Free Cardiology mock test

Cardiology sample questions with answers

10 more original exam-style Cardiology questions, worked in full. They are not real or recalled exam questions, and none of them is in the mock above or on the bank page, so sit the mock first if you have not.

1. Question 1 · Heart Failure and Cardiomyopathies

   A 63-year-old man with previous mediastinal radiotherapy has ascites, raised JVP with a prominent y descent and Kussmaul sign. Echocardiography shows normal wall thickness, a septal bounce, respirophasic septal shift, medial e' of 12 cm/s exceeding lateral e' (annulus reversus), and expiratory diastolic flow reversal in the hepatic veins. Which diagnosis do these findings support?

   1. AConstrictive pericarditis
   2. BRestrictive cardiomyopathy due to amyloidosis
   3. CSevere tricuspid regurgitation
   4. DRight ventricular infarction
   Show answer and explanation

   Correct answer: A. Constrictive pericarditis

   Septal bounce, respirophasic septal shift, annulus reversus (medial e' greater than lateral because the lateral annulus is tethered by the rigid pericardium), preserved or exaggerated medial e' and expiratory hepatic vein diastolic flow reversal are the Mayo echocardiographic criteria for constriction, and prior mediastinal radiotherapy is a classic cause. Restrictive cardiomyopathy typically shows increased wall thickness, biatrial enlargement and reduced tissue Doppler velocities at both annuli without respiratory interdependence. The findings are not those of isolated tricuspid regurgitation or right ventricular infarction.

   Reference: Welch et al., Echocardiographic diagnosis of constrictive pericarditis (Circ Cardiovasc Imaging 2014); 2015 ESC Guidelines on pericardial diseases

2. Question 2 · Arrhythmias, Electrophysiology and ECG Interpretation

   A 72-year-old man undergoes uncomplicated implantation of a Watchman left atrial appendage occlusion device. Transoesophageal echocardiography at the end of the procedure confirms good device seating with no peri-device leak. Which post-procedural antithrombotic regimen corresponds to the protocol used in the pivotal PROTECT AF and PREVAIL trials?

   1. AAspirin alone from the day of implantation
   2. BOral anticoagulation plus aspirin for 45 days, then dual antiplatelet therapy until 6 months, then aspirin alone
   3. CLifelong full-dose oral anticoagulation in addition to the device
   4. DNo antithrombotic therapy at all after implantation
   Show answer and explanation

   Correct answer: B. Oral anticoagulation plus aspirin for 45 days, then dual antiplatelet therapy until 6 months, then aspirin alone

   The trial protocol continued oral anticoagulation with aspirin for 45 days until imaging confirmed device sealing and endothelialisation, then switched to dual antiplatelet therapy until six months, then aspirin alone indefinitely. Aspirin alone from day one or no therapy at all leaves the un-endothelialised device surface exposed and risks device-related thrombus. Lifelong full-dose anticoagulation would defeat the whole purpose of the device, which is to allow anticoagulation to be stopped.

   Reference: Holmes DR et al. PROTECT AF, Lancet (2009) and PREVAIL, Journal of the American College of Cardiology (2014); 2023 ACC/AHA/ACCP/HRS Atrial Fibrillation Guideline

3. Question 3 · Cardiovascular Imaging and Diagnostic Testing

   A 34-year-old man has concentric left ventricular hypertrophy of 16 mm, proteinuria, a history of burning pain in the hands and feet since childhood, and corneal whorling. Cardiac MRI shows basal inferolateral mid-wall late gadolinium enhancement and a reduced native myocardial T1 value. What is the most likely diagnosis?

   1. ACardiac AL amyloidosis
   2. BAnderson-Fabry disease
   3. CSarcomeric hypertrophic cardiomyopathy
   4. DHypertensive heart disease
   Show answer and explanation

   Correct answer: B. Anderson-Fabry disease

   Reduced (low) native myocardial T1 is essentially specific to intramyocardial sphingolipid accumulation in Anderson-Fabry disease, and the basal inferolateral mid-wall late gadolinium enhancement plus acroparaesthesia, cornea verticillata and proteinuria complete a classic picture. Both AL and ATTR amyloidosis raise native T1 and extracellular volume, typically with diffuse subendocardial enhancement and difficult myocardial nulling. Sarcomeric hypertrophic cardiomyopathy and hypertensive heart disease show normal or mildly elevated native T1 and lack the extracardiac features.

   Reference: Sado DM et al., Identification of Anderson-Fabry disease by T1 mapping, Circulation: Cardiovascular Imaging 2013; 2023 ESC Guidelines for the Management of Cardiomyopathies

4. Question 4 · Aortic Disease and Peripheral Vascular Disease

   A 31-year-old woman has thin translucent skin with visible veins, easy bruising, a history of spontaneous sigmoid colon perforation at age 27, and a first-degree relative who died of a ruptured artery in the third decade. Genetic testing identifies a pathogenic COL3A1 variant. Which statement about her management is correct?

   1. AElective arterial surgery and routine invasive angiography are preferred because arterial tissue holds sutures well
   2. BAortic root replacement is indicated once the root reaches 4.0 cm, as in Loeys-Dietz syndrome
   3. CEctopia lentis is the characteristic ocular finding and mandates annual slit-lamp examination
   4. DNon-invasive imaging surveillance is preferred and celiprolol has been shown to reduce arterial events
   Show answer and explanation

   Correct answer: D. Non-invasive imaging surveillance is preferred and celiprolol has been shown to reduce arterial events

   A COL3A1 pathogenic variant establishes vascular Ehlers-Danlos syndrome, in which arterial and hollow-viscus tissue is extremely friable; elective invasive arteriography and surgery carry high complication rates, so non-invasive imaging (CT/MR angiography, ultrasound) is preferred and intervention is generally reserved for life-threatening events at experienced centres. The BBEST trial demonstrated that celiprolol reduced arterial rupture and dissection events in vascular EDS. Ectopia lentis is a feature of Marfan syndrome, not vascular EDS, and the low-diameter surgical thresholds used in Loeys-Dietz syndrome are not the paradigm for vascular EDS, where rupture often occurs at normal diameters.

   Reference: 2022 ACC/AHA Aortic Disease Guideline; BBEST trial (Ong et al., Lancet 2010); 2017 International Classification of the Ehlers-Danlos Syndromes

5. Question 5 · Professionalism, Ethics, Patient Safety and Quality

   A 48-year-old professional heavy-goods-vehicle driver receives a secondary-prevention ICD after resuscitated ventricular fibrillation. He asks when he can return to work. What advice is correct?

   1. AHe may resume commercial driving after six months if he receives no shocks
   2. BHe may resume driving immediately, since the device now protects him
   3. CHe is permanently disqualified from professional/commercial driving; private driving may resume after the restriction period specified by the applicable regulations
   4. DRestrictions apply only if he actually receives a device therapy
   Show answer and explanation

   Correct answer: C. He is permanently disqualified from professional/commercial driving; private driving may resume after the restriction period specified by the applicable regulations

   Across European and most international licensing frameworks, implantation of an ICD for any indication is a permanent bar to Group 2 (commercial/heavy vehicle) licensing because of the consequences of incapacity at the wheel of a large vehicle. Private (Group 1) driving is restricted for a defined period after a secondary-prevention implant and after any appropriate shock, then permitted if the patient is stable. The restriction is triggered by the underlying arrhythmic risk and the implant itself, not only by the occurrence of a shock, and requires sensitive occupational counselling and support.

   Reference: ESC Consensus on Driving and Arrhythmias / 2022 ESC Guidelines for the Management of Ventricular Arrhythmias and Prevention of Sudden Cardiac Death; DVLA Assessing Fitness to Drive (current edition)

6. Question 6 · Basic Cardiovascular Sciences and Clinical Examination

   A 39-year-old woman from a rheumatic-endemic region has mitral stenosis with a loud S1, an opening snap and a mid-diastolic rumble. Compared with her examination two years ago, the interval between the aortic component of S2 and the opening snap is now shorter. What does this change indicate?

   1. ASignificant aortic regurgitation has developed
   2. BThe stenosis has become less severe
   3. CThe mitral valve has become heavily calcified and immobile
   4. DThe stenosis has become more severe with a higher left atrial pressure
   Show answer and explanation

   Correct answer: D. The stenosis has become more severe with a higher left atrial pressure

   The opening snap occurs when left ventricular pressure falls below left atrial pressure; as left atrial pressure rises with worsening stenosis, the valve opens earlier and the A2-opening snap interval shortens, so a short interval indicates more severe disease. A longer interval indicates milder stenosis. A heavily calcified immobile valve tends to abolish both the loud S1 and the opening snap rather than shorten the interval, and coexisting aortic regurgitation does not shorten A2-OS in this way.

   Reference: 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease; Braunwald's Heart Disease, 12th edition, 2022

7. Question 7 · Coronary Artery Disease and Acute Coronary Syndromes

   A 51-year-old woman has recurrent rest chest pain, often in the early morning, with transient ST elevation captured on a Holter recording. Angiography shows unobstructed coronaries, and intracoronary acetylcholine provocation reproduces her pain with more than 90% focal epicardial narrowing and ST elevation, relieved by intracoronary nitrate. Which management is most appropriate?

   1. AA non-dihydropyridine or dihydropyridine calcium channel blocker as first-line therapy, avoiding non-selective beta-blockers
   2. BHigh-dose bisoprolol as first-line therapy
   3. CImmediate stenting of the segment that narrowed during provocation
   4. DLong-term dual antiplatelet therapy with no anti-anginal drug
   Show answer and explanation

   Correct answer: A. A non-dihydropyridine or dihydropyridine calcium channel blocker as first-line therapy, avoiding non-selective beta-blockers

   The findings define epicardial vasospastic (Prinzmetal) angina, for which calcium channel blockers, often combined with long-acting nitrates, are first-line and smoking cessation is essential. Non-selective beta-blockers can worsen spasm through unopposed alpha-mediated vasoconstriction, stenting a spastic but anatomically normal segment does not treat the disorder and risks stent-related complications, and antiplatelet therapy alone does not prevent spasm.

   Reference: COVADIS international standardised diagnostic criteria for vasospastic angina (2017); ESC Chronic Coronary Syndromes Guidelines (2024)

8. Question 8 · Valvular Heart Disease and Infective Endocarditis

   A 74-year-old man with a body surface area of 2.1 m2 underwent surgical aortic valve replacement with a 19 mm bioprosthesis. At the six-week echocardiogram he has a mean gradient of 32 mmHg, normal leaflet opening on fluoroscopy, no paravalvular or transvalvular regurgitation, and an indexed effective orifice area of 0.60 cm2/m2. What is the most likely explanation?

   1. ASevere patient-prosthesis mismatch
   2. BProsthetic valve thrombosis
   3. CPannus ingrowth causing obstruction
   4. DEarly structural valve deterioration
   Show answer and explanation

   Correct answer: A. Severe patient-prosthesis mismatch

   An indexed effective orifice area of 0.65 cm2/m2 or less in the aortic position defines severe patient-prosthesis mismatch, which produces high gradients from the first postoperative study despite a structurally normal, normally moving prosthesis, and is typical of a small prosthesis in a large patient. Thrombosis and pannus cause restricted leaflet motion and generally develop later, with thrombosis usually accompanied by subtherapeutic anticoagulation and a mass on imaging. Structural deterioration of a bioprosthesis takes years and is usually accompanied by leaflet thickening, calcification or new regurgitation.

   Reference: 2021 ESC/EACTS Valvular Heart Disease Guidelines; EACVI/ASE Recommendations for the Imaging Assessment of Prosthetic Heart Valves (2016)

9. Question 9 · Cardiac Pharmacology and Therapeutics

   A 52-year-old woman on stable warfarin for a mechanical mitral valve has an unexpectedly high INR of 6.2 without bleeding. She recently started a new medication. Which of the following is the most likely culprit through inhibition of warfarin metabolism?

   1. ARifampicin
   2. BCarbamazepine
   3. CFluconazole
   4. DCholestyramine
   Show answer and explanation

   Correct answer: C. Fluconazole

   Fluconazole is a potent inhibitor of CYP2C9, the enzyme clearing the more active S-enantiomer of warfarin, so it raises INR sharply. Rifampicin and carbamazepine are strong enzyme inducers that lower INR, and cholestyramine reduces warfarin absorption and therefore also lowers INR.

   Reference: Goodman & Gilman's The Pharmacological Basis of Therapeutics, 14th edition, 2023; CHEST Antithrombotic Therapy Guidelines

10. Question 10 · Hypertension, Pulmonary Hypertension and Preventive Cardiology

    A 59-year-old man with prior myocardial infarction and type 2 diabetes has LDL cholesterol at goal (1.3 mmol/L) on maximally tolerated atorvastatin, but fasting triglycerides remain 2.6 mmol/L (230 mg/dL) after alcohol and glycaemic optimisation. Which addition has randomised evidence of reducing cardiovascular events in this setting?

    1. AExtended-release niacin
    2. BFenofibrate
    3. CIcosapent ethyl 2 g twice daily
    4. DMixed omega-3 fish oil supplement 1 g daily
    Show answer and explanation

    Correct answer: C. Icosapent ethyl 2 g twice daily

    REDUCE-IT randomised statin-treated patients with elevated triglycerides and either established cardiovascular disease or diabetes with risk factors, and showed a 25% relative reduction in the primary composite endpoint with high-dose icosapent ethyl (purified eicosapentaenoic acid), at the cost of increased atrial fibrillation and bleeding. Niacin failed to add benefit on a statin background in AIM-HIGH and HPS2-THRIVE, fibrate outcome trials such as ACCORD-Lipid and PROMINENT were neutral overall, and low-dose mixed omega-3 supplements have not reduced events.

    Reference: REDUCE-IT (Bhatt et al., N Engl J Med 2019;380:11-22); PROMINENT (Das Pradhan et al., N Engl J Med 2022)