Ten questions in the format the boards actually use, each followed by the reasoning for the correct option and for the distractors. Work through each one and commit to an answer before reading on — a question read passively teaches nothing.
1. Irregular narrow-complex tachycardia
A 68-year-old man has palpitations and mild breathlessness. The ECG shows an irregularly irregular rhythm with no discernible P waves.
Answer: atrial fibrillation. Irregular irregularity with absent discrete P waves replaced by fibrillatory activity is the combination. Atrial flutter is regular with a sawtooth baseline, and where block varies the irregularity is stepwise. Multifocal atrial tachycardia is irregular but shows at least three distinct P morphologies — P waves present and abnormal, not absent. Ventricular tachycardia is broad-complex and regular.
2. Discordant aortic stenosis
Valve area 0.8 cm², mean gradient 28 mmHg, ejection fraction 55%.
Answer: measure the stroke volume index. This is the paradoxical low-flow low-gradient pattern. An index below 35 mL/m² confirms genuinely low flow and the stenosis may be severe despite the gradient. Proceeding straight to intervention or dismissing it as moderate are both premature. Dobutamine stress belongs in the reduced ejection fraction variant, not this one.
3. Antithrombotics after PCI in atrial fibrillation
A patient with atrial fibrillation on apixaban undergoes PCI with a drug-eluting stent for a non-ST elevation acute coronary syndrome.
Answer: apixaban plus clopidogrel, with aspirin only for the first week. AUGUSTUS, PIONEER AF-PCI and RE-DUAL PCI all show that extended triple therapy adds bleeding without a matching ischaemic gain. Twelve months of triple therapy is the classic wrong answer. Dropping the anticoagulant leaves the stroke risk untreated.
4. Heart failure with reduced ejection fraction
Ejection fraction 30%, NYHA class II, already on an ACE inhibitor and a beta blocker at target dose, eGFR 55, potassium 4.2.
Answer: add an SGLT2 inhibitor and a mineralocorticoid receptor antagonist. The four pillars are established regardless of diabetic status, and DAPA-HF and EMPEROR-Reduced both showed benefit within weeks. Waiting for symptoms to worsen before adding therapy is the error the question is testing.
5. Syncope during exertion
A 22-year-old collapses while running. Examination shows a harsh systolic murmur that increases on standing.
Answer: hypertrophic cardiomyopathy. A dynamic outflow murmur that increases as preload falls — standing, Valsalva — is the discriminator. Aortic stenosis softens with reduced preload. The manoeuvre response is the entire question.
6. Broad-complex tachycardia
A 70-year-old with a previous anterior infarct has a regular broad-complex tachycardia at 170 and a systolic pressure of 95.
Answer: treat as ventricular tachycardia. Structural heart disease with a previous infarct makes VT overwhelmingly likely, and treating VT as supraventricular with aberrancy is the dangerous direction of error. Verapamil in this setting can precipitate arrest.
7. Anticoagulation in atrial fibrillation
A 76-year-old woman with hypertension and diabetes, no prior stroke.
Answer: CHA₂DS₂-VASc 5 — anticoagulate. Age ≥ 75 scores 2, hypertension 1, diabetes 1, female sex 1. A high HAS-BLED score would prompt correction of modifiable factors and closer review, never withholding treatment. Calculate both here.
8. Device indication
Ejection fraction 30% three months after infarction, NYHA class II, QRS 160 ms with left bundle branch block, on optimal therapy.
Answer: cardiac resynchronisation therapy with a defibrillator. Left bundle morphology with QRS above 150 ms is where resynchronisation benefit is greatest, and the ejection fraction independently meets primary prevention criteria. A defibrillator alone forgoes the resynchronisation benefit.
9. Stable coronary disease
Moderate ischaemia on functional testing, symptoms controlled on medical therapy, preserved ventricular function.
Answer: continue optimal medical therapy. ISCHEMIA found no reduction in death or infarction with a routine invasive strategy in this population. Revascularisation remains indicated for refractory symptoms, left main disease, and reduced ejection fraction with viability.
10. Chest pain with a normal angiogram
A 45-year-old woman with recurrent rest pain, transient inferior ST elevation captured during an episode, unobstructed coronary arteries.
Answer: coronary vasospasm. Transient elevation during pain with normal arteries is the pattern. Treatment is a calcium channel blocker; beta blockers can worsen it. Takotsubo produces apical ballooning with a longer course, and dissection would be visible angiographically.
How to use questions properly
Score matters less than the record of which distractor attracted you. Re-read the topic behind every attractive wrong option, and repeat the question a week later rather than the same day. A dated schedule that builds this in is set out in the six-month study plan.
Full question banks are in the examination preparation reading list and the examination collections. More free practice on the question bank page and the quiz of the month.