Question 3.
a) What do you understand by the term “cardiomyopathy”?
b) Give a classification of cardiomyopathy.
A 28 year old athlete collapses and dies suddenly during a ½ marathon race. At autopsy, he is found to
have cardiomegaly, with a posterior left ventricular wall thickness of 16mm, and a septal wall thickness of
27 mm.
(a) What condition did this man have, and why? (give reasons for your opinion).
(b) What would you reasonably expect to see on histological examination of tissue samples of this man’s
(5 marks)
(a) Briefly discuss “splitting” of the second heart sound, its underlying cause(s) and timing.
(8 marks)
(b) “Fixed splitting” (of the second heart sound) is a sign of what condition(s)?
(2 marks)
Question 7.
In the blood microcirculation and / or lymphatic circulation:
a) according to current physiological texts, a significant volume of fluid is thought to
move from plasma to interstitium at the arterial regions of capillaries
b) white blood cells are less deformable than erythrocytes
c) blood viscosity is significantly higher in microvessels than in large blood vessels
d) chylomicra are not a significant component of lymph draining via the right lymph duct
e) the endothelial glycocalyx plays no significant role in the rate of plasma flow along
the capillary
(2.5 marks)
Question 11
Calcium channel blockers
a) are subdivided into four sub-classes, according to their pharmacologic characteristics
b) exert their antihypertensive effects primarily by reducing cardiac contractility
c) have beneficial effects in patients with both hypertension and ischaemic heart disease
d) can cause bilateral ankle oedema
e) do not cause hypokalemia
(2.5 marks)
Patient Presentation: Mr Peters, an 82 year old man, is brought to the emergency department at
Flinders Medical Centre by ambulance. He experienced a sudden loss of consciousness at home,
whilst washing up the dishes in the kitchen. His wife came from another room in the house and
found him lying on the floor. She reported that he was initially unconscious, with his eyes rolled
back. However he regained consciousness within a minute and was awake and alert, asking what had
happened. The ambulance paramedics reported that he was awake and alert on their arrival 10
minutes after the event, and that his blood pressure was normal, but his pulse was irregular and slow.
Blood sugar was normal. He had not sustained any significant injury with the collapse, except for a
small bruise on the arm. He remained stable on transfer and on arrival at the Emergency
Background: Mr Peters’ past medical history includes a prior myocardial infarction in 1993, with
subsequent coronary artery bypass grafting in 1994. He has been generally well in recent years with
only occasional effort angina, responsive to sub-lingual GTN. However over the previous 6 weeks,
he has noticed occasional dizzy spells. His current medications are as follows: Aspirin 150mg daily,
Perindopril 5mg daily, Simvastatin 40mg daily, Frusemide 40mg daily, Atenolol 25mg daily.
List and justify the key clinical examinations you suggest the Emergency Dept. Doctor should perform on
this patient at this time.
(5 marks)
What key specific investigations should be undertaken in this patient within the next 24 hrs?
Explain how each investigation you mention would assist you to establish the underlying
cause(s) of this patient's recent problem.
(10 marks)
Describe the pharmacological mode of action of GTN (anginine), and outline how it works to relieve
chest pain in an appropriate situation?
(10 marks)
Physical examination:
Mr Peters remains stable in the Emergency Department. On examination he is found to have a
systolic murmur in the aortic area. The jugular venous pressure is elevated by 3 cm above normal
and there is mild ankle oedema. The chest sounds clear.
Investigations are as follows:
Blood pressure: 115/70 supine
CBP: Blood count, urea, creatinine and electrolytes are normal.
Troponin T negative.
Thyroid function normal
Non-fasting lipids: cholesterol 5.3, LDL 2.9
CXR shows cardiomegaly.
ECG: see 12 lead ECG on next page.
Echocardiogram: Moderate to severe LV systolic dysfunction with anterior akinesia.
LV ejection fraction 28%. Mild aortic stenosis and mild mitral incompetence.
What is the (a) cardiac rhythm, and (b) the heart rate,
as shown on the 12 lead ECG trace taken the following day?
(5 marks)
The emergency doctor is concerned that Mr Peters has had cardiac syncope. Please give 3 possible
causes for cardiac syncope that might apply in this case.
(9 marks)
Assuming that the now observed LV akinesia is due to a regional infarction in 1993, which coronary
vessel(s) was/were affected at that time?
(5 marks)
(a) Describe the correct procedure of blood pressure measurement:
(6 marks)
(b) Describe the physiological basis of Korotkoff sounds.
(6 marks)
Patient Management: Mr Peters is admitted to hospital and kept under observation on a cardiac
monitor. The atenolol is ceased, because of concern about intermittent bradycardia as a possible
cause of his syncope. Despite cessation of atenolol, the cardiac monitor reveals some prolonged
pauses between QRS complexes (up to 5 seconds duration), with which he feels dizzy.
A decision is made to offer Mr Peters a permanent pacemaker. A biventricular pacemaker is chosen,
as he has significant left ventricular impairment and broad QRS complexes.
After the pacemaker is implanted, Mr Peters is restarted on a different beta blocker (carvedilol is
chosen) and he is anticoagulated with warfarin.
The complete list of his medications at the time of hospital discharge is as follows:
carvedilol 12.5mg bd, warfarin (variable dose adjusted to achieve a target INR of 2-3), perindopril
5mg daily, simvastatin 80mg daily, frusemide 40mg daily.
The postoperative notes say that the left-ventricular (LV) lead of the pacemaker was positioned via
the coronary sinus.
(a) What is the coronary sinus?
(b) Describe precisely where this is located anatomically.
(c) Nominate the ideal location for the distal end of the LV pacemaker lead.
(9 marks)
With respect to his discharge medications, and from the history and findings available so far:
a) Why is the beta blocker carvedilol prescribed for Mr Peters?
b) What is the indication for warfarin in Mr Peters?
(8 marks)
If Mr Peters had died as a result of his myocardial infarction in 1993, outline the sequence of both gross
and microscopic appearances to be seen in the affected myocardium, where the death occurred at 0,
24, 48, 72 hrs, 1-2 weeks, and at >2 months post infarct.
(you may find it convenient to use a table for your answer)
(12 marks)

Question 2.
Describe the initiation of the cardiac action potential, and its dispersal through the heart, mentioning the
role of the Purkinje system and of cardiac skeleton.
(10 marks)
Question 5.
The third heart sound:
a) occurs at the end of early diastolic filling
b) is always pathological
c) is more easily heard with the diaphragm of the stethoscope than the bell
d) may be heard in mitral regurgitation
e) is always absent in atrial fibrillation
(2.5 marks)
Question 7.
Signs associated with aortic stenosis include:
a) a wide pulse pressure
b) a “collapsing” arterial pulse
c) a sustained apex beat consistent with left ventricular hypertrophy
d) a 4th heart sound
e) radiation of a murmur to the carotids
(2.5 marks)
Question 9.
The diagram below depicts normal pressure traces (in mmHg) vs time for the atria, ventricles & outflow
arteries of the right & left heart, during a single cardiac cycle. Lettered arrows label individual graph
Record your answers on the green answer sheet provided.
Write your answers in the appropriate space.
Indicate, using single letters (eg “g”), letter pairs (eg “c-d”), or a series of letters (eg “i-j-k”; “i-j + op”,
etc. as appropriate), the following events of the cardiac cycle:
a) the moment when the softer component of the second heart sound occurs
b) the moment of Tricuspid valve opening
c) the period of iso-volumetric contraction of the right ventricle
d) the period during which a fourth heart sound would be heard, if present
e) the period during which Mitral regurgitation might occur, in a susceptible person.
(10 marks)
Mr Jack Brown, 78-yr-old man, presents to his GP complaining of breathlessness and chest tightness. He reports
gradually worsening exertional breathlessness over the past 12 months, with associated mild chest tightness. He
also reports orthopnoea over the last 3 weeks, requiring 3 pillows to prop himself up at night. He remembers
seeing a respiratory physician 6 months previously and was reassured that he had no evidence of airways disease,
but the symptoms have progressed since then and he remains concerned.
Past Medical History
The history includes known coronary artery disease, with a previous myocardial infarction in 1986 and
subsequent coronary artery bypass surgery in 1987. He has known hypertension and hyperlipidaemia. His
current medication is aspirin 100mg daily, hydrochlorothiazide 12.5mg daily, amlodipine 5mg daily, and
simvastatin 40mg daily.
Clinical Examination
On examination, he appears comfortable sitting at rest. He is in sinus rhythm at 92 beats per minute and has a
blood pressure of 165/90mmHg. The jugular venous pressure is elevated 3cm above the normal level. On
auscultation of the heart, there is a pan-systolic murmur heard loudest at the apex, radiating to the axilla. Chest
examination reveals some scattered crackles at the bases of the lungs. There is mild pitting oedema of both
Question 10.
What is orthopnoea and how is it caused? (5 marks)
Question 11.
a) List the possible causes of a systolic murmur. (4 marks)
b) Indicate how these causes can be distinguished on clinical examination. (4 marks)
c) What is the most likely cause of the systolic murmur in this case? (1 mark)
Question: 12.
a) Describe how JVP is measured. (4 marks)
b) Outline why JVP is a measurement of clinical interest with this patient. (2 marks)
Question 13.
List and justify the preliminary investigations that the GP might arrange at this initial consultation.
(10 marks)
The GP arranges a number of tests, including routine biochemistry & haematology, a 12 lead ECG, a CXR and an
echocardiogram. She also arranges consultation with a cardiologist. The next available cardiologist’s
appointment is in 2 weeks time. The GP defers any additional treatment until the test results are available.
Further Developments
One week later, before he is seen by the cardiologist, Jack wakes in the night at 2am with sudden and severe
breathlessness. It partially settles when he stands up or sits upright in bed, but he remains uncomfortable and
distressed. After 2 hours, he calls an ambulance and is taken to the emergency department (ED).
Observations in Emergency Department
Breathless at rest, oxygen saturation 88% on air. Afebrile (T=36.7)
Heart rate – see rhythm strip below
BP 135/80
JVP to ear lobes sitting upright
Apex beat displaced to the anterior axillary line
Murmur: pansystolic, loudest at apex, radiating to axilla
Chest crackles to mid zones bilaterally
Rapid Troponin T: negative (blood sample taken at 5am)
Print out from cardiac monitor:
Question 14.
What is the rate & rhythm shown on the ECG strip?
(2 marks)
Question 15.
Comment on the clinical significance of the negative troponin T in this instance.
(5 marks)
continued next page
Question 16.
List 2 possible causes of the current decompensation in his condition?
(2 marks)
Question 17.
What would be appropriate immediate treatment in the emergency department?
(5 marks)
Question 18.
If the pressures in Jack’s cardiac chambers, ascending aorta and pulmonary trunk were measured now by
right and left heart catheterization, and the left ventricular diastolic pressure was 30mmHg, predict a
consistent set of pressures throughout the heart and great arteries (ie RA, RV, PA, LA, LV systolic, Ao).
(6 marks)
Ongoing Management
Jack is considered to be in acute pulmonary oedema, probably precipitated by rapid atrial fibrillation. The
initial treatment in the emergency department included sitting the patient up, continuous positive airways
pressure (CPAP), intravenous frusemide (80mg) and intravenous digoxin (500mcg). After 60 minutes he is
much improved. The CPAP is withdrawn and he is comfortable at rest, maintaining O2 saturation 97% with
oxygen via mask.
The following day, an echocardiogram shows a dilated left ventricle with severe global left ventricular
systolic dysfunction (estimated ejection fraction 21%). There is moderate central mitral incompetence into a
dilated left atrium.
Jack is stabilized on medical treatment and allowed home after 5 days in hospital. Discharge medication
comprises: Warfarin (variable dose; target INR 2-3), Frusemide 80mg daily, Ramipril 2.5mg bd, Carvedilol
6.25mg bd, digoxin 125 μg daily, Simvastatin 40mg daily,
Question 19.
a) Describe the mechanism of action of ACE inhibitors.
(8 marks)
b) Nominate a common side effect of ACE inhibitors (15-20% incidence) likely to prevent continued individual
patient use of this drug class, and outline the underlying cause of this side effect.
(2 marks)
Question 20.
If Jack were to die now and come to autopsy, mature scarring (presumably related to the old 1986 MI ) confined
to the anterior LV, associated with ventricular aneurysm formation and mural thrombosis, would be seen.
a) What would have been the pathogenesis of the infarction in 1986?
(5 marks)
b) Describe the coronary artery lesion that would have been expected in the acute phase in 1986, and identify in
which coronary artery the lesion would have been located.
(5 marks)
c) What complications could occur from the current (2007) ventricular mural thrombus?
(3 marks)
d) In which other site(s) in Jack’s heart might thrombus be expected during this autopsy (2007)? Explain!
(2 marks)
Over the following 6 months Jack remained stable, but was still limited by exertional breathlessness. Six
weeks after the above presentation, an attempt was made to cardiovert him from atrial fibrillation; sinus
rhythm was restored, but he was back in atrial fibrillation within 7 days. Subsequent long term strategy for
his atrial fibrillation was by rate control (beta blocker and digoxin) and anticoagulation (warfarin).
Regarding his heart failure, tablet treatment was optimised, with incrementation of ACE inhibitor and beta
blocker treatment to the maximum tolerated doses, plus the addition of spironolactone.
Biventricular pacing (“resynchronisation therapy”) was considered, but Jack was thought unlikely to benefit
from this as he has narrow QRS complexes and no evidence of dysynchrony on a detailed
echocardiographic study. He was however treated with an implantable cardioverter defibrillator to protect
him from lethal arrhythmias, on the basis of the echocardiogram showing severe left ventricular systolic
dysfunction, despite optimal medical treatment.

Question 4.
Mr X is a 63-year-old smoker with a history of hypertension. He has been prescribed diltiazem
(calcium channel antagonist) for his hypertension, but he has been poorly compliant in taking this
medication. You have not seen him for 12 months and he now presents to your general practice
complaining of progressive exertional dyspnea, ankle oedema and orthopnea over the previous 2
months. You suspect he has heart failure.
a) List and justify the key clinical features on history and examination you would explore at this
consultation to help you determine the cause of Mr X’s heart failure?
(5 marks)
b) Two days later, an echocardiogram you ordered confirms severe left ventricular systolic
dysfunction. What medication(s) should Mr X be commenced on? (in your answer, explain
how each drug will help, mechanistically).
(5 marks)
c) List and comment briefly on 5 distinct patho-physiological causes of ankle oedema (not
necessarily present in this patient).
(5 marks)

Question 9.
The diagram below depicts normal pressure traces (in mmHg) vs time for the atria, ventricles &
outflow arteries of the right & left heart, during a single cardiac cycle. Lettered arrows label
individual graph lines.
Indicate, using single letters (eg “g”), letter pairs (eg “c-d”), or a series of letters (eg “i-j-k”; “ij
+ o-p”, as appropriate), the following events of the normal cardiac cycle:
Record your answers on the green answer sheet provided.
Write your answers in the appropriate space.
a) the moment when the louder component of the second heart sound occurs
b) the moment of pulmonary valve opening
c) the period during which diastolic filling of the right ventricle occurs
d) the period during which the “P” wave of the ECG occurs
e) the period during which aortic regurgitation might occur, in a susceptible person.
(10 marks)

Mr Lewis describes the recent discomfort during exercise as a painful tightness or pressure
sensation in the mid-anterior chest ("like a heavy weight sitting on my chest"); this sensation
occasionally radiates to the left jaw and left shoulder area. When the tightness is present, he feels
unable to take a deep breath, although the pain/discomfort does not get worse with breathing. Rest
always relieves the discomfort, and it lasts only a few minutes after he stops exertion.
Past Medical History
He is known to have had hypertension over the last 6 years. He is currently treated with
hydrochlorothiazide (12.5 mg/day). He is not known to be diabetic.
Family History
Mr Lewis’s father died suddenly at age 48 from a presumed heart attack. His mother is alive and
well, age 78; his brother age 55, has been hypertensive for l0 years. There is no family history of
diabetes or asthma.
Lifestyle Factors
Tobacco: never smoked
Alcohol: has one brandy or glass of wine per evening.
Caffeine: several cups of strong brewed coffee per day.
Last year, he had his cholesterol checked and remembers the level was elevated. He was supposed to
have his cholesterol level rechecked after appropriate dietary modification, but never got around to
Physical Examination
Head/ENT: moist mucous membranes
conjunctiva normal, pink
Neck: jugular veins not distended
carotid pulses normal; no bruits
Chest: movement, auscultation and percussion all normal
Cardiovascular: Blood Pressure 140/90
apex beat normal strength; at 5th interspace, mid-clavicular line
heart sounds both normal; S2 physiologically split
no murmurs; no S3 or S4 gallop
peripheral pulses all normal and symmetrical
Extremities: no fingernail clubbing, no cyanosis, no oedema
No other significant findings.
Resting ECG: normal
Fasting lipids:
Total cholesterol 7.2 mmol/L (Desirable value <4.0)*
HDL cholesterol 0.9 mmol/L (Desirable value ≥ 1.0)*
LDL cholesterol 4.1 mmol/L (Desirable value <2.5)*
(* for patients at increased risk of CHD)
Fasting blood sugar 5.1 mmol/L (Ref Range <6.0)
Question 11.
Based on the information to this point:
a) what is the single most likely hypothesis to account for Mr Lewis’s condition, and why?
(5 marks)
b) Do these physical examination findings and initial test results confirm or alter your original
hypothesis? Please explain.
(5 marks)
Question 12.
Which antihypertensive drug classes may be useful in relieving this patient’s symptoms? Explain
the mechanisms of action for these beneficial effects.
(10 marks)
Question 13.
List the various patterns of cardiac-related pain experienced by patients. Give the underlying basis
for cardiac pain distribution patterns.
(5 marks)

Question 2
Outline the anatomy and physiology of the cardiac conduction system. Include in your answer the
depolarisation and repolarization sequence.
(10 marks)
Question 3
(a) Briefly discuss “splitting” of the second heart sound, its underlying cause(s) and timing.
(8 marks)
(b) “Fixed splitting” (of the second heart sound) is a sign of what condition(s)?
(2 marks)
Question 4
In a 12 lead electrocardiogram (ECG):
a) a prolonged PR interval indicates conduction delay of the AV node
b) leads 2, 3 and AVF look at the lateral portion of the left ventricle
c) the cardiac QRS axis normally lies between 30 and 150 degrees
d) the amplitude of the QRS complex will be decreased in the presence of left ventricular
e) a prolonged QT interval can occur due to electrolyte disturbances and drugs and may result
in arrhythmia
(2.5 marks)

Question 9
Record your answers on the green answer sheet provided. Write your answers in the
appropriate space.
The diagram depicts normal Pressure traces (in mmHg) vs Time for the atria, ventricles &
outflow arteries of the right & left heart, during a single cardiac cycle. Lettered arrows label
individual graph lines.
Indicate, using either single letters (eg “g”), letter pairs (eg “c-d”), or a series of letters (eg “i-j-k”;
“i-j + o-p”; etc as appropriate), the following events of the normal cardiac cycle:
(A) the moment of the first heart sound
(B) the moment of pulmonary valve closing
(C) the period during which the “QRS” wave of the ECG occurs
(D) the period during which the “ST” segment of the ECG occurs
(E) the period during which aortic regurgitation might occur, in a susceptible person
(10 marks)