degradation of circulating natriuretic peptides.4 Relaxation of smooth muscle through opening KATP channels.
5 Blocking the angiotensin I binding site on angiotensin converting enzyme (ACE).
6 Interfering with Ca2+ release on the sarcoplasmic reticulum.
7 Increased guanylyl cyclase activity.
1 37. Minoxidil
2 38. Sacubitril
3 39. Moxonidine
4 40. Captopril
5 41. Glyceryl trinitrate
6 42. Nebivolol
7 43. Hydralazine.
QUESTIONS (44–51) REFER TO THE FOLLOWING INFORMATION
Match the clinical features listed below to the most likely type of congenital heart disease or clinical syndrome found in patients.
1 Atrial septal defect (ASD).
2 Ventricular septal defect (VSD).
3 Patent ductus arteriosus (PDA).
4 Coarctation of the aorta (CoA).
5 Eisenmenger's syndrome.
6 Marfan's syndrome.
7 Tetralogy of Fallot.
8 Transposition of the great arteries.
44. Cyanosis, clubbing, polycythaemia, an elevated JVP with a dominant a wave pattern, right ventricular heave, palpable pulmonary component of the second heart sound (P2), loud P2, fourth heart sound, pulmonary ejection click, and pulmonary regurgitation on auscultation.
45. Cyanosis, clubbing, polycythaemia, right ventricular heave, a thrill at the left sternal edge, a single second heart sound (A2) and short pulmonary ejection murmur on auscultation, a boot shape heart, right ventricular enlargement, and decreased vascularity of lung vessels on CXR.
46. A better developed upper body in comparison with the lower limbs, radiofemoral delay, and hypertension in the upper limbs only, midsystolic murmur over the precordium and back, hypertensive changes in the fundi, a small aortic knuckle and rib notching on CXR.
47. Fixed splitting of the second heart sound (S2), pulmonary systolic ejection murmur (increasing on inspiration), signs of pulmonary hypertension.
48. A thrill and a harsh pansystolic murmur to the left sternal edge, mitral regurgitation.
49. Arachnodactyly, joint hypermobility, long, thin limbs, a long and narrow face, lens dislocation, blue sclerae, a high‐arched palate, pectus excavatum, aortic regurgitation, mitral valve prolapse, kyphoscoliosis, and arm span exceeding overall height.
50. A continuous murmur along the left sternal border, ECG shows left ventricular hypertrophy, CXR shows increased pulmonary vasculature.
Answers
1. Answer: C
An aneurysm is an artery that has enlarged to greater than 1.5 times the expected diameter. In the infrarenal aorta, the threshold diameter is accepted as 3.0 cm. Abdominal aortic aneurysm (AAA) affects approximately 4–7% of men and 1–2% of women over the age of 65 years.
Medical therapy options remain limited and no aneurysm‐specific pharmacotherapy is currently available. Medical management of AAA generally involves cardiovascular risk reduction, including antiplatelet, statin, and antihypertensive therapy. The best medical management is generally not intended to limit expansion or reduce the size of the AAA. However, managing cardiovascular risk factors is crucial for improving the overall survival of patients and the outcomes of future AAA repair.
Australian national driving regulations stipulate that untreated atherosclerotic aortic aneurysms >5.5 cm disqualify patients from an unconditional driver's licence, except with the approval of a treating vascular surgeon.
Patients with large aneurysms (men >5.5 cm; women >5.0 cm) should be considered for elective aneurysm repair. The optimal management of small AAAs (4.0–5.5 cm) has been clarified by several large, randomised control trials which demonstrate no long‐term survival benefit with open or endovascular repair.
Most AAAs detected with screening or as an incidental finding are below the threshold for elective repair. The risk of AAA rupture increases with AAA diameter (Table 1.1). The surveillance interval for asymptomatic AAA also depends on AAA diameter (Table 1.2).
Table 1.1 Annual AAA rupture risk by diameter.
| AAA diameter (cm) | Rupture risk (%/year) |
| 3.0–3.9 | 0% |
| 4.0–4.9 | 1% |
| 5.0–5.9 | 1–10% |
| 6.0–6.9 | 10–22% |
| >7.0 | 30–50% |
Source: Based on Chuen J. Abdominal aortic aneurysm: An update AJGP 2018;47:252–56
Table 1.2 AAA surveillance intervals by diameter.
| AAA diameter (cm) | Surveillance interval (months) |
| 3.0–3.9 | 24 |
| 4.0–4.5 | 12 |
| 4.6–5.0 | 6 |
| >5.0 | 3 |
Chuen J. Abdominal aortic aneurysm: An update AJGP 2018;47:252–56.
https://www1.racgp.org.au/ajgp/2018/may/aaa‐an‐update/
2. Answer: B
The ECG shows Atrial Fibrillation (AF) with a rapid ventricular response. A fourth heart sound (S4) is a late diastolic sound due to a high pressure atrial wave reflected back from a poorly compliant ventricle.
