How to Pass the FRACP Written Examination. Jonathan Gleadle

Professor Mihir Wechalekar Consultant Rheumatologist Department of Rheumatology Flinders Medical Centre and College of Medicine and Public Health, Flinders University

      Dr Anthea Gist

      Senior Registrar, Advanced Trainee in Rheumatology

      Canberra Hospital, ACT

1 Cardiology

      Questions

      Answers can be found in the Cardiology Answers section at the end of this chapter.

      1 1. A 65‐year‐old accountant undergoes an abdominal ultrasound because of mildly abnormal liver function tests. The ultrasound reveals a few mobile gallstones and a 5 cm abdominal aortic aneurysm. He drinks three to four standard drinks of alcohol every day and is an ex‐smoker. He is known to have hypertension and is taking irbesartan 150 mg daily. Blood pressure control is satisfactory with mean systolic BP of 130 mmHg.What is your most appropriate course of action?Abdominal CT with contrast immediately and suspension of driver's license.Endovascular aneurysm repair immediately.Follow up ultrasound in 6 months and continue driving.Open surgical aneurysm repair immediately.

      2 2. A 39‐year‐old man with a known atrial septal defect presents to emergency department with a 6‐hour history of palpitations. His ECG is shown below:Which one of the following signs is UNLIKELY to be present?Fixed splitting of second heart sound.Fourth heart sound.Loud first heart sound.Third heart sound.

      3 3. Which of the following patient characteristics is LEAST LIKELY to increase an individual's susceptibility to anthracycline cardiomyopathy?Age of 70 years.Male sex.Mediastinal radiotherapy.Positive carrier status for C282Y HFE gene.

      4  4. A 65‐year‐old‐man presents with a three‐month history of exertional dyspnoea. He is found to have aortic stenosis with a valve area of 0.9 cm2 and a mean transvalvular pressure gradient of 15 mmHg. His left ventricle ejection fraction (LVEF) is 35%. A Dobutamine Stress Echocardiography (DSE) has been arranged which will provide all of the following information, EXCEPT:Confirming the suitability for valve replacement.Deciding the need for cardiac resynchronisation therapy.Predicting prognosis post valve replacement.Diagnosing low‐flow, low‐gradient aortic stenosis.

      5 5. An 84‐year‐old man with severe aortic stenosis complains of shortness of breath after walking for 20 metres and a couple of episodes of unexplained collapse. He is independent with activities of daily living. His medical history includes hypertension, hyperlipidaemia, cholecystectomy, and hernia repair.What is the most appropriate management approach?Aortic valve balloon valvuloplasty.Implantable cardioverter–defibrillator (ICD).Surgical aortic valve replacement (SAVR).Transcatheter aortic valve implantation (TAVI).

      6 6. You see a 75‐year‐old woman with a new diagnosis of atrial fibrillation. Her CHA2DS2‐VASc score is 4. She has a history of myocardial infarction four years ago, treated with percutaneous coronary intervention and a bare‐metal stent inserted in the right coronary artery, and is currently on aspirin.Which of the following options is the most appropriate regarding ongoing anti‐thrombotic therapy?Coronary angiogram to guide further therapy.Rivaroxaban and clopidogrel.Rivaroxaban and aspirin.Rivaroxaban monotherapy.

      7 7. Beta‐blockers are recommended as first line therapy for stable angina. Their main mechanism of action is explained by:Increased coronary artery blood flow.Plaque stabilisation.Reduction in blood pressure.Reduction in myocardial oxygen demand.

      8 8. What is the management strategy for a patient with the following ECG?Amiodarone.Beta‐blocker.Implantable cardioverter–defibrillator (ICD).Pacemaker.

      9 9. A 54‐year‐old man is admitted to hospital because of syncope. This is his third presentation with syncope due to severe postural hypotension over the past six months. He has developed chronic diarrhoea and lost 6 kg of body weight in the past six months. He has no significant past medical history. On examination, BP is 90/50 mmHg. HR is 86 bpm. There are no murmurs. Urinary analysis shows ++++ protein but no RBCs nor RBC casts. His investigation results are shown below. ECG shows sinus rhythm and low voltage in all leads. Echocardiogram reports moderate left ventricular hypertrophy, biatrial dilatation and grade 2 diastolic dysfunction.TestsResultsNormal valuesHaemoglobin108 g/L135–175White blood cell5.48 x 109/L4.0–11.0Platelet206 x 109/L150–450Sodium133 mmol/L135–145Potassium4.3 mmol/L3.5–5.2Creatinine156 μmol/L60–110Albumin22 g/L34–48Globulin42 g/L21–41Liver function testsnormalTroponin<29 ng/L0–29N‐terminal pro b‐type Natriuretic Peptide (NT‐proBNP)1800 ng/L0–124What would you consider the most appropriate next investigation?Cardiac MRI.Coronary artery angiogram.Holter monitor.Implantable loop recorder.

      10 10. Which one of the following increases cardiac output?Atropine.Acidosis.Beta‐blockers.Hypertension.

      11 11. A 72‐year‐old woman presents to emergency department after an episode of loss of consciousness. Which of the following clinical features, if present, DO NOT increase the likelihood that her loss of consciousness was due to cardiac syncope?Breathlessness prior to the episode.Cyanosis during the episode.History of atrial fibrillation.Significant injury as a result of loss of consciousness.

      12 12. An 80‐year‐old man presents to emergency department with sudden onset of left‐sided weakness two hours ago. His medical history includes hypertension, hypercholesterolaemia, and atrial fibrillation for which he is taking aspirin only. CT head shows acute right middle cerebral artery territory infarction. He is treated with thrombolysis followed by bridging low molecular weight heparin then a direct thrombin inhibitor. Two weeks later while in rehabilitation, he develops low grade fever, myalgia, painful feet (shown below), anaemia, and AKI.The most likely diagnosis is:Acute allergic reaction to direct thrombin inhibitor.Antiphospholipid syndrome.Cholesterol embolisation.Multiple emboli due to inappropriate use of an oral direct thrombin inhibitor.

      13 13. Which one of the following patients can be investigated appropriately with a computed tomography coronary angiography (CTCA)?An asymptomatic patient with history of type 2 diabetes and normal renal function.A patient with previous coronary stents presenting with chest pain and possible in‐stent restenosis.A patient presenting with central chest pain and rapid atrial fibrillation.A patient with chest pain but with a low pre‐test probability of coronary artery disease.

      14 14. A 75‐year‐old man presents with transient weakness of his left arm. He is diagnosed with a transient ischaemic attack. He is known to have hypertension, type 2 diabetes, alcohol dependence, recent weight loss, and a low‐grade fever. He undergoes a transthoracic echocardiogram which reveals a 12 mm mitral‐valve vegetation.Which one of the following statements is true?Blood culture is negative in over 20% of cases of infectious endocarditis.Cerebral complications are the most frequent extracardiac complications.Majority (80%) of cases of infectious endocarditis develop in patients with known valvular disease.Streptococci in the most common pathogen isolated.

      15 15. A 75‐year‐old man presents with increasing dyspnoea. You note that he had four admissions in the past year due to decompensated CCF. He is known to have ischaemic heart disease with a drug eluting stent in two coronary arteries, insulin dependent type 2 diabetes, hypertension, stage 4 CKD with an eGFR of 26 ml/min/1.73 m2 and severe smoking related COPD. His medications include aspirin, clopidogrel, perindopril, gliclazide, frusemide, digoxin, spironolactone, atorvastatin, formoterol/,budesonide inhaler, and tiotropium inhaler. Physical examination findings are consistent with decompensated CCF. His ECG is shown below. A dobutamine stress echocardiogram demonstrates no reversible ischaemic change but a large antero‐apical area of akinesia. The ejection fraction is 30%.The most effective treatment to reduce the frequency of readmissions and improve survival is:Add a SGLT2 inhibitor.Commence a beta‐blocker.Insert a biventricular pacemaker and defibrillator.Insert a dual‐chamber pacemaker.

      16 16. Which one of the following medications is recommended in patients with type 2 diabetes with cardiovascular disease and inadequate glycaemic control despite metformin, to reduce the risk of cardiovascular events and hospitalisation for heart failure?Dipeptidyl peptidase‐4 (DPP‐4) inhibitors.Glucagon‐like peptide‐1 (GLP‐1) analogues.Sodium‐glucose co‐transporter‐2 (SGLT2) inhibitors.Thiazolidinediones.

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