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Iraqi Board Cardiology study materials
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Iraqi Board Cardiology practice questions

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Question 1Basic sciences relevant to cardiology (anatomy, physiology, pharmacology, pathology, genetics)

During cannulation of the right internal jugular vein, which anatomic relationship best protects against inadvertent carotid artery puncture?

  1. The internal jugular vein lies anterior and medial to the carotid artery within the carotid sheath
  2. The internal jugular vein lies posterior to the sympathetic trunk in the neck
  3. The internal jugular vein lies deep to the prevertebral fascia at the level of C6
  4. The internal jugular vein lies lateral to the carotid artery within the carotid sheath Correct answer.

Explanation

Within the carotid sheath the internal jugular vein sits lateral (and slightly anterior) to the common carotid artery, so a needle directed too medially risks arterial puncture. The vein is superficial to the prevertebral fascia and anterior to the cervical sympathetic chain, not behind it. Recognizing this lateral relationship guides the standard approach to the vein.

Question 2Basic sciences relevant to cardiology (anatomy, physiology, pharmacology, pathology, genetics)

Occlusion of the left anterior descending artery proximal to the first septal perforator most directly compromises which structure?

  1. The papillary muscles of the right ventricle
  2. The sinoatrial node
  3. The anterior two-thirds of the interventricular septum Correct answer.
  4. The posterior third of the interventricular septum

Explanation

Septal perforators from the proximal LAD supply the anterior two-thirds of the interventricular septum, so proximal occlusion threatens the conduction system and septal function. The posterior third of the septum is supplied by the posterior descending artery. The SA node is usually supplied by the right coronary artery.

Question 3Basic sciences relevant to cardiology (anatomy, physiology, pharmacology, pathology, genetics)

A patient develops flushing, hypotension, and bronchospasm minutes after intravenous vancomycin. Which mediator most directly explains the bronchospasm and vasodilation?

  1. Histamine released from mast cells Correct answer.
  2. Leukotriene B4 released from neutrophils
  3. Prostacyclin released from endothelium
  4. Bradykinin generated by ACE inhibition

Explanation

Vancomycin can trigger non-IgE-mediated direct mast cell degranulation (a pseudoallergic reaction), releasing histamine, which causes vasodilation, flushing, and bronchospasm. Leukotriene B4 is a neutrophil chemoattractant rather than the principal driver of this acute reaction. Bradykinin relates to ACE inhibitor effects, not vancomycin infusion reactions.

Question 4Basic sciences relevant to cardiology (anatomy, physiology, pharmacology, pathology, genetics)

Which change in the cardiac action potential most directly prolongs the QT interval on the surface ECG?

  1. Increased phase 2 plateau duration from reduced net repolarizing current Correct answer.
  2. Faster phase 0 depolarization in Purkinje fibers
  3. More negative resting membrane potential in atrial myocytes
  4. Enhanced phase 4 automaticity in the SA node

Explanation

The QT interval reflects ventricular action potential duration, which is set largely by the phase 2 plateau. When net outward repolarizing current falls (for example with IKr blockade), the plateau lengthens and QT prolongs. Phase 0 velocity and phase 4 slope affect conduction and automaticity, not repolarization time.

Question 5Basic sciences relevant to cardiology (anatomy, physiology, pharmacology, pathology, genetics)

According to the Frank-Starling relationship, an acute increase in left ventricular end-diastolic volume within the physiologic range produces which immediate effect?

  1. Unchanged stroke volume because preload does not affect contractile force
  2. Reduced cardiac output because wall stress rises with dilation
  3. Decreased stroke volume due to reduced actin-myosin cross-bridge formation
  4. Increased stroke volume due to greater myofilament overlap and calcium sensitivity Correct answer.

Explanation

Within physiologic limits, greater end-diastolic volume stretches sarcomeres toward optimal overlap and increases myofilament calcium sensitivity, augmenting force and stroke volume. Excessive dilation beyond this range raises wall stress and can reduce efficiency, but that is not the immediate physiologic response. Preload clearly modulates contractile force.

Question 6Basic sciences relevant to cardiology (anatomy, physiology, pharmacology, pathology, genetics)

A 60-year-old man has a bicuspid aortic valve. Which associated vascular lesion should be specifically sought on imaging?

  1. Renal artery fibromuscular dysplasia
  2. Abdominal aortic coarctation
  3. Pulmonary artery aneurysm
  4. Ascending aortic dilatation Correct answer.

Explanation

Bicuspid aortic valve is associated with aortopathy, particularly dilatation of the ascending aorta, which can progress to dissection and requires surveillance. Coarctation is linked with bicuspid valves, but the classic vascular lesion to look for is ascending aortic dilatation. Renal dysplasia and pulmonary aneurysm are not the recognized association.

Question 7Basic sciences relevant to cardiology (anatomy, physiology, pharmacology, pathology, genetics)

A 72-year-old with atrial fibrillation and heart failure with reduced ejection fraction is started on digoxin. Which mechanism best explains its positive inotropic effect?

  1. Inhibition of phosphodiesterase-3 increasing cyclic AMP degradation
  2. Blockade of L-type calcium channels in the sarcolemma
  3. Direct activation of beta-1 adrenergic receptors on myocytes
  4. Inhibition of sarcolemmal Na+/K+-ATPase raising intracellular sodium and calcium Correct answer.

Explanation

Digoxin inhibits the Na+/K+-ATPase, so intracellular sodium rises and the Na+/Ca2+ exchanger extrudes less calcium, increasing intracellular calcium and contractility. Its vagotonic effect slows AV conduction. It does not act through beta receptors, calcium channel blockade, or phosphodiesterase inhibition.

Question 8Basic sciences relevant to cardiology (anatomy, physiology, pharmacology, pathology, genetics)

A 55-year-old man with hypertension and chronic kidney disease develops ST elevation after receiving a drug that blocks the angiotensin II type 1 receptor. Which mechanism most likely explains vasodilatation and improved hemodynamics with this agent?

  1. Blockade of alpha-1 receptors in arterioles
  2. Direct inhibition of renin release from juxtaglomerular cells
  3. Reduced aldosterone secretion and decreased sodium reabsorption Correct answer.
  4. Increased bradykinin degradation in the pulmonary circulation

Explanation

Angiotensin II type 1 receptor blockers prevent angiotensin II from stimulating aldosterone release and sodium reabsorption, lowering blood pressure and preload. They do not inhibit renin (renin rises reflexively) and do not affect bradykinin, which distinguishes them from ACE inhibitors. Alpha-1 blockade is a separate mechanism.

Question 9Basic sciences relevant to cardiology (anatomy, physiology, pharmacology, pathology, genetics)

A 45-year-old woman has recurrent syncope with a prolonged QT interval and a family history of sudden death. Which ion channel defect is most classically implicated in congenital long QT syndrome type 2?

  1. Loss-of-function mutation in the KCNH2 gene reducing IKr Correct answer.
  2. Gain-of-function mutation in SCN5A increasing late sodium current
  3. Loss-of-function mutation in the RyR2 ryanodine receptor
  4. Mutation in the LDL receptor gene

Explanation

Long QT syndrome type 2 results from loss-of-function variants in KCNH2, reducing the rapid delayed rectifier potassium current IKr and prolonging repolarization. Gain-of-function SCN5A variants cause long QT type 3. RyR2 mutations cause catecholaminergic polymorphic ventricular tachycardia.

Question 10Basic sciences relevant to cardiology (anatomy, physiology, pharmacology, pathology, genetics)

A 68-year-old with severe aortic stenosis undergoes valve replacement. Which histologic feature is most characteristic of the stenotic valve?

  1. Lipid accumulation with chronic inflammation and subsequent leaflet calcification Correct answer.
  2. Myxomatous degeneration with mucopolysaccharide pooling
  3. Acute fibrinous vegetations with bacterial colonies
  4. Active caseating granulomas with giant cells

Explanation

Calcific aortic stenosis begins with lipid deposition and chronic inflammation, followed by fibrotic thickening and nodular calcification on the aortic surface of the cusps. Caseating granulomas suggest tuberculosis, myxomatous change underlies prolapse, and infected vegetations indicate endocarditis.

Question 11Basic sciences relevant to cardiology (anatomy, physiology, pharmacology, pathology, genetics)

A 30-year-old man has a bicuspid aortic valve and an ascending aortic aneurysm. Which connective tissue protein abnormality is most often implicated in this aortopathy?

  1. Absence of type I collagen in the vessel wall
  2. Excess elastin cross-linking with stiffened media
  3. Loss of von Willebrand factor from the endothelium
  4. Deficiency of fibrillin-1 with disrupted elastic fiber architecture Correct answer.

Explanation

Bicuspid valve aortopathy shows reduced fibrillin-1 and disrupted elastic fibers with cystic medial degeneration, weakening the aortic wall. Type I collagen defects cause vascular Ehlers-Danlos syndrome, and excess cross-linking is not the mechanism. Von Willebrand factor relates to hemostasis, not wall strength.

Question 12Basic sciences relevant to cardiology (anatomy, physiology, pharmacology, pathology, genetics)

A patient receiving high-dose furosemide develops muscle weakness and a prolonged QT interval. Which electrolyte disturbance most directly explains these findings?

  1. Hypokalemia Correct answer.
  2. Hypernatremia
  3. Hyperchloremia
  4. Hyperkalemia

Explanation

Loop diuretics increase distal sodium delivery and potassium loss, producing hypokalemia that hyperpolarizes cells, causes muscle weakness, and delays repolarization, prolonging the QT interval. Hyperkalemia tends to cause peaked T waves rather than QT prolongation. Sodium and chloride shifts do not produce this pattern.

Question 13Basic sciences relevant to cardiology (anatomy, physiology, pharmacology, pathology, genetics)

A 58-year-old man is started on a drug that blocks the rapid delayed rectifier potassium current. Which ECG change should be monitored most carefully?

  1. Peaked T waves with a narrow QRS
  2. Shortened PR interval
  3. ST-segment elevation in contiguous leads
  4. Prolonged QT interval with risk of torsades de pointes Correct answer.

Explanation

Blocking IKr slows phase 3 repolarization, lengthening the QT interval and predisposing to early afterdepolarizations and torsades de pointes. PR shortening reflects enhanced AV conduction, not potassium channel blockade. ST elevation indicates ischemia.

Question 14Basic sciences relevant to cardiology (anatomy, physiology, pharmacology, pathology, genetics)

A 40-year-old woman has hypertrophic cardiomyopathy with a pathogenic sarcomere variant. Which functional consequence of the mutation best explains the diastolic dysfunction?

  1. Reduced myofilament calcium sensitivity with faster relaxation
  2. Increased myofilament calcium sensitivity with impaired relaxation Correct answer.
  3. Loss of troponin C causing complete absence of contraction
  4. Enhanced sarcoplasmic reticulum calcium reuptake with rapid relaxation

Explanation

Many hypertrophic cardiomyopathy sarcomere variants increase calcium sensitivity and reduce cross-bridge detachment kinetics, slowing relaxation and causing diastolic stiffening. Reduced calcium sensitivity or faster reuptake would enhance relaxation, not impair it. Complete loss of troponin C would abolish contraction and is not the mechanism.

Question 15Basic sciences relevant to cardiology (anatomy, physiology, pharmacology, pathology, genetics)

A 65-year-old man with chronic stable angina is prescribed a nitrate. Which mechanism underlies its antianginal effect?

  1. Inhibition of the funny current in the SA node
  2. Opening of L-type calcium channels in vascular smooth muscle
  3. Release of nitric oxide increasing cyclic GMP and causing venodilation Correct answer.
  4. Blockade of beta-1 receptors reducing heart rate

Explanation

Nitrates are converted to nitric oxide, which activates guanylate cyclase, raises cyclic GMP, and relaxes vascular smooth muscle, predominantly venodilation that lowers preload and myocardial oxygen demand. Beta blockade and funny current inhibition describe other antianginal classes. Opening calcium channels would cause vasoconstriction.

Question 16Basic sciences relevant to cardiology (anatomy, physiology, pharmacology, pathology, genetics)

A 70-year-old woman with a mechanical mitral valve requires anticoagulation. Which pharmacodynamic property best explains why warfarin is effective but requires bridging initially?

  1. It inhibits vitamin K epoxide reductase, reducing synthesis of functional factors II, VII, IX, and X Correct answer.
  2. It blocks platelet glycoprotein IIb/IIIa receptors
  3. It activates antithrombin III to inactivate factor Xa
  4. It directly inhibits thrombin in the circulation

Explanation

Warfarin inhibits vitamin K epoxide reductase, decreasing gamma-carboxylation of factors II, VII, IX, and X, but existing factors must decay before full effect, so bridging is needed. Direct thrombin inhibition, antithrombin activation, and glycoprotein IIb/IIIa blockade describe other anticoagulants or antiplatelets.

Question 17Basic sciences relevant to cardiology (anatomy, physiology, pharmacology, pathology, genetics)

A newborn has cyanosis and echocardiography shows transposition of the great arteries. Which embryologic process most directly explains this defect?

  1. Failure of the aorticopulmonary septum to spiral Correct answer.
  2. Premature closure of the foramen ovale
  3. Failure of the endocardial cushions to fuse
  4. Failure of the sinus venosus to incorporate into the right atrium

Explanation

Transposition results when the aorticopulmonary septum fails to spiral, so the aorta arises from the right ventricle and the pulmonary artery from the left. Endocardial cushion failure produces septal and atrioventricular valve defects. Foramen ovale closure and sinus venosus incorporation are unrelated to great artery alignment.

Question 18Basic sciences relevant to cardiology (anatomy, physiology, pharmacology, pathology, genetics)

A 25-year-old man has Marfan syndrome with aortic root dilatation. Which molecular abnormality most directly weakens the aortic media?

  1. Reduced type III collagen synthesis
  2. Deficiency of alpha-galactosidase A with glycosphingolipid accumulation
  3. Defective fibrillin-1 microfibrils with increased TGF-beta signaling Correct answer.
  4. Absent dystrophin in vascular smooth muscle

Explanation

Marfan syndrome results from FBN1 mutations causing defective fibrillin-1 microfibrils; these normally sequester TGF-beta, so excess TGF-beta signaling drives cystic medial degeneration and root dilatation. Alpha-galactosidase A deficiency causes Fabry disease. Dystrophin relates to muscle, and type III collagen defects cause vascular Ehlers-Danlos syndrome.

Question 19Basic sciences relevant to cardiology (anatomy, physiology, pharmacology, pathology, genetics)

A 50-year-old man with a failing heart has elevated plasma norepinephrine. Which receptor-mediated change most directly contributes to adverse remodeling and arrhythmia risk?

  1. Beta-2 receptor stimulation causing bronchodilation
  2. Alpha-2 receptor stimulation reducing presynaptic norepinephrine release
  3. Beta-1 receptor stimulation increasing cyclic AMP and calcium loading Correct answer.
  4. Muscarinic M2 receptor activation reducing heart rate

Explanation

Chronic beta-1 stimulation raises cyclic AMP and intracellular calcium, increasing oxygen demand, promoting myocyte apoptosis, and enhancing arrhythmogenicity, which drives adverse remodeling. Presynaptic alpha-2 and muscarinic effects are counter-regulatory, and beta-2 bronchodilation does not explain cardiac remodeling.

Question 20Basic sciences relevant to cardiology (anatomy, physiology, pharmacology, pathology, genetics)

A 35-year-old woman has a cardiac arrest during exercise and is found to have a mutation causing excessive sarcoplasmic reticulum calcium leak. Which channelopathy is most consistent with this presentation?

  1. Short QT syndrome from gain of function in potassium channels
  2. Congenital long QT syndrome type 1 from KCNQ1 mutation
  3. Brugada syndrome from SCN5A loss of function
  4. Catecholaminergic polymorphic ventricular tachycardia from RyR2 mutation Correct answer.

Explanation

RyR2 gain-of-function causes diastolic calcium leak from the sarcoplasmic reticulum, triggering delayed afterdepolarizations and bidirectional or polymorphic ventricular tachycardia during adrenergic stress. Long QT type 1 and Brugada syndrome involve repolarization or depolarization abnormalities rather than calcium leak. Short QT syndrome shortens repolarization.

Question 21History, physical examination and clinical reasoning in cardiovascular disease

A 58-year-old man with a 40-pack-year smoking history reports calf discomfort that reliably appears after walking two blocks and resolves within minutes of standing still. Which historical feature most strongly supports a vascular rather than neurogenic cause of his leg symptoms?

  1. A burning quality of discomfort that radiates to the buttock
  2. Reproducible walking distance before symptom onset that is relieved by stopping Correct answer.
  3. Presence of lumbar spine tenderness on examination
  4. Symptoms that are worse in the evening after prolonged standing

Explanation

Intermittent claudication is defined by a reproducible, distance-dependent cramping discomfort relieved promptly by rest, which reflects exercise-induced limb ischaemia. Neurogenic claudication is typically posture-dependent, worsened by standing or extension and relieved by sitting or flexion, and lacks a fixed walking distance. Smoking history further raises the pretest probability of peripheral arterial disease and coexisting coronary disease.

Question 22History, physical examination and clinical reasoning in cardiovascular disease

Which physical sign is most characteristic of severe aortic stenosis on palpation of the precordium?

  1. A sustained, heaving apical impulse displaced laterally
  2. A diastolic shock felt at the apex
  3. A parasternal heave with a normal apical impulse
  4. A palpable systolic thrill at the upper right sternal edge Correct answer.

Explanation

Severe aortic stenosis generates a harsh ejection systolic murmur with a slow-rising carotid pulse, and when the gradient is large a systolic thrill is palpable in the aortic area at the upper right sternal edge. The left ventricle is pressure-loaded and concentrically hypertrophied, so the apex usually remains undisplayed until decompensation. A parasternal heave and displaced apex suggest different lesions such as right ventricular hypertrophy or volume overload.

Question 23History, physical examination and clinical reasoning in cardiovascular disease

A 34-year-old woman presents with pleuritic chest pain, and a friction rub is heard best at the left sternal edge, louder on inspiration and with the patient leaning forward. Which diagnosis do these findings most directly support?

  1. Acute pericarditis Correct answer.
  2. Pulmonary embolism without infarction
  3. Mitral valve prolapse
  4. Aortic dissection

Explanation

A superficial, scratching, inspiratory-varying friction rub that is accentuated by leaning forward is the classic sign of acute pericarditis. The rub is produced by inflamed pericardial surfaces moving against each other and may be transient or evanescent. Pleuritic pain alone is nonspecific, so the rub is the discriminating finding.

Question 24History, physical examination and clinical reasoning in cardiovascular disease

Which component of the jugular venous waveform is normally absent in a patient with atrial fibrillation, and why?

  1. The x descent, because of pericardial constraint
  2. The a wave, because of loss of effective atrial contraction Correct answer.
  3. The c wave, because of tricuspid regurgitation
  4. The v wave, because of reduced venous return

Explanation

The a wave reflects atrial contraction against a closed tricuspid valve, so it disappears when organised atrial systole is lost, as in atrial fibrillation. The v wave reflects venous filling against a closed tricuspid valve and is preserved or even prominent. The c wave relates to carotid transmission and tricuspid bulging, and the x descent to atrial relaxation.

Question 25History, physical examination and clinical reasoning in cardiovascular disease

A 62-year-old man with known heart failure has a blood pressure of 88/60 mmHg, cool mottled extremities, and a lactate of 4.2 mmol/L. Which bedside finding best indicates that his cardiac output is critically reduced rather than that his blood pressure is merely low?

  1. A loud third heart sound with a tachycardic rhythm
  2. Bibasal crepitations with a raised jugular venous pressure
  3. Bilateral ankle oedema with elevated jugular venous pressure
  4. Narrow pulse pressure with cool peripheries and prolonged capillary refill Correct answer.

Explanation

Cool peripheries, prolonged capillary refill, and a narrow pulse pressure indicate high systemic vascular resistance and low stroke volume, so hypoperfusion is present despite the measured pressure. Congestion signs such as crepitations, raised venous pressure, and oedema describe filling pressures, not adequacy of forward flow. A third heart sound supports a volume-loaded ventricle but does not by itself prove low output.

Question 26History, physical examination and clinical reasoning in cardiovascular disease

A 70-year-old woman with a history of hypertension and diabetes develops sudden, painless loss of vision in the right eye lasting about 15 minutes, with complete recovery. Which feature of the history is most important to establish the likely embolic source?

  1. Whether she has had similar transient episodes in the same eye Correct answer.
  2. Whether she wears corrective lenses
  3. Whether she has seasonal allergies
  4. Whether she has a family history of glaucoma

Explanation

Amaurosis fugax is a transient monocular visual loss caused by retinal ischaemia, usually from emboli arising from the internal carotid artery or heart. Recurrent stereotyped episodes in the same eye strengthen the diagnosis and prompt urgent carotid and cardiac evaluation. Family history of glaucoma, refractive correction, and allergy do not address the embolic mechanism.

Question 27History, physical examination and clinical reasoning in cardiovascular disease

A patient with a dilated cardiomyopathy has a soft pansystolic murmur at the apex that radiates to the axilla and is unchanged by respiration. Which bedside manoeuvre best distinguishes this from tricuspid regurgitation?

  1. Listening with the bell over the left axilla
  2. Asking the patient to perform a sustained handgrip
  3. Observing the effect of inspiration on murmur intensity Correct answer.
  4. Auscultating during the Valsalva strain phase

Explanation

Right-sided murmurs, including tricuspid regurgitation, characteristically increase with inspiration because venous return to the right heart rises, whereas left-sided murmurs such as mitral regurgitation change little or decrease. Handgrip increases afterload and would augment both mitral and aortic regurgitation, so it is less discriminating. The Valsalva strain reduces venous return and diminishes most murmurs.

Question 28History, physical examination and clinical reasoning in cardiovascular disease

A 45-year-old man is found to have a blood pressure of 168/104 mmHg in both arms on three separate visits, with no symptoms. Which element of the clinical assessment is most useful for detecting a secondary cause before starting treatment?

  1. Auscultating the lungs for basal crackles
  2. Measuring the respiratory rate at rest
  3. Checking for radiofemoral delay and comparing arm pressures Correct answer.
  4. Palpating the thyroid gland for tenderness

Explanation

Radiofemoral delay and interarm pressure differences screen for coarctation and subclavian stenosis, which are treatable causes of secondary hypertension with characteristic bedside signs. Basal crackles, respiratory rate, and thyroid tenderness do not systematically identify secondary hypertension, though thyroid disease is a recognised endocrine cause. A structured search for secondary causes also includes renal bruits and cushingoid features.

Question 29History, physical examination and clinical reasoning in cardiovascular disease

A 28-year-old woman reports exertional breathlessness and presyncope. On examination the jugular venous pressure is raised with a prominent a wave, and there is a loud P2 with a parasternal heave. Which pathophysiological mechanism best explains these findings?

  1. Right ventricular pressure overload from elevated pulmonary vascular resistance Correct answer.
  2. Left ventricular volume overload from aortic regurgitation
  3. Tricuspid stenosis with a low right atrial pressure
  4. Constrictive pericarditis with equalised diastolic pressures

Explanation

A prominent a wave means the right atrium is contracting against a stiff, high-pressure right ventricle, and a parasternal heave with loud P2 indicates right ventricular hypertrophy and pulmonary hypertension. Together these point to right ventricular pressure overload, as in pulmonary arterial hypertension. Aortic regurgitation causes left ventricular volume overload without these right-sided signs.

Question 30History, physical examination and clinical reasoning in cardiovascular disease

A 66-year-old man with known coronary disease describes chest tightness that occurs at rest in the early morning and lasts 10 to 15 minutes. Which historical detail is most important for distinguishing unstable angina from stable exertional angina?

  1. The patient has a known history of hypertension
  2. The symptoms occur at rest without a change in physical activity Correct answer.
  3. The discomfort radiates to the left shoulder
  4. The discomfort is described as tightness rather than burning

Explanation

Unstable angina is defined by ischaemic symptoms that are new, occur at rest, or are accelerating in frequency or severity, so rest pain without exertion is the key discriminator. Quality, radiation, and risk factors are supportive but do not separate stable from unstable syndromes. Rest pain lasting more than 20 minutes should also raise concern for infarction.

Question 31History, physical examination and clinical reasoning in cardiovascular disease

A 72-year-old woman with long-standing rheumatic disease has a low-pitched diastolic rumble at the apex preceded by an opening snap. Which additional physical finding is most consistent with severe mitral stenosis?

  1. A loud first heart sound with an accentuated P2 Correct answer.
  2. A systolic click followed by a late systolic murmur
  3. A fixed split second heart sound
  4. A collapsing pulse with a wide pulse pressure

Explanation

In mitral stenosis the valve leaflets are thickened but still mobile early in the disease, so the first heart sound is loud, and pulmonary hypertension from chronic left atrial pressure elevation accentuates P2. The opening snap follows S2 and becomes closer to S2 as stenosis worsens. A collapsing pulse and fixed split belong to other lesions.

Question 32History, physical examination and clinical reasoning in cardiovascular disease

A 55-year-old man with a history of poorly controlled hypertension presents with sudden severe interscapular pain. Blood pressure is 190/100 mmHg in the right arm and 150/90 mmHg in the left arm, and the left radial pulse is diminished. Which finding most strongly supports the diagnosis?

  1. Bilateral basal crepitations on auscultation
  2. A holosystolic murmur at the apex radiating to the axilla
  3. A raised jugular venous pressure with a prominent v wave
  4. A new diastolic murmur of aortic regurgitation with pulse asymmetry Correct answer.

Explanation

Acute aortic dissection typically produces abrupt tearing pain with interarm blood pressure and pulse differences, and proximal extension can cause aortic regurgitation. The combination of pulse asymmetry and a new diastolic murmur is highly suggestive. Basal crackles, a large v wave, and an apical systolic murmur are nonspecific or indicate other lesions.

Question 33History, physical examination and clinical reasoning in cardiovascular disease

A 60-year-old man with atrial fibrillation has a blood pressure of 120/70 mmHg with a clearly visible systolic peak and a low diastolic trough on the monitor. Which physical finding would best confirm that this appearance is a true arterial waveform rather than artefact?

  1. A palpable radial pulse with a slow, irregular rate Correct answer.
  2. A systolic murmur at the left sternal edge
  3. A raised jugular venous pressure
  4. A third heart sound at the apex

Explanation

Confirming the arterial waveform requires palpating a peripheral pulse that matches the timing and rate on the monitor, which in atrial fibrillation is irregularly irregular. A slow, irregular pulse with a visible systolic peak supports a genuine pressure waveform. Murmurs, venous pressure, and extra heart sounds do not validate the arterial trace.

Question 34History, physical examination and clinical reasoning in cardiovascular disease

A 38-year-old man has a blood pressure of 150/95 mmHg in the clinic but normal readings at home. Which historical feature most strongly suggests white-coat effect rather than sustained hypertension?

  1. Occasional migraine headaches
  2. Repeatedly normal home and ambulatory readings outside the clinic Correct answer.
  3. A body mass index of 32 kg/m2
  4. A family history of hypertension in both parents

Explanation

White-coat hypertension is defined by elevated clinic readings with normal out-of-office measurements, so repeated normal home or ambulatory readings are the defining feature. Family history, obesity, and migraine raise the probability of true hypertension but do not establish the white-coat pattern. Ambulatory monitoring is the reference standard for confirming it.

Question 35History, physical examination and clinical reasoning in cardiovascular disease

A 24-year-old athlete is found to have a grade 2/6 soft midsystolic murmur at the left sternal edge that decreases with squatting and disappears with the Valsalva manoeuvre. Which statement best explains these findings?

  1. They indicate hypertrophic cardiomyopathy with dynamic obstruction
  2. They indicate a ventricular septal defect
  3. They are typical of a benign flow murmur and require no further investigation Correct answer.
  4. They indicate aortic stenosis with a fixed obstruction

Explanation

A soft, short midsystolic murmur in a young asymptomatic person that diminishes with manoeuvres reducing preload is characteristic of a physiological flow murmur. Hypertrophic cardiomyopathy also decreases with Valsalva but is typically louder, harsher, and associated with other features. Ventricular septal defect and aortic stenosis produce different murmur characteristics and responses.

Question 36History, physical examination and clinical reasoning in cardiovascular disease

A 68-year-old man with a history of myocardial infarction has a blood pressure of 105/85 mmHg, distended neck veins, and clear lungs. Which finding best supports cardiac tamponade over left ventricular failure as the cause of his shock?

  1. Pulsus paradoxus with a prominent x descent and absent y descent Correct answer.
  2. A displaced apical impulse with a pansystolic murmur
  3. A raised jugular venous pressure that falls with inspiration
  4. Bibasal crackles with a third heart sound

Explanation

Tamponade raises intrapericardial pressure, so diastolic filling is impaired and the y descent is blunted or absent while the x descent persists, and pulsus paradoxus is common. Clear lungs with distended veins also favour tamponade over pulmonary oedema. A falling venous pressure with inspiration (Kussmaul sign) is more typical of constriction.

Question 37History, physical examination and clinical reasoning in cardiovascular disease

A 30-year-old woman has a mid-diastolic rumble with presystolic accentuation at the apex, a loud first heart sound, and an opening snap. Which combination of findings would most suggest that the stenosis is severe rather than mild?

  1. A third heart sound with a mid-diastolic flow murmur
  2. A short interval between the second heart sound and the opening snap Correct answer.
  3. A soft first heart sound with a normal opening snap interval
  4. A wide, fixed split of the second heart sound

Explanation

As mitral stenosis worsens, left atrial pressure rises and the opening snap occurs earlier, shortening the S2-opening snap interval. A short interval therefore supports severe stenosis, whereas a longer interval suggests milder disease. A soft first heart sound, third heart sound, and fixed split are features of other conditions.

Question 38History, physical examination and clinical reasoning in cardiovascular disease

A 58-year-old man with cirrhosis and ascites has a systolic murmur that increases with inspiration and a pulsatile liver. Which mechanism best explains the murmur?

  1. Aortic stenosis from calcific degeneration
  2. Tricuspid regurgitation from right ventricular dilatation Correct answer.
  3. Pulmonary stenosis from right ventricular outflow obstruction
  4. Mitral regurgitation from left atrial enlargement

Explanation

A systolic murmur that increases with inspiration is right-sided, and a pulsatile liver indicates transmission of right ventricular systolic pressure into the hepatic veins, which occurs in tricuspid regurgitation. Right ventricular dilatation from volume or pressure overload is a common cause. Mitral, aortic, and pulmonary stenosis murmurs do not explain a pulsatile liver.

Question 39History, physical examination and clinical reasoning in cardiovascular disease

A 40-year-old man has a blood pressure of 160/100 mmHg, episodic palpitations, and sweating. Which finding during an attack would most strongly suggest a phaeochromocytoma rather than an anxiety disorder?

  1. A paroxysmal rise in blood pressure accompanied by pallor and tremor Correct answer.
  2. A gradual rise in blood pressure during the whole clinic visit
  3. A blood pressure that falls on standing
  4. A normal heart rate with a resting tremor

Explanation

Phaeochromocytoma classically produces paroxysmal catecholamine surges with abrupt hypertension, pallor, palpitations, sweating, and tremor, often with headache. Anxiety produces sustained rather than paroxysmal pressure elevation and lacks the abrupt surge pattern. Orthostatic hypotension can occur with volume depletion but is not the discriminating feature.

Question 40History, physical examination and clinical reasoning in cardiovascular disease

A 50-year-old woman has a blood pressure of 150/90 mmHg with a radial pulse that is weak and delayed compared with the femoral pulse. Which additional finding would most support coarctation of the aorta?

  1. A loud first heart sound with an opening snap
  2. A fixed split of the second heart sound
  3. A diastolic murmur at the left sternal edge
  4. A continuous murmur over the interscapular region with rib notching on imaging Correct answer.

Explanation

Coarctation causes upper limb hypertension with radiofemoral delay, and collateral flow through intercostal arteries produces continuous murmurs and rib notching on chest imaging. A diastolic murmur, opening snap, and fixed split belong to other valvular or congenital lesions. The combination of pulse delay and collateral signs is diagnostic.

Question 41Ischaemic heart disease and acute coronary syndromes

A 58-year-old man with diabetes presents 4 hours after the onset of crushing central chest pain. His ECG shows 3 mm ST elevation in leads V2–V4. Which reperfusion strategy is most appropriate if primary PCI can be delivered within 90 minutes?

  1. Primary percutaneous coronary intervention Correct answer.
  2. Intravenous thrombolysis with streptokinase
  3. Elective coronary angiography in one week
  4. Conservative management with aspirin alone

Explanation

Primary PCI is the reperfusion strategy of choice for STEMI when it can be performed promptly by an experienced team, ideally within 90 minutes of first medical contact. It achieves higher rates of infarct-related artery patency and lower rates of reinfarction and intracranial haemorrhage than fibrinolysis. Fibrinolysis is reserved for cases where timely PCI is unavailable and symptom onset is within 12 hours.

Question 42Ischaemic heart disease and acute coronary syndromes

Which cardiac troponin finding best defines acute myocardial infarction in a patient with ischaemic symptoms?

  1. A rise and/or fall of values with at least one above the 99th percentile upper reference limit Correct answer.
  2. A value that doubles after 24 hours only
  3. A single value above the upper reference limit
  4. Any detectable troponin level measured by any assay

Explanation

The universal definition of myocardial infarction requires detection of a rise and/or fall of cardiac troponin with at least one value above the 99th percentile upper reference limit, together with evidence of ischaemia. A single elevated value cannot distinguish acute from chronic myocardial injury. The dynamic change is what establishes acuity.

Question 43Ischaemic heart disease and acute coronary syndromes

A patient with NSTEMI is being risk-stratified. Which score is most widely used to estimate in-hospital mortality and guide an early invasive strategy?

  1. Wells score
  2. MELD score
  3. GRACE score Correct answer.
  4. CHA2DS2-VASc score

Explanation

The GRACE risk score incorporates age, heart rate, systolic blood pressure, creatinine, Killip class, cardiac arrest at admission, ST deviation and elevated cardiac markers to predict in-hospital and six-month mortality in acute coronary syndromes. Higher scores identify patients who benefit most from an early invasive approach. The other scores assess stroke risk in atrial fibrillation, pretest probability of pulmonary embolism, and liver disease severity respectively.

Question 44Ischaemic heart disease and acute coronary syndromes

Which ECG finding is most consistent with an acute transmural inferior myocardial infarction?

  1. ST elevation in leads II, III and aVF Correct answer.
  2. Tall peaked T waves in leads V4–V6
  3. ST elevation in leads V1–V3
  4. ST depression in leads II, III and aVF

Explanation

Leads II, III and aVF are the inferior leads, so ST elevation in this territory indicates an inferior wall injury current, typically from right coronary artery occlusion. Reciprocal ST depression may appear in aVL and I. Anterior precordial leads reflect the anterior wall, and ST depression in inferior leads more typically represents reciprocal change from a high lateral or anterior event.

Question 45Ischaemic heart disease and acute coronary syndromes

A 62-year-old smoker with hypertension reports chest tightness that occurs predictably after climbing two flights of stairs and resolves within minutes at rest. Which diagnosis is most likely?

  1. Stable angina pectoris Correct answer.
  2. Pulmonary embolism
  3. Aortic dissection
  4. Acute pericarditis

Explanation

Predictable exertional chest discomfort relieved by rest, in a patient with atherosclerotic risk factors, is the classic presentation of stable angina caused by flow-limiting coronary stenosis. The reproducible threshold and rapid relief with rest distinguish it from acute coronary syndromes. Pericarditis, pulmonary embolism and dissection produce different patterns and associated features.

Question 46Ischaemic heart disease and acute coronary syndromes

Which medication has been shown to reduce cardiovascular events in patients with stable coronary artery disease by inhibiting platelet cyclo-oxygenase-1?

  1. Warfarin
  2. Verapamil
  3. Isosorbide mononitrate
  4. Aspirin Correct answer.

Explanation

Aspirin irreversibly acetylates platelet cyclo-oxygenase-1, blocking thromboxane A2 synthesis and platelet aggregation, and is the cornerstone of secondary prevention in coronary artery disease. Warfarin is an anticoagulant used for specific indications such as atrial fibrillation, while verapamil and nitrates relieve symptoms without proven antiplatelet benefit.

Question 47Ischaemic heart disease and acute coronary syndromes

Which biomarker elevation pattern is most characteristic of acute myocardial infarction rather than chronic myocardial injury?

  1. Elevated troponin with normal serial values
  2. Stable mildly elevated troponin on repeated sampling
  3. A clear rise and fall in serial troponin measurements Correct answer.
  4. A single borderline value at presentation

Explanation

Acute myocardial infarction is distinguished from chronic myocardial injury by a dynamic rise and/or fall in troponin on serial testing, reflecting acute myocyte necrosis. Stable or unchanging elevations suggest chronic injury such as from renal impairment or heart failure. Serial sampling is therefore essential to interpretation.

Question 48Ischaemic heart disease and acute coronary syndromes

A 70-year-old woman with an NSTEMI has ongoing chest pain, dynamic ST depression and elevated troponin. According to current practice, which management strategy is preferred?

  1. Early invasive coronary angiography and revascularisation Correct answer.
  2. Long-term bed rest without catheterisation
  3. Fibrinolytic therapy within 30 minutes
  4. Discharge with outpatient stress testing

Explanation

High-risk NSTEMI features such as refractory pain, dynamic ST changes and positive biomarkers warrant an early invasive strategy with coronary angiography and revascularisation where appropriate. Fibrinolysis is not indicated in NSTE-ACS and may cause harm. Outpatient testing or prolonged bed rest would delay necessary intervention in a high-risk patient.

Question 49Ischaemic heart disease and acute coronary syndromes

A patient develops STEMI and receives streptokinase. Which finding is the most reliable non-invasive marker of successful reperfusion?

  1. Resolution of ST segment elevation on ECG Correct answer.
  2. New bundle branch block
  3. Persistent Q waves on ECG
  4. Continued chest pain

Explanation

Resolution of ST elevation, along with relief of pain and reperfusion arrhythmias, indicates restored epicardial flow after fibrinolysis. Persistent ST elevation or ongoing pain suggests failed reperfusion and prompts consideration of rescue PCI. Q waves and bundle branch block reflect myocardial damage rather than reperfusion success.

Question 50Ischaemic heart disease and acute coronary syndromes

Which finding on physical examination most strongly suggests cardiogenic shock complicating acute myocardial infarction?

  1. Pericardial friction rub
  2. Systolic blood pressure below 90 mmHg with cool clammy peripheries and raised jugular venous pressure Correct answer.
  3. Systolic murmur at the apex
  4. Bilateral basal crackles with normal blood pressure

Explanation

Cardiogenic shock is defined by sustained hypotension with evidence of hypoperfusion such as cool peripheries, oliguria and altered mentation, often with elevated filling pressures. A systolic pressure below 90 mmHg with poor perfusion after infarction suggests extensive left ventricular dysfunction or a mechanical complication. Crackles alone or murmurs indicate other problems.