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.
QUESTIONS (37–43) REFER TO THE FOLLOWING INFORMATION
Match the following blood pressure lowering agents to their mechanism of action.
1 Decreased renin secretion and decreased heart rate.
2 Decreased central synthesis of catecholamines.
