1.A 79-year-old man is admitted with congestive cardiac failure.

Bloods on admission show:

BNP

354 pg/ml

Which one of the following would result from elevated BNP levels?ia
A.A Decreased sodium diuresisia
B.A Vasoconstriction of the coronary arteriesia
C.A Inhibition of the renin-angiotensin-aldosterone systemia
D.A Vasoconstriction of the pulmonary vesselsia
E.A

Increased sympathetic toneia

BNP - actions:

vasodilator

diuretic and natriuretic

suppresses both sympathetic tone and the renin-angiotensin-aldosterone system

B-type natriuretic peptide (BNP) hormone produced mainly by the left ventricular
myocardium in response to strain
Whilst heart failure is the most obvious cause of raised BNP levels any cause of left ventricular
dysfunction such as myocardial ischaemia or valvular disease may raise levels. Raised levels
may also be seen due to reduced excretion in patients with chronic kidney disease. Factors which
reduce BNP levels include treatment with ACE inhibitors, angiotensin-2 receptor blockers and
diuretics.
Effects of BNP

vasodilator

diuretic and natriuretic

suppresses both sympathetic tone and the renin-angiotensin-aldosterone system

Clinical uses of BNP

Diagnosing patients with acute dyspnoea

a low concentration of BNP(< 100pg/ml) makes a diagnosis of heart failure unlikely, but
raised levels should prompt further investigation to confirm the diagnosis

NICE currently recommends BNP as a helpful test to rule out a diagnosis of heart failure

Prognosis in patients with chronic heart failure

initial evidence suggests BNP is an extremely useful marker of prognosis

Guiding treatment in patients with chronic heart failure

effective treatment lowers BNP levels

Screening for cardiac dysfunction

not currently recommended for population screening

2. Where is the site of action of spironolactone?ia

A.A

Proximal convoluted tubuleia

B.A

Ascending loop of Henleia

C.A

Descending loop of Henleia

D.A

Distal convoluted tubuleia

E.A

Macula densaia

Spironolactone
Spironolactone is an aldosterone antagonist which acts act in the distal convoluted tubule
Indications

ascites: patients with cirrhosis develop a secondary hyperaldosteronism. Relatively large

doses such as 100 or 200mg are often used

heart failure (see RALES study below)

nephrotic syndrome

Conn's syndrome

Adverse effects

hyperkalaemia

gynaecomastia

RALES

NYHA III + IV, patients already taking ACE inhibitor

low dose spironolactone reduces all cause mortality

3. Which of the following drugs is most likely to cause impaired glucose tolerance?ia
A.A

Frusemideia

B.A

Perindoprilia

C.A

Salicylatesia

D.A

Co-amoxiclavia

E.A

Beta-blockersia

Drug-induced impaired glucose tolerance

sqweqwesf erwrewfsdfs adasd dhe
Drugs which are known to cause impaired glucose tolerance include:

thiazides, frusemide (less common)

steroids

tacrolimus, ciclosporin

interferon-alpha

nicotinic acid

Beta-blockers cause a slight impairment of glucose tolerance. They should also be used with
caution in diabetics as they can interfere with the metabolic and autonomic responses to
hypoglycaemia
4. Which one of the following statements regarding B-type natriuretic peptide is incorrect?ia
A.A Effective treatment for heart failure lowers a patients BNP levelia
B.A Acts as a diureticia
C.A A hormone produced mainly by the left ventricular myocardium in response to
strainia
D.A Is a good marker of prognosis in patients with chronic heart failureia
E.A The positive predictive value of BNP is greater than the negative predictive
valueia
BNP has a good negative predictive value rather than positive predictive value
B-type natriuretic peptide
sqweqwesf erwrewfsdfs adasd dhe
B-type natriuretic peptide (BNP) hormone produced mainly by the left ventricular myocardium
in response to strain
Whilst heart failure is the most obvious cause of raised BNP levels any cause of left ventricular
dysfunction such as myocardial ischaemia or valvular disease may raise levels. Raised levels
may also be seen due to reduced excretion in patients with chronic kidney disease. Factors which
reduce BNP levels include treatment with ACE inhibitors, angiotensin-2 receptor blockers and
diuretics.
Effects of BNP

vasodilator

diuretic and natriuretic

suppresses both sympathetic tone and the renin-angiotensin-aldosterone system

Clinical uses of BNP

Diagnosing patients with acute dyspnoea

a low concentration of BNP(< 100pg/ml) makes a diagnosis of heart failure unlikely, but
raised levels should prompt further investigation to confirm the diagnosis

NICE currently recommends BNP as a helpful test to rule out a diagnosis of heart failure

Prognosis in patients with chronic heart failure

initial evidence suggests BNP is an extremely useful marker of prognosis

Guiding treatment in patients with chronic heart failure

effective treatment lowers BNP levels

Screening for cardiac dysfunction

not currently recommended for population screening

5. A 17-year-old female presents after taking an overdose of her grandmothers medication.

Investigations revealed a serum potassium of 6 mmol/L (3.5-4.9).
Which one of the following drugs is the most likely cause of this abnormality?
(Please select an option)
Aspirin
Digoxin
Fluoxetine
Omeprazole
Propranolol

Question: 5 of 10 / Overall score: 80%

8279

A 17-year-old female presents after taking an overdose of her grandmothers medication.

Investigations revealed a serum potassium of 6 mmol/L (3.5-4.9).
Which one of the following drugs is the most likely cause of this abnormality?
(Please select an option)
Aspirin
Digoxin

Incorrect answer selected

Fluoxetine
Omeprazole
Propranolol

This is the correct answer

Betablockers, particularly propranolol, in overdose can cause hyperkalaemia by transmembrane

shifts. It is useful to think of the opposite - beta-agonists such as salbutamol are far more widely
known to cause hypokalaemia.
Overdose of digoxin therapy most commonly manifests as rhythm disturbance, and may be
exacerbated by hyper- or hypokalaemia. Salicylate overdose causes metabolic acidosis and
respiratory alkalosis.
6. A 50-year-old man with hypertension already on furosemide, ramipril and digoxin is found to
poor left ventricular function on echocardiogram. Which antihypertensive should be added?
(Please select an option)
Carvedilol
Diltiazem
Doxazosin
Hydrallazine
Nifedipine

Question: 6 of 20 / Overall score: 67%

11317

A 50-year-old man with hypertension already on furosemide, ramipril and digoxin is found to
poor left ventricular function on echocardiogram. Which antihypertensive should be added?
(Please select an option)
Carvedilol

Correct

Diltiazem
Doxazosin
Hydrallazine
Nifedipine
This patient has hypertension and reduced EF on echo indicating an element of failure. Under
these circumstances the most appropriate agent with evidence to support its use for reducing
morbidity and mortality in failure would be the addition of a beta blocker.
7. Which of the following is true regarding the action of Clopidogrel?
(Please select an option)
It inhibits cyclo-oxygenase
It is an ADP receptor antagonist

Correct

It is a glycoprotein IIb/IIIa inhibitor

It is a selective factor Xa inhibitor
It is Hydroxymethyl Coenzyme A inhibitor
Clopidogrel prevents platelet aggregation through antagonism of the ADP receptor. It has been
shown to reduce mortality from stroke and IHD in primary prevention studies.
8. Which of the following findings is the most specific for a diagnosis of myocardial infarction?

(Please select an option)

An akinetic area of LV wall motion on ECHO
Elevated cardiac enzymes
Evolution of Q waves on ECG
History of severe chest pain
ST elevation on ECG

Question: 1 of 40 / Overall score: 100%

4462

Which of the following findings is the most specific for a diagnosis of myocardial infarction?
(Please select an option)
An akinetic area of LV wall motion on ECHO
Elevated cardiac enzymes
Evolution of Q waves on ECG

Correct

History of severe chest pain

ST elevation on ECG
Cardiac enzymes may be elevated in PE, Renal failure and raised ST segments associated with
pericarditis. Akinetic wall motion on the echo may occur with any regional disease process like
amyloid et. The evolution of Q waves is the most suggestive of an infarct.
9. A 73-year-old male with type 2 diabetes requires improved glycaemic control. He also suffers
from heart failure which is controlled with a diuretic and an ACE inhibitor.
Which of the following hypoglycaemic agents is contraindicated in this patient?
(Please select an option)

Acarbose
Glipizide
Nateglinide
Repaglinide
Rosiglitazone

Correct

Rosiglitazone can result in fluid retention of unknown aetiology which may cause a mild
dilutional anaemia (haemoglobin typically falls by 1 to 2 g/dL) and ankle oedema. It is
contraindicated in hepatic dysfunction and congestive heart failure. Sulphonylureas are
contraindicated in renal failure: all should be stopped and insulin started if serum creatinine
exceeds 250 mol/L. The recent United Kingdom Prospective Diabetes Study found no evidence
that patients treated with sulphonylureas suffered cardiovascular events more often than those
treated with insulin. Contraindications of Metformin include all the major organ failures renal,
hepatic, cardiac, and respiratory. It should not be used when serum creatinine concentration
exceeds 150 mol/L. Side-effects of Acarbose are due to carbohydrate malabsorption (flatus,
abdominal bloating, gassy diarrhoea).
10. In a normal heart, the oxygen saturation of a sample of blood taken from a catheter in the
pulmonary capillary wedge position should be equal to a sample from which of the following?
(Please select an option)
Coronary sinus
Femoral artery
Pulmonary artery
Right atrium
Right ventricle

Question: 8 of 40 / Overall score: 75%

4467

In a normal heart, the oxygen saturation of a sample of blood taken from a catheter in the
pulmonary capillary wedge position should be equal to a sample from which of the following?

(Please select an option)

Coronary sinus
Femoral artery

Correct

Pulmonary artery
Right atrium
Right ventricle
Pulmonary capillary wedge normal values reflect pressures and saturations of the left side of the
heart. Consequently wedge pressures are between 6-12 mmHg and the saturations of blood taken
from the wedged source reflects blood in the pulmonary vein and hence high sats similar to that
seen in the femoral artery.
11. A 60-year-old man's echocardiogram shows a dilated left ventricular cavity with the
remainder of the other chamber sizes normal. The most likely diagnosis is which of the
following?
(Please select an option)
Aortic regurgitation
Aortic stenosis
Hypertensive heart disease
Mitral regurgitation
Mitral stenosis

Question: 9 of 40 / Overall score: 78%

4468

A 60-year-old man's echocardiogram shows a dilated left ventricular cavity with the remainder of
the other chamber sizes normal. The most likely diagnosis is which of the following?
(Please select an option)

Aortic regurgitation

Correct

Aortic stenosis
Hypertensive heart disease
Mitral regurgitation
Mitral stenosis
No echocardiographic data are provided regarding the valves but a volume overload as with AR
would result in dilatation of the left ventricle. MR, AS, and hypertension would have the effect of
causing hypertrophy and a smaller LV cavity. MS would have little effect on LV dimensions.
12. You are asked to see a patient in the Intensive Care Unit who is short of breath and
tachycardic to rule out a cardiac cause of her symptoms. A right heart catheter reveals that the
mixed venous O2 saturation is 70%; the pulmonary capillary wedge O2 saturation is 97%. The
haemoglobin is normal and the patient is afebrile. Which of the following is the most appropriate
statement that could be applied to her features?
(Please select an option)
Her cardiac output is decreased
Her cardiac output is normal

Correct

Her heart is normal

She has high-output failure
She is in shock due to a non-cardiac cause
The right heart and wedge catheters show normal sats, the latter suggesting that she has good
pulmonary oxygenation and so these features would argue against any failure - decreased or high
output failure and would certainly argue against shock of any sort. Therefore, one cannot go as
far as to say that she has a normal heart, so the best response (by a process of elimination) is that
she has a normal output.
13. Whilst attending the cardiology clinic, the staff nurse measures the blood pressure of a 61year-old man, and finds that it is 183/100 mmHg sitting and 190/105 standing. He has a heart
rate of 81/minute, with an irregularly irregular rhythm. On auscultation of the heart, there are no
murmurs, but he has bibasilar crackles on chest examination. Which of the following
pathological findings is most likely to be present?

(Please select an option)

Left ventricular hypertrophy

Correct

Left atrial myxoma

Occlusive coronary atherosclerosis
Cor pulmonale
Mitral regurgitation
This gentleman is likely to have a hypertensive cardiomyopathy with a left ventricle
hypertrophy.The LVH is secondary to increased afterload, as a result of chronic hypertension.
The AF, suggested by an irregularly irregular pulse is an indicator of diastolic dysfunction and
poor ventricular filling.This in turn the pulmonary congestion, as evidenced by the bibasal
crackles. There is no murmur or plop to suggest atrial myxoma.
14. A 58-year-old male presents with acute dyspnoea following a convulsion. On examination his
blood pressure was 240/120 mmHg and fundal examination reveals pailloedema with
haemorrhages and cotton wool spots. His urea, electrolytes and creatinine are normal but chest
X-ray reveals pulmonary oedema and cardiomegaly. Which one of the following is the most
appropriate immediate treatment?
(Please select an option)
atenolol 50 mg orally
intravenous labetalol
intravenous sodium nitroprusside
nifedipine 5 mg sublingually
nifedipine LA 30 mg orally
15. You wish to calculate a patients ejection fraction as the patient complains of dyspnoea.
Which of the following echocardiographic measures would be mandatory?
(Please select an option)
Aortic valve peak velocity

Pulse wave of mitral inflow

Left ventricular end diastolic diameter
M-mode of the mitral valve
M-mode of the aortic valve

Question: 7 of 20 / Overall score: 86%

11864

You wish to calculate a patients ejection fraction as the patient complains of dyspnoea. Which of
the following echocardiographic measures would be mandatory?
(Please select an option)
Aortic valve peak velocity
Pulse wave of mitral inflow
Left ventricular end diastolic diameter

This is the correct answer

M-mode of the mitral valve

M-mode of the aortic valve

Incorrect answer selected

One way of measuring ejection fraction is estimated by the ratio between the M-mode readings
of the left ventricular end diastolic diameter divided by the end systolic diameter.