1.

Cardiac catheterisation data are shown from a 26-year-old man who was noted
to have finger clubbing.
Oxygen
saturation (%)

Anatomical site

Pressure (mmHg) End

systolic/End diastolic

Superior vena cava

70

Inferior vena cava

66

Right atrium

69

Right ventricle

68

120/15

Pulmonary artery

68

120/95

Left ventricle

88

110/5

Aorta

89

120/70

Pulmonary capillary wedge

pressure

What is the diagnosis?

Ebstein's anomaly
Fallot's tetralogy
Primary pulmonary hypertension
Sinus venosus atrial septal defect
Ventricular septal defect
ANS: E
The pressures in the RV and PA are grossly elevated and exceed those on the left.
The saturations on the left side are subnormal, but there is no evidence of a stepdown from the data presented. The diagnosis is VSD with Eisenmenger's syndrome.
2. A 19-year-old man, a recent immigrant to the U.K. from Eastern Europe, consults
his General Practitioner with a history of intermittent dizzy spells. He reports
having a limited exercise capacity since childhood, but this had not been
investigated in the past. On examination he is a slight man, has a dusky blue
discolouration to his lips and tongue, and has finger clubbing. A murmur is also
heard. The GP refers him to a Cardiologist.
The results of a cardiac catheter study are given below:
Anatomical site

Oxygen
saturation (%)

Pressure (mmHg) End

systolic/End diastolic

Superior vena cava

58

Inferior vena cava

52

Right atrium (mean)

56

10

Right ventricle

55

105/9

Pulmonary artery

16

Pulmonary capillary
Wedge pressure

Left atrium

97

Left ventricle

84

108/10

Aorta

74

110/80

What is the most likely explanation for the step-down in oxygen saturation between
the left ventricle and aorta?
Anomalous pulmonary venous drainage
Over-riding aorta
Patent ductus arteriosus
Transposition of the great vessels
Ventricular septal defect
ANS: B
The patient has Fallot's tetralogy.
Fallot's tetralogy consists of:
1.
2.
3.
4.

Ventricular septal defect

Pulmonary stenosis
Right ventricular hypertrophy
Over-riding aorta
In the data presented, these features are indicated by:
VSD: step-down in oxygen saturation between LA and LV, indicating right to left
shunt at the level of the ventricles.
Pulmonary stenosis: there is an 89 mmHg gradient across the pulmonary valve
(105 mmHg RV systolic - 16 mmHg pulmonary artery pressure).
RVH: Right ventricular pressures are high and there is a right to left shunt, as
indicated by the oxygen saturations.
Over-riding aorta: there is a further step-down in oxygen saturation between
the LV and aorta. This could occur in either Fallot's or with a patent ductus
arteriosus with right to left shunting. However, given the other features of Fallot's,

this is most likely to be caused by an over-riding aorta with reduced saturations

due to a mixture of deoxygenated blood from the RV entering the left heart
circulation.
3. This gentleman is being treated for ischaemic heart disease and a dilated
cardiomyopathy.

Which of the following agents is most likely the cause of this appearance?
Metoprolol
Furosemide
Isosorbide mononitrate
Lisinopril
Amiodarone
ANS: D
The slide shows gynaecomastia. Drugs that induce gynaecomastia include:
inhibitors of testosterone synthesis (ketoconazole, metronidazole, cimetidine,
etomidate, cisplatin), oestrogens (digitalis, oral contraceptive pill); other drugs in
which the mechanism is not known (isoniazid, diazepam, omeprazole, calciumchannel blockers, ACE inhibitors, tricyclic antidepressants, busulphan, marijuanha,
heroin, spironolactone).
4. 18. A 54-year-old man was admitted to hospital with acute chest pain. His
electrocardiogram showed inferior ST segment elevation. He was thrombolysed
with t-PA and did not have any pain following thrombolysis. On day 5 after his
admission he became acutely unwell. He complained of sudden onset of severe
central chest pain and dyspnoea. On examination he looked unwell; was pale and
sweating.
Data obtained from urgent cardiac catheterisation are shown below:

Oxygen saturation
(%)

Anatomical site

Pressure (mmHg) End systolic/End

diastolic

Right atrium
(mean)

Right ventricle

50/12

Left ventricle

90/12

97

100/50

Femoral artery

What measurement would confirm the diagnosis?

Cardiac index
Estimation of gradient across the aortic valve
Pressure measurement in the aorta and pulmonary artery
Pulmonary capillary wedge pressure
Oxygen saturation in right atrium and pulmonary artery
ANS: E
The differential diagnoses are post-MI VSD or post-MI rupture of papillary muscle
(causing acute mitral regurgitation). VSD and papillary rupture are difficult to
distinguish clinically. The diagnosis is established by demonstration of a left to right
shunt. The presence of a VSD would be confirmed by detecting a step-up in the
oxygen saturation between the RA and PA; if there is no step-up, the diagnosis is
probably papillary muscle rupture.
5. 19. A 54-year-old woman presents to hospital with a 2 year history of increasing
exertional dyspnoea.
Her echocardiogram is abnormal and cardiac catheterisation is performed. The
results are shown below:
Oxygen
saturation (%)

Anatomical site

Pressure (mmHg) End

systolic/End diastolic

Superior vena cava

75

Inferior vena cava

71

Right atrium (mean)

74

Right ventricle

73

60/7

Pulmonary artery

73

55/44

26

Pulmonary capillary

wedge pressure
Left ventricle

97

110/6

Aorta

98

120/80

What is the diagnosis?

Aortic incompetence
Hypertrophic cardiomyopathy
Mitral stenosis
Primary pulmonary hypertension
Pulmonary stenosis
ANS: C
The diagnosis is mitral stenosis (MS). The commonest cause of MS is rheumatic
valve disease; rare causes include connective tissue disease and metastatic
neoplasia (causing marantic endocarditis). The catheter data show a gradient
across the mitral valve (LA pressure LV end diastolic pressure); it is usual to use
the PCWP as a surrogate for LA pressure. In this case the gradient is 26-6 = 20
mmHg. There is also evidence of right ventricular hypertrophy, with markedly
elevated RV pressures due to secondary pulmonary hypertension. The severity of
mitral stenosis can be graded:
Severity of mitral stenosis

Severity Valve area (cm2)

Gradient (mmHg)

Mild

1.6 2.0

<5

Moderate

1.0 1.5

5 - 10

Severe

<1.0

>10

6. 28. A 17-year-old woman consulted her General Practitioner because she had
become slightly breathless on exertion over the preceding six months. Examination
was unremarkable apart from a soft systolic murmur at the left sternal edge. An
echocardiogram was requested and she was subsequently referred for a cardiology
opinion. The data obtained from cardiac catheterisation are shown below.
Anatomical site

Oxygen
saturation (%)

Pressure (mmHg)End
systolic/End diastolic

Superior vena cava

74

Inferior vena cava

70

Right atrium (high)

72

Right atrium (mid)

72

Right atrium (low)

80

Right ventricle

79

44/12

Pulmonary artery

81

42/15

Left ventricle

96

125/9

Aorta

97

120/70

Pulmonary capillary
wedge pressure

What is the likely diagnosis?

Primary pulmonary hypertension
Septum primum atrial septal defect
Septum secundum atrial septal defect
Ventricular septal defect
Ventricular septal defect with Eisenmengers syndrome
ANS: B
The oxygen saturation in the RA and SVC should be the same; however, there is a
step-up in oxygen saturation at the level of the low RA. This can only result from
the addition of oxygenated blood to the deoxygenated blood in the right heart
circulation i.e. an abnormal connection between the right and left sides of the
heart. Since this is occurring in the atria, this must be due to an ASD. The location
of the step-up is suggestive of a primum defect since these lesions occur low down
in the A-V septum, lying immediately above the atrioventricular valves. These
lesions can affect the function of the anterior leaflet of the mitral valve, causing
mitral regurgitation. Right ventricular pressures are high; this is more likely to
occur with primum ASDs.
7. 32. A 17-year-old woman consulted her General Practitioner because she had
become slightly breathless on exertion over the preceding six months. Examination
was unremarkable apart from a soft systolic murmur at the left sternal edge. An
echocardiogram was requested and she was subsequently referred for a cardiology
opinion. The data obtained from cardiac catheterisation are shown below.
Anatomical site

Oxygen
saturation (%)

Pressure (mmHg) End

systolic/End diastolic

Superior vena cava

74

Inferior vena cava

70

Right atrium (high)

72

7 (mean)

Right atrium (mid)

71

7 (mean)

Right atrium (low)

82

7 (mean)

Right ventricle

79

44/12

Pulmonary artery

81

42/15

Left ventricle

96

125/9

Aorta

97

120/70

Pulmonary capillary
wedge pressure

What abnormalities are likely to be seen on her electrocardiogram?

[Select two]
(Please select 2 options)
A. Atrial fibrillation
B. Lateral T wave inversion
C. Left axis deviation
D. Left bundle branch block
E. Left ventricular strain
F. Peaked T waves
G. Right axis deviation
H. Right bundle branch block
I. Episodes of sinus arrest
J. ST segment depression
ANS: C,H
The oxygen saturation in the RA and SVC should be the same; however, there is a
step-up in oxygen saturation at the level of the low RA. This can only result from
the addition of oxygenated blood to the deoxygenated blood in the right heart
circulation i.e. an abnormal connection between the right and left sides of the
heart. Since this is occurring in the atria, this must be due to an ASD. The location
of the step-up is suggestive of a primum defect since these lesions occur low down
in the A-V septum, lying immediately above the atrioventricular valves. These
lesions can affect the function of the anterior leaflet of the mitral valve, causing

mitral regurgitation. Right ventricular pressures are high; this is more likely to
occur with primum ASDs.
In ostium primum ASDs, the AV node is displaced posteriorly and inferiorly and
atrial and/or AV nodal conduction is often delayed. There is left axis deviation with
Q waves in leads I and aVL. Delayed conduction through the atria or through the AV
node may lead to prolongation of the PR interval (ie first degree heart block). The
QRS pattern typically is either an rSr' or an rsR' resulting from dilation and
hypertrophy of the right ventricular outflow tract caused by volume overload of the
right heart.
Primum ASD LAD & RBBB
Secundum ASD RAD & RBBB
9.A 55-year-old woman is found to have ++ glycosuria and had a maternal history
of Type II diabetes mellitus. She is a smoker of 20 cigarettes per day. Examination
reveals no specific abnormalities apart from a BMI of 30. Blood pressure was
132/88 mmHg.
Investigations reveal:
Serum creatinine
Plasma glucose (fasting)
Total serum cholesterol
HDL cholesterol

80 mol/L (60-110)
11.3 mmol/L (3.0-6.0)
5.5 mmol/L (<5.2)
1.4 mmol/L (>1.55)

What is most likely to improve her life expectancy?

Metformin 500 mg bd
Ramipril 10 mg daily
Simvastatin 10 mg daily
Stopping smoking
Weight loss to achieve a BMI of 25
ANS: D
She is diabetic and obese as defined by her BMI of 30. She is most prone to risk of
cardiovascular disease with evidence suggesting that diabetics have at least a two
to four-fold increased cardiovascular mortality. In terms of improving life
expectancy, of the risk factors mentioned, diabetes, mild dyslipidaemia,
hypertension, stopping smoking would without question be expected to have the
greatest benefit. Tight glycaemic control unfortunately does little to reduce
cardiovascular risk (UKPDS) and statin therapy would be expected to have a small

but significant impact in this patient according to primary prevention studies

(WOSCOPS).
Stopping smoking is the first priority ... even if it causes further weight gain. Drugs
such as 'reductil' can be used to help patients limit weight gain when stopping
smoking.
Smoking is associated with a cardiovascular risk of 6x in women and 3x in men.
Stopping smoking (after an MI) reduces the risk of recurrent MI by 50%

10. 56. This CT was performed on a 63-year-old male who presents with acute
central chest pain 9 out of 10 in severity. He gave up smoking 10 years ago, has a
past history of hypertension for which he takes amlodipine and has no family
history of heart disease.
On examination, he is sweaty and pale, has a blood pressure of 162/80 mmHg, a
pulse of 108 per minute. Ausculatation of the heart reveals a soft early diastolic
murmur but nothing else.
Investigations show normal FBC, U+Es and a cholesterol of 6 mmol/l. ECG reveals
1mm ST segment elevation of the leads II and III.

What is the most appropriate treatment for this patient?

Aspirin
Cardiac catheteristion +/- angioplasty
IV metoprolol
Low molecular weight heparin and isoket
Thrombolysis
ANS: C
This CT demonstrates an obvious flap in the thoracic aorta indicating aortic
dissection. The aortic regurgitant murmur would alert the examiner to this and
mediastinal widening may be seen on X-ray. Occassionally, there is involvement of
the right coronary artery in the dissection process giving rise to the acute ECG
changes. However, if you said that you would give thrombolysis then you would

have killed this patient! The most appropriate management strategy is to provide
adequate analgesia and urgently reduce the blood pressure with IV
antihypertensives - beta blockers first line and then Nitroprusside. Then contact the
cardiothoracic surgeons.

11. A 20-year-old woman complains of recurrent syncope. Each attack has occurred after
attending an aerobics class. On examination, a systolic murmur is heard which worsens with
the Valsalva manoeuvre and improves on squatting.
What could be the diagnosis?

Epilepsy

Hypertrophic obstructive cardiomyopathy

Atrial fibrillation

Aortic stenosis

Vasovagal attack

Dyspnoea is usually the most common complaint of patients with hypertrophic obstructive
cardiomyopathy. However, angina or syncope may also occur. A left ventricular apical
impulse, a prominent S4 gallop and a harsh systolic ejection murmur are typical findings
in these cases. Valsalva manoeuvre decreases venous return to the heart, which results in
a smaller ventricular size. This leads to an increase in the murmur. An echocardiogram is

the diagnostic procedure of choice. Most patients with pure or predominant aortic
stenosis have gradually increasing obstruction for years but do not become symptomatic
until their sixth to eighth decades.

12. A 54-year-old man is referred with increased swelling of his ankles and abdomen, and a degree of
shortness of breath on exertion. His jugular venous pressure is elevated with prominent x- and ydescents. Apex beat is normal. ECG shows atrial fibrillation with widespread non-specific ST-segment
abnormalities. Echo reveals preserved left ventricular systolic function with biatrial enlargement and
an estimated pulmonary artery systolic pressure of around 60 mmHg. Chest X-ray shows atrial
enlargement but no other abnormalities.
What is the most likely cardiac diagnosis?

Chronic pulmonary emboli

Dilated cardiomyopathy

Restrictive cardiomyopathy

Secundum ASD

Tricuspid regurgitation

Restrictive cardiomyopathy results from fibrosis or infiltration of the endo- or myocardium. The
result is failure of the ventricles to relax, with a subsequent increase in ventricular end-diastolic
pressures leading on to biatrial enlargement. Systolic function is normal. Underlying causes include
amyloidosis, storage disorders, sarcoidosis, haemochromatosis and endomyocardial fibrosis.
Symptoms are usually those of predominant right heart failure and atrial fibrillation is common.
The ECG may be normal but diffuse ST-segment and T-wave changes are commonly seen. Diuretics
are the mainstay of symptomatic treatment. It can be very difficult to differentiate restrictive
cardiomyopathy from constrictive pericarditis. In restriction the pulmonary artery systolic pressure
is usually elevated to > 45 mmHg, while it is lower in constriction. Right and left heart catheter
may aid differentiation.

13. A 30-year-old woman is routinely seen by her GP 24 weeks into her first pregnancy. She is well
without adverse symptoms. Her blood pressure is 150/96 mmHg. Her baseline blood pressure at booking
was 136/84 mmHg. No other abnormalities are found.
What drug therapy would you prescribe?

Bendrofluazide

Moxonidine

Labetalol

Losartan

Ramipril

C
Hypertension in pregnancy is defined as a blood pressure > 140/90 mmHg or a rise of 25 mmHg of
systolic and/or 15 mmHg of diastolic pressure above baseline. It is seen in around 10% of all
pregnancies. Gestational hypertension is more common than pre-eclampsia, which is associated
with maternal organ dysfunction. While the latter is treated by delivery, drug therapy is often
required to treat gestational hypertension. First-line agents, proven to be safe in pregnancy,
include labetalol and methyldopa. Second-line agents include nifedipine, hydralazine and prazosin.
Thiazides, ACE inhibitors and angiotensin receptor blockers are not recommended for use in
pregnancy due to the risk of adverse effects on the developing fetus.

14. What is the most likely lipid abnormality in a 48-year-old Asian man with good
glycaemic control?
Elevated high-density lipoprotein (HDL)
Elevated low-density lipoprotein (LDL)
Elevated LDL/elevated triglycerides

Low HDL/elevated LDL

Low HDL/elevated triglycerides
E
Asians do not have classical LDLrelated risk for ischaemic heart disease.
Their profile includes low HDL and elevated triglycerides, meaning that
measurement of LDL alone may underestimate their risk.

15. A 36-year-old old woman presents with a cerebral infarct following treatment for a deep vein
thrombosis. Cardiovascular examination is entirely normal.
The most likely underlying cardiac abnormality is?
Partial anomalous pulmonary venous drainage
Ostium primum atrial septal defect
Ostium secundum
Common atrium
Patent foramen ovale
E
The incidence and importance of patent foramen ovale (PFO) remain controversial but up
to 25% of people have a PFO which may allow passage of a thrombus from the venous to
systemic circulation when the right heart pressures are increased characteristically with
Valsalva or following a pulmonary embolus. PFOs are not associated with clinical signs and
cannot normally be identified on transthoracic echo. Use of agitated saline contrast during
echo is helpful in identifying PFOs. Other types of ASDs are much less common than PFOs
and abnormal clinical signs are usually present. Partial anomalous pulmonary venous

drainage means that between one and three pulmonary veins open into the right atrium
rather than the left atrium. There is no increased risk of right-to-left shunting.