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My Masterclass exam #58292

My Masterclass Q1.
Your exam progress
My history A 68-year-old man presented with breathlessness. On examination he had an early 0/30
diastolic murmur at the left sternal edge. Which of the following features would 0.0%
My details suggest that his aortic incompetence is clinically significant?

Create exam A Austin-Flint murmur

Website extension offer B Displaced apex beat

PACES screencasts C Graham-Steele murmur

D Long diastolic murmur

E Narrow pulse pressure

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My history A 68-year-old man presented with breathlessness. On examination he had an early 58.5%
diastolic murmur at the left sternal edge. Which of the following features would of users
My details suggest that his aortic incompetence is clinically significant? answered
this
Create exam A Austin-Flint murmur
correctly

Website extension offer B Displaced apex beat


Your exam progress
PACES screencasts   C Graham-Steele murmur 1/30
3.3%
  D Long diastolic murmur

  E Narrow pulse pressure

Answer comments

Severe aortic incompetence is suggested by the presence of one or more of the


following clinical features:

1.Short early diastolic murmur (diastolic pressure in the left ventricle rapidly
approaches that in the aorta)
2.Wide pulse-pressure
3.Displaced, hyperdynamic apex beat - implying significant volume overload.

An Austin-Flint murmur may be heard in aortic incompetence (fluttering of the


anterior mitral valve leaflet due to turbulance from the regurgitant jet), but it is not
an indication of severity.

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My Masterclass exam #58292

My Masterclass Q2.
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My history A 67 yr old man was admitted with tearing interscapular pain. Whilst in the 1/30
Emergency Department he also developed significant abdominal discomfort. Aortic 3.3%
My details dissection was suspected and a CT with contrast of his chest and abdomen was
performed. The radiologist reported the presence of a type B (distal) aortic dissection
Create exam causing mesenteric and left renal ischaemia.

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What is the best immediate course of action?

PACES screencasts A Start IV low (renal) dose dopamine

B Start IV sodium nitroprusside

C Start unfractionated IV heparin

D Refer immediately to cardiothoracic surgical service

E Refer immediately to renal service


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My Masterclass Q2.
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My history A 67 yr old man was admitted with tearing interscapular pain. Whilst in the 59.6%
Emergency Department he also developed significant abdominal discomfort. Aortic of users
My details dissection was suspected and a CT with contrast of his chest and abdomen was answered
performed. The radiologist reported the presence of a type B (distal) aortic dissection this
Create exam causing mesenteric and left renal ischaemia. correctly

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What is the best immediate course of action? Your exam progress
PACES screencasts   A Start IV low (renal) dose dopamine 2/30
6.7%
  B Start IV sodium nitroprusside

  C Start unfractionated IV heparin

D Refer immediately to cardiothoracic surgical service

  E Refer immediately to renal service


Answer comments

Type A (proximal) dissections are managed surgically. Type B (distal) dissections are
managed medically, excepting when they cause ischaemia of limbs or organs, or
threaten to rupture, when surgery is recommended. Some patients not suitable for
surgery can be treated with percutaneous stenting.

Medical management of Type B dissection aims to decrease systolic pressure below


120mmHg with IV labetalol, or the combination of IV beta-blockade with IV
nitroprusside, but blood pressure should not be reduced so low as to compromise end
organ perfusion.

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My Masterclass Q3.
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My history A 56 year old Caucasian man presented with 1 year of shortness of breath and 3/30
fatigue on minimal exertion. He had previously undergone coronary artery bypass 10.0%
My details grafting 8 years ago following a myocardial infarction. He was currently taking
aspirin, bisoprolol, ramipril, furosemide and simvastatin. On examination his pulse
Create exam was 80/min (regular), BP 110/76 mmHg, JVP elevated 4cm, and there was a soft
mitral regurgitant murmur, a few basal crackles, and a trace of ankle oedema. His
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ECG showed sinus rhythm, with left bundle branch block. An echocardiogram
revealed severe left ventricular dysfunction and moderate secondary mitral
PACES screencasts
regurgitation.

What is the most appropriate treatment?

  A Biventricular pacemaker implantation

  B Digoxin

  C Hydralazine and Isosorbide Dinitrate

  D Mitral valve surgery

E Spironolactone

Answer comments

Spironolactone is recommended by NICE as second line treatment for heart failure.


Hydralazine/Nitrate is also supported, but would only be preferred in Afro-Caribbean
patients. Digoxin is only recommended as third line therapy, and biventricular pacing
should only be considered after optimization of medical therapy.

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My history A 35 year-old man with palpitations presented to the Emergency Department at 3/30
10.00h. He described a clear onset of palpitations upon waking at 09.00h on the 10.0%
My details previous morning (25 hours previously). He had no significant past medical history.
Cardiovascular examination revealed an irregularly, irregular pulse (140-150/min,
Create exam and BP 120/80 mmHg. There were no signs of cardiac failure. His ECG showed AF
with a ventricular rate of 160/min.
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What is the most appropriate treatment?


PACES screencasts
A IV amiodarone

B IV beta-blocker

C IV flecainide

D Low molecular weight heparin

E Oral amiodarone

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My history A 35 year-old man with palpitations presented to the Emergency Department at 61.9%
10.00h. He described a clear onset of palpitations upon waking at 09.00h on the of users
My details previous morning (25 hours previously). He had no significant past medical history. answered
Cardiovascular examination revealed an irregularly, irregular pulse (140-150/min, this
Create exam and BP 120/80 mmHg. There were no signs of cardiac failure. His ECG showed AF correctly
with a ventricular rate of 160/min.
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Your exam progress
What is the most appropriate treatment?
PACES screencasts 4/30
  A IV amiodarone 13.3%

B IV beta-blocker

C IV flecainide

  D Low molecular weight heparin

  E Oral amiodarone

Answer comments

As the onset of symptoms is under 48 hours, ESC guidelines suggest he should be


cardioverted. As he has no contraindication, this should be attempted with IV
flecainide, with DC cardioversion reserved for non-responders.

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My Masterclass exam #58292

My Masterclass Q5.
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My history A 26 yr old woman presented with 24 hours of pleuritic chest pain. There was no 4/30
obvious precipitant, and she had no other respiratory features. Examination of her 13.3%
My details cardiovascular and respiratory systems, and of her legs, was normal. The serum D-
dimer was marginally elevated. A chest radiograph was normal. She was given an
Create exam injection of a treatment dose of low molecular weight heparin and admitted
overnight.
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The next morning a lung V/Q scan was reported as normal. Further history was taken
PACES screencasts
from the patient who said she felt generally a bit under the weather, also that she
had had a rash on her cheeks during the last summer, but this had now gone.

What would be the most appropriate investigation to do next?

A CT pulmonary angiogram

A CT pulmonary angiogram

B Serum antinuclear antibodies

B Serum anti-neutrophil cytoplasmic antibodies

C Serum anti-neutrophil cytoplasmic antibodies

C Serum antinuclear antibodies

D Thrombophilia screen

D Thrombophilia screen

E Ultrasound / Doppler of leg veins (left and right)

E Ultrasound / Doppler of leg veins (left and right)

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My Masterclass Q5.
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My history A 26 yr old woman presented with 24 hours of pleuritic chest pain. There was no 54.9%
obvious precipitant, and she had no other respiratory features. Examination of her of users
My details cardiovascular and respiratory systems, and of her legs, was normal. The serum D- answered
dimer was marginally elevated. A chest radiograph was normal. She was given an this
Create exam injection of a treatment dose of low molecular weight heparin and admitted correctly
overnight.
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Your exam progress
The next morning a lung V/Q scan was reported as normal. Further history was taken
PACES screencasts 5/30
from the patient who said she felt generally a bit under the weather, also that she
16.7%
had had a rash on her cheeks during the last summer, but this had now gone.

What would be the most appropriate investigation to do next?

  A CT pulmonary angiogram

  A CT pulmonary angiogram

B Serum antinuclear antibodies

  B Serum anti-neutrophil cytoplasmic antibodies

  C Serum anti-neutrophil cytoplasmic antibodies

C Serum antinuclear antibodies

  D Thrombophilia screen

  D Thrombophilia screen

  E Ultrasound / Doppler of leg veins (left and right)

  E Ultrasound / Doppler of leg veins (left and right)

Answer comments

The likely diagnosis is systemic lupus erythematosus, manifesting with a


photosensitive skin rash and pleurisy. Testing for serum antinuclear antibodies would
be the appropriate screening test. If this was positive, the diagnosis would be
confirmed (in the overwhelming majority of cases) by the finding of antibodies
against double-stranded DNA (anti-dsDNA).

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My Masterclass exam #58292

My Masterclass Q6.
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My history A 38-year old woman, 24 weeks into her second pregnancy, presented to the 77.4%
Emergency Department with sudden onset central crushing chest pain radiating to of users
My details the left arm. Her heart rate was 90/ min and BP 150/90 mmHg. Cardiac auscultation answered
was normal. A 12-lead ECG showed 3mm ST elevation in the anterior pre-cordial this
Create exam leads V2-V6. A chest radiograph was normal. correctly

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Which is the most appropriate management plan? Your exam progress
PACES screencasts   A Administer thrombolytic therapy 6/30
20.0%
  B Give aspirin, start intravenous heparin

C Refer for emergency coronary angiography

  D Request CT scan chest

  E Request lung ventilation/perfusion scan

Answer comments

Although uncommon, cardiovascular disease is the most common cause of maternal


death in the developed world. The patient is suffering an acute STEMI and the best
treatment option for this is emergency coronary angiography and PCI without any
delay. In this situation, the welfare of the mother takes priority over the unborn fetus.
The potential causes of STEMI in pregnancy include atherosclerotic plaque rupture,
coronary dissection, coronary spasm and embolic occlusion.

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My Masterclass Q7.
Your exam progress
My history A 64-year-old woman presented to a primary angioplasty service via ambulance. She 6/30
complained of sudden onset, sustained central chest discomfort associated with 20.0%
My details sweating and breathlessness that had come on two hours previously, shortly after an
argument with a passing motorist. She had no significant past medical history.
Create exam

12 lead electrocardiography showed 3mm of ST segment elevation in leads V1-6, I


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and AVL. She was treated with 300mg of Aspirin and 180mg Ticagrelor.

PACES screencasts
Emergency coronary angiography revealed smooth, normal coronary arteries, with
normal flow. Left ventricular angiography showed a ballooned, akinetic left
ventricular apex extending to and involving the mid-anterior and mid-inferior wall.
The basal segments contracted well.

An ECG performed shortly after transfer to coronary care showed persistent ST


segment elevation. 

What is the most likely diagnosis?

A Acute anterior ST-segment elevation myocardial infarction (STEMI)

B Coronary embolus

C Non ST-segment elevation myocardial infarction (NSTEMI)

D Pulmonary embolus

E Tako-Tsubo Cardiomyopathy

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My Masterclass Q7.
Question statistics
My history A 64-year-old woman presented to a primary angioplasty service via ambulance. She 80.3%
complained of sudden onset, sustained central chest discomfort associated with of users
My details sweating and breathlessness that had come on two hours previously, shortly after an answered
argument with a passing motorist. She had no significant past medical history. this
Create exam
correctly
12 lead electrocardiography showed 3mm of ST segment elevation in leads V1-6, I
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and AVL. She was treated with 300mg of Aspirin and 180mg Ticagrelor. Your exam progress
PACES screencasts 7/30
Emergency coronary angiography revealed smooth, normal coronary arteries, with
23.3%
normal flow. Left ventricular angiography showed a ballooned, akinetic left
ventricular apex extending to and involving the mid-anterior and mid-inferior wall.
The basal segments contracted well.

An ECG performed shortly after transfer to coronary care showed persistent ST


segment elevation. 

What is the most likely diagnosis?

  A Acute anterior ST-segment elevation myocardial infarction (STEMI)

  B Coronary embolus

  C Non ST-segment elevation myocardial infarction (NSTEMI)

D Pulmonary embolus

E Tako-Tsubo Cardiomyopathy

Answer comments

This is a typical presentation of Tako-Tsubo cardiomyopathy/apical ballooning


syndrome, which can mimic STEMI closely. The key differences are that the coronary
arteries are normal, the pattern of left ventricular akinesis does not correspond to a
single coronary artery territory, and the ST-segment elevation has persisted in spite
of coronary flow being normal. It is frequently reported to have been preceded by
emotional stress.

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My Masterclass exam #58292

My Masterclass Q8.
Question statistics
My history A 28-year-old woman presented with breathlessness and pleuritic chest pain. Which 49.7%
of the following test results is more than 90% specific for excluding pulmonary of users
My details embolism (PE) in a patient presenting with a high clinical probability of the answered
diagnosis? this
Create exam
correctly
  A Negative D-Dimer
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Your exam progress
B Normal chest radiograph and arterial blood gases
PACES screencasts 8/30
C Normal lung perfusion on V/Q scan 26.7%

  D No evidence of deep vein thrombosis (DVT) on lower limb venography

  E No evidence of PE on spiral CT

Answer comments

A normal lung perfusion scan has a specificity of around 98% for PE, whilst specificity
for CT is usually quoted at around 85%. CT scanning does, however, have other
clinical advantages over V/Q scanning, most notably because it may reveal an
alternative explanation for a patient’s symptoms.

Although negative D-dimer is helpful in the context of a low clinical suspicion, some
studies have indicated a false negative rate as high as 20% for patients with high
clinical probability.

Neither normal chest radiograph, normal arterial blood gases nor the absence of DVT
can be used in isolation to rule out pulmonary embolism, although they may all be
helpful as part of an algorithm for the management of patients with breathlessness
or pleuritic chest pain of uncertain cause.

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My Masterclass exam #58292

My Masterclass Q9.
Your exam progress
My history A 65 year old man was reviewed in the outpatient clinic with gradually worsening 8/30
shortness of breath, which now caused him to stop halfway when walking up the 26.7%
My details stairs. He had an acute coronary syndrome six years ago. He had been taking
bisoprolol, ramipril, furosemide and spironolactone for a diagnosis of heart failure for
Create exam the last year. Attempts to increase the doses of these drugs had been prevented by
hypotension. An echocardiogram confirmed severe left ventricular impairment. An
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ECG showed sinus rhythm at 60 bpm, a long PR interval (240 ms), and left bundle
branch block.
PACES screencasts
What is the most appropriate treatment to consider next?

A Cardiac resynchronization therapy

B Cardiac transplantation

C Coronary artery bypass grafting

D Dual chamber pacemaker

E Ivabradine

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My Masterclass Q9.
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My history A 65 year old man was reviewed in the outpatient clinic with gradually worsening 75.1%
shortness of breath, which now caused him to stop halfway when walking up the of users
My details stairs. He had an acute coronary syndrome six years ago. He had been taking answered
bisoprolol, ramipril, furosemide and spironolactone for a diagnosis of heart failure for this
Create exam the last year. Attempts to increase the doses of these drugs had been prevented by correctly
hypotension. An echocardiogram confirmed severe left ventricular impairment. An
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ECG showed sinus rhythm at 60 bpm, a long PR interval (240 ms), and left bundle Your exam progress
branch block.
PACES screencasts 9/30
What is the most appropriate treatment to consider next? 30.0%

A Cardiac resynchronization therapy

  B Cardiac transplantation

  C Coronary artery bypass grafting

D Dual chamber pacemaker

  E Ivabradine

Answer comments

Cardiac resynchronization therapy (CRT), also known as biventricular pacing, reduces


symptoms and improves prognosis in patients with heart failure. It is currently
indicated in patients on optimal medical therapy, and with a broad QRS on ECG.
Implantation is similar to a dual chamber pacemaker, but with the insertion of an
extra lead to pace the left ventricle via the coronary sinus.

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My Masterclass exam #58292

My Masterclass Q10.
Your exam progress
My history A 34 year old woman presented to the Emergency Department at 23:45h with new 9/30
onset fast atrial fibrillation (120/min). She was 32 weeks pregnant and well known to 30.0%
My details the hospital’s Grown Up Congenital Heart Unit with surgically corrected Fallot’s
tetralogy. She was haemodynamically stable, with pulse oximetry showing a
Create exam saturation of 97% on air.

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What is the next most appropriate management action?

PACES screencasts A Amiodarone (intravenous)

B Amiodarone (oral)

C Bisoprolol (oral)

D DC cardioversion

E Seek urgent specialist advice

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My Masterclass Q10.
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My history A 34 year old woman presented to the Emergency Department at 23:45h with new 73.9%
onset fast atrial fibrillation (120/min). She was 32 weeks pregnant and well known to of users
My details the hospital’s Grown Up Congenital Heart Unit with surgically corrected Fallot’s answered
tetralogy. She was haemodynamically stable, with pulse oximetry showing a this
Create exam saturation of 97% on air. correctly

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What is the next most appropriate management action? Your exam progress
PACES screencasts   A Amiodarone (intravenous) 10/30
33.3%
  B Amiodarone (oral)

  C Bisoprolol (oral)

D DC cardioversion

E Seek urgent specialist advice

Answer comments

This is a very complex patient with congenital heart disease and a general physician
should realize that this is not something that can be managed without expert
assistant. Although a DC cardioversion is likely to be required even without
haemodynamic compromise, this is not a decision to be taken lightly, and the
specialists that look after her should be informed (via cardiology on call) about her
admission to hospital.

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My Masterclass exam #58292

My Masterclass Q11.
Your exam progress
My history A 64-year-old man was referred to the medical out-patient department after he was 10/30
found to be suffering from paroxysmal atrial fibrillation. He had no past medical 33.3%
My details history of note and was a non-smoker. A trans-thoracic echocardiogram showed that
the left atrium was not dilated.
Create exam

What would you advise with regard to anti-thrombotic therapy against stroke?
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A Aspirin
PACES screencasts
B Clopidogrel

C No anti-thrombotic therapy indicated

D Rivaroxaban

E Warfarin

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My Masterclass exam #58292

My Masterclass Q11.
Question statistics
My history A 64-year-old man was referred to the medical out-patient department after he was 56.5%
found to be suffering from paroxysmal atrial fibrillation. He had no past medical of users
My details history of note and was a non-smoker. A trans-thoracic echocardiogram showed that answered
the left atrium was not dilated. this
Create exam
correctly
What would you advise with regard to anti-thrombotic therapy against stroke?
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Your exam progress
  A Aspirin
PACES screencasts 11/30
  B Clopidogrel 36.7%

C No anti-thrombotic therapy indicated

  D Rivaroxaban

  E Warfarin

Answer comments

Paroxysmal AF is known to be associated with increased risk of stroke as are


persistent and permanent AF. CHA2DS2-VASc scale is used for risk stratification.
CHA2DS2-VASc stands for,

Congestive heart failure – 1


Hypertension – 1
Age (65-74) – 1
Age (≥75) – 2
Diabetes – 1
Stroke or TIA history – 2
Female – 1
Vascular disease – 1

A score of 0 indicates either no treatment or aspirin with the former preferred. A


score of 1 indicates either aspirin or oral anti-coagulation agent with the latter
preferred. A score of ≥2 indicates oral anti-coagulation agent. For more see
guidelines by European Society of Cardiology 2010.

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My Masterclass exam #58292

My Masterclass Q12.
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My history A 70 year old woman presented with 8 hours of chest pain. Her pulse rate was 58.3%
40/minute and blood pressure 105/85 mmHg. The ECG showed complete heart block, of users
My details also ST segment elevation and Q waves in leads II, III and AVF. What should be the answered
immediate treatment? this
Create exam
correctly
  A Adenosine (IV bolus)
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B Atropine (IV bolus)
PACES screencasts 12/30
  C Isoprenaline (IV infusion) 40.0%

D Thrombolysis

  E Transvenous pacing

Answer comments

The top priority is to achieve myocardial reperfusion. The bradycardia is not causing
very significant hypotension: it does not require immediate symptomatic treatment,
and it may resolve with reperfusion.

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My Masterclass exam #58292

My Masterclass Q13.
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My history A 55 year old banker was admitted to the Emergency Department with crushing 38.9%
central chest pain radiating to his jaw, associated with sweating and nausea. He had of users
My details oxygen saturations of 88% on air and BP 175/85 mmHg. His ECG showed ST answered
elevation in leads V4, V5 and V6. On the basis of a diagnosis of acute ST-elevation this
Create exam MI it was decided to transfer him to the nearest primary percutaneous coronary correctly
intervention (PCI) centre, 20 minutes away by ambulance.
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Your exam progress
Which combination of drugs should he ideally receive before transfer?
PACES screencasts 13/30
  A Aspirin, clopidogrel, fondaparinux, oxygen and GTN spray 43.3%

B Aspirin, prasugrel, bivaludin, tirofiban and oxygen

  C Aspirin, prasugrel, fondaparinux, GTN and tirofiban

D Clopidogrel, ticagrelor, enoxaparin, tirofiban and GTN spray

  E Morphine, oxygen, GTN spray, ramipril and bisoprolol

Answer comments

The European Society of Cardiology currently recommends that every patient


undergoing reperfusion for a STEMI should receive aspirin, plus an ADP-receptor
blocker. All patients should receive an injectable anticoagulant, ideally this should be
bivaludin. Fondaparinux is not recommended for patients undergoing primary PCI.
High risk patients who are being transferred for primary PCI should be considered for
a GP IIb/IIIA inhibitor such as Tirofiban or Abciximab.

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My Masterclass exam #58292

My Masterclass Q14.
Your exam progress
My history A 49 year old man known to have aortic stenosis secondary to a bicuspid aortic valve 13/30
presented with a week of malaise and feeling sweaty and feverish over the last 24-48 43.3%
My details hours. Examination revealed temperature 38.0oC, pulse 106/min, blood pressure
118/70 mmHg. There was a loud ejection systolic murmur and a soft early diastolic
Create exam murmur at the left sternal edge. Non-visible haematuria was found on dipstick
urinalysis. Several blood cultures were taken.
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What would be the most appropriate further management?


PACES screencasts
A Start benzylpenicillin

B Start ciprofloxacin

C Start flucloxacillin and gentamicin

D Start vancomycin, gentamicin and rifampicin

E Wait for blood culture results

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My Masterclass exam #58292

My Masterclass Q14.
Question statistics
My history A 49 year old man known to have aortic stenosis secondary to a bicuspid aortic valve 63.9%
presented with a week of malaise and feeling sweaty and feverish over the last 24-48 of users
My details hours. Examination revealed temperature 38.0oC, pulse 106/min, blood pressure answered
118/70 mmHg. There was a loud ejection systolic murmur and a soft early diastolic this
Create exam murmur at the left sternal edge. Non-visible haematuria was found on dipstick correctly
urinalysis. Several blood cultures were taken.
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Your exam progress
What would be the most appropriate further management?
PACES screencasts 14/30
  A Start benzylpenicillin 46.7%

  B Start ciprofloxacin

C Start flucloxacillin and gentamicin

  D Start vancomycin, gentamicin and rifampicin

  E Wait for blood culture results

Answer comments

Antibiotic treatment should be started immediately after multiple blood cultures


have been taken where there is a strong clinical suspicion of infective endocarditis, as
in this case. Waiting for culture results is the correct thing to do if the diagnosis is
possible but unlikely. Streptococci (especially Streptococcus viridans) are the
commonest organisms isolated in infective endocarditis, but staphylococci make up
25% of isolates, hence the need in this context to give antibiotics with action against
these organisms.

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My Masterclass exam #58292

My Masterclass Q15.
Your exam progress
My history A 51-year old man presented to the Emergency Department with a recurrence of left- 14/30
sided chest pain. This had lasted for three hours, and was less intense when he sat 46.7%
My details forward. He had suffered three or four similar attacks in the previous couple of years.
Clinical examination was normal. A chest radiograph was unremarkable. An ECG was
Create exam performed (see image).

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What treatment would you recommend to prevent his recurrent chest pain?

PACES screencasts See image

A Aspirin

B Colchicine

C Ibuprofen

D Prednisolone

E Warfarin

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My Masterclass exam #58292

My Masterclass Q15.
Question statistics
My history A 51-year old man presented to the Emergency Department with a recurrence of left- 53.9%
sided chest pain. This had lasted for three hours, and was less intense when he sat of users
My details forward. He had suffered three or four similar attacks in the previous couple of years. answered
Clinical examination was normal. A chest radiograph was unremarkable. An ECG was this
Create exam performed (see image). correctly

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What treatment would you recommend to prevent his recurrent chest pain? Your exam progress
PACES screencasts See image 15/30
50.0%
  A Aspirin

B Colchicine

  C Ibuprofen

D Prednisolone
  E Warfarin

Answer comments

The ECG demonstrates widespread ST segment elevation and PR segment depression


that is most consistent with acute pericarditis. Anti-platelets agents and
anticoagulants should be avoided. Non-steroidal anti-inflammatory drugs are the
treatment of choice for acute episodes, and in patients with recurrent episodes
colchicine has been shown to be beneficial in preventing attacks.

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My Masterclass exam #58292

My Masterclass Q16.
Your exam progress
My history A 66 yr old man with a history of peripheral vascular disease and chronic obstructive 15/30
pulmonary disease presented to the Emergency Department following 2 hours of 50.0%
My details chest and back pain, which he was too unwell to describe in detail.

Create exam On examination he was breathless (respiratory rate 22/min), tachycardic (110/min,
regular), hypotensive (85/60 mmHg), and had a slow capillary refill time (5 seconds).
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Other findings on cardiovascular examination were that his pulse was difficult to feel
on inspiration, and his JVP was grossly elevated. There was no palpable right
PACES screencasts
ventricular heave. His chest sounds were clear. The ECG showed significant inferior ST
segment depression.

What is the most likely diagnosis?

A Acute inferior myocardial infarction

B Acute pulmonary embolism


C Acute tricuspid regurgitation

D Cardiac tamponade

E Severe / ‘life threatening’ exacerbation of chronic obstructive


pulmonary disease

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My Masterclass Q16.
Question statistics
My history A 66 yr old man with a history of peripheral vascular disease and chronic obstructive 70.8%
pulmonary disease presented to the Emergency Department following 2 hours of of users
My details chest and back pain, which he was too unwell to describe in detail. answered
this
Create exam On examination he was breathless (respiratory rate 22/min), tachycardic (110/min, correctly
regular), hypotensive (85/60 mmHg), and had a slow capillary refill time (5 seconds).
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Other findings on cardiovascular examination were that his pulse was difficult to feel Your exam progress
on inspiration, and his JVP was grossly elevated. There was no palpable right
PACES screencasts 16/30
ventricular heave. His chest sounds were clear. The ECG showed significant inferior ST
53.3%
segment depression.

What is the most likely diagnosis?

  A Acute inferior myocardial infarction

  B Acute pulmonary embolism

  C Acute tricuspid regurgitation

D Cardiac tamponade

  E Severe / ‘life threatening’ exacerbation of chronic obstructive


pulmonary disease

Answer comments

The feature of pulsus paradoxus (an exaggerated fall in systolic blood pressure on
inspiration) along with the grossly elevated JVP makes cardiac tamponade the most
likely cause of this man’s circulatory collapse and apparent right heart failure. The
history of arterial disease, chest and back pain, and inferior ischaemia on ECG would
suggest that the cause of pericardial effusion and tamponade is aortic dissection in
this case.

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My Masterclass Q17.
Your exam progress
My history A 72 year retired cab driver presented to the outpatient clinic with a history of central 16/30
dull chest pain radiating to the arm and jaw, brought on by exertion and cold 53.3%
My details weather, and relieved with rest. He was hypertensive and on metformin and gliclazide
for type II diabetes. He smoked 20 cigarettes a day. A 12 lead ECG showed T wave
Create exam inversion in V2-V6.

Website extension offer What is the most appropriate investigation to consider next?

PACES screencasts A Coronary angiography

B CT coronary angiogram

C Dobutamine stress echocardiography

D Exercise ECG

E Myocardial perfusion scintigraphy

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My Masterclass Q17.
Question statistics
My history A 72 year retired cab driver presented to the outpatient clinic with a history of central 72.4%
dull chest pain radiating to the arm and jaw, brought on by exertion and cold of users
My details weather, and relieved with rest. He was hypertensive and on metformin and gliclazide answered
for type II diabetes. He smoked 20 cigarettes a day. A 12 lead ECG showed T wave this
Create exam inversion in V2-V6. correctly

Website extension offer What is the most appropriate investigation to consider next? Your exam progress
PACES screencasts A Coronary angiography 17/30
56.7%
  B CT coronary angiogram

  C Dobutamine stress echocardiography

D Exercise ECG

  E Myocardial perfusion scintigraphy

Answer comments

This man gives a typical history for angina, and he has multiple risk factors for
coronary artery disease. NICE guidance currently indicates patients with this risk
profile typical history should proceed directly to coronary angiography without stress
testing first. Due to its poor sensitivity, exercise ECG is not on the current NICE
guidance for the evaluation of new onset chest pain.

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My Masterclass Q18.
Your exam progress
My history A 31-year-old man was admitted with fevers and a new murmur. Three sequential 17/30
blood cultures were positive for staphylococcus aureus. Clinical examination revealed 56.7%
My details peripheries that were cool to touch, pulse 110/min, blood pressure 75/45 mmHg
(arterial oxygen saturation 89% on room air), bi-basal crackles and pedal oedema to
Create exam mid-shins. Laboratory tests included haemoglobin 8.2 g/dL and serum albumin 28
g/L. A transthoracic echocardiogram showed a normal sized left ventricle with severe
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aortic regurgitation and a 0.5cm vegetation on the aortic valve.

PACES screencasts
The most important step in management is to:

A Give intravenous furosemide

B Refer for emergency valve replacement surgery

C Start appropriate intravenous antibiotics

D Start continuous positive airways pressure respiratory support

E Transfer to ICU for haemodynamic support

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My Masterclass Q18.
Question statistics
My history A 31-year-old man was admitted with fevers and a new murmur. Three sequential 57.1%
blood cultures were positive for staphylococcus aureus. Clinical examination revealed of users
My details peripheries that were cool to touch, pulse 110/min, blood pressure 75/45 mmHg answered
(arterial oxygen saturation 89% on room air), bi-basal crackles and pedal oedema to this
Create exam mid-shins. Laboratory tests included haemoglobin 8.2 g/dL and serum albumin 28 correctly
g/L. A transthoracic echocardiogram showed a normal sized left ventricle with severe
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aortic regurgitation and a 0.5cm vegetation on the aortic valve. Your exam progress
PACES screencasts 18/30
The most important step in management is to:
60.0%
  A Give intravenous furosemide

B Refer for emergency valve replacement surgery

  C Start appropriate intravenous antibiotics

D Start continuous positive airways pressure respiratory support

  E Transfer to ICU for haemodynamic support

Answer comments

This patient has acute bacterial endocarditis. He has severe aortic regurgitation and
septic shock. He needs emergency surgery. Other indications for urgent surgery would
include: large vegetations (>10mm), embolic events, recurrent pulmonary oedema,
abscess formation, conduction defects.

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My Masterclass Q19.
Your exam progress
My history A 28-year-old woman was sent to the Medical Assessment Unit with pain in the left 18/30
side of her chest. The pain was sharp, exacerbated by twisting, taking a deep breath, 60.0%
My details or coughing. She was tender over the left 5th and 6th ribs, but examination was
otherwise entirely normal. Her oxygen saturation (breathing air) by pulse oximetry
Create exam was 99%. She said that the pain came on shortly after she had to haul her
misbehaving three-year-old daughter out of a shop. What is the most likely cause of
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her chest pain?

PACES screencasts A Musculoskeletal

B Pericarditis

C Pneumonia

D Pneumothorax

E Pulmonary embolism

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My Masterclass Q19.
Question statistics
My history A 28-year-old woman was sent to the Medical Assessment Unit with pain in the left 92.1%
side of her chest. The pain was sharp, exacerbated by twisting, taking a deep breath, of users
My details or coughing. She was tender over the left 5th and 6th ribs, but examination was answered
otherwise entirely normal. Her oxygen saturation (breathing air) by pulse oximetry this
Create exam was 99%. She said that the pain came on shortly after she had to haul her correctly
misbehaving three-year-old daughter out of a shop. What is the most likely cause of
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her chest pain? Your exam progress
PACES screencasts A Musculoskeletal 19/30
63.3%
  B Pericarditis

C Pneumonia

  D Pneumothorax

  E Pulmonary embolism

Answer comments

The history and physical findings mean that musculoskeletal pain is much the most
likely cause for her presentation, but pneumothorax and pulmonary embolism would
be reasonable considerations, although both would seem unlikely.

Pneumothorax is best excluded by chest radiography.

If blood D-dimer concentration is not elevated, then the likelihood of pulmonary


embolism is negligible in a patient with low pre-test probability of this diagnosis.
Hence, if D-dimers are not elevated in this patient, she can be reassured and
discharged (with analgesic medication if required) without recourse to investigation
such as ventilation / perfusion scanning or CT pulmonary angiography.

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My Masterclass Q20.
Your exam progress
My history A 17-year-old boy is brought to the doctor because his mother has noticed that his 19/30
exercise capacity is decreasing and he ‘looks a funny colour’. She says that ‘he had a 63.3%
My details heart murmur when he was a baby’ and he is cyanosed and clubbed. The most likely
diagnosis is:
Create exam
A Atrial septal defect
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B Coarctation of the aorta
PACES screencasts
C Eisenmenger’s syndrome.

D Tetralogy of Fallot

E Transposition of the Great Arteries

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My Masterclass Q20.
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My history A 17-year-old boy is brought to the doctor because his mother has noticed that his 69.5%
exercise capacity is decreasing and he ‘looks a funny colour’. She says that ‘he had a of users
My details heart murmur when he was a baby’ and he is cyanosed and clubbed. The most likely answered
diagnosis is: this
Create exam
correctly
  A Atrial septal defect
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Your exam progress
  B Coarctation of the aorta
PACES screencasts 20/30
C Eisenmenger’s syndrome. 66.7%

  D Tetralogy of Fallot

  E Transposition of the Great Arteries

Answer comments

Presentation with cyanosis of cardiac cause in adolescence is typical of


Eisenmenger’s syndrome, the pathophysiology of which is as follows: a large
congenital left-to-right shunt causes increased pulmonary blood flow, resulting in a
rise in pulmonary vascular resistance and pulmonary hypertension. When the
pulmonary vascular resistance exceeds the systemic vascular resistance the shunt is
reversed, causing cyanosis.

Virtually any large left-to-right shunt can lead to Eisenmenger’s syndrome, including
atrial septal defect, ventricular septal defect, patent ductus arteriosus and Ebstein’s
anomaly.

Tetralogy of Fallot and Transposition of the Great Arteries present at birth or in


infancy.

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My Masterclass exam #58292

My Masterclass Q21.
Your exam progress
My history A 35 yr old female school teacher woke in the early hours of the morning with ‘raw’ 20/30
central chest pain. She thought the pain was due to a spicy meal she had the night 66.7%
My details before and tried to go back to sleep. By the morning the pain was much worse, it
radiated to her neck and shoulders, and was exacerbated by breathing in deeply. She
Create exam was very worried because her father died of a heart attack in his 50’s with similar
symptoms, and she called an ambulance.
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Which would most support the diagnosis of pericarditis?


PACES screencasts
A ECG showing convex ST elevation with loss of R waves across the chest
leads

B Fever

C High JVP

D Pericardial rub

E Pulsus paradoxus

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My Masterclass Q21.
Question statistics
My history A 35 yr old female school teacher woke in the early hours of the morning with ‘raw’ 66.4%
central chest pain. She thought the pain was due to a spicy meal she had the night of users
My details before and tried to go back to sleep. By the morning the pain was much worse, it answered
radiated to her neck and shoulders, and was exacerbated by breathing in deeply. She this
Create exam was very worried because her father died of a heart attack in his 50’s with similar correctly
symptoms, and she called an ambulance.
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Your exam progress
Which would most support the diagnosis of pericarditis?
PACES screencasts 21/30
  A ECG showing convex ST elevation with loss of R waves across the chest 70.0%
leads

  B Fever

C High JVP

D Pericardial rub

  E Pulsus paradoxus

Answer comments

The diagnosis of pericarditis can be made with two out of the following three criteria:
(1) Characteristic chest pain; (2) ECG changes; (3) Pericardial rub - found in up to
85% of patients.

The concave ‘saddle’ ST elevation found in pericarditis should be distinguished from


the convex ST elevation and ‘reciprocal depression’ found in acute myocardial
infarction.

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My Masterclass exam #58292

My Masterclass Q22.
Your exam progress
My history A 21-year old woman was referred to the cardiology clinic because of recent onset 21/30
shortness of breath on exertion. Clinical examination was notable for fixed splitting 70.0%
My details of the second heart sound, with a soft systolic murmur over the left sternal edge. A
12-lead ECG demonstrated a right bundle branch block pattern with right axis
Create exam deviation.

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What is the most likely cardiac defect?

PACES screencasts A Patent foramen ovale

B Primum atrial septal defect

C Pulmonary stenosis

D Secundum atrial septal defect

E Ventricular septal defect

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My Masterclass Q22.
Question statistics
My history A 21-year old woman was referred to the cardiology clinic because of recent onset 66.6%
shortness of breath on exertion. Clinical examination was notable for fixed splitting of users
My details of the second heart sound, with a soft systolic murmur over the left sternal edge. A answered
12-lead ECG demonstrated a right bundle branch block pattern with right axis this
Create exam deviation. correctly

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What is the most likely cardiac defect? Your exam progress
PACES screencasts   A Patent foramen ovale 22/30
73.3%
B Primum atrial septal defect

  C Pulmonary stenosis

D Secundum atrial septal defect

  E Ventricular septal defect

Answer comments

Fixed splitting of the second heart sound is often due to the presence of an ASD. The
defect creates a left to right shunt that increases the blood flow to the right side of
the heart, thereby causing the pulmonary valve to close later than the aortic valve
independent of inspiration/expiration. On the 12-lead ECG, Secundum ASD is
associated with RBBB+ right axis deviation whilst Primum ASD is associated with a
RBBB+ left axis deviation.

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My Masterclass exam #58292

My Masterclass Q23.
Question statistics
My history A 48-year-old woman was referred for a cardiological opinion because of 56.3%
palpitations. There were no other associated symptoms, but she did have a family of users
My details history of sudden death in a cousin, who died when she was in her 40's. Physical answered
examination was normal, as was her ECG and echocardiogram. A 24 hour ECG this
Create exam demonstrated frequent ventricular ectopic activity. What is the likely diagnosis? correctly

Website extension offer   A Arrhythmogenic right ventricular dysplasia Your exam progress
PACES screencasts   B Brugada syndrome 23/30
76.7%
C Hypertrophic obstructive cardiomyopathy

  D Long QT syndrome

E No significant cardiac disease

Answer comments

Palpitations are a very common presenting feature and reassurance is generally all
that is needed in the context of a normal ECG and echo. The distant family history of
sudden death requires more information but is likely not to be relevant. However, all
conditions listed - aside from 'no significant cardiac disease' - will generally have
abnormal ECGs, and in the absence of a specific family history of them it is likely that
she will need no further investigation.

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My Masterclass Q24.
Your exam progress
My history A 75 year old man was seen in pre-op assessment clinic for a scheduled curative 23/30
hemicolectomy for colon cancer. He had a past history of hypertension and atrial 76.7%
My details fibrillation for which he was on bisoprolol. He admitted to being short of breath on
minimal exertion. On auscultation you heard a 4/6 ejection systolic murmur and a
Create exam soft S2. A transthoracic echocardiogram performed a month ago shows an aortic
valve area of 0.9 cm2 and a gradient of 44 mmHg.
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What will be your recommendation?


PACES screencasts
A Proceed to hemicolectomy after discontinuation of bisoprolol

B Proceed to hemicolectomy while continuing the bisoprolol

C Refer for palliative care

D Refer for surgical aortic valve replacement

E Refer for transcathter aortic valve implantation

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My Masterclass Q24.
Question statistics
My history A 75 year old man was seen in pre-op assessment clinic for a scheduled curative 48.1%
hemicolectomy for colon cancer. He had a past history of hypertension and atrial of users
My details fibrillation for which he was on bisoprolol. He admitted to being short of breath on answered
minimal exertion. On auscultation you heard a 4/6 ejection systolic murmur and a this
Create exam soft S2. A transthoracic echocardiogram performed a month ago shows an aortic correctly
valve area of 0.9 cm2 and a gradient of 44 mmHg.
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Your exam progress
What will be your recommendation?
PACES screencasts 24/30
  A Proceed to hemicolectomy after discontinuation of bisoprolol 80.0%

  B Proceed to hemicolectomy while continuing the bisoprolol

  C Refer for palliative care

D Refer for surgical aortic valve replacement

E Refer for transcathter aortic valve implantation

Answer comments

Aortic stenosis is a risk factor for perioperative mortality and nonfatal myocardial
infarction. For patients unsuitable to undergo surgical valve replacement,
transcatheter aortic-valve implantation (TAVI) can be beneficial. Indications for
TAVI are: inoperable patients with severe aortic stenosis (mean gradient >40 mmHg
or jet velocity >4 m/s) or AVA<1 cm², NYHA ≥ II and predicted surgical mortality risk
of >50%. Studies have shown a mortality benefit for patients undergoing TAVI when
compared to medical therapy including balloon valvotomy.

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My Masterclass exam #58292

My Masterclass Q25.
Your exam progress
My history A 45 year old man had been followed up in cardiology outpatients for some years 24/30
after being found to have a murmur at a routine medical. At a 6 month follow-up 80.0%
My details appointment he complained of exertional dyspnoea which had progressed over the
preceding few months, such that at the time of the appointment he had to stop to
Create exam catch his breath after walking 500 yards. He had no other symptoms. He had no
other significant past medical history and took no regular medications.
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On examination, blood-pressure was 130/60mmHg, the JVP was not elevated, the
PACES screencasts
apex beat was not displaced, but there was a loud early diastolic murmur, heard best
at the left sternal edge.

Echocardiography, last performed 6 months ago, had showed a bicuspid aortic valve
with no stenosis and severe aortic regurgitation. The aortic root was not dilated. The
left ventricle was not dilated with good systolic function, left ventricular end-systolic
diameter: 4.5cm, left ventricular end diastolic diameter: 5.7cm.

What is the most appropriate management?

A Arrange trans-oesophageal echocardiogram

B Commence bisoprolol

C Commence ramipril

D Refer for aortic valve replacement

E Review in outpatients in 3 months

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My Masterclass exam #58292

My Masterclass Q25.
Question statistics
My history A 45 year old man had been followed up in cardiology outpatients for some years 70.2%
after being found to have a murmur at a routine medical. At a 6 month follow-up of users
My details appointment he complained of exertional dyspnoea which had progressed over the answered
preceding few months, such that at the time of the appointment he had to stop to this
Create exam catch his breath after walking 500 yards. He had no other symptoms. He had no correctly
other significant past medical history and took no regular medications.
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Your exam progress
On examination, blood-pressure was 130/60mmHg, the JVP was not elevated, the
PACES screencasts 25/30
apex beat was not displaced, but there was a loud early diastolic murmur, heard best
83.3%
at the left sternal edge.

Echocardiography, last performed 6 months ago, had showed a bicuspid aortic valve
with no stenosis and severe aortic regurgitation. The aortic root was not dilated. The
left ventricle was not dilated with good systolic function, left ventricular end-systolic
diameter: 4.5cm, left ventricular end diastolic diameter: 5.7cm.

What is the most appropriate management?

A Arrange trans-oesophageal echocardiogram

  B Commence bisoprolol

  C Commence ramipril

D Refer for aortic valve replacement

  E Review in outpatients in 3 months

Answer comments

This man has established severe aortic regurgitation and has been under
surveillance. He has not undergone surgery thus far because he was (presumably)
asymptomatic and did not meet echo criteria for requiring surgery in the absence of
symptoms. He now has symptoms and deferring surgery at this stage is associated
with adverse outcomes, irrespective of whether there has been echocardiographic
deterioration.

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My Masterclass Q26.
Your exam progress
My history A 50-year old man presented 3 months after (metallic) mitral valve replacement 25/30
(MVR) with increasing shortness of breath, fever and weight loss. Clinically he was in 83.3%
My details pulmonary oedema. Transoesophageal echocardiography (TOE) confirmed severe
paravalvular mitral regurgitation. The first blood culture was positive for Staph
Create exam epidermidis. After initial management of pulmonary oedema, which is the best
therapeutic approach?
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A Intravenous antibiotics for 4 weeks and then repeat TOE.
PACES screencasts
B Intravenous antibiotics for 4 weeks and then re-do MVR (bioprosthetic).

C Intravenous antibiotics for 4 weeks and then re-do MVR (metallic).

D Re-do MVR (bioprosthetic) and then complete 4 weeks of intravenous


antibiotics.

E Re-do MVR (metallic) and then complete 4 weeks of intravenous


antibiotics.

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My Masterclass Q26.
Question statistics
My history A 50-year old man presented 3 months after (metallic) mitral valve replacement 53.9%
(MVR) with increasing shortness of breath, fever and weight loss. Clinically he was in of users
My details pulmonary oedema. Transoesophageal echocardiography (TOE) confirmed severe answered
paravalvular mitral regurgitation. The first blood culture was positive for Staph this
Create exam epidermidis. After initial management of pulmonary oedema, which is the best correctly
therapeutic approach?
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Your exam progress
A Intravenous antibiotics for 4 weeks and then repeat TOE.
PACES screencasts 26/30
  B Intravenous antibiotics for 4 weeks and then re-do MVR (bioprosthetic). 86.7%

  C Intravenous antibiotics for 4 weeks and then re-do MVR (metallic).

  D Re-do MVR (bioprosthetic) and then complete 4 weeks of intravenous


antibiotics.

E Re-do MVR (metallic) and then complete 4 weeks of intravenous


antibiotics.

Answer comments

Clinically this man has an infected MVR, with severe paravalvular leak. Following
surgery, the commonest infecting organisms (up to around 9 months) are coagulase
negative staphylococci. Antibiotics alone will not cure the infection; the valve must be
replaced again. In this case this should be with a metallic valve since a bioprosthetic
valve would be likely to need replacing after 10-15 years due to degeneration
thereby subjecting him to a high-risk third operation. Bioprosthetic and metallic
valves have similar risk for subsequent endocarditis.

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My Masterclass Q27.
Your exam progress
My history An 80 year-old woman with heart failure on a background of two previous 26/30
myocardial infarctions several years ago was referred to the cardiology clinic because 86.7%
My details she continued to have NYHA III symptoms despite maximal pharmacological
therapy. Her ECG showed sinus rhythm with left bundle branch block and an
Create exam echocardiogram showed a left ventricular ejection fraction of 28%.

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What is the most appropriate next step?

PACES screencasts A Electrophysiological testing to look for inducible ventricular tachycardia

B Holter recording to look for non-sustained ventricular tachycardia

C Implantation of a cardiac resynchronisation device with defibrillator


(CRT-D)

D Implantation of a cardiac resynchronisation device with pacing (CRT-P)

E Implantation of a dual chamber pacemaker

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My Masterclass exam #58292

My Masterclass Q27.
Question statistics
My history An 80 year-old woman with heart failure on a background of two previous 56.9%
myocardial infarctions several years ago was referred to the cardiology clinic because of users
My details she continued to have NYHA III symptoms despite maximal pharmacological answered
therapy. Her ECG showed sinus rhythm with left bundle branch block and an this
Create exam echocardiogram showed a left ventricular ejection fraction of 28%. correctly

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What is the most appropriate next step? Your exam progress
PACES screencasts A Electrophysiological testing to look for inducible ventricular tachycardia 27/30
90.0%
  B Holter recording to look for non-sustained ventricular tachycardia

C Implantation of a cardiac resynchronisation device with defibrillator


(CRT-D)

  D Implantation of a cardiac resynchronisation device with pacing (CRT-P)

  E Implantation of a dual chamber pacemaker

Answer comments

A combination of sinus rhythm, left bundle branch block, QRS > 150ms, ejection
fraction < 35% and NYHA III symptoms on maximal medical therapy qualify for
cardiac resynchronisation. An ejection fraction < 30%, previous MI and QRS > 120ms
qualify for ICD implant for primary prevention. This lady qualifies for both, in the
form of CRT-D (CRT-D also has all the pacing capabilities of CRT-P).

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My Masterclass Q28.
Your exam progress
My history A 65 year old man was reviewed in the outpatient clinic with gradually worsening 27/30
shortness of breath, which now caused him to stop halfway when walking up the 90.0%
My details stairs. He had an acute coronary syndrome six years ago. He had been taking
bisoprolol, ramipril, furosemide and spironolactone for a diagnosis of heart failure for
Create exam the last year. Attempts to increase the doses of these drugs had been prevented by
hypotension. An echocardiogram confirmed severe left ventricular impairment. An
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ECG showed sinus rhythm at 60 bpm, a long PR interval (240 ms), and left bundle
branch block.
PACES screencasts

What is the most appropriate treatment to consider next?

A Cardiac resynchronization therapy

B Cardiac transplantation

C Coronary artery bypass grafting

D Dual chamber pacemaker

E Ivabradine

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My Masterclass Q28.
Question statistics
My history A 65 year old man was reviewed in the outpatient clinic with gradually worsening 77.8%
shortness of breath, which now caused him to stop halfway when walking up the of users
My details stairs. He had an acute coronary syndrome six years ago. He had been taking answered
bisoprolol, ramipril, furosemide and spironolactone for a diagnosis of heart failure for this
Create exam the last year. Attempts to increase the doses of these drugs had been prevented by correctly
hypotension. An echocardiogram confirmed severe left ventricular impairment. An
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ECG showed sinus rhythm at 60 bpm, a long PR interval (240 ms), and left bundle Your exam progress
branch block.
PACES screencasts 28/30
93.3%
What is the most appropriate treatment to consider next?

A Cardiac resynchronization therapy

  B Cardiac transplantation

  C Coronary artery bypass grafting

  D Dual chamber pacemaker

  E Ivabradine

Answer comments

Cardiac resynchronization therapy (CRT), also known as biventricular pacing, reduces


symptoms and improves prognosis in patients with heart failure. It is currently
indicated in patients on optimal medical therapy, and with a broad QRS on ECG.
Implantation is similar to a dual chamber pacemaker, but with the insertion of an
extra lead to pace the left ventricle via the coronary sinus.

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My Masterclass exam #58292

My Masterclass Q29.
Your exam progress
My history 70 year old man presented to the Emergency Department with 4-hour history of 28/30
central chest pain and shortness of breath. His past medical history included 93.3%
My details hypertension and diabetes, and his regular medications were amlodipine 5mg od and
metformin 500mg bd. His ECG showed sinus rhythm with anterolateral ischaemia
Create exam and his troponin was elevated. He was diagnosed with NSTEMI and started on
aspirin, clopidogrel and fondaparinaux, and arrangements were made to transfer
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him to the CCU.

PACES screencasts
Whilst still in the Emergency Department he suddenly developed a sustained regular
broad complex tachycardia. He was painfree and his vital signs included pulse
180/min, BP 110/60mmHg, SaO2 95% on air, and respiratory rate 20/min. His chest
was clear on auscultation.

What is the best next management?

A Adenosine

B Amiodarone (intravenous)

C Amiodarone (oral)

D Bisoprolol

E DC cardioversion

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My Masterclass exam #58292

My Masterclass Q29.
Question statistics
My history 70 year old man presented to the Emergency Department with 4-hour history of 64.5%
central chest pain and shortness of breath. His past medical history included of users
My details hypertension and diabetes, and his regular medications were amlodipine 5mg od and answered
metformin 500mg bd. His ECG showed sinus rhythm with anterolateral ischaemia this
Create exam and his troponin was elevated. He was diagnosed with NSTEMI and started on correctly
aspirin, clopidogrel and fondaparinaux, and arrangements were made to transfer
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him to the CCU. Your exam progress
PACES screencasts 29/30
Whilst still in the Emergency Department he suddenly developed a sustained regular
96.7%
broad complex tachycardia. He was painfree and his vital signs included pulse
180/min, BP 110/60mmHg, SaO2 95% on air, and respiratory rate 20/min. His chest
was clear on auscultation.

What is the best next management?

A Adenosine

B Amiodarone (intravenous)

  C Amiodarone (oral)

  D Bisoprolol

  E DC cardioversion

Answer comments

In the context of acute myocardial infarction the most likely diagnosis is sustained
ventricular tachycardia. Given that the patient is currently hemodynamically stable,
painfree and not in cardiac failure, intravenous amiodarone should be tried first.
However, the anaesthetist should be called to attend urgently as the patient might
require DC cardioversion if amiodarone is unsuccessful or the patient develops
adverse features. Bisoprolol is a medication that the patient should be started on but
is not going to help much in this acute scenario. Adenosine is not indicated.

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My Masterclass exam #58292

My Masterclass Q30.
Your exam progress
My history A 35 year old man presented with increasing breathless over 8 months, such that at 29/30
presentation he had an exercise tolerance of around 200m. Echocardiography 96.7%
My details showed a raised mean pulmonary artery pressure of 44mm Hg, for which no obvious
underlying cause could be found. 
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Which treatment is most likely to be useful?


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A Bosentan
PACES screencasts
B Lisinopril

C Methotrexate

D Terbutaline

E Theophylline

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My Masterclass exam #58292

My Masterclass Q30.
Question statistics
My history A 35 year old man presented with increasing breathless over 8 months, such that at 91.4%
presentation he had an exercise tolerance of around 200m. Echocardiography of users
My details showed a raised mean pulmonary artery pressure of 44mm Hg, for which no obvious answered
underlying cause could be found.  this
Create exam
correctly
Which treatment is most likely to be useful?
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Your exam progress
A Bosentan
PACES screencasts 30/30
  B Lisinopril 100.0%

  C Methotrexate

  D Terbutaline

  E Theophylline

Answer comments

The endothelin antagonist bosentan has been shown to improve haemodynamics


and exercise capacity in primary pulmonary hypertension. The PDE5 antagonist
sildenafil has been shown to have similar benefits. Acute vasodilator testing at right
heart catheterisation detects those who may benefit from the use of high dose
calcium channel blockade. Anticoagulation, diuretics and oxygen should also be
considered.

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