KFP – Cardiovascular health

Julie Hamilton, aged 58, presents to your general practice in a regional town complaining of increasing shortness of breath on exertion over the past two months. She describes needing to stop when walking up a hill near her home that she previously managed without difficulty. She also notes mild ankle swelling at the end of the day and occasional palpitations in the evening.

Medications: perindopril 4 mg daily, simvastatin 20 mg nocte

Allergies: Nil known

Past history: Hypertension, hyperlipidaemia

Family history: Father died of a heart attack aged 61, mother has type 2 diabetes

Social history: Non-smoker, drinks 1-2 standard drinks per week. No recreational drug use. Lives with her husband. Walks regularly for exercise.

Examination findings: BP 138/88 mmHg, HR 92 bpm and irregularly irregular, JVP elevated 4 cm above the sternal angle, bilateral pitting oedema to mid-calf. Heart sounds: S1 and variable S2, no murmurs. Bibasal fine crackles on chest auscultation.

Investigations: ECG shows absent P waves and irregularly irregular QRS complexes (see image)

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What are the most appropriate next steps in management? Select four (4) from the following list:

Michael Ross, a 66-year-old retired truck driver, presents with a six-month history of worsening exertional chest tightness and shortness of breath when mowing the lawn or walking up stairs. He also mentions having to stop more frequently during his morning walks due to fatigue. He denies any palpitations or syncope.

Medications: atorvastatin 20 mg nocte, irbesartan 150 mg daily

Allergies: Nil known

Past history: Hypertension, hypercholesterolaemia, smoking (20 pack-year history, quit 5 years ago)

Family history: Brother had myocardial infarction at 54

Social history: Lives with wife, does gardening and bowls weekly, no alcohol or illicit drug use

Examination findings: BP 128/82 mmHg, HR 72 bpm regular, normal heart sounds with a harsh systolic murmur loudest at the right upper sternal border radiating to the carotids. No peripheral oedema. Carotid upstroke is slow and reduced in volume. Lungs clear on auscultation.

Investigations: ECG shows left ventricular hypertrophy. Echocardiogram shows calcified aortic valve with reduced cusp movement and a peak aortic jet velocity of 4.3 m/s.

What are the most appropriate next steps in management? Select three (3) from the following list:

Leanne Edwards, a 48-year-old primary school teacher, presents with sudden onset left-sided chest pain that started while she was marking papers. She describes the pain as sharp, worsened by deep inspiration and coughing. She denies any exertional component. She has also noticed mild shortness of breath and dry cough over the past 2 days. She has not had any fevers or coryzal symptoms.

Medications: none

Allergies: Nil known

Past history: Depression (resolved), two uncomplicated pregnancies, no cardiac history

Family history: Father had type 2 diabetes and hypertension

Social history: Non-smoker, drinks socially, BMI 27, no recent long-haul travel or surgery

Examination findings: HR 108 bpm, BP 126/82 mmHg, RR 20, SpO2 95% on room air. Temperature 37.2°C. Lungs: reduced breath sounds and pleuritic rub at left base. Cardiovascular exam normal.

Investigations: ECG shows sinus tachycardia. Chest X-ray shows blunting of the left costophrenic angle (see image)

[Insert Image Here]

What are the most appropriate next steps in management? Select three (3) from the following list:

Mohammed Khalil, a 71-year-old man, presents for routine review. He reports generally feeling well, though he mentions that over the past six months he has had occasional episodes of light-headedness when standing up quickly. He denies chest pain, palpitations, or exertional symptoms.

Medications: metoprolol 50 mg BD, perindopril 5 mg daily, aspirin 100 mg daily, atorvastatin 40 mg nocte

Allergies: Nil known

Past history: Ischaemic heart disease (MI 3 years ago), hypertension, dyslipidaemia

Family history: Mother had stroke aged 80, father died of MI at 67

Social history: Retired mechanic, lives with wife, non-smoker, occasional glass of wine, independent with ADLs

Examination findings: BP 132/78 mmHg lying, 102/64 mmHg standing after 3 minutes, HR 58 bpm and regular. No carotid bruits. Heart sounds dual with no murmurs. No peripheral oedema.

Investigations: Recent ECG shows sinus bradycardia at 52 bpm, otherwise normal. HbA1c 5.8%, electrolytes normal, TSH normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Angela Wood, a 34-year-old woman, presents with progressive fatigue and exertional breathlessness over the past two months. She also reports occasional palpitations and has recently noticed some ankle swelling in the evenings. She denies chest pain, cough, or orthopnoea.

Medications: Oral contraceptive pill (ethinylestradiol + levonorgestrel)

Allergies: Nil known

Past history: Migraine with aura, iron deficiency anaemia (treated)

Family history: Mother had dilated cardiomyopathy diagnosed at 45

Social history: Non-smoker, no alcohol or drug use. Office worker, sedentary job. BMI 30

Examination findings: BP 110/72 mmHg, HR 106 bpm and regular, JVP not elevated. Apex beat is displaced and diffuse. S3 gallop present. Mild pedal oedema. Lungs clear to auscultation.

Investigations: ECG: sinus tachycardia, non-specific ST-T changes. Chest X-ray: cardiomegaly without pulmonary congestion. Bloods: Hb 128 g/L, TSH normal, eGFR 85, electrolytes normal.

What are the most appropriate next steps in management? Select four (4) from the following list:

Bruce Cartwright, a 59-year-old truck driver, presents with a sudden onset of central chest pain radiating to the back while loading a delivery. He describes the pain as tearing in nature, severe, and unlike anything he has experienced before. He looks visibly distressed.

Medications: irbesartan 150 mg daily, atorvastatin 40 mg nocte

Allergies: Nil known

Past history: Hypertension (diagnosed 8 years ago), dyslipidaemia

Family history: Father died of ‘heart complications’ at 62, no known aneurysms

Social history: Smoker (15 cigarettes/day), minimal alcohol, no recreational drugs

Examination findings: BP 178/96 mmHg right arm, 150/92 mmHg left arm. HR 98 bpm, RR 22, SpO2 97% on room air. Normal heart sounds. Radial and femoral pulses present but asymmetric. No signs of heart failure or pulmonary oedema.

Investigations: ECG: Sinus rhythm, no ischaemic changes. Troponin normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Peter Lang, a 76-year-old retired accountant, presents with increasing fatigue and breathlessness when climbing stairs. He also reports occasional dizziness when standing up and a loss of appetite. He denies chest pain, cough, or orthopnoea. His symptoms have progressed gradually over the past three months.

Medications: amlodipine 5 mg daily, aspirin 100 mg daily

Allergies: Nil known

Past history: Hypertension, osteoarthritis, stage 3 chronic kidney disease

Family history: Non-contributory

Social history: Lives alone, active with gardening and walking. Non-smoker, drinks wine occasionally. BMI 23

Examination findings: BP 110/64 mmHg sitting, 94/58 mmHg standing. HR 88 bpm regular. Pale conjunctivae, systolic flow murmur over the apex without radiation. No peripheral oedema. Mild hepatomegaly. No focal neurological signs.

Investigations: Hb 89 g/L (NR 135–180), MCV 76 fL (NR 80–100), Ferritin 9 µg/L (NR 30–300), eGFR 48 mL/min/1.73m², urea and electrolytes otherwise normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Rajeev Chandran, a 62-year-old man, presents with a 4-week history of bilateral lower limb swelling and increasing fatigue. He reports waking at night short of breath and needing to sleep with three pillows. He denies chest pain or recent illness. He is known to have type 2 diabetes and is on oral hypoglycaemics.

Medications: metformin 1 g BD, gliclazide MR 60 mg daily, rosuvastatin 10 mg nocte

Allergies: Nil known

Past history: Type 2 diabetes (10 years), diabetic retinopathy, hypertension

Family history: Brother died suddenly aged 59, presumed cardiac

Social history: Migrant from India, has lived in Australia for 15 years. Works as a security guard. Non-smoker. Rare alcohol intake.

Examination findings: BP 146/84 mmHg, HR 88 bpm regular, JVP elevated 5 cm, S3 present, bibasal crepitations, bilateral pitting oedema to mid-shin.

Investigations: ECG: Left ventricular hypertrophy. Chest X-ray: cardiomegaly, pulmonary congestion. HbA1c: 8.6%. eGFR: 52, urea and creatinine mildly elevated.

What are the most appropriate next steps in management? Select four (4) from the following list:

Chloe Dawson, a 25-year-old university student, presents after experiencing two episodes of syncope in the past month. Both episodes occurred while standing in a crowded train. She felt light-headed, nauseated, and then lost consciousness for approximately 30 seconds. She recovered spontaneously and did not sustain any injuries. She denies chest pain, palpitations, or seizures.

Medications: None

Allergies: Nil known

Past history: Nil significant

Family history: Paternal uncle died suddenly at age 28 (cause unknown)

Social history: Non-smoker, drinks socially, active lifestyle, normal BMI

Examination findings: BP 112/70 mmHg lying, 106/68 mmHg standing. HR 72 bpm, regular. Cardiovascular and neurological exams unremarkable.

Investigations: ECG: Normal sinus rhythm, QTc 470 ms (upper limit of normal), no delta wave or Brugada pattern

What are the most appropriate next steps in management? Select three (3) from the following list:

Margaret Hall, a 67-year-old woman, presents with progressive exertional dyspnoea and reduced exercise tolerance over the past 3 months. She also reports orthopnoea and needing to use two pillows at night. There has been no chest pain. She has a known history of long-standing poorly controlled hypertension and type 2 diabetes mellitus.

Medications: perindopril 10 mg daily, metformin 1 g BD, amlodipine 10 mg daily, atorvastatin 20 mg nocte

Allergies: Nil known

Past history: Hypertension, type 2 diabetes mellitus, diabetic nephropathy

Family history: Mother had heart failure in her 70s, father died of stroke at 68

Social history: Retired nurse, lives alone, BMI 35, ex-smoker (quit 10 years ago)

Examination findings: BP 158/92 mmHg, HR 84 bpm irregularly irregular, bibasal crackles on auscultation, S4 gallop heard, mild peripheral oedema, JVP 3 cm above sternal angle

Investigations: ECG: Atrial fibrillation. Echocardiogram: Normal LV ejection fraction, concentric LV hypertrophy, impaired LV relaxation (Grade II diastolic dysfunction)

What are the most appropriate next steps in management? Select three (3) from the following list:

Thomas Green, a 53-year-old man, presents with acute onset of left calf pain and swelling over the past 24 hours. He describes the pain as a dull ache that is worse when walking. He denies trauma, chest pain, or shortness of breath. He recently returned from a two-week overseas flight and reports spending most of the time seated during the flight.

Medications: None

Allergies: Nil known

Past history: Smoker (30 pack-years), no other significant history

Family history: Father had myocardial infarction at 58, mother has varicose veins

Social history: Works in IT, mostly desk-based, no regular exercise

Examination findings: Left calf is tender, swollen (2.5 cm larger than right), warm and erythematous. No oedema in right leg. No signs of pulmonary involvement. Vitals: BP 132/78 mmHg, HR 88 bpm, SpO2 98% RA

What are the most appropriate next steps in management? Select three (3) from the following list:

Katherine Liu, a 45-year-old woman, presents with a three-month history of episodic palpitations. She describes a sudden onset of rapid heartbeats lasting several minutes, often triggered by stress or caffeine. Episodes resolve spontaneously. There is no associated chest pain or syncope. She reports some anxiety around the episodes.

Medications: None

Allergies: Nil known

Past history: Mild asthma, GORD

Family history: Father has hypertension and had atrial fibrillation diagnosed at age 68

Social history: Works as a lawyer, high-stress environment, drinks 3–4 coffees per day, no smoking or alcohol use

Examination findings: HR 78 bpm regular, BP 122/76 mmHg, normal heart sounds, no murmurs. No signs of thyrotoxicosis. Cardiovascular and respiratory examinations normal.

Investigations: ECG (in clinic) during asymptomatic period: sinus rhythm, PR interval 160 ms, QTc 420 ms. No delta waves or pre-excitation features. Thyroid function tests and electrolytes normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Brian Carter, a 64-year-old man, presents for review after experiencing increasing chest discomfort over the last six weeks. He describes it as a tightness in the centre of his chest brought on by walking briskly or climbing stairs and relieved by rest within minutes. He denies associated dyspnoea, palpitations, or syncope.

Medications: simvastatin 40 mg nocte, aspirin 100 mg daily

Allergies: Nil known

Past history: Hypertension, hypercholesterolaemia

Family history: Brother had coronary artery bypass surgery at 58

Social history: Retired electrician, non-smoker, drinks 1–2 glasses of wine nightly, walks his dog daily. BMI 28

Examination findings: BP 138/84 mmHg, HR 78 bpm regular, cardiovascular and respiratory exams normal

Investigations: ECG: normal sinus rhythm, no ST or T wave changes. Fasting lipids: TC 5.8, LDL 3.4, HDL 1.1, TG 1.9. HbA1c 5.6%

What are the most appropriate next steps in management? Select three (3) from the following list:

Susan Yilmaz, a 74-year-old woman, presents with a three-day history of worsening shortness of breath, orthopnoea, and a dry cough. She has a history of heart failure and reports recent non-adherence to her medications due to nausea. She denies chest pain or fever. Her weight has increased by 2.5 kg in the past week.

Medications: perindopril 5 mg daily, frusemide 40 mg daily (not taken for 4 days), bisoprolol 5 mg daily

Allergies: Nil known

Past history: Chronic heart failure with reduced ejection fraction (HFrEF), hypertension

Family history: Non-contributory

Social history: Lives alone, independent with ADLs, ex-smoker

Examination findings: HR 96 bpm, BP 144/86 mmHg, RR 24, SpO2 94% RA. Bibasal crackles, elevated JVP, pitting oedema to knees. No murmurs.

Investigations: ECG: sinus rhythm. UEC: creatinine 118 μmol/L (baseline 90), Na 134, K 4.8. BNP elevated.

What are the most appropriate next steps in management? Select three (3) from the following list:

David Nguyen, a 38-year-old man, presents with sudden onset of severe, sharp chest pain that worsens on lying flat and improves when sitting forward. He reports a recent viral illness one week ago with low-grade fever and sore throat. He denies dyspnoea, cough, or leg swelling.

Medications: None

Allergies: Nil known

Past history: Unremarkable

Family history: No cardiac disease

Social history: Software engineer, non-smoker, occasional alcohol use

Examination findings: Temp 37.8°C, BP 124/76 mmHg, HR 92 bpm, regular. Heart sounds: pericardial rub audible. Lungs clear. No oedema. No JVP elevation.

Investigations: ECG shows widespread concave ST elevation and PR depression. Troponin slightly elevated. Chest X-ray normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Maria Thompson, a 58-year-old Aboriginal woman, presents for a routine cardiovascular risk assessment. She feels well and is asymptomatic. She has a history of gestational diabetes and reports her father had a heart attack at 52. She has not had a health check for several years.

Medications: None

Allergies: Nil known

Past history: Gestational diabetes (resolved), obesity

Family history: Father had MI at 52, mother has type 2 diabetes

Social history: Lives in a rural community with limited access to transport. Ex-smoker, quit 6 months ago. Drinks socially. BMI 33

Examination findings: BP 142/86 mmHg, waist circumference 102 cm. Heart sounds dual, no murmurs. No peripheral oedema. Non-fasting BGL in clinic: 7.9 mmol/L

Investigations: HbA1c 6.3%, eGFR 90, Total cholesterol 6.2, LDL 3.9, HDL 0.9, TG 2.0. Urine ACR elevated. No previous cardiovascular events.

What are the most appropriate next steps in management? Select four (4) from the following list:

Leonard Faulkner, a 69-year-old man, presents with new-onset bilateral calf cramping when walking 100–200 metres, which resolves with rest. He has also noticed his feet feel cold at night. He denies chest pain, breathlessness, or neurological symptoms.

Medications: atorvastatin 20 mg nocte, perindopril 5 mg daily

Allergies: Nil known

Past history: Hypertension, hyperlipidaemia, former smoker (40 pack-year history)

Family history: Brother has coronary artery disease, father had stroke at 72

Social history: Retired mechanic, walks daily but now limited by leg symptoms. Lives independently.

Examination findings: BP 144/84 mmHg, HR 76 bpm regular. Femoral pulses palpable bilaterally, dorsalis pedis and posterior tibial pulses diminished. Capillary refill >4 seconds in both feet. No ulcers or gangrene.

Investigations: ECG: normal sinus rhythm. HbA1c 5.7%, Total cholesterol 5.2, LDL 3.1, HDL 1.0. Ankle-brachial index (ABI): Right 0.65, Left 0.60

What are the most appropriate next steps in management? Select three (3) from the following list:

Emily Foster, a 32-year-old woman, presents for assessment after recording several elevated blood pressure readings at home over the past two weeks. She is asymptomatic. Her average home BP readings are 142/92 mmHg. She has no history of cardiovascular disease.

Medications: None

Allergies: Nil known

Past history: Polycystic ovarian syndrome (PCOS)

Family history: Mother has hypertension, father had myocardial infarction at 50

Social history: Works as a primary school teacher. BMI 31. No smoking, drinks socially. Regular exercise, on a low-GI diet for weight loss.

Examination findings: BP in clinic: 144/88 mmHg (seated, repeated x2). HR 74 bpm, BMI 31, waist circumference 98 cm. Cardiovascular and respiratory exams normal. No bruits. Fundoscopy normal.

Investigations: UEC: normal. HbA1c: 5.9%, eGFR 92. Lipids: TC 5.6, LDL 3.2, HDL 1.2, TG 1.5. Urine ACR normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

John Ellis, a 72-year-old man, presents after a recent episode of collapse while gardening. He was unconscious for less than a minute and regained full awareness quickly. He did not experience chest pain, palpitations, or seizure activity. His wife reports that he appeared pale and clammy prior to the event. He has no prior history of syncope.

Medications: perindopril 5 mg daily, simvastatin 20 mg nocte

Allergies: Nil known

Past history: Hypertension, dyslipidaemia

Family history: Brother died suddenly at 66 (unclear cause)

Social history: Retired teacher, non-smoker, drinks 1–2 beers per week. Independent and active.

Examination findings: BP 134/78 mmHg lying, 118/70 mmHg standing. HR 54 bpm and regular. No murmurs. Cardiovascular and neurological exams otherwise normal.

Investigations: ECG: sinus bradycardia, first-degree AV block (PR 220 ms). Electrolytes, BGL and TSH all normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Linda Pascoe, a 63-year-old woman, presents with gradually worsening dyspnoea on exertion and fatigue over the past three months. She reports needing to pause when climbing stairs and has noticed mild swelling in her ankles by the end of the day. She denies chest pain or palpitations. She has no known cardiac history.

Medications: Metformin 1g BD, atorvastatin 20 mg nocte

Allergies: Nil known

Past history: Type 2 diabetes mellitus, osteoarthritis

Family history: Mother had heart failure, father died of MI at age 59

Social history: Retired school principal. BMI 35. Non-smoker, rarely drinks alcohol

Examination findings: HR 88 bpm, BP 148/88 mmHg. JVP elevated. Bibasal crepitations and bilateral pitting oedema to mid-shin. Heart sounds: dual, no murmurs. No hepatosplenomegaly.

Investigations: ECG: sinus rhythm, LVH pattern. HbA1c 7.1%, eGFR 68. Echocardiogram: preserved ejection fraction, impaired relaxation (diastolic dysfunction), moderate left atrial enlargement.

What are the most appropriate next steps in management? Select three (3) from the following list:

Mark Peterson, a 46-year-old man, presents after being told during a workplace health check that he has a ‘heart murmur’. He has no symptoms and feels well. He exercises regularly and has no chest pain, dyspnoea, or syncope. He has never had rheumatic fever.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Father had aortic valve replacement at 60

Social history: Works in logistics, non-smoker, drinks socially, BMI 26

Examination findings: HR 72 bpm regular, BP 124/78 mmHg. Auscultation reveals an early-peaking systolic murmur, best heard at the right upper sternal border, radiating to the carotids. No heave or thrill. Normal heart sounds otherwise.

Investigations: ECG: normal sinus rhythm, left ventricular hypertrophy. No PR prolongation or ST-T abnormalities. No echocardiogram has yet been performed.

What are the most appropriate next steps in management? Select three (3) from the following list:

Yvonne Carmichael, a 56-year-old woman, presents for review of her blood pressure and cardiovascular risk. She feels well and has no symptoms. Her last health check was 3 years ago. She has gained 8 kg over the last two years and has not been exercising regularly.

Medications: Nil

Allergies: Nil known

Past history: Nil

Family history: Father had stroke at age 63, mother has type 2 diabetes

Social history: Works full time in administration. BMI 31, waist circumference 106 cm. Smokes 10 cigarettes per day. Drinks 1–2 glasses of wine nightly.

Examination findings: BP 152/90 mmHg (repeated twice). HR 84 bpm. Normal heart sounds. No oedema or bruits.

Investigations: Fasting lipids: TC 6.0 mmol/L, LDL 3.8 mmol/L, HDL 1.0 mmol/L, TG 2.2 mmol/L. HbA1c: 6.0%. eGFR 90, urine ACR normal. CV risk calculator: 16% 5-year risk.

What are the most appropriate next steps in management? Select three (3) from the following list:

Stephen Barrett, a 70-year-old man, presents with palpitations that began suddenly 3 hours ago. He describes a rapid, irregular heartbeat associated with mild shortness of breath. He denies chest pain, dizziness, or syncope. He has never experienced this before.

Medications: None

Allergies: Nil known

Past history: Hypertension, well controlled. No known cardiac disease.

Family history: Father had AF and stroke in his 70s

Social history: Retired, walks daily, BMI 28. Non-smoker. Drinks 1–2 glasses of wine per day

Examination findings: HR 132 bpm, irregularly irregular. BP 132/80 mmHg. No JVP elevation. Chest clear, heart sounds irregular with no murmur. No signs of heart failure or neurological deficits.

Investigations: ECG: Atrial fibrillation with rapid ventricular response, no ischaemic changes. Bloods: normal electrolytes, renal function, and TSH.

What are the most appropriate next steps in management? Select three (3) from the following list:

Nicole Walsh, a 61-year-old woman, presents with new-onset exertional dyspnoea and mild ankle swelling over the last two months. She denies chest pain or orthopnoea but reports increasing fatigue. Her only medication is rosuvastatin, started six months ago for elevated cholesterol.

Medications: Rosuvastatin 20 mg nocte

Allergies: Nil known

Past history: Hypercholesterolaemia, menopause at age 50

Family history: Sister had non-ischaemic cardiomyopathy in her 60s

Social history: Office worker, walks daily, BMI 26. Non-smoker, 1–2 standard drinks on weekends

Examination findings: HR 86 bpm, BP 130/78 mmHg. Mild pedal oedema, JVP not elevated. Heart sounds dual with soft S3, lungs clear.

Investigations: ECG: normal sinus rhythm. Echocardiogram: LVEF 45%, global hypokinesis, mild LV dilatation. Troponin normal. BNP mildly elevated. eGFR 76, TSH normal. No valvular pathology.

What are the most appropriate next steps in management? Select three (3) from the following list:

James Rutledge, a 74-year-old man, presents with a two-month history of progressively worsening shortness of breath and decreased exercise tolerance. He now becomes breathless after walking 50 metres. He denies chest pain or palpitations but has occasional orthopnoea. He had a myocardial infarction 4 years ago and has been stable since.

Medications: Bisoprolol 5 mg daily, perindopril 10 mg daily, atorvastatin 40 mg nocte, aspirin 100 mg daily

Allergies: Nil known

Past history: Ischaemic heart disease, previous anterior STEMI, type 2 diabetes, hypertension

Family history: Brother had heart failure, father died of stroke at 72

Social history: Retired accountant, non-smoker, drinks 1–2 glasses of wine per week, lives with partner. BMI 29

Examination findings: HR 62 bpm, BP 124/74 mmHg. Elevated JVP, displaced apex beat, bibasal crackles, bilateral ankle oedema.

Investigations: ECG: sinus rhythm with Q waves in anterior leads. Echocardiogram: LVEF 30%, global hypokinesis. eGFR 64, Na 137, K 4.7. HbA1c 7.2%

What are the most appropriate next steps in management? Select three (3) from the following list:

Anna Rossi, a 50-year-old woman, presents with recurrent brief episodes of chest pain over the past month. The pain typically occurs at rest, lasts 5–10 minutes, and resolves spontaneously. It is retrosternal, described as tightness, and sometimes occurs overnight. She denies dyspnoea, palpitations, or syncope. She has no exercise limitation.

Medications: None

Allergies: Nil known

Past history: Migraine with aura, Raynaud’s phenomenon

Family history: Mother had angina in her 60s

Social history: Office worker, non-smoker, no alcohol or recreational drug use. BMI 22.

Examination findings: HR 72 bpm, BP 124/76 mmHg. Cardiovascular and respiratory exams normal. No murmurs or signs of fluid overload.

Investigations: ECG: Normal sinus rhythm with transient ST elevation in V2–V4 on one recorded episode. Troponin negative. Normal fasting lipids and HbA1c.

What are the most appropriate next steps in management? Select three (3) from the following list:

Graham Weston, a 68-year-old man, presents for review after feeling increasingly light-headed when getting out of bed in the morning. He has had two near-falls in the past week. He denies chest pain or palpitations. He has a history of hypertension and benign prostatic hyperplasia (BPH).

Medications: Amlodipine 10 mg daily, tamsulosin 0.4 mg nocte

Allergies: Nil known

Past history: Hypertension, BPH, hyperlipidaemia

Family history: Father had stroke at 70, mother with hypertension

Social history: Retired builder, lives with wife, independent with ADLs. Walks daily. No alcohol or tobacco use.

Examination findings: BP 134/82 mmHg lying, 100/66 mmHg standing after 3 minutes. HR 64 bpm, regular. No focal neurological signs. Heart sounds dual, no murmurs. No oedema.

Investigations: ECG: sinus rhythm, normal intervals. Electrolytes, renal function, and FBC all normal. HbA1c 6.0%

What are the most appropriate next steps in management? Select three (3) from the following list:

Samantha Leigh, a 45-year-old woman, presents with a two-week history of intermittent palpitations described as a fluttering in her chest. Episodes last a few minutes and occur at rest or during stress. She denies syncope, chest pain, or dyspnoea. She has a history of generalised anxiety disorder, currently well-controlled without medication.

Medications: None

Allergies: Nil known

Past history: Generalised anxiety disorder (GAD), resolved postpartum thyroiditis

Family history: Mother has hypertension, father has atrial fibrillation

Social history: Schoolteacher, drinks 3–4 coffees/day, no alcohol or smoking. Exercises irregularly.

Examination findings: HR 82 bpm, BP 124/78 mmHg. Cardiovascular and respiratory exams unremarkable. No murmurs or thyroid enlargement.

Investigations: ECG (at rest): normal sinus rhythm, QTc 420 ms. TSH and electrolytes normal. Holter monitor: sinus rhythm with several short runs of supraventricular ectopy.

What are the most appropriate next steps in management? Select three (3) from the following list:

Joseph Malouf, a 78-year-old man, presents with worsening exertional dyspnoea and recent onset of chest tightness when walking uphill. He denies orthopnoea or syncope. He has a history of type 2 diabetes and well-controlled hypertension.

Medications: Metformin 1g BD, perindopril 5 mg daily, atorvastatin 40 mg nocte

Allergies: Nil known

Past history: Type 2 diabetes, hypertension

Family history: Father died of MI aged 70, no known valvular disease

Social history: Lives independently, non-smoker, no alcohol. Walks daily. BMI 27.

Examination findings: HR 78 bpm, BP 136/84 mmHg. Harsh systolic murmur at right upper sternal border radiating to carotids. Slow-rising pulse. No peripheral oedema or signs of heart failure.

Investigations: ECG: normal sinus rhythm, left ventricular hypertrophy. Echocardiogram: severe aortic stenosis with a valve area of 0.8 cm² and mean gradient of 45 mmHg. Normal LVEF.

What are the most appropriate next steps in management? Select three (3) from the following list:

Daniel O’Connor, a 55-year-old man, presents with sudden onset left-sided chest pain and shortness of breath that began one hour ago while watching television. He describes the pain as sharp and pleuritic. He also reports a dry cough over the past week. He has no history of cardiovascular disease.

Medications: None

Allergies: Nil known

Past history: Recent knee arthroscopy 10 days ago, no other significant history

Family history: Sister had unprovoked DVT in her 40s

Social history: Accountant, returned to work last week. Non-smoker. No recent travel. BMI 29

Examination findings: HR 108 bpm, BP 126/84 mmHg, RR 22, SpO2 94% on room air. Chest clear, no calf tenderness or swelling. Cardiovascular exam otherwise normal.

Investigations: ECG: sinus tachycardia. D-dimer elevated. CXR: clear. Wells score: 5.5 (moderate probability)

What are the most appropriate next steps in management? Select three (3) from the following list:

Fiona Rees, a 66-year-old woman, presents with progressive breathlessness and fatigue. She reports needing to stop to catch her breath after walking 100 metres. She denies chest pain but has developed a dry nocturnal cough and has difficulty lying flat. She had a mitral valve repair for mitral regurgitation 8 years ago and was lost to follow-up.

Medications: Perindopril 5 mg daily, furosemide 20 mg PRN

Allergies: Nil known

Past history: Rheumatic fever in adolescence, mitral valve repair

Family history: Nil cardiac history

Social history: Retired teacher, non-smoker, occasional wine. BMI 26. Lives with husband, independent with ADLs.

Examination findings: BP 118/74 mmHg, HR 92 bpm irregularly irregular. Bibasal crepitations, pitting oedema to ankles. JVP 4 cm above sternal angle. Soft systolic murmur at apex. No fever or peripheral signs of endocarditis.

Investigations: ECG: atrial fibrillation. CXR: pulmonary congestion. Echocardiogram: moderate mitral regurgitation, left atrial enlargement, LVEF 48%

What are the most appropriate next steps in management? Select three (3) from the following list:

Lucy Tran, a 60-year-old woman, presents with a two-week history of new-onset chest discomfort described as a dull ache in the centre of her chest. The discomfort occurs after eating large meals or when bending forward. She has also noticed increased belching and occasional sour taste in her mouth. She is otherwise well and denies dyspnoea, palpitations, or exertional symptoms.

Medications: Rosuvastatin 20 mg nocte

Allergies: Nil known

Past history: Hyperlipidaemia, hysterectomy (age 52)

Family history: Brother had MI at age 59

Social history: Retired hairdresser, BMI 30, non-smoker, drinks wine occasionally. No regular exercise.

Examination findings: HR 78 bpm, BP 132/80 mmHg. Cardiovascular and respiratory examinations unremarkable.

Investigations: ECG: normal sinus rhythm, no ST/T wave changes. Fasting lipids and HbA1c normal. No previous cardiac events.

What are the most appropriate next steps in management? Select three (3) from the following list:

George Poulos, a 70-year-old man, presents with new-onset exertional dyspnoea and fatigue over the past month. He denies chest pain or syncope. He has a history of long-standing poorly controlled hypertension and chronic kidney disease stage 3a.

Medications: Amlodipine 10 mg daily, atorvastatin 20 mg nocte

Allergies: Nil known

Past history: Hypertension, CKD stage 3a (eGFR 54), hyperlipidaemia

Family history: Father died of stroke, mother had congestive heart failure

Social history: Retired butcher, non-smoker, BMI 32. Moderate alcohol intake

Examination findings: HR 84 bpm, BP 158/92 mmHg, bibasal crepitations, mild pitting oedema, no murmur, elevated JVP

Investigations: ECG: sinus rhythm, LVH. CXR: cardiomegaly with pulmonary congestion. BNP elevated. Echocardiogram: preserved LVEF, concentric LVH, Grade II diastolic dysfunction

What are the most appropriate next steps in management? Select three (3) from the following list:

Melanie Singh, a 36-year-old woman, presents with episodic pounding heartbeats that begin suddenly and resolve spontaneously within 10–15 minutes. She has had three episodes in the past two months, often triggered by stress or caffeine. During one episode at work, a colleague noted her pulse was very fast and regular. She denies chest pain or syncope, but feels anxious during the episodes.

Medications: None

Allergies: Nil known

Past history: Migraine with aura

Family history: Father had hypertension, mother has hypothyroidism

Social history: Office worker, drinks 3–4 coffees/day, non-smoker, occasional alcohol. No recreational drugs.

Examination findings: HR 78 bpm, BP 118/74 mmHg. Normal cardiovascular and respiratory examination.

Investigations: ECG in clinic: sinus rhythm, PR interval 120 ms, narrow QRS complexes. No delta waves. TSH and electrolytes normal. Echocardiogram: structurally normal heart. Holter monitor: episode of supraventricular tachycardia (SVT) at 160 bpm lasting 12 minutes.

What are the most appropriate next steps in management? Select three (3) from the following list:

Ronald King, a 64-year-old man, presents with a three-month history of progressive lower limb oedema and increasing abdominal girth. He reports mild breathlessness on exertion but no chest pain. He has a history of chronic alcohol use and was recently diagnosed with liver cirrhosis. He denies recent travel or calf pain.

Medications: Frusemide 40 mg daily, thiamine

Allergies: Nil known

Past history: Chronic alcohol use, liver cirrhosis (Child-Pugh B)

Family history: Non-contributory

Social history: Lives alone, drinks 6–8 standard drinks daily, currently unemployed

Examination findings: BP 106/66 mmHg, HR 92 bpm, irregularly irregular. Elevated JVP. Peripheral oedema to thighs. Ascites with shifting dullness. No murmurs or hepatomegaly. Mild finger clubbing present.

Investigations: ECG: atrial fibrillation. LFTs: elevated GGT and bilirubin. INR 1.8. Echocardiogram: moderate biventricular dilatation, global hypokinesis, LVEF 35%. BNP elevated.

What are the most appropriate next steps in management? Select three (3) from the following list:

Peter Zhang, a 52-year-old man, presents for review after an episode of left arm pain and tightness in the chest while mowing the lawn two days ago. The discomfort resolved after resting for 10 minutes and has not recurred. He reports no palpitations, dyspnoea, or dizziness. He has never had similar symptoms before.

Medications: Nil

Allergies: Nil known

Past history: Mild asthma in childhood, no known cardiac disease

Family history: Father died from MI at age 54

Social history: Works as a warehouse manager, BMI 28. Smokes 10 cigarettes/day. Drinks 2–3 beers/night. No regular exercise.

Examination findings: BP 138/86 mmHg, HR 84 bpm regular. Normal heart sounds, chest clear. No peripheral oedema.

Investigations: ECG: normal sinus rhythm, no ST-T changes. Lipids: TC 6.4, LDL 4.1, HDL 0.9. HbA1c 5.7%

What are the most appropriate next steps in management? Select three (3) from the following list:

Angela Morrison, a 49-year-old woman, presents with a two-month history of progressive fatigue and occasional light-headedness. She denies chest pain, palpitations, or syncope. She has been feeling generally ‘sluggish’ and has had difficulty concentrating at work. She reports heavier than usual menstrual periods over the past year.

Medications: None

Allergies: Nil known

Past history: Iron deficiency in her 30s, no cardiovascular disease

Family history: Mother had thyroid disease, father had hypertension

Social history: School librarian, vegetarian, no alcohol, non-smoker

Examination findings: BP 112/72 mmHg, HR 52 bpm and regular. No murmurs. Mild pallor noted. No oedema. ECG: sinus bradycardia

Investigations: Hb 98 g/L (115–160), MCV 72 fL (80–96), ferritin 8 µg/L (20–200), TSH 3.1 mIU/L (normal). Echocardiogram: normal chambers and function

What are the most appropriate next steps in management? Select three (3) from the following list:

Michael D’Souza, a 59-year-old man, presents for review following a recent diagnosis of atrial fibrillation identified during a routine health check. He is asymptomatic and unaware of any palpitations or fatigue. He has well-controlled type 2 diabetes and hypertension.

Medications: Metformin 1g BD, perindopril 10 mg daily, atorvastatin 40 mg nocte

Allergies: Nil known

Past history: Type 2 diabetes, hypertension

Family history: Father had a stroke at 70, mother has type 2 diabetes

Social history: Accountant, non-smoker, drinks wine occasionally. Walks regularly. BMI 26

Examination findings: HR 76 bpm irregularly irregular, BP 128/78 mmHg. No signs of heart failure. Cardiovascular and respiratory exams normal.

Investigations: ECG: atrial fibrillation, no other abnormalities. Echocardiogram: normal LVEF, no structural heart disease. CHA₂DS₂-VASc score = 3

What are the most appropriate next steps in management? Select three (3) from the following list:

Pauline Everett, a 72-year-old woman, presents with a one-week history of low-grade fever, malaise, and new onset of breathlessness. She also reports dull chest discomfort and has been feeling generally unwell. She had a permanent pacemaker inserted 6 months ago for complete heart block.

Medications: Perindopril 5 mg daily, paracetamol PRN

Allergies: Nil known

Past history: Complete heart block, hypertension

Family history: Nil significant

Social history: Lives alone, no smoking or alcohol. Retired librarian. BMI 25.

Examination findings: T 37.8°C, HR 84 bpm (paced), BP 122/70 mmHg. Mild peripheral oedema, JVP not elevated. No murmur. Lungs clear. No rash or peripheral stigmata of endocarditis.

Investigations: ECG: ventricular paced rhythm. CRP 48 mg/L (↑), WBC 11.5 ×10⁹/L. Blood cultures pending. TTE: possible echo-dense mass on pacing lead.

What are the most appropriate next steps in management? Select three (3) from the following list:

Alan Bright, a 45-year-old man, presents for assessment of an incidental heart murmur noted during a pre-employment medical. He denies any symptoms including dyspnoea, chest pain, or palpitations. He has no exercise intolerance and regularly jogs 5 km without issue.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Father had aortic valve replacement at 65 for bicuspid aortic valve

Social history: Non-smoker, drinks socially, works in IT. BMI 24

Examination findings: HR 72 bpm, BP 130/76 mmHg. Early-peaking ejection systolic murmur best heard at the right upper sternal border, radiating to the carotids. No heave, thrill, or added sounds. Normal respiratory and neurological exams.

Investigations: ECG: normal sinus rhythm, no hypertrophy or conduction delays. No echocardiogram has been performed to date.

What are the most appropriate next steps in management? Select three (3) from the following list:

Leanne Carter, a 58-year-old woman, presents with recent episodes of palpitations and mild shortness of breath while climbing stairs. These have been occurring several times per week for the past month. She describes a rapid, irregular heartbeat lasting a few minutes, resolving spontaneously. She denies chest pain or syncope. She has hypertension and obesity.

Medications: Amlodipine 10 mg daily

Allergies: Nil known

Past history: Hypertension, BMI 34, no prior cardiovascular events

Family history: Mother had atrial fibrillation, father had type 2 diabetes

Social history: School administrator, sedentary lifestyle, drinks wine on weekends, non-smoker

Examination findings: BP 142/86 mmHg, HR 78 bpm regular. No murmur, lungs clear. ECG (performed today): sinus rhythm with occasional PACs

Investigations: TSH and electrolytes normal. Holter monitor: several episodes of paroxysmal atrial fibrillation, longest lasting 18 minutes. Echocardiogram: LVEF 60%, mild left atrial enlargement

What are the most appropriate next steps in management? Select three (3) from the following list:

John Naylor, a 67-year-old man, presents with worsening bilateral leg swelling over the past month. He also reports a sensation of fullness in his abdomen and mild breathlessness when lying flat. He has a history of ischaemic heart disease and had a coronary artery bypass graft (CABG) 5 years ago.

Medications: Bisoprolol 5 mg daily, ramipril 10 mg daily, atorvastatin 40 mg nocte, aspirin 100 mg daily

Allergies: Nil known

Past history: CABG, hypertension, hyperlipidaemia

Family history: Brother with congestive heart failure

Social history: Retired electrician, non-smoker, occasional alcohol, BMI 30

Examination findings: HR 68 bpm, BP 118/70 mmHg. Elevated JVP, bilateral pitting oedema to knees, hepatomegaly with mild tenderness. Clear chest on auscultation. No cardiac murmurs.

Investigations: ECG: sinus rhythm with old Q waves. Echocardiogram: normal LVEF, moderate tricuspid regurgitation, dilated right atrium and right ventricle. BNP mildly elevated.

What are the most appropriate next steps in management? Select three (3) from the following list:

Rachel Moon, a 34-year-old woman, presents with acute onset sharp chest pain that worsens when lying flat and improves when sitting forward. The pain began 24 hours ago following an upper respiratory tract infection. She denies dyspnoea or palpitations. She is otherwise well.

Medications: None

Allergies: Nil known

Past history: Nil significant

Family history: Mother has rheumatoid arthritis

Social history: Accountant, non-smoker, no alcohol, BMI 22

Examination findings: HR 92 bpm, BP 118/74 mmHg, temp 37.4°C. Pericardial rub heard on auscultation. Lungs clear. No peripheral oedema or JVP elevation.

Investigations: ECG: widespread concave ST elevation with PR depression. Troponin mildly elevated. CXR: normal. Echocardiogram: small pericardial effusion, no tamponade.

What are the most appropriate next steps in management? Select three (3) from the following list:

Yasir Ahmed, a 62-year-old man, presents with progressive shortness of breath and decreased exercise tolerance over the last 3 months. He denies chest pain but reports needing to sleep propped up on two pillows. He has type 2 diabetes, managed with oral hypoglycaemics.

Medications: Metformin 1g BD, gliclazide MR 60 mg daily, atorvastatin 40 mg nocte

Allergies: Nil known

Past history: Type 2 diabetes mellitus, dyslipidaemia

Family history: Brother with heart failure, father had MI at 58

Social history: Bus driver, BMI 33. Non-smoker, no alcohol

Examination findings: HR 88 bpm, BP 140/82 mmHg. JVP elevated, bibasal crackles, bilateral ankle oedema. No murmur. No hepatosplenomegaly.

Investigations: ECG: sinus rhythm, left atrial enlargement. Echocardiogram: LVEF 38%, moderate concentric LVH. HbA1c 7.4%. BNP elevated.

What are the most appropriate next steps in management? Select three (3) from the following list:

Emily Fox, a 28-year-old woman, presents with episodes of chest pain and shortness of breath during intense emotional situations. The episodes are brief, non-radiating, and not related to exertion. She also reports palpitations and occasional light-headedness. She has no past medical history and is otherwise well.

Medications: Nil

Allergies: Nil known

Past history: Nil

Family history: Nil cardiac disease

Social history: University student, non-smoker, no alcohol or drug use, BMI 21

Examination findings: HR 84 bpm, BP 116/72 mmHg. Normal heart sounds, no murmurs. No signs of heart failure.

Investigations: ECG: sinus rhythm, QTc 460 ms. Troponin: normal. Echocardiogram: structurally normal heart. Holter monitor: sinus rhythm with occasional premature ventricular contractions (PVCs)

What are the most appropriate next steps in management? Select three (3) from the following list:

Henry Wallace, a 76-year-old man, presents for review after a recent hospital admission for acute decompensated heart failure. He reports feeling better on his new medications but still experiences mild dyspnoea on exertion. He has a history of hypertension and chronic kidney disease stage 3.

Medications: Bisoprolol 2.5 mg daily, perindopril 5 mg daily, frusemide 40 mg daily, atorvastatin 40 mg nocte

Allergies: Nil known

Past history: Hypertension, CKD stage 3 (eGFR 45), recent heart failure with reduced ejection fraction (LVEF 32%)

Family history: Father died of MI at age 70

Social history: Widower, lives alone, independent in ADLs, non-smoker, drinks occasionally

Examination findings: BP 122/68 mmHg, HR 66 bpm. No JVP elevation. Mild peripheral oedema. Lungs clear.

Investigations: Repeat echocardiogram: LVEF 35%, no valvular pathology. Creatinine 125 µmol/L, eGFR 45, K+ 4.9 mmol/L

What are the most appropriate next steps in management? Select three (3) from the following list:

Jessica Lin, a 39-year-old woman, presents with sudden onset palpitations and light-headedness while at work. She describes her heart rate as racing and regular. The episode lasted about 20 minutes and resolved spontaneously. She has had similar episodes twice in the past year, usually triggered by stress. She denies chest pain, syncope, or exertional symptoms.

Medications: None

Allergies: Nil known

Past history: Nil significant

Family history: Sister has paroxysmal supraventricular tachycardia (SVT)

Social history: Works in retail, drinks 2–3 coffees daily, non-smoker, no alcohol

Examination findings: HR 74 bpm, BP 116/72 mmHg. Cardiovascular exam normal. No murmur or signs of heart failure.

Investigations: ECG: sinus rhythm, no conduction abnormalities. TSH and electrolytes normal. Holter monitor: episode of narrow complex tachycardia at 180 bpm lasting 12 minutes

What are the most appropriate next steps in management? Select three (3) from the following list:

David Reilly, a 70-year-old man, presents with gradually worsening exertional breathlessness and fatigue over the past 6 months. He denies chest pain or palpitations. He has a history of hypertension and chronic kidney disease stage 3b. He has not had recent cardiovascular imaging.

Medications: Amlodipine 10 mg daily, atorvastatin 40 mg nocte

Allergies: Nil known

Past history: Hypertension, CKD stage 3b (eGFR 38)

Family history: Father died of stroke, mother had hypertension

Social history: Retired teacher, non-smoker, BMI 31, drinks wine on weekends

Examination findings: BP 132/78 mmHg, HR 78 bpm. Soft systolic murmur at the apex. Mild bilateral ankle oedema. No JVP elevation. Chest clear.

Investigations: ECG: LVH. Echocardiogram: preserved LVEF, Grade II diastolic dysfunction, moderate left atrial enlargement, mild mitral regurgitation

What are the most appropriate next steps in management? Select three (3) from the following list:

Sophie Delaney, a 30-year-old woman, presents with exertional chest discomfort and occasional palpitations. She reports a history of fatigue and episodes of dizziness when standing quickly. Her symptoms have been gradually worsening over the last 6 months. She has no known past medical history and is not on any regular medications.

Medications: None

Allergies: Nil known

Past history: Nil significant

Family history: Uncle died suddenly at age 32 from a ‘heart problem’

Social history: Yoga instructor, vegetarian, does not drink alcohol or smoke

Examination findings: BP 100/64 mmHg, HR 64 bpm. Ejection systolic murmur loudest at the left lower sternal edge, increasing with Valsalva. No oedema. Normal respiratory exam.

Investigations: ECG: left ventricular hypertrophy with repolarisation changes. Echocardiogram: asymmetric septal hypertrophy, LV outflow tract gradient of 45 mmHg at rest

What are the most appropriate next steps in management? Select three (3) from the following list:

Thomas Bradley, a 74-year-old man, presents with gradually worsening fatigue and exertional breathlessness over the past few months. He denies chest pain but reports a sense of ‘slowing down’ and occasional light-headedness. He has a history of hypertension and hyperlipidaemia. He is not currently on any rate-limiting medications.

Medications: Perindopril 5 mg daily, atorvastatin 40 mg nocte

Allergies: Nil known

Past history: Hypertension, hyperlipidaemia

Family history: Brother has coronary artery disease

Social history: Retired engineer, non-smoker, drinks 2 beers/week, BMI 26

Examination findings: HR 44 bpm, BP 110/66 mmHg. Regular bradycardia. No murmur. Chest clear. Capillary refill normal.

Investigations: ECG: sinus bradycardia with first-degree AV block. No ST changes. Echocardiogram: LVEF 60%, no valvular disease

What are the most appropriate next steps in management? Select three (3) from the following list: