%.The most effective treatment to reduce the frequency of readmissions and improve survival is:Add a SGLT2 inhibitor.Commence a beta‐blocker.Insert a biventricular pacemaker and defibrillator.Insert a dual‐chamber pacemaker.

16 16. Which one of the following medications is recommended in patients with type 2 diabetes with cardiovascular disease and inadequate glycaemic control despite metformin, to reduce the risk of cardiovascular events and hospitalisation for heart failure?Dipeptidyl peptidase‐4 (DPP‐4) inhibitors.Glucagon‐like peptide‐1 (GLP‐1) analogues.Sodium‐glucose co‐transporter‐2 (SGLT2) inhibitors.Thiazolidinediones.

17 17. A 70‐year‐old woman presents with a 2‐month history of exertional dyspnoea for evaluation. Her medical history includes longstanding hypertension, obesity, OSA, and permanent AF. On examination, there are clinical signs consistent with CCF. Her troponin level is normal, but NT‐pro BNP level is elevated. Her echocardiogram demonstrates a left ventricular ejection fraction of 55%, left ventricular end‐diastolic volume index (LVEDI) <97 mL/m2 and the ratio of mitral early diastolic inflow velocity to mitral early annular lengthening velocity (E/e')>15.Which one of the following treatments will reduce mortality for this patient?Angiotensin‐converting enzyme inhibitor.No pharmacological treatment proven to reduce mortality.Phosphodiesterase‐5 inhibitor.Selective sinus node If sodium channel inhibitor.

18 18. In a 28‐year‐old man with known hypertrophic cardiomyopathy (HOCM) who has had one episode of syncope at work, which one of the following treatments should be instituted?Amiodarone.Anticoagulation.Atenolol.Implantable cardioverter–defibrillator.

19 19. A 56‐year‐old man presents to emergency department with severe headaches and blurred vision. He is known to have IgA nephropathy but has no regular follow up for this. His BP is 210/110 mmHg. You have performed a fundoscopic examination which is shown below:What does the fundoscopy show?Keith‐Wagener (KG) grade 3 hypertensive retinopathy.Keith‐Wagener (KG) grade 4 hypertensive retinopathy.Retinal artery occlusion.Retinal vein occlusion.

20 20. Which one of the following patients DOES NOT have an indication for an implantable cardioverter defibrillator (ICD) implantation?A 20‐year‐old man with congenital long QT syndrome with recurrent syncope who cannot tolerate beta‐blockers.A 65‐year‐old woman with haemodynamically unstable ventricular tachycardia not due to reversible causes.A 59‐year‐old man with ischaemic cardiomyopathy with a myocardial infarction two weeks ago with left ventricular ejection fraction of 30%.A 22‐year‐old asymptomatic female with hypertrophic cardiomyopathy, unexplained syncope but no family history of sudden cardiac death.

21 21. A 56‐year‐old man with a background history of type 2 diabetes, hypertension, and hyperlipidaemia presents with unexplained syncope and palpitations that happen around 6‐monthly. His previous cardiac investigations, including repeated 12‐lead ECG and 24‐hour Holter monitoring, are normal.What is the appropriate next step to investigate palpitations?Three‐day Holter monitoring.Seven‐day Holter monitoring.Wearable device.Implantable loop recorder.

22 22. Which one of the following lipid‐lowering agents acts by blocking the inhibition of lysosomal degradation of low‐density lipoprotein (LDL) receptors, thereby increasing the body's ability to sequester LDL?Evolocumab.Ezetimibe.Mipomersen.Rosuvastatin.

23 23. A 65‐year‐old man presents with dizziness and syncope. His ECG shows a QTc interval of 520 ms. Review of medical history, family history, medications, electrolytes, and echocardiogram did not find a reversible cause of the condition.What is the first‐line treatment for this patient?Amiodarone.Beta‐blockers.Implantable cardioverter defibrillator (ICD).Left cardiac sympathetic denervation (LCSD).

24 24. A 25‐year‐old Aboriginal and Torres Strait Islander woman presents with a 3‐month history of exertional dyspnoea. She has had an unproductive cough but no fevers, chest pain or other illnesses. She takes no medication. On examination, BP is 120/70 mmHg, HR 90/min and regular, there is a 2/6 diastolic murmur and a 3/6 systolic murmur, chest is clear, there is pitting oedema of both ankles. Echocardiogram reveals mitral stenosis with a mean transvalvular gradient of 14 mmHg and moderate mitral regurgitation. The left atrium is enlarged. There is normal biventricular size and function, as well as pulmonary hypertension with a pulmonary arterial pressure of 50 mmHg.Which of the following is the most appropriate management?Balloon mitral valvuloplasty.Commence ACE inhibitor and repeat echocardiogram in 6 months.Mitral valve open commissurotomy.Mitral valve replacement.

25 25. A 65‐year‐old man suffers from ischaemic heart disease, chronic AF, insulin‐dependent type 2 diabetes, stage 3 CKD, peripheral vascular disease with chronic claudication. He is taking multiple medications and is asking your advice about taking omega‐3 fish oil supplements.Which one of the following pieces of advice regarding omega‐3 fish oil supplements for this patient is correct?It is associated with a statistically significant reduction on all‐cause mortality.It has a beneficial effect on glycaemic control and increased fasting insulin levels.It can improve walking distance, ankle brachial pressure index, and angiographic findings.It can reduce serum triglycerides and raise HDL and LDL levels.

26 26. A 55‐year‐old man presents with repeated clinic blood pressure measurements of around 150/90 mmHg, after six months of therapy with perindopril, amlodipine, and hydrochlorothiazide at maximal doses. He is compliant with his medications and is engaging actively with lifestyle modifications.Which one of the following additional agents is most likely to be beneficial?Atenolol.Doxazosin.Hydralazine.Spironolactone.

27 27. A 50‐year‐old woman with haemochromatosis presents with dyspnoea. She undergoes an echocardiogram. Which of the echocardiogram findings is most commonly seen in patients with early‐stage restrictive cardiomyopathy?Left ventricular dilatation with reduced left ventricular ejection fraction <45%.Left ventricular outflow tract obstruction.Normal ventricular size and systolic function with a restrictive ventricular filling pattern.Regional wall motion abnormality in a non‐coronary distribution.

28 28. Which of the following statements is correct regarding acute rheumatic fever (ARF) in Aboriginal and Torres Strait Islander (ATSI)?It is usually associated with Group B streptococcal infection.Secondary prophylaxis following rheumatic fever should be oral doxycycline.The highest rates of ARF in ATSI are between the ages 34 to 45.The major manifestations of ARF include carditis and chorea.

29 29. A 60‐year‐old woman presents with epigastric pain, nausea, vomiting, and shortness of breath. She has a HR of 58 bpm and a BP of 90/60 mmHg. Her ECG is shown below:The occlusion of which coronary artery is likely to have produced this presentation.Circumflex.Left anterior descending.Left marginal.Right.

30 30. A 55‐year‐old man is referred by his GP because of bradycardia with a heart rate as low as 45 bpm at night. He has hypertension for which he is taking amlodipine 5 mg daily. An ECG performed today shows a sinus bradycardia 55/min and he is asymptomatic.Which one of the following statements is correct?Nocturnal bradycardia is an indication for permanent pacing.Sinus node dysfunction is most likely due to ischaemic heart disease.Sleep apnoea is not associated with nocturnal bradycardia.There is no minimum heart rate or pause duration for which permanent pacing is recommended in sinus node dysfunction.

31 31. A 38‐year‐old woman is admitted to intensive care unit because of septic shock due to meningococcal septicaemia. She complains of increased dyspnoea on day 3 when she is discharged to the ward. She has a medical history of asthma and chronic back pain. She has been experiencing depressive symptoms since her husband passed away one year ago. Her ECG shows ST depression in the lateral leads. Initial Troponin I level is 54 ng/L [<29], N‐terminal pro‐B‐type brain natriuretic peptide (NT‐proBNP) level is 5400 ng/L [0–124]. Her echocardiogram shows ballooning of the left ventricular apex.Which of the following medications will improve her survival at one year?Angiotensin‐receptor blockers.Beta‐blockers.Calcium channel blockers.Digitalis glycosides.

32 32. Which of the following statements is correct regarding transcatheter aortic valve implantation (TAVI) in inoperable and high‐risk elderly patients?Patients should be anticoagulated with a novel oral anticoagulant (NOAC) for 3 months post implantation.Patients should be anticoagulated with dual antiplatelet therapy for 3 months post implantation.Patients with asymptomatic severe aortic stenosis at intermediate surgical risk should be offered TAVI.The need for permanent pacemaker insertion due to bradyarrhythmias post TAVI is about 30%.

33 33. A 62‐year‐old man presents with vague chest discomfort for 6 hours. He is known to have insulin‐dependent type 2 diabetes, hypertension, hyperlipidaemia, stage 3A CKD with serum creatinine 150 μmol/L [60–110] and psoriatic arthritis treated with adalimumab. His ECG is shown below. His coronary artery angiography shows 50% stenosis of the left main, 75% stenosis of the left circumflex, 70% stenosis of the proximal left anterior descending artery, and 50% stenosis of the right coronary artery. Left ventricular systolic function is reduced with an ejection fraction of 40%.Which one of the following is the best management option?Coronary artery bypass graft surgery (CABG).Infarct‐related artery (IRA)‐only revascularisation in primary PCI.PCI plus biventricular pacemaker–defibrillator.Percutaneous coronary intervention (PCI).

34 34. A 51‐year‐old woman presents to the emergency department with cellulitis of her left lower leg and epigastric discomfort after being on oral antibiotics for three days. She is otherwise well and has no other symptoms and ECG is normal. She is known to have autosomal dominant polycystic kidney disease with a serum creatinine of 86 μmol/L [60–110]. A serum high‐sensitivity troponin (hs‐cTn) is requested and the result is 40 ng/L [<29].What is the best interpretation of this result in terms of the likelihood of acute coronary syndrome?Likely because the specificity of hs‐cTn is high.Likely because the pre‐test probability is high.Unlikely because the specificity of hs‐cTn is low.Unlikely because the pre‐test probability is low.

35 35. A 78‐year‐old woman is admitted to the Acute Medical Unit with severe community acquired pneumonia. Her BP is 90/60 mmHg and oxygen saturation is 90% on 4 L of oxygen. Her other medical history includes type 2 diabetes, stage 3B CKD, and hypertension. A central venous line is inserted because of difficult venous access. She complains of increased dyspnoea. A bedside ECG is taken and shown below. Troponin level is 289 ng/L [<29].Which one of the following is the most likely diagnosis?Type 1 myocardial infarction.Type 2 myocardial infarction.Type 3 myocardial infarction.Type 4 myocardial infarction.

36 36. A 55‐year‐man presents with a 2‐hour history of palpitations and chest discomfort. He had a similar episode one year ago. He is known to have ankylosing spondylitis, diet‐controlled type 2 diabetes, and asthma. He uses a salbutamol inhaler two to three times a week. On examination, he is alert and orientated, BP is 110/60 mmHg, pulse rate is 150 bpm, SaO2 on room air is 95%. There is scattered expiratory wheeze. There is no heart murmur. His current ECG is shown in Figure 1.1A, while Figure 1.1B shows an ECG taken 1‐year ago during an infective exacerbation of asthma. His biochemistry results and troponin T are within normal reference range.Figure 1.1AFigure 1.1BThe most appropriate treatment for rate control is:Intravenous adenosine.Intravenous digoxin.Intravenous flecainide.Intravenous verapamil.