Free UKMLA cardiovascular questions with explanations

A. Intravenous magnesium sulfate

The rhythm is torsades de pointes, a polymorphic ventricular tachycardia associated with QT prolongation, here precipitated by a QT-prolonging drug. The immediate treatment in a patient with a pulse is intravenous magnesium sulfate (typically 2 g over 10 minutes), alongside stopping the offending drug and correcting electrolytes. Synchronised cardioversion is used if the patient becomes unstable, and unsynchronised defibrillation if she becomes pulseless.

A. Dressler syndrome

Dressler syndrome is a post-myocardial infarction pericarditis that appears weeks after the event and is thought to be immune-mediated. It presents with fever, pleuritic chest pain relieved by leaning forward, a pericardial rub and raised inflammatory markers, with troponin no longer elevated. Management is anti-inflammatory therapy with high-dose aspirin plus colchicine; other NSAIDs are avoided after myocardial infarction because they impair infarct healing.

E. Thyroid function tests and liver function tests

Amiodarone is highly iodine-rich and lipophilic, accumulating in thyroid and liver, both thyroid dysfunction (hypo- or hyperthyroidism) and transaminitis/hepatitis are well-recognised and may be asymptomatic, hence TFTs and LFTs are recommended at baseline and every 6 months. Chest radiography is performed at baseline and repeated if respiratory symptoms develop to screen for pulmonary fibrosis/pneumonitis, and serum potassium and ECG are also checked at baseline.

A. Apixaban

A DOAC such as apixaban or rivaroxaban is first-line for most patients with cancer-associated VTE, reflecting trial evidence (Caravaggio, ADAM-VTE) showing non-inferior efficacy with the convenience of oral dosing. With a non-luminal, non-gastrointestinal malignancy, normal renal function, and no bleeding, an oral DOAC is the clear first choice. Low molecular weight heparin is the preferred alternative in luminal gastrointestinal cancers, where DOACs carry higher gastrointestinal bleeding risk. Drug interactions and gut absorption should be reviewed before starting.

D. Andexanet alfa

Andexanet alfa is a recombinant decoy factor Xa with no procoagulant activity; it competes with native Xa for the apixaban (and rivaroxaban) binding site, restoring endogenous Xa function. Onset is rapid; effect lasts the duration of infusion. In UK practice 4-factor PCC is used for intracranial or pre-surgical bleeding, because NICE (TA697) recommends andexanet only for life-threatening gastrointestinal bleeding.

Takeaway: Andexanet alfa reverses factor Xa inhibitors (apixaban, rivaroxaban); idarucizumab reverses dabigatran (a IIa inhibitor).

E. Right ventricular failure

In pulmonary arterial hypertension (PAH), progressive elevation of pulmonary vascular resistance imposes sustained pressure overload on the right ventricle, causing hypertrophy, dilatation and ultimately decompensated right heart failure; this is the predominant mode of death in registry data (REVEAL, French PAH registry). The patient's exertional breathlessness and abdominal bloating (suggesting hepatic congestion and ascites) reflect worsening right-sided failure.

C. Buerger disease

Buerger disease (thromboangiitis obliterans) is a non-atherosclerotic segmental inflammatory occlusive disease of small and medium distal arteries that occurs almost exclusively in heavy tobacco users, typically men under 45, producing distal digital ischaemia and ulceration with preserved proximal pulses and no conventional atherosclerotic risk factors. Complete and permanent smoking cessation is the only intervention shown to alter disease course.

D. CT angiography of mesenteric vessels

CT angiography of the mesenteric vessels is the recommended first-line imaging in suspected acute mesenteric ischaemia because it rapidly identifies arterial or venous occlusion, its cause (embolic, thrombotic, dissection), and secondary signs of bowel ischaemia such as bowel wall thickening, pneumatosis intestinalis, portal venous gas and pneumoperitoneum. It is widely available, accurate, and directly guides endovascular or surgical management.

B. Carotid Doppler ultrasound

After a confirmed TIA in patients suitable for revascularisation, urgent carotid imaging is required within 24 hours of specialist assessment, with carotid duplex ultrasound the usual first-line, non-invasive modality; the National Clinical Guideline for Stroke 2023 accepts carotid duplex ultrasound, CT angiography or MR angiography for this, with stenosis reported by the NASCET method. Symptomatic 50-99% stenosis (NASCET) is offered carotid endarterectomy within 7 days of symptom onset.

C. Autosomal dominant

Marfan syndrome is an autosomal dominant connective tissue disorder caused by mutations in the FBN1 gene on chromosome 15q21 encoding fibrillin-1, a key component of extracellular microfibrils. Each offspring of an affected individual has a 50% risk of inheriting the mutation, and around 25% of cases arise from de novo mutations. UK clinical genetics services (per the Ghent nosology) confirm diagnosis using systemic scoring plus aortic root or ectopia lentis findings, with FBN1 testing.