These sample questions demonstrate the format, difficulty level, and explanation depth of the iatroX SCE Cardiology question bank. Each reflects the best-of-five SBA format used in the real exam, with the answer followed by a full explanation referencing the relevant guideline.
Question 1
A 62-year-old man with HFrEF (LVEF 28%) is on ramipril 10 mg daily, bisoprolol 10 mg daily, and spironolactone 50 mg daily. He remains in NYHA class II. His eGFR is 55 mL/min/1.73m² and potassium is 4.8 mmol/L. What is the most appropriate next step?
A. Add ivabradine B. Switch ramipril to sacubitril-valsartan C. Add dapagliflozin D. Refer for CRT assessment E. Add hydralazine and isosorbide dinitrate
Answer: C
This patient is on three of the four recommended HFrEF drug pillars (ACEi, beta-blocker, MRA) but is missing an SGLT2 inhibitor. The 2023 ESC heart failure guidelines recommend all four pillars for every patient with HFrEF. Dapagliflozin (or empagliflozin) should be added as the fourth pillar regardless of diabetes status, based on the DAPA-HF and EMPEROR-Reduced trials. Sacubitril-valsartan (B) is recommended if the patient remains symptomatic despite optimised therapy, but the SGLT2 inhibitor should be established first as it is the missing pillar. Ivabradine (A) is reserved for patients with heart rate above 70 bpm despite maximally tolerated beta-blocker — his heart rate is not given as elevated. CRT (D) requires assessment of QRS duration and morphology, not mentioned here. Hydralazine-nitrate (E) is an alternative for patients who cannot tolerate ACEi/ARB, which does not apply.
Question 2
A 45-year-old woman presents with palpitations. Her ECG shows a regular narrow complex tachycardia at 150 bpm with no visible P waves. Vagal manoeuvres and two doses of adenosine 12 mg have no effect on the tachycardia. What is the most likely diagnosis?
A. AVNRT B. AVRT C. Atrial flutter with 2:1 block D. Atrial tachycardia E. Sinus tachycardia
Answer: C
A regular narrow complex tachycardia at exactly 150 bpm that does not respond to adenosine should raise strong suspicion of atrial flutter with 2:1 block. The atrial rate in typical flutter is approximately 300 bpm, and 2:1 conduction produces a ventricular rate of 150 bpm. Adenosine may transiently increase the AV block and reveal flutter waves but does not terminate flutter — the question states it had no effect on the tachycardia itself, which is consistent with flutter (the tachycardia continues, unlike AVNRT/AVRT which typically terminates with adenosine). AVNRT (A) and AVRT (B) usually terminate with adenosine. Atrial tachycardia (D) may slow with adenosine. Sinus tachycardia (E) does not present as exactly 150 bpm with absent P waves.
Question 3
A 72-year-old man with severe symptomatic aortic stenosis (mean gradient 48 mmHg, AVA 0.8 cm², LVEF 55%) is assessed by the heart team. He has a logistic EuroSCORE of 22% and significant frailty. What is the most appropriate intervention?
A. Surgical aortic valve replacement B. Transcatheter aortic valve implantation (TAVI) C. Balloon aortic valvuloplasty D. Medical management only E. Ross procedure
Answer: B
This patient has severe symptomatic aortic stenosis meeting criteria for intervention (mean gradient above 40 mmHg and AVA below 1.0 cm²). The high surgical risk (logistic EuroSCORE 22%) and significant frailty make him a candidate for TAVI rather than surgical AVR, per ESC 2021 valvular heart disease guidelines. The heart team assessment is the correct decision-making framework. SAVR (A) would be preferred in low-risk patients. BAV (C) is a temporising measure with high restenosis rates, not a definitive treatment. Medical management alone (D) carries a poor prognosis in severe symptomatic AS. The Ross procedure (E) involves replacing the aortic valve with the patient's own pulmonary valve — used in younger patients, not a 72-year-old with frailty.
Question 4
A 28-year-old man is found to have a type 1 Brugada ECG pattern on a routine ECG. He is asymptomatic with no family history of sudden cardiac death. What is the most appropriate management?
A. Immediate ICD implantation B. Electrophysiology study with programmed ventricular stimulation C. Flecainide challenge D. Risk stratification and follow-up E. Reassurance and discharge
Answer: D
An asymptomatic type 1 Brugada pattern without family history of sudden death or syncope places this patient in a lower risk category. The ESC 2022 guidelines on ventricular arrhythmias recommend risk stratification and follow-up rather than immediate ICD implantation (A) for asymptomatic patients. ICD is recommended for Brugada syndrome with documented VT/VF or syncope of arrhythmic origin. EPS with programmed stimulation (B) is no longer recommended as a routine risk stratification tool for Brugada syndrome — its predictive value is debated. A flecainide challenge (C) is used to unmask a Brugada pattern in patients with a suspected but non-diagnostic ECG — this patient already has a type 1 pattern. Reassurance and discharge (E) would be inappropriate given the arrhythmic risk — structured follow-up is required.
Question 5
A 58-year-old woman with persistent atrial fibrillation has a CHA₂DS₂-VASc score of 3 (female sex, hypertension, diabetes). She has normal renal function. What is the most appropriate anticoagulation?
A. Aspirin 75 mg daily B. Apixaban 5 mg twice daily C. Warfarin with target INR 2.0–3.0 D. Edoxaban 60 mg daily E. No anticoagulation required
Answer: B
With a CHA₂DS₂-VASc score of 3, this patient has a clear indication for anticoagulation. The ESC 2024 AF guidelines recommend a DOAC in preference to warfarin for eligible patients. Apixaban 5 mg twice daily is the standard dose for patients with normal renal function. Aspirin (A) is not recommended for stroke prevention in AF — the ESC guidelines explicitly advise against antiplatelet monotherapy. Warfarin (C) is an alternative if DOACs are contraindicated (for example, mechanical heart valve or moderate-to-severe mitral stenosis) but is not first-line. Edoxaban (D) is also a valid DOAC, but the question asks for the most appropriate — both B and D are defensible, though apixaban has the broadest evidence base including in elderly populations. No anticoagulation (E) is inappropriate at this risk level.
These questions are representative of the style and difficulty in the iatroX SCE Cardiology bank. Over 1,500 questions with detailed guideline-referenced explanations are available. All included at £29 per month or £99 per year.