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passmed mrcp, plab, usmle step 2 practice questions
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Question 1 of 171A 65-year-old man with a history of paroxysmal atrial fibrillation presents with palpitations. He has no
other history of note and a recent echocardiogram was normal. An ECG confirms fast atrial fibrillation.
Which one of the following agents is most likely to cardiovert him into sinus rhythm?
A. Sotalol
B. Procainamide
C. Flecainide
D. Disopyramide
E. Digoxin
Atrial fibrillation - cardioversion: amiodarone + flecainide
Atrial fibrillation: pharmacological cardioversion
The Royal College of Physicians and NICE published guidelines on the management of
atrial fibrillation (AF) in 2006. The following is also based on the joint American Heart
Association (AHA), American College of Cardiology (ACC) and European Society of
Cardiology (ESC) 2002 guidelines
Agents with proven efficacy in the pharmacological cardioversion of atrial fibrillation
ξ Amiodarone
ξ Flecainide (if no structural heart disease)
ξ Others (less commonly used in UK): quinidine, dofetilide, ibutilide, propafenone
Less effective agents
ξ Beta-blockers (including sotalol)
ξ Calcium channel blocks
ξ Digoxin
ξ Disopyramide
ξ Procainamide
1
, Question 2 of 171
A 17-year-old girl is brought into resus in cardiac arrest. On admission she is in asystole and attempts to
resuscitate are unsuccessful. She collapsed whilst competing in a 1,500m race at college. The only past
medical of note was asthma for which she occasionally used a salbutamol inhaler. There is no relevant
family history. What is the most likely underlying cause of death?
A. Long QT syndrome
B. Hypertrophie obstructive cardiomyopathy
C. Catecholaminergic polymorphic ventricular tachycardia
D. Brugada syndrome
E. Arrhythmogenic right ventricular dysplasia
Hypertrophie obstructive cardiomyopathy (HOCM) is a more common cause of
sudden cardiac death than arrhythmogenic right ventricular dysplasia (ARVD)
HOCM: features
Hypertrophie obstructive cardiomyopathy (HOCM) is an autosomal dominant disorder of
muscle tissue caused by defects in the genes encoding contractile proteins
Features
ξ dyspnoea, angina, syncope
ξ sudden death ost commonly due to ventricular arrhythmias), arrhythmias, heart failure
ξ jerky pulse, large 'a' waves, double apex beat
ξ ejection systolic murmur: increases with Valsalva manoeuvre and decreases on squatting
Associations
ξ Friedreich's ataxia
ξ WPW
Echo
ξ systolic anterior motion (SAM) of the anterior mitral valve leaflet
ξ asymmetric hypertrophy (ASH)
ξ mitral regurgitation
, 2
ECG
ξ LVH
ξ progressive T wave inversion
ξ deep Q waves
ξ AF
Question 3 of 171
A 62-year-old female with a known history of a sigmoid adenocarcinoma is admitted to hospital with
shortness of breath and pyrexia. On examination a murmur is heard and an echo reveals vegetations on the
aortic valve. Which one of the following organisms is most characteristically associated with causing infective
endocarditis in patients with colorectal cancer?
A. Escherichia colli
B. Enterococcus faecalis
C. Salmonella
D. Campylobacter
E. Streptococcus bovis
Streptococcus bovis endocarditis is associated with colorectal cancer
Infective endocarditis
Patients affected by endocarditis
ξ previously normal valves (50%, typically acute presentation)
ξ rheumatic valve disease (30%)
ξ prosthetic valves
ξ congenital heart defects
ξ intravenous drug users (IVDUs, e.g. typically causing tricuspid lesion)
, Causes
3
ξ Streptococcus viridans ost common cause - 40-50%)
ξ Staphylococcus epidermidis (especially prosthetic valves)
ξ Staphylococcus aureus (especially acute presentation, IVDUs)
ξ Streptococcus bovis is associated with colorectal cancer
ξ non-infective: systemic lupus erythematosus (Libman-Sacks), malignancy: marantic
endocarditis
Culture negative causes
ξ prior antibiotic therapy
ξ Coxiella burnetii
ξ Bartonella
ξ Brucella
HACEK: Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella)
ξ Following prosthetic valve surgery Staphylococcus epidermidis is the most common organism
in the first 2 months and is usually the result of perioperative contamination.
ξ After 2 months the spectrum of organisms which cause endocarditis return to normal, except
with a slight increase in Staph aureus infections
Question 4 of 171
A 26-year-old female is admitted to hospital with palpitations. ECG shows a shortened PR interval and
wide QRS complexes associated with a slurred upstroke seen in lead II. W hat is the definitive management
of this condition?
A. Accessory pathway ablation
B. Lifelong aspirin
C. AV node ablation
D. Lifelong amiodarone
E. Permanent pacemaker
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