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1hls book has a collecLlon of mulLlple cholce quesLlons ln cardlovascular
medlclne. 1he quesLlons are caLegorlzed accordlng Lo dlfferenL subLoplcs. 1he
correcL answers, LogeLher wlLh a relevanL dlscusslon, are glven aL Lhe end of
each secLlon.

lL ls hoped LhaL Lhls collecLlon wlll be of use Lo medlcal sLudenLs and
posLgraduaLes preparlng for MCC examlnaLlons.



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lSCPALMlC PLA81 ulSLASL 4
Answers for lschemlc PearL ulsease quesLlons 11

PLA81 lAlLu8L 18
Answers Lo PearL lallure quesLlons 24

P?L81LnSlCn 32
Answers Lo PyperLenslon quesLlons 39

CA8ulCvASCuLA8 u8uCS 47
Answers Lo cardlovascular drugs quesLlons 33

CA8ulAC A88LS1 61
Answers Lo cardlac arresL quesLlons 68

8PLuMA1lC PLA81 ulSLASL 74
Answers Lo 8hemaLlc PearL ulsease quesLlons 81

A88P?1PMlAS 90
Answers Lo arrhyLhmla quesLlons 96

CA8ulCM?CA1PlLS 103
Answers Lo CardlomyopaLhy quesLlons 109

CL8L88CvASCuLA8 ulSLASL 116
Answers Lo cardlovascular dlsease quesLlons 122

ulA8L1LS MLLLl1uS 130
Answers Lo ulabeLes MelllLus quesLlons 136
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1) A 40 year old execuLlve consulLs Lhe docLor for a rouLlne medlcal check.
Pe has no sympLoms. Pe ls overwelghL, blood pressure ls 130/70, smokes
3 clgareLLes per day, and hls serum cholesLerol ls 230mg/dL. Pe ls a
LeeLoLaler. Pe has no famlly hlsLory of lschaemlc hearL dlsease.
a) Pe should reduce welghL Lo achleve a body mass lndex of 24
b) Pe should sLarL drlnklng alcohol ln moderaLlon
c) Pe should reduce smoklng
d) Pe should be lmmedlaLely sLarLed on a sLaLln.
e) Pe should be advlsed Lo Lake regular exerclse

2) 1he followlng sympLoms are suggesLlve of and need furLher lnvesLlgaLlon
for suspecLed anglna pecLorls
a) ChesL paln on cllmblng 2 fllghLs of sLalrs
b) LplgasLrlc paln afLer meals
c) ChesL paln aL nlghL durlng sleep whlch causes Lhe paLlenL Lo wake up
d) ShorLness of breaLh and Llredness on moderaLe exerLlon
e) A LlghLenlng sensaLlon ln Lhe LhroaL durlng exerLlon

3) 8egardlng Lhe rlsk facLors for lschaemlc hearL dlsease
a) lL ls commoner ln obese people
b) 1he rlsk from smoklng decllnes Lo almosL normal soon afLer sLopplng
smoklng
c) ModeraLe consumpLlon of alcohol reduces Lhe rlsk for lschaemlc
hearL dlsease
d) MedlLaLlon has been proven Lo reduce Lhe rlsk of developlng
lschaemlc hearL dlsease
e) remenopausal dlabeLlc women have almosL Lhe same rlsk as men Lo
develop lschaemlc hearL dlsease

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4) 8egardlng Lhe rlsk facLors for lschaemlc hearL dlsease
a) 8egular aeroblc exerclse proLecLs agalnsL lschaemlc hearL dlsease
b) LlevaLed serum homocysLelne levels ls an lndependenL rlsk facLor
c) 8lood pressure lowerlng reduces Lhe rlsk of lschaemlc cardlac evenLs
d) A parenL wlLh lschaemlc hearL dlsease aL Lhe age of 70 years ls a rlsk
facLor for an lndlvldual Lo develop lschaemlc hearL dlsease
e) Women on hormone replacemenL Lherapy are proLecLed agalnsL
lschaemlc hearL dlsease

3) 1he followlng are of proven value ln reduclng Lhe rlsk of lschaemlc hearL
dlsease
a) 1reaLmenL wlLh anLlbloLlcs
b) 1reaLmenL wlLh low dose asplrln
c) WelghL reducLlon
d) 1reaLmenL wlLh sLaLlns
e) AcupuncLure

6) A 43 year old man ls admlLLed wlLh cenLral chesL paln and sweaLlng. Pls
LCC shows 1 wave lnverslons ln Lhe anLerlor leads, a prevlous LCC whlch
he broughL ls normal. A Lroponln 1 LesL ls negaLlve.
a) unsLable anglna ls a llkely dlagnosls
b) Pe should be glven sLrepLoklnase
c) lnLravenous heparln ls lndlcaLed
d) Pe has a hlgh chance of geLLlng a myocardlal lnfarcLlon wlLhln Lhe
nexL few days
e) A non-S1 elevaLlon myocardlal lnfarcLlon ls a posslble dlagnosls

7) A 38 year old woman presenLs wlLh severe cenLral chesL paln and
shorLness of breaLh. She ls ln pulmonary oedema, and her blood pressure
ls 190/100mmPg. LCC shows a lefL bundle branch block whlch has noL
been presenL before. A Lroponln 1 LesL ls poslLlve.
a) An acuLe anLerlor myocardlal lnfarcLlon ls a llkely dlagnosls
b) Per rlsk of dylng due Lo Lhls evenL ls greaLer Lhan 30
c) 8lood pressure reducLlon ls beneflclal
d) SLrepLoklnase ls lndlcaLed
e) eLhldlne ls sulLable for analgesla


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8) A 33 year old woman presenLs wlLh chesL paln on exerLlon. She has no
rlsk facLors.
a) A normal resLlng LCC excludes Lhe presence of lschaemlc hearL
dlsease
b) She should be sLarLed on asplrln
c) 1he llkellhood of an exerclse LCC belng poslLlve ls very low
d) A coronary anglogram should be arranged
e) An echocardlogram ls warranLed

9) ulfferences beLween Lhe sexes ln cardlovascular dlsease and lLs
LreaLmenL lnclude
a) cough caused by ACL lnhlblLors ls commoner ln women
b) lsolaLed sysLollc hyperLenslon ls commoner ln men
c) women are llkely Lo llve longer Lhan men from Lhe daLe of onseL of
anglna
d) prevalence of coronary arLery dlsease ln women wlLh chesL paln ls
less Lhan ln men wlLh chesL paln
e) women presenLlng wlLh coronary arLery dlsease Lend Lo have more
severe dlsease

10) A 30 year old man develops acuLe severe rlghL chesL paln. robable
causes lnclude
a) neumoLhorax
b) AcuLe myocardlal lnfarcLlon
c) AcuLe cholecysLlLls
d) leurlsy
e) 8heumaLlc fever

11) Causes of lncreased oxygen demand of Lhe hearL lnclude
a) AorLlc sLenosls
b) LefL venLrlcular hyperLrophy
c) regnancy
d) 1reaLmenL wlLh dllLlazem
e) 1reaLmenL wlLh nlfedlplne

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12) 1he followlng are lmporLanL rlsk facLors for lschaemlc hearL dlsease
a) CbeslLy
b) Smoklng
c) Plgh salL lnLake
d) Plgh glucose lnLake
e) Pyperllpldaemla

13) 1he followlng are Lrue regardlng lschaemlc hearL dlsease
a) A male aged 40 years has nearly a 30 percenL rlsk of developlng
lschaemlc hearL dlsease durlng hls llfeLlme.
b) 1he ma[orlLy of men wlLh lschaemlc hearL dlsease presenL wlLh
chronlc anglna raLher Lhan myocardlal lnfarcLlon
c) Cne Lhlrd of all deaLhs over Lhe age of 33 years are due Lo lschaemlc
hearL dlsease
d) osL menopausal women are aL Lhree Llmes Lhe rlsk of developlng
lschaemlc hearL dlsease Lhan premenopausal women of Lhe same
age
e) 1he use of hormone replacemenL Lherapy ln posLmenopausal women
markedly reduces Lhelr rlsk of developlng lschaemlc hearL dlsease

14) 8egardlng smoklng and lschaemlc hearL dlsease
a) MosL smokers are aware LhaL smoklng wlll lncrease Lhe rlsk of hearL
dlsease
b) Smoklng doubles Lhe rlsk of developlng coronary arLery dlsease
c) ln women, Lhe rlsk of myocardlal lnfarcLlon ls lncreased slx fold lf
Lhey smoke
d) asslve smoklng lncreases Lhe rlsk of coronary arLery dlsease by 20
e) Clgar smoklng does noL lncrease Lhe rlsk of coronary arLery dlsease

13) 1 wave lnverslons on Lhe LCC are seen ln Lhe followlng condlLlons
a) Myocardlal lnfarcLlon
b) MlLral valve prolapse
c) Pyperkalaemla
d) Subarachnold haemorrhage
e) MyocardlLls

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16) 1he followlng facLors conLrlbuLe Lo Lhe developmenL of myocardlal
lschaemla
a) Anaemla
b) olycyLhaemla
c) LefL venLrlcular hyperLrophy
d) AorLlc valve sLenosls
e) MlLral valve sLenosls

17) A posslble dlagnosls of acuLe myocardlal lnfarcLlon should be consldered
ln Lhe followlng slLuaLlons
a) Sudden onseL severe cenLral chesL paln
b) Sudden severe lefL venLrlcular fallure
c) Sudden deaLh
d) new onseL compleLe hearL block
e) Severe burnlng eplgasLrlc paln

18) ln Lhe presence of chesL paln, LCC changes suggesLlve of an acuLe
myocardlal lnfarcLlon lnclude
a) Saddle shaped S1 segmenL elevaLlons ln all leads
b) new lefL bundle branch block
c) new CompleLe hearL block
d) ueep 1 wave lnverslons ln Lhe anLerlor leads
e) venLrlcular Lachycardla

19) 8egardlng evenLs afLer a acuLe anLerlor myocardlal lnfarcLlon
a) venLrlcular flbrlllaLlon occurrlng wlLhln Lhe flrsL 24 hours has a
relaLlvely good prognosls
b) uresslers syndrome occurs wlLhln 48 hours
c) lf compleLe hearL block occurs, paclng ls usually requlred
d) MulLlple venLrlcular ecLoplcs should be LreaLed wlLh anLlarrhyLhmlcs
e) 1reaLmenL wlLh an ACL lnhlblLor ls lndlcaLed

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20) 8egardlng Lhe LreaLmenL of myocardlal lnfarcLlon
a) SLrepLoklnase ls lndlcaLed ln non S1 LlevaLlon myocardlal lnfarcLlon
b) Peparln ls lndlcaLed ln paLlenLs glven sLrepLoklnase
c) Lenolol wlll reduce Lhe rlsk of sudden deaLh
d) Asplrln wlll reduce morLallLy by 23
e) An ACL lnhlblLor wlll reduce Lhe rlsk of developlng hearL fallure laLer
on
21) 1he followlng are lnsLances of unsLable anglna
a) Anglnal paln occurrlng for Lhe flrsL Llme
b) Anglnal paln occurrlng afLer meals
c) A sudden reducLlon ln Lhe dlsLance Lhe paLlenL can walk wlLhouL
chesL paln
d) ChesL paln on walklng Lo Lhe LolleL on Lhe 4Lh day afLer myocardlal
lnfarcLlon
e) Anglna aL resL

22) A paLlenL who developed an acuLe lnferlor myocardlal lnfarcLlon ls belng
dlscharged. 1he followlng are Lrue
a) Pe should have a llmlLed exerclse LCC prlor Lo dlscharge
b) Pe should absLaln from sex for 3 monLhs
c) Pe cannoL drlve a car for 6 monLhs
d) Pe should be referred for coronary anglography ln 6 weeks Llme
e) Pe should be advlsed Lo Lake subllngual glyceryl LrlnlLraLe ln case he
develops anglna agaln

23) ln a paLlenL who has had a recenL myocardlal lnfarcLlon and whose LoLal
cholesLerol 3.3 - 8.0 mmol/l Lhe lnLroducLlon of PMC CoA reducLase
lnhlblLor would
a) decrease Lhe relnfarcLlon raLe
b) lncrease lncldence non-cardlac deaLhs
c) slows Lhe raLe of aLherosclerosls
d) reduce Lhe rlsk of sudden deaLh
e) ls a recognlsed cause of rhabdomyolysls





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24) A 31 year old woman complalns of palplLaLlons, breaLhlessness and chesL
paln, radlaLlng Lo Lhe lefL arm. She had been well, and developed
sympLoms slx weeks ago when her faLher dled of a hearL aLLack. She has
no rlsk facLors. She complalns of dlfflculLy ln falllng asleep aL nlghL. She
has had abdomlnal paln, backache, headache, and numbness of Lhe llmbs
for several years, for whlch she has Laken LreaLmenL repeaLedly. Whlch
of Lhe followlng dlagnoses are llkely
a) uepresslon
b) lacLlLlous dlsorder
c) SomaLlzaLlon dlsorder
d) CasLrlLls
e) ALLenLlon seeklng

23) Whlch of Lhe followlng sLaLemenLs concernlng Lhe LreaLmenL of acuLe
myocardlal lnfarcLlon ls correcL?
a) A pansysLollc murmur developlng wlLhln Lhe flrsL 24 hours does noL
requlre furLher lnvesLlgaLlon.
b) ulpyrldamole Lherapy reduces relnfarcLlon wlLhln Lhe flrsL year.
c) Peparln ls beneflclal lf glven wlLh sLrepLoklnase.
d) rophylacLlc llgnocalne glven ln Lhe flrsL 48 hours ls effecLlve ln
prevenLlng venLrlcular flbrlllaLlon
e) 1reaLmenL wlLh a dlhydropyrldlne calclum anLagonlsL ls assoclaLed
wlLh lncreased cardlovascular morLallLy.




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1) 1lll1
CverwelghL, smoklng, elevaLed serum llplds are all lmporLanL rlsk facLors, buL
Lhls lndlvldual has no sympLoms of lschaemlc hearL dlsease aL presenL. Pe
should sLop, noL reduce, smoklng. WelghL reducLlon Lo ldeal body mass lndex
of 24 ls recommended. uleL conLrol should be Lrled ouL for aL leasL 3 monLhs
Lo lower hls llplds. lf lL falls, llpld lowerlng Lherapy should be sLarLed - sLaLlns
have beneflLs ln prlmary prevenLlon, and are Lhe preferred drugs. Alcohol ln
moderaLlon reduces cardlovascular morLallLy by beneflclal effecLs on llplds,
buL a person who does noL drlnk should noL be advlsed Lo sLarL drlnklng Lo
reduce coronary rlsk. lL may lead Lo hls drlnklng above Lhe safe llmlL. 8egular
exerclse helps ln malnLalnlng body welghL and lncreases cardlovascular
flLness.

2) 11111
All of Lhese could be manlfesLaLlons of anglna. LplgasLrlc paln afLer meals
could be due Lo a gasLrlc ulcer, buL could also occur ln lschaemla of Lhe
lnferlor wall of Lhe hearL. nocLurnal anglna characLerlsLlcally wakes Lhe
paLlenL up from hls sleep. A LlghLenlng sensaLlon ln Lhe LhroaL durlng exerLlon
ls very suggesLlve of anglna.

3) 1l1l1
CbeslLy ls an lndependenL rlsk facLor for lschaemlc hearL dlsease. 1he rlsk
from smoklng decllnes Lo normal 10 years afLer sLopplng smoklng. ModeraLe
alcohol consumpLlon (3 unlLs per day) has beneflclal effecLs on serum llplds,
and Lhere ls some evldence LhaL lL may reduce cardlovascular and overall
morLallLy. ln splLe of Lhls, Lhe oLher rlsks, boLh soclal and medlcal, of asklng
people Lo sLarL drlnklng are hlgh. eople who already drlnk ln moderaLlon
should be Lold LhaL lL ls alrlghL Lo conLlnue, buL Lhose whose don'L drlnk
should never be asked Lo sLarL drlnklng. MedlLaLlon, Lhough wldely LouLed as
belng good for your hearL, has no proven beneflL. osL menopausal women
have almosL Lhe same rlsk of developlng lschaemlc hearL dlsease as men, buL
premenopausal women are proLecLed. 1hls proLecLlon ls losL ln dlabeLlc
women.


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4) 111l1
8egular aeroblc exerclse ls proLecLlve agalnsL lschaemlc hearL dlsease.
LlevaLed homocysLelne levels are LhoughL Lo lnduce a proLhromboLlc sLaLe,
and lncrease Lhe rlsk of lschaemlc hearL dlsease and sLroke. PyperLenslon ls
one of Lhe mosL lmporLanL rlsk facLors for lschaemlc hearL dlsease, and blood
pressure lowerlng reduces cardlovascular rlsk. A slgnlflcanL famlly hlsLory ls
presenL lf a parenL developed lschaemlc hearL dlsease below Lhe age of 30
years. lamlly hlsLory of lschaemlc hearL dlsease developlng aL Lhe age of 70
years does noL confer any addlLlonal rlsk. AlLhough slnce premenopausal
women are proLecLed agalnsL lschaemlc hearL dlsease lL was LhoughL LhaL
hormone replacemenL Lherapy would glve Lhe same beneflL, evldence from
Lrlals ls Lo Lhe conLrary. Pormone replacemenL Lherapy may acLually lncrease
cardlovascular rlsk, and ls no longer recommended Lo paLlenLs wlLh a hlgh
llkellhood of developlng lschaemlc hearL dlsease.

3) l111l
AlLhough Lhere ls some evldence LhaL lnfecLlons, especlally wlLh Chlamydla,
may play a causaLlve role ln aLheroma, Lhere ls no evldence yeL LhaL
anLlbloLlcs are beneflclal. Low dose asprlrln, welghL reducLlon and LreaLmenL
wlLh sLaLlns are of proven value, boLh ln prlmary and secondary prevenLlon.
1here ls no evldence LhaL acupuncLure ls of any use.

6) 1l11l
A negaLlve Lroponln 1 makes a myocardlal lnfarcLlon less llkely. 1he sympLoms
and lschaemlc LCC changes make Lhls unsLable anglna by deflnlLlon.
SLrepLoklnase ls Lherefore noL lndlcaLed. A paLlenL wlLh unsLable anglna
paLhologlcally has a rupLured aLheromaLous plaque wlLhouL an occluslve
coronary Lhrombosls. Pe has a very hlgh chance of developlng an occluslve
coronary Lhrombosls resulLlng ln a myocardlal lnfarcLlon ln Lhe nexL few days.
lnLravenous heparln or subcuLaneous low molecular welghL heparln are useful
ln prevenLlng Lhls.

7) 1l11l
ln vlew of Lhe Lyplcal hlsLory and poslLlve Lroponln 1 LesL, Lhls ls an acuLe
myocardlal lnfarcLlon by deflnlLlon. new lefL bundle branch block ls
suggesLlve, ln Lhls seLLlng, of an acuLe anLerlor myocardlal lnfarcLlon, and Lhls
ls an lndlcaLlon for sLrepLoklnase. Per rlsk of dylng ls abouL 33 Lo 40 percenL,
ln vlew of Lhe presence of lefL venLrlcular fallure. 8lood pressure reducLlon ls
beneflclal as lL wlll reduce Lhe afLerload, and reduce myocardlal oxygen
"#$%&'()$!%'&*+!,)#'&#'-./#0'*#!

13

consumpLlon. eLhldlne ls unsulLable for analgesla as lL causes pulmonary
venoconsLrlcLlon and lncreases venous reLurn. Morphlne glven
lnLramuscularly ls Lhe drug of cholce.

8) ll1ll
1he resLlng LCC can be normal ln lschaemlc hearL dlsease. Powever, ln a
premenopausal women wlLh no rlsk facLors, Lhe chances of Lhe chesL paln
belng due Lo lschaemlc hearL dlsease ls very low. Per preLesL probablllLy of
Lhe exerclse LCC belng poslLlve ls very low. Asplrln ls noL lndlcaLed. A
coronary anglogram ls lndlcaLed only ln Lhe presence of a poslLlve exerclse
LCC LesL. 1here ls no real lndlcaLlon for an echocardlogram elLher.

9) 11111
ACL lnhlblLor lnduced occurs a few weeks afLer commenclng Lhe drug, and
dlsappears a few days afLer sLopplng lL. lL ls commoner ln women. Women
wlLh coronary arLery dlsease generally have more dlffuse dlsease, lnvolvlng
smaller vessels. Men wlLh chesL paln are more llkely Lo have lschaemlc hearL
dlsease Lhan women.

10) 1111l
8heumaLlc fever can cause chesL paln due Lo perlcardlLls, buL lL ls more ofLen
on Lhe lefL, and a man of 30 years ls less llkely Lo have rheumaLlc fever. 1he
paln of myocardlal lnfarcLlon ls known Lo manlfesL as rlghL slded chesL paln.

11) 111ll
CondlLlons where Lhere ls volume overload (aorLlc regurglLaLlon, mlLral
regurglLaLlon, pregnancy, LhyroLoxlcosls and oLher hlgh ouLpuL sLaLes) as well
as Lhose causlng pressure overload (aorLlc sLenosls and sysLemlc
hyperLenslon) wlll lncrease myocardlal oxygen demand. ullLlazem and
aLenolol are negaLlve lnoLropes and chronoLropes and wlll reduce myocardlal
oxygen demand. nlfedlplne ls prlmarlly a vasodllaLor, and wlll cause reflex
Lachycardla, whlch wlll lncrease myocardlal oxygen demand. 1hls ls
posLulaLed Lo be one mechanlsm by whlch shorL acLlng nlfedlplne lncreases
morLallLy when used ln Lhe LreaLmenL of hyperLenslon.

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14

12) 111l1
CbeslLy, smoklng, dlabeLes melllLus, hyperllpldaemla, hyperLenslon, hlgh salL
lnLake are all lmporLanL rlsk facLors for lschaemlc hearL dlsease. Plgh glucose
lnLake may resulL ln obeslLy, buL lL ls noL, by lLself and lndependenL rlsk facLor.

13) 1l111
lschaemlc hearL dlsease ls a common dlsease. MosL men presenL for Lhe flrsL
Llme wlLh a myocardlal lnfarcLlon Lhan wlLh chronlc anglna. osL menopausal
women are much more llkely Lo develop lschaemlc hearL dlsease, buL conLrary
Lo expecLaLlons, hormone replacemenL Lherapy does noL reduce Lhls rlsk. ln
facL Lhere ls evldence LhaL hormone replacemenL Lherapy may lncrease Lhe
rlsk.

14) l111l
Many smokers do noL belleve LhaL smoklng ls harmful. ln one sLudy, up Lo 60
percenL of smokers were dld noL belleve LhaL Lhey were aL lncreased rlsk for
lschaemlc hearL dlsease. Smoklng doubles Lhe rlsk of lschaemlc hearL dlsease,
and women who smoke are slx Llmes more llkely Lo develop lschaemlc hearL
dlsease compared Lo Lhose who do noL smoke. asslve smoklng lncreases Lhe
rlsk of lschaemlc hearL dlsease by abouL 20 percenL. AlLhough clgar smoklng ls
generally percelved as belng safer Lhan clgareLLe smoklng, lL Loo lncreases Lhe
rlsk of myocardlal lnfarcLlon.

13) 11l11
1all LenLed 1 waves are seen ln hyperkalaemla. lschaemla and myocardlLls
can boLh cause L wave lnverslons. aLlenLs wlLh mlLral valve prolapse ofLen
have 1 wave lnverslons on Lhe LCC, buL Lhelr slgnlflcance ls noL known.
aLlenLs wlLh lnLracranlal evenLs, subarachnold haemorrhage ln parLlcular, can
have lschaemlc changes on Lhe LCC. 1hese are posLulaLed Lo be due Lo a
lncreased caLecholamlne release.

16) 1111l
Anaemla can worsen lschaemla by reduclng oxygen dellvery. ln
polycyLhaemla, hypervlscoslLy of blood can cause coronary and cerebral
lschaemla. ln lefL venLrlcular hyperLrophy myocardlal oxygen demand ls
greaLer, and ln Lhe presence of coronary arLery dlsease, myocardlal lschaemla
can develop. 1he oxygen supply Lo Lhe subendocardlal reglons of Lhe lefL
venLrlcle ls parLlcularly compromlsed. ln aorLlc sLenosls, coronary arLery
blood flow ls reduced due Lo reduced effecLlve cardlac ouLpuL. Coronary
"#$%&'()$!%'&*+!,)#'&#'-./#0'*#!

13

arLery dlsease may coexlsL. ln addlLlon, lefL venLrlcular hyperLrophy ls ofLen
presenL. ln mlLral valve sLenosls, Lhe lefL venLrlcle ls usually small and
myocardlal oxygen demand ls low.

17) 11111
All of Lhese can be presenLaLlons of an acuLe Ml. ln Lhe elderly, ln dlabeLlcs,
paLlenLs ln renal fallure, hyper and hyperLhyrold paLlenLs, sllenL myocardlal
lnfarcLlon can occur. 1hese may presenL as lefL venLrlcular fallure, or
dysrrhyLhmlas. An lnferlor myocardlal lnfarcLlon can presenL wlLh eplgasLrlc
burnlng paln mlmlcklng pepLlc ulcer dlsease.

18) l1111
Saddle shaped S1 segmenL elevaLlons are seen ln perlcardlLls. 1hey are ofLen
wldespread. 1he S1 elevaLlons ln myocardlal lnfarcLlon are dome shaped, and
are usually conflned Lo speclflc leads reflecLlng Lhe area of lnfarcLlon. new
lefL bundle branch block ls dlagnosLlc of an Ml. new compleLe hearL block
may be Lhe presenLlng feaLure of a sllenL myocardlal lnfarcLlon. ueep
symmeLrlcal 1 wave lnverslons are seen ln non-S1 elevaLlon myocardlal
lnfarcLlon. An acuLe Ml may presenL wlLh venLrlcular Lachycardla.

19) 1l1l1
rlmary vl or vl occurrlng wlLhln Lhe flrsL 24 hours generally does noL denoLe
a worse prognosls, and does noL affecL ouLcome. lf lL occurs durlng or soon
afLer sLrepLoklnase, lL may be a reperfuslon arrhyLhmla. uresslers syndrome
usually occurs abouL a week Lo 10 days afLer Lhe Ml. CompleLe hearL block,
when lL occurs ln an anLerlor Ml, needs paclng as lL ls unllkely Lo recover
sponLaneously. lf lL occurs wlLh an lnferlor Ml, lL reverLs sponLaneously ln
mosL cases. MulLlple ecLoplcs whlch do noL cause haemodynamlc
compromlse do noL requlre LreaLmenL - ln facL LreaLmenL can be harmful
because anLlarrhyLhmlc agenLs Lhemselves can cause dangerous arrhyLhmlas.
AnLerlor Mls are usually large, and ACL lnhlblLors wlll be of parLlcular beneflL
ln modlfylng venLrlcular remodellng.

20) l1111
SLrepLoklnase ls lndlcaLed ln S1 elevaLlon Ml. 1here ls no place for lLs use ln
non-S1 elevaLlon Ml, as lL has noL shown beneflL ln LhaL slLuaLlon. Peparln ls
usually noL necessary afLer sLrepLoklnase ls glven, excepL for prevenLlon of
deep veln Lhrombosls. ALenolol has been shown Lo reduce Lhe rlsk of sudden
cardlac deaLh wlLhln Lhe flrsL year afLer myocardlal lnfarcLlon, and ls probably
"#$%&'()$!%'&*+!,)#'&#'-./#0'*#!

16

beneflclal lf used for longer perlods. 1he maln mechanlsm by whlch aLenolol
prevenLs deaLhs ls posLulaLed Lo be Lhe reducLlon of llfe LhreaLenlng
arrhyLhmlas. Asplrln reduces morLallLy afLer myocardlal lnfarcLlon by 23
percenL and sLrepLoklnase by 23 percenL. 1he comblnaLlon of asplrln and
sLrepLoklnase reduces morLallLy by 43 percenL. ACL lnhlblLors have complex
beneflclal effecLs on venLrlcular remodellng and wlll reduce Lhe rlsk of hearL
fallure laLer on.

21) 1l111
8ecenL onseL anglna, a change ln Lhe paLLern of anglna, anglna aL resL and
posL myocardlal lnfarcLlon anglna are all Lypes of unsLable anglna. 1hey are
due Lo plaque rupLure, and need Lo be managed lnLenslvely because Lhe
llkellhood of developlng a myocardlal lnfarcLlon ls hlgh

22) 1llll
ldeally a modlfled exerclse LCC should be performed prlor Lo dlscharge, ln
order Lo sLraLlfy lmmedlaLe rlsk. 1he paLlenL can resume sexual acLlvlLy afLer
abouL 2 weeks. Pe should avold drlvlng a car for abouL 6 weeks, buL Lhe
regulaLlons vary from counLry Lo counLry. MosL paLlenLs would have an
echocardlogram and an exerclse LCC aL 6 weeks. Coronary anglogram ls
performed only lf Lhe exerclse LCC ls poslLlve. AfLer a myocardlal lnfarcLlon,
mosL paLlenLs would be free of paln, because Lhe lschaemlc area ls now dead.
1he presence of anglnal paln lndlcaLes Lhere are oLher areas wlLh crlLlcal
lschaemla. osL myocardlal lnfarcLlon anglna ls a Lype of unsLable anglna and
should be managed aggresslvely. 1he paLlenL should be Lold Lo reporL back Lo
hosplLal raLher Lhan slmply use glyceryl LrlnlnLraLe LableLs lf he develops
slgnlflcanL chesL paln.

23) 1l1l1
SLaLlns are useful ln secondary prevenLlon. 1hey reduce Lhe raLe of
relnfarcLlon, posslbly by slowlng Lhe raLe of aLherosclerosls. 1here ls no
evldence of lncrease ln non cardlac deaLhs. 1here ls no deflnlLe LhaL lL
reduces Lhe rlsk of sudden deaLh. SLaLlns are known Lo cause rhabdomyolysls,
especlally lf comblned wlLh flbraLes.

"#$%&'()$!%'&*+!,)#'&#'-./#0'*#!

17

24) 1l1ll
SomaLlzaLlon dlsorder ls characLerlzed by mulLlple recurrlng palns and
gasLrolnLesLlnal, sexual, and pseudo-neurologlc sympLoms LhaL occur over a
perlod of years. 1o meeL Lhe dlagnosLlc crlLerla for somaLlzaLlon dlsorder, Lhe
paLlenLs' physlcal complalnLs musL noL be lnLenLlonally lnduced and musL
resulL ln medlcal aLLenLlon or slgnlflcanL lmpalrmenL ln soclal, occupaLlonal, or
oLher lmporLanL areas of funcLlonlng. 8y deflnlLlon, Lhe flrsL sympLoms appear
ln adolescence and Lhe full crlLerla are meL by 30 years of age. Cf all Lhe oLher
dlsorders "facLlLlous dlsorder" would seem Lhe leasL llkely. uepresslon due Lo
Lhe faLher's deaLh can cause some degree of somaLlzaLlon.

23) llll1
1he occurrence of a pansysLollc murmur suggesL Lhe dangerous posslblllLles of
elLher an acqulred vSu or a rupLured chorda Lendlnae leadlng Lo mlLral
regurglLaLlon. 1he former ls more llkely because acuLe mlLral regurglLaLlon wlll
presenL wlLh lefL venLrlcular fallure raLher Lhan a murmur. 1he morLallLy ls
very hlgh ln boLh Lhese condlLlons. urgenL echocardlography and referral for
surgery ls lndlcaLed. 1here ls no evldence LhaL dlpyrldamole ls useful afLer an
Ml. aLlenLs glven sLrepLoklnase do noL need heparln excepL ln a few selecLed
slLuaLlons. 1here ls no place for prophylacLlc llgnocalne. 1reaLmenL wlLh
dlhydropyrldlne calclum channel anLagonlsLs ls assoclaLed wlLh lncreased
morLallLy afLer myocardlal lnfarcLlon.
1'&*+!2&)34*'
18

IGJ3K!CJE=:3G!

1) 8egardlng hearL fallure
a) 1he prevalence lncreases wlLh age
b) lL accounLs for abouL 3 of hosplLal admlsslons
c) AbouL 30 of paLlenLs dle wlLhln 3 monLhs of Lhe onseL of hearL
fallure
d) 1he ma[orlLy of paLlenLs have sysLollc hearL fallure
e) valvular hearL dlsease ls an lmporLanL cause ln Lhe developlng world

2) 1he followlng are known Lo resulL ln chronlc hearL fallure
a) lschaemlc hearL dlsease
b) Alcohol abuse
c) 1hyroLoxlcosls
d) vlLamln deflclency
e) 8hyLhm dlsLurbances

3) 1he followlng are Lrue
a) A hlgh sysLollc blood pressure excludes a dlagnosls of hearL fallure
b) 1he hearL raLe ls usually hlgh due Lo lncreased adrenerglc acLlvlLy
c) roducLlon of plnk froLhy spuLum ls a common feaLure
d) uyspnoea ls commonly due Lo arLerlal hypoxla
e) Lhe perlpherles are warm

4) 1he followlng may be early sympLoms of hearL fallure
a) uyspnoea on walklng 2 fllghLs of sLalrs
b) nocLurnal cough
c) Waklng up ln Lhe nlghL wlLh dyspnoea
d) A sense of eplgasLrlc fullness
e) Wheezlng on exerLlon

3) ln a paLlenL wlLh hearL fallure
a) Coarse basal crackles can be heard ln Lhe lungs
b) 1he hearL sounds may be normal
c) A palpable Lender llver may be presenL
d) 1he presence of a pan sysLollc murmur usually lndlcaLes rheumaLlc
mlLral valve dlsease
e) A wheeze may be presenL

1'&*+!2&)34*'
19

6) 1he followlng are Lrue regardlng Lhe LCC ln hearL fallure
a) Cld changes of myocardlal lnfarcLlon musL be looked for
b) LefL bundle branch block suggesLs LhaL Lhere ls slgnlflcanL venLrlcular
damage
c) A -pulmonale lndlcaLes Lhe presence of lefL hearL fallure
d) Slnus Lachycardla ls a feaLure
e) 1he presence of u waves suggesLs hypokalaemla due Lo LreaLmenL

7) 8egardlng Lhe chesL radlograph ln hearL fallure
a) A normal slze hearL excludes hearL fallure
b) upper lobe dlverslon of blood ls seen
c) A large unllaLeral pleural effuslon suggesLs a paLhology oLher Lhan
hearL fallure
d) leural effuslons are commoner on Lhe lefL
e) CalclflcaLlon of Lhe valves ls seen

8) 8egardlng Lhe echocardlogram ln hearL fallure
a) lL ls an essenLlal lnvesLlgaLlon prlor Lo commenclng LreaLmenL
b) lL ls a rellable lnvesLlgaLlon Lo dlagnose lefL venLrlcular dlasLollc
dysfuncLlon
c) An e[ecLlon fracLlon below 40 ls compaLlble wlLh hearL fallure
d) ln mlLral regurglLaLlon, Lhe e[ecLlon fracLlon can be hlgh
e) LefL aLrlal Lhrombl can be deLecLed

9) 8egardlng dlasLollc hearL fallure
a) lL occurs ln paLlenLs wlLh longsLandlng hyperLenslon
b) 1he e[ecLlon fracLlon can be normal
c) ulmonary oedema can occur
d) ACL lnhlblLors are useful ln LreaLmenL
e) Can be dlfferenLlaLed from sysLollc fallure based on Lhe response Lo
dlureLlcs

10) 1he followlng are causes of rlghL hearL fallure
a) Chronlc lefL hearL fallure
b) Lmphysema
c) rlmary pulmonary hyperLenslon
d) ALrlal sepLal defecL
e) neumoLhorax

1'&*+!2&)34*'
20

11) Plgh ouLpuL fallure occurs ln
a) 1hyroLoxlcosls
b) SepLlc shock
c) ageL's dlsease
d) 8erl berl
e) AorLlc regurglLaLlon

12) 8egardlng rlghL hearL fallure
a) lL occurs secondary Lo pulmonary hyperLenslon
b) Lmphysema ls a known cause
c) 1he prognosls ls beLLer Lhan for lefL hearL fallure
d) lL may resulL ln Lrlcuspld regurglLaLlon
e) Slldenafll lmproves survlval ln paLlenLs wlLh pulmonary hyperLenslon

13) A 63 year old paLlenL ls admlLLed wlLh severe shorLness of breaLh. Pls
blood pressure ls 130/90mmPg, hearL raLe 120 beaLs per mlnuLe, and he
has bllaLeral basal crackles. Pls LCC ls normal. Pe has a pasL hlsLory of
chronlc hearL fallure due Lo lschaemlc hearL dlsease
a) 1he paLlenL should be placed ln Lhe head low poslLlon Lo lmprove
cerebral perfuslon
b) Morphlne ls useful ln reduclng pulmonary oedema
c) lrusemlde should be glven orally
d) lnLravenous ACL lnhlblLors are effecLlve ln LreaLmenL
e) A nlLraLe lnfuslon can be used Lo relleve sympLoms

14) 8egardlng cardlogenlc shock
a) Warm exLremlLles wlLh a boundlng pulse ls a cllnlcal feaLure
b) confuslon and resLlessness occurs
c) elevaLed cenLral venous pressure ls presenL
d) collolds are used Lo expand clrculaLory volume
e) lnLra-arLerlal blood pressure monlLorlng ls recommended

13) 8egardlng cardlac fallure
a) LefL venLrlcular end dlasLollc volume ls lncreased
b) 8radycardla ls usually presenL
c) Syncope ls a sympLom
d) PyperLenslon ls a cause
e) A Lender enlarged llver lndlcaLes Lhe presence of rlghL hearL fallure

1'&*+!2&)34*'
21

16) ln Lhe managemenL of acuLe lefL venLrlcular fallure
a) Lhe paLlenL ls kepL suplne ln Lhe head low poslLlon
b) Lhlazlde dlureLlcs are lndlcaLed
c) oxygen ls glven vla a face mask
d) morphlne ls glven lnLramuscularly
e) venLllaLlon ls requlred ln severe cases

17) A 33 year old woman pregnanL woman presenLs wlLh acuLe dyspnoea.
1he followlng are llkely causes
a) MlLral sLenosls
b) ulmonary embollsm
c) AsLhma
d) AcuLe myocardlal lnfarcLlon
e) neumonla

18) 1he followlng drugs when glven ln LherapeuLlc dosage may cause cardlac
fallure
a) phenylbuLazone
b) carblmazole
c) daunorublcln
d) propranolol
e) plogllLazone

19) 1he followlng llfesLyle measures are effecLlve ln Lhe LreaLmenL of hearL
fallure
a) WelghL reducLlon
b) 8educLlon of salL ln dleL
c) AdequaLe resL
d) Avoldance of exerclse
e) ModeraLe consumpLlon of alcohol

20) 8egardlng Lhe LreaLmenL of hearL fallure
a) 1here ls no beneflL ln glvlng frusemlde by Lhe lnLravenous rouLe
compared Lo Lhe oral rouLe
b) Large meals should be avolded
c) 8ed resL ls beneflclal
d) lrusemlde ls beLLer glven aL nlghL
e) Cral nlLraLes are usually glven aL 8 hourly lnLervals

1'&*+!2&)34*'
22

21) 1he followlng are Lrue regardlng Lhe LreaLmenL of hearL fallure
a) ACL lnhlblLors reduce morLallLy
b) ulgoxln lmproves sympLoms buL worsens morLallLy
c) SplronolacLone lmproves survlval
d) 8eLa blockers are conLralndlcaLed
e) Cardlac lnoLropes llke dobuLamlne lmprove survlval

22) 1he followlng are Lrue of rlghL venLrlcular fallure?
a) lL resulLs ln ankle oedema
b) emphysema ls a rare cause
c) prlmary pulmonary hyperLenslon ls a cause
d) cenLral venous pressure ls usually greaLer Lhan 4mmPg
e) Lhe prognosls ls beLLer Lhan LhaL for lefL venLrlcular fallure

23) 1he followlng drugs are of proven beneflL ln lmprovlng prognosls ln
chronlc hearL fallure
a) enalaprll ln mlld hearL fallure
b) dlgoxln
c) nlLraLes and prazosln comblnaLlon
d) nlLraLes and hydralazlne comblnaLlon
e) dobuLamlne lnfuslon

24) ln lefL venLrlcular fallure
a) 1he developmenL of pulmonary hyperLenslon resulLs ln ollgaemlc
lung flelds
b) 8reaLhlessness ls usually due Lo hypoxaemla
c) Lhe aCC2 ls lncreased ln pulmonary oedema
d) efforL dyspnoea always precedes orLhopnoea and paroxysmal
nocLurnal dyspnoea
e) Lhe x-ray plcLure may be mlsLaken for solld lung Lumour

1'&*+!2&)34*'
23

23) A 70-year-old man wlLh dllaLed cardlomyopaLhy remalns sympLomaLlc ln
n?PA class 2 due Lo chronlc hearL fallure. Cn examlnaLlon hls pulse ls 90
regular, 8 140/90, hearL sounds normal, chesL ausculLaLlon dld noL
reveal any abnormallLles. Pe ls currenLly Laklng enalaprll 10mg bd and
lrusemlde 40 mg bd. Whlch of Lhe followlng drugs could be consldered Lo
opLlmlze hls Lherapy
a) Amlodarone
b) Carvedllol
c) ulgoxln
d) SplronolacLone
e) CandesarLen
!
!
!
!
!
1'&*+!2&)34*'-./#0'*#!

24

J'%L0)%!>+!I0()>!C(&/.)0!M.0%>&+'%!
!
1) 11111
1he prevalence of hearL fallure lncreases wlLh age and affecLs 8 of Lhose
aged over 63 years. 1he prevalence of hearL fallure caused by lefL venLrlcular
(Lv) sysLollc dysfuncLlon ls abouL 1 overall. AlLhough sysLollc fallure ls
probably commoner, a slgnlflcanL number of paLlenLs may have hearL fallure
wlLhouL sysLollc dysfuncLlon, elLher dlasLollc fallure or valvular PearL fallure
accounLs for 3 of acuLe hosplLal admlsslons, placlng a large burden on Lhe
healLh care sysLem. ApproxlmaLely 30 of paLlenLs wlLh hearL fallure are
admlLLed each year. 30 of paLlenLs dle wlLhln 3 monLhs of Lhe onseL of hearL
fallure, and Lhe annual morLallLy ls abouL 10 LhereafLer. valvular hearL
dlsease ls an lmporLanL cause of hearL fallure ln Lhe developlng world, whlle
effecLlve LreaLmenL of rheumaLlc fever and beLLer overall llvlng condlLlons
have resulLed ln a marked decrease ln developed counLrles

2) 1111l
lschaemlc hearL dlsease, valvular hearL dlsease, cardlomyopaLhles, Loxlns llke
alcohol, drugs, vlLamln deflclency sLaLes llke 8erl 8erl are all causes of hearL
fallure. 1hyroLoxlcosls causes hlgh uLpuL hearL fallure. 8hyLhm dlsLurbances
can resulL ln LranslenL hearL fallure, Lachycardlas can shorLen dlasLollc fllllng
Llme, resulLlng ln a reducLlon ln cardlac ouLpuL. 8radycardlas can resulL ln a
drop ln cardlac ouLpuL slmply because of Lhe slow raLe, Lhough Lhls ls noL
commone. 1achycardlas can cause LranslenL cardlomyopaLhy whlch can
perslsL for some Llme. 1hese condlLlons are noL ofLen lmpllcaLed as causes of
chronlc hearL fallure, and reversal of Lhe arrLhyLhmla resulLs ln reversal of Lhe
cardlac dysfuncLlon. ArrhyLhmlas can however worsen sympLoms ln paLlenLs
wlLh preexlsLlng hearL fallure.

3) l1lll
1he sysLollc blood pressure ls usually on Lhe low slde ln hearL fallure.
Powever, lf sysLollc funcLlon ls preserved, Lhe blood pressure can be hlgh. A
hlgh blood pressure wlll worsen hearL fallure by lncreaslng afLerload.
Lowerlng of Lhe blood pressure ls ofLen beneflclal. As a compensaLory
mechanlsm Lhere ls acLlvaLlon of Lhe adrenerglc sysLem ln hearL fallure, and
Lhls ofLen resulLs ln Lachycardla. AcLlvaLlon of Lhe chollnerglc sympaLheLlcs
resulLs ln sweaLlng of Lhe palms and perlpheral vasoconsLrlcLlon. Cold clammy
exLremlLles are a feaLure. lnk froLhy spuLum ls a feaLure of acuLe alveolar
1'&*+!2&)34*'-./#0'*#!

23

oedema whlch occurs lf Lhe hearL fallure ls very acuLe. ln mosL paLlenLs wlLh
chronlc hearL fallure, pulmonary arLerlal vasoconsLrlcLlon proLecLs agalnsL a
rapld rlse ln pulmonary venous pressure. lnLersLlLlal oedema occurs flrsL,
resulLlng ln sLlffness of Lhe lung and lncreased work of breaLhlng. 1hls ls Lhe
usual cause of dyspnoea. ln acuLe hearL fallure, Lhe pulmonary venous
pressure rlses dramaLlcally, and alveolar oedema ensues, resulLlng ln alveolar
oedema. ArLerlal hypoxla occurs only ln very severe hearL fallure and
cardlogenlc shock.

4) 11111
All Lhese may be feaLures of hearL fallure, lncludlng nocLurnal cough. A sense
of eplgasLrlc fullness can occur ln congesLlve or rlghL hearL fallure because of
congesLlon of Lhe llver, and someLlmes due Lo guL oedema. Wheezlng on
exerLlon can occur ln hearL fallure buL ls also a feaLure of exerclse lnduced
asLhma. Lchocardlography and lung funcLlon LesLlng are useful Lo dlfferenLlaLe
Lhe Lwo.

3) l11l1
llne raLher Lhan coarse crackles are heard ln hearL fallure. 1he hearL sounds
can be normal. A loud pulmonary second hearL sound ls heard lf pulmonary
hyperLenslon ls presenL. 1he aorLlc second sound can be loud lf Lhe aeLlology
of hearL fallure ls hyperLenslon. A loud flrsL hearL sound generally lndlcaLes
LhaL mlLral sLenosls ls Lhe llkely cause of sympLoms. A palpable Lender llver ls
ofLen felL ln congesLlve hearL fallure, and ls due Lo congesLlon. lf Lrlcuspld
regurglLaLlon ls presenL, Lhe llver may be Lender. A pan sysLollc murmur ls
ofLen heard ln a dllaLed hearL due dllaLaLlon of Lhe mlLral valve rlng, resulLlng
ln funcLlonal mlLral regurglLaLlon. Cedema of Lhe bronchlal mucosa can occur
ln hearL fallure and glve rlse Lo a wheeze.

6) 11l11
CfLen ln paLlenLs wlLh hearL fallure, changes of old myocardlal lnfarcLlon (C
waves, lefL bundle branch block) are seen. LefL bundle branch ls ofLen
paLhologlcal, and lndlcaLes slgnlflcanL damage Lo Lhe venLrlcle. A p pulmonale
lndlcaLes LhaL Lhere ls rlghL aLrlal enlargemenL. Slnus Lachycardla ls ofLen seen
ln hearL fallure due Lo a compensaLory lncrease ln sympaLheLlc acLlvlLy.
ulureLlcs ofLen resulL ln hypokalaemla, and Lhe presence of u waves suggesLs
LhaL poLasslum supplemenLaLlon musL be glven.


1'&*+!2&)34*'-./#0'*#!

26

7) l11ll
usually Lhe hearL ls enlarged due Lo chamber dllaLaLlon. Powever ln cerLaln
condlLlons Lhe hearL may be normal slze. ln PCCM, resLrlcLlve
cardlomyopaLhy and aorLlc sLenosls Lhe hearL slze ls normal. ulmonary
oedema occurs malnly due Lo dlasLollc hearL fallure. ln Lhls condlLlon cardlac
sysLollc funcLlon ls normal, buL lnadequaLe relaxaLlon of Lhe lefL venLrlcle
resulLs ln lncreased lefL aLrlal pressure. upper lobe dlverslon of blood ls
usually seen ln Lhe chesL radlograph, and ls due Lo lncreased pulmonary
venous pressure. 1he callber of Lhe blood vessels ln Lhe upper and lower
zones of Lhe lung are equal. leural effuslons are seen ln hearL fallure and are
usually small. 1hey may be unllaLeral. Large effuslons can occur. Powever a
large unllaLeral effuslon ofLen prompLs Lhe cllnlclan Lo look for oLher,
parLlcularly lnfecLlve, paLhologles. CalclflcaLlon of Lhe valves Lakes place ln
valvular hearL dlsease.

8) l1111
1he echocardlogram ls noL essenLlal prlor Lo sLarLlng LreaLmenL. Powever lL ls
useful ln ldenLlfylng Lhe followlng, Lo deLermlne sysLollc funcLlon, Lo
deLermlne wheLher Lhe hearL fallure ls due Lo lschaemlc hearL dlsease or
dllaLed cardlomyopaLhy (reglonal wall moLlon abnormallLles vs global
dllaLaLlon), Lo ldenLlfy valvular leslons, and Lo ldenLlfy lnLracardlac Lhrombl. lL
ls noL a very rellable lnvesLlgaLlon Lo dlagnose dlasLollc dysfuncLlon. ln mlLral
regurglLaLlon, Lhe e[ecLlon fracLlon ls hlgh, due Lo large lefL venLrlcular end
dlasLollc dlameLer as a resulL of a large reLurn of regurglLaLed blood from Lhe
aLrlum.

9) 1111l
ulasLollc dysfuncLlon ls a syndrome ln whlch Lhe predomlnanL cause of
sympLoms ls lncreased venLrlcular sLlffness and aLrlal flbrlllaLlon raLher Lhan
reduced conLracLlon. lL ls ofLen presenL and ofLen underdlagnosed. lL may
accounL for a slgnlflcanL proporLlon of paLlenLs wlLh hearL fallure. LefL
venLrlcular hyperLrophy ls ofLen presenL, Lherefore lL ls common ln paLlenLs
prone Lo LvP, such as longsLandlng hyperLenslon and aorLlc sLenosls.
ulmonary oedema due Lo boLh sysLollc and dlasLollc fallure responds Lo
dlureLlcs, whlch acL malnly Lhrough pulmonary venodllaLaLlon

10) 1111l
Chronlc lefL hearL fallure resulLs ln pulmonary hyperLenslon whlch evenLually
resulLs ln rlghL venLrlcular hyperLrophy and rlghL hearL fallure. Lmphysema
1'&*+!2&)34*'-./#0'*#!

27

commonly causes pulmonary hyperLenslon and rlghL hearL fallure.
Llsenmengers syndrome ln an ASu resulLs ln pulmonary hyperLenslon and
rlghL hearL fallure. rlmary pulmonary hyperLenslon, where pulmonary
hyperLenslon occurs wlLhouL slgnlflcanL lefL hearL dlsease, valvular hearL
dlsease or lung dlsease evenLually causes Lhe rlghL hearL Lo fall. Chronlc
subcllnlcal pulmonary embollsm ls LhoughL Lo be a cause. A pneumoLhorax ls
usually an acuLe evenL, and alLhough ln Lhe acuLe sLage lL can cause cardlac
compromlse, lL ls noL a cause of rlghL hearL fallure per se.

11) 1111l
ln mosL paLlenLs wlLh hearL fallure Lhe cardlac ouLpuL ls low. ln cerLaln
clrcumsLances Lhe cardlac ouLpuL ls elevaLed and Lhe sysLemlc vascular
reslsLance ls very low. 1hls ls known as hlgh ouLpuL fallure and ls
characLerlzed by an elevaLed resLlng cardlac lndex beyond Lhe normal range
of 2.3 Lo 4.0 L/mln per m2. lneffecLlve blood volume and pressure, chronlc
acLlvaLlon of Lhe sympaLheLlc nervous sysLem and renln-angloLensln-
aldosLerone axls, lncreased serum AuP, and chronlc volume overload
gradually cause venLrlcular enlargemenL, remodellng, and hearL fallure.
Several characLerlsLlc flndlngs help Lo dlfferenLlaLe hlgh ouLpuL fallure from
sLandard low ouLpuL fallure. 1he hearL raLe ls Lyplcally beLween 83 and 103
beaLs per mlnuLe, buL lL may be hlgher wlLh some causes, ln parLlcular
LhyroLoxlcosls. A cervlcal venous hum maybe heard over Lhe lnLernal [ugular
velns, more marked on Lhe rlghL slde. 1he arLerlal pulse ls usually boundlng,
and Lhe pulse pressure ls wlde. lsLol shoL sounds may be heard over Lhe
femoral arLerles, and may cause confuslon wlLh aorLlc regurglLaLlon or paLenL
ducLus arLerlosus. A mld sysLollc murmur due Lo lncreased venLrlcular fllllng,
and a Lhlrd hearL sound may be heard. ulmonary oedema also occurs ln
splLe of Lhe hlgh cardlac ouLpuL. Plgh ouLpuL sLaLes may be physlologlcal and
can occur durlng exclLemenL or exerclse, ln pregnancy and fever. aLhologlcal
causes lnclude arLerlovenous flsLulas, LhyroLoxlcosls. Anemla, berlberl
(vlLamln 81 or Lhlamlne deflclency), psorlasls and exfollaLlve dermaLlLls,
ageLs dlsease eLc. ln sepLlc shock, Lhe perlpheral vascular reslsLance ls low
and Lhe cardlac ouLpuL ls normal or hlgh, lL ls a hlgh ouLpuL sLaLe by deflnlLlon,
alLhough Lhe Lerm 'fallure' ls noL always used unless feaLures of hearL fallure
are presenL.

12) 11l1l
8lghL hearL fallure ofLen occurs secondary Lo pulmonary hyperLenslon.
ulmonary hyperLenslon could be prlmary, or secondary Lo lefL hearL fallure,
1'&*+!2&)34*'-./#0'*#!

28

mlLral sLenosls, or chronlc lung dlsease such as emphysema, chronlc lung
flbrosls or bronchlecLasls. lLs prognosls ls poorer Lhan lefL hearL fallure, as Lhe
rlghL venLrlcle wall ls Lhlnner and less capable of wlLhsLandlng dllaLaLlon.
ullaLaLlon of Lhe Lrlcuspld valve rlng resulLs ln Lrlcuspld regurglLaLlon, whlch
manlfesLs wlLh promlnenL v waves ln Lhe [ugular venous pulse, and a Lender
pulsaLlle llver. Slldenafll has been used ln some paLlenLs wlLh pulmonary
hyperLenslon, and has been demonsLraLed Lo reduce pulmonary arLerlal
pressures, buL lLs survlval beneflL has noL been esLabllshed yeL.

13) l1l11
1hls paLlenLs has an exacerbaLlon of chronlc hearL fallure, and ls ln pulmonary
oedema evldenced by Lhe flne crackles ln hls lung bases and Lachycardla. Pe ls
noL ln cardlogenlc shock slnce hls blood pressure ls malnLalned. Pe has
prlmarlly backward fallure, and no forward fallure. 1he posslblllLy of an acuLe
myocardlal lnfarcLlon could be consldered, glvlng rlse Lo acuLe lefL venLrlcular
dysfuncLlon. Powever Lhe normal LCC makes Lhls unllkely. A paLlenL ls placed
ln Lhe head down poslLlon Lo lmprove cerebral perfuslon ln shock. 1hls
paLlenL ls ln lefL venLrlcular fallure and noL ln shock - he should be propped up
Lo reduce venous reLurn, and also Lo reduce Lhe pressure of Lhe abdomlnal
conLenLs on Lhe dlaphragm. Morphlne ls useful ln acuLe lefL venLrlcular fallure
- lL reduces pulmonary oedema by causlng pulmonary venodllaLaLlon, and
also relleves anxleLy, and slows Lhe resplraLory raLe, Lhls resulLs ln reduclng
Lhe workload of Lhe hearL. lrusemlde can be glven orally or lnLravenously. ln
paLlenLs wlLh chronlc hearL fallure can have oedema of Lhe guL wall, resulLlng
ln decreased absorpLlon of oral drugs. ln acuLe lefL venLrlcular fallure,
lnLravenous frusemlde acLs more rapldly and ls generally preferred.
lnLravenous ACL lnhlblLors cause perlpheral vasodllaLaLlon, reduce Lhe
afLerload, and offload Lhe hearL. nlLraLes glven by lnfuslon cause sysLemlc
and pulmonary venodllaLaLlon and reduce preload.

14) l11l1
Cardlogenlc shock ls due Lo pump fallure, or lnablllLy of Lhe hearL Lo pump
blood Lo malnLaln adequaLe perfuslon of Lhe Llssues. lL ls manlfesLed by a low
blood pressure (sysLollc blood pressure below 90 mmPg or mean arLerlal
pressure below 70mmPg). As a resulL Lhere ls acLlvaLlon of Lhe sympaLheLlc
sysLem, resulLlng ln Lachycardla & perlpheral vasoconsLrlcLlon leadlng Lo a
rapld Lhready pulse. AcLlvaLlon of Lhe chollnerglc sympaLheLlcs resulLs ln
sweaLlng of Lhe palms. Slmllar feaLures are seen ln hypovolaemlc shock, l.e.,
shock due Lo bleedlng of fluld depleLlon. ln conLrasL, ln sepLlc shock Lhere ls
1'&*+!2&)34*'-./#0'*#!

29

marked perlpheral vasodllaLaLlon. 1he pulse volume ls good, and Lhe
exLremlLles are warm. Cerebral hypoperfuslon resulLs ln confuslon and
resLlessness. 1he cenLral venous pressure may or may noL be elevaLed.
Collolds are generally noL used, ln facL excess flulds can be dangerous as lL can
worsen pulmonary oedema. lnLra-arLerlal blood pressure monlLorlng ls
preferred ln order Lo LlLraLe lnoLropes.

13) 1l111
Cenerally, ln hearL fallure, Lhere ls dllaLaLlon of Lhe venLrlcles. 1he lefL
venLrlcular end dlasLollc volume ls lncreased. As a compensaLory mechanlsm
Lhere ls ofLen lncreased adrenerglc acLlvlLy whlch causes Lachycardla. 1hls ls
deLrlmenLal Lo Lhe paLlenL because lL lncreases myocardlal work. 8eLa
blockers are used ln hearL fallure based on Lhls hypoLhesls. 1he presence of
bradycardla suggesLs elLher hearL block or hypoLhyroldlsm. Syncope occurs ln
hearL fallure ofLen on exerLlon, when Lhe hearL cannoL lncrease lLs ouLpuL Lo
malnLaln cerebral perfuslon. Long sLandlng hyperLenslon leads Lo lefL
venLrlcular hyperLrophy and evenLually dllaLaLlon resulLlng ln hearL fallure. A
Lender enlarged llver ls seen ln rlghL hearL fallure, where hepaLlc congesLlon
causes sLreLchlng of Lhe llver capsule, whlch ls paln senslLlve. ln Lrlcuspld
regurglLaLlon Lhe llver can be pulsaLlle.

16) ll1l1
1he head low poslLlon ls used for paLlenLs wlLh cardlogenlc shock, Lo lmprove
cerebral perfuslon. ln acuLe Lvl Lhe paLlenL ls kepL propped up, Lo reduce
venous reLurn and preload, and also Lo reduce Lhe compresslon of Lhe
dlaphragm by Lhe abdomlnal conLenLs. 1hlazlde dlureLlcs are mlld dlureLlcs,
and whlle Lhey have an lmporLanL place ln Lhe LreaLmenL of hyperLenslon,
Lhey are lnadequaLe ln Lhe managemenL of acuLe Lvl. Cxygen ls usually glven
by a face mask. Morphlne reduces pulmonary oedema by causlng pulmonary
venodllaLaLlon. lL ls glven lnLravenously, as lnLramuscular absorpLlon ls erraLlc.
ln severe cases of pulmonary oedema, Lhe paLlenL may need venLllaLlon.
Careful appllcaLlon of LL helps Lo augmenL cardlac ouLpuL.

17) 111l1
1he haemodynamlc changes ln pregnancy, ln parLlcular Lhe lncreased plasma
volume, can preclplLaLe pulmonary oedema ln Lvl. 1here ls an lncreased rlsk
of pulmonary embollsm durlng pregnancy. AsLhma and pneumonla are all
causes of acuLe dyspnoea. AcuLe myocardlal lnfarcLlon ls uncommon ln young
women ln Lhe reproducLlve age group.
1'&*+!2&)34*'-./#0'*#!

30


18) 1l111
nSAlus cause fluld reLenLlon and can preclplLaLe hearL fallure. uaunorublcln,
a cyLoLoxlc drug, has dlrecL cardloLoxlc effecLs, and can cause an acuLe
cardlomyopaLhy. ropranolol, due Lo lLs negaLlve lnoLroplc and chronoLroplc
effecLs, can worsen hearL fallure, however beLa blockers are used ln hearL
fallure, and have survlval beneflL. logllLazone causes fluld reLenLlon, and can
worsen hearL fallure, especlally ln comblnaLlon wlLh sulphonylureas or lnsulln.

19) 111ll
Achlevlng ldeal body welghL and reducLlon of salL ln Lhe dleL ls useful ln Lhe
LreaLmenL of hearL fallure. AL Llmes of exacerbaLlons, bed resL ls useful
because redlsLrlbuLlon of blood flow lmproves dluresls. ModeraLe exerclse ls
a valuable ln lmprovlng cardlovascular flLness. Alcohol ln any amounL ls besL
avolded, as alcohol depresses myocardlal funcLlon.

20) l11ll
ln paLlenLs wlLh hearL fallure, guL oedema may llmlL Lhe absorpLlon of oral
drugs. lnLravenous frusemlde ls more effecLlve ln Lhls slLuaLlon. Small meals aL
more frequenL lnLervals are preferred. 8ed resL lmproves renal perfuslon and
dluresls. When frusemlde ls glven aL nlghL lL wlll make Lhe paLlenL have Lo geL
up many Llmes Lo pass urlne - ln addlLlon Lo belng slmply lnconvenlenL, lL wlll
resulL ln lnadequaLe resL, whlch wlll be deLrlmenLal Lo a paLlenL ln hearL
fallure. nlLraLes glven aL regular lnLervals cause Lolerance, ln LhaL Lhelr acLlon
wlll be lneffecLlve aL a glven dose. 1hey are glven aL sLaggered lnLervals,
allowlng for a nlLraLe free lnLerval.

21) 1l1ll
Many sLudles have shown LhaL ACL lnhlblLors reduce sympLoms, hosplLal
admlsslons and morLallLy ln paLlenLs wlLh hearL fallure. ulgoxln has been used
for ages for hearL fallure. Powever Lhere were concerns abouL wheLher
dlgoxln has an adverse effecL on survlval ln splLe of allevlaLlng sympLoms. A
large sLudy, Lhe ulglLalls lnvesLlgaLlon Croup Lrlal demonsLraLed LhaL whlle
dlgoxln lmproves sympLoms and reduces hosplLal admlsslons, lL has nelLher a
poslLlve nor negaLlve effecL on survlval. SplronolacLone, a poLasslum sparlng
dlureLlc has been shown Lo reduce morLallLy when used ln paLlenLs wlLh hearL
fallure. AlLhough beLa blockers would be expecLed Lo make hearL fallure
worse because of Lhelr negaLlve lnoLroplc and chronoLroplc properLles,
Carvedllol, and subsequenLly oLher beLa blockers, have been shown Lo reduce
1'&*+!2&)34*'-./#0'*#!

31

morLallLy ln hearL fallure. uobuLamlne ls ofLen used ln paLlenL wlLh
cardlogenlc shock. Powever prolonged use of Lhese drugs has noL been shown
Lo lmprove survlval, and ln facL may lncrease morLallLy.

22) ll1ll
Chronlc rlghL hearL fallure resulLs ln lncreased sysLemlc venous pressures, and
causes ankle oedema, elevaLed [ugular venous pressure and hepaLlc
congesLlon. Lmphysema and prlmary pulmonary hyperLenslon are lmporLanL
causes. Slnce Lhe myocardlum of Lhe rlghL hearL ls Lhlnner, lL dllaLes earller
and Lhe prognosls once rlghL hearL fallure develops ls very poor.

23) 1ll1l
ACL lnhlblLors lmprove survlval and ouLcome ln paLlenLs wlLh all degrees of
hearL fallure. ulgoxln has nelLher a negaLlve nor a poslLlve effecL on survlval,
alLhough lL helps reduce sympLoms and hosplLal admlsslons. Whlle nlLraLes
alone are of no survlval beneflL, Lhe comblnaLlon of nlLraLes and hydralazlne
lmproves survlval ln hearL fallure. uobuLamlne probably worsens ouLcome ln
hearL fallure.

24) 1lll1
ullaLed proxlmal pulmonary arLerles wlLh prunlng of Lhe perlpheral vessels ls
seen on Lhe chesL radlograph ln pulmonary hyperLenslon. 8reaLhlessness ln
Lvl ls due Lo pulmonary lnLersLlLlal oedema and lncreased sLlffness of Lhe
lungs. Pypoxla occurs only ln very severe pulmonary oedema, when alveolar
oedema develops and compromlses gas Lransfer. PypervenLllaLlon ln Lvl
resulLs ln CC2 washouL, and low aCC2. CrLhopnoea and paroxysmal
nocLurnal dyspnoea may precede efforL dyspnoea, and Lhe presence of Lhese
sympLoms alone wlLh a normal exerclse Lolerance warranLs lnvesLlgaLlon.
lluld ln Lhe obllque flssure may mlmlc a solld Lumour on Lhe chesL radlograph.

23) l1111
AnLlarrhyLhmlcs have no place ln Lhe LreaLmenL of chronlc hearL fallure ln Lhe
absence of any arrhyLhmlas. Carvedllol reduces morLallLy and lmproves
sympLoms. ulgoxln wlll lmprove sympLoms wlLhouL affecLlng survlval.
SplronolacLone reduces morLallLy. CandesarLen lmproves survlval ln hearL
fallure.


156'*+'/#)7/!

32

IN8G3KGF1EOF
!
1) 1he followlng are Lrue regardlng hyperLenslon
a) A susLalned blood pressure of 130/83 mmPg ln a 63 year old man ls
lndlcaLlve LhaL he ls hyperLenslve.
b) ln a 20 year old male, a blood pressure of 133/83 ls opLlmal
c) ln a dlabeLlc wlLh nephropaLhy, Lhe LargeL blood pressure ls below
120/70mmPg
d) ln a hyperLenslve paLlenL wlLh a hlsLory of lschaemlc sLroke 6 monLhs
ago, a blood pressure of 140/90 mmPg lndlcaLes adequaLe conLrol
e) ln a paLlenL who has susLalned an lschaemlc sLroke 24 hours ago, a
blood pressure of 170/93mmPg requlres anLlhyperLenslve LreaLmenL

2) 1he followlng are Lrue regardlng Lhlazlde dlureLlcs ln Lhe managemenL of
hyperLenslon
a) 1hey are usually admlnlsLered once dally ln Lhe mornlng
b) 1he anLlhyperLenslve effecL ls due Lo susLalned reducLlon ln plasma
volume
c) ComblnaLlon wlLh oLher anLlhyperLenslves ls noL recommended due
Lo drug lnLeracLlons
d) 1here are no recenL cllnlcal Lrlals showlng efflcacy of Lhlazldes ln
hyperLenslon
e) 1hey should be avolded ln paLlenLs wlLh dlabeLes

3) A 36 year old dlabeLlc man ls seen by hls general pracLlLloner. Pe ls found
Lo have a blood pressure of 180/110mmPg. Pe ls noL obese, and ls a non
smoker. Pls serum cholesLerol and renal funcLlon are normal.
a) Pe should be glven subllngual nlfedlplne Lo reduce Lhe blood
pressure
b) Pe should be Lrled on llfesLyle modlflcaLlon alone for 3 monLhs
c) 8amlprll ls an approprlaLe flrsL llne anLlhyperLenslve
d) 1hlazlde dlureLlcs are conLralndlcaLed
e) Pls LargeL blood pressure ls 140/90mmPg




156'*+'/#)7/!

33

4) 1he followlng non pharmacologlcal meLhods have been shown Lo reduce
Lhe blood pressure ln sub[ecLs wlLh hyperLenslon
a) WelghL reducLlon
b) lncreased frulL and vegeLable lnLake
c) 8egular aeroblc exerclse
d) CessaLlon of smoklng
e) 8educed alcohol consumpLlon

3) PyperLenslon ls caused by
a) 8enal arLery sLenosls
b) CoarcLaLlon of Lhe aorLa
c) porphyrla
d) Cral conLracepLlon
e) 8enln secreLlng Lumours

6) A 43 year old man ls found Lo have a blood pressure of 130/90. Pe ls
overwelghL, and smokes a pack of clgareLLes a day, buL has no oLher rlsk
facLors. 1he followlng are Lrue
a) Pe should be sLarLed on a Lhlazlde dlureLlc
b) Pe should be advlsed Lo reduce welghL
c) MedlLaLlon ls an effecLlve meLhod of reduclng hls blood pressure
d) Pe should reduce smoklng
e) Pe should reduce Lhe amounL of salL ln hls dleL

7) 1he followlng non-pharmacologlcal measures are useful ln Lhe LreaLmenL
of hyperLenslon
a) moderaLe dleLary sodlum resLrlcLlon
b) welghL reducLlon ln Lhe obese
c) medlLaLlon
d) avoldance of excess alcohol lnLake
e) regular aeroblc exerclse








156'*+'/#)7/!

34

8) 1he followlng are Lrue
a) PyperLenslon ls deflned as a susLalned blood pressure above
140/90mmPg
b) A blood pressure of 138/83mmPg ls deflned as normal
c) A paLlenL wlLh a dlasLollc blood pressure above 100mmPg ls
consldered Lo have sLage 2 hyperLenslon
d) A paLlenL wlLh a sysLollc blood pressure of 130mmPg has sLage 2
hyperLenslon
e) 1o sLage hyperLenslon, boLh sysLollc and dlasLollc values musL be
above Lhe deflned level

9) 1he followlng are Lrue
a) PyperLenslon ls Lhe mosL lmporLanL cause of sLroke
b) 1he prevalence of hyperLenslon ls on Lhe lncrease
c) ConLrol of hyperLenslon ls achleved ln only 30 percenL of people
worldwlde
d) PyperLenslon ls commoner ln poorer socloeconomlc classes
e) PyperLenslon ls commoner ln Lhe elderly

10) 1he followlng people are more llkely Lo be lacklng ln awareness of hlgh
blood pressure
a) aLlenLs over Lhe age of 63 years
b) Males
c) WhlLe women
d) 1hose who have noL vlslLed a docLor wlLhln Lhe lasL year
e) Smokers

11) 8egardlng blood pressure measuremenL
a) A slngle blood pressure readlng of 180/110mmPg ls adequaLe Lo
dlagnose hyperLenslon
b) SLrenuous exerclse can resulL ln a falsely low blood pressure
c) urlnklng coffee [usL before checklng Lhe blood pressure can resulL ln
a falsely hlgh readlng
d) 1o measure Lhe blood pressure ln a regular smoker, he should noL
have smoked for Lhe pasL 30 mlnuLes
e) aLlenLs should be asked Lo sklp Lhelr regular dose of
anLlhyperLenslve medlcaLlons prlor Lo comlng Lo check Lhelr blood
pressure

156'*+'/#)7/!

33

12) 8egardlng measuremenL of blood pressure
a) Anerold sphygmomanomeLers are as accuraLe as mercury
sphygmomanomeLers
b) 1he lengLh of Lhe bladder should be 73 percenL of Lhe clrcumference
of Lhe upper arm
c) 1he wldLh of Lhe bladder should be more Lhan 30 percenL of Lhe
lengLh of Lhe upper arm
d) 1he use of a cuff whlch ls Loo small wlll resulL ln a falsely low blood
pressure readlng
e) ln pregnancy, Lhe blood pressure should be measured ln Lhe laLeral
recumbenL poslLlon

13) 8egardlng Lhe measuremenL of blood pressure
a) 1he cuff should be lnflaLed Lo 10mmPg above Lhe sysLollc pressure
deLecLed by palpaLlon of Lhe brachlal arLery
b) 1he arm musL be supporLed so LhaL Lhe brachlal arLery ls aL Lhe level
of Lhe hearL
c) 1he dlasLollc pressure ls Lhe polnL aL whlch Lhe koroLkov sounds
dlsappear
d) 1he polnL of muffllng of Lhe koroLkov sounds ls Laken ln hlgh ouLpuL
sLaLes
e) 1he blood pressure apparaLus musL be placed aL Lhe level of Lhe
hearL

14) 8egardlng 'WhlLe CoaL' hyperLenslon
a) ls presenL ln less Lhan 3 percenL of people wlLh elevaLed blood
pressure
b) ls less llkely lf Lhe dlasLollc blood pressure measured by Lhe docLor ls
>103mmPg
c) ambulaLory blood pressure monlLorlng ls useful ln dlagnosls
d) lL does noL cause any abnormallLles on echocardlography
e) lL does noL glve rlse Lo susLalned hyperLenslon

13) 8lsk facLors for Lhe developmenL of preeclampsla lnclude
a) MulLlparlLy
b) dlabeLes melllLus
c) a pasL hlsLory of renal dlsease
d) a hlsLory of chronlc hyperLenslon
e) age below 13 years
156'*+'/#)7/!

36


16) re-eclampsla
a) ls assoclaLed wlLh lncreased perlnaLal morbldlLy and morLallLy
b) ls dlagnosed by measuremenL of Lwo elevaLed blood pressures, aL
leasL 6 h aparL
c) When assoclaLed wlLh proLelnurla, denoLes a worse prognosls
d) ls reduced by Lhe use of asplrln
e) Cedema ls a feaLure

17) 8egardlng severe pre-eclampsla
a) 8enal fallure occurs
b) 1he presence of LhrombocyLopaenla, hemolysls, and elevaLed llvers
enzymes lndlcaLes a poor prognosls
c) lnLracranlal haemorrhage ls a compllcaLlon
d) lL does noL occur afLer dellvery
e) flLs occur only ln Lhe presence of very hlgh blood pressure

18) 8egardlng Lhe managemenL of pre-eclampsla
a) ln severe pre-eclampsla dellvery of Lhe baby ls recommended afLer
32 weeks of gesLaLlon
b) conLrol of blood pressure Lo below 160/110 mmPg reduces Lhe rlsk
of sLroke
c) rapld reducLlon of blood pressure ls lndlcaLed
d) lnLravenous labeLalol ls used
e) lnLravenous phenyLoln ls Lhe preferred drug ln selzures

19) 8egardlng Lhe drug managemenL of hyperLenslon
a) An angloLensln converLlng enzyme lnhlblLor ls Lhe preferred flrsL llne
drug
b) razocln lmproves survlval
c) ShorL acLlng calclum channel blockers are assoclaLed wlLh lncreased
morLallLy
d) 8eLa blockers reduce morLallLy
e) AngloLensln recepLor blockers are safe ln pregnancy





156'*+'/#)7/!

37

20) 8egardlng hyperLenslon due Lo endocrlne causes
a) PyperparaLhyroldlsm ls a known cause
b) ln renal arLery sLenosls, hyperkalaemla ls a feaLure
c) ln ecLoplc AC1P syndrome, marked proxlmal muscle weakness ls
seen
d) 8eLlnal haemorrhages wlLhouL oLher hyperLenslve changes ln Lhe
reLlna suggesLs Lhe posslblllLy of phaeochromocyLoma
e) Carclnold syndrome ls a recognlzed cause

21) 1he followlng anLlhyperLenslve drugs are approprlaLe cholces ln Lhe
condlLlons named
a) PydrochloroLhlazlde ! benlgn prosLaLlc hyperLrophy
b) LosarLen ! advanced renal fallure
c) 8amlprll ! dlabeLes melllLus
d) MeLoprolol ! congesLlve hearL fallure
e) MeLhyldopa ! elderly

22) ln a paLlenL wlLh moderaLe chronlc renal fallure
a) 1lghL blood pressure conLrol ls beneflclal
b) ullLlazem reduces proLelnurla ln dlabeLlc nephropaLhy
c) AngloLensln recepLor blockers are Lhe preferred drug for blood
pressure conLrol
d) uleLary sodlum resLrlcLlon ls helpful ln reduclng Lhe blood pressure
e) Pyperkalaemla may occur wlLh ACL lnhlblLors

23) 8egardlng renovascular hyperLenslon
a) lL ls commoner ln blacks
b) A low serum poLasslum ls seen
c) 1he presence of asymmeLry ln renal slzes ls suggesLlve of Lhe
dlagnosls
d) 8enal arLerlography ls Lhe gold sLandard ln dlagnosls
e) lasma renln acLlvlLy ls reduced







156'*+'/#)7/!

38

24) 8egardlng hyperLenslve emergency
a) 1he blood pressure musL be reduced wlLhln 3 mlnuLes Lo prevenL
hyperLenslve encephalopaLhy
b) lnLravenous labeLalol ls Lhe drug of cholce
c) Subllngual nlfedlplne ls lndlcaLed
d) MannlLol ls lndlcaLed Lo reduce cerebral oedema
e) AorLlc dlssecLlon ls a compllcaLlon

23) PyperLenslon lncreases Lhe rlsk of developlng Lhe followlng
a) 8enal fallure
b) AsLhma
c) CongesLlve cardlac fallure
d) SLroke
e) Anglna





156'*+'/#)7/-./#0'*#!

39

J'%L0)%!>+!I@50)>0'%&+'!M.0%>&+'%!

1) 1l1ll
8oLh Lhe !nC vlll and WPC guldellnes on hyperLenslon deflne hyperLenslon as
a blood pressure hlgher Lhan 140/90 mmPg, aL any age. 1here ls no dlfference
ln Lhe level of blood pressure cuL offs aL dlfferenL ages, and anyone wlLh a
blood pressure over Lhls value ls hyperLenslve. lf only one value (sysLollc or
dlasLollc) ls greaLer Lhan Lhe upper llmlL, Lhe hlgher value ls Laken. Whlle Lhe
dlagnosls of hyperLenslon ls based on Lhese cuL-offs, Lhe opLlmal blood
pressure ls deflned as a blood pressure of 120/70. Lvldence from Lhe PC1
Lrlal lndlcaLed LhaL Lhe lower Lhe blood pressure, Lhe lower Lhe rlsk of
cardlovascular evenLs. 1he lowesL polnL below whlch lowerlng Lhe blood
pressure can be deLrlmenLal, has noL been deLermlned yeL. ln an
uncompllcaLed paLlenL, Lhe LargeL would be Lo reduce blood pressure below
140/90, however ln paLlenLs wlLh dlabeLlc nephropaLhy, Lhe LargeL blood
pressure ls much lower. Slmllarly, lower blood pressure LargeLs are necessary
for secondary prevenLlon of sLroke. Powever, soon afLer an lschaemlc sLroke,
blood pressure reducLlon ls noL lndlcaLed, and can be dangerous, unless Lhe
blood pressure ls over 220/120.

2) 1lll1
1hlazldes are usually admlnlsLered ln Lhe mornlng as a slngle dose. 1helr
anLlhyperLenslve effecLs are noL prlmarlly due Lo a reducLlon ln plasma
volume. AlLhough plasma volume does fall lnlLlally, compensaLory
mechanlsms brlng plasma volume back Lo normal wlLhln a few days. 1hlazldes
show Lhe maxlmum beneflL ln hyperLenslon, and are Lhe flrsL llne LreaLmenL
of mosL hyperLenslves. 1hey can be safely comblned wlLh mosL oLher
anLlhyperLenslves. Lower doses of Lwo anLlhyperLenslves ln comblnaLlon are
beLLer Lhan one anLlhyperLenslve ln hlgh dose. Several Lrlals lncludlng Lhe
large ALLPA1 Lrlal, Lhe largesL anLlhyperLenslve LreaLmenL Lrlal, showed LhaL
Lhlazldes are Lhe mosL effecLlve and beneflclal drugs ln hyperLenslon. 1he
beneflclal effecLs of Lhlazldes overrlde any adverse effecLs Lhey mlghL have ln
dlabeLlcs.

3) ll1ll
1here ls no urgency Lo reduce Lhe blood pressure unless Lhere ls evldence of
hyperLenslve encephalopaLhy. Subllngual nlfedlplne can cause a drasLlc
reducLlon ln blood pressure and can even cause a sLroke. ln a dlabeLlc paLlenL
156'*+'/#)7/-./#0'*#!

40

wlLh Lhls degree of blood pressure, llfesLyle modlflcaLlon alone ls lnadequaLe,
and he should be sLarLed on LreaLmenL. ACL lnhlblLors are approprlaLe drugs
for Lhe LreaLmenL of dlabeLlc paLlenLs. 1hlazldes are also safe and effecLlve ln
dlabeLlcs, and Lhelr supposed adverse effecLs on llplds are noL of much
prognosLlc slgnlflcance. 1he LargeL blood pressure ls 130/80mmPg ln a
dlabeLlc paLlenL.

4) 11111
All Lhese measures are helpful ln reduclng blood pressure. Smoklng causes a
LranslenL rlse ln blood pressure whlch may noL conLrlbuLe Lo susLalned
hyperLenslon, buL ln vlew of Lhe oLher lncreased cardlovascular rlsk, ls besL
avolded. Peavy alcohol consumpLlon lncreases blood pressure.

3) 111l1
Cral conLracepLlon ls noL assoclaLed wlLh hyperLenslon, alLhough lL may
lncrease cardlovascular rlsk ln cerLaln paLlenLs. orphyrla causes abdomlnal
paln and hyperLenslon. 8lood pressure rlse ls usually LranslenL, and lL may noL
be a cause of chronlc hyperLenslon.

6) l1ll1
lnlLlally llfesLyle measures such as welghL reducLlon, reduced salL ln Lhe dleL,
regular exerclse can be Lrled ouL slnce Lhls paLlenL has sLage l hyperLenslon.
urug Lherapy ls noL urgenLly lndlcaLed, buL Lhlazldes would be Lhe drugs of
flrsL cholce. 1here ls no proof LhaL medlLaLlon ls useful ln reduclng hls blood
pressure. Pe should sLop, noL reduce, smoklng.

7) 11l11
1here ls no convlnclng evldence LhaL medlLaLlon resulLs ln a susLalned
lowerlng of blood pressure, alLhough LranslenL reducLlon ln blood pressure
has been observed durlng Lhe Llme of medlLaLlon.

8) 1l1ll
PyperLenslon ls deflned as a blood pressure over 140/90mmPg ln a paLlenL
who ls noL on anLlhyperLenslve medlcaLlon. Powever, a blood pressure of
138/83mmPg falls lnLo Lhe pre-hyperLenslon range. 1he deflnlLlons based on
Lhe !nC vll reporL are,
normal blood pressure: sysLollc <120 mmPg and dlasLollc <80
rehyperLenslon: sysLollc 120-139 or dlasLollc 80-89
PyperLenslon:
156'*+'/#)7/-./#0'*#!

41

SLage 1: sysLollc 140-139 or dlasLollc 90-99
SLage 2: sysLollc > or =160 or dlasLollc > or =100
ln Lhe case of a dlsparlLy ln caLegory beLween Lhe sysLollc and dlasLollc
pressures, Lhe hlgher value deLermlnes Lhe severlLy of Lhe hyperLenslon. 1he
sysLollc pressure ls Lhe greaLer predlcLor of rlsk ln paLlenLs over Lhe age of 30
Lo 60.

9) 11ll1
PyperLenslon ls on Lhe lncrease. lL ls Lhe mosL lmporLanL rlsk facLor for sLroke.
Cnly 23 percenL of people wlLh hyperLenslon worldwlde are properly
conLrolled. PyperLenslon ls commoner ln Lhe affluenL classes, buL conLrol and
compllance may be poorer among poorer people. 1he lncldence lncreases
wlLh lncreaslng age.


10) 11l1l
1he followlng are lndependenL predlcLors of a lack of awareness of hlgh blood
pressure, age greaLer Lhan 63 years (mosL lmporLanL varlable), male sex, non-
Plspanlc black race, and lack of a physlclan vlslL wlLhln Lhe lasL year. 1here ls
no evldence LhaL smoklng predlcLs lack of awareness of hyperLenslon.

11) l111l
A slngle blood pressure readlng ls never adequaLe Lo dlagnose blood pressure.
MulLlple readlngs are essenLlal, and lf Lhe flrsL measuremenL ls hlgh, Lhe
paLlenL should be resLed for some Llme and Lhe blood pressure rechecked. 1o
dlagnose hyperLenslon, 3 readlngs aL leasL one week aparL musL be elevaLed.
SLrenuous exerclse ls more llkely Lo cause an erroneously low blood pressure
and noL, as would be expecLed, a falsely hlgh readlng. Lspeclally ln non-
hablLual coffee drlnkers, lngesLlon of caffelne wlLhln Lhe lasL 1 hour can ralse
Lhe blood pressure. Smoklng LranslenLly ralses Lhe blood pressure, and
smokers should be asked noL Lo smoke for 30 mlnuLes before checklng Lhelr
blood pressure. ln paLlenLs who smoke heavlly, however, Lhls means LhaL Lhe
blood pressure measured wlll be falsely low. aLlenLs should Lake Lhelr
regular medlcaLlons before comlng for blood pressure measuremenL. A
common problem ln cllnlcal pracLlce ls where paLlenLs sklp Lhe mornlng dose
of drugs Lo see lf Lhe pressure ls conLrolled now"!


12) l11l1
156'*+'/#)7/-./#0'*#!

42

Mercury sphygmomanomeLers are much more accuraLe Lhan anerold
sphygmomanomeLers. Anerold sphygmomanomeLers musL be callbraLed
agalnsL a mercury apparaLus every slx monLhs. 1he lengLh of Lhe bladder
musL be 73-80 percenL of Lhe clrcumference of Lhe upper arm, and Lhe wldLh
of Lhe bladder musL be more Lhan 30 percenL of Lhe lengLh of Lhe upper arm.
lf Loo small a cuff ls used, Lhe pressure generaLed by lnflaLlng Lhe cuff may noL
be fully LransmlLLed Lo Lhe brachlal arLery, and Lhe pressure ln Lhe cuff may be
conslderably hlgher Lhan Lhe lnLraarLerlal pressure. 1hls can lead Lo
overesLlmaLlon of Lhe sysLollc pressure by 10 Lo as much as 30 mmPg ln obese
paLlenLs.

13) l111l
1he cuff should be lnflaLed Lo 30mmPg above Lhe sysLollc pressure deLecLed
by palpaLlon. AusculLaLlon alone ls noL sufflclenL Lo deLermlne sysLollc
pressure, as Lhe koroLkov sounds may dlsappear LranslenLly as Lhe cuff ls
lnflaLed, Lhls ls known as Lhe 'ausculLaLory gap'. 1he arm musL be supporLed
so LhaL Lhe brachlal arLery ls aL Lhe level of Lhe hearL. lf Lhe arm ls allowed Lo
hang down, Lhe brachlal arLery wlll be abouL 10-13 cm below Lhe level of Lhe
hearL, resulLlng ln false elevaLlon of Lhe measured blood pressure by 10-
12mmPg because of hydrosLaLlc pressure. 1he dlasLollc pressure ls usually
Laken as Lhe polnL where Lhe koroLkov sounds dlsappear, however ln hlgh
ouLpuL sLaLes Lhere can be a gap of more Lhan 10mmPg beLween Lhe polnL of
muffllng and Lhe polnL of dlsappearance of Lhe sounds. ln Lhls slLuaLlon Lhe
polnL of muffllng ls Laken as Lhe dlasLollc pressure. 1he blood pressure
apparaLus does noL need Lo be kepL aL hearL level, only Lhe cuff musL be aL
hearL level. 1hls ls a common mlsconcepLlon whlch has been handed down
Lhrough generaLlons of medlcal sLudenLs.

14) l11ll
WhlLe coaL hyperLenslon or lsolaLed offlce hyperLenslon ls a slLuaLlon where
blood pressure ls elevaLed when measured by Lhe docLor, buL ls repeaLedly
normal when measured aL home, aL work, or by ambulaLory 8 monlLorlng. lL
ls seen ln as much as 20-23 percenL of paLlenLs wlLh elevaLed blood pressure,
and ls more common ln Lhe elderly and ln chlldren. lL ls unllkely ln paLlenLs
wlLh offlce dlasLollc pressures > or =103 mmPg. AmbulaLory monlLorlng ls
useful ln dlagnosls. WhlLe coaL hyperLenslon ls noL necessarlly normal.
aLlenLs wlLh whlLe coaL hyperLenslon are more llkely Lo be overwelghL, have
hlgher plasma lnsulln and Lrlglycerlde levels, and are more llkely Lo have a
famlly hlsLory of hyperLenslon. 1hey are more llkely Lo develop susLalned
156'*+'/#)7/-./#0'*#!

43

hyperLenslon, and are more llkely Lo have lefL venLrlcular hyperLrophy on
echocardlography.

13) l1111
8lsk facLors for Lhe developmenL of preeclampsla lnclude nulllparlLy, dlabeLes
melllLus, a hlsLory of renal dlsease or chronlc hyperLenslon, a prlor hlsLory of
preeclampsla, exLremes of maLernal age (>33 years or <13 years), obeslLy,
anLlphosphollpld anLlbody syndrome, and mulLlple gesLaLlon.
!
16) 111l1
re-eclampsla ls Lhe new onseL of hyperLenslon (blood pressure >140/90
mmPg), proLelnurla (>300 mg per 24 h), and paLhologlc oedema ln pregnancy.
1he preclse cause of preeclampsla ls noL known, buL lL ls LhoughL Lo be due Lo
facLors of placenLal orlgln, Lhe end resulL ls vasospasm and endoLhellal ln[ury
ln mulLlple organs. reeclampsla ls assoclaLed wlLh abnormallLles of cerebral
clrculaLory auLoregulaLlon, whlch lncrease Lhe rlsk of sLroke aL near-normal
blood pressures. When assoclaLed wlLh proLelnurla, Lhe prognosls ls worse,
and correlaLes wlLh greaLer degrees of proLelnurla. 1here ls no evldence LhaL
asplrln ls beneflclal, alLhough lL was earller LhoughL Lo be so.

17) 111ll
1he cllnlcal feaLures of severe preeclampsla lnclude headaches, blurred vlslon,
selzures, coma, marked elevaLlons of blood pressure (>160/110 mmPg),
severe proLelnurla (>3 g per 24 h), ollgurla or renal fallure, pulmonary edema,
hepaLocellular ln[ury (AL1 > 2 Lhe upper llmlLs of normal), LhrombocyLopenla
(plaLeleL counL < 100,000/uL), or dlssemlnaLed lnLravascular coagulaLlon. 1he
mosL serlous compllcaLlon ls lnLracranlal haemorrhage. Pemolysls, elevaLed
llver enzymes and low plaLeleLs comprlses Lhe PLLL syndrome, a speclal
subgroup of severe preeclampsla. lL ls a ma[or cause of morbldlLy and
morLallLy ln Lhls dlsease. 1he presence of plaLeleL dysfuncLlon and coagulaLlon
dlsorders furLher lncreases Lhe rlsk of sLroke. re-eclampsla ls known Lo occur
before, durlng and soon afLer dellvery. llLs can occur aL relaLlvely ln paLlenLs
wlLh blood pressures whlch are only sllghLly elevaLed.

18) 11l1l
uellvery of Lhe baby ls Lhe deflnlLlve LreaLmenL for pre-eclampsla, and dellvery
ls generally recommended ln severe pre-eclampsla afLer 32 weeks of
gesLaLlon. Lowerlng Lhe blood pressure Lo below 160/110 reduces Lhe rlsk of
compllcaLlons, however blood pressure lowerlng below Lhls has noL been
156'*+'/#)7/-./#0'*#!

44

shown Lo lmprove ouLcome, and may lmpalr placenLal perfuslon. 8lood
pressure reducLlon should be gradual excepL ln severe pre-eclampsla.
lnLravenous labeLalol ls safe and effecLlve. lnLravenous magneslum sulphaLe
ls superlor Lo phenyLoln ln Lhe LreaLmenL of selzures, and ls Lhe LreaLmenL of
cholce.

19) ll11l
Clven Lhe morLallLy beneflLs seen wlLh Lhe use of Lhlazlde dlureLlcs ln
hyperLenslon, Lhese drugs should be Lhe preferred flrsL llne Lherapy. AlLhough
Lhere ls no deflnlLe evldence for or agalnsL prazocln, ln Lhe ALLPA1 Lrlal, Lhe
largesL Lrlal of anLlhyperLenslves Lo daLe, doxazocln, a relaLed drug was found
Lo lncrease morLallLy. ShorL acLlng calclum channel anLagonlsLs llke nlfedlplne
have been shown Lo lncrease morLallLy. Long acLlng calclum channel
anLagonlsLs are safe. 8eLa blockers have conslsLenLly been shown Lo reduce
morLallLy. AngloLensln recepLor blockers can cause uLerlne lschaemla and
lmpalred feLal renal funcLlon, and are conLralndlcaLed ln pregnancy.

20) 1l11l
PyperparaLhyroldlsm ls known Lo cause hyperLenslon, alLhough Lhe exacL
mechanlsm of Lhls ls noL clear. Pypokalaemla occurs ln renal arLery sLenosls.
lf a hyperLenslve paLlenL has a low serum poLasslum, Lhe posslblllLy of elLher
renal arLery sLenosls or hyperaldosLeronlsm should be consldered. ln ecLoplc
AC1P syndrome, Lhe classlcal feaLures of Cushlngs dlsease are noL apparenL,
marked proxlmal muscle weakness may be Lhe only feaLure. ln
phaeochromocyLoma Lhe rlses ln blood pressure may be eplsodlc. Classlcal
hyperLenslve reLlnopaLhy changes may noL be presenL, and only flame
haemorrhages whlch occur durlng Lhe sudden lncreases ln blood pressure
may be seen. Carclnold syndrome can cause LranslenL elevaLlon of blood
pressure, buL ls generally noL a cause of susLalned hyperLenslon.

21) l111l
Whlle Lhlazlde dlureLlcs are good anLlhyperLenslve drugs, Lhey are noL ldeal
for use ln a paLlenL wlLh benlgn prosLaLlc hyperLrophy. llrsLly, dluresls wlll
resulL ln lncreased frequency of urlne. Secondly, prazocln wlll relleve
sympLoms of prosLaLlsm and ls probably Lhe preferred drug ln Lhls slLuaLlon.
AlLhough ACL lnhlblLors and angloLensln recepLor blockers can worsen renal
funcLlon by alLerlng lnLrarenal auLoregulaLlon, and can cause hyperkalaemla,
boLh Lhese drugs have long Lerm beneflLs ln reLardlng Lhe progresslon of renal
fallure, even ln advanced renal dlsease. 8amlprll reduces proLelnurla and ls
156'*+'/#)7/-./#0'*#!

43

nephroproLecLlve ln dlabeLlc paLlenLs. MeLoprolol and oLher beLa blockers, ln
parLlcular carvedllol, reduce morLallLy ln paLlenLs wlLh congesLlve cardlac
fallure. MeLhyldopa can resulL ln posLural hyperLenslon and depresslon ln
elderly paLlenLs and ls noL Lhe besL cholce ln Lhese paLlenLs.

22) 11l11
1lghL blood pressure conLrol ls probably Lhe mosL effecLlve mechanlsm of
prevenLlng Lhe progresslon of renal fallure aL ay sLage of renal dysfuncLlon.
ullLlazem ls effecLlve ln reduclng proLelnurla ln paLlenLs wlLh dlabeLlc
nephropaLhy, alLhough ofLen ACL lnhlblLors are used for Lhls purpose because
of Lhelr morLallLy beneflLs. ACL lnhlblLors and angloLensln recepLor blockers
are boLh equally effecLlve ln prevenLlng Lhe progresslon of renal fallure.
Powever Lhese drugs should be used wlLh care because Lhey can lnlLlally
cause deLerloraLlon of renal funcLlon. 1hey are also known Lo cause
hyperkalaemla. uleLary resLrlcLlon of sodlum ls an effecLlve non-
pharmacologlcal meLhod of LreaLmenL of hyperLenslon.

23) l111l
lor reasons whlch are unknown, renovascular hyperLenslon ls rare among
blacks. Among non-blacks, renovascular hyperLenslon ls one of Lhe mosL
lmporLanL causes of severe hyperLenslon. A low serum poLasslum ln a
hyperLenslve paLlenL should alerL Lhe physlclan Lo Lhe posslblllLy of renal
arLery sLenosls or Conn's syndrome. 8enal arLerlography ls sLlll Lhe gold
sLandard for dlagnosls. lasma renln acLlvlLy ls lncreased ln renal arLery
sLenosls.

24) llll1
1he alm ln hyperLenslve emergency ls Lo reduce Lhe blood pressure by noL
more Lhan 23 wlLhln 2 hours. 8apld reducLlon of blood pressure may cause
lschaemlc sLroke or myocardlal lnfarcLlon. lnLravenous nlLroprusslde ls Lhe
drug of flrsL cholce due Lo lLs shorL duraLlon of acLlon. lLs effecLs can be
reversed rapldly by sLopplng Lhe lnfuslon. Subllngual nlfedlplne can drasLlcally
drop Lhe blood pressure and can lncrease Lhe rlsk of sLroke. lL should noL be
used. 1here ls no place for Lhe use of mannlLol, blood pressure lowerlng
alone ls usually enough. AorLlc dlssecLlon ls one of Lhe mosL serlous
compllcaLlons of hyperLenslve emergency.
!
!
23) 1l111
156'*+'/#)7/-./#0'*#!

46

PyperLenslon ls one of Lhe mosL lmporLanL causes of congesLlve cardlac
fallure and sLroke. lschaemlc hearL dlsease ls more llkely ln hyperLenslves.
LongsLandlng hyperLenslon can cause renal fallure, and ln paLlenLs wlLh
exlsLlng renal dlsease, unconLrolled hyperLenslon ls Lhe mosL lmporLanL facLor
whlch worsens Lhe rapldlLy of progresslon.
!
8&*,)79&#$43&*!,*4:#!
47

#J36EOPJ1#:=J3!63:Q1!

1) Asplrln
a) 8educes morLallLy afLer a myocardlal lnfarcLlon
b) MusL be dlsconLlnued lf Lhe paLlenL complalns of dyspepsla
c) ls effecLlve ln prlmary prevenLlon of myocardlal lnfarcLlon
d) revenLs sLroke
e) Clves addlLlve beneflL when comblned wlLh warfarln afLer pulmonary
embollsm

2) 8egardlng anLlcoagulaLlon
a) Warfarln ls lndlcaLed ln paLlenLs wlLh mlLral sLenosls and aLrlal
flbrlllaLlon
b) Low molecular welghL heparln ls less effecLlve Lhan unfracLlonaLed
heparln ln unsLable anglna
c) AfLer a pulmonary embollsm, warfarln LreaLmenL ls lndlcaLed for aL
leasL 3 monLhs
d) aLlenLs wlLh recurrenL LranslenL lschaemlc aLLacks should be LreaLed
wlLh warfarln
e) ln paLlenLs on long Lerm warfarln lL ls sufflclenL Lo check Lhe ln8
every 3 monLhs

3) lsosorblde dlnlLraLe
a) lmproves ln anglna by causlng coronary vasodllaLaLlon
b) 8educes morLallLy afLer myocardlal lnfarcLlon
c) Causes headache
d) Causes Lolerance
e) ls effecLlve when admlnlsLered LranscuLaneously

4) 8eLa blockers
a) 8educe anglna by reduclng myocardlal oxygen demand
b) Are conLralndlcaLed ln hearL fallure
c) Are conLralndlcaLed ln chronlc obsLrucLlve alrways dlsease
d) 8educe lefL venLrlcular hyperLrophy
e) 8educe Lhe lncldence of sudden cardlac deaLh afLer myocardlal
lnfarcLlon



8&*,)79&#$43&*!,*4:#!
48

3) 1hlazlde dlureLlcs
a) are flrsL llne drugs ln hearL fallure
b) are flrsL llne drugs ln hyperLenslon
c) are unsulLable for use ln paLlenLs wlLh sLage 2 hyperLenslon
d) maybe safely comblned wlLh angloLensln recepLor blockers
e) Are conLralndlcaLed ln dlabeLes melllLus

6) SplronolacLone
a) reduces morLallLy ln hearL fallure
b) hlgh doses should be used ln hearL fallure
c) can cause hyperkalaemla when comblned wlLh ACL lnhlblLors
d) ls safe ln moderaLe renal fallure
e) can cause gynaecomasLla

7) ulgoxln
a) ls lndlcaLed ln paLlenLs wlLh mlLral sLenosls ln slnus rhyLhm
b) lmproves survlval ln hearL fallure
c) reduces sympLoms ln hearL fallure
d) can cause LachyarrhyLhmlas
e) can cause hearL block

8) AngloLensln converLlng enzyme lnhlblLors are lndlcaLed ln
a) ln a 40 year old paLlenL wlLh ldlopaLhlc dllaLed cardlomyopaLhy
b) ln a paLlenL afLer a myocardlal lnfarcLlon
c) ln a paLlenL wlLh aorLlc sLenosls
d) A hyperLenslve paLlenL wlLh proLelnurla
e) A normoLenslve dlabeLlc wlLhouL proLelnurla

9) AngloLensln recepLor blockers
a) Are conLralndlcaLed ln renal fallure
b) Pave beneflclal effecLs ln dlabeLes melllLus
c) Can be safely comblned wlLh oLher anLlhyperLenslves
d) Pave anLlarrhyLhmlc properLles
e) 8educe morLallLy ln hearL fallure





8&*,)79&#$43&*!,*4:#!
49

10) 1rue or false
a) vlLamln L ls of proven value ln Lhe LreaLmenL of hyperLenslon
b) razocln has survlval beneflL ln hyperLenslon
c) lollc acld supplemenLaLlon may be beneflclal ln prevenLlng lschaemlc
hearL dlsease
d) 8eLa caroLene has beneflclal effecLs ln lschaemlc hearL dlsease
Lhrough lLs anLloxldanL effecLs
e) nlcoLlnlc acld ls an effecLlve cholesLerol lowerlng agenL

11) 1he slde effecLs of angloLensln converLlng enzyme lnhlblLors lnclude
a) Cough
b) Peadache
c) Pyperkalaemla
d) Worsenlng of renal funcLlon ln paLlenLs wlLh chronlc renal fallure
e) PypoLenslon wlLh Lhe flrsL dose

12) Amlodarone
a) Can cause hypoLhyroldlsm
b) Pas a half llfe of 3 days
c) Causes prolongaLlon of Lhe C1 lnLerval
d) ls useful ln Lhe LreaLmenL of aLrlal flbrlllaLlon
e) ls safe ln pregnancy

13) 8egardlng Calclum channel blockers
a) 8educe morLallLy ln paLlenLs wlLh lschaemlc hearL dlsease
b) Are effecLlve anLlanglnal agenLs
c) 8educe proLelnurla
d) ShorL acLlng nlfedlplne lncreases morLallLy ln hyperLenslon
e) Can be used Lo delay surgery ln paLlenLs wlLh aorLlc regurglLaLlon

14) Slde effecLs of Lhlazlde dlureLlcs lnclude
a) hypercalcaemla
b) acuLe pancreaLlLls
c) hyperglycaemla
d) cholesLaLlc [aundlce
e) hyperkalaemla



8&*,)79&#$43&*!,*4:#!
30


13) SLrepLoklnase LreaLmenL ln acuLe myocardlal lnfarcLlon
a) has now been shown Lo be effecLlve lf glven vla Lhe lnLramuscular
rouLe
b) may be assoclaLed wlLh an anaphylacLlc reacLlon
c) ls assoclaLed wlLh a 23 percenL reducLlon ln morLallLy
d) ls lndlcaLed ln non S1 elevaLlon Ml
e) ls as effecLlve ln lmprovlng prognosls ln paLlenLs wlLh lnferlor as well
as anLerlor lnfarcLlons

16) lrusemlde
a) Clven lnLravenously Lakes 6 hours Lo brlng rellef ln acuLe lefL
venLrlcular fallure
b) 8educes preload
c) ls a less efflcaclous dlureLlc Lhan amllorlde
d) ls preferred Lo hydrochloroLhlazlde ln Lhe managemenL of
hyperLenslon
e) ls known Lo preclplLaLe pre-renal uraemla

17) ln hearL fallure
a) Carvedllol ls conLralndlcaLed as lL has negaLlve lnoLroplc effecLs
b) 1he compensaLory paLhophyslologlcal mechanlsms have harmful
effecLs ln Lhe long Lerm
c) SalL resLrlcLlon ls used as a form of Lherapy
d) Cedema ls lnlLlally deLecLed ln Lhe face
e) CapLoprll lmproves survlval

18) Asplrln
a) ls lndlcaLed ln Lhe managemenL of acuLe LhromboLlc sLroke
b) ln low dose (130 Lo 300mg dally) ls known Lo lnfluence Lhe regular
LesLs of bleedlng funcLlon
c) Allergy manlfesLs as bronchospasm
d) uoes noL lmprove survlval ln paLlenLs afLer myocardlal lnfarcLlon
e) And sLrepLoklnase should noL be glven concurrenLly
8&*,)79&#$43&*!,*4:#!
31


19) 1he followlng drugs and Lhelr acLlons are correcLly palred
a) ulpyrldamole - lnhlblLs plaLeleL phosphodlesLerase
b) Clopldogrel - lnhlblLs acLlvaLlon of Lhe glycoproLeln llb/llla recepLors
ln Lhe plaLeleLs
c) 1lroflban - lnhlblLs llpooxygenase recepLors
d) Low dose asplrln - alLers Lhe balance beLween Lhromboxane A2 and
prosLaglandln l2 ln plaLeleLs and vessel wall
e) Abclxlmab - blocks glycoproLeln llb/llla recepLors ln Lhe plaLeleLs

20) SLrepLoklnase
a) ls exLracLed from culLures of beLa-haemolyLlc sLrepLococcl
b) Pas hlgh efflcacy ln dlssolvlng arLerlal Lhrombl LhaL are abouL 3 weeks
old
c) uoes noL have anLlgenlc properLles
d) ls glven as a rapld lnLravenous bolus
e) ls classlfled as an anLlplaLeleL drug

21) 1he followlng are Lrue
a) Asplrln ls converLed Lo sallcylaLe by flrsL pass meLabollsm ln Lhe llver
b) llbrlnolyLlc drugs are lneffecLlve ln reduclng morLallLy afLer
myocardlal lnfarcLlon ln Lhose over 70 years
c) ALenolol ls a llpld soluble beLa blocker
d) llbrlnolyLlc drugs are conLralndlcaLed ln severe unconLrolled
hyperLenslon
e) SLrepLoklnase when used Lo LreaL myocardlal lnfarcLlon ls known Lo
produce arrhyLhmlas

22) 1he followlng drugs and Lhelr effecLs are correcLly palred
a) SlmvasLaLln - lowers hepaLlc cholesLerol synLhesls
b) vlLamln L- lncreases PuL cholesLerol
c) Cemflbrozll - lncreases hepaLlc llpld synLhesls
d) CholesLyramlne - lnhlblLs enLerohepaLlc reupLake of blle salLs
e) nlcoLlnlc acld - decreases serum Lrlglycerldes

8&*,)79&#$43&*!,*4:#!
32

23) SLaLlns
a) Are conLralndlcaLed lf serum Lransamlnases are perslsLenLly elevaLed
b) Cause rhabdomyolysls
c) Are safely used durlng pregnancy
d) Are effecLlve ln Lhe prlmary prevenLlon of coronary evenLs
e) Are recommended Lo be Laken ln Lhe mornlng

24) CauLlons abouL Lhe use of dlglLalls lnclude
a) Pypokalaemla
b) Cld age
c) ulabeLes melllLus
d) Low plaLeleLs
e) resence of aLrlal flbrlllaLlon

23) Whlch of Lhe followlng ls Lrue regardlng Lhe acLlon of Clopldogrel?
a) lL ls useful ln sLroke
b) lL ls lndlcaLed ln unsLable anglna
c) lL can cause LhrombocyLopaenla
d) lL should noL be comblned wlLh asplrln
e) lL causes hyperLenslon

8&*,)79&#$43&*!,*4:#-./#0'*#!
33

J'%L0)%!>+!#()*&+,(%-./()!*).R%!M.0%>&+'%!
!
1) 1l11l
Low dose asplrln lrreverslbly lnhlblLs plaLeleL cyclooxygenase, resulLlng ln
reducLlon of Lhromboxane A2 whlch ls a promoLer of plaLeleL aggregaLlon,
Lhereby reduclng Lhe rlsk of LhromboLlc vascular evenLs. 1hls effecL of asplrln
ls seen wlLh low doses, l.e., 73 Lo 130mg per day. Larger doses do noL confer
addlLlonal beneflL, and ln facL may have deleLerlous effecLs by lnhlblLlng
endoLhellal synLhesls of prosLacyclln, whlch ls a vasodllaLor and lnhlblLor of
plaLeleL aggregaLlon. Asplrln ls useful ln secondary prevenLlon afLer acuLe
myocardlal lnfarcLlon , occluslve sLroke, LranslenL lschemlc aLLack, sLable
anglna, and coronary arLery bypass. lL ls also used ln Lhe LreaLmenL of acuLe
lschemlc syndromes such as acuLe Ml and unsLable anglna, and ln acuLe
occluslve sLroke. lL ls also of beneflL ln prlmary prevenLlon of myocardlal
lnfarcLlon. lL probably has no addlLlve value Lo LreaLmenL wlLh warfarln ln
pulmonary embollsm. Asplrln causes gasLrlc eroslons and dyspepsla, buL Lhls
alone should noL be an lndlcaLlon Lo sLop LreaLmenL, unless a gasLrlc ulcer
develops, or Lhe paLlenL has upper Cl bleedlng.

S< 1l1ll!
Warfarln reduces Lhe rlsk of sLroke ln paLlenLs wlLh aLrlal flbrlllaLlon, by
reduclng Lhrombus formaLlon ln Lhe dllaLed aLrlum ln paLlenLs wlLh mlLral
sLenosls. ln paLlenLs wlLh caroLld arLery sLenosls who develop a 1lA, Lhere ls a
place for LreaLmenL wlLh warfarln Lo prevenL a sLroke. Powever Lhere are no
clear guldellnes regardlng Lhe use of warfarln rouLlnely ln paLlenLs wlLh 1lAs
where Lhe cause has noL been ldenLlfled. AfLer a pulmonary embollsm,
warfarln LreaLmenL should be conLlnued for aL leasL 3 monLhs, preferably
longer. aLlenLs on long Lerm warfarln musL, ln mosL lnsLances, have Lhelr
proLhrombln Llme ln8 monlLored every 2 Lo 3 weeks. !
!
3) l1111
When coronary aLheroma ls presenL, Lhe coronary arLerles are Loo rlgld Lo
dllaLe ln response Lo nlLraLes. 1he beneflclal effecLs of nlLraLes ls noL due Lo
coronary vasodllaLaLlon, buL occurs as a resulL of pulmonary and sysLemlc
venodllaLaLlon resulLlng ln reduced preload. AlLhough of sympLomaLlc beneflL,
Lhere ls no evldence LhaL lsosorblde dlnlLraLe lmproves morLallLy afLer
myocardlal lnfarcLlon. lsosorblde dlnlLraLe ls well known Lo cause headache,
especlally soon afLer commenclng Lherapy. lL ls usually easlly LreaLed wlLh
slmple analgeslcs, and lL ls only rarely LhaL Lhe headaches are so severe as Lo
8&*,)79&#$43&*!,*4:#-./#0'*#!
34

warranL dlsconLlnuaLlon of Lhe drug. WlLh conLlnued use, Lhe headaches
usually resolve. nlLraLes are also well known Lo cause Lolerance, and lL ls
essenLlal Lo have nlLraLe free lnLervals Lo prevenL Lhls. nlLraLes can be
effecLlvely admlnlsLered subllngually, orally, lnLravenously, or
LranscuLaneously.
!
4) 1l111
8eLa blockers have negaLlve lnoLroplc and chronoLroplc effecLs, Lhereby
reduclng myocardlal oxygen demand. 1hese effecLs are beneflclal ln coronary
lschaemla. AlLhough on physlologlcal grounds beLa blockers should worsen
hearL fallure Lhls ls noL Lhe case. aLlenLs wlLh hearL fallure have hlgh
adrenerglc drlve, whlch resulLs ln worsenlng of sympLoms and survlval.
Careful use of beLa blockers can be used Lo LreaL Lhls. 8eLa blockers, ln
parLlcular Carvedllol, has been proven Lo reduce morLallLy ln paLlenLs wlLh
moderaLe hearL fallure. Care musL be Laken Lo commence beLa blockers ln
paLlenLs wlLh hearL fallure, as an lnlLlal deLerloraLlon ln funcLlonal sLaLus can
occur. 8eLa blockers cause bronchoconsLrlcLlon, and are conLralndlcaLed ln
asLhma and CCu. 8eLa blockers reduce lefL venLrlcular hyperLrophy, Lhough
ACL lnhlblLors are more effecLlve for Lhls purpose. AfLer a myocardlal
lnfarcLlon, beLa blockers reduce Lhe lncldence of sudden cardlac deaLh,
probably by reduclng Lhe occurrence of llfe LhreaLenlng LachyarrhyLhmlas.

3) l1l1l
1hlazldes are mlld dlureLlcs, and are ofLen lnadequaLe for hearL fallure. Loop
dlureLlcs such as frusemlde are preferred. 1hlazldes can, however, be used as
add on drugs ln chronlc hearL fallure. 1hlazldes have been conslsLenLly shown
Lo have survlval beneflL ln paLlenLs wlLh hyperLenslon, and are nor
recommended as Lhe flrsL llne drugs ln hyperLenslon. 1hey are sulLable elLher
alone or ln comblnaLlon ln all sLages of hyperLenslon. 1hey can be safely
comblned wlLh almosL any oLher anLlhyperLenslve. 1hlazldes ln larger doses
have adverse effecLs on serum llplds, and may have adverse effecLs on
dlabeLlc conLrol, buL evldence from Lhe largesL Lrlal on anLlhyperLenslve
LreaLmenL, Lhe ALLPA1 Lrlal, demonsLraLed LhaL Lhlazldes slgnlflcanLly reduced
cardlovascular morLallLy ln all paLlenLs lncludlng dlabeLlcs. 1hlazldes are no
longer conLralndlcaLed ln dlabeLlcs.

6) 1l111
Low doses of splronolacLone have been shown Lo reduce morLallLy ln paLlenLs
wlLh hearL fallure. uue Lo lLs poLasslum sparlng effecLs, hyperkalaemla can
8&*,)79&#$43&*!,*4:#-./#0'*#!
33

occur, especlally when used ln comblnaLlon wlLh ACL lnhlblLors. ln low doses,
hyperkalaemla ls ofLen noL a problem, excepL when renal funcLlon ls lmpalred.
lL can be used wlLh care ln moderaLe renal fallure, buL serum poLasslum levels
musL be closely monlLored. SplronolacLone causes gynaecomasLla, by lLs anLl-
androgen effecLs.
!
7) ll111
ulgoxln has complex pharmacodynamlcs and pharmacoklneLlcs. lL has cardlac
lnoLroplc effecLs, can cause hearL block, and ln overdose can resulL ln varlous
Lypes of LachyarrhyLhmlas. 1here has been much conLroversy abouL Lhe use
of dlgoxln ln hearL fallure. When dlgoxln was flrsL dlscovered lL was found Lo
be effecLlve ln congesLlve hearL fallure. SubsequenLly Lhere were concerns
LhaL alLhough lL lmproves sympLoms lL may lncrease morLallLy. 1he ulglLalls
lnvesLlgaLlon Croup or ulC Lrlal showed LhaL dlgoxln lmproved sympLoms and
reduced hosplLal admlsslons, buL nelLher lncreased nor decreased morLallLy. lL
ls used ln reslsLanL hearL fallure as an add-on drug Lo more beneflclal drugs
llke ACL lnhlblLors and splronolacLone, and ls no longer a flrsL llne drug ln
hearL fallure. Powever, ln mlLral sLenosls wlLh aLrlal flbrlllaLlon, lL ls useful ln
reduclng Lhe venLrlcular raLe. 1here ls no lndlcaLlon for lLs use ln paLlenLs wlLh
mlLral sLenosls who are ln slnus rhyLhm.!
!
8) 11l1l
ACL lnhlblLors have a varleLy of beneflclal effecLs. 1hey reduce sympLoms and
morLallLy ln paLlenLs wlLh hearL fallure due Lo any cause. ACL lnhlblLors also
have effecLs on venLrlcular remodellng afLer a myocardlal lnfarcLlon, and can
reduce Lhe rlsk of developmenL of myocardlal dysfuncLlon. ACL lnhlblLors
reduce proLelnurla ln normoLenslve dlabeLlcs wlLh proLelnurla, and
hyperLenslves wlLh proLelnurla. 1here ls no lndlcaLlon for lLs use ln a
normoLenslve dlabeLlc paLlenL wlLhouL proLelnurla. ACL lnhlblLors cause
sysLemlc vasodllaLaLlon, and are conLralndlcaLed ln paLlenLs wlLh aorLlc
sLenosls, as Lhey can resulL ln hypoLenslon.
!
9) l11l1
AngloLensln recepLor blockers cause hyperkalaemla, and may affecL lnLrarenal
auLoregulaLlon. 1ranslenL worsenlng of renal funcLlon ls someLlmes seen.
Powever, ln Lhe long Lerm Lhese drugs reLard Lhe progresslon of renal fallure.
1hey have beneflclal effecLs ln dlabeLes melllLus, especlally ln Lhe prevenLlon
of proLelnurla and progresslon of nephropaLhy. 1hey can be safely comblned
8&*,)79&#$43&*!,*4:#-./#0'*#!
36

wlLh oLher anLlhyperLenslves. Llke ACL lnhlblLors, Lhey have been shown Lo
reduce morLallLy ln hearL fallure.
!
10) ll1l1
AlLhough anLloxldanLs such as vlLamln L and beLa caroLene have long been
LhoughL Lo be beneflclal ln Lhe LreaLmenL of cardlovascular dlsease, Lhere ls
no convlnclng Lrlal evldence of such beneflL. LlevaLed homocysLelne levels
lncrease cardlovascular rlsk by lLs procoagulanL effecLs. lolaLe deflclency may
resulL ln elevaLed homocysLelne levels, and lL ls LhoughL LhaL ln paLlenLs who
are folaLe deflclenL, follc acld supplemenLaLlon may be of use. Agaln, Lhere ls
no deflnlLe evldence. nlcoLlnlc acld ls an effecLlve, buL poorly LoleraLed,
cholesLerol lowerlng agenL.

11) 1l111
Peadache ls noL a recognlsed slde effecL of ACL lnhlblLors. Cough ls common,
and ls an lndlcaLlon Lo swlLch over Lo an angloLensln recepLor blocker.
Pyperkalaemla ls a known slde effecL, especlally ln paLlenLs on
splronolacLone, and Lhose ln renal fallure. ACL lnhlblLors are useful even ln
laLe sLages of renal fallure, however worsenlng of renal funcLlon can occur,
due Lo changes ln lnLrarenal auLoregulaLlon. lf renal funcLlon deLerloraLes,
Lhe ACL lnhlblLor may need Lo be dlsconLlnued. llrsL dose hypoLenslon ls a
well known slde effecL, and paLlenLs are Lherefore advlsed Lo Lake Lhe flrsL
dose whlle lylng ln bed.

12) 1l11l
Amlodarone can cause boLh hypo and hyperLhyroldlsm. lL has a very long half
llfe of nearly 100 days. lL causes prolongaLlon of Lhe C1 lnLerval, and can be
arrhyLhmogenlc. lL ls used Lo converL aLrlal flbrlllaLlon Lo slnus rhyLhm, and
Lherefore has a place ln medlcal cardloverslon of acuLe aLrlal flbrlllaLlon.
loeLal Lhyrold abnormallLles are known Lo occur, and Lhe drug ls
conLralndlcaLed ln pregnancy.

13) l1111
1hough calclum channel anLagonlsLs are effecLlve anLl anglnal agenLs, Lhere ls
llLLle evldence LhaL Lhey affecL survlval ln paLlenLs wlLh lschaemlc hearL
dlsease. 1here ls some evldence LhaL dllLlazem prevenLs relnfarcLlon ln
paLlenLs wlLh non C Ml. Calclum channel blockers reduce proLelnurla ln
paLlenLs wlLh dlabeLes. ShorL acLlng nlfedlplne, alLhough an effecLlve
anLlhyperLenslve agenL, lncreases morLallLy ln paLlenL wlLh hyperLenslon and
8&*,)79&#$43&*!,*4:#-./#0'*#!
37

should noL be used. nlfedlplne ls used ln paLlenLs wlLh aorLlc regurglLaLlon Lo
reduce sympLoms and delay surgery.

14) l111l
1he mosL lmporLanL slde effecLs of Lhlazldes are orLhosLaLlc hypoLenslon,
phoLosenslLlvlLy, hypokalemla, anorexla and eplgasLrlc dlsLress. PepaLlc
dysfuncLlon, acuLe pancreaLlLls, and eryLhema mulLlforme are known Lo occur.
1here are concerns LhaL Lhlazldes can cause hyperglycaemla and worsen
dlabeLes, buL Lhls effecL ls cllnlcally noL of lmporLance.

13) l11l1
AparL from Lhe facL LhaL sLrepLoklnase ls effecLlve only lf glven lnLravenously,
lL causes bleedlng, and lf glven by Lhe lnLramuscular rouLe wlll resulL ln Lhe
formaLlon of a muscle haemaLoma. lL ls well known Lo cause anaphylacLlc
reacLlons. 1reaLmenL wlLh sLrepLoklnase ls assoclaLed wlLh a 23 percenL
reducLlon ln morLallLy. 1he beneflclal effecLs ln Lerms of survlval are long
Lerm, as demonsLraLed by Lhe 10 year follow up of Lhe cohorL of paLlenLs
LreaLed wlLh sLrepLoklnase ln Lhe lSlS-2 Lrlal. 1here ls no beneflL seen wlLh
sLrepLoklnase LreaLmenL ln non S1 elevaLlon Ml. SLrepLoklnase ls equally
effecLlve ln all Lypes of S1 elevaLlon Ml.

16) l1ll1
lrusemlde acLs ln lefL venLrlcular fallure by causlng pulmonary venodllaLaLlon
and reduclng preload raLher Lhan Lhrough dluresls, Lhls acLlon ls rapld, and
brlngs rellef wlLhln 30 mlnuLes. 8elng a loop dlureLlc, lL ls a much more poLenL
dlureLlc Lhan amllorlde, whlch ls a poLasslum sparlng dlureLlc. 1hlazldes are
Lhe drugs of flrsL cholce ln hyperLenslon, and frusemlde ls noL used as a flrsL
llne drug ln hyperLenslon. 8y causlng volume conLracLlon, frusemlde can
preclplLaLe pre-renal uraemla.

17) l11l1
AlLhough Lhe negaLlve lnoLroplc and chronoLroplc effecLs of beLa blockers
should resulL ln Lhelr worsenlng hearL fallure, cllnlcal Lrlals have shown LhaL
beLa blockers, ln parLlcular Carvedllol, lmproves survlval ln hearL fallure. Plgh
levels of adrenerglc acLlvlLy are presenL ln paLlenLs wlLh hearL fallure, as a
compensaLory mechanlsm Lo Lhe low cardlac ouLpuL sLaLe. 1hls excesslve
adrenerglc acLlvlLy ls ln facL deLrlmenLal. 8eLa blockers are posLulaLed Lo help
by blocklng excesslve Lhe excesslve adrenerglc response ln hearL fallure. SalL
resLrlcLlon ls of proven value ln hearL fallure. Cedema ls usually seen ln
8&*,)79&#$43&*!,*4:#-./#0'*#!
38

dependenL areas ln hearL fallure. ACL lnhlblLors lmprove survlval ln hearL
fallure.

18) 1l1ll
Low dose asplrln lrreverslbly lnhlblLs plaLeleL cyclooxygenase, resulLlng ln
reducLlon of Lhromboxane A2 whlch ls a promoLer of plaLeleL aggregaLlon,
Lhereby reduclng Lhe rlsk of LhromboLlc vascular evenLs. 1hls effecL of asplrln
ls seen wlLh low doses, l.e., 73 Lo 130mg per day. Larger doses do noL confer
addlLlonal beneflL, and ln facL may have deleLerlous effecLs by lnhlblLlng
endoLhellal synLhesls of prosLacyclln, whlch ls a vasodllaLor and lnhlblLor of
plaLeleL aggregaLlon. Asplrln ls useful ln secondary prevenLlon afLer acuLe
myocardlal lnfarcLlon , occluslve sLroke, LranslenL lschemlc aLLack, sLable
anglna, and coronary arLery bypass. lL ls also used ln Lhe LreaLmenL of acuLe
lschemlc syndromes such as acuLe Ml and unsLable anglna, and ln acuLe
occluslve sLroke. lL ls also of beneflL ln prlmary prevenLlon of myocardlal
lnfarcLlon. ln low doses lL does noL lnfluence Lhe resulLs of regular LesLs of
bleedlng. Allergy Lo asplrln can manlfesL as bronchospasm, and asplrln can
worsen asLhma. Many Lrlals have shown LhaL asplrln lmproves survlval ln
myocardlal lnfarcLlon, belng as effecLlve as sLrepLoklnase when glven durlng
Lhe acuLe aLLack. SLrepLoklnase and asplrln glven ln comblnaLlon have
addlLlve effecLs ln reduclng morLallLy afLer a myocardlal lnfarcLlon.

19) 1ll11
ulpyrldamole lnhlblLs phosphodlesLerase-medlaLed breakdown of cycllc AM
whlch prevenLs plaLeleL acLlvaLlon by mulLlple mechanlsms. 1lclopldlne and
clopldogrel achleve Lhelr anLlplaLeleL effecL by blocklng Lhe blndlng of Au Lo
a speclflc plaLeleL recepLor 2?12 LhaL acLlvaLes Cl, Lhereby lnhlblLlng adenylyl
cyclase and plaLeleL aggregaLlon. 1lroflban and abclxlmab are glycoproLeln
llb/llla lnhlblLors whlch lnhlblL plaLeleL aggregaLlon. Low dose asplrln
preferenLlally blocks Lhromboxane A2 ln Lhe plaLeleLs and vessel wall.

20) 1llll
SLrepLoklnase ls a slngle chaln polypepLlde derlved from beLa-hemolyLlc
sLrepLococcus culLures. lL blnds Lo plasmlnogen, formlng a complex whlch
becomes an acLlve enzyme LhaL cleaves pepLlde bonds on oLher plasmlnogen
molecules, leadlng Lo plasmln acLlvaLlon. lL ls effecLlve ln dlssolvlng newly
formed arLerlal Lhrombl. lL ls hlghly anLlgenlc, and anLlbodles form afLer lLs
admlnlsLraLlon, llmlLlng repeaLed use. lL ls glven as an lnfuslon over an hour.

8&*,)79&#$43&*!,*4:#-./#0'*#!
39


21) lll11
Asplrln ls hydrolyzed Lo sallcylaLe, whlch ls acLlve, by esLerases ln Cl mucosa,
red blood cells, synovlal fluld, and blood, meLabollsm of sallcylaLe occurs
prlmarlly by hepaLlc con[ugaLlon. llbrlnolyLlc drugs are effecLlve even ln
elderly paLlenLs, alLhough Lhelr beneflLs are llmlLed ln Lhose over Lhe age of 80
years. ALenolol ls a waLer soluble beLa blocker and does noL cross Lhe blood
braln barrler. llbrlnolyLlc drugs are conLralndlcaLed ln severe hyperLenslon as
Lhey may cause lnLracranlal bleeds. SLrepLoklnase glven durlng myocardlal
lnfarcLlon cause arrhyLhmlas, whlch arlse due Lo reperfuslon of Lhe lschaemlc
myocardlum . 1helr presence ls a slgn LhaL reperfuslon ls Laklng place.

22) 1ll11
SLaLlns are PMC CoA reducLase lnhlblLors, and lnhlblL hepaLlc cholesLerol
synLhesls. vlLamln L has no deflnlLe effecLs on serum llplds. 1he exacL
mechanlsm of acLlon of gemflbrozll ls unknown, lL ls posLulaLed Lo lnhlblL
llpolysls and decrease subsequenL hepaLlc faLLy acld upLake as well as lnhlblL
hepaLlc secreLlon of vLuL, LogeLher Lhese acLlons decrease serum vLuL levels,
lncreases PuL-cholesLerol. CholesLyramlne forms a nonabsorbable complex
wlLh blle aclds ln Lhe lnLesLlne, releaslng chlorlde lons ln Lhe process, lnhlblLs
enLerohepaLlc reupLake of lnLesLlnal blle salLs and Lhereby lncreases Lhe fecal
loss of blle salL-bound low denslLy llpoproLeln cholesLerol. nlcoLlnlc acld
lnhlblLs Lhe synLhesls of very low denslLy llpoproLelns. lL ls effecLlve ln
lowerlng serum Lrlglycerlde levels.

23) 11l1l
SLaLlns are conLralndlcaLed lf Lhe serum Lransamlnases are perslsLenLly
elevaLed. 1hey are also known Lo cause rhabdomyolysls. 1hey are
conLralndlcaLed ln pregnancy. SLaLlns are effecLlve ln boLh prlmary and
secondary prevenLlon of coronary evenLs. 1hey are Laken aL nlghL, slnce mosL
of Lhe hepaLlc cholesLerol synLhesls Lakes place aL nlghL.

24) 11lll
Pypokalaemla worsens dlglLalls LoxlclLy. Powever, ln overdose, dlgoxln causes
hyperkalaemla. Llderly paLlenLs are aL greaLer rlsk of dlgoxln LoxlclLy because
of reduced renal funcLlon. ulgoxln has no effecL on plaLeleLs. 1he presence of
aLrlal flbrlllaLlon ls an lndlcaLlon raLher Lhan a cauLlon for Lhe use of dlgoxln.
ulgoxln ls used Lo conLrol Lhe venLrlcular raLe ln aLrlal flbrlllaLlon.

8&*,)79&#$43&*!,*4:#-./#0'*#!
60

23) 111l1
Clopldogrel ls useful ln Lhe secondary prevenLlon of sLroke. lL ls also lndlcaLed
ln unsLable anglna. Clopldogrel can cause LhrombocyLopaenla, and Lhere are
some reporLs of LhromboLlc LhrombocyLopaenlc purpura. lL can be safely
comblned wlLh asplrln. PyperLenslon ls a rare buL recognlzed slde effecL.
!
8&*,)&$!&**'#+!
61

#J36EJ#!J33G1K!

1) 1he followlng are Lrue regardlng a cardlac arresL occurrlng ouL of hosplLal
a) More Lhan 30 percenL wlll survlve
b) aLlenLs wlLh asysLollc arresL are more llkely Lo survlve Lhan Lhose
wlLh venLrlcular flbrlllaLlon
c) ?ounger paLlenLs are more llkely Lo survlve
d) A paLlenL wlLh a wlLnessed cardlac arresL ls more llkely Lo survlve
e) 1reaLmenL wlLh aLroplne for a bradyarrhyLhmla afLer resusclLaLlon ls
llkely Lo lmprove survlval

2) 8egardlng sudden cardlac deaLh
a) lL ls deflned as deaLh occurrlng wlLhln 10 mlnuLes of Lhe Lermlnal
cllnlcal evenL
b) 30 per cenL of all cardlac deaLhs are due Lo cardlac arresL
c) 1he rlsk of sudden cardlac deaLh ls hlgher durlng Lhe flrsL 6 monLhs of
llfe compared Lo chlldren over Lhe age of 1 year.
d) lL ls commoner ln men Lhan ln women
e) up Lo 30 percenL of sudden cardlac deaLhs are due Lo non-cardlac
causes

3) 1he followlng are causes of sudden cardlac deaLh
a) AcuLe coronary syndrome
b) vlral myocardlLls
c) Wolff arklnson WhlLe syndrome
d) 1reaLmenL wlLh eryLhromycln and asLemlzole ln comblnaLlon
e) Pyperkalaemla

4) 1rue or false regardlng drugs used ln cardlopulmonary resusclLaLlon
a) 1he lnlLlal dose of adrenallne ls 1mg (10 mL of 1:10000 soluLlon)
glven lnLravenously
b) Sodlum blcarbonaLe should be glven durlng Lhe flrsL cycle of
resusclLaLlon
c) lnLravenous magneslum ls rouLlnely used
d) 1he dose of aLroplne used ln non venLrlcular flbrlllaLlon / venLrlcular
Lachycardla arresL ls 3mg lnLravenously
e) 1racheal admlnlsLraLlon of drugs needs 2 Lo 3 Llmes Lhe doses used


8&*,)&$!&**'#+!
62

3) 1he followlng are Lrue
a) ALrlal flbrlllaLlon causes cardlac arresL ln adulLs
b) ueflbrlllaLlon ls Lhe LreaLmenL for pulseless venLrlcular Lachycardla
c) 1mg of adrenallne lnLravenously ls glven for venLrlcular flbrlllaLlon
d) Calclum gluconaLe ls Lhe drug of cholce for LreaLmenL of non vl/v1
cardlac arresL
e) 1hrombombollsm ls a known cause of non vl / v1 arresL

6) 8egardlng baslc llfe supporL
a) 8esponslveness of Lhe vlcLlm ls assessed by applylng a palnful
sLlmulus
b) !aw LhrusL ls Lhe besL alrway maneuver ln suspecLed cervlcal splne
ln[ury
c) lf Lhere ls no breaLhlng, 2 effecLlve breaLhs should be glven
d) Check of clrculaLlon ln an adulL ls by palpaLlng for Lhe presence of a
brachlal pulse
e) LocaLlon for chesL compresslons ls Lhe upper half of Lhe sLernum

7) A 36 year old paLlenL develops sudden chesL paln and falnLlshness. Pls
blood pressure ls 90/30mmPg, and perlpherles are cold. LCC shows a
venLrlcular Lachycardla.
a) Pe should be poslLloned ln Lhe head down poslLlon
b) 1he mosL llkely dlagnosls ls an acuLe myocardlal lnfarcLlon
c) Pe should be glven cardlac massage
d) lnLravenous llgnocalne ls lndlcaLed
e) lnLravenous adrenallne 1mg ls lndlcaLed

8) A 33 year old woman wlLh lschaemlc hearL dlsease and lefL venLrlcular
fallure develops venLrlcular flbrlllaLlon whlle ln hosplLal. 1he followlng are
Lrue
a) Per chances of survlval are approxlmaLely 23 percenL
b) She should be glven cardlac massage
c) lnLravenous amlodarone ls Lhe flrsL llne drug
d) lnLravenous adrenallne ls lndlcaLed
e) deflbrlllaLlon ls Lhe LreaLmenL of cholce

8&*,)&$!&**'#+!
63

9) noncardlac causes of sudden deaLh lnclude
a) nonLraumaLlc bleedlng
b) polsonlng
c) drownlng
d) sLroke
e) pulmonary embollsm

10) An elderly man walklng Lo Lhe hosplLal cllnlc suddenly collapses abouL 30
meLres away from Lhe lnLenslve care unlL. Cn examlnaLlon he ls
unresponslve, buL ls breaLhlng.
a) ?ou should call for help before aLLempLlng Lo resusclLaLe Lhe paLlenL
b) lf many bysLanders are presenL, Lhe paLlenL should be qulckly carrled
Lo Lhe lnLenslve care unlL
c) Pls radlal arLery should be palpaLed Lo feel for Lhe pulse
d) Pe should be poslLloned ln Lhe suplne poslLlon lf hls clrculaLlon ls
lnLacL
e) Cardlac massage should be commenced lf hls pulse cannoL be felL

11) 1he followlng cllnlcal feaLures are seen ln a paLlenL wlLh cardlac arresL
a) absenL pulses
b) cyanosls
c) Lachypnoea
d) warm exLremlLles
e) flushlng of Lhe face

12) 8egardlng cardlac arresL
a) venLrlcular flbrlllaLlon has a beLLer prognosls Lhan asysLole
b) Larly deflbrlllaLlon ls Lhe slngle mosL lmporLanL LherapeuLlc
deLermlnanL of survlval
c) ALrlal flbrlllaLlon ls a cause
d) CompleLe hearL block ls a known predlsposlng cause
e) 8esplraLlon ls always absenL

8&*,)&$!&**'#+!
64

13) 1he followlng manouvres are used ln cardlopulmonary resusclLaLlon
a) Calllng for help before aLLempLlng Lo resusclLaLe Lhe paLlenL
b) unplugglng Lhe elecLrlcal devlce ln Lhe case of elecLrocuLlon
c) Pead LllL chln llfL manouvre ln a paLlenL ln[ured ln a road Lrafflc
accldenL
d) 1he presence of sponLaneous breaLhlng ls assessed by feellng for Lhe
flow of alr from Lhe nosLrlls
e) MouLh Lo mouLh resplraLlon should be sLarLed prlor Lo assessmenL of
breaLhlng and clrculaLlon lf Lhe paLlenL ls unconsclous

14) 1he followlng are effecLlve ln Lhe LreaLmenL of supravenLrlcular
Lachycardla
a) ulgoxln
b) ropranolol
c) Adenoslne
d) lsoprenallne
e) verapamll

13) ln cardlogenlc shock
a) uopamlne ls Lhe drug of flrsL cholce
b) uobuLamlne wlll help augmenL cardlac ouLpuL
c) noradrenallne wlll lncrease Lhe workload on Lhe hearL
d) vasopressln ls used
e) lnLravenous nlLraLes are used

16) 1he followlng are used Lo assess wheLher Lhe paLlenL ls breaLhlng or noL
a) Looklng for Lhe chesL rlslng and falllng
b) LlsLenlng for alr escaplng durlng exhalaLlon
c) Poldlng a mlrror ln fronL of Lhe paLlenLs nose
d) leellng for Lhe flow of alr
e) lnchlng Lhe paLlenL Lo see lf he Lakes a deep breaLh
8&*,)&$!&**'#+!
63

17) When cardlopulmonary resusclLaLlon ls underLaken
a) lnlLlal rescue breaLhlng should be provlded Lo Lhe unresponslve,
nonbreaLhlng vlcLlm before looklng for clrculaLlon
b) chesL compresslons should be sLarLed only lL Lhe person ls sure LhaL
Lhere ls no pulse, because chesL compresslons are dangerous lf Lhe
hearL ls beaLlng
c) chesL compresslons and venLllaLlons should be glven ln a raLlo of 3
compresslons Lo 1 venLllaLlon
d) ln glvlng chesL compresslons, Lhe heel of Lhe hand ls placed over Lhe
xlphlsLernum
e) lf Lhe rescuer ls unwllllng Lo perform mouLh Lo mouLh breaLhlng, lL ls
purposeless Lo conLlnue wlLh chesL compresslons

18) 1he followlng are compllcaLlons of cardlac massage
a) rlb fracLures
b) fracLure of Lhe sLernum
c) pneumoLhorax
d) hemoLhorax
e) cardlac rupLure

19) A 46 year old woman ls admlLLed wlLh a polymorphlc venLrlcular
Lachycardla. AfLer reverslon Lo slnus rhyLhm lL ls noLed LhaL she has an
abnormally long C1 lnLerval
a) 1he condlLlon could be congenlLal
b) 1he use of Lhe comblnaLlon of eryLhromycln and asLemlzole ls a llkely
cause
c) Pypocalcaemla ls a known cause
d) 8eLa blockers are recommended ln LreaLmenL
e) lnLravenous magneslum ls Lhe drug of cholce ln Lhe presence of
venLrlcular Lachycardla ln Lhls paLlenL

8&*,)&$!&**'#+!
66

20) ln Lhe LreaLmenL of cardlac arresL, lf Lhe elecLrocardlogram shows
venLrlcular flbrlllaLlon
a) 1hree uC shocks uslng energles of 200, 200 Lo 300, and 360 [oules
should be glven ln sequence
b) lf Lhere ls no response Lhe sequence of Lhree shocks should be
repeaLed lmmedlaLely
c) blcarbonaLe should be glven lmmedlaLely Lo reduce acldosls
d) lnLubaLlon ls lndlcaLed lf Lhere ls no response Lo lnlLlal Lherapy
e) lnLravenous adrenallne ls lndlcaLed

21) A 30 year old paLlenL wlLh lschaemlc hearL dlsease develops venLrlcular
Lachycardla. Per blood pressure ls 130/80mmPg. 1he followlng are Lrue
a) AnLlarrhyLhmlc Lherapy ls noL lndlcaLed as she ls haemodynamlcally
sLable
b) Synchronlzed uC cardloverslon aL 100 [oules ls Lhe recommended
managemenL
c) lnLravenous llgnocalne 30-100mg ls effecLlve
d) Amlodarone ls Lhe drug of flrsL cholce
e) verapamll ls effecLlve

22) ln Lhe managemenL of a paLlenL wlLh anaphylaxls:
a) lnLravenous flulds musL be glven
b) P2 recepLor anLagonlsLs are effecLlve as ad[uncLlve Lherapy
c) Adrenallne should be glven subcuLaneously
d) aLroplne ls lndlcaLed
e) PydrocorLlsone wlll acL wlLhln 10 mlnuLes

23) ln a paLlenL wlLh cardlac arresL, lf Lhe elecLrocardlogram shows asysLole
a) 1hree uC shocks uslng energles of 200, 200 Lo 300, and 360 [oules
should be glven ln sequence
b) C8 should be conLlnued
c) venLrlcular flbrlllaLlon may develop
d) Adrenallne 1 mg lnLravenously every Lhree Lo flve mlnuLes should be
admlnlsLered
e) vasopressln ls more effecLlve Lhan adrenallne

8&*,)&$!&**'#+!
67

24) A 30 year old male develops cardlac arresL. Pe ls noL breaLhlng, and
pulses are noL palpable. Pls elecLrocardlogram shows a regular rhyLhm
wlLh a raLe of 60 beaLs per mlnuLe
a) ulseless elecLrlcal acLlvlLy ls Lhe llkely dlagnosls
b) ulmonary embollsm ls a cause
c) Sodlum blcarbonaLe ls lndlcaLed ln Lhe presence of hyperkalaemla
d) lf Lhe complexes are wlde, Lhe prognosls ls poor
e) has a beLLer prognosls Lhan asysLole

23) Cn dlscoverlng an unconsclous paLlenL ouLslde hosplLal
a) 8apld assessmenL of Lhe alrway and breaLhlng musL be performed
lnlLlally
b) Cross lnfecLlon wlLh nelsserla menlnglLldls may occur durlng C8
c) 1wo effecLlve rescue breaLhs should be glven once apnoea ls
conflrmed
d) Cn conflrmlng an arresL, one mlnuLe of C8 should be performed
before leavlng Lhe paLlenL and geLLlng help
e) Cn conflrmlng an arresL, a raLlo of 13 compresslons Lo 2 venLllaLlons
should be adopLed aL all Llmes
8&*,)&$!&**'#+-./#0'*#!
68

J'%L0)%!>+!#()*&(-!J))0%>!M.0%>&+'%!

1. ll11l
1he survlval raLe of ouL of hosplLal cardlac arresL ls around 20 percenL.
venLrlcular flbrlllaLlon has a much beLLer prognosls Lhan asysLollc arresL, ln
whlch Lhe ouLcome ls dlsmal. 1he facLors assoclaLed wlLh lncreased survlval
afLer arresL are, wlLnessed arresL, lower paLlenL age, shorLer Llme Lo arrlval of
emergency medlcal personnel, and no LreaLmenL wlLh aLroplne for a
bradyarrhyLhmla afLer resusclLaLlon.

2. l1111
Sudden cardlac deaLh ls deaLh occurrlng wlLhln 1 hour of Lhe Lermlnal cllnlcal
evenL. 1he rlsk of sudden deaLh ls hlgh up Lo Lhe age of 6 years, Lhe sudden
lnfanL deaLh syndrome. lL ls commoner ln men.

3. 11111
lschaemlc hearL dlsease, vlral myocardlLls, WW syndrome can all glve rlse Lo
dangerous arrhyLhmlas lncludlng venLrlcular flbrlllaLlon. 8oLh eryLhromycln
and asLemlzole cause prolongaLlon of Lhe C1 lnLerval, and Lhls can glve rlse Lo
polymorphlc v1 and sudden deaLh. 1he comblnaLlon used Lo be a common
one ln Lhe LreaLmenL of sore LhroaLs, cllnlclans preferrlng eryLhromycln Lo
penlclllln because of fears abouL penlclllln allergy, and asLemlzole Lo
chlorphenlramlne because of sedaLlon. Pyperkalaemla ls a well recognlzed
cause of asysLole and sudden deaLh.

4. 1ll11
Plgher doses of drugs are needed for Lracheal admlnlsLraLlon. Magneslum ls
lndlcaLed ln polymorphlc v1. 1he lndlcaLlon for sodlum blcarbonaLe are as
follows, preexlsLlng hyperkalemla, preexlsLlng blcarbonaLe-responslve acldosls
ls presenL, for LreaLmenL of Lrlcycllc anLldepressanL overdose, and Lo alkallnlze
Lhe urlne ln asplrln or oLher drug overdose.

3. l11l1
ALrlal flbrlllaLlon does noL cause cardlac arresL, excepL ln WW syndrome
where lL can deLerloraLe lnLo v1. ueflbrlllaLlon ls Lhe LreaLmenL for pulseless
v1/vl. ulmonary Lhromboembollsm ls a known cause of non vl/v1 arresL.



8&*,)&$!&**'#+-./#0'*#!
69

6. l11ll
8esponslveness of Lhe vlcLlm ls assessed by calllng Lhe vlcLlms name, and
shaklng hlm. 1he head LllL chln llfL manouvre ls usually used Lo ensure alrway
paLency, buL ln suspecLed cervlcal splne ln[ury lL can cause cord compresslon.
!aw LhrusL alone ls used here. ClrculaLlon ls checked uslng Lhe caroLld pulse,
and ls noL always easy Lo feel, especlally for Lhe layman. ChesL compresslons
are glven wlLh Lhe heel of Lhe hand over Lhe lower parL of Lhe sLernum.

7. 11lll
1he head down poslLlon ls sulLable for Lhls hypoLenslve paLlenL Lo maxlmlze
cerebral blood flow. 1he mosL llkely cause of Lhls presenLaLlon ln a male of
Lhls age ls an acuLe myocardlal lnfarcLlon. Cardlac massage ls noL lndlcaLed as
hls pulse ls recordable, and he ls breaLhlng and ls alerL. lnLravenous
llgnocalne ls lndlcaLed ln haemodynamlcally sLable v1 - Lhls paLlenL should
recelve uC cardloverslon Lo reverL Lhe v1. 1here ls no place for adrenallne.

8. 11l11
Per chances of survlval are poor. Powever, Lhe chances are beLLer because lL
ls a wlLnessed arresL. Cardlac massage ls lndlcaLed as Lhere ls no venLrlcular
ouLpuL ln venLrlcular flbrlllaLlon, buL Lhe deflnlLlve Lherapy ls deflbrlllaLlon,
wlLhouL whlch she wlll dle. lnLravenous adrenallne ls lndlcaLed ln asysLollc
arresL Lo Lry and lnduce vl, whlch has a beLLer prognosls. !

9. 11111
All of Lhese can cause sudden deaLh, Lhough sLrlcLly speaklng, ln pulmonary
embollsm deaLh ls due Lo cardlovascular compromlse. !
!
10. 1lll1
1he flrsL Lhlng Lo do ls Lo call for help. 1he paLlenL should noL be moved,
because lL has been shown Lo worsen ouLcome. Someone should go Lo Lhe
lCu and brlng Lhe resusclLaLlon equlpmenL ouL Lo Lhe paLlenL. 1he caroLld
arLery ls used Lo feel for clrculaLlon. lf clrculaLlon ls lnLacL he musL be
poslLloned ln Lhe lefL laLeral poslLlon. Cardlac massage musL be performed lf
hls pulse cannoL be felL.
!
11. 11lll
AbsenL pulses, cyanosls, absenL or gasplng resplraLlon are feaLures of cardlac
arresL. Warm exLremlLles and flushlng are suggesLlve of an anaphylacLlc
reacLlon.
8&*,)&$!&**'#+-./#0'*#!
70


12. 11l1l
venLrlcular flbrlllaLlon has a much beLLer prognosls provlded LhaL Lhe paLlenL
recelves advanced cardlac llfe supporL. WlLhouL deflbrlllaLlon, vl wlll almosL
never reverL Lo normal. Larly deflbrlllaLlon ls, of all Lhe manouvres, Lhe mosL
lmporLanL deLermlnanL of survlval. ALrlal flbrlllaLlon does noL cause cardlac
arresL. CompleLe hearL block can glve rlse Lo escape arrhyLhmlas due Lo Lhe
very slow hearL raLe, lncludlng v1 and vl. 8esplraLlon may be presenL for
some Llme afLer cardlac arresL.

13. 1ll1l
Always call for help flrsL. ALLempLlng Lo unplug Lhe elecLrlcal devlce can resulL
ln Lhe rescuer geLLlng elecLrocuLed, as Lhe elecLrlcal shorL maybe aL Lhe plug
polnL. LlLher Lhe maln swlLch should be Lurned off, or Lhe elecLrlcal devlce
knocked ouL of Lhe way wlLh a wooden sLlck whlle Lhe rescuer sLands on a
book or oLher non conducLlng surface. 1he head LllL chln llfL manouvre can
cause cord compresslon lf Lhe paLlenL has a cervlcal splne ln[ury. !aw LhrusL
alone ls performed ln Lhls slLuaLlon. SponLaneous breaLhlng ls assessed by
looklng for Lhe chesL rlslng and falllng, llsLenlng for alr escaplng durlng
exhalaLlon, and feellng for Lhe flow of alr from Lhe nosLrlls. AssessmenL of
breaLhlng and clrculaLlon should always be performed prlor Lo commenclng
mouLh Lo mouLh resplraLlon.

14. 111l1
lsoprenallne ls a beLa agonlsL whlch lncreases Lhe hearL raLe. lL ls someLlmes
used ln hearL block where paclng faclllLles are noL avallable. ulgoxln ls used Lo
slow Lhe venLrlcular response ln aLrlal flbrlllaLlon. ropranolol and verapamll
are boLh used for Lhe same purpose ln aLrlal flbrlllaLlon, and verapamll ls used
ln Lhe LreaLmenL of aLrlovenLrlcular reenLranL Lachycardla.

13. l11ll
uopamlne has cardlac lnoLroplc effecLs and also causes perlpheral
vasoconsLrlcLlon. noradrenallne and vasopressln lncrease perlpheral
reslsLance. 1hese drugs lncrease Lhe afLerload, whlch ls noL deslrable ln low
cardlac ouLpuL sLaLes. 1hey are Lhe preferred drugs ln sepLlc shock, where Lhe
cardlac ouLpuL ls normal, buL perlpheral vasodllaLaLlon ls presenL.
uobuLamlne ls Lhe drug of cholce. lnLravenous nlLraLes cause vasodllaLaLlon
and wlll furLher reduce Lhe arLerlal pressure.

8&*,)&$!&**'#+-./#0'*#!
71

16. 11l1l
8reaLhlng ls assessed by dolng all Lhree of Lhe followlng, looklng for Lhe chesL
rlslng and falllng, llsLenlng for alr escaplng durlng exhalaLlon, and feellng for
Lhe flow of alr from Lhe nosLrlls.

17. 1llll
1wo rescue breaLhs should be glven prlor Lo assesslng clrculaLlon. Laymen
ofLen have dlfflculLy feellng Lhe caroLld pulse. ChesL compresslons musL be
sLarLed lf Lhe rescuer feels LhaL Lhere ls no clrculaLlon, l.e., lf Lhe paLlenL ls
unresponslve and noL breaLhlng, lL wlll do no harm even lf Lhe hearL ls
beaLlng. 1he heel of Lhe hand ls placed over Lhe lower parL of Lhe body of Lhe
sLernum, nC1 Lhe xlphlsLernum. lf mouLh Lo mouLh breaLhs cannoL be glven,
chesL compresslons should be conLlnued, lL has been shown Lo be beneflclal.

18. 1111l
1he compllcaLlons assoclaLed wlLh cardlac massage are, rlb fracLures, fracLure
of Lhe sLernum, separaLlon of Lhe rlbs from Lhe sLernum, pneumoLhorax,
hemoLhorax, lung conLuslons, laceraLlon of Lhe llver and spleen, and faL
embollsm. Cardlac rupLure ls noL known Lo occur.

19. 111l1
1here are many causes of Lhe long C1 syndrome, whlch predlsposes Lo
Lorsades de polnLes or polymorphlc v1. CongenlLal causes lnclude Lhe
8omano Ward Syndrome and Lhe !ervell Lange nellsen syndrome, Lhe laLLer
whlch ls assoclaLed wlLh deafness. Pypoglycaemla, hypocalcaemla are known
Lo cause lL. ln hypokalaemla, low ampllLude 1 waves and Lhe presence of u
waves [usL afLer Lhe 1 waves glve a false lmpresslon of C1 lnLerval
prolongaLlon. Many drugs can cause lL, lncludlng amlodarone, qulnlne,
Lrlcycllc anLldepressanLs, phenoLhlazlnes, eryLhromycln and newer
anLlhlsLamlnes such as asLemlzole. 8eLa blockers wlll slow Lhe hearL raLe and
Lhus prolong Lhe C1 lnLerval. urugs llke salbuLamol and lsoprenallne wlll
acceleraLe Lhe hearL raLe and shorLen Lhe C1 lnLerval, reduclng Lhe rlsk of
developlng v1. lnLravenous magneslum ls Lhe drug of flrsL cholce ln Lhls
condlLlon.

20. 1ll1l
1hree unsynchronlzed uC shocks ln Lhe sequence 200, 200 and 360 should be
glven. lf Lhe rhyLhm does noL reverL C8 musL be recommenced before
aLLempLlng Lo shock agaln. 1here ls no lndlcaLlon Lo glve blcarbonaLe unless
8&*,)&$!&**'#+-./#0'*#!
72

Lhe arresL was due Lo hyperkalaemla or severe meLabollc acldosls. lnLubaLlon
ls lndlcaLed lf Lhere ls no response. lnLravenous adrenallne ls lndlcaLed ln non
v1/vl arresL.

21. ll11l
AlLhough Lhe paLlenL ls haemodynamlcally sLable, lf Lhe v1 conLlnues, cardlac
ouLpuL wlll fall, and she wlll become haemodynamlcally unsLable. uC
cardloverslon ls lndlcaLed ln haemodynamlcally unsLable paLlenLs, ln Lhls
paLlenL elLher amlodarone or llgnocalne wlll be effecLlve. Amlodarone ls Lhe
recommended drug. verapamll ls used ln Sv1, and ls dangerous ln v1.

22. 11lll
lnLravenous fluld, collolds and crysLallolds are lndlcaLed ln anaphylacLlc shock.
P2 recepLor anLagonlsLs are also posLulaLed Lo be effecLlve as ad[uncLlve
Lherapy, especlally Lo reduce gasLrlc hyperacldlLy. Adrenallne ls usually glven
lnLramuscularly. 1here ls no lndlcaLlon for aLroplne. PydrocorLlsone wlll Lake
several hours Lo acL.

23. l111l
uC cardloverslon ls noL helpful ln asysLole, excepL where flne venLrlcular
flbrlllaLlon ls presenL, and mlmlcs asysLole. C8 should be conLlnued, and
aLLempLs should be made Lo converL Lhe asysLole Lo venLrlcular flbrlllaLlon,
uslng adrenallne. vasopressln has been shown Lo be useful ln ouL of hosplLal
cardlac arresL, buL Lhere ls sLlll lnadequaLe evldence Lo show LhaL lL ls more
effecLlve Lhan adrenallne.

24. 1111l
ulseless elecLrlcal acLlvlLy (prevlously called elecLromechanlcal dlssoclaLlon)
ls deflned by Lhe presence of some Lype of elecLrlcal acLlvlLy oLher Lhan v1 or
vl ln Lhe absence of a deLecLable pulse. LA ls ofLen assoclaLed wlLh speclflc
cllnlcal sLaLes LhaL can be reversed when ldenLlfled early and effecLlvely
LreaLed. lL can be assoclaLed wlLh poLenLlally reverslble causes, such as
acldosls, perlcardlal Lamponade, hypoLhermla, hypoxla, pulmonary embollsm
or a varleLy of drug overdoses (eg, Lrlcycllc anLldepressanLs, beLa blockers,
calclum channel blockers). ln Lhese condlLlons Lhe complexes are narrow, and
Lhe prognosls ls beLLer. Survlval ls poor when elecLrlcal acLlvlLy ls wlde and
slow, Lhe rhyLhm ofLen represenLlng Lhe lasL elecLrlcal acLlvlLy of a dylng
myocardlum 8lcarbonaLe ls lndlcaLed ln preexlsLlng hyperkalaemla, when
preexlsLlng blcarbonaLe-responslve acldosls ls presenL, for LreaLmenL of
8&*,)&$!&**'#+-./#0'*#!
73

Lrlcycllc anLldepressanL overdose, and Lo alkallnlze Lhe urlne ln asplrln or
oLher drug overdoses. lL ls noL rouLlnely used for Lhe acuLe lacLlc acldosls
assoclaLed wlLh C8, buL may be glven lf Lhe lnlLlal lnLervenLlons
(deflbrlllaLlon, venLllaLlon, cardlac compresslon, and vasopressor Lherapy)
have been lneffecLlve. 1he use of blcarbonaLe ls accepLable ln lnLubaLed and
venLllaLed paLlenLs wlLh a long arresL lnLerval.

23. 1l1l1
Assesslng Lhe envlronmenL Lo see lf lL ls safe Lo approach ls Lhe flrsL prlorlLy
when conslderlng provldlng ald Lo an unconsclous paLlenL. C8 relaLed
lnfecLlons are exLremely rare, alLhough 1uberculosls, Plv and nelsserla
menlnglLldls have all been recorded. Cnce lL has been conflrmed LhaL Lhe
paLlenL ls noL breaLhlng one musL geL help or alerL Lhe emergency servlces,
even lf Lhls means leavlng Lhe paLlenL. Powever, lf Lhe paLlenL ls an lnfanL or
chlld, a vlcLlm of Lrauma, a near drownlng or lf drug or alcohol lnLoxlcaLlon ls
llkely, Lhen one mlnuLe of C8 should be performed before golng for help. 1he
correcL raLlo of compresslons Lo venLllaLlons ls 13:2 regardless of Lhe number
of rescuers presenL.


;%'4(&+)$!%'&*+!,)#'&#'!
74

3IG:"JKE#!IGJ3K!6E1GJ1G!
!
1) 1he followlng epldemlologlcal facLors lncrease Lhe rlsk of acuLe
rheumaLlc fever
a) lower sLandards of llvlng
b) poor denLal hygelne
c) overcrowdlng
d) oor socloeconomlc class
e) Lack of access Lo healLh care

2) AcuLe rheumaLlc fever
a) occurs afLer pharyngeal lnfecLlons wlLh SLrepLococcus pyogenes
Lancefleld Croup A
b) occurs predomlnanLly ln chlldren under Lhe age of 10 years
c) causes dlfuse lnflammaLory oedema of Lhe endocardlum
d) causes permanenL deformlLy of affecLed [olnLs
e) ls compllcaLed by flbrosls of affecLed valves

3) ln a 12 year old chlld wlLh fever and [olnL palns, Lhe followlng cllnlcal
feaLures are suggesLlve of acuLe rheumaLlc fever
a) aln and swelllng of Lhe small [olnLs of Lhe hands
b) MlgraLory arLhrlLls
c) 1he leg [olnLs Lyplcally belng lnvolved flrsL
d) An early dlasLollc murmur aL Lhe lefL sLernal edge
e) 1he presence of an enlarged spleen

4) vegeLaLlons ln acuLe rheumaLlc fever
a) are mosL commonly slLuaLed on Lrlcuspld and pulmonary valves
b) are large and frlable
c) are asepLlc
d) conLaln mlcroscoplc Aschoff bodles
e) cause rupLure of valve cusps

;%'4(&+)$!%'&*+!,)#'&#'!
73

3) 8egardlng Lhe paLhology of mlLral valve sLenosls
a) Large frlable vegeLaLlons are seen on Lhe mlLral valve durlng eplsodes
of acuLe rheumaLlc fever
b) llbrosls of Lhe valve occurs
c) luslon of Lhe valve commlssures occurs
d) 1hlckenlng and shorLenlng of Lhe chordae Lendlnae cause llmlLaLlon
of valve moblllLy
e) A valve area of less Lhan 2cm
2
ls deflned as LlghL mlLral sLenosls

6) ln acuLe rheumaLlc cardlLls
a) CompleLe hearL block ls known Lo occur
b) Cardlomegaly ls seen on Lhe chesL radlograph
c) 1he presence of a perlcardlal rub lndlcaLes Lhe presence of
perlcardlLls
d) MlLral sLenosls ls Lhe commonesL valvular leslon
e) Severe congesLlve hearL fallure ls known Lo occur

7) 8egardlng Sydenhams chorea
a) perlpheral sensory loss ls seen
b) 1he abnormal movemenLs are ofLen asymmeLrlcal
c) LmoLlonal changes may occur ln chlldren
d) ls known Lo occur 6 monLhs afLer sLrepLococcal lnfecLlon
e) lL ls self llmlLlng

8) 8egardlng Lhe subcuLaneous nodules of rheumaLlc fever
a) 1hey are Lender
b) 1he overlylng skln can be moved easlly over Lhe nodules.
c) 1hey are characLerlsLlcally seen ln assoclaLlon wlLh chorea
d) 1hey are usually symmeLrlc.
e) nodules are presenL for approxlmaLely slx weeks

;%'4(&+)$!%'&*+!,)#'&#'!
76

9) 8egardlng acuLe rheumaLlc fever
a) ln young chlldren, ls preceded by sore LhroaL ln more Lhan 70 per
cenL of paLlenLs
b) SLrepLococcal skln lnfecLlon ls a recognlzed cause
c) AdequaLe LreaLmenL of sLrepLococcal pharynglLls markedly reduces
Lhe lncldence
d) AnLlsLrepLococcal anLlbodles have a hlgh senslLlvlLy ln dlagnosls of
anLecedenL sLrepLococcal lnfecLlon
e) 1he lncldence ls on Lhe rlse ln developlng counLrles

10) 8egardlng Lhe LreaLmenL of acuLe rheumaLlc fever
a) CorLocosLerolds are Lhe flrsL llne LreaLmenL for arLhrlLls
b) CardlLls ls LreaLed wlLh hlgh dose asplrln
c) Cral penlclllln ln a dose of 300 mg Lwo Lo Lhree Llmes dally for adulLs
for 10 days ls lndlcaLed Lo eradlcaLe sLrepLococcal lnfecLlon
d) LryLhromycln ls used for LreaLmenL ln paLlenLs who are allerglc Lo
penlclllln
e) 1reaLmenL wlLh asplrln ls conLlnued unLll Lhe LS8 reLurns Lo normal

11) 8egardlng Lhe prevenLlon of acuLe rheumaLlc fever
a) lamlly conLacLs should have LhroaL swab culLure
b) 1he dlsease ls noLlflable
c) 1reaLmenL of documenLed sLrepLococcal pharynglLls has been shown
Lo reduce Lhe lncldence
d) Long Lerm penlclllln prophylaxls reduces Lhe recurrence raLe
e) Larly LreaLmenL of sLrepLococcal skln sepsls has been shown Lo
reduce Lhe lncldence

12) 8egardlng Lhe recurrence of rheumaLlc fever
a) 8ecurrence ls mosL common wlLhln Lhe flrsL 2 years afLer Lhe flrsL
eplsode
b) lnLramuscular benzaLhlne penlclllln ls more efflcaclous aL prevenLlng
a recurrence Lhan oral penlclllln
c) 8enzaLhlne penlclllln prophylaxls should be glven every 4 weeks ln
paLlenLs wlLh rheumaLlc cardlLls
d) ln a paLlenL wlLh documenLed cardlLls, penlclllln prophylaxls ls
conLlnued unLll Lhe age of 21 years
e) 1he sLrepLococcal vacclne ls used as an alLernaLlve Lo penlclllln
prophylaxls
;%'4(&+)$!%'&*+!,)#'&#'!
77


13) 8egardlng chronlc rheumaLlc hearL dlsease
a) Less Lhan 23 percenL of paLlenLs wlLh acuLe rheumaLlc fever wlll
develop chronlc valvular hearL dlsease
b) 8heumaLlc mlLral valve sLenosls ls known Lo occur ln paLlenLs under
Lhe age of 20 years
c) nearly all paLlenLs wlLh mlLral sLenosls recall a hlsLory of rheumaLlc
fever
d) AorLlc valve regurglLaLlon ls Lhe commonesL valvular leslon
e) 1rlcuspld valve regurglLaLlon ls always secondary Lo pulmonary
hyperLenslon

14) Causes of sudden acuLe breaLhlessness ln a paLlenL wlLh mlLral sLenosls
lnclude
a) 1he developmenL of aLrlal flbrlllaLlon
b) 1he developmenL of a LachyarrhyLhmla
c) Myocardlal lnfarcLlon
d) lnfecLlve endocardlLls
e) ChesL lnfecLlon

13) ln mlLral sLenosls
a) lefL venLrlcular fallure ls a characLerlsLlc feaLure
b) aLrlal dllaLaLlon leads Lo aLrlal flbrlllaLlon
c) Lhe rlsk of embollc sLroke ls lncreased
d) Lhe pulse volume ls hlgh
e) haemopLysls ls known Lo occur

16) ln a paLlenL wlLh mlLral sLenosls, Lhe followlng feaLures on
echocardlography lndlcaLe LhaL Lhe valve ls unsulLable for balloon mlLral
valvuloplasLy
a) 1lghL mlLral sLenosls
b) CalclflcaLlon of Lhe valve
c) An audlble openlng snap
d) ALrlal flbrlllaLlon
e) llbrosls of Lhe subvalvular apparaLus

;%'4(&+)$!%'&*+!,)#'&#'!
78

17) ln a paLlenL wlLh LlghL mlLral sLenosls
a) 1he developmenL of aLrlal flbrlllaLlon wlll resulL ln worsenlng of
sympLoms
b) An pulmonary regurglLanL murmur may be heard
c) 1he presysLollc accenLuaLlon of Lhe mld dlasLollc murmur ls noL heard
lf aLrlal flbrlllaLlon ls presenL
d) 1he presence of a dlsplaced cardlac apex ls suggesLlve of LlghL mlLral
sLenosls
e) A LhrusLlng apex beaL ls felL

18) 8egardlng Lhe elecLrocardlographlc flndlngs ln mlLral sLenosls
a) 1he presence of a Lall p wave ln Lead ll and an uprlghL p wave ln v1
lndlcaLes Lhe presence of lefL venLrlcular dllaLaLlon.
b) 1he presence of p-mlLrale lndlcaLes Lhe developmenL of pulmonary
hyperLenslon
a) LefL venLrlcular hyperLrophy ls presenL
b) LefL axls devlaLlon ls seen
c) 8lghL bundle branch block ls seen

19) 8egardlng Lhe chesL radlograph appearance ln mlLral sLenosls
a) Cardlomegaly ls a characLerlsLlc feaLure
b) A sLralghL lefL hearL border ls seen
c) dllaLaLlon of Lhe upper lobe pulmonary velns ls a feaLure
d) ln a laLeral radlograph, Lhe oesophagus may be compressed
e) ollgaemlc lung flelds lndlcaLe slgnlflcanL pulmonary hyperLenslon

20) 8egardlng Lhe pharmacologlcal LreaLmenL of mlLral sLenosls
a) lrusemlde wlll reduce sympLoms by reduclng LoLal blood volume
b) 8eLa blockers are conLralndlcaLed
c) ulgoxln ls lndlcaLed even ln Lhe absence of aLrlal flbrlllaLlon
d) vasodllaLors are conLralndlcaLed
e) Warfarln ls lndlcaLed ln aLrlal flbrlllaLlon

;%'4(&+)$!%'&*+!,)#'&#'!
79

21) ln a paLlenL wlLh chronlc rheumaLlc hearL dlsease, Lhe followlng are
lndlcaLlons for mlLral valve replacemenL
a) 1lghL mlLral sLenosls ln pregnancy
b) Severe pulmonary hyperLenslon
c) AssoclaLed mlLral regurglLaLlon
d) Severely calclfled valves
e) ulsLorLed valves wlLh a valve area below 1 cm2

22) ln a paLlenL wlLh mlxed mlLral valve dlsease, Lhe followlng cllnlcal feaLures
suggesL slgnlflcanL mlLral valve regurglLaLlon
a) A LhrusLlng apex beaL
b) A dlsplaced apex
c) oor volume pulse
d) a pan sysLollc murmur
e) aLrlal flbrlllaLlon

23) 8egardlng mlLral regurglLaLlon
a) ln wesLern populaLlons, rheumaLlc fever ls Lhe commonesL cause of
mlLral regurglLaLlon
b) MlLral valve prolapse ls a cause
c) lL ls a hlgh rlsk leslon for lnfecLlve endocardlLls
d) lL occurs ln hyperLroplc obsLrucLlve cardlomyopaLhy
e) luncLlonal mlLral regurglLaLlon occurs ln dllaLed cardlomyopaLhy

24) 1he followlng are lndlcaLlons for valve replacemenL ln a paLlenL wlLh
mlLral regurglLaLlon
a) AcuLe mlLral regurglLaLlon afLer myocardlal lnfarcLlon
b) SympLomaLlc paLlenLs wlLh severe chronlc regurglLaLlon
c) LefL venLrlcular e[ecLlon fracLlon < 60
d) LefL venLrlcular sysLollc dlmenslon > 43 mm
e) Severe lefL venLrlcular dysfuncLlon

23) 1he followlng cllnlcal feaLures are seen ln aorLlc regurglLaLlon
a) A collapslng pulse
b) uurozlezs slgn
c) An e[ecLlon sysLollc murmur radlaLlng Lo Lhe neck
d) A mld dlasLollc murmur ln Lhe mlLral area
e) A dlsplaced apex beaL

;%'4(&+)$!%'&*+!,)#'&#'!
80

26) 8egardlng aorLlc valve dlsease
a) AcuLe aorLlc regurglLaLlon may occur ln lnfecLlve endocardlLls due Lo
valve cusp rupLure
b) severe regurglLaLlon wlLh a lefL venLrlcular e[ecLlon fracLlon < 33 ln
an asympLomaLlc paLlenL ls an lndlcaLlon for valve replacemenL
c) SympLomaLlc paLlenLs wlLh aorLlc sLenosls can be managed medlcally
lf Lhelr lefL venLrlcular funcLlon ls preserved
d) aLlenLs wlLh aorLlc sLenosls can be LreaLed wlLh vasodllaLors
e) aLlenLs wlLh aorLlc sLenosls over Lhe age of 40 years should have a
coronary anglogram prlor Lo valve surgery

;%'4(&+)$!%'&*+!,)#'&#'-./#0'*#!
81

J'%L0)%!>+!3?0A(>&-!I0()>!6&%0(%0!M.0%>&+'%!

1) 1l111
Lower sLandards of llvlng, overcrowdlng, poor socloeconomlc class all lncrease
Lhe rlsk of geLLlng rheumaLlc fever. ln Lhe developed world Lhe lncldence has
been sLeadlly falllng, buL lL ls sLlll a slgnlflcanL problem ln Lhe developlng
world. Lack of prophylacLlc penlclllln LreaLmenL lncreases Lhe rlsk of
recurrences. oor denLal hyglene lncreases Lhe rlsk of lnfecLlve endocardlLls
ln paLlenLs wlLh valve dlsorders, buL does noL have a slgnlflcanL effecL on Lhe
causaLlon of rheumaLlc fever.

2) 1l1l1
AcuLe rheumaLlc fever occurs afLer pharyngeal lnfecLlons wlLh sLrepLococcus
pyogenes sLralns belonglng Lo Lancefleld group A. 1he dlsease ls mosL
common ln Lhe second decade, and lL ls less common ln very young chlldren.
A pancardlLls occurs, wlLh lnvolvemenL of Lhe perlcardlum, myocardlum and
endocardlum. A fllLLlng or mlgraLory arLhrlLls of large [olnLs occurs, buL Lhe
arLhrlLls ls self llmlLlng, and permanenL deformlLy does noL usually occur.
8ecurrenL eplsodes of rheumaLlc cardlLls can resulL ln progresslve valvular
damage, wlLh flbrosls of Lhe affecLed valves.

3) l11ll
1he classlcal paLLern of arLhrlLls ln acuLe rheumaLlc fever ls a fllLLlng, or
mlgraLory arLhrlLls affecLlng Lhe large [olnLs, wlLh a predllecLlon Lo Lhe lower
llmb [olnLs. 1he [olnLs are palnful and Lender. lnflammaLlon of each [olnL
usually lasLs less Lhan one week. 1he synovlal fluld from Lhe lnflamed [olnLs ls
sLerlle. 1he classlcal cardlac leslon ln acuLe rheumaLlc fever aL presenLaLlon ls
a mlLral regurglLanL murmur, Lhe Carey-Coombs murmur. AorLlc regurglLaLlon
and mlLral or aorLlc sLenosls, Lhough common ln chronlc rheumaLlc hearL
dlsease, are unusual ln acuLe rheumaLlc cardlLls. 1he presence of an enlarged
spleen ln a chlld wlLh arLhrlLls and fever suggesLs an alLernaLlve dlagnosls,
such as [uvenlle rheumaLold arLhrlLls, SLllls dlsease, or a sysLemlc lnfecLlve
lllness.

4) ll11l
vegeLaLlons ln acuLe rheumaLlc fever are small and flrmly aLLached Lo Lhe
marglns of Lhe valve. 1hey do noL embollze. 1he commonesL slLe ls Lhe mlLral
valve. 1he characLerlsLlc hlsLologlcal leslon ls Lhe Aschoff body, whlch ls
paLhognomonlc of rheumaLlc fever. 1he Aschoff body ls an aggregaLe of large
;%'4(&+)$!%'&*+!,)#'&#'-./#0'*#!
82

cells, wlLh polymorphous nuclel and basophlllc cyLoplasm, arranged as a
roseLLe around an avascular core of flbrlnold, Lhe aggregaLe ls usually
perlvascular. ln conLrasL Lo Lhe vegeLaLlons of rheumaLlc fever Lhe vegeLaLlons
of lnfecLlve endocardlLls are large and frlable, and frequenLly embollze.
8upLure of valve cusps ls uncommon.
!
3) l111l
vegeLaLlons ln acuLe rheumaLlc fever are small and flrmly aLLached Lo Lhe
marglns of Lhe valve. 1hey do noL embollze. ln conLrasL Lo Lhe vegeLaLlons of
rheumaLlc fever Lhe vegeLaLlons of lnfecLlve endocardlLls are large and frlable,
and frequenLly embollze. llbrosls of Lhe valve and fuslon of Lhe valve
commlssures occurs wlLh recurrenL eplsodes of rheumaLlc fever, and
Lhlckenlng and shorLenlng of Lhe chordae causes llmlLaLlon ln valve moblllLy
whlch adversely affecLs Lhe openlng and closure of Lhe valve. A valve area of
less Lhan 1cm
2
ls deflned as LlghL.

6) 111l1
A pancardlLls occurs ln acuLe rheumaLlc fever. MyocardlLls ls assoclaLed wlLh
varylng degrees of aLrlovenLrlcular conducLlon defecLs, flrsL degree hearL
block ls Lhe classlcal LCC flndlng ln acuLe rheumaLlc cardlLls buL compleLe
hearL block ls known Lo occur. Cardlomegaly ls Lhe commonesL flndlng on Lhe
chesL radlograph, and ls due Lo acuLe myocardlLls. Mlld Lo moderaLe chesL
dlscomforL, pleurlLlc chesL paln, or a perlcardlal frlcLlon rub are lndlcaLlons of
perlcardlLls. 1he commonesL valvular leslon aL presenLaLlon ls mlLral
regurglLaLlon. MlLral sLenosls ls Lhe commonesL leslon ln chronlc rheumaLlc
hearL dlsease, buL ls rare aL flrsL presenLaLlon of acuLe rheumaLlc fever.
CongesLlve hearL fallure ls known Lo occur, due Lo a comblnaLlon of severe
myocardlLls and valvular dysfuncLlon. ln severe cases, lL may mlmlc vlral
myocardlLls, lL ls a llfe LhreaLenlng slLuaLlon, and musL be LreaLed early and
aggresslvely.

7) l1111
Sydenham chorea, chorea mlnor, or "SL. vlLus dance" ls a neurologlc dlsorder
conslsLlng of abrupL, purposeless, nonrhyLhmlc lnvolunLary movemenLs,
muscular weakness, and emoLlonal dlsLurbances. Sensory loss ls noL a feaLure.
Muscle weakness ls demonsLraLed by asklng Lhe paLlenL Lo squeeze Lhe
examlner's hands, Lhe pressure of Lhe paLlenL's grlp lncreases and decreases
conLlnuously, a phenomenon known as relapslng grlp or "mllklng slgn. "1he
chorea can be more marked on one slde, and can occaslonally be unllaLeral.
;%'4(&+)$!%'&*+!,)#'&#'-./#0'*#!
83

ln chlldren, lL can presenL wlLh emoLlonal dlsLurbance, wlLh ouLbursLs of
lnapproprlaLe behavlor, lncludlng crylng and resLlessness. 8arely a LranslenL
psychosls can occur. Chorea ls self llmlLlng, and long Lerm neurologlcal
sequelae are unusual. lL has a longer laLenL perlod Lhan Lhe oLher
manlfesLaLlons of rheumaLlc fever, and can occur up Lo 8 monLhs afLer
sLrepLococcal lnfecLlon.

8) l1lll
SubcuLaneous nodules are anoLher of Lhe uuckeLL-!ones ma[or crlLerla for Lhe
dlagnosls of rheumaLlc fever. 1hey are characLerlsLlcally non Lender, range
from a few mllllmeLers Lo one Lo Lwo cenLlmeLers ln dlameLer, and mosL
commonly are locaLed over a bony surface or promlnence or near Lendons.
1ender nodules should ralse Lhe susplclon of eryLhema nodosum, whlch are
also seen ln rheumaLlc fever, alLhough Lhey are noL relevanL ln dlagnosls. 1he
overlylng skln ls moblle over Lhe nodules, and ls noL lnflamed. 1he nodules
are symmeLrlc. ln number Lhey range from a slngle leslon Lo a few dozen, and
average 3 Lo 4. 1hey lasL for one or Lwo weeks. 1he dlfferenLlal dlagnosls ls
rheumaLold nodules, whlch are larger and perslsL for a longer perlod of Llme.
AlLhough Lhe elbows are lnvolved mosL frequenLly ln boLh dlseases, rheumaLlc
fever nodules are more common on Lhe olecranon, whereas rheumaLold
nodules usually are found 3 Lo 4 cm dlsLally.

9) ll11l
1he recollecLlon of sore LhroaL ls less Lhan 20 percenL ln younger chlldren,
whlle ln older chlldren and young adulLs lL approaches 70 percenL.
SLrepLococcal pharynglLls ls Lhe only sLrepLococcal lnfecLlon assoclaLed wlLh
acuLe rheumaLlc fever - lL does noL follow sLrepLococcal skln sepsls.
1reaLmenL of documenLed sLrepLococcal pharynglLls has been shown Lo
reduce Lhe lncldence of rheumaLlc fever. AL leasL one of Lhe anLlsLrepLococcal
anLlbodles (sLrepLolysln "C", hyaluronldase, and sLrepLoklnase) are presenL ln
Lhe ma[orlLy of paLlenLs wlLh acuLe rheumaLlc fever. 1he lncldence has
decllned ln boLh Lhe developlng and Lhe developed world, however, lL remalns
a slgnlflcanL healLh problem ln developlng counLrles, wlLh an esLlmaLed 10 Lo
20 mllllon new cases per year.

10) ll11l
1he flrsL llne anLl-lnflammaLory drug for Lhe LreaLmenL of arLhrlLls ls asplrln, ln
hlgh doses, 80 Lo 100 mg/day ln chlldren and 4 Lo 8 g/day ln adulLs. ln cardlLls,
Lhere ls conLroversy as Lo Lhe use of asplrln, as sallcylaLes cause salL and waLer
;%'4(&+)$!%'&*+!,)#'&#'-./#0'*#!
84

reLenLlon and may worsen congesLlve hearL fallure. CorLlcosLerolds are
Lherefore preferred ln cardlLls wlLh hearL fallure, however sLudles have shown
confllcLlng resulLs, and Lhere ls no clear evldence ln Lerms of shorL Lerm
(resoluLlon of sympLoms and slgns) or long Lerm (need for valve surgery laLer
on) beneflL. Cral penlclllln for 10 days eradlcaLes sLrepLococcal lnfecLlon, and
reduces Lhe severlLy of Lhe dlsease. Sulphonamldes and eryLhromycln are
alLernaLlves. 1reaLmenL wlLh asplrln musL be conLlnued unLll Lhe sympLoms
have dlsappeared and Lhe LS8 reLurns Lo normal.

11) 1l11l
lamlly and close conLacLs should have Lhelr LhroaL culLured, and Lhose found
poslLlve for sLrepLococcus should be LreaLed wlLh penlclllln. 1he dlsease ls noL
noLlflable. 1reaLmenL of sLrepLococcal pharynglLls has been shown Lo prevenL
Lhe lncldence of Lhe dlsease, buL slnce skln sepsls does noL glve rlse Lo acuLe
rheumaLlc fever, LreaLmenL of skln sepsls does noL, alLhough lL reduces Lhe
rlsk of acuLe glomerulonephrlLls. Long Lerm penlclllln prophylaxls reduces Lhe
rlsk of recurrenL lnfecLlons, and reduces valvular damage.

12) 1llll
AlLhough a recurrence of rheumaLlc fever can occur aL any Llme, lL mosL
commonly occurs wlLhln Lhe flrsL Lwo years. ln paLlenLs who are noL allerglc
Lo penlclllln, elLher benzaLhlne penlclllln 1.2 mllllon unlLs lnLramuscularly
every 3 weeks, or oral penlclllln v 230mg Lwlce dally are used Lo prevenL
sLrepLococcal pharynglLls and Lhus reduce Lhe llkellhood of recurrence of
rheumaLlc fever. Sulphadlazlne 300mg-1000mg dally or eryLhromycln 230mg
Lwlce dally are alLernaLlves lf Lhe paLlenL ls allerglc Lo penlclllln. 1here ls no
convlnclng evldence LhaL benzaLhlne penlclllln ls superlor Lo oral prophylaxls
ln Lerms of efflcacy, however where compllance may be a problem, parenLeral
prophylaxls ls preferred. 8enzaLhlne penlclllln ln[ecLlons every Lhree weeks
are more effecLlve aL prevenLlng recurrence Lhan when glven every four
weeks. ln documenLed cases of rheumaLlc cardlLls, benzaLhlne penlclllln
should be glven llfelong, because rheumaLlc fever can recur even laLe ln llfe.
A sLrepLococcal vacclne ls noL avallable commerclally as yeL, alLhough Lhere ls
a loL of ongolng research lnLo developlng one.

13) l1lll
Cver 30 percenL of paLlenLs wlLh acuLe rheumaLlc fever wlll ulLlmaLely develop
chronlc valvular hearL dlsease, Lhls raLe ls hlgher ln developlng counLrles
compare Lo developed counLrles. 1he reasons posLulaLed for Lhls dlfference
;%'4(&+)$!%'&*+!,)#'&#'-./#0'*#!
83

lnclude Lhe lncreased number of recurrences due Lo lnadequaLe use of
prophylaxls, and lncrease vlrulence of Lhe lnfecLlng sLrepLococcl. MlLral
sLenosls can develop early ln paLlenLs ln developlng counLrles, for Lhe same
reason. A hlsLory of rheumaLlc fever ls reporLed ln 30 Lo 70 percenL of
paLlenLs. MlLral sLenosls ls Lhe commonesL rheumaLlc valvular leslon, and ls
presenL ln 90 of paLlenLs. Whlle Lrlcuspld regurglLaLlon occurs due Lo
dllaLaLlon of Lhe Lrlcuspld valve rlng secondary Lo severe pulmonary
hyperLenslon, prlmary lnvolvemenL of Lhe Lrlcuspld valve ls a recognlzed
occurrence.

14) 11l11
ln a paLlenL wlLh mlLral sLenosls, Lhe developmenL of aLrlal flbrlllaLlon ln a
paLlenL prevlously ln slnus rhyLhm ofLen resulLs ln acuLe breaLhlessness. ln Lhe
normal hearL, aLrlal conLracLlon conLrlbuLes llLLle Lo venLrlcular fllllng, mosL of
whlch Lakes place durlng early dlasLole. When Lhe mlLral valve ls sLenosed, Lhe
aLrlal klck conLrlbuLes slgnlflcanLly Lo venLrlcular fllllng. 1he sudden loss of
aLrlal conLracLlon resulLs ln a sudden reducLlon ln venLrlcular fllllng, and Lhls
resulLs ln worsenlng of Lhe pulmonary oedema. ln addlLlon, lf Lhere ls aLrlal
flbrlllaLlon wlLh a rapld venLrlcular response, dlasLole wlll be shorLened, and
venLrlcular fllllng Llme reduced. A slmllar effecL occurs lf a LachyarrhyLhmla
occurs. lnfecLlve endocardlLls and chesL lnfecLlon can cause boLh cause
worsenlng dyspnoea. Whlle myocardlal lnfarcLlon can cause breaLhlessness
due Lo lefL venLrlcular fallure, lL ls relaLlvely uncommon, flrsLly, mlLral sLenosls
ls presenL ln younger female paLlenLs who are aL a lower rlsk for lschaemlc
hearL dlsease, secondly, Lhe lefL venLrlcle ls ofLen small due Lo compromlsed
fllllng, and Lherefore ls less suscepLlble Lo lschaemla.

13) l11l1
ln mlLral sLenosls, lefL venLrlcular fallure does noL usually occur, unless
slgnlflcanL mlLral regurglLaLlon ls coexlsLanL. 8ecause of compromlsed lefL
venLrlcular fllllng Lhe lefL venLrlcular end dlasLollc dlameLer ls small. 1he
pulse volume ls Lherefore low. ulmonary oedema occurs because of Lhe
sLenosls of Lhe mlLral valve resulLlng ln lncreased lefL aLrlal, and Lherefore
lncrease pulmonary venous pressure. CfLen cllnlclans refer Lo Lhls as lefL
venLrlcular fallure, whlch ls Lechnlcally speaklng, a mlsnomer. 1he rlsk of
embollc sLroke ls hlgh ln paLlenLs wlLh mlLral sLenosls, and Lhls ls greaLly
lncreased ln Lhe presence of aLrlal flbrlllaLlon. PaemopLysls ls known Lo occur
ln LlghL mlLral sLenosls due Lo rupLure of pulmonary-bronchlal venous
connecLlons secondary Lo pulmonary venous hyperLenslon. lL occurs mosL
;%'4(&+)$!%'&*+!,)#'&#'-./#0'*#!
86

frequenLly ln paLlenLs who have elevaLed LA pressures wlLhouL markedly
elevaLed pulmonary vascular reslsLances. lL ls almosL never faLal

16) l1ll1
SympLomaLlc paLlenLs wlLh LlghL mlLral sLenosls are ofLen consldered for
mlLral balloon valvuloplasLy. 1he sulLablllLy of Lhe valve for Lhe procedure ls
ofLen deLermlned echocardlographlcally. Wllklns eL all devlsed a scorlng
sysLem whlch would predlcL success of balloon valvuloplasLy. A score of 0 Lo 4
for each of four facLors:
1he degree of leafleL rlgldlLy
1he severlLy of leafleL Lhlckenlng
1he amounL of leafleL calclflcaLlon.
1he exLenL of subvalvular Lhlckenlng and calclflcaLlon
1he maxlmum score ls 16, hlgher scores lndlcaLe more severe anaLomlc
dlsease and a lower llkellhood of a successful balloon valvoLomy. 1he
presence of an openlng snap lndlcaLes LhaL Lhe valve ls pllable and Lherefore
sulLable for balloon valvuloplasLy. ALrlal flbrlllaLlon ls noL a conLralndlcaLlon.

17) 11lll
1he developmenL of aLrlal flbrlllaLlon usually marks a worsenlng of Lhe
progresslon of sympLoms. ln Lhe normal hearL, aLrlal conLracLlon conLrlbuLes
llLLle Lo venLrlcular fllllng, mosL of whlch Lakes place durlng early dlasLole.
When Lhe mlLral valve ls sLenosed, Lhe aLrlal klck conLrlbuLes slgnlflcanLly Lo
venLrlcular fllllng. 1he sudden loss of aLrlal conLracLlon resulLs ln a sudden
reducLlon ln venLrlcular fllllng, and Lhls resulLs ln worsenlng of Lhe pulmonary
oedema. ln addlLlon, lf Lhere ls aLrlal flbrlllaLlon wlLh a rapld venLrlcular
response, dlasLole wlll be shorLened, and venLrlcular fllllng Llme reduced. A
pulmonary regurglLaLanL murmur, Lhe Craham SLeel murmur, occurs due Lo
dllaLaLlon of Lhe pulmonary valve rlng, and lndlcaLes Lhe presence of severe
pulmonary hyperLenslon. ConvenLlonally, Lhe presysLollc accenLuaLlon of Lhe
mld dlasLollc murmur of mlLral sLenosls ls due Lo Lhe lncrease ln flow across
Lhe mlLral valve durlng aLrlal conLracLlon. Powever presysLollc accenLuaLlon ls
heard ln Lhe presence of aLrlal flbrlllaLlon as well- Lhe gradual apposlLlon of
Lhe valve cusps Lowards Lhe end of dlasLole resulLs ln lncreaslng Lurbulence ln
flow across Lhe already sLenosed valve, and can resulL ln an lncrease ln
murmur lnLenslLy. ln LlghL mlLral sLenosls Lhe lefL venLrlcular end sysLollc
volume ls reduced, and cardlac dllaLaLlon does noL occur, a dlsplaced apex
suggesLs LhaL Lhere ls coexlsLanL mlLral regurglLaLlon or aorLlc valve dlsease. A
Lapplng apex, due Lo a palpable flrsL hearL sound ls felL on palpaLlon ln mlLral
;%'4(&+)$!%'&*+!,)#'&#'-./#0'*#!
87

sLenosls, a LhrusLlng apex lndlcaLes volume overload and suggesLs Lhe
presence of mlLral regurglLaLlon.


18) lllll
1he presence of a Lall p wave ln lead ll and an uprlghL p wave ln v1 lndlcaLes
Lhe presence of severe pulmonary hyperLenslon leadlng Lo rlghL hearL fallure
and rlghL venLrlcular hyperLrophy, Lhls ls Lhe p-pulmonale paLLern. ln p-
mlLrale, broad, ofLen noLched waves ln Lhe llmb leads and a blphaslc wave
ln lead v
1
wlLh a promlnenL negaLlve componenL represenLlng delayed
depolarlzaLlon of Lhe LA ls seen, Lhls ls due Lo lefL aLrlal dllaLaLlon, and does
noL by lLself lndlcaLe Lhe presence of pulmonary hyperLenslon. LefL
venLrlcular hyperLrophy ls noL seen as lefL venLrlcular overload or dllaLaLlon
does noL occur ln pure mlLral sLenosls. 1he axls ls usually rlghL due Lo rlghL
venLrlcular hyperLrophy caused by pulmonary hyperLenslon. 8lghL bundle
branch ls noL characLerlsLlc, alLhough lL can occur ln severe rlghL hearL
dllaLaLlon, lL ls a characLerlsLlc of aLrlal sepLal defecL.

19) l1111
1he lefL venLrlcle ls usually small, due Lo reduced fllllng across Lhe mlLral valve.
Cardlomegaly, lf seen, lndlcaLes elLher assoclaLed mlLral regurglLaLlon, or
gross rlghL venLrlcular dllaLaLlon. A sLralghL lefL hearL border ls seen ln mlLral
sLenosls due Lo enlargemenL of Lhe lefL aLrlum. upper lobe dlverslon ls
characLerlsLlc of pulmonary oedema, Lhe callber of Lhe pulmonary velns ln Lhe
upper and lower lobes wlll be equal. Slmllarly, kerley 8 llnes wlll be seen,
Lhese are dense, opaque, horlzonLal llnes mosL promlnenL ln Lhe lower and
mldlung flelds and LhaL resulL from dlsLenLlon of lnLerlobular sepLa and
lymphaLlcs wlLh edema when Lhe resLlng mean lefL aLrlal pressure exceeds
approxlmaLely 20 mmPg. An enlarged lefL aLrlum may compress Lhe
oesophagus, and ln exLreme cases ls a cause for dysphagla. ln slgnlflcanL
pulmonary hyperLenslon, perlpheral prunlng of Lhe pulmonary vascular Lree
occurs, resulLlng ln ollgaemlc lung flelds.

20) llll1
AlLhough lnlLlally frusemlde wlll reduce blood volume Lhrough dluresls, wlLh
prolonged use Lhe blood volume reLurns Lo normal. 1he beneflclal effecLs are
largely Lhrough pulmonary venodllaLaLlon. ulgoxln ls used for raLe conLrol ln
aLrlal flbrlllaLlon, lL has no proven beneflL ln lmprovlng sympLoms or morLallLy
ln paLlenLs ln slnus rhyLhm. 8eLa blockers can be used for raLe conLrol lf
;%'4(&+)$!%'&*+!,)#'&#'-./#0'*#!
88

dlgoxln does noL work, lf Lhe paLlenL has aLrlal flbrlllaLlon wlLh a very rapld
venLrlcular response, a beLa blocker may be Lhe preferred drug. vasodllaLors
are conLralndlcaLed ln aorLlc sLenosls, as perlpheral vasodllaLlon may resulL ln
hypoLenslon as Lhe cardlac ouLpuL cannoL lncrease. 1he rlsk of embollc sLroke
ln paLlenLs wlLh mlLral sLenosls and aLrlal flbrlllaLlon ls very hlgh, and
warfarlnlzaLlon Lo malnLaln Lhe ln8 beLween 2 and 3 ls lndlcaLed.

21) ll11l
Severe mlLral sLenosls ln pregnancy needs urgenL LreaLmenL, buL mlLral
balloon valvuloplasLy ls Lhe preferred LreaLmenL, mlLral valve replacemenL ls
ofLen noL lndlcaLed, and Lhe operaLlve rlsks and rlsks of anLlcoagulaLlon are
hlgh. Severe pulmonary hyperLenslon lLself ls noL an lndlcaLlon for valve
replacemenL, and such a paLlenL ls llkely Lo have a poor ouLcome whaLever
Lhe LreaLmenL. AssoclaLed mlLral regurglLaLlon, severely calclfled valves or
valves dlsLorLed by prevlous valvoLomy are lndlcaLlons for valve replacemenL.
AlLhough when Lhe valve orlflce ls less LhaL 1cm Lhe mlLral sLenosls ls
consldered LlghL, lL ls suggesLed LhaL mlLral valve replacemenL should be
underLaken lf Lhe area ls below 0.6 cm wlLh severe sympLoms.

22) 11l1l
A LhrusLlng dlsplace apex beaL due Lo volume overload resulLlng ln lefL
venLrlcular dllaLaLlon ls characLerlsLlc of mlLral regurglLaLlon. A poor volume
pulse suggesLs slgnlflcanL mlLral sLenosls or aorLlc sLenosls. A pan sysLollc
murmur radlaLlng Lo Lhe axllla ls characLerlsLlc of M8. ALrlal flbrlllaLlon occurs
earller ln mlLral sLenosls Lhan mlLral regurglLaLlon, and ln general Lhe presence
of aLrlal flbrlllaLlon favours domlnanL mlLral sLenosls.

23) l1111
8heumaLlc fever ls sLlll probably Lhe commonesL cause of mlLral regurglLaLlon
ln Lhe developlng world, buL Lhe lncldence has been markedly reduced ln
developed counLrles, and now Lhe commonesL cause of mlLral regurglLaLlon ln
Lhese counLrles ls mlLral valve prolapse. 8ecause of Lhe hlgh flow raLes across
Lhe dlseased valve, Lhe rlsk of lnfecLlve endocardlLls ls hlgh. ullaLaLlon of Lhe
mlLral valve rlng ln dllaLed cardlomyopaLhy resulLs ln funcLlonal mlLral
regurglLaLlon. lL also occurs ln PCCM.

24) 1111l
AcuLe mlLral regurglLaLlon ls ofLen an lndlcaLlon for urgenL valve replacemenL.
Surgery ls lndlcaLed ln all sympLomaLlc paLlenLs wlLh severe chronlc mlLral
;%'4(&+)$!%'&*+!,)#'&#'-./#0'*#!
89

regurglLaLlon, and ln asympLomaLlc paLlenLs wlLh slgns of mlld Lv dysfuncLlon
(e[ecLlon fracLlon < 60 or Lv sysLollc dlmenslon > 43 mm. ln paLlenLs wlLh
very severe lefL venLrlcular dysfuncLlon, wlLh an e[ecLlon fracLlon below 30,
Lhe hlgh operaLlve rlsk and poor llkellhood of success make valve replacemenL
unfeaslble.

23) 11l11
1he hlgh pulse pressure resulLs ln a collapslng pulse. uurozlez's slgn - A
sysLollc and dlasLollc brulL heard when Lhe femoral arLery ls parLlally
compressed ls also characLerlsLlc. An e[ecLlon sysLollc murmur can ofLen be
heard ln Lhe aorLlc area due Lo Lhe lncreased flow across Lhe aorLlc valve. 1hls
does noL necessarlly lndlcaLe Lhe presence of aorLlc sLenosls. Powever as
aorLlc sLenosls ofLen coexlsLs lL ls lmporLanL Lo dlfferenLlaLe lL from a flow
murmur. 1he presence of a sysLollc e[ecLlon Lhrlll, and radlaLlon of Lhe
murmur Lo Lhe caroLlds, LogeLher wlLh a blsferlens pulse lndlcaLes Lhe
presence of sLrucLural aorLlc sLenosls. A mld dlasLollc murmur ls ofLen heard
and can mlmlc Lhe murmur of mlLral valve sLenosls. 1hls ls known as LheAusLln
lllnL murmur ls a mld Lo laLe dlasLollc rumble, heard aL Lhe apex as a resulL of
anLegrade LurbulenL dlasLollc blood flow from Lhe lefL aLrlum compeLlng wlLh
Lhe reLrograde regurglLanL flow from Lhe aorLa. 1he absence of boLh a loud S1
and an openlng snap of Lhe mlLral valve helps ln dlfferenLlaLlng Lhls murmur
from LhaL of mlLral sLenosls. ullaLaLlon of Lhe lefL venLrlcle occurs due Lo
volume overload ln aorLlc regurglLaLlon, and resulLs ln a dlsplace apex beaL.

26) 11ll1
lnfecLlve endocardlLls can cause valve cusp rupLure leadlng Lo severe acuLe
aorLlc regurglLaLlon. urgenL valve replacemenL ls lndlcaLed. Severe aorLlc
regurglLaLlon wlLh compromlsed lefL venLrlcular funcLlon ls an lndlcaLlon for
valve replacemenL. aLlenLs wlLh aorLlc sLenosls who become sympLomaLlc
musL undergo surgery, because Lhe onseL of sympLoms ofLen heralds Lhe
developmenL of lefL venLrlcular dysfuncLlon. vasodllaLors such as nlfedlplne
and ACL lnhlblLors are used Lo offload Lhe hearL and delay Lhe Llme Lo surgery
ln paLlenLs wlLh aorLlc regurglLaLlon. 1hey are conLralndlcaLed ln aorLlc
sLenosls as Lhey can cause cardlovascular collapse. aLlenLs wlLh aorLlc
sLenosls over Lhe age of 40 years may have coexlsLlng coronary arLery dlsease,
and wlll need anglography Lo deLermlne lf Lhey need coronary arLery bypass
grafLlng aL Lhe Llme of aorLlc valve replacemenL.

.**%5+%()&#!
90

J33INKI"EJ1!
!
1) A 24 year old man ls referred afLer and army medlcal for lnvesLlgaLlon of
mulLlple unlfocal venLrlcular ecLoplcs.
a) Pe ls llkely Lo have serlous organlc hearL dlsease
b) Pe should be advlsed Lo sLop smoklng
c) An echocardlogram ls lndlcaLed
d) A hlsLory of excesslve coffee drlnklng should be looked for
e) Pe should be sLarLed on anLlarrhyLhmlcs

2) A 43 year old man admlLLed wlLh an acuLe myocardlal lnfarcLlon develops
mulLlple ecLoplcs. Pls blood pressure ls sLable.
a) Pe should be LreaLed wlLh lnLravenous amlodarone
b) Pypomagnesaemla ls a posslble cause
c) Pypokalaemla should be looked for
d) lL ls a slgn of ongolng myocardlal lschaemla
e) lf an 8 on 1 phenomenon ls presenL he ls aL rlsk of developlng
venLrlcular flbrlllaLlon

3) 1he followlng are lndlcaLlons Lo refer paLlenLs Lo a cardlologlsL for
evaluaLlon of an arrhyLhmla
a) Al wlLh a raLe LhaL ls dlfflculL Lo conLrol or recurrences LhaL are
refracLory Lo sLandard Lheraples
b) nonsusLalned v1, parLlcularly ln a paLlenL wlLh suspecLed or proven
sLrucLural hearL dlsease
c) SympLomaLlc slnus bradycardla
d) Second Av block
e) asympLomaLlc flrsL degree hearL block

4) A paLlenL wlLh an acuLe lnferlor myocardlal lnfarcLlon develops compleLe
hearL block
a) urgenL Lemporary cardlac paclng ls lmmedlaLely lndlcaLed
b) lL ls unllkely Lo recover sponLaneously
c) lL ls a slgn of exLenslve lnfarcLlon
d) lsoprenallne lnfuslon ls lndlcaLed
e) ALroplne may reverL hls rhyLhm Lo normal

.**%5+%()&#!
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3) 1he followlng changes can occur ln hyperkalaemla
a) shorLenlng of Lhe 8 lnLerval
b) Lall peaked 1 waves
c) Wldenlng of Lhe C8S complex
d) AsysLole
e) 8radycardla

6) 1he followlng cardlac rhyLhm changes may be normally presenL ln
aLhleLes
a) slnus bradycardla
b) slnus arresL of less Lhan Lhree second's duraLlon
c) wanderlng aLrlal pacemaker
d) nodal bradycardla
e) aLrlal fluLLer

7) 1he followlng can cause dangerous arrhyLhmlas
a) ulgoxln overdose
b) Snake blLe
c) MyocardlLls
d) ?ellow oleander polsonlng
e) CrganophosphaLe polsonlng

8) 1he followlng are Lrue
a) A narrow complex Lachycardla wlLh a hearL raLe of 130 beaLs per
mlnuLes suggesLs Lhe posslblllLy of aLrlal fluLLer wlLh 2:1 block
b) venLrlcular Lachycardla ls almosL always paLhologlcal
c) A narrow complex Lachycardla cannoL be venLrlcular Lachycardla
d) A broad complex Lachycardla can occur ln supravenLrlcular
Lachycardla wlLh bundle branch block
e) 1he rhyLhm ln venLrlcular Lachycardla ls regular

9) ln pregnancy
a) 1he presence of mulLlple ecLoplc beaLs warranLs LreaLmenL
b) SupravenLrlcular Lachycardlas ofLen lndlcaLe underlylng sLrucLural
hearL dlsease
c) 1he presence of aLrlal flbrlllaLlon ralses Lhe posslblllLy of underlylng
mlLral valve dlsease
d) ALrlal fluLLer ls common
e) Second degree hearL block ls a common flndlng
.**%5+%()&#!
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10) 1he followlng are lndlcaLlons for permanenL cardlac paclng
a) Slnus bradycardla wlLh a raLe of 43 beaLs per mlnuLe
b) Second degree hearL block
c) CompleLe hearL block
d) SympLomaLlc Lachy-brady syndrome
e) PyperLrophlc obsLrucLlve cardlomyopaLhy

11) A long correcLed C1 lnLerval ln Lhe LCC
a) ls a recognlsed consequence of hypokalaemla
b) ls a recognlsed consequence of hypercalcaemla
c) may be due Lo amlodarone
d) can be congenlLal
e) ls a recognlsed consequence of rheumaLlc cardlLls

12) 1he followlng condlLlons may be suggesLed by characLerlsLlc feaLures on
Lhe LCC
a) hypercalcaemla
b) PyponaLraemla
c) mlLral valve prolapse
d) hypoLhermla
e) hypomagnesaemla

13) 1he followlng are Lrue of Wolff-arklnson-WhlLe syndrome
a) aLlenLs presenL wlLh eplsodlc Sv1
b) venLrlcular Lachycardla does noL occur
c) ulgoxln ls Lhe LreaLmenL of cholce
d) 1he LCC Laken aL Lhe Llme of Lhe Sv1 shows characLerlsLlc changes
e) ALrlal flbrlllaLlon wlLh wlde C8S complexes can occur

14) 1he followlng are Lrue of aLrlal flbrlllaLlon
a) ulgoxln ls of use ln Lhe prevenLlon of paroxysmal aLrlal flbrlllaLlon.
b) MlLral sLenosls ls a cause
c) PyperLrophlc obsLrucLlve cardlomyopaLhy ls a cause
d) ulgoxln wlll converL Lhe aLrlal flbrlllaLlon Lo slnus rhyLhm
e) lL resulLs ln lncreased rlsk of sLroke

.**%5+%()&#!
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13) Adenoslne ls used ln
a) aLrlal fluLLer wlLh 2:1 aLrlovenLrlcular block
b) aLrlal flbrlllaLlon
c) aLrlovenLrlcular nodal re-enLry Lachycardla
d) mulLlple ecLoplcs
e) venLrlcular Lachycardla

16) SupravenLrlcular Lachycardla wlLh aberranL conducLlon ls Lhe llkely
dlagnosls ln broad complex Lachycardla when
a) Lhe blood pressure ls normal
b) 1 waves are lnverLed
c) Lhe C8S complexes are very wlde
d) Lhe rhyLhm ls lrregularly lrregular
e) waves are seen followlng each C8S complex

17) MulLlfocal aLrlal Lachycardla
a) ls usually assoclaLed wlLh chronlc resplraLory dlsease
b) ls lrregularly lrregular
c) ls abollshed by dlgoxln
d) Lhe morphology of Lhe p wave ls varlable
e) may be caused by dlgoxln

18) ln Lhe slck slnus syndrome
a) paLlenLs are Lyplcally under 63 years
b) compleLe hearL block ls a common feaLure
c) sysLemlc embollsm may occur
d) fallure Lo lncrease hearL raLe wlLh exerclse ls a feaLure
e) sympLomaLlc paLlenLs should have a permanenL pacemaker
lmplanLed.

19) 1yplcal feaLures of compleLe hearL block lnclude
a) 8egular hearL raLe
b) lrregular cannon 'a' waves
c) paradoxlcal spllLLlng of Lhe second hearL sound
d) a loud flrsL hearL sound
e) a mld-dlasLollc murmur over Lhe apex

.**%5+%()&#!
94

20) 1he flrsL hearL sound ls llkely Lo be varlable ln
a) aLrlal flbrlllaLlon
b) aLrlal fluLLer
c) mulLlple ecLoplc beaLs
d) compleLe aLrlovenLrlcular block
e) lefL bundle branch block

21) 1he followlng can cause bradycardla
a) hypoLhermla
b) hypoLhyroldlsm
c) severe anaemla
d) subdural haemaLoma
e) shock

22) 1he followlng are Lrue regardlng Lhe LreaLmenL of venLrlcular Lachycardla
(v1)
a) uC cardloverslon ls lndlcaLed ln haemodynamlcally unsLable v1
b) Amlodarone ls effecLlve
c) lnLravenous magneslum ls used ln polymorphlc v1
d) verapamll ls effecLlve
e) unsynchronlzed uC cardloverslon can resulL ln venLrlcular flbrlllaLlon

23) A broad complex Lachycardla ls more llkely Lo be supravenLrlcular
Lachycardla wlLh abberaLlon Lhan venLrlcular Lachycardla lf
a) cannon waves are seen ln Lhe neck waves
b) fuslon beaLs are seen on Lhe LCC
c) Lhe Lachycardla ls abollshed by caroLld massage
d) Lhe prevlous LCC ls normal
e) Lhere ls a concordanL paLLern across Lhe precordlal leads

24) Causes of aLrlal flbrlllaLlon lnclude
a) consLrlcLlve perlcardlLls
b) ASu
c) anxleLy
d) recenL Ml
e) compleLe hearL block


.**%5+%()&#!
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23) A 33 year old woman presenLed wlLh a hlsLory of lnLermlLLenL llghL-
headedness. 1he followlng are posslble causes
a) ALrlal premaLure beaLs.
b) Slnus pauses
c) SupravenLrlcular Lachycardla.
d) 1ranslenL MoblLz Lype 1 aLrlovenLrlcular block.
e) venLrlcular premaLure beaLs.

!
!
!
.**%5+%()&#-./#0'*#!
96

J'%L0)%!>+!J))?@>?A&(!M.0%>&+'%!
!
1) l111l
venLrlcular ecLoplcs may be assoclaLed wlLh an lncreased rlsk of sudden deaLh
ln some paLlenLs, buL are of no lmporLance ln oLhers. 1helr slgnlflcance musL
be consldered ln assoclaLlon wlLh many oLher facLors slnce Lhelr presence
alone ls usually of llLLle lmporLance. ln an asympLomaLlc young man who ls
oLherwlse healLhy, Lhe llkellhood of serlous organlc hearL dlsease ls very
small. Powever, baslc lnvesLlgaLlons are necessary, as ls a search for posslble
conLrlbuLory facLors, such as Lhe use of alcohol, recreaLlonal drugs, excesslve
caffelne lngesLlons eLc. Smoklng can also cause ecLoplcs, and ln any case
sLopplng smoklng ls advlsable even lf unrelaLed Lo Lhe problem. An
echocardlogram ls ofLen lndlcaLed Lo exclude valvular hearL dlsease or
cardlomyopaLhy, and exerclse LesLlng may be lndlcaLed ln selecLed cases.
LvaluaLlon should be made by a cardlologlsL Lo deLermlne Lhe need for speclal
LesLs. 1here ls no place for anLlarrhyLhmlc Lherapy ln asympLomaLlc paLlenLs
wlLh venLrlcular ecLoplcs, and ln facL, as mosL anLlarrhyLmlc drugs are have
pro-arrhyLhmogenlc slde effecLs Lhey are beLLer avolded.

2) l1111
venLrlcular ecLoplcs are common afLer a myocardlal lnfarcLlon, and ls also
more llkely lf Lhe paLlenL has recelved Lhrombolysls - Lhese are known as
reperfuslon arrhyLhmlas. 1hey generally do noL requlre drug LreaLmenL.
LlecLrolyLe dlsLurbances are common conLrlbuLory facLors. lf Lhe 8 on 1
phenomenon ls seen Lhere ls a hlgher llkellhood of developlng venLrlcular
flbrlllaLlon. LcLoplcs can be harmless, buL can reflecL ongolng coronary
lschaemla, and serlal LCC changes should be looked for. AnLlarrhyLhmlc
Lherapy ls noL lndlcaLed for haemodynamlcally sLable ecLoplcs, non-susLalned
venLrlcular Lachycardla, or acceleraLed ldlovenLrlcular rhyLhm wlLh a hearL
raLe beLween 100 and 120.

3) 1111l
1he alms of evaluaLlng and LreaLlng an arrhyLhmla are, Lo ellmlnaLe
sympLoms, prevenL lmmlnenL deaLh and hemodynamlc collapse due Lo a llfe-
LhreaLenlng arrhyLhmla, and offseL Lhe long-Lerm rlsk LhaL a non-llfe-
LhreaLenlng arrhyLhmla may porLend ln a hlgh-rlsk paLlenL. ln general,
paLlenLs wlLh sLrucLural hearL dlsease who develop an arrhyLhmla need formal
evaluaLlon. 1he followlng are speclflc lnsLances where referral Lo a
cardlologlsL ls lndlcaLed,
.**%5+%()&#-./#0'*#!
97

aLlenLs resusclLaLed from vl
Al wlLh a raLe LhaL ls dlfflculL Lo conLrol or recurrences LhaL are
refracLory Lo sLandard Lheraples
SusLalned v1
non susLalned v1 ln a paLlenL wlLh suspecLed or proven sLrucLural
hearL dlsease
SympLomaLlc Sv1
SympLomaLlc slnus bradycardla
Second degree or compleLe hearL block
unexplalned venLrlcular ecLopy ln Lhe aLhleLe or ln a sympLomaLlc
paLlenL
aLlenLs wlLh devlces (pacemakers, lCus) and unconLrolled rhyLhm
problems

4) llll1
CompleLe hearL block ls a common compllcaLlon of lnferlor myocardlal
lnfarcLlon. lL occurs due Lo LranslenL lschaemla of Lhe aLrlovenLrlcular node
whlch ls supplled by Lhe rlghL coronary arLery. lL ls noL a slgn of a large
lnfarcLlon, and ln any case mosL lnferlor myocardlal lnfarcLlons do noL cause
exLenslve damage Lo Lhe myocardlum MosL of Lhe Llme lL ls shorL lasLlng, and
ofLen reverLs wlLh aLroplne. 1emporary paclng ls noL urgenLly lndlcaLed, buL
has a place lf Lhe rhyLhm does noL reverL Lo normal. An lsoprenallne lnfuslon
ls noL advlsable as lL can provoke arrhyLhmlas. ln conLrasL, compleLe hearL
block whlch occurs ln anLerlor myocardlal lnfarcLlon usually lndlcaLes a very
large myocardlal lnfarcLlon. lL does noL recover sponLaneously, and needs
Lemporary cardlac paclng.

3) l1111
8 lnLerval prolongaLlon, Lall LenLed 1 waves and wldenlng of Lhe C8S
complex occurs ln hyperkalaemla. 8radycardla ls also a feaLure. 1he wldened
C8S complex ulLlmaLely Lakes Lhe form of a slne wave, whlch ls a slgn of
lmmlnenL cardlac arresL. AsysLole occurs lf hyperkalaemla ls noL LreaLed. 1he
senslLlvlLy of Lhe myocardlum Lo hyperkalaemla ls dependenL on Lhe level of
serum poLasslum as well as Lhe raLe of rlse of Lhe serum poLasslum.

6) 111ll
Slnus bradycardla, slnus arrhyLhmla, slnus arresLs lasLlng less Lhan 3 seconds,
and wanderlng aLrlal pacemaker are ofLen seen ln Lralned aLhleLes. 1hese are
slgns of hlgh vagal Lone. 1hey have no paLhologlcal slgnlflcance, and ln facL
.**%5+%()&#-./#0'*#!
98

may be a slgn of cardlovascular healLh. nodal bradycardla and aLrlal fluLLer
are usually of paLhologlcal slgnlflcance, and musL be lnvesLlgaLed.

7) 11111
ulgoxln and yellow oleander boLh conLaln cardlac glycosldes, and overdose
can resulL ln a varleLy of cardlac arrhyLhmlas. 8oLh Lachy and brady
arrLhyLhmlas are seen, varlous degrees of hearL block, slck slnus syndrome,
nodal Lachycardla, as well as Sv1 and v1 can arlse. Pypokalaemla makes Lhe
Loxlc effecLs worse, however dlglLalls LoxlclLy causes hyperkalaemla whlch can
also cause arrhyLhmlas. varlous LachyarrhyLhmlas occur ln myocardlLls,
lncludlng v1. Snake blLe wlLh cerLaln snakes can also cause myocardlal
LoxlclLy and cardlac arrhyLhmlas. CrganophosphaLe polsonlng can resulL ln
bradyarrhyLhmlas due Lo lncreased chollnerglc acLlvlLy, and can also resulL ln
escape LachyarrhyLhmlas.

8) 11l11
1he aLrlal raLe ln aLrlal fluLLer ls usually 300 beaLs per mlnuLe. Slnce Lhe
venLrlcles cannoL conLracL aL Lhls raLe, Lhere ls lnvarlable some degree of
aLrlovenLrlcular nodal block. lf 2:1 block ls presenL, Lhe venLrlcular raLe wlll be
130 bpm, and lf Lhe block ls 3:1 lL wlll be 100 bpm. venLrlcular Lachycardla ls
almosL due Lo serlous paLhology. CharacLerlsLlcally Lhe complexes are wlde ln
v1, however narrow complexes could be seen lf Lhe Lachycardla arlses hlgh ln
Lhe bundle of Pls. ln supravenLrlcular Lachycardla Lhe complexes are usually
narrow, buL Lhe C8S complex can be broad lf bundle branch block ls presenL,
or lf Lhere ls conducLlon Lhrough an aberranL paLhway. 1he rhyLhm ln v1 ls
regular, and an lrregular broad complex rhyLhm ls usually aLrlal flbrlllaLlon
wlLh bundle branch block or aberranL conducLlon.

9) ll1ll
venLrlcular ecLoplcs are a frequenL flndlng ln pregnancy, are harmless,
provlded LhaL Lhere ls no underlylng hearL dlsease. 1reaLmenL ls noL requlred.
SupravenLrlcular Lachycardla also occurs ln some pregnanL women, Lhe cause
for whlch ls noL clearly undersLood. 8y lLself lL does noL lndlcaLe underlylng
sLrucLural hearL dlsease. ALrlal flbrlllaLlon and fluLLer are boLh ofLen
paLhologlcal, and are only rarely found ln normal pregnanL women. 1he
presence of aLrlal flbrlllaLlon should make one suspecL underlylng mlLral
sLenosls. llrsL degree hearL block can be seen, buL second degree and
compleLe hearL block are very rare.

.**%5+%()&#-./#0'*#!
99

10) l1111
AsympLomaLlc slnus bradycardla wlLh a raLe above 40 bpm does noL requlre
paclng. A hearL raLe of 43 bpm does noL glve rlse Lo sympLoms. Second
degree or compleLe hearL block usually requlres paclng. ln sympLomaLlc Lachy
brady syndrome, sympLoms are ofLen due Lo LachyarrhyLhmlas. Powever
Lhese cannoL be easlly LreaLed because of Lhe rlsk of causlng bradycardla. 1he
sLandard LreaLmenL ls Lo pace Lhe paLlenL, and conLrol Lhe LachyarrhyLhmla
wlLh a calclum channel blocker or beLa blocker as Lhere ls Lhen no rlsk of
bradycardla. 1here ls some evldence LhaL rlghL venLrlcular cardlac paclng ls
beneflclal, as early acLlvaLlon of Lhe sepLum by Lhe pacemaker resulLs ln
reducLlon of Lhe ouLflow LracL obsLrucLlon.

11) ll111
Low 1 waves and promlnenL u waves ln hypokalaemla may glve a false
lmpresslon of prolongaLlon of Lhe C1 lnLerval. Amlodarone, qulnlne and
qulnldlne, Lrlcycllc anLldepressanLs, phenoLhlazlnes, eryLhromycln, asLemlzole
and many oLher drugs cause prolongaLlon of Lhe C1 lnLerval. lL can be
congenlLal, and can be assoclaLed wlLh deafness. Pypocalcaemla causes a
long C1, hypercalcaemla causes a shorL C1. lL can be occaslonally found ln
rheumaLlc cardlLls.

12) ll11l
Pypercalcaemla causes a shorL S1 segmenL glvlng rlse Lo a shorL C1 lnLerval.
PyponaLraemla does noL cause slgnlflcanL changes on Lhe LCC. 1 wave
lnverslons are seen ln mlLral valve prolapse, buL Lhese are non speclflc and
non dlagnosLlc. ln facL Lhey ofLen cause dlagnosLlc confuslon wlLh changes of
lschaemlc hearL dlsease. ! waves are seen ln hypoLhermla. Pypomagnesaemla
glves rlse Lo changes slmllar Lo hypokalaemla, llke u waves and flaLLenlng of 1
waves.

13) 1lll1
WW syndrome ls due Lo Lhe presence of an abnormal bundle of kenL
connecLlng Lhe aLrla and venLrlcles. lL ofLen presenLs wlLh aLrlovenLrlcular
reenLranL Lachycardla or Sv1. venLrlcular Lachycardla can occur and ls llfe
LhreaLenlng. ulgoxln and verapamll block conducLlon ln Lhe normal Av node,
and lncreases Lhe rlsk of developlng Sv1 by lncreaslng Lhe llkellhood of
lmpulses Lravellng Lhrough Lhe abnormal paLhway. ALrlal flbrlllaLlon can occur
wlLh conducLlon Lo Lhe venLrlcles occurrlng Lhrough Lhe abnormal paLhway,
resulLlng ln wlde C8S complexes.
.**%5+%()&#-./#0'*#!
100


14) l11l1
ulgoxln ls used for raLe conLrol ln aLrlal flbrlllaLlon, by slowlng conducLlon
across Lhe Av node. lL does noL converL Lhe aLrlal flbrlllaLlon Lo slnus rhyLhm.
MlLral sLenosls, lschaemlc hearL dlsease, and cardlomyopaLhles are all
recognlzed causes. 1he rlsk of sLroke ls lncreased ln aLrlal flbrlllaLlon due Lo
sLrucLural hearL dlsease, buL noL ln lone aLrlal flbrlllaLlon.

13) 1l1ll
Adenoslne causes LranslenL compleLe hearL block. lL ls used prlmarlly Lo
lnLerrupL Lhe reenLranL clrculL ln Av nodal reenLranL Lachycardla. lLs duraLlon
of acLlon ls Loo shorL Lo be of beneflL ln conLrolllng Lhe raLe ln aLrlal
flbrlllaLlon. ln aLrlal fluLLer wlLh 2:1 block, where dlagnosls ls a problem, lL can
be used Lo lncrease Lhe block and reveal Lhe fluLLer waves, Lhus helplng wlLh
dlagnosls.

16) lll1l
1he blood pressure can be normal ln boLh Sv1 and v1. 1he 1 waves are ofLen
lnverLed ln any Lachycardla, due Lo repolarlzaLlon abnormallLles. very wlde
C8S complexes suggesL v1. An lrregularly lrregular rhyLhm occurs ln aLrlal
flbrlllaLlon wlLh aberranL conducLlon, whlch ls ln effecL a supravenLrlcular
Lachycardla. waves can be seen followlng Lhe C8S complexes ln Sv1.

17) 11l11
MulLlfocal aLrlal Lachycardla ls ofLen assoclaLed wlLh chronlc resplraLory
dlsease or congesLlve hearL fallure. 1he rhyLhm ls lrregularly lrregular, ofLen
mlmlcklng aLrlal flbrlllaLlon. ulgoxln does noL abollsh lL, and ln facL lL can be
caused by dlgoxln LoxlclLy. 1he morphology of Lhe p waves varles, and lf Lhe
raLe ls below 100 bpm lL ls known as a wanderlng aLrlal pacemaker.

18) 1l111
Slck slnus syndrome ls common ln Lhe elderly due Lo degeneraLlve changes ln
Lhe slnus node. lL can be assoclaLed wlLh lschaemlc hearL dlsease and
cardlomyopaLhles. CompleLe hearL block ls noL a feaLure, alLhough lL can be
assoclaLed lf Lhe degeneraLlve process progresses Lo lnvolve Lhe resL of Lhe
conducLlng sysLem. SysLemlc embollsm can occur, alLhough lL ls noL common.
lL ls due Lo aLrlal arrhyLhmlas whlch may develop. 1he hearL raLe does noL
lncrease ln response Lo exerclse, and can resulL ln exerLlonal syncope or
Llredness. SympLomaLlc paLlenLs musL be paced.
.**%5+%()&#-./#0'*#!
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19) 11lll
1he hearL raLe ln compleLe hearL block ls regular. lrregular cannon waves are
seen ln Lhe [ugular velns, due Lo conLracLlon of Lhe aLrla durlng venLrlcular
sysLole. 1he flrsL sound ls varlable ln lnLenslLy, and depends on Lhe
relaLlonshlp Lo Lhe aLrlal conLracLlon. aradoxlcal spllLLlng of Lhe second
hearL sound ls seen ln lefL bundle branch block.

20) 1l11l
ln aLrlal flbrlllaLlon, ecLoplcs, and compleLe hearL block, venLrlcular fllllng Llme
ls varlable. 1he flrsL hearL sound ls Lherefore varlable. ln aLrlal fluLLer and lefL
bundle branch block Lhere ls aLrlovenLrlcular synchrony, and Lhe lnLenslLy of
Lhe flrsL hearL sound ls normal.

21) 11l1l
PypoLhermla, hypoLhyroldlsm, [aundlce, can all cause bradycardla. lL can also
be seen ln Lralned aLhleLes. Anaemla and shock causes Lachycardla. A
subdural haemaLoma can resulL ln lncreased lnLracranlal pressure, leadlng Lhe
Cushlng reflex - hyperLenslon and bradycardla. lL ls a slgn of lncreaslng
lnLracranlal pressure and posslble lmmlnenL conlng.

22) 111l1
uC cardloverslon ls lndlcaLed ln haemodynamlcally unsLable v1, l.e., when
Lhere ls a low blood pressure, anglna, lefL venLrlcular fallure. Amlodarone ls
used ln haemodynamlcally sLable v1. ln 1orsade de polnLes Lhe drug of cholce
ls lnLravenous magneslum. verapamll ls used ln supravenLrlcular Lachycardla,
buL can cause cardlac arresL lf used ln v1. uC cardloverslon musL be
synchronlzed, Lo avold a posslble 8 on 1 phenomenon.

23) ll1ll
Cannon waves are seen lf Lhere ls aLrlovenLrlcular dlssoclaLlon resulLlng ln
slmulLaneous conLracLlon of Lhe aLrla and venLrlcles. luslon beaLs and capLure
beaLs are seen ln v1. CaroLld slnus massage can abollsh Sv1 buL has no effecL
on v1. A prevlously normal LCC suggesLs LhaL v1 ls more llkely, whlle Lhe
presence of bundle branch block or WW syndrome on Lhe prevlous LCC
suggesLs Sv1 wlLh aberranL conducLlon. Concordance across Lhe precordlal
leads ls seen ln v1.


.**%5+%()&#-./#0'*#!
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24) 1111l
erlcardlal dlsease can cause aLrlal flbrlllaLlon. ALrlal enlargemenL ln ASu can
resulL ln aLrlal flbrlllaLlon. lschaemlc hearL dlsease ls a recognlzed cause of
aLrlal flbrlllaLlon. 8arely lL can occur ln anxleLy.

23) 11111
All of Lhe above can cause lnLermlLLenL llghLheadedness


8&*,)7(576&+%)'#!
103

#J36EO"NO8JKIEG1!

1) 8egardlng dllaLed cardlomyopaLhy
a. PyperLenslon ls a recognlzed cause
b. 1he ma[orlLy of cases are ldlopaLhlc
c. 23 per cenL of ldlopaLhlc dllaLed cardlomyopaLhles are famlllal
d. lL has a beLLer prognosls compared Lo lschaemlc cardlomyopaLhy
e. erslsLenL vlral lnfecLlon has been lmpllcaLed as a posslble cause

2) 1he followlng are recognlzed causes of dllaLed cardlomyopaLhy
a. PaemochromaLosls
b. lrledrlch's aLaxla
c. Cyclophosphamlde Lherapy
d. Wllson's dlsease
e. SysLemlc sclerosls

3) 1he followlng are suggesLlve of ldlopaLhlc dllaLed cardlomyopaLhy raLher
Lhan lschaemlc hearL cardlomyopaLhy
a. ullaLaLlon of all four chambers of Lhe hearL on echocardlography
b. Cccurrence ln a young paLlenL
c. 1he absence of pulmonary hyperLenslon
d. AsymmeLrlcal hyperLrophy of Lhe sepLum of Lhe hearL on
echocardlography
e. A normal LCC

4) aLlenLs wlLh dllaLed cardlomyopaLhy may presenL wlLh
a. sLroke
b. haemopLysls
c. Sudden cardlac deaLh
d. Syncope
e. SupravenLrlcular arrhyLhmla

8&*,)7(576&+%)'#!
104

3) 8egardlng lnvesLlgaLlons ln dllaLed cardlomyopaLhy
a. 1he LCC shows 1 wave lnverslons ln mulLlple leads
b. ALrlal flbrlllaLlon may be seen on LCC
c. ChesL radlograph shows a dllaLed hearL wlLh clear lung flelds
d. Coronary anglography ls lndlcaLed ln paLlenLs over Lhe age of 40
years
e. Lchocardlogram shows dllaLaLlon of Lhe lefL venLrlcle more Lhan Lhe
rlghL venLrlcle

6) ln a perlcardlal effuslon
a. Cn chesL radlograph Lhe hearL ls globular
b. 1he lung flelds are pleLhorlc
c. Lchocardlography ls useful ln dlagnosls
d. 8radycardla ls a feaLure
e. A low pulse volume ls an lndlcaLlon for urgenL asplraLlon

7) ln dllaLed cardlomyopaLhy
a. urug LreaLmenL ls slmllar Lo LhaL of hearL fallure
b. Warfarln ls lndlcaLed lf a hlsLory of LranslenL lschaemlc aLLacks ls
presenL
c. AnLlarrhyLhmlcs are lndlcaLed lf Lhe paLlenL has recurrenL
arrhyLhmlas
d. WelghL reducLlon ls helpful ln managemenL
e. Cardlac LransplanLaLlon ls Lhe maln opLlon of LreaLmenL for paLlenLs
who do noL respond Lo medlcal Lherapy

8) 1he followlng commonly cause myocardlLls
a. uengue fever
b. LepLosplrosls
c. Malarla
d. radlaLlon
e. 1rypanosoma cruzl

9) ln a paLlenL wlLh myocardlLls due Lo dengue fever
a. 1he cardlac enzymes are usually normal
b. PearL block maybe seen
c. 1he absence of 1 wave changes makes Lhe dlagnosls unllkely
d. venLrlcular arrhyLhmlas may cause deaLh
e. Lchocardlography shows reglonal wall moLlon abnormallLles
8&*,)7(576&+%)'#!
103


10) 8egardlng aLrlal myxoma
a. 1he sympLoms and slgns can mlmlc lnfecLlve endocardlLls
b. A mld dlasLollc murmur may be presenL
c. 1he lefL aLrlum ls a common slLe
d. lL ls mallgnanL
e. Surglcal removal ls lndlcaLed

11) 1he followlng cllnlcal feaLures suggesL a dlagnosls of hyperLrophlc
obsLrucLlve cardlomyopaLhy
a. uouble aplcal pulsaLlon
b. A mlLral regurglLaLlon murmur
c. Collapslng pulse
d. An e[ecLlon sysLollc murmur made louder by squaLLlng
e. A fourLh hearL sound

12) 1he followlng are seen ln hyperLrophlc obsLrucLlve cardlomyopaLhy
a. AsymmeLrlcal sepLal hyperLrophy on echocardlography
b. LefL venLrlcular hyperLrophy
c. S1 segmenL elevaLlons ln Lhe laLeral leads on LCC
d. AnLerlor movemenL of Lhe mlLral valve durlng sysLole on
echocardlography
e. Cardlomegaly on chesL radlograph

13) 1he followlng are causes of resLrlcLlve cardlomyopaLhy
a. Loefflers endocardlLls
b. Amyloldosls
c. 1uberculosls
d. ulabeLes melllLus
e. Sarcoldosls

14) ln resLrlcLlve cardlomyopaLhy
a. 1here ls cardlomegaly on chesL radlography
b. 1he lung flelds are clear
c. Low volLage complexes are seen on Lhe LCC
d. Lndomyocardlal blopsy ls useful ln dlagnoslng Lhe cause
e. 1here ls no speclflc LreaLmenL

8&*,)7(576&+%)'#!
106

13) A 33 year old man presenLs wlLh recurrenL syncope. Cn one eplsode he ls
documenLed Lo have venLrlcular Lachycardla. Pls LCC shows 1 wave
lnverslons ln v1 Lo v3. Lchocardlography shows rlghL venLrlcular
dllaLaLlon. A dlagnosls of arrhyLhmogenlc rlghL venLrlcular dysplasla ls
made.
a. Chronlc lung dlsease ls a llkely cause
b. 8lghL hearL fallure may develop
c. lL may presenL wlLh sudden deaLh
d. M8l demonsLraLes faLLy lnfllLraLlon of Lhe rlghL venLrlcle
e. lL ls LreaLed wlLh beLa blockers

16) erlparLum cardlomyopaLhy
a. May develop afLer dellvery
b. ls commoner ln women under 30 years of age
c. lL ls due Lo a vlral lnfecLlon
d. lL ls commoner ln mulLlparous women
e. lL has a morLallLy of up Lo 30

17) 8egardlng consLrlcLlve perlcardlLls
a. 1uberculosls ls Lhe mosL lmporLanL cause ln Lhe developlng world
b. erlcardlal calclflcaLlon may be seen on a laLeral chesL radlograph
c. PypoLhyroldlsm ls a known cause
d. lL ls a cause of aLrlal flbrlllaLlon
e. 1he LreaLmenL ls perlcardloLomy
18) 1rue or false
a. ln dlabeLes melllLus, hearL fallure ls always secondary Lo coronary
arLery dlsease
b. carclnold syndrome causes a dllaLed cardlomyopaLhy
c. myocardlLls ls caused by coxsackle vlrus lnfecLlon
d. vlral myocardlLls may resulL ln lrreverslble dllaLed cardlomyopaLhy
e. perslsLenL Lachycardla can resulL ln cardlomyopaLhy

19) 1he followlng are recognlsed causes of reverslble dllaLed
cardlomyopaLhy:-
a. Alcohol
b. Selenlum deflclency
c. Acromegaly
d. Lead polsonlng
e. Coxsackle vlrus
8&*,)7(576&+%)'#!
107


20) Speclflc hearL muscle dlsease may resulL from
a. vlLamln 81 deflclency
b. cholera
c. Cushlng's syndrome
d. carclnold syndrome
e. scleroderma

21) PyperLrophlc cardlomyopaLhy
a. ls famlllal
b. ls assoclaLed wlLh lrledrlch's aLaxla
c. may be usefully LreaLed wlLh nlLraLes
d. LreaLed wlLh beLa adrenerglc blockers has a lower rlsk of sudden
deaLh
e. ls besL screened for by a 12-lead elecLrocardlogram

22) 1he followlng are causes of speclflc hearL muscle dlsease
a. amyloldosls
b. sarcoldosls
c. emphysema
d. haemoslderosls
e. pregnancy

23) Whlch of Lhe followlng lnfecLlons cause myocardlLls?
a. Coxsackle vlrus
b. ulphLherla
c. Chagas ulsease
d. Syphlllls
e. 1oxoplasmosls

8&*,)7(576&+%)'#!
108

24) A 21 year old man wlLh PyperLrophlc CardlomyopaLhy presenLs ln cllnlc
wlLh dlzzy spells buL has noL had any syncopal eplsodes. Whlch of Lhe
followlng, lf presenL, would lndlcaLe an lncreased rlsk of sudden cardlac
deaLh?
a. AsymmeLrlc sepLal hyperLrophy
b. 8lood ressure drop of 20mmPg durlng peak exerclse Lolerance
LesLlng
c. A famlly hlsLory of sudden deaLh
d. SysLollc AnLerlor MovemenL of Lhe mlLral valve on echocardlography
e. worsenlng exerLlonal anglna

23) A 28-year-old man who ls known Lo have PyperLrophlc CardlomyopaLhy
has an ouL of hosplLal cardlac arresL and ls successfully resusclLaLed. 1he
followlng are posslble LreaLmenL opLlons
a. Alcohol SepLal AblaLlon
b. Amlodarone
c. 8eLa 8locker
d. lmplanLable ueflbrlllaLor
e. MyomecLomy






8&*,)7(576&+%)'#-./#0'*#!
109

J'%L0)%!>+!#()*&+A@+5(>?@!M.0%>&+'%!
!
1) 111l1
PyperLenslon causes lefL venLrlcular hyperLrophy. LvenLually, long sLandlng
hyperLenslon can cause chamber dllaLaLlon and resulL ln dllaLed
cardlomyopaLhy. 1hls accounLs for approxlmaLely 4 percenL of paLlenLs. ln 30
percenL of paLlenLs Lhe aeLlology ls noL know, Lhls ls referred Lo as ldlopaLhlc
dllaLed cardlomyopaLhy. vlral myocardlLls ls Lhe second commonesL cause,
and lschaemlc hearL dlsease ls Lhe nexL mosL common cause. 1he prognosls
of lschaemlc cardlomyopaLhy ls beLLer Lhan LhaL of cardlomyopaLhy due Lo
oLher causes. 1he condlLlon ls famlllal ln abouL 23 percenL of paLlenLs wlLh
Lhe ldlopaLhlc Lype.

2) 111l1
1he llsL of causes for dllaLed cardlomyopaLhy ls very long. ln general,
lschaemla, Loxlns, nuLrlLlonal deflclencles, drugs, endocrlne dlseases,
deposlLlon dlseases, neuromuscular dlsorders, lnfecLlons, connecLlve Llssue
dlseases, and many oLhers can resulL ln dllaLed cardlomyopaLhy. Wllson's
dlsease, where Lhere ls excesslve deposlLlon of copper ln Lhe Llssues, does noL
usually cause a cardlomyopaLhy.

3) 1l1l1
ln boLh lschaemlc cardlomyopaLhy and ldlopaLhlc dllaLed cardlomyopaLhy
chamber dllaLaLlon occurs. ln ldlopaLhlc dllaLed cardlomyopaLhy, slnce Lhe
myocardlum ls lnLrlnslcally affecLed, all four chambers wlll be affecLed
slmulLaneously. lf, aL Lhe onseL, dllaLaLlon of all four chambers ls seen, lL ls
more llkely Lo be ldlopaLhlc dllaLed cardlomyopaLhy. ulmonary hyperLenslon
may noL develop because all chambers have been affecLed slmulLaneously. ln
lschaemlc cardlomyopaLhy Lhe lefL hearL ls much more llkely Lo be affecLed,
because of lLs greaLer Lhlckness and Lherefore greaLer suscepLlblllLy Lo
lschaemla. ullaLaLlon of Lhe rlghL hearL occurs secondary Lo Lhe developmenL
of pulmonary hyperLenslon. A young paLlenLs ls more llkely Lo have ldlopaLhlc
dllaLed cardlomyopaLhy. 1he presence of asymmeLrlcal sepLal hyperLrophy
suggesLs a dlagnosls of hyperLrophlc obsLrucLlve cardlomyopaLhy. 1he LCC ls
ofLen abnormal ln lschaemlc hearL dlsease. A normal LCC may be seen ln
ldlopaLhlc dllaLed cardlomyopaLhy - however Lhe LCC ls ofLen abnormal ln
Lhls condlLlon Loo.


8&*,)7(576&+%)'#-./#0'*#!
110

4) 1l111
ullaLaLlon of Lhe venLrlcles and aLrla can resulL ln sLasls of blood ln Lhe
chambers of Lhe hearL, resulLlng ln Lhrombosls and Lhromboembollc sLroke.
1he rlsk of embollc sLroke ls hlgher ln paLlenLs wlLh dllaLed cardlomyopaLhy.
Powever, anLlcoagulaLlon wlLh warfarln ls noL rouLlnely glven unless Lhere are
demonsLrable Lhrombl ln Lhe venLrlcles or aLrla, or lf Lhe paLlenL has had 1lAs
or a sLroke. PaemopLysls occurs due Lo rupLure of dllaLed pulmonary venules
ln paLlenLs wlLh elevaLed pulmonary venous pressure, lL ls commonly seen ln
mlLral sLenosls. ln dllaLed cardlomyopaLhy, slnce all four chambers are dllaLed,
Lhe pulmonary venous pressures are usually noL very hlgh, and haemopLysls ls
noL a promlnenL feaLure. Sudden cardlac deaLh can occur ln dllaLed
cardlomyopaLhy and oLher Lypes of cardlomyopaLhy as well, ln parLlcular
PCCM. Sudden deaLh ls ofLen due Lo arrhyLhmlas. Any Lype of arrhyLhmla
can occur, lncludlng aLrlal flbrlllaLlon, Sv1, v1 and venLrlcular flbrlllaLlon.
Syncope ls a frequenL complalnL among paLlenLs wlLh dllaLed cardlomyopaLhy,
and ls due Lo low cardlac ouLpuL or arrhyLhmlas whlch resulL ln a drop ln
cardlac ouLpuL.

3) 11l1l
LCC changes such as S1 - 1 changes can be seen ln dllaLed cardlomyopaLhy.
varlous forms of bundle branch block may be presenL. 1he presence of C
waves may suggesL myocardlal lschaemla as a probable aeLlologlcal facLor.
ullaLaLlon of all chambers of Lhe hearL occurs, aLrlal flbrlllaLlon can occur as a
consequence of aLrlal dllaLaLlon. 1he chesL radlograph ofLen shows a dllaLed
hearL wlLh congesLed lung flelds. ln younger paLlenLs, lschaemla ls noL a
common cause of dllaLed cardlomyopaLhy, however ln any paLlenL over Lhe
age of 40 years Lhere ls a posslblllLy of lschaemlc hearL dlsease as an
underlylng aeLlology. Such paLlenLs may have a 'hlbernaLlng myocardlum',
where Lhe myocardlum ls dormanL as a response Lo chronlc lschaemla. ln
such paLlenLs, revascularlzaLlon may lmprove cardlac funcLlon. ullaLaLlon of
Lhe lefL venLrlcle more Lhan Lhe lefL venLrlcle ls noL characLerlsLlc of dllaLed
cardlomyopaLhy, ofLen Lhls lndlcaLes lschaemlc hearL dlsease where Lhe lefL
venLrlcle ls more prone Lo lschaemlc damage.

6) 1l1l1
A globular hearL wlLh clear lung flelds ls characLerlsLlcally seen on Lhe chesL
radlograph ln perlcardlal effuslon. Slnce Lhe effuslon compresses boLh
chambers of Lhe hearL, rlghL hearL fllllng ls also reduced, hence Lhe lung flelds
are clear. Lchocardlography ls Lhe mosL useful lnvesLlgaLlon ln Lhe dlagnosls
8&*,)7(576&+%)'#-./#0'*#!
111

of perlcardlal effuslon. 1achycardla ls ofLen seen ln perlcardlal effuslon, as a
compensaLory response Lo low cardlac ouLpuL. lf bradycardla ls presenL, Lhe
posslblllLy of hypoLhyroldlsm as an underlylng cause should be consldered. A
low pulse volume lndlcaLes slgnlflcanL myocardlal compromlse, and ls an
lndlcaLlon for urgenL asplraLlon.

7) 11111
ullaLed cardlomyopaLhy resulLs ln congesLlve cardlac fallure, and Lhe drug
LreaLmenL ls largely LhaL of hearL fallure. Slnce all chambers of Lhe hearL are
dllaLed, Lhere ls an lncreased rlsk of lnLracardlac Lhrombl, and hence
embollsaLlon resulLlng ln sLroke. Powever Lhere ls conLroversy as Lo wheLher
paLlenLs should rouLlnely be LreaLed wlLh anLlcoagulanLs. lf a hlsLory of 1lAs ls
presenL, warfarlnlzaLlon ls usually lndlcaLed. WelghL reducLlon ln paLlenLs
who are overwelghL Lo achleve ldeal body welghL lmproves sympLoms. 1he
deflnlLlve LreaLmenL ln paLlenLs who do noL respond Lo medlcal Lherapy ls
cardlac LransplanLaLlon.

8) 11111
A varleLy of bacLerlal, vlral, proLozoal and helmlnLhlc lnfecLlons, and many
Loxlns and drugs can cause myocardlLls. ln Lroplcal counLrles, lepLosplrosls ls
an lmporLanL cause. uengue fever and oLher vlral lnfecLlons can cause
myocardlLls, usually presenLlng wlLh chesL paln and 1 wave lnverslons on Lhe
LCC. Cardlac enzymes are ofLen elevaLed, and Lroponln 1 may be poslLlve.
Amerlcan Lrypanosomlasls ls an lmporLanL cause ln CenLral Amerlca.
8adlaLlon for cancer of Lhe lung ls an lmporLanL cause.

9) l111l
MyocardlLls ls seen ln a slgnlflcanL proporLlon of paLlenLs wlLh uengue fever.
ln mosL lnsLances lL ls asympLomaLlc, and does noL glve rlse Lo serlous
compllcaLlons. 1he commonesL flndlng on Lhe LCC ls 1 wave lnverslons ln Lhe
anLerlor leads. Slnus bradycardla ls common, varylng degrees of hearL block
are seen occaslonally. Llfe LhreaLenlng venLrlcular arrhyLhmlas such as
venLrlcular Lachycardla and venLrlcular flbrlllaLlon may occur, parLlcular lf
elecLrolyLe lmbalance ls presenL. A compleLely normal LCC makes Lhe
dlagnosls unllkely. venLrlcular arrhyLhmlas can cause deaLh. 8eglonal wall
moLlon abnormallLles are seen ln lschaemlc hearL dlsease due Lo reglonal
lschaemla. 1he changes ln dengue myocardlLls are ofLen global, l.e., lnvolve
all parLs of Lhe venLrlcle.

8&*,)7(576&+%)'#-./#0'*#!
112

10) 111l1
1he mosL common prlmary cardlac neoplasm ls myxoma. 1hese Lumors
hlsLologlcally conslsL LhroughouL of coplous mucopolysaccharlde sLroma,
whlch are scaLLered sollLary or clusLered polygonal cells, Lhe sLromal cells
orlglnaLe from mulLlpoLenL mesenchyme capable of neural and endoLhellal
dlfferenLlaLlon. 1hey are frequenLly pedunculaLed, and 73 percenL arlse ln Lhe
lefL aLrlum close Lo Lhe fossa ovalls. A mld dlasLollc murmur ls presenL due Lo
obsLrucLlon of dlasLollc flow. 1he sympLoms and slgns can mlmlc endocardlLls,
and lL can presenL wlLh perlpheral embollzaLlon. lL ls non mallgnanL. Cardlac
Lumours whlch are mallgnanL lnclude anglosarcomas and
rhabdomyosarcomas. MesoLhellomas can arlse ln Lhe perlcardlum. Surglcal
removal ls Lhe LreaLmenL.

11) 11ll1
A double aplcal pulsaLlon and a [erky pulse should alerL Lhe cllnlclan Lo Lhe
posslblllLy of PCCM. 1he condlLlon ls famlllal, wlLh an auLosomal domlnanL
paLLern of lnherlLance. MlLral regurglLaLlon occurs ln almosL all paLlenLs wlLh
obsLrucLlve PCCM as a consequence of sysLollc anLerlor movemenL of Lhe
mlLral valve leafleLs and lmpalred mlLral leafleL coapLaLlon. CondlLlons whlch
lncrease perlpheral vascular reslsLance such as squaLLlng and handgrlp wlll
reduce Lhe lnLenslLy of Lhe murmur. 1hls ls because lncreaslng Lhe perlpheral
reslsLance wlll reduce Lhe degree of obsLrucLlon caused by Lhe hyperLrophled
sepLum. A fourLh sound ls ofLen hearL, especlally ln younger paLlenLs.

12) 1111l
AsymmeLrlcal sepLal hyperLrophy ls a characLerlsLlc flndlng ln PCCM. LefL
venLrlcular hyperLrophy occurs wlLh feaLures of lefL venLrlcular sLraln, l.e., S1
segmenL depresslons ln Lhe laLeral leads As a resulL of Lhe sepLal hyperLrophy
Lall 8 waves ln Lhe sepLal leads (v1-v3) and promlnenL C waves ln Lhe laLeral
and lnferlor leads may be seen. AnLerlor movemenL of Lhe mlLral valve durlng
sysLole ls characLerlsLlcally seen ln Lhe M Mode echocardlogram. PyperLrophy
ls ofLen conflned Lo Lhe sepLum, and cardlomegaly does noL usually occur.
Long sLandlng mlLral regurglLaLlon can resulL ln cardlomegaly laLer on.

13) 11ll1
8esLrlcLlve cardlomyopaLhy ls a dlsLlncL enLlLy whlch has morphologlc and
hemodynamlc characLerlsLlcs LhaL separaLe lL from dllaLed and hyperLrophlc
cardlomyopaLhles. lL ls comparaLlvely rare. ln resLrlcLlve cardlomyopaLhy Lhe
venLrlcles are noL dllaLed, wall Lhlckness ls normal. 1he venLrlcular walls are
8&*,)7(576&+%)'#-./#0'*#!
113

rlgld, resulLlng ln resLrlcLlon Lo dlasLollc fllllng and Lherefore dlasLollc
dysfuncLlon. lefL venLrlcular sysLollc funcLlon ls normal. lL may be ldlopaLhlc,
or may be due Lo one of Lhe followlng condlLlons, amyloldosls, sarcoldosls,
hemochromaLosls, chemoLherapy or radlaLlon, hypereoslnophlllc syndrome
such as Loefflers, endomyocardlal flbrosls, and long-Lerm chloroqulne
Lherapy. 1uberculosls ofLen lnvolves Lhe perlcardlum, resulLlng ln consLrlcLlve
perlcardlLls. 1he cllnlcal feaLures of consLrlcLlve perlcardlLls can resemble
Lhose of resLrlcLlve cardlomyopaLhy.

14) 1ll1l
AlLhough Lhe venLrlcles are ofLen noL dllaLed ln resLrlcLlve cardlomyopaLhy,
cardlomegaly ls ofLen presenL due Lo aLrlal dllaLaLlon. 1he lung flelds are
pleLhorlc, and pleural effuslons may be seen. A varleLy of LCC changes may
be seen ln resLrlcLlve cardlomyopaLhy, lncludlng aLrlal flbrlllaLlon, S1-1
changes, however Lhe C8S complexes are usually normal. Low volLage
complexes suggesL consLrlcLlve perlcardlLls. Lndomyocardlal blopsy ls helpful
ln dlagnoslng secondary causes. lf an underlylng secondary cause can be
found, LreaLmenL of LhaL cause mlghL lmprove Lhe cardlomyopaLhy. 1here ls
no deflnlLlve LreaLmenL for ldlopaLhlc resLrlcLlve cardlomyopaLhy.

13) l111l
ArrhyLhmogenlc rlghL venLrlcular dysplasla, whlch ls also called rlghL
venLrlcular cardlomyopaLhy, ls a rare enLlLy characLerlzed by venLrlcular
arrhyLhmlas and an unusual faLLy appearance of Lhe 8v free wall. Sudden
arrhyLhmlc deaLh, ofLen exerclse lnduced, are known Lo occur. 1he M8l ls
useful ln dlagnosls. 1he Class lll anLlarrhyLhmlc drug SoLalol ls Lhe mosL
effecLlve drug ln LreaLmenL.

16) 1ll11
erlparLum cardlomyopaLhy ls characLerlzed by Lhe developmenL of cardlac
fallure ln Lhe lasL monLh of pregnancy or wlLhln flve monLhs of dellvery. lL ls
very rare before 36 weeks of gesLaLlon. 1hese paLlenLs have no ldenLlflable
cause for cardlac fallure, and have had no evldence of hearL dlsease prlor Lo
Lhe lasL monLh of pregnancy. lL ls commoner among Lhe followlng, women
over 30 years of age, mulLlparous women, women of Afrlcan descenL, women
wlLh mulLlple pregnancy, women wlLh a hlsLory of preeclampsla, women wlLh
a hlsLory of cocaln abuse, and Lhose on long Lerm LocolyLlc Lherapy wlLh
salbuLamol. varlous aeLlologles have been suggesLed, lncludlng vlral
8&*,)7(576&+%)'#-./#0'*#!
114

lnfecLlon, buL Lhe cause ls unknown. 1he condlLlon has a morLallLy of up Lo 30
percenL.

17) 11l11
1here are many causes of consLrlcLlve perlcardlLls. ln Lhe developlng world,
Luberculosls ls probably Lhe mosL common. erlcardlal calclflcaLlon may be
seen ln Lhe laLeral chesL radlograph. PypoLhyroldlsm causes perlcardlal
effuslon, buL noL consLrlcLlve perlcardlLls. ALrlal flbrlllaLlon can occur.
erlcardloLomy ls Lhe deflnlLlve LreaLmenL.

18) ll111
Coronary arLery dlsease ofLen co-exlsLs wlLh dlabeLes melllLus. Powever Lhere
ls some evldence LhaL an lndependenL 'dlabeLlc cardlomyopaLhy' may exlsL.
Carclnold syndrome resulLs ln endomyocardlal flbrosls and resulLs ln a
resLrlcLlve Lype of cardlomyopaLhy. Coxsackle vlrus lnfecLlon ls a well known
cause of vlral myocardlLls. MosL cases of vlral myocardlLls compleLely recover,
a small number go on Lo develop lrreverslble dllaLed cardlomyopaLhy.
erslsLenL Lachycardla due Lo any cause can resulL ln myocardlal dysfuncLlon,
known as Lachycardla lnduced cardlomyopaLhy.

19) 111l1
A varleLy of Loxlns, lnfecLlons and meLabollc derangemenLs can cause
reverslble dllaLed cardlomyopaLhy. Lead polsonlng does noL characLerlsLlcally
cause cardlomyopaLhy.

20) 1ll11
vlLamln 8 deflclency can resulL ln 8erl 8erl. Many vlruses can cause
myocardlLls, buL cholera ls noL one of Lhem. LefL venLrlcular hyperLrophy
secondary Lo hyperLenslon, and cardlac fallure, can occur ln Cushlngs, buL a
speclflc hearL muscle dlsease does noL occur. Carclnold syndrome can cause
endomyocardlal flbrosls. Myocardlal flbrosls can occur ls scleroderma, and
has a poor prognosls.

21) 11l1l
PyperLrophlc cardlomyopaLhy (PCM) ls a geneLlc dlsease of Lhe cardlac
sarcomere, wlLh an auLosomal domlnanL paLLern of lnherlLance. lL ls
assoclaLed wlLh lrledrlch's aLaxla. vasodllaLors worsen Lhe ouLflow LracL
obsLrucLlon by reduclng perlpheral reslsLance. 8eLa blockers or verapamll can
prevenL sudden cardlac deaLh. 1he LCC ofLen shows lefL venLrlcular
8&*,)7(576&+%)'#-./#0'*#!
113

hyperLrophy, however an echocardlogram ls Lhe mosL useful screenlng LesL.
Lchocardlography shows Lhe characLerlsLlc asymmeLrlcal sepLal hyperLrophy
and sysLollc anLerlor movemenL of Lhe mlLral valve.

22) 11l11
Lmphysema causes rlghL hearL fallure secondary Lo pulmonary hyperLenslon.
Amyloldosls, sarcoldosls, and haemochromaLosls can cause cardlomyopaLhy.
erlparLum cardlomyopaLhy ls a recognlzed enLlLy.

23) 11111
All of Lhese condlLlons can cause myocardlLls.

24) l11ll
A blood pressure drop durlng exerclse LesLlng, a famlly hlsLory of sudden
deaLh, and worsenlng exerLlonal anglna are predlcLors of sudden cardlac
deaLh.

23) 11111
All of Lhe above are posslble LreaLmenL opLlons. Powever an lmplanLable
deflbrlllaLor ls probably Lhe mosL useful LherapeuLlc modallLy Lo prevenL
sudden cardlac deaLh ln Lhls paLlenL.
!
8'*'<*79&#$43&*!,)#'&#'!
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#G3GT3OPJ1#:=J3!6E1GJ1G
!
1) SLroke
a. ls deflned as a focal neurologlcal deflclL of vascular orlgln
b. lL ls Lhe Lhlrd mosL lmporLanL cause of deaLh ln Lhe developed world
c. lL ls more common ln Lhe elderly
d. 8heumaLlc hearL dlsease ls an lmporLanL causaLlve facLor
e. lL ls commoner ln women

2) 8egardlng Lhe causes of sLroke
a. ln hyperLenslve paLlenLs, cerebral haemorrhage ls more common
Lhan lnfarcLlon
b. Subarachnold haemorrhage ls commoner ln paLlenLs wlLh
hyperLenslon
c. A Lumour of Lhe braln can mlmlc a sLroke
d. lsolaLed, or lone aLrlal flbrlllaLlon lncreases Lhe rlsk of sLroke
a. ulssecLlon of Lhe caroLld arLery ls a recognlzed cause

3) 1he followlng are lmporLanL rlsk facLors for sLroke
a. PyperLenslon
b. Smoklng
c. ModeraLe alcohol consumpLlon
d. olycyLhaemla vera
e. LlevaLed homocysLelne levels ln Lhe blood

4) 8egardlng LranslenL lschaemlc aLLacks
a. 1hey are usually due Lo cerebral embollsm
b. 1he usually lasL abouL 7-8 hours
c. osLural hypoLenslon ls a recognlzed cause
d. 1ranslenL loss of vlslon ln one eye can occur
e. local epllepsy can mlmlc a LranslenL lschaemlc aLLack

3) 8egardlng LranslenL lschaemlc aLLacks
a. 1here ls an lncreased rlsk ln valvular hearL dlsease
b. AnLlphosphollpld syndrome ls a cause
c. 30 of people wlLh a 1lA wlll develop a sLroke wlLhln a year
d. lL ls never caused by haemorrhage
e. long Lerm asplrln reduces Lhe rlsk of sLroke afLer a 1lA

8'*'<*79&#$43&*!,)#'&#'!
117

6) 1he followlng should be looked for ln a paLlenL wlLh a 1lA
a. A caroLld arLery brulL
b. PearL murmur
c. 8radycardla
d. vascullLlc rash
e. ulabeLes melllLus

7) 1he followlng are recognlzed manlfesLaLlons of a 1lA
a. Mlgralne
b. Aphasla
c. verLlgo
d. 1ranslenL global amnesla
e. Loss of consclousness

8) 8egardlng lschaemlc sLroke
a. 1he mosL common slLe ls Lhe parleLal corLex
b. A very dense sLroke ln a paLlenL who ls fully consclous and alerL ls
llkely Lo be ln Lhe lnLernal capsule
c. Peadache ls common
d. 1he reflexes are brlsk soon afLer Lhe occurrence of Lhe sLroke
e. Lpllepsy ls a common presenLaLlon

9) 8egardlng lnfarcLlon of Lhe braln sLem
a. 1he laLeral medullary syndrome occurs due Lo Lhrombosls of Lhe
posLerlor lnferlor cerebellar arLery
b. A palnful Lhlrd nerve palsy wlLh a pupll whlch does noL reacL Lo llghL
suggesLs a mldbraln lnfarcL
c. Coma can occur ln a braln sLem sLroke
d. Weakness of Lhe upper and lower llmb on Lhe rlghL slde, wlLh faclal
weakness on Lhe lefL slde occurs ln a medullary sLroke
e. Weakness of Lhe rlghL faclal nerve and rlghL laLeral recLus palsy
lndlcaLes a ponLlne lnfarcL

10) 1he followlng can occur due Lo sLroke
a. uemenLla
b. Pemlanoplc vlsual loss
c. arklnsonlsm
d. 1remor
e. ALaxla
8'*'<*79&#$43&*!,)#'&#'!
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11) Lhe followlng cllnlcal feaLures are rellable ln dlsLlngulshlng an lnfarcL from
a haemorrhage
a. headache
b. loss of consclousness
c. a hlsLory of hyperLenslon
d. A C1 scan braln
e. LLC

12) A 60 year old man ls admlLLed wlLh a dense rlghL face arm leg weakness.
Pe ls fully alerL. Pls blood pressure ls 180/100mmhg.
a. Pe should be glven asplrln 300mg sLaL
b. Pe should be sLarLed on lnLravenous heparln
c. Pls blood pressure should be urgenLly reduced Lo 140/90
d. nlfedlplne subllngually ls Lhe drug of cholce for blood pressure
reducLlon
e. lf he has been on anLlhyperLenslves, Lhese should be conLlnued

13) 8egardlng Lhe managemenL of acuLe sLroke
a. Cxygen by mask should be glven
b. Pyperglycaemla wlLh a blood glucose under 230mg/dl need noL be
LreaLed
c. PyperLenslon musL be LreaLed lf Lhe blood pressure ls above
220/130mPg
d. lever should be LreaLed wlLh anLlpyreLlcs and Lepld sponglng
e. 1hrombolysls wlLh Llssue plasmlnogen acLlvaLor ls lndlcaLed ln mosL
large sLrokes

14) 8egardlng acuLe sLroke
a. Swallowlng ls assessed by checklng Lhe gag reflex
b. A C1 scan braln ls lndlcaLed only ln paLlenLs wlLh severe headache or
drowslness
c. Cerebellar haemorrhage ls an lndlcaLlon for urgenL referral Lo Lhe
neurosurgeon
d. ln Lhe presence of swallowlng dlfflculLy, Lhe paLlenL ls kepL on nC
feeds for 3 monLhs
e. 8eferral Lo a mulLldlsclpllnary sLroke unlL lmproves ouLcome

8'*'<*79&#$43&*!,)#'&#'!
119

13) 8egardlng Lhe C1 scan ln sLroke
a. A conLrasL C1 scan braln ls lndlcaLed lmmedlaLely afLer Lhe sLroke
b. A haemorrhage can be deLecLed ln a C1 scan wlLhln 2 hours
c. An lnfarcL ls deLecLable ln a non-conLrasL C1 scan wlLhln 6 hours
d. 1he maln place of a C1 scan braln ls Lo exclude a haemorrhage
e. 1he C1 scan ls a senslLlve lnvesLlgaLlon Lo deLecL lnfarcLs ln Lhe
posLerlor cranlal fossa

16) 8egardlng Lhe managemenL of acuLe sLroke
a. Asplrln ls lndlcaLed ln all lschaemlc sLrokes
b. ln Lhe presence of aLrlal flbrlllaLlon, warfarln ls lndlcaLed ln a large
mlddle cerebral arLery LerrlLory sLroke
c. Low molecular welghL heparln ls lndlcaLed ln lschaemlc sLroke
d. 1he goals of blood pressure conLrol are lower ln haemorrhaglc sLroke
compared Lo lschaemlc sLroke
e. Clopldogrel ls useful ln Lhe secondary prevenLlon of lschaemlc sLroke

17) 1he followlng lnvesLlgaLlons are rouLlnely lndlcaLed ln a 43 year old
paLlenL wlLh a sLroke
a. M8l braln
b. LCC
c. Paemoglobln level
d. 8lood homocysLelne level
e. Lumbar puncLure

18) ln a paLlenL wlLh chronlc aLrlal flbrlllaLlon who develops a sLroke
a. 1here ls a hlgh rlsk of a second sLroke
b. Warfarln ls lndlcaLed
c. Asplrln, when comblned wlLh warfarln, has addlLlve proLecLlve
effecLs
d. Converslon of aLrlal flbrlllaLlon Lo slnus rhyLhm should be aLLempLed
e. Warfarln lncreases Lhe rlsk of cerebral haemorrhage

8'*'<*79&#$43&*!,)#'&#'!
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19) 8egardlng Lhe prognosls afLer a sLroke
a. 23 of paLlenLs dle wlLhln 2 years of a sLroke
b. 1he ma[orlLy of deaLhs afLer sLroke occur wlLhln Lhe flrsL monLh
c. 1he ma[orlLy of deaLhs occur due Lo recurrenL sLroke
d. 1he ma[orlLy of survlvors of sLroke reLurn Lo lndependenL moblllLy
e. aLlenLs wlLh a haemorrhaglc sLroke are Lwlce as llkely Lo dle early
compared Lo Lhose wlLh lschaemlc sLroke

20) 1he followlng are poor prognosLlc feaLures afLer sLroke
a. urowslness
b. Con[ugaLe gaze palsy
c. Swallowlng dlfflculLy
d. Aphasla
e. PyperLenslon soon afLer Lhe sLroke

21) 8egardlng haemorrhaglc sLroke
a. lL ls responslble for around 10 of sLrokes
b. lL ls caused by rupLure of large arLerlal aneurysms mosL commonly
c. 1he basal ganglla are a characLerlsLlc slLe
d. Cerebral amylold anglopaLhy ls a cause
e. PyperLenslon ls Lhe mosL lmporLanL rlsk facLor

22) 1he followlng sympLoms / slgns are correcLly palred wlLh Lhe slLe of Lhe
sLroke
a. uysarLhrla ! braln sLem
b. 8lghL homonymous hemlanopla ! rlghL occlplLal corLex
c. Lxpresslve dysphasla ! Lemporal lobe
d. Pemlsensory loss !parleLal corLex
e. 1ranslenL global amnesla ! fronLal corLex

23) 8egardlng haemorrhaglc sLroke
a. CloL evacuaLlon ls consldered ln large bleeds causlng a mldllne shlfL
b. Asplrln ls conLralndlcaLed
c. Cerebellar haemorrhage ls an lndlcaLlon for urgenL surglcal
evacuaLlon of Lhe cloL
d. 1he prognosls ls poor
e. lnLracranlal arLerlovenous malformaLlons should be looked for as a
cause

8'*'<*79&#$43&*!,)#'&#'!
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24) 8egardlng subarachnold haemorrhage
a. ls ofLen assoclaLed wlLh a hlsLory of Lrauma Lo Lhe head
b. lL ls usually due Lo a rupLure of a berry aneurysm ln Lhe clrcle of Wlllls
c. lL accounLs for 3 of sLrokes
d. lL ls commoner ln paLlenLs wlLh polycysLlc kldney dlsease
e. Sudden severe occlplLal headache ls a feaLure

23) 8egardlng Lhe managemenL of subarachnold haemorrhage
a. 1he bood pressure musL be conLrolled Lo less Lhan 140mmPg sysLollc
b. nlmodlplne reduces secondary cerebral vasospasm and lmproves
ouLcome
c. ConsLlpaLlon musL be avolded
d. A four vessel anglogram musL be done wlLhln 48-72 hours
e. Surglcal cllpplng of Lhe aneurysm ls lndlcaLed

!
!
8'*'<*79&#$43&*!,)#'&#'-./#0'*#!
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J'%L0)%!>+!#()*&+,(%-./()!6&%0(%0!M.0%>&+'%!

1) 1111l
SLroke ls deflned as a focal neurologlcal deflclL of vascular orlgln. lL ls Lhe Lhlrd
commonesL cause of deaLh ln Lhe developed world. 1he lncldence of sLroke
lncreases wlLh lncreaslng age. 8heumaLlc hearL dlsease resulLlng ln chronlc
valvular dlsease, ln parLlcular mlLral sLenosls wlLh aLrlal flbrlllaLlon ls a ma[or
causaLlve facLor ln Lhe developmenL of embollc sLroke. SLroke ls commoner ln
men.
!
2) l11l1
Cverall lnfarcLlon ls commoner Lhan haemorrhage as a cause of sLroke. ln
hyperLenslve paLlenLs, and even ln paLlenLs who have had a cerebral
haemorrhage, lnfarcLlon ls more common. Subarachnold haemorrhage ls
ofLen due Lo rupLure of a berry aneurysm ln Lhe clrcle of wlllls, and Lhe
lncldence ls hlgher ln paLlenLs wlLh hyperLenslon. 1umours ofLen presenL wlLh
more lnsldlous slgns and sympLoms, ln parLlcular feaLures of lncreased
lnLracranlal pressure such as early mornlng headaches wlLh vomlLlng, and
gradually worsenlng neurologlcal slgns. Powever, haemorrhage lnLo a Lumour
can resulL ln sudden expanslon of Lhe Lumour, and can presenL acuLely wlLh a
focal neurologlcal deflclL mlmlcklng a sLroke. ALrlal flbrlllaLlon ls an lmporLanL
rlsk facLor for embollc sLroke, however ln Lhe absence of a cause, l.e., lsolaLed
or lone aLrlal flbrlllaLlon, Lhe lncldence of sLroke ls noL lncreased.
AnLlcoagulaLlon ls lndlcaLed ln mosL cases of aLrlal flbrlllaLlon, buL ls ofLen noL
lndlcaLed ln lone aLrlal flbrlllaLlon. A dlssecLlon of a caroLld arLery can resulL ln
a sLroke ln Lhe LerrlLory supplled by LhaL vessel.

3) 11l11
PyperLenslon, smoklng, dlabeLes melllLus, hyperllpldaemla are all ma[or rlsk
facLors for Lhe developmenL of lschaemlc sLroke. PyperLenslon lncreases Lhe
rlsk of haemorrhaglc sLroke. Peavy alcohol consumpLlon can lncrease Lhe rlsk
of sLrokes, buL drlnklng ln moderaLlon has been shown Lo be useful ln Lhe
prlmary prevenLlon of sLroke. ln polycyLhaemla vera, Lhe lncreased vlscoslLy
of blood due Lo Lhe hlgh haemaLocrlL, as well as Lhe assoclaLed lncrease ln
plaLeleLs whlch ofLen co-exlsLs can resulL ln LhromboLlc sLroke. aLlenLs wlLh
homocysLelnurla have elevaLed blood homocysLelne levels due Lo an lnherlLed
enzyme defecL. 1hese paLlenLs have a hlgh lncldence of arLerlal Lhrombosls
and sLroke. LlevaLed blood homocysLelne levels lncrease Lhe LhrombogenlclLy
of blood and ls a rlsk facLor for LhromboLlc sLroke. lolaLe deflclency ls known
8'*'<*79&#$43&*!,)#'&#'-./#0'*#!
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Lo resulL ln elevaLed blood homocysLelne levels, Lhere ls some evldence LhaL
follc acld Lherapy ln such paLlenLs ls useful ln lowerlng homocysLelne levels
and may proLecL agalnsL sLrokes.

4) 1l111
8y deflnlLlon, a 1lA ls a focal neurologlcal deflclL whlch lasLs less Lhan 24
hours, ln pracLlce however Lhe ma[orlLy resolve wlLhln half an hour. 1lAs are
usually due Lhe passage of small emboll Lhrough Lhe cerebral clrculaLlon. 1lAs
due Lo small haemorrhages have been reporLed, buL Lhls ls a very rare cause.
CfLen, a source of embollsm ls presenL such as caroLld arLery sLenosls, aLrlal
flbrlllaLlon, valvular hearL dlsease or endocardlLls, or dllaLed cardlomyopaLhy
wlLh venLrlcular Lhrombl. osLural hypoLenslon, bradycardla, hyperLenslon,
dlabeLes melllLus are recognlzed causes. A proLhromboLlc sLaLe may be Lhe
underlylng cause, such as polycyLhaemla or anLlphosphollpld syndrome.

3) 11ll1
1he rlsk of 1lA ls lncreased many fold ln paLlenLs wlLh valvular hearL dlsease.
MlLral sLenosls wlLh aLrlal flbrlllaLlon lncreases Lhe rlsk 13 Llmes.
AnLlphosphollpld syndrome ls a known rlsk facLor for arLerlal or venous
Lhrombosls. Cne flfLh of paLlenLs wlLh a 1lA wlll develop a sLroke wlLhln a
year. AlLhough Lhe ma[orlLy of sLrokes are caused by embollsm, Lhere are a
few case reporLs of 1lAs due Lo small haemorrhages. Asplrln glven long Lerm
afLer a 1lA wlll reduce Lhe rlsk of sLroke. Clopldogrel, anoLher anLlplaLeleL drug
has been shown Lo be more effecLlve ln reduclng Lhe rlsk of sLroke.

6) 11111
CondlLlons whlch lncreases Lhe rlsk of aLherosclerosls, vascullLlc condlLlons,
valvular cardlac leslons, proLhromboLlc sLaLes, and low cardlac ouLpuL sLaLes
and arrhyLhmlas, can cause 1lAs. ln Lhe rouLlne evaluaLlon of a paLlenL wlLh a
1lA cllnlcal feaLures polnLlng Lo any of Lhese condlLlons should be looked for.

7) l1111
Mlgralne can mlmlc a 1lA and ls an lmporLanL dlfferenLlal dlagnosls. 1he
presence of headache makes a 1lA less llkely. Any Lype of focal neurologlcal
defecL can occur ln a 1lA. 1ranslenL global amnesla ls a condlLlon of posslbly
vascular eLlology, LhaL Lyplcally occurs afLer Lhe age of 30. AffecLed paLlenLs
have a deflclL of shorL-Lerm memory LhaL beglns abrupLly and perslsLs for
mlnuLes Lo hours, wlLhouL oLher cognlLlve or moLor lmpalrmenL. lL ls
someLlmes classlfled as a separaLe enLlLy, buL ls ofLen regarded as a Lype of
8'*'<*79&#$43&*!,)#'&#'-./#0'*#!
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1lA. Loss of consclousness ls rare, buL can occur due Lo a 1lA lnvolvlng Lhe
posLerlor clrculaLlon.

8) l1lll
1he commonesL slLe of lschaemlc sLroke ls Lhe lnLernal capsule. lor a very
dense sLroke Lo occur, Lhe leslon may be elLher a small lnfarcL ln Lhe lnLernal
capsule where many of Lhe pyramldal flbres are close Lo each oLher, or a large
lnfarcL of Lhe corLex. lf Lhe paLlenLs level of consclousness ls preserved Lhe
leslon ls more llkely Lo be ln Lhe lnLernal capsule, as lnvolvemenL of a large
area of Lhe corLex wlll lnvarlably resulL ln slgnlflcanL cerebral oedema causlng
drowslness. Peadache ls of poor dlscrlmlnaLory value ln dlsLlngulshlng a
haemorrhage from an lnfarcL, buL ls commoner afLer a haemorrhage. Soon
afLer a sLroke, Lhe reflexes are dlmlnlshed due Lo splnal shock. SubsequenLly
Lhe reflexes reLurn, and evenLually become brlsk. Lpllepsy ls known Lo occur
afLer an lnfarcL, buL ls more commonly seen due Lo haemorrhage. 1he
presence of epllepsy slgnlfles an lrrlLaLlve leslon, and a space occupylng leslon
should be excluded.

9) 111l1
Locallslng sLrokes whlch occur ln Lhe braln sLem ls easy lf one has a good
knowledge of Lhe anaLomy and locaLlon of Lhe varlous nuclel and flbres ln Lhe
braln sLem. 1he laLeral medullary syndrome occurs due Lhrombosls of Lhe
posLerlor lnferlor cerebellar arLery. known as Wallenberg syndrome, lL resulLs
from a leslon of Lhe laLeral medulla and was orlglnally descrlbed as lnvolvlng
paln and LemperaLure loss on Lhe lpsllaLeral face and conLralaLeral llmbs and
Lrunk. Accompanylng slgns and sympLoms lnclude loss of vlbraLlon and
proprlocepLlon as well as aLaxla ln Lhe lpsllaLeral llmbs. An lpsllaLeral Porner's
syndrome, verLlgo, nysLagmus, hoarseness, and dysphagla are ofLen presenL.

10) 11111
vascular demenLla ls due Lo mulLlple small sLrokes over a perlod of Llme.
Pemlanoplc vlsual loss can occur due Lo a sLroke of Lhe occlplLal corLex.
Cerebrovascular dlsease ls a known aeLlologlcal facLor ln parklnsonlsm.
1remor and aLaxla can occur due Lo sLrokes lnvolvlng Lhe basal ganglla.





8'*'<*79&#$43&*!,)#'&#'-./#0'*#!
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11) lll1l
CfLen, Lhe presence of headache afLer a sLroke ls LhoughL Lo be due Lo
haemorrhage. Powever lL ls an unrellable sympLom, as up Lo 30 percenL of
haemorrhages presenL wlLhouL headache. Loss of consclousness occurs more
commonly due Lo haemorrhage, buL can occur wlLh a large lnfarcL wlLh
cerebral oedema, or wlLh a braln sLem lnfarcL. AlLhough hyperLenslon ls one
of Lhe aeLlologlcal facLors predlsposlng Lo haemorrhage, even ln
hyperLenslves, lschaemlc sLroke ls commoner. 1he LLC ls unhelpful ln
dlfferenLlaLlon an lnfarcL from a haemorrhage, and a non-conLrasL-enhanced
C1 scan braln ls Lhe mosL useful lnvesLlgaLlon. A haemorrhage ls deLecLable
almosL lmmedlaLely, whlle an lnfarcL can be deLecLed afLer abouL 24 hours.
1herefore lL ls Lhe mosL useful lnvesLlgaLlon Lo exclude a haemorrhage.

12) llll1
Asplrln or anLlcoagulaLlon ls lndlcaLed ln sub-masslve lnfarcLs. A haemorrhage
or a very large lnfarcL ls a conLralndlcaLlon Lo asplrln and anLlcoagulaLlon. ln
Lhls man a large corLlcal lnfarcL or haemorrhage ls unllkely as he ls fully alerL.
1he mosL llkely leslon ls Lhe lnLernal capsule. Powever, a C1 scan musL be
performed Lo make sure of Lhls before asplrln or anLlcoagulaLlon ls glven.
8lood pressure reducLlon ls only necessary lf Lhe blood pressure ls over
220/120mmPg, and even ln Lhls case, should be reduced gradually. Sudden
reducLlon ln blood pressure, especlally wlLh Lhe use of subllngual nlfedlplne
lncreases Lhe rlsk of sLroke, and should noL be glven. lf Lhe paLlenL has been
on anLlhyperLenslves Lhey should be conLlnued.

13) 1l11l
AfLer a sLroke, Lhe area of braln whlch ls lnfarcLed ls no longer vlable.
Surroundlng Lhe area of lschaemla ls a area of braln whlch ls lschaemlc buL
sLlll vlable, Lhe lschaemlc penumbra. roLecLlon of Lhls lschaemlc penumbra ls
of vlLal lmporLance Lo prevenL furLher neurologlcal damage. 1he facLors whlch
can harm Lhls area lnclude hyperLhermla, hypo or hyperglycaemla, hypoxla,
and elecLrolyLe lmbalance. Cxygen ls ofLen glven Lo lmprove hypoxla.
normoglycaemla should be malnLalned. AfLer a sLroke, Lhere ls a
compensaLory lncrease ln blood pressure. PyperLenslon musL be LreaLed only
Lhe blood pressure ls above 220/130mmPg. AnLlpyreLlcs and Lepld sponglng
are used Lo prevenL hyperpyrexla. 1he crlLerla for Lhrombolysls are very
sLrlngenL, and ln mosL large sLrokes Lhrombolysls ls probably conLralndlcaLed.


8'*'<*79&#$43&*!,)#'&#'-./#0'*#!
126

14) ll1l1
Assesslng Lhe gag reflex ls unrellable ln deLermlnlng wheLher Lhe swallowlng
mechanlsm ls lnLacL. 1he preferred meLhod ls Lo geL Lhe paLlenL Lo swallow a
few Leaspoonfuls of waLer, followed by half a glass of waLer. lf he does noL
gag or cough he can be allowed Lo Lake orally. lf he has any dlfflculLy ln
swallowlng, an nC Lube should be kepL ln place for 2 weeks, by whlch Llme
Lhe swallowlng mechanlsm generally recovers. Cllnlcal slgns and sympLoms
are unrellable ln dlsLlngulshlng beLween lschaemlc and haemorrhaglc sLroke.
ln mosL lnsLances surgery ls noL urgenLly requlred for supraLenLorlal
haemorrhage. Powever cerebellar haemorrhage ls an urgenL lndlcaLlon for
evacuaLlon as lL can resulL ln compresslon of Lhe braln sLem and also
obsLrucLlve hydrocephalus. 1here ls clear evldence LhaL Lhe ouLcome of
sLroke paLlenLs ls beLLer lf Lhey are LreaLed ln a mulLldlsclpllnary sLroke unlL.

13) l1l1l
1he role of C1 scannlng of Lhe braln afLer a sLroke musL be clearly undersLood
lf one ls Lo obLaln useful lnformaLlon from lL. ln a non conLrasL C1 scan, a
haemorrhage wlll be vlslble as a hyperdense or whlLe area, and an lnfarcL as a
hypodense or dark area. A haemorrhage ls vlslble soon afLer lLs occurrence,
buL an lnfarcL ls vlslble only afLer abouL 24 hours. 1he maln place of C1 scan
braln ls Lo deLecL a haemorrhage, Lhls ls because Lhe presence of a
haemorrhage wlll be a conLralndlcaLlon for asplrln, and also because lL mlghL
need neurosurglcal lnLervenLlon. lL ls dlfflculL Lo dlfferenLlaLe a haemorrhage
from an lnfarcL ln a conLrasL C1 scan, as Lhe lnfarcL may enhance wlLh conLrasL
and appear llke a haemorrhage. C1 scans use x rays, whlch poorly peneLraLe
bone. lL ls noL senslLlve for posLerlor cranlal fossa lnfarcLs because of Lhe hlgh
bone denslLy.

16) 1lll1
Asplrln has been shown Lo be beneflclal ln Lhe secondary prevenLlon of
sLroke, and ls lndlcaLed ln all paLlenLs wlLh lschaemlc sLroke. 1here ls new
evldence Lhe Clopldogrel may be more effecLlve ln secondary prevenLlon of
sLroke. lL ls noL clear wheLher Lhe comblnaLlon of clopldogrel and asplrln glves
addlLlve beneflL. 1here ls no place for low molecular welghL heparln ln Lhe
rouLlne managemenL of lschaemlc sLroke, excepL ln Lhe presence of aLrlal
flbrlllaLlon. Warfarln ls lndlcaLed ln paLlenLs wlLh aLrlal flbrlllaLlon who have
developed a sLroke (and ln facL ln Lhe prlmary prevenLlon of sLroke ln paLlenLs
wlLh aLrlal flbrlllaLlon. Powever, lf Lhe lnfarcL ls large, Lhere ls an lncreased
8'*'<*79&#$43&*!,)#'&#'-./#0'*#!
127

rlsk of secondary bleedlng lnLo Lhe lnfarcL, warfarln ls conLralndlcaLed ln Lhls
lnsLance.


17) l111l
A C1 scan ls rouLlnely done Lo deLermlne wheLher Lhe sLroke ls lschaemlc or
haemorrhaglc. An M8l ls lndlcaLed only ln selecLed lnsLances, for example
where Lhe leslon does noL correspond Lo Lhe neurologlcal deflclL, or where an
alLernaLlve dlagnosls ls suspecLed. An LCC ls essenLlal, Lo deLermlne any
rhyLhm dlsLurbances, ln parLlcular aLrlal flbrlllaLlon, and also Lo look for
coexlsLenL lschaemlc hearL dlsease. olycyLhaemla ls a known cause of
LhromboLlc sLroke. LlevaLed serum homocysLelne levels ls an lndependenL rlsk
facLor for sLroke. 1here ls no lndlcaLlon for lumbar puncLure unless an SAP ls
suspecLed.

18) 11ll1
1he rlsk of sLroke ls greaLly lncreased ln a paLlenL wlLh aLrlal flbrlllaLlon,
especlally ln a paLlenL who has already had a sLroke. AnLlcoagulaLlon Lo
malnLaln Lhe ln8 beLween 2 and 3 ls necessary ln Lhe absence of
conLralndlcaLlons. lL ls noL clearly known wheLher comblnlng asplrln and
warfarln ls of any addlLlve beneflL. ALLempLs Lo converL chronlc aLrlal
flbrlllaLlon Lo slnus rhyLhm are very llkely Lo be unsuccessful, converslon Lo
slnus rhyLhm ls also rlsky, as lL may resulL ln an aLrlal Lhrombus geLLlng
dlslodged causlng embollsaLlon. Warfarln lncreases Lhe rlsk of cerebral
haemorrhage, and regular esLlmaLlng of Lhe proLhrombln Llme ln8 ls
essenLlal. Where Lhere ls a chance LhaL paLlenL compllance ls poor, cllnlclans
ofLen prefer noL Lo use lL, as Lhe rlsks may ouLwelgh Lhe poLenLlal beneflL.

19) 11ll1
AbouL 23 percenL of paLlenLs wlLh sLroke dle wlLhln 2 years. up Lo 30 percenL
dle wlLhln Lhe flrsL monLh, ofLen due Lo lmmedlaLe compllcaLlons such as
asplraLlon. ln Lhe resL, myocardlal lnfarcLlon ls probably Lhe commonesL
cause of deaLh. Cf Lhe survlvors, one Lhlrd wlll reLurn Lo lndependenL
moblllLy, and abouL anoLher one Lhlrd wlll have severe resldual deblllLy. 1he
morLallLy ls much hlgher among paLlenLs wlLh haemorrhaglc sLroke.

20) 1111l
urowslness or coma, con[ugaLe gaze palsy, severe hemlplegla are all poor
prognosLlc facLors. Swallowlng dlfflculLy lncreases Lhe rlsk of asplraLlon and
8'*'<*79&#$43&*!,)#'&#'-./#0'*#!
128

lncreases morLallLy. aLlenLs wlLh aphasla flnd rehablllLaLlon more dlfflculL.
PyperLenslon occurs as a compensaLory mechanlsm Lo malnLaln cerebral
perfuslon afLer a sLroke, and ls noL by lLself assoclaLed wlLh poor ouLcome.


21) 1l111
Around 10 percenL of sLrokes are due Lo lnLracerebral haemorrhage. MosL
commonly, lL ls caused by rupLure of mlcroaneurysms ln small deep
peneLraLlng arLerles. 1he basal ganglla, pons, cerebellum and subcorLlcal
whlLe maLLer are Lhe usual slLes. Cerebral amylold anglopaLhy ls characLerlzed
by Lhe deposlLlon of amylold ln small Lo medlum-slzed blood vessels of Lhe
braln., Lhe amylold deposlLs cause breakdown of Lhe blood vessel wall wlLh
resulLanL hemorrhage. lL ls commoner ln Lhe elderly, and has no parLlcular
assoclaLlon wlLh hyperLenslon. Cverall, hyperLenslon ls Lhe mosL lmporLanL
rlsk facLor ln cerebral haemorrhage.
!
22) 1ll1l
uysarLhrla ls ofLen assoclaLed wlLh leslons of Lhe braln sLem. A rlghL occlplLal
corLex leslon wlll produce a lefL homonymous hemlanopla. 8roca's area, or
Lhe moLor speech area, ls ln Lhe fronLal corLex. Pemlsensory loss can be
caused by a leslon ln Lhe parleLal corLex. 1he exacL aeLlology of LranslenL
global amnesla ls noL known, buL lL ls LhoughL Lo be due Lo posLerlor
clrculaLlon lschaemla.

23) 1111
CfLen surgery ls noL performed ln small haemorrhages, buL a large bleed
causlng mldllne shlfL ls an lndlcaLlon for surglcal evacuaLlon. Cerebellar
haemorrhage ls a deflnlLe lndlcaLlon for surgery, Lhe mass effecL of a bleed ln
Lhe posLerlor cranlal fossa can cause braln sLem compresslon and conlng, and
ls a neurosurglcal emergency. 1he prognosls lf poor wlLh haemorrhaglc
sLroke, wlLh Lhe rlsk of dylng belng abouL Lwlce LhaL of lschaemlc sLroke.
lnLracranlal arLerlovenous malformaLlons are a posslble cause, and should
always be looked for as Lhey are poLenLlally LreaLable wlLh surgery.

24) l1111
SAP accounLs for 3-10 of sLrokes. MosL SAPs are due Lo rupLure of a
saccular aneurysm ln Lhe clrcle of Wlllls. 1rauma Lo Lhe head resulLs ln
subdural or exLradural haemorrhage. olycysLlc kldney dlsease ls assoclaLed
wlLh berry aneurysms, and Lherefore SAP ls commoner ln such paLlenLs,
8'*'<*79&#$43&*!,)#'&#'-./#0'*#!
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especlally as Lhey are usually hyperLenslve as well. 8upLure of an aneurysm
releases blood dlrecLly lnLo Lhe cerebrosplnal fluld under arLerlal pressure.
1he blood spreads qulckly wlLhln Lhe CSl, rapldly lncreaslng lnLracranlal
pressure. 1he bleedlng usually lasLs only a few seconds, buL rebleedlng ls
common and occurs more ofLen wlLhln Lhe flrsL day. Sudden severe headache
ls characLerlsLlc, occurrlng aL nlghL ln 30 percenL of cases. neck sLlffness ls a
feaLure. 30 Lo 30 percenL of paLlenLs have a mlnor hemorrhage or "leak,"
manlfesLed only by a sudden and severe headache (Lhe senLlnel headache)
LhaL precedes a ma[or SAP by 6 Lo 20 days 1he complalnL of Lhe sudden onseL
of severe headache ls sufflclenLly characLerlsLlc LhaL a mlnor SAP should
always be consldered.


23) 11111
ConLrol of Lhe blood pressure Lo below 140mmPg sysLollc ls helpful ln
reduclng bleedlng. nlmodlplne, a calclum channel anLagonlsL, reduces
secondary cerebral vasospasm and lmproves ouLcome lf sLarLed early.
LaxaLlves are prescrlbed Lo prevenL Lhe paLlenL from sLralnlng. 8ebleedlng ls
llkely wlLhln 14 days, and a four vessel anglogram musL be performed Lo
ldenLlfy Lhe aneurysm. Surglcal cllpplng ls lndlcaLed.

!
=)&<'+'#!('33)+4#!
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6EJTGKG1!"G==EK:1

1) ulabeLes melllLus
a. AffecLs more Lhan 120 mllllon people worldwlde
b. 1he lncldence ls rlslng worldwlde
c. ls curable lf deLecLed ln Lhe early sLages
d. 8educes llfe expecLancy even wlLh opLlmal LreaLmenL
e. 1he lncldence ln Asla ls lower Lhan LhaL ln Lurope

2) 8egardlng Lhe paLhogenesls of dlabeLes
a. Low blrLh welghL ls a rlsk facLor for developlng dlabeLes laLer ln llfe
b. CbeslLy lncreases Lhe rlsk of developlng dlabeLes
c. Low lnLake of frulLs and vegeLables lncreases Lhe chance of geLLlng
dlabeLes
d. hyslcal acLlvlLy proLecLs agalnsL Lhe developmenL of dlabeLes
e. 1aklng a loL of sugar conLalnlng foods ln predlsposes Lo dlabeLes

3) 8egardlng Lhe Lypes of dlabeLes melllLus
a. 1ype l dlabeLes ls due Lo lnsulln deflclency
b. 1ype ll dlabeLes ls due Lo lnsulln reslsLance
c. Chronlc pancreaLlLls resulLs ln Lype l dlabeLes
d. CesLaLlonal dlabeLes ls a form of Lype ll dlabeLes
e. 1ype l dlabeLes does noL occur ln Lhose over Lhe age of 30 years

4) 8egardlng Lype l dlabeLes melllLus
a. lL ls ofLen lmmune medlaLed
b. lL ls commonesL ln Asla
c. 1he rlsk of developlng Lype l dlabeLes ls greaLer wlLh a dlabeLlc faLher
Lhan a dlabeLlc moLher
d. lL ls assoclaLed wlLh oLher auLolmmune dlsorders
e. aLlenLs are usually obese

3) 8egardlng Lype ll dlabeLes melllLus
a. lL runs ln famllles
b. lL ls commoner among more affluenL people
c. aLlenLs are usually obese
d. lL can occur ln chlldren
e. C-pepLlde dlsappears from Lhe blood

=)&<'+'#!('33)+4#!
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6) 1he followlng skln leslons are common ln dlabeLlcs
a. CellullLls of Lhe leg
b. non heallng ulcers of Lhe fooL
c. 8alanlLls
d. vulvovaglnlLls
e. Lczema

7) 1he followlng presenLaLlons should make one suspecL Lhe posslblllLy of
Lhe paLlenL havlng dlabeLes
a. 8alanlLls
b. unexplalned welghL loss
c. CellullLls of Lhe leg
d. CeLLlng up frequenLly aL nlghL Lo pass urlne
e. 1lnea lnfecLlon ln Lhe skln

8) 8egardlng Lhe dlagnosls of dlabeLes
a. 1he normal fasLlng plasma glucose ls <110 mg/dL (6.1 mmol/L)
b. ulabeLes ls dlagnosed when Lhe lC ls above 126 mg/dL (7.0
mmol/L)
c. random blood glucose above 200 mg/dL (11.1 mmol/L) ls dlagnosLlc
of dlabeLes
d. 1he oral glucose Lolerance LesL ls performed ln borderllne paLlenLs
e. lmpalred glucose Lolerance ls a rlsk facLor for cardlovascular
compllcaLlons

9) A 40 year old man ls found Lo be dlabeLlc. Pe ls obese, smokes 10
clgareLLes a day, and Lakes a loL of faLLy foods ln hls dleL. Pe ls oLherwlse
healLhy
a. Pe should be sLarLed on drug LreaLmenL rlghL away
b. WelghL reducLlon wlll reduce hls rlsk of geLLlng a hearL aLLack
c. Pe should reduce Lhe faLs ln hls dleL
d. Pe should noL eaL frulLs
e. Pe should be referred Lo a dleLlclan

=)&<'+'#!('33)+4#!
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10) 1he followlng measures are effecLlve ln reduclng Lhe rlsk of compllcaLlons
ln a dlabeLlc paLlenL
a. A hlgh proLeln dleL
b. Low salL dleL
c. 8egular meals
d. ConLrol of blood pressure
e. Low dose asplrln

11) aLlenLs wlLh Lype l dlabeLes
a. Can be Lrled on oral hypoglycaemlcs flrsL
b. Should be sLarLed on lnsulln Lo prevenL keLosls
c. musL be advlsed Lo sLop lnsulln lf he sklps a meal
d. Should be LaughL Lo monlLor for keLoacldosls
e. Should be advlsed Lo drlnk plenLy of waLer

12) 8egardlng Lhe use of lnsulln ln Lype l dlabeLlcs
a. 1he dose should be sklpped lf Lhe paLlenL ls sklpplng a meal
b. lnsulln should be sLored ln Lhe freezer
c. aLlenLs who do noL have a refrlgeraLor could sLore lL suspended
lnslde a narrow mouLh clay poL wlLh a llLLle waLer aL Lhe boLLom
d. lnsulln can be comblned wlLh meLformln
e. Should be glven Lo Lhe same skln slLe every day

13) 8egardlng lnsulln ln[ecLlons
a. Soluble lnsulln should be admlnlsLered LogeLher wlLh Lhe meals
b. lnsulln should be sLored ln Lhe door of Lhe refrlgeraLor
c. Long acLlng lnsulln should never be glven lnLravenously
d. 1he needle should be lnserLed aL an angle of 43 degrees Lo Lhe skln
e. 1he needle can be used only once

14) ln Lhe LreaLmenL of Lype ll dlabeLes
a. WelghL reducLlon alone wlll be adequaLe ln a proporLlon of paLlenLs
b. lnsulln ls Lhe ldeal LreaLmenL
c. MeLformln ls recommended ln Lhln paLlenLs
d. Cllbenclamlde can cause welghL galn
e. logllLazone lmproves Lhe acLlon of lnsulln on Lhe Llssues

=)&<'+'#!('33)+4#!
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13) 8lguanldes have Lhe followlng advanLages over sulphonylureas
a. 1hey cause loss of welghL and are useful ln obese paLlenLs
b. 1hey can be used safely ln renal lmpalrmenL
c. Are less llkely Lo cause hypoglycaemla
d. 1hey have llpld lowerlng acLlvlLy
e. 1hey are less llkely Lo cause lacLlc acldosls

16) Sulphonylureas have Lhe followlng advanLages over blguanldes
a. 1hey can be used safely ln paLlenLs wlLh llver clrrhosls
b. Are less llkely Lo cause hypoglycaemla
c. 1hey are effecLlve ln paLlenLs wlLh Lype l dlabeLes
d. 1hey cause welghL loss
e. 1hey can be used ln pregnancy

17) 8egardlng newer oral hypoglycaemlc drugs
a. 1he gllLazones should be avolded ln hearL fallure
b. Acarbose enhances lnsulln acLlon ln Lhe Llssues
c. 8epagllnlde lncreases lnsulln secreLlon
d. CllLazones can be comblned wlLh sulphonylureas
e. CllLazones reduce blood Lrlglycerlde levels

18) 8egardlng dlabeLlc nephropaLhy
a. lL manlfesLs wlLhln 3 years of dlagnosls
b. ls commoner ln young dlabeLlcs
c. Mlcroalbumlnurla ls Lhe earllesL manlfesLaLlon
d. lL ls unllkely ln a paLlenL wlLh no dlabeLlc reLlnopaLhy
e. lL resulLs ln renal fallure

19) 8egardlng dlabeLlc nephropaLhy
a. 1he kldneys are usually small ln dlabeLlc nephropaLhy
a. ACL lnhlblLors prevenL Lhe progresslon of nephropaLhy
b. uleLary measures are useful ln prevenLlon
c. 1he blood pressure musL be conLrolled Lo 140/90mmPg
d. A rlslng plasma creaLlnlne ls Lhe flrsL slgn of dlabeLlc nephropaLhy

=)&<'+'#!('33)+4#!
134

20) 8egardlng screenlng for compllcaLlons ln a dlabeLlc paLlenL
a. A paLlenL wlLh Lype l dlabeLes musL be senL for reLlnopaLhy screenlng
aL Lhe Llme of flrsL dlagnosls
b. urlne for mlcroalbumlnurla ls useful for deLecLlng early nephropaLhy
c. 1he serum llplds should be measured
d. An exerclse LCC ls recommended ln all paLlenLs above Lhe age of 40
years
e. 8eLlnopaLhy screenlng should be performed annually ln Lype ll
dlabeLes

21) Lhe followlng are lndlcaLlons for urgenL (wlLhln one week) referral Lo an
ophLhalmologlsL fln a paLlenL wlLh dlabeLlc reLlnopaLhy
a. pre-prollferaLlve
b. reduced vlsual aculLy suggesLlve of macular oedema
c. hard exudaLes wlLhln one dlsc dlameLer of Lhe fovea
d. new vessel formaLlon
e. rubeosls lrldls

22) 1he followlng are useful ln prevenLlng dlabeLlc reLlnopaLhy
a. LlghL conLrol of blood glucose
b. conLrol of blood pressure Lo less Lhan 130/80
c. low salL dleL
d. vlLamlns
e. llpld lowerlng Lherapy

23) 1lghL glycaemlc conLrol
a. 8educes Lhe rlsk of developlng dlabeLlc nephropaLhy
b. 8educes Lhe rlsk of myocardlal lnfarcLlon
c. 8educes Lhe rlsk of perlpheral vascular dlsease
d. ls beneflclal ln paLlenLs soon afLer acuLe myocardlal lnfarcLlon
e. 8educes Lhe rlsk of lmpoLence

24) 8egardlng dlabeLlc keLoacldosls
a. ls commoner ln Lype ll dlabeLlcs
b. urlne keLones are always poslLlve
c. Lhe paLlenL ls usually very dehydraLed
d. urgenL referral Lo a hosplLal ls lndlcaLed
e. 1he paLlenL wlll requlre llfeLlme lnsulln ln fuLure

=)&<'+'#!('33)+4#!
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23) ulabeLlc neuropaLhles whlch have a good prognosls and may resolve
compleLely lnclude
a. auLonomlc neuropaLhy
b. ulabeLlc amyoLrophy
c. mononeurlLls lnvolvlng cranlal nerves
d. enLrapmenL neuropaLhles
e. mlxed sensory moLor neuropaLhy


=)&<'+'#!('33)+4#-./#0'*#!
136

J'%L0)!>+!6&(D0>0%!"0//&>.%!M.0%>&+'%!
!
1) 11l11
ulabeLes melllLus ls a global dlsease, affecLlng more Lhan 120 mllllon people
worldwlde. ln Lurope and norLh Amerlca Lhe lncldence ls relaLlvely hlgh. 1he
lncldence ln Afrlca ls generally lnLermedlaLe, and LhaL ln Asla ls low.
Worldwlde Lhe lncldence of dlabeLes ls rlslng, and Lhe raLe of rlse ls greaLesL ln
Asla, probably due Lo changlng llfesLyles. AlLhough dlabeLes can be
conLrolled, a cure ls noL posslble. Cood conLrol and opLlmal LreaLmenL of
oLher rlsk facLors prevenLs many compllcaLlons, buL even ln such paLlenLs llfe
expecLancy ls reduced.

2) 1111l
Low blrLhwelghL lncreases Lhe rlsk of developlng dlabeLes ln laLer llfe. 1hls has
led Lo conLroversy wlLh regard Lo Lhe LhrlfLy genoLype hypoLhesls. ln Lhls
'LhrlfLy phenoLype' hypoLhesls, Lhe rlsk of dlabeLes and oLher adulL
dlsorders ls programmed by feLal nuLrlLlon and Lhe paLLern of early
growLh. 1ype ll dlabeLes, Lhe predomlnanL form of dlabeLes, ls due Lo a
comblnaLlon of lnsulln reslsLance and relaLlve lnsulln lnsufflclency. 1he maln
rlsk facLors for Lype 2 dlabeLes are age, obeslLy, famlly hlsLory, physlcal
lnacLlvlLy and dleLary facLors such as a hlgh proporLlon of energy
consumed as saLuraLed faL and low lnLake of frulL and vegeLables.
1aklng sugar conLalnlng foods predlsposes Lo obeslLy, however a dlrecL llnk
beLween eaLlng sweeLs and Lhe developmenL of dlabeLes ls noL clear.

3) 11ll1
1ype l dlabeLes ls due Lo an absoluLe deflclency of lnsulln secreLlon. aLlenLs
are more ofLen Lhln, and are predlsposed Lo keLosls. 1ype ll dlabeLlcs have a
comblnaLlon of perlpheral lnsulln reslsLance and relaLlve lnsulln lack. Such
paLlenLs are ofLen obese, and are noL predlsposed Lo keLosls. 1ype l dlabeLes
usually occurs ln young paLlenLs, buL ls known Lo occur ln older paLlenLs as
well. Chronlc pancreaLlLls and oLher causes of dlabeLes whlch are secondary
Lo pancreaLlc damage are noL classlfled as Lype l or Lype ll. CesLaLlonal
dlabeLes, l.e., dlabeLes occurrlng durlng pregnancy alone ls also classlfled as a
separaLe group, someLlmes called Lype lv. Powever boLh Lype l and Lype ll
dlabeLes can manlfesL for Lhe flrsL Llme ln pregnancy.



=)&<'+'#!('33)+4#-./#0'*#!
137

4) 1l11l
1ype l dlabeLes ls due Lo auLolmmune desLrucLlon of pancreaLlc beLa cells. lL ls
occaslonally assoclaLed wlLh oLher auLolmmune dlsorders and
endocrlnopaLhles. CAu anLlbodles are Lhe mosL frequenLly ldenLlfled
anLlbodles ln Lype l dlabeLes. 1he lncldence ls hlghesL ln Lurope, lnLermedlaLe
ln Afrlca, and generally low ln Asla. 1he rlsk of developlng Lype l dlabeLes ls
greaLer lf Lhe faLher ls dlabeLlc. CeneLlc suscepLlblllLy ls lmporLanL buL ls noL
Lhe sole deLermlnanL Lowards Lhe developmenL of Lhe dlsease. 1he exacL
aeLlologlcal facLors are noL clearly known. aLlenLs are usually Lhln, and are
prone Lo keLosls lf Lhey fasL or mlss lnsulln. 1hey are LreaLed wlLh lnsulln.

3) 1111l
1ype ll dlabeLes ls an example of a dlsease wlLh polygenlc lnherlLance. lL runs
ln famllles, buL ls lnfluences by a varleLy of envlronmenLal and oLher facLors. lL
ls commoner among more affluenL people, probably due Lo hlgher
carbohydraLe conLenL ln Lhe dleL. aLlenLs are usually obese, alLhough Lhey
may markedly lose welghL when Lhey develop dlabeLes. AlLhough mosL
common over Lhe age of 30 years, lL can occur ln chlldren, Lhls ls known as
maLurlLy onseL dlabeLes ln Lhe young, or MCu?. lL ls prlmarlly due Lo lnsulln
reslsLance ln Lhe perlpheral Llssues wlLh relaLlve lnsulln deflclency. C pepLlde
usually remalns deLecLable ln blood, ln conLrasL wlLh Lype l dlabeLes ln whlch
C pepLlde dlsappears from Lhe blood. 1he presence of C pepLlde lndlcaLes
acLlve lnsulln producLlon.

6) 1111l
ulabeLes lncreases Lhe rlsk of skln lnfecLlons. 1he leg ls parLlcular affecLed,
due Lo a comblnaLlon of neuropaLhy (whlch predlsposes Lo ln[ury),
macrovascular changes leadlng Lo perlpheral vascular dlsease and
mlcrovascular dlsease, boLh of Lhese resulLlng ln poor clrculaLlon, and Lhe
presence of a hlgh glucose conLenL ln Lhe lnLersLlLlal space. ulcers of Lhe fooL
can be very hard Lo LreaL, and can lead Lo ampuLaLlon. Cangrene ls also a
common compllcaLlon. CellullLls of a llmb ls also a common presenLaLlon.
8alanlLls and vulvovaglnlLls are common presenLaLlons ln dlabeLlcs, and are
due Lo candldal lnfecLlon. 1here ls no lncrease ln Lhe lncldence of eczema ln
dlabeLlcs.

7) 11111
ulabeLlcs are more prone Lo fungal lnfecLlons. 8alanlLls and vulvovaglnlLls are
common presenLaLlons ln Lhe unconLrolled dlabeLlc. A blood sugar should be
=)&<'+'#!('33)+4#-./#0'*#!
138

checked ln all such paLlenLs, whlle keeplng ln mlnd LhaL sexually LransmlLLed
dlseases can be a cause. CellullLls of a llmb ls more llkely Lo develop ln a
dlabeLlc. lrequency of urlnaLlon ls a common presenLaLlon, lL ls lmporLanL Lo
flnd ouL wheLher Lhe quanLlLy of urlne ls hlgh, frequenL passage of small
amounLs of urlne can be due Lo urlnary LracL lnfecLlon (whlch ls also more
llkely ln a dlabeLlc). ln an elderly paLlenL Lhe posslblllLy of prosLaLlsm should
be consldered.

8) 11111
1he classlflcaLlon of dlabeLes accordlng Lo Lhe Amerlcan ulabeLlc AssoclaLlon
and Lhe WPC are as follows,
normal - lasLlng plasma glucose (lC) <110 mg/dL (6.1 mmol/L).
lmpalred fasLlng glucose (llC) - lasLlng plasma glucose beLween 110 and
123 mg/dL (6.1 Lo 6.9 mmol/L). 1hls ls broadly equlvalenL Lo Lhe caLegory
of lC1, whlch was based upon boLh fasLlng and Lwo-hour values ln Lhe
CC11.
ulabeLes melllLus - lC aL or above 126 mg/dL (7.0 mmol/L) or a random
(or Lwo-hour value ln an CC11) aL or above 200 mg/dL (11.1 mmol/L).
1he place of Lhe oral glucose Lolerance LesL ls conLroverslal, buL lL ls sLlll
performed ln paLlenLs wlLh borderllne values. lmpalred fasLlng glucose ls
assoclaLed wlLh lncreased cardlovascular rlsk, such paLlenLs should be on
llfesLyle modlflcaLlon, and monlLored closely for Lhe developmenL of dlabeLes.

9) l11l1
uleL conLrol and llfesLyle modlflcaLlon should be Lrled ouL flrsL ln Lhls obese
man who smokes and Lakes an unhealLhy dleL. WelghL reducLlon ls an
lmporLanL facLor whlch wlll reduce hls cardlovascular rlsk. 8educLlon of
carbohydraLes and faLs ln hls dleL wlll be beneflclal ln conLrolllng Lhe dlabeLes
and reduclng welghL. Pe does noL need Lo avold frulLs. 8eferral Lo a
dleLlclan ls ofLen useful ln helplng paLlenLs conLrol Lhelr dleL. MosL
lmporLanLly he musL sLop smoklng.

10) l1111
A hlgh proLeln dleL may lncrease Lhe rlsk of proLelnurla and renal damage, a
normal proLeln dleL ls usually recommended ln paLlenLs wlLhouL renal dlsease.
8educLlon of dleLary salL ls useful ln reduclng blood pressure and
cardlovascular rlsk. 8egular meals may prevenL flucLuaLlons ln blood glucose
levels, maklng Llmlng of medlcaLlon and compllance dlfflculL. 8lood pressure
conLrol ls one of Lhe mosL lmporLanL measures Lo reduce compllcaLlons and
=)&<'+'#!('33)+4#-./#0'*#!
139

cardlovascular rlsk, Lhe LargeL blood pressure ls 130/80mmPg or lower. Low
dose asplrln reduces cardlovascular rlsk ln mosL paLlenLs wlLh rlsk facLors.

11) l1l11
aLlenLs wlLh Lype l dlabeLlcs always need lnsulln, Lhe absoluLe lack of lnsulln
predlsposes Lhem Lo keLosls and llfe LhreaLenlng keLoacldosls. 1reaLmenL
wlLh lnsulln prevenLs keLosls. 1hey should never sLop lnsulln, even lf Lhey feel
nauseaLed or sklp a meal. aLlenLs should be educaLed abouL Lhe rlsks of
developlng keLoacldosls and Lhe lmporLance of recognlzlng warnlng slgns of
keLosls. 1hey should drlnk plenLy of waLer Lo prevenL dehydraLlon.

12) ll11l
1he dose of lnsulln should noL be sklpped even lf Lhe paLlenL sklps a meal. lf
Lhe paLlenL ls nauseaLed or has vomlLlng or abdomlnal paln, he should see a
docLor as Lhese may be slgns of keLoacldosls. lnsulln ls sLored ln Lhe door of
Lhe refrlgeraLor, l.e., abouL 4 degrees Celslus. lf sLored ln Lhe freezer lL loses
poLency and musL be dlscarded. An alLernaLlve meLhod of sLorage for paLlenLs
who do noL have a refrlgeraLor ls Lo suspend Lhe lnsulln vlal ln a narrow
mouLhed claw poL wlLh some waLer aL Lhe boLLom. 1he porous wall of Lhe poL
causes slow evaporaLlon of waLer and cools Lhe lnslde. 1he slLe of lnsulln
ln[ecLlon should be roLaLed wlLh each ln[ecLlon.

13) l11ll
Soluble lnsulln should be admlnlsLered approxlmaLely half an hour before Lhe
meal. lnsulln ls sLored ln Lhe door of Lhe refrlgeraLor, aL abouL 4 degrees
Celslus. lreezlng lnacLlvaLed lL, and lf sLored ln Lhe freezer lL musL be
dlscarded. Long acLlng lnsullns are a suspenslon and musL never be ln[ecLed
lnLravenously. 1he usually Lechnlque of ln[ecLlon ls Lo plnch up a fold of skln
and lnserL Lhe shorL lnsulln needle verLlcally. 1he needle should ldeally be
used only once, buL ln mosL lnsLances Lhls ls lmpracLlcal due Lo cosL lssues.
8euse of Lhe needle (for Lhe same paLlenL) a few Llmes ls noL assoclaLed wlLh
any lncrease ln skln lnfecLlon.

14) 1ll11
1ype ll dlabeLes ls due Lo lnsulln reslsLance and relaLlve lnsulln lack. lnsulln
levels are lnlLlally normal or hlgh. WelghL reducLlon alone ls adequaLe Lo
conLrol Lhe blood sugar ln a slzable proporLlon of people. lnsulln ls noL
requlred ln Lhe early sLages, alLhough as Lhe dlsease advances lL may be
requlred Lo achleve conLrol. WlLh Llme some degree of beLa cell exhausLlons
=)&<'+'#!('33)+4#-./#0'*#!
140

causes Lhe body's lnsulln secreLlon Lo fall, and aL Lhls sLage lnsulln ls requlred.
MeLformln causes welghL loss, and ls useful ln obese paLlenLs. lL ls noL ldeal ln
Lhln paLlenLs as Lhey may lose more welghL. Sulphonylureas cause welghL
galn and should be avolded ln obese paLlenLs. logllLazone enhances Lhe
acLlon of lnsulln on Lhe Llssues. lL can be used ln comblnaLlon wlLh lnsulln,
alLhough Lhere are concerns LhaL concurrenL use wlLh lnsulln may resulL ln or
worsen hearL fallure. 1hls ls probably due Lo Lhe fluld reLenLlon effecLs of Lhe
gllLazones. CllLazones may be comblned wlLh sulphonylureas or meLformln
safely.

13) 1l1ll
8lguanldes cause welghL loss, and are ldeal ln obese paLlenLs. Sulphonylureas
on Lhe oLher hand cause welghL galn, whlch ln Lurn can worsen lnsulln
reslsLance. LacLlc acldosls ls an lmporLanL slde effecL of blguanldes, and whlle
ln a normal paLlenL Lhe rlsk wlLh meLformln ls low, Lhe rlsk of lacLlc acldosls ls
much hlgher wlLh renal or hepaLlc lmpalrmenL. CllLazones and meLformln
have llpld lowerlng acLlvlLy. 8lguanldes are much less llkely Lo cause
hypoglycaemla Lhan sulphonylureas.

16) lllll
Sulphonylureas are excreLed by Lhe llver, and are besL avolded ln llver dlsease.
1hey are well known Lo cause hypoglycaemla, whlch can perslsL even for
several days afLer sLopplng LreaLmenL. Cral hypoglycaemlcs are noL lndlcaLed
ln Lype l dlabeLlcs, who should be LreaLed wlLh lnsulln. Sulphonylureas cause
welghL galn. Whlle Lhere are some reporLs LhaL sulphonylureas may besafe ln
pregnancy, pregnanL dlabeLlcs should be managed on lnsulln.

17) 1l11l
CllLazones cause fluld reLenLlon and should be avolded ln hearL fallure. 1he
effecL of causlng hearL fallure ls sald Lo be worse lf gllLazones are glven ln
comblnaLlon wlLh lnsulln or sulphonylureas, however plogllLazone ls llcensed
for use ln comblnaLlon wlLh sulphonylureas and lnsulln, and of course wlLh
meLformln. CllLazones reduce LuL levels and lncrease PuL levels. MeLformln
reduces blood Lrlglycerlde levels. .Acarbose acLs largely by llmlLlng
carbohydraLe absorpLlon from Lhe guL. 8epagllnlde enhances lnsulln
secreLlon.



=)&<'+'#!('33)+4#-./#0'*#!
141

18) l1111
ulabeLlc nephropaLhy ls Lhe mosL lmporLanL cause of renal fallure and deaLh
ln a young dlabeLlc paLlenL. lL usually occurs 10 - 13 years afLer Lhe
developmenL of dlabeLes. assage of small amounLs of albumln noL deLecLed
on Lhe rouLlne urlne full reporL or dlpsLlcks ls known as mlcroalbumlnurla, and
ls Lhe earllesL lndlcaLlon of Lhe developmenL dlabeLlc nephropaLhy. ulabeLlc
nephropaLhy ls almosL always assoclaLed wlLh reLlnopaLhy. A dlabeLlc paLlenL
wlLh evldence of nephropaLhy an apparenLly normal opLlc fundal examlnaLlon
should have a fluoresceln fundal anglogram Lo deLecL reLlnopaLhy. lf Lhls ls
normal, an alLernaLe cause for Lhe nephropaLhy musL be soughL.

19) l11l1
1he osmoLlc load on Lhe kldney ln a dlabeLlc resulLs ln glomerular hyperLrophy
and enlarged kldneys. When renal fallure develops Lhe kldneys shrlnk,
Lherefore normal slze kldneys ln a dlabeLlc paLlenL are compaLlble wlLh
chronlc renal fallure. ACL lnhlblLors reduce proLelnurla and reLard Lhe
progresslon of nephropaLhy by mechanlsms lndependenL of slmple blood
pressure lowerlng. 8educLlon of proLelns and salL ln Lhe dleL ls useful ln
prevenLlng nephropaLhy. 1he LargeL blood pressure ls 130/80mmPg ln a
dlabeLlc wlLh nephropaLhy.

20) l11l1
aLlenLs wlLh Lype l dlabeLes do noL have reLlnopaLhy aL Lhe Llme of dlagnosls
- lL usually develops afLer 10-13 years. aLlenLs wlLh Lype ll dlabeLes can have
reLlnopaLhy aL flrsL presenLaLlon, and screenlng ls recommended. 1hey also
need Lo have repeaL screenlng every year. urlne for mlcroalbumlnurla ls Lhe
mosL useful LesL for early deLecLlon of nephropaLhy and should be performed
ln all Lype ll dlabeLlcs. Llpld abnormallLles are common ln dlabeLlcs, especlally
elevaLed Lrlglycerldes. An exerclse LCC ls noL lndlcaLed unless Lhe paLlenL ls
sympLomaLlc.

21) lll11
1he lndlcaLlons for referral Lo an ophLhalmologlsL for posslble laser LreaLmenL
are as follows,
urgenL (wlLhln 1 week) : neovascularlzaLlon (new vessel formaLlon) aL Lhe
dlsk or elsewhere rubeosls lrldls, vlLreous haemorrhage, reLlnal
deLachmenL
=)&<'+'#!('33)+4#-./#0'*#!
142

Larly (2-4 weeks): pre-prollferaLlve reLlnopaLhy, reduced vlsual aculLy
suggesLlve of macular oedema, haemorrhages and/or hard exudaLes
wlLhln one dlsc dlameLer of Lhe fovea.

22) 111ll
1he rlsk facLors for dlabeLlc reLlnopaLhy are many. 1he duraLlon of dlabeLes ls
Lhe mosL lmporLanL - lL usually occurs 10-13 years afLer Lhe onseL of dlabeLes.
1lghL glycaemlc conLrol reduces Lhe rlsk of reLlnopaLhy, alLhough lL can
cause LranslenL worsenlng. A small group of dlabeLlc paLlenLs develop
neovascularlzaLlon durlng pregnancy Powever women who develop
gesLaLlonal dlabeLes are noL aL rlsk of reLlnopaLhy. PyperLenslon ls
assoclaLed wlLh worsenlng of reLlnopaLhy and, parLlcularly, developmenL of
new vessels. ConLrol of hlgh blood pressure proLecLs agalnsL progresslon of
reLlnopaLhy. Pyperllpldaemla ls a rlsk facLor for severe exudaLlve
maculopaLhy. aLlenLs wlLh end sLage renal dlsease ofLen develop worsenlng
of boLh maculopaLhy and prollferaLlve reLlnopaLhy. CaLaracL surgery can
predlspose Lo maculopaLhy. Cn Lhe oLher hand afLer caLaracL surgery Lhe
fundus ls easler Lo vlsuallze, and screenlng becomes easler.

23) 11l11
1lghL glycaemlc conLrol reduces Lhe rlsk of mlcrovascular compllcaLlon such as
nephropaLhy, reLlnopaLhy and neuropaLhy. lmpoLence ls caused by
neuropaLhy and occaslonally macrovascular dlsease. 1he effecLs on
macrovascular dlsease are less promlnenL. Cverall Lhe rlsk of myocardlal
lnfarcLlon ls probably reduced, buL probably noL perlpheral vascular dlsease.
AfLer an Ml, LlghL glycaemlc conLrol has been shown Lo reduce morLallLy.

24) ll111
ulabeLlc keLoacldosls ls common ln Lype l dlabeLlcs, and ls due Lo absoluLe
lnsulln lack. urlne keLones are noL always poslLlve, buL blood keLones usually
are poslLlve. 1he masslve dluresls resulLs ln severe dehydraLlon. 1he paLlenL
musL be managed ln hosplLal, and has Lo be kepL on lnsulln llfelong Lo prevenL
keLosls.

23) l111l
AuLonomlc neuropaLhy and perlpheral neuropaLhy rarely resolve compleLely.
ulabeLlc amyoLrophy has a relaLlvely good conLrol and may resolve wlLh good
dlabeLlc conLrol. MosL paLlenLs wlLh mononeurlLls recover. LnLrapmenL
neuropaLhles are poLenLlally LreaLable lf Lhe enLrapmenL ls released.