Cardiology

1. Regarding the electrical activity of the heartA. Under normal conditions, the SA node is the dominant pacemakerB. Vagal stimulation is negatively chronotropicC. Na+ is not required for cardiac action potential generationD. The AV node lies in the junction of the right atrium and the SVCE. The absolute refractory period follows the relative refractory period

2. SA nodeA. The intrinsic discharge rate of the SA node is lower than the AV nodeB. Senile amyloidosis may cause sinus node dysfunctionC. May be supplied by the right coronary arteryD. SA node dysfunction causes sick sinus syndromeE. Sinus tachycardia is when the HR is >100

3. Heart soundsA. S2 refers to the closure of the aortic and the tricuspid valvesB. Splitting of the second heart sound may be physiologicalC. Splitting of the first heart sound may be physiologicalD. S3 is usually due to rapid ventricular filling in patients under 40E. S4 is associated with effective ventricular contraction

4. Heart murmursA. Can be graded from 0 to 5B. A grade 4 murmur can be felt as a thrillC. Vasalva murmur decreases the intensity of all murmursD. Pansystolic murmurs are seen in VSDE. Middiastolic murmurs are typical of mitral stenosis

5. The following are causes of atrial fibrillationA. Community acquired PneumoniaB. Hospital acquired pneumoniaC. HyperthyroidismD. Atrial myxomaE. Smoking

6. ArrythmiasA. Atrial flutter is seen as ‘regular sawtooth like’ activity on ECGB. Atrial fibrillation are uncommon following open heart surgeryC. Wollf – Parkinson – White syndrome rarely causes arrhythmiasD. Mobitz type I is associated with progressive prolongation of the PR intervalE. First degree heart block may be 2:1 or 3:1

7. Causes of displaced apex beat areA. DextrocardiaB. SplenomegalyC. Right ventricular hypertrophy

D. Left ventricular hypertrophyE. Fibrosis of left upper lung lobe

8. Kussmaul sign is seen inA. Cardiac tamponadeB. Diabetic ketoacidosisC. Constrictive pericarditisD. Right ventricular myocardial infarctionE. Restrictive cardiomyopathy

9. AtherosclerosisA. Usually develops over a period of monthsB. Homocysteine is protective against plaque formationC. Diabetes mellitus promotes plaque formationD. May present as intermittent claudicationE. Statins do not help in increasing the HDL level

10. Ischemic Heart DiseaseA. Atherosclerotic plaques in the heart are commonly seen in the ant. descending coronary art.B. Percutaneous coronary intervention (PCI) is indicated in 3 vessel diseaseC. ST elevation is indicative of myocardial infarctionD. All patients with IHD have stenotic lesions in their coronary arteriesE. CABG has a higher risk of recurrence as compared to PCI

11. The following are true regarding cardiac tamponadeA. Caused by neoplastic diseaseB. Presence of pulsus paradoxusC. ECG shows large QRS complexesD. There will be a drop in JVPE. A positive Kussmaul’s sign is sometimes present

12. CardiomyopathiesA. May be caused by systemic hypertensionB. Refers to primary disease of the myocardiumC. Clinically classified as dilated, obstructive and constrictiveD. Duchenne progressive muscular dystrophy (DMD) may cause dilated cardiomyopathyE. A systolic murmur may be heard in hypertrophic cardiomyopathy

13. The following are risk factors for acute MIA. Ethnic originB. BMI >30C. Active lifestyleD. Family history of premature CHDE. Low serum HDL

14. Cardiac markersA. Troponin C is used as a cardiac marker for AMIB. Myoglobin may be used as a cardiac marker of AMI

C. LDH is highly specific for myocardial infarctionD. CKMB levels persist in blood longer than the cardiac troponinE. A single measurement of raised troponin is insufficient to diagnose AMI

15. The following are complications of thrombolytic therapyA. Allergic reactionsB. HypotensionC. Deep Vein ThrombosisD. Bone fracturesE. Bleeding

16. The following are clinical manifestations of heart failureA. HepatomegalyB. CachexiaC. Cheyne – Stokes respirationD. Hepatojugular refluxE. Tachycardia

ANSWERS

1. Regarding the electrical activity of the heartA) T – In normal heart only one region demonstrates spontaneous electrical electrical activity (as pacemaker) (Human physiology Fox ,page 400)B) T – vagal activation release Ach on SA node decrease pacemaker rate. ( Essential human physiology, Amar Chartterjee.page 102)C) F – Entry of Na+ predominates and produces a depolarization of pacemaker. ( Human physiology Fox, page 400)D)F – AV node located at inferior portion of the interatrial septum. SA node is the one located in the right atrium, near the opening of SVC. ( Human physiology Fox, page 402)E) F – First is absolute refractory period, then relative refractory period. ( Human physiology Fox, page 402)

2. SA nodeA. false: The SA node, AV node and the remaining specialized conduction tissue of the heart

but the SA node is the normal cardiac pacemaker as it is intrinsically faster discharged ratePS: Clinical Anesthesia By Paul G. Barash, Bruce F. Cullen, Robert K. Stoelting, Michael Cahalan, P218http://books.google.com.my/books

B. True: senile amyloidosis is an infiltrative disorder usually around 9th decade of life where the deposition of amyloid protein in atrial myocardium can result in SA node dysfunctionp/s: Harrison's Cardiovascular Medicine By Eugene Braunwald, Joseph Loscalzo, p134-135 http://books.google.com.my/books

C. True: SA nodes receive blood supply from sa nodal artery (branch of right coronary artery) in 59% of patient, 38% patient received blood supply from left circumflex artery, and 3% patient from both arteryp/s :Hurst's the heart, Book 1 P894http://books.google.com.my/books?id

D. True: sick sinus syndrome is result from fibrous tissue displacement in the SA node p/s: Harrison's Cardiovascular Medicine By Eugene Braunwald, Joseph Loscalzo, p134-135 http://books.google.com.my/books?

E. True: sinus rate acccelaration >100 is known as sinus tachycardiaKumar and clark, p716

3. Heart soundsA. False: S2 is closing of aortic and pulmonary valve, or semilunar valve. B. True: S2 splitting associated with inspiration is physiological. (in inspiration, the blood is more in

R atrium but less in L atrium, t/fore, closer of P2 is delayed)C. False: S1 is usually indicates abnormalities-RBBB, ebstein’s anomalyD. True: S3 may normal in youngsters due to ventricular fillingE. False: S4 may heard in elderly due to rigid ventricle(hypertrophy).

4. Heart murmursA. F – Grade 1 to 6 (Talley & Connor, 2nd Edition, pg.55)B. T – Grading of Murmur: (Talley & Connor, 2nd Edition, pg.55, Medical Secrets by Zollo, pg 64)

1: very soft and barely audible intensity (only cardiologist can hear it)2: soft and low intensity murmur (heard by experienced one)

3: moderate murmur but no thrill (everyone can hear it) 4: loud murmur with palpable thrill5: loud murmur (still require stethoscope to hear it)6: loudest murmur (heard without even placing the stethoscope)

C. F – Valsalva maneuvers mean forceful expiration against closed glottis. Ask the patient to hold his nose, close the mouth and breath out hard and hold as long as possible. It will decrease preload thus reducing the intensity of murmur in case of aortic stenosis, mitral regurgitation and systolic murmur of hypertrophic cardiomyopathy (Talley & Connor, 2nd Edition, pg.55-56)

D. T – Other causes of pansystolic murmur: mitral regurgitation, tricuspid regurgitation, VSD, aortopulmonary shunt. (Talley & Connor, 2nd Edition, pg.53)E. T – Mid-diastolic murmur: low pitch, due to impaired ventricular filling mitral stenosis,

tricuspid stenosis, atrial myxoma (rare)

5. The following are causes of atrial fibrillationA. T – dalam infection, selalunye akan ade increase in catecholamine. Catecholamine ni terdiri daripada adrenaline and noradrenaline. 2 ekor makhluk ni akan exert sympathetic effect so dekat heart, mereka ni akan menyebabkan increase in the force of contractionof the heart increasing heart rate, blood pressure, and blood sugar. Tapi bile dah byk sgt 2 ekor ni, they can cause overcharging of the cardiovascular system, which can precipitate arrthymia. Sumber: http://www.zimbio.com/Catecholamine/articles/2/Beta+BlockersB. T – sama seperti di atas.C. T - Thyroid hormones upregulate sarcoplasmic Calcium ATPase, myosin heavy chain alfa, voltage gated K+ channels, Na+ channels and beta1 adrenergic receptors. These effects result in increased heart rate, systolic hypertension, increased ventricular contractility and cardiac hypertrophy. Changes in electrophysiological characteristics of atria result in dysrhythmias, especially atrial fibrillation, in patients with hyperthyroidism. Sumber: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1431605/D. F – atrial myxoma is the commonest heart tumor walaupun heart tumor ni secara umumnya sangatlah rare. The most common heart tumor yg boleh present with AF is rhabdomyoma and fibroma. Ini kerana mereka ini akan men’damage’kan myocardium or conduction system. Sumber: http://resources.metapress.com/pdf-preview.axd?code=ekxjgn975qpmexrd&size=largest E. T – merokok boleh meningkatkan kandungan catecholamine di dalam darah. Maka, ape yg akan berlaku sama seperti di jawapan A tadi. http://www.nejm.org/doi/full/10.1056/NEJM197609092951101

6. ArrythmiasA. True - ECG shows regular sawtooth-like atrial flutter waves(F waves) between QRS complexes <--K&C pg. 725B. False - Atrial fibrillation occurs in one-third of patients

after coronary bypass surgery and in more than half of thoseundergoing valvular surgery <---K&C pg 724C. T – http://emedicine.medscape.com/article/159222-overviewD. True -Mobitz I block (Wenckebach block phenomenon) is

progressive PR interval prolongation until a P wave fails to conduct. The PR interval before the blocked P wave is much longer than the PR interval after the blocked P wave <-- K&C pg 721

E. False - 2nd degree <--K&C 721

7. Causes of displaced apex beat areA. T : dextrocardia is congenital defect in which position of heart adalah mirror image of its normal

position. Oleh it, secara automatic apex beat dia adalah displacedB. F: spenomegaly menghala kepada inferiomedially ke arah right iliac fossa. Oleh itu, apex beat

xkan displaced.C. T: hypertrophy boleh menyebabkan displaced mengikut buku oxford text book of medicine 4th

edition page 852 ataupun 2852. Xsure page yg exact coz ade copy online. Kat online die tulis P.2.852. Another source http://www.mediscuss.org/examination-cardiac-apex-beat-44.html

D. T : sama seperti alasan di atas http://www.mediscuss.org/examination-cardiac-apex-beat-44.html

E. T: fibrosis of left upper lung lobe akan menyebabkan mediastinal shift. Kalau ikut muka surat yg sama., maka jawapannya adalah true.

8. Kussmaul sign is seen ina. T b. F c. Td. Te. T

Kussmaul's sign is the observation of a rise in JVP on inspiration. Do not confuse with Kussmaul breathing, ie a deep and labored breathing pattern often associated with severe metabolic acidosis, particularly DKA but also renal failure.

The classical differential diagnosis are constrictive pericarditis, restrictive cardiomyopathy, cardiac tamponade. (Ref: http://www.gpnotebook.co.uk/simplepage.cfm?ID=1369047062 )Cardiac conditions that may be associated with a positive Kussmaul's sign include right atrial myxoma, tricuspid stenosis, constrictive pericarditis, pericardial effusion, restrictive myocardopathy, and severe pulmonary hypertension. Overall, the commonest cause is severe right-sided congestive heart failure. (Ref: http://www.etsu.edu/com/medicalmystery/KussmaulsSign.aspx)

9. AtherosclerosisA. Usually develops over a period of months

Ans = FalseReference = Harrison vol II page 1501ATH occurs over a period of many years.

B. Homocysteine is protective against plaque formationAns = FalseReference = Harrisons vol II page 1508 & http://www.medicinenet.com/homocysteine/article.htmHomocysteine is a naturally occurring amino acid found in blood plasma produced by the body, usu as a byproduct of consuming meat.Increased homocysteine – lead to increased risk of ATH cause narrowing & hardening of the arteries.So, homocysteine is actually hazardous than protective

C. Diabetes mellitus promotes plaque formationAns = TrueReference = mama robin page 345 & John’s book of DM (http://books.google.com.my/books?id=ohgjG0qAvfgC&pg=PA870&lpg=PA870&dq=How+diabetes+mellitus+promote+plaque+formation&source=bl&ots=yIzn5AJ9Is&sig=VCD9rrPVL_ATe8GyZ5y5Zr0WVJ8&hl=en&ei=RUO-TaC6M8virAfNm-DtBQ&sa=X&oi=book_result&ct=result&resnum=6&ved=0CDMQ6AEwBQ#v=onepage&q&f=false) IN DM – thereis hyperglycemia & insulin resistance – lead to increased expression of (E-selectin, vascular-cell adhesion molecule-1 VCAM-1, intracellular adhesion molecule-1 ICAM-1) by endothelial cells….--- so, promote leucocyte infiltration into arterial wall (endothelial)…----then, leucocyte infiltrate into subendothelial by stimulation of monocyte chemoattractant protein-1 (MCP-1)-----infiltrated monocyte differentiate into macrophages----!!!these are the proatherogenic effect by accumulating lipids & releasing proinflammatory cytokines and matrix metalloproteinase which likely promotes plaque formation & expansion.

D. May present as intermittent claudicationAns = TrueReference= Harrison vol II page1501ATH occur in peripheral circulation can cause intermittent caludication

E. Statins do not help in increasing the HDL levelAns = FalseReference = Harrisons vol II page 2427Statin= HMG-CoA reductase inhibitorsStatin inhibit the HMG-CoA reductase – then inhibit the synthesis of cholesterol. At the same time, d/t decrease synthesis of cholesterol in the cell, in menyebabkan hepatic LDL receptor activity on the cell increasing & there is accelerated clearance of circulating LDL in the blood so that, cholesterol will be transferred in the cell.Meaning – main role of statin is LDL lowering agent, but can also reduce TG & have modest HDL raising effect.

10. Ischemic Heart DiseaseA. Atherosclerotic plaques in the heart are commonly seen in the ant. descending coronary art.

Ans = TrueReference = Harrisons vol II page 1515Common seen in the ant descending artery (L)

B. Percutaneous coronary intervention (PCI) is indicated in 3 vessel diseaseAns = FalseReference = harrisons vol II (page 1525 & 1526 –choice b/w PCI & CABG)PCI –ptnts w single @ 2 vessel dis w normal LV fx & anatomically suitable lesionsCABG – 3 vessel dis @ 2-vessel dis that includes proximal L descending coronary a.

C. ST elevation is indicative of myocardial infarctionAns = FalseReference = harrisons vol II fig 239-1page 1532 & page 1534MI can be STEMI @ NSTEMI. So, MI x semestinya ad ST elevation

Cardiac trop-T(cTnT) & trop-I(cTnI) is indicative and can distinguish from UA & NSTEMI. Levels of cTnT and cTnI may remain elevated for 7-10 days after STEMI

D. All patients with IHD have stenotic lesions in their coronary arteriesAns = FalseReference = harrisons vol II page 1514Not all have stenotic lesion because some ptient w IHD can also be due to coronary spasm (prinzmetal’s variant angina)

E. CABG has a higher risk of recurrence as compared to PCIAns = falseReference = harrisons vol II page 1526PCI is higher compared to CABG

11. The following are true regarding cardiac tamponadeA. T. Caused by neoplastic diseaseB. T. Presence of pulsus paradoxusC. F. ECG shows large QRS complexesD. F. There will be a drop in JVPE. F. A positive Kussmaul’s sign is sometimes present

A. 1. “Malignant disease is the most common cause of pericardial effusion with tamponade.” http://emedicine.medscape.com/article/759642-overview

2. “Neoplastic disease, particularly advanced, is the most frequent cause of tamponade in the hospitals.” http://www.heartalex.com/alexheartfiles/undergraduate/lectures%20notes/

Pericardial%20 disease%20r.pdfB. 1. “Blood pressure may fall (pulsus paradoxical) when the person inhales deeply.”

http://www.nlm.nih.gov/medlineplus/ency/article/000194.htmC. 1. “Electrical alternans is pathognomonic of cardiac tamponade and is characterized by

alternating levels of ECG voltage of the P wave, QRS complex, and T waves. This is a result of the heart swinging in a large effusion.” http://emedicine.medscape.com/article/759642-diagnosis

D. 1. “Elevation of jugular venous pressure with a prominent x descent and a diminutive or absent y descent” http://www.harrisonspractice.com/practice/ub/view/Harrisons

%20Practice/141253/1/cardi ac_tamponadeE. 1. “Kussmaul’s sign is not seen in patients with cardiac tamponade because even though the

increase in pericardial pressure exerts an inward force compressing the entire heart during inspiration, the increase in negative intrathoracic pressure is still able to be transmitted to the right side of the heart and subsequent increase in blood flow to the right atrium ensues.” http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2757428/

12. Cardiomyopathies

A) T – http://www.mayoclinic.com/health/cardiomyopathy/DS00519/DSECTION=causesB) T – When abnormality is primary in and localized to myocardium, the condition is called cardiomyopathy. ( Baby Robbins Patho, page 307). Tapi, base on definition by AHA, it divides into primary and secondary..so susah nak cakap, but ikut je definition Dorland, it is a primary diseasehttp://www.emedicinehealth.com/cardiomyopathy/page2_em.htm#causesC) F – divided into dilated, hypertrophic and restrictive. ( Baby Robbins Patho, page 307)D) T – The cause is frequently unknown (idiopathic dilated cardiomyopathy), but some pathology may contribute, such as genetic defect for example X-linked cardiomyopathy (Duchenne and Becker muscular dystrophies). ( Baby Robbins Patho, page 307)E) T – Some of the classic physical findings are ejection systolic murmur (due to left ventricular outflow obstruction) and pansystolic murmur (due to mitral regurgitation). ( Kumar&Clark Medicine, page 851)

13. The following are risk factors for acute MIa. False: no evidence regarding ethnic predisposition

Ps: kumar and clark, p745b. TRUE : 5% male and 6% female death of CAD is due to obesity(bmi>30)

Ps: kumar and clark, p746c. False: sedentary life style

Ps: kumar and clark, p747d. True: first degree relative has developed ishaemic heart disease before age of 50

Ps: kumar and clark, p745e. True: high serum cholesterol with low serum HDL associated strongly with coronary artheroma

Ps: kumar and clark, p746

14. Cardiac markersA.False: troponin C is associated with cardiac and skeletal muscle.so, its not used for myocardiac damageB.True: myoglobin can be used in itC:False :LDH is not highly specific cardiac marker as troponin, they are also high in tissue breakdown and hemolysisD.False:CKMB persist for about 72 hrs. but troponin can last 7-10 daysE.False: regarding http://emedicine.medscape.com/article/811905-overview , some authorities have called for a troponin standard alone and recommend eliminating CK-MB..(haa korang bace la sket)

15. The following are complications of thrombolytic therapy Thrombolytic therapy: a.k.a fibrinolytic f(x): dissolve (lyse) blood clots eg: tissue plasminogen

activator (tPA), streptokinase, urokinase. Complications include bleeding, allergic reactions (mostly streptokinase), emboli (http://med-lib.ru/english/oxford/thromb_ther.php: emboli, http://ezinearticles.com/?Complications-With-Thrombolytics&id=5367300 : allergic, https://www.vascularweb.org/vascularhealth/Pages/thrombolytic-therapy.aspx : hypotension)

A. T mostly streptokinaseB. T complication due to bleedingC. F salah satu kegunaan thrombolytic utk treat DVT bukan nye thrombolytic menyebabkan DVTD. F thrombolytic tk menyebabkan fracture!!!E. T can occur at the site of drug administration, from other puncture sites, or from areas of recent

surgery

16. The following are clinical manifestations of heart failureA. T – selalunye berlaku dlm right sided heart failure. Akan ade engorgement of systemic and portal

venous system. Sumber: papa robin page 563. Severe heart failure causes blood to back up from the heart into the inferior vena cava (the large vein that carries blood from the lower parts of the body to the heart). Such congestion increases pressure in this vein and other veins that carry blood to it, including the hepatic veins (which drain blood from the liver). If this pressure is high enough, the liver becomes engorged (congested) with blood and malfunctions. Sumber: http://www.merckmanuals.com/home/sec10/ch138/ch138g.html

B. T – wujud satu keadaan yg di panggil cardiac cachexia. Menurutnya, CHF akan menghasilkan TNF yg byk. Maka, TNF ini akan impair the synthesis or accelerate the catabolism of proteins in the skeletal muscle. Sumber: http://eurheartj.oxfordjournals.org/content/18/2/187.full.pdf

C. T – yes,boleh jd dlm severe heart failure. Sumber: kumar and clark page 688. Instability of respiratory control underpins the development of Cheyne-Stokes respiration and results from hyperventilation, prolonged circulation time, and reduced blood gas buffering capacity. Sumber: http://thorax.bmj.com/content/53/6/514.full

D. T –it is a reflection of a right ventricle that cannot accommodate augmented venous return. Sumber: http://www.amjmed.com/article/S0002-9343(00)00443-5/abstract

E. T – in order utk maintain CO, heart akan try utk beat faster.manifest as tachy. Sumber: http://www.aafp.org/afp/20000301/1319.html