Key points
- These are single-best-answer clinical vignettes in the style used by licensing and final exams worldwide. Read the stem, choose one answer, then reveal the explanation.
- Each explanation says why the answer is right and why the common distractors are wrong, because that is where the learning is.
- Topics: acute coronary syndromes, heart failure, arrhythmias, valve disease, hypertension, pericardial disease, infective endocarditis and rheumatic fever.
- Doses and thresholds follow widely used international guidelines. Local protocols differ, so check yours before treating a patient.
How to use this bank
- Cover the options and think of the diagnosis from the stem alone.
- Pick an answer, then reveal it. Write down every question you got wrong.
- Come back to the missed ones after two days. Aim for 80% or more before moving on.
Questions
1. A 58-year-old man has 40 minutes of crushing central chest pain with sweating. The ECG shows 3 mm ST elevation in leads II, III and aVF. Which artery is most likely occluded?
A. Left anterior descending artery
B. Left circumflex artery
C. Right coronary artery
D. Left main stem
E. Posterior descending artery only
Answer: C. ST elevation in II, III and aVF is an inferior infarct, which is usually supplied by the right coronary artery. Left anterior descending occlusion causes anterior changes (V1 to V4). Circumflex occlusion gives lateral changes (I, aVL, V5, V6). Check right-sided leads (V4R) because inferior infarcts often involve the right ventricle.
2. In the patient from question 1, blood pressure is 80/50 mmHg with clear lungs and raised jugular venous pressure. Which treatment should be given with caution?
A. Intravenous fluids
B. Aspirin
C. Nitrates
D. Primary percutaneous coronary intervention
E. Oxygen only if saturation is low
Answer: C. This picture suggests right ventricular infarction. These patients depend on preload, so nitrates and diuretics can cause profound hypotension. They are treated with fluids and early reperfusion. Aspirin and reperfusion are still indicated.
3. A 66-year-old woman with a previous myocardial infarction has breathlessness on exertion, ankle swelling and an ejection fraction of 30%. She is already taking furosemide. Which drug class improves her survival?
A. Loop diuretics
B. Digoxin
C. Beta-blockers licensed for heart failure
D. Calcium channel blockers
E. Nitrates alone
Answer: C. Evidence-based beta-blockers (bisoprolol, carvedilol, metoprolol succinate) reduce mortality in heart failure with reduced ejection fraction, as do ACE inhibitors or ARBs, mineralocorticoid receptor antagonists and SGLT2 inhibitors. Loop diuretics relieve symptoms but do not improve survival. Digoxin reduces admissions without improving survival. Non-dihydropyridine calcium channel blockers can worsen reduced ejection fraction.
4. A 72-year-old man has an irregularly irregular pulse of 130 per minute, no P waves on ECG and a blood pressure of 120/80 mmHg. He is otherwise well. He also has hypertension and diabetes. What is the most important long-term measure?
A. Digoxin for life
B. Anticoagulation based on stroke risk
C. Aspirin alone
D. Amiodarone for life
E. Reassurance
Answer: B. This is atrial fibrillation. The main danger is cardioembolic stroke, so long-term oral anticoagulation is chosen using a score such as CHA2DS2-VASc. His age, hypertension and diabetes already give a score that supports anticoagulation. Aspirin alone is not recommended for stroke prevention in atrial fibrillation. Rate or rhythm control treats symptoms and does not remove the stroke risk.
5. A 25-year-old woman has palpitations. The ECG shows a regular narrow-complex tachycardia at 180 per minute. She is haemodynamically stable. Vagal manoeuvres fail. What is the next step?
A. Intravenous adenosine
B. Intravenous amiodarone
C. Synchronised cardioversion
D. Intravenous verapamil with a beta-blocker
E. Oral digoxin
Answer: A. Regular narrow-complex tachycardia that does not respond to vagal manoeuvres is treated with a rapid intravenous adenosine bolus. Warn the patient of a brief feeling of doom and chest tightness. Synchronised cardioversion is for an unstable patient. Verapamil with a beta-blocker risks profound bradycardia and heart block.
6. A 60-year-old man collapses and the monitor shows ventricular fibrillation. What is the immediate treatment?
A. Intravenous amiodarone
B. Synchronised cardioversion
C. Unsynchronised defibrillation
D. Intravenous adrenaline
E. Atropine
Answer: C. Ventricular fibrillation and pulseless ventricular tachycardia are shockable rhythms and need immediate unsynchronised defibrillation along with high-quality chest compressions. Adrenaline and amiodarone come after the third shock in standard algorithms. Atropine has no role. Synchronised shocks are for tachycardias with a pulse.
7. A 70-year-old woman has syncope on exertion, angina and breathlessness. There is a slow-rising pulse and an ejection systolic murmur radiating to the carotids. What is the diagnosis?
A. Mitral regurgitation
B. Aortic stenosis
C. Hypertrophic cardiomyopathy
D. Mitral stenosis
E. Aortic regurgitation
Answer: B. Angina, syncope and heart failure are the classic triad of symptomatic aortic stenosis, with a slow-rising pulse, narrow pulse pressure and a murmur radiating to the carotids. Once symptoms appear the prognosis is poor without valve replacement. Hypertrophic cardiomyopathy murmurs get louder with Valsalva and are less likely to radiate to the carotids.
8. A 30-year-old woman who had rheumatic fever as a child has a mid-diastolic rumbling murmur at the apex with an opening snap. What is the most likely complication of her valve lesion?
A. Left ventricular hypertrophy
B. Atrial fibrillation with left atrial thrombus
C. Aortic dissection
D. Pulmonary hypertension never occurs
E. Complete heart block
Answer: B. This is mitral stenosis. The left atrium enlarges and fibrillates, and stasis leads to thrombus and systemic emboli, so these patients need anticoagulation (warfarin in rheumatic mitral stenosis with atrial fibrillation). Pulmonary hypertension is common, not absent. The left ventricle is typically protected from overload in pure mitral stenosis.
9. A 45-year-old man who injects drugs has a fever for two weeks, a new pansystolic murmur and splinter haemorrhages. Which investigation is the most important before starting antibiotics?
A. Chest X-ray
B. At least three sets of blood cultures from separate sites
C. Echocardiography only
D. Erythrocyte sedimentation rate
E. Urine culture
Answer: B. Suspected infective endocarditis needs multiple blood cultures before antibiotics, because bacteraemia is continuous and identifying the organism guides therapy. Echocardiography follows and is used with the modified Duke criteria. Right-sided endocarditis in people who inject drugs is commonly caused by Staphylococcus aureus and involves the tricuspid valve.
10. A 22-year-old has pleuritic chest pain that eases when leaning forward, a friction rub and widespread concave ST elevation with PR depression. What is the first-line treatment?
A. Thrombolysis
B. High-dose NSAID with colchicine
C. Intravenous heparin
D. Pericardiocentesis
E. Beta-blocker
Answer: B. This is acute pericarditis. First-line treatment is an NSAID (for example ibuprofen or aspirin) plus colchicine, which reduces recurrence. Thrombolysis and heparin are inappropriate because this is not coronary occlusion. Pericardiocentesis is for tamponade.
11. A 55-year-old man has a blood pressure of 165/100 mmHg on three separate visits. He is of African descent and has no other disease. Which first-line drug is most appropriate according to many guidelines?
A. Beta-blocker
B. ACE inhibitor alone
C. Calcium channel blocker or thiazide-like diuretic
D. Alpha-blocker
E. Loop diuretic
Answer: C. In people of African descent without diabetes or heart failure, a calcium channel blocker or a thiazide-like diuretic is usually more effective first line than an ACE inhibitor or ARB. Beta-blockers are no longer first line for uncomplicated hypertension. Combination therapy is common when blood pressure is well above target.
12. Which finding on the ECG points to hyperkalaemia?
A. Prominent U waves
B. Peaked tall T waves
C. Delta wave
D. Epsilon wave
E. ST elevation in all leads
Answer: B. Hyperkalaemia causes tall peaked T waves, then a flattened P wave, a widened QRS and finally a sine-wave pattern. Prominent U waves suggest hypokalaemia. A delta wave suggests pre-excitation (Wolff-Parkinson-White). Emergency treatment starts with intravenous calcium to protect the myocardium.
13. A 40-year-old man has sudden tearing chest pain radiating to the back. The blood pressure differs by 30 mmHg between the arms. Which is the best next investigation in a stable patient?
A. Exercise ECG
B. CT angiography of the aorta
C. D-dimer alone
D. Lung ventilation-perfusion scan
E. Troponin alone
Answer: B. This is suspected aortic dissection, and CT angiography confirms it. Control heart rate and blood pressure first with intravenous beta-blockade. Exercise testing is dangerous. Do not give anticoagulants or thrombolytics. Type A dissections need emergency surgery.
14. A 35-year-old man has a heart rate of 40 per minute, dizziness and a PR interval that lengthens until a beat is dropped, then repeats. What is this rhythm?
A. First-degree heart block
B. Mobitz type I (Wenckebach)
C. Mobitz type II
D. Third-degree heart block
E. Sinus arrhythmia
Answer: B. Progressive PR lengthening followed by a dropped beat is Mobitz type I (Wenckebach). It is often benign and sits at the AV node. Mobitz II has a fixed PR interval with sudden dropped beats and can progress to complete block, so it often needs a pacemaker. In third-degree block, atria and ventricles beat independently.
15. A 68-year-old man with heart failure takes an ACE inhibitor, bisoprolol and furosemide. He now has a potassium of 6.2 mmol/L and a rising creatinine. Which combination likely contributed?
A. Furosemide and bisoprolol
B. ACE inhibitor with a potassium-sparing diuretic or potassium supplement
C. Bisoprolol alone
D. Furosemide alone
E. Aspirin alone
Answer: B. ACE inhibitors reduce aldosterone and raise potassium. Adding spironolactone, a potassium supplement or an NSAID, or having renal impairment, can lead to dangerous hyperkalaemia. Loop diuretics tend to lower potassium. Check urea, electrolytes and creatinine one to two weeks after starting or changing these drugs.
References
- European Society of Cardiology guidelines on acute coronary syndromes, heart failure, atrial fibrillation and valvular heart disease.
- American Heart Association and American College of Cardiology guidelines on hypertension, heart failure and cardiac arrest.
- Kumar and Clark's Clinical Medicine. Elsevier.
- Davidson's Principles and Practice of Medicine. Elsevier.