Cardiology Prometric exam questions with answers

1. Question 1Coronary Artery Disease and Acute Coronary Syndromesmedium

   A 58-year-old man presents to a hospital without catheterisation facilities 2 hours after onset of chest pain, with 3 mm ST elevation in V1 to V5. Transfer for primary PCI would take about 150 minutes from diagnosis. He has no contraindications to fibrinolysis. What is the most appropriate strategy?

   1. AGive fibrinolysis and manage locally without angiography
   2. BStart heparin alone and observe for spontaneous reperfusion
   3. CGive fibrinolysis now, then transfer to a PCI-capable centre
   4. DTransfer for primary PCI regardless of the expected delay
   Show answer and explanation▾

   Answer: C. Give fibrinolysis now, then transfer to a PCI-capable centre

   When primary PCI cannot be delivered within 120 minutes of STEMI diagnosis, guidelines recommend fibrinolysis within 12 hours of symptom onset, ideally within 10 minutes of diagnosis. All patients should then be transferred to a PCI centre for rescue PCI if lysis fails, or routine angiography within 2 to 24 hours if it succeeds. Accepting a 150-minute delay to primary PCI loses the time advantage of reperfusion.

2. Question 2Coronary Artery Disease and Acute Coronary Syndromeshard

   Four days after a late-presenting anterior STEMI, a 69-year-old woman develops sudden dyspnoea and hypotension with a new harsh holosystolic murmur and thrill at the left lower sternal border. Right heart catheterisation shows oxygen saturation of 64% in the right atrium and 82% in the pulmonary artery. What is the most likely diagnosis?

   1. ALeft ventricular free wall rupture with tamponade
   2. BPost-infarction ventricular septal rupture
   3. CRight ventricular infarction with low output
   4. DPapillary muscle rupture with acute mitral regurgitation
   Show answer and explanation▾

   Answer: B. Post-infarction ventricular septal rupture

   An oxygen saturation step-up between the right atrium and pulmonary artery indicates a left-to-right shunt at ventricular level, which with a new harsh murmur and thrill after a late-presenting MI confirms septal rupture. Papillary muscle rupture causes acute mitral regurgitation with pulmonary oedema and large v waves but no oximetric step-up, and its murmur is often soft and apical. Management is haemodynamic support followed by surgical or transcatheter closure.

3. Question 3Heart Failure and Cardiomyopathiesmedium

   A 76-year-old woman with heart failure with preserved ejection fraction (LVEF 58%) remains NYHA class II on furosemide 40 mg daily. Blood pressure is 138/76 mmHg, eGFR 48 mL/min/1.73 m2, and she does not have diabetes. Which addition is most strongly recommended to reduce heart failure hospitalisation or cardiovascular death?

   1. ASpironolactone
   2. BAn SGLT2 inhibitor such as empagliflozin or dapagliflozin
   3. CDigoxin
   4. DIvabradine
   Show answer and explanation▾

   Answer: B. An SGLT2 inhibitor such as empagliflozin or dapagliflozin

   EMPEROR-Preserved and DELIVER showed that SGLT2 inhibitors reduce the composite of heart failure hospitalisation or cardiovascular death in patients with mildly reduced or preserved ejection fraction, regardless of diabetes, and they now carry a class I recommendation. Spironolactone has weaker evidence in HFpEF (TOPCAT) and only a weak recommendation in selected patients. Digoxin and ivabradine have no outcome benefit in HFpEF.

4. Question 4Heart Failure and Cardiomyopathieshard

   A 79-year-old man with heart failure with preserved ejection fraction has a history of bilateral carpal tunnel syndrome, low-voltage QRS complexes despite left ventricular wall thickness of 17 mm, and apical sparing on strain imaging. Technetium-99m pyrophosphate scintigraphy shows grade 3 myocardial uptake. Which additional result allows a non-biopsy diagnosis of transthyretin cardiac amyloidosis?

   1. ADiffuse late gadolinium enhancement on cardiac MRI
   2. BNo monoclonal protein on serum and urine immunofixation and a normal free light chain ratio
   3. CA persistently normal high-sensitivity troponin
   4. DAn NT-proBNP concentration above 3,000 ng/L
   Show answer and explanation▾

   Answer: B. No monoclonal protein on serum and urine immunofixation and a normal free light chain ratio

   Grade 2 or 3 myocardial uptake on bone scintigraphy has very high specificity for ATTR cardiac amyloidosis, but only once AL amyloidosis has been excluded, because AL can also cause uptake. Absence of a monoclonal protein on serum and urine immunofixation with a normal free light chain ratio therefore allows diagnosis without biopsy, followed by TTR gene sequencing. NT-proBNP and MRI enhancement support amyloidosis but do not distinguish ATTR from AL.

5. Question 5Valvular Heart Disease and Infective Endocarditismedium

   An 83-year-old woman with exertional syncope has severe aortic stenosis (peak velocity 4.6 m/s, mean gradient 52 mmHg, valve area 0.7 cm2), a tricuspid aortic valve and suitable iliofemoral access. Which intervention is most appropriate?

   1. ATransfemoral transcatheter aortic valve implantation
   2. BMedical therapy with repeat echocardiography in 6 months
   3. CSurgical replacement with a mechanical prosthesis
   4. DBalloon aortic valvuloplasty as definitive treatment
   Show answer and explanation▾

   Answer: A. Transfemoral transcatheter aortic valve implantation

   Symptomatic severe aortic stenosis requires valve intervention, and for older patients with suitable transfemoral access (ESC age 75 or over, ACC/AHA over 80) TAVI is recommended. Balloon valvuloplasty has short-lived benefit and is only a bridge or palliation. A mechanical surgical valve would require lifelong warfarin and is not appropriate at this age.

6. Question 6Arrhythmias, Electrophysiology and ECG Interpretationmedium

   A 24-year-old man has palpitations. The ECG shows an irregular, broad-complex tachycardia at 230/min with varying QRS morphology and delta waves. Blood pressure is 124/78 mmHg. Which drug is contraindicated?

   1. AIntravenous procainamide
   2. BIntravenous ibutilide
   3. CIntravenous flecainide
   4. DIntravenous verapamil
   Show answer and explanation▾

   Answer: D. Intravenous verapamil

   This is pre-excited atrial fibrillation in Wolff-Parkinson-White syndrome. AV nodal blocking drugs such as verapamil, diltiazem, digoxin, adenosine and beta-blockers can increase conduction down the accessory pathway and precipitate ventricular fibrillation. Drugs that slow accessory pathway conduction, such as procainamide or ibutilide, or synchronised cardioversion if unstable, are appropriate, followed by catheter ablation.

7. Question 7Arrhythmias, Electrophysiology and ECG Interpretationeasy

   A 74-year-old man has episodes of dizziness. His ECG shows a constant PR interval of 180 ms with intermittent P waves not followed by a QRS complex, and right bundle branch block. No reversible cause is found. What is the most appropriate management?

   1. AReassurance, as this rhythm is benign
   2. BOral theophylline to increase the heart rate
   3. CPermanent pacemaker implantation
   4. DLow-dose bisoprolol to control symptoms
   Show answer and explanation▾

   Answer: C. Permanent pacemaker implantation

   Dropped beats with a constant PR interval define Mobitz type II block, which reflects infranodal conduction disease, frequently progresses to complete heart block and is an indication for permanent pacing, especially when symptomatic. It is not benign, unlike Wenckebach (Mobitz I) block with a narrow QRS. Beta-blockers would worsen conduction.

8. Question 8Cardiac Pharmacology and Therapeuticsmedium

   An 81-year-old woman taking digoxin presents with nausea, yellow-tinged vision and bidirectional ventricular tachycardia. Serum potassium is 6.3 mmol/L and creatinine has doubled from baseline. What is the most appropriate specific treatment?

   1. AIntravenous amiodarone
   2. BIntravenous magnesium alone
   3. CDigoxin-specific antibody fragments
   4. DHaemodialysis to remove digoxin
   Show answer and explanation▾

   Answer: C. Digoxin-specific antibody fragments

   Life-threatening arrhythmia and hyperkalaemia in digoxin toxicity are indications for digoxin-specific antibody fragments, which bind digoxin and reverse its effects within an hour. Digoxin has a large volume of distribution, so haemodialysis removes very little. Antiarrhythmics such as amiodarone do not address the cause and may worsen conduction.

9. Question 9Cardiovascular Imaging and Diagnostic Testinghard

   A 66-year-old man with ischaemic cardiomyopathy undergoes dobutamine stress echocardiography. The akinetic anterior wall shows improved thickening at low dose (5 to 10 micrograms/kg/min) and then becomes akinetic again at peak dose. Which interpretation is correct?

   1. AViable but ischaemic myocardium
   2. BViable myocardium without inducible ischaemia
   3. CTransmural scar without viability
   4. DNormal myocardium with a false-positive peak response
   Show answer and explanation▾

   Answer: A. Viable but ischaemic myocardium

   A biphasic response, with contractile reserve at low dose and deterioration at higher dose, indicates viable myocardium supplied by a flow-limiting stenosis and is the pattern most predictive of functional recovery after revascularisation. Sustained improvement suggests viability without significant ischaemia (for example stunning), whereas no change at any dose suggests scar. Revascularisation decisions also consider anatomy and symptoms.

10. Question 10Hypertension, Pulmonary Hypertension and Preventive Cardiologyeasy

    A 62-year-old man's clinic and home blood pressures remain about 156/94 mmHg despite adherence to maximally tolerated amlodipine, ramipril and indapamide. Serum potassium is 4.0 mmol/L and eGFR 70 mL/min/1.73 m2. Secondary causes have been excluded. Which drug is the preferred fourth-line addition?

    1. ASpironolactone
    2. BMoxonidine
    3. CDoxazosin
    4. DHydralazine
    Show answer and explanation▾

    Answer: A. Spironolactone

    In resistant hypertension, low-dose spironolactone was the most effective add-on in the PATHWAY-2 trial and is the preferred fourth agent when potassium is 4.5 mmol/L or less and renal function allows, with monitoring of potassium and creatinine. Doxazosin or a beta-blocker are alternatives if spironolactone is not tolerated or contraindicated. Moxonidine and hydralazine are less effective later options.

11. Question 11Hypertension, Pulmonary Hypertension and Preventive Cardiologymedium

    A 36-year-old woman with idiopathic pulmonary arterial hypertension undergoes acute vasoreactivity testing with inhaled nitric oxide during right heart catheterisation. Which response defines a positive test?

    1. AFall in mean PAP of at least 20%, with any change in cardiac output
    2. BFall in pulmonary vascular resistance of 10%, with a fall in cardiac output
    3. CFall in mean PAP of at least 10 mmHg to 40 mmHg or less, with unchanged or increased cardiac output
    4. DFall in mean PAP to below 25 mmHg, with a fall in cardiac output
    Show answer and explanation▾

    Answer: C. Fall in mean PAP of at least 10 mmHg to 40 mmHg or less, with unchanged or increased cardiac output

    A positive acute vasoreactivity response is a reduction in mean pulmonary arterial pressure of at least 10 mmHg to an absolute value of 40 mmHg or less, with cardiac output unchanged or increased. Only these responders, a small minority, are candidates for high-dose calcium channel blocker therapy. A fall in cardiac output is not an acceptable response.

12. Question 12Pericardial Diseaseeasy

    A 32-year-old man has 2 days of pleuritic chest pain relieved by sitting forward, a pericardial rub, and widespread concave ST elevation with PR depression. Echocardiography shows a small effusion and troponin is normal. What is the recommended first-line treatment?

    1. APericardiocentesis followed by an NSAID
    2. BColchicine alone for 2 weeks
    3. CPrednisolone 1 mg/kg daily as first-line therapy
    4. DHigh-dose aspirin or an NSAID plus colchicine for 3 months
    Show answer and explanation▾

    Answer: D. High-dose aspirin or an NSAID plus colchicine for 3 months

    First-line treatment of acute pericarditis is aspirin or an NSAID with gastroprotection plus colchicine for 3 months, which reduces recurrence. Corticosteroids are second-line because they increase the risk of recurrence and are reserved for contraindications, specific indications or failure. Pericardiocentesis is only needed for tamponade or suspected purulent or neoplastic effusion.

13. Question 13Aortic Disease and Peripheral Vascular Diseasehard

    A 59-year-old hypertensive man has an acute type B aortic dissection on CT. Despite intravenous beta-blockade, he develops a pale left leg with absent pulses and a rising creatinine from renal malperfusion. What is the most appropriate management?

    1. AThoracic endovascular aortic repair (TEVAR)
    2. BContinued medical therapy with tighter blood pressure targets
    3. CFemoro-femoral crossover bypass as the only procedure
    4. DEmergency open replacement of the ascending aorta
    Show answer and explanation▾

    Answer: A. Thoracic endovascular aortic repair (TEVAR)

    Uncomplicated type B dissection is managed medically, but malperfusion, rupture, refractory pain or uncontrolled hypertension define complicated dissection, for which TEVAR to cover the primary entry tear and expand the true lumen is the recommended treatment. Further medical therapy will not relieve dynamic visceral and limb malperfusion. Ascending aortic replacement is for type A dissection, and an extra-anatomic bypass would not treat renal malperfusion.

14. Question 14Systemic Disease, Cardio-Obstetrics and Special Populationsmedium

    A 28-year-old woman at 24 weeks' gestation has rheumatic mitral stenosis (valve area 1.1 cm2) and new exertional dyspnoea, with a heart rate of 108/min in sinus rhythm. What is the most appropriate first step?

    1. AStart an ACE inhibitor to reduce afterload
    2. BStart digoxin to control the heart rate
    3. CArrange urgent percutaneous mitral commissurotomy
    4. DStart a beta-1 selective blocker such as metoprolol
    Show answer and explanation▾

    Answer: D. Start a beta-1 selective blocker such as metoprolol

    The increased heart rate and blood volume of pregnancy shorten diastolic filling and raise left atrial pressure in mitral stenosis; a beta-1 selective blocker (with diuretics if congested) is first-line, and percutaneous commissurotomy is considered if symptoms persist despite medical therapy. ACE inhibitors are contraindicated in pregnancy. Digoxin does not usefully slow sinus rhythm.

15. Question 15Basic Cardiovascular Sciences and Clinical Examinationeasy

    A 30-year-old woman has a mid-systolic click followed by a late systolic murmur at the apex. Which manoeuvre would move the click earlier in systole?

    1. ASustained isometric handgrip
    2. BStanding up from a squatting position
    3. CPassive leg raising
    4. DSquatting from a standing position
    Show answer and explanation▾

    Answer: B. Standing up from a squatting position

    Reducing left ventricular volume makes the mitral leaflets prolapse earlier, so standing (or the strain phase of Valsalva) moves the click earlier and lengthens the murmur. Squatting and passive leg raising increase venous return and LV size, delaying the click. Handgrip increases afterload and LV size, which also delays the click.

Last reviewed September 2026. Questions are original and written to the published exam blueprint; they are not taken from any real paper.