Cardiology Prometric exam questions

The Cardiology exam in every GCC country

From each regulator's own exam pages; anything a regulator does not publish says so. Assessment mode also depends on your licence title, so confirm your route on your eligibility notice.

12 worked Cardiology practice questions

Original exam-style questions from the bank, spread across the blueprint domains. They are not real or recalled exam questions. Try each one, then open the answer for the rationale and reference. None of them appear in the free mock exam, so reading them will not spoil it.

1. Question 1 · Coronary Artery Disease and Acute Coronary Syndromes

   A 79-year-old woman weighing 60 kg with an eGFR of 55 mL/min/1.73 m2 receives tenecteplase for an anterior ST-elevation myocardial infarction at a district hospital. Enoxaparin is to be added as adjunctive anticoagulation. What is the correct enoxaparin regimen for her?

   1. A30 mg intravenous bolus followed by 1 mg/kg subcutaneously every 12 hours
   2. BNo intravenous bolus; 0.75 mg/kg subcutaneously every 12 hours
   3. C1.5 mg/kg subcutaneously once daily with no bolus
   4. DFull-dose unfractionated heparin infusion is mandatory instead, as enoxaparin is contraindicated after fibrinolysis
   Show answer and explanation

   Correct answer: B. No intravenous bolus; 0.75 mg/kg subcutaneously every 12 hours

   In patients aged 75 years or older receiving fibrinolysis, the intravenous enoxaparin bolus is omitted and the subcutaneous dose is reduced to 0.75 mg/kg twice daily to limit intracranial haemorrhage, a schedule derived from ExTRACT-TIMI 25. The standard 30 mg bolus plus 1 mg/kg twice daily applies only to patients under 75, once-daily dosing is reserved for severe renal impairment with creatinine clearance below 30 mL/min, and enoxaparin is in fact the preferred adjunct to fibrinolysis rather than being contraindicated.

   Reference: Antman EM et al., ExTRACT-TIMI 25, New England Journal of Medicine (2006); ESC Acute Coronary Syndromes Guidelines (2023)

2. Question 2 · Valvular Heart Disease and Infective Endocarditis

   A 58-year-old woman with native aortic valve endocarditis develops severe aortic regurgitation with pulmonary oedema on day 3 of appropriate antibiotics. On the same day she suffers a middle cerebral artery ischaemic stroke; she is drowsy but has no coma, and CT of the head shows a moderate infarct with no haemorrhagic transformation. What is the most appropriate management of the valve?

   1. AProceed with urgent valve surgery without delay
   2. BDelay surgery for at least four weeks after the stroke
   3. CDelay surgery for two weeks and repeat brain imaging before deciding
   4. DManage medically and avoid surgery because of the stroke
   Show answer and explanation

   Correct answer: A. Proceed with urgent valve surgery without delay

   After an ischaemic stroke without haemorrhage and without coma, valve surgery indicated for heart failure, uncontrolled infection or high embolic risk should not be postponed, since the risk of neurological deterioration is outweighed by the haemodynamic threat. Delay of at least one month is advised after intracranial haemorrhage, not after an uncomplicated ischaemic infarct. Withholding surgery in acute heart failure from severe regurgitation carries very high mortality, and arbitrary two- or four-week delays would be inappropriate here.

   Reference: 2023 ESC Guidelines for the Management of Endocarditis; 2020 ACC/AHA Valvular Heart Disease Guideline

3. Question 3 · Cardiac Pharmacology and Therapeutics

   Compared with alteplase, which pharmacological property best explains why tenecteplase can be given as a single weight-based intravenous bolus in ST-elevation myocardial infarction?

   1. AIt is a non-fibrin-specific agent with a broad systemic lytic effect
   2. BIt is derived from streptococci and therefore antigenic
   3. CIt activates plasminogen only after binding to platelet glycoprotein IIb/IIIa
   4. DIt has a longer plasma half-life and greater resistance to plasminogen activator inhibitor-1
   Show answer and explanation

   Correct answer: D. It has a longer plasma half-life and greater resistance to plasminogen activator inhibitor-1

   Tenecteplase is a genetically engineered variant of alteplase with amino acid substitutions that prolong plasma half-life to about 20 minutes, increase fibrin specificity and confer roughly 80-fold greater resistance to plasminogen activator inhibitor-1, permitting single-bolus administration. Streptokinase is the antigenic streptococcal-derived, non-fibrin-specific agent; tenecteplase is more, not less, fibrin specific, and it does not act via glycoprotein IIb/IIIa.

   Reference: ASSENT-2 trial, Lancet 1999; ESC Guidelines for the Management of Acute Coronary Syndromes, 2023

4. Question 4 · Hypertension, Pulmonary Hypertension and Preventive Cardiology

   Which set of findings correctly summarises the ASPREE trial of low-dose aspirin in community-dwelling adults aged 70 years and over without cardiovascular disease?

   1. AAspirin significantly reduced cardiovascular events and all-cause mortality with no increase in bleeding
   2. BAspirin did not prolong disability-free survival, significantly increased major haemorrhage, and was associated with higher all-cause mortality driven largely by cancer deaths
   3. CAspirin reduced dementia incidence but increased ischaemic stroke
   4. DAspirin halved the incidence of colorectal cancer and reduced major bleeding
   Show answer and explanation

   Correct answer: B. Aspirin did not prolong disability-free survival, significantly increased major haemorrhage, and was associated with higher all-cause mortality driven largely by cancer deaths

   ASPREE found no benefit of aspirin 100 mg daily on its primary endpoint of disability-free survival, a significant excess of major haemorrhage, and an unexpected increase in all-cause mortality driven mainly by cancer-related deaths. Cardiovascular events were not significantly reduced, and no benefit was demonstrated on dementia or physical disability. The trial, together with ASCEND and ARRIVE, underpins the current recommendation against initiating aspirin for primary prevention in older adults.

   Reference: ASPREE Investigators, N Engl J Med 2018;379:1499-1508, 1509-1518 and 1519-1528

5. Question 5 · Systemic Disease, Cardio-Obstetrics and Special Populations

   A 61-year-old man has taken amiodarone for 18 months for recurrent ventricular tachycardia. He develops weight loss and worsening arrhythmia. TSH is suppressed with elevated free T4 and free T3. There is no goitre, no thyroid antibodies, and colour flow Doppler of the thyroid shows absent parenchymal vascularity. What is the most appropriate treatment?

   1. AHigh-dose carbimazole alone
   2. BUrgent total thyroidectomy
   3. CPotassium perchlorate combined with methimazole
   4. DOral prednisolone
   Show answer and explanation

   Correct answer: D. Oral prednisolone

   Absent thyroidal vascularity on colour Doppler in a previously normal gland indicates type 2 amiodarone-induced thyrotoxicosis, a destructive thyroiditis releasing preformed hormone, which responds to glucocorticoids. Thionamides with or without perchlorate are the treatment for type 1 disease, which occurs in a nodular or autonomous gland with preserved or increased vascularity. Thyroidectomy is reserved for refractory or mixed disease with severe cardiac decompensation.

   Reference: 2018 European Thyroid Association Guidelines for the Management of Amiodarone-Associated Thyroid Dysfunction (Bartalena et al., European Thyroid Journal)

6. Question 6 · Adult Congenital Heart Disease

   A 30-year-old woman with repaired tetralogy of Fallot and moderate residual pulmonary regurgitation with preserved right ventricular function is 34 weeks pregnant. She is asymptomatic and there are no obstetric complications. What is the most appropriate delivery plan?

   1. AElective caesarean section at 37 weeks to avoid haemodynamic stress
   2. BPlanned vaginal delivery with regional analgesia and an assisted second stage if needed
   3. CElective caesarean section under general anaesthesia at 39 weeks
   4. DInduction at 34 weeks with strict avoidance of any analgesia
   Show answer and explanation

   Correct answer: B. Planned vaginal delivery with regional analgesia and an assisted second stage if needed

   In most women with congenital heart disease, including well-repaired tetralogy of Fallot with preserved ventricular function, vaginal delivery is preferred because it is associated with less blood loss, lower infection and thromboembolic risk, and fewer haemodynamic swings than caesarean section; early regional analgesia blunts the sympathetic surge of labour and an assisted second stage limits prolonged Valsalva. Caesarean section is reserved for obstetric indications or specific cardiac situations such as aortic dilatation, severe obstructive lesions, decompensated heart failure or a patient anticoagulated with a vitamin K antagonist in labour. Preterm induction is not indicated in an asymptomatic, stable patient.

   Reference: 2018 ESC Guidelines for the Management of Cardiovascular Diseases During Pregnancy, European Heart Journal 2018

7. Question 7 · Pericardial Disease

   A 39-year-old HIV-positive man not yet established on antiretroviral therapy has confirmed tuberculous pericarditis with a large effusion. Standard four-drug antituberculous therapy is started. Regarding adjunctive corticosteroids, which statement is correct?

   1. AAdjunctive prednisolone reliably reduces all-cause mortality in every patient with tuberculous pericarditis
   2. BCorticosteroids are mandatory in HIV-positive patients to prevent immune reconstitution disease
   3. CIn the IMPI trial adjunctive prednisolone did not reduce the primary composite outcome, and among HIV-positive patients it was associated with an increased incidence of HIV-associated malignancy, so it should be avoided in this group
   4. DCorticosteroids are contraindicated in HIV-negative patients with tuberculous pericarditis
   Show answer and explanation

   Correct answer: C. In the IMPI trial adjunctive prednisolone did not reduce the primary composite outcome, and among HIV-positive patients it was associated with an increased incidence of HIV-associated malignancy, so it should be avoided in this group

   The IMPI randomised trial found no reduction in the composite of death, tamponade requiring pericardiocentesis or constriction with adjunctive prednisolone, although it did reduce constrictive pericarditis and hospitalisation; in HIV-positive participants it significantly increased HIV-associated malignancy, chiefly Kaposi sarcoma. Corticosteroids may therefore be considered selectively in HIV-negative patients (particularly with large effusions or marked inflammation) but should be avoided in HIV-positive patients not on antiretroviral therapy, making options A, B and D incorrect.

   Reference: Mayosi et al., IMPI trial, New England Journal of Medicine 2014; ESC Pericardial Disease Guidelines 2015

8. Question 8 · Heart Failure and Cardiomyopathies

   A 54-year-old woman with obstructive hypertrophic cardiomyopathy (resting LVOT gradient 68 mmHg, EF 68%) remains NYHA class III on maximally tolerated beta-blockade. She is started on mavacamten. Which monitoring requirement is most important during therapy?

   1. ASerial serum potassium because of a high risk of hyperkalaemia
   2. BSerial echocardiographic assessment of ejection fraction, with dose interruption if EF falls below 50%
   3. CWeekly liver function tests for the first 3 months
   4. DRegular ophthalmological review for retinal deposits
   Show answer and explanation

   Correct answer: B. Serial echocardiographic assessment of ejection fraction, with dose interruption if EF falls below 50%

   Mavacamten is a selective cardiac myosin inhibitor that reduces actin-myosin cross-bridge formation and hypercontractility; its principal hazard is excessive negative inotropy causing systolic dysfunction, so protocolised echocardiography with dose interruption if EF falls below 50% is mandated, along with attention to CYP2C19/CYP3A4 interactions and avoidance in pregnancy. Hyperkalaemia, hepatotoxicity and retinal deposition are not recognised class effects of mavacamten.

   Reference: EXPLORER-HCM (Lancet 2020); VALOR-HCM (JACC 2022); 2024 AHA/ACC Guideline for the Management of Hypertrophic Cardiomyopathy

9. Question 9 · Arrhythmias, Electrophysiology and ECG Interpretation

   A 76-year-old man has had three episodes of unexplained syncope without prodrome. His ECG shows right bundle branch block with left anterior fascicular block and a PR interval of 190 ms. Ambulatory monitoring and echocardiography are unremarkable. At electrophysiology study his baseline HV interval is 85 ms. What is the most appropriate management?

   1. AReassure him; the syncope is most likely vasovagal
   2. BImplant a permanent pacemaker
   3. CImplant a loop recorder and review in 12 months
   4. DStart fludrocortisone and increase salt intake
   Show answer and explanation

   Correct answer: B. Implant a permanent pacemaker

   In a patient with bifascicular block and unexplained syncope, a baseline HV interval of 70 ms or more at electrophysiology study demonstrates infra-Hisian conduction disease and is a class I indication for permanent pacing, since intermittent complete infranodal block is the likely mechanism. Syncope without prodrome in an elderly patient with conduction disease is not typical of reflex syncope, so reassurance and fludrocortisone are inappropriate. A loop recorder is reserved for unexplained syncope when the electrophysiology study is negative; here the study has already provided the diagnosis.

   Reference: 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy (European Heart Journal, 2021); 2018 ESC Guidelines for the diagnosis and management of syncope

10. Question 10 · Cardiovascular Imaging and Diagnostic Testing

    Simultaneous high-fidelity left and right ventricular pressure recordings during quiet respiration in a patient with unexplained oedema and raised jugular venous pressure show right ventricular systolic pressure rising while left ventricular systolic pressure falls during inspiration, with the opposite pattern during expiration. What does this discordance indicate?

    1. ARestrictive cardiomyopathy
    2. BSevere pulmonary arterial hypertension
    3. CConstrictive pericarditis
    4. DChronic obstructive pulmonary disease alone
    Show answer and explanation

    Correct answer: C. Constrictive pericarditis

    Respiratory discordance of right and left ventricular systolic pressures reflects enhanced ventricular interdependence within a fixed pericardial volume and is the most accurate invasive discriminator of constrictive pericarditis, with a systolic area index above 1.1 offering high sensitivity and specificity. In restrictive cardiomyopathy the two ventricular pressures rise and fall concordantly with respiration, and the left ventricular end-diastolic pressure typically exceeds the right by more than 5 mmHg. Pulmonary hypertension and airflow obstruction do not produce this pattern of interdependence.

    Reference: Talreja DR et al., Constrictive pericarditis in the modern era: novel criteria for diagnosis in the cardiac catheterization laboratory, J Am Coll Cardiol 2008; 2015 ESC Pericardial Disease Guidelines

11. Question 11 · Aortic Disease and Peripheral Vascular Disease

    A 73-year-old man with diffuse atherosclerosis has a 75% ostial right renal artery stenosis with a normal-sized left kidney and stable creatinine of 128 micromol/L. His blood pressure is 138/78 mmHg on two agents and he has no episodes of flash pulmonary oedema. What does the best available randomised evidence support?

    1. ARenal artery stenting reduces cardiovascular and renal events compared with medical therapy in this situation
    2. BBilateral nephrectomy with dialysis to control renin-driven hypertension
    3. CACE inhibitors are absolutely contraindicated in all unilateral renal artery stenosis
    4. DOptimal medical therapy alone, as stenting has not shown incremental benefit in this setting
    Show answer and explanation

    Correct answer: D. Optimal medical therapy alone, as stenting has not shown incremental benefit in this setting

    The ASTRAL and CORAL randomised trials showed no significant benefit of renal artery revascularisation added to optimal medical therapy for atherosclerotic renal artery stenosis in terms of blood pressure control, renal function or cardiovascular events, while procedural complications occurred. Revascularisation is therefore reserved for selected patients with recurrent flash pulmonary oedema, rapidly deteriorating renal function, or truly refractory hypertension. Nephrectomy is not a management option here, and ACE inhibitors are appropriate in unilateral stenosis with monitoring of creatinine and potassium; they are avoided principally in bilateral stenosis or stenosis in a solitary functioning kidney.

    Reference: ASTRAL trial (NEJM 2009); CORAL trial (Cooper et al., NEJM 2014); 2017 ESC/ESVS Peripheral Arterial Diseases Guidelines

12. Question 12 · Systemic Disease, Cardio-Obstetrics and Special Populations

    A 46-year-old man presents with heart failure. Echocardiography shows a dilated left ventricle with an ejection fraction of 32%. He also has newly diagnosed diabetes, painful metacarpophalangeal joints and slate-grey skin pigmentation. Ferritin is 1900 microgram/L and transferrin saturation is 78%. He has never been transfused. What is the most appropriate next step?

    1. AStart deferasirox as first-line therapy for iron removal
    2. BPerform liver biopsy, which remains essential for diagnosis
    3. CPerform HFE genotyping and begin therapeutic venesection alongside guideline-directed heart failure therapy
    4. DAttribute the ferritin elevation to heart failure as an acute phase response and take no specific action
    Show answer and explanation

    Correct answer: C. Perform HFE genotyping and begin therapeutic venesection alongside guideline-directed heart failure therapy

    A transferrin saturation above 45% with a high ferritin in a non-transfused patient with the triad of cardiomyopathy, diabetes and arthropathy points to hereditary haemochromatosis, confirmed by HFE genotyping, and venesection is the first-line iron removal therapy in a patient who is not anaemic. Chelation is reserved for those who cannot tolerate venesection or who are anaemic, typically secondary iron overload. Liver biopsy and MRI now have a limited confirmatory role once genotyping is available, and a raised transferrin saturation is not explained by an acute phase response, which typically raises ferritin while saturation stays normal or low.

    Reference: EASL Clinical Practice Guidelines on haemochromatosis, Journal of Hepatology 2022; 2023 ESC Guidelines for the management of cardiomyopathies

Cardiology reference books and guidelines

Every question in this bank names the textbook or guideline its answer rests on. These are the sources our Cardiology questions cite most often - the reading list to revise from alongside the bank.

Where your regulator publishes a reading list, use the editions it names. Exam questions are not taken from any one book.