The 2027 Cardiology ST4 Interview Revision Platform: Question Bank, Live Practice and Mocks with Other Candidates

I'd begin with an A-to-E assessment. The ED team will hopefully have started to stabilise her and her observations look stable, but I'd confirm she's still haemodynamically stable before going further, and stabilise her if not. An early arterial blood gas is important here to look for acidosis or respiratory failure. If she remains in respiratory failure despite initial management, I'd discuss her with level 2 care (HDU or ITU) for more intensive support.

I'd characterise the breathlessness: when it started and how quickly, whether there's a cough and if the sputum is pink and frothy (pulmonary oedema) or discoloured (infection), and any associated chest pain or palpitations. I'd ask specifically about orthopnoea and paroxysmal nocturnal dyspnoea, how many pillows she sleeps on, her exercise tolerance over recent months, and any leg swelling or weight change against her known dry weight. I'd cover cardiovascular risk factors and screen for non-cardiac causes such as infection, COPD and pulmonary embolism. Past medical, drug (especially adherence to diuretics and cardioprotective medications) and social history complete the picture. For a cardiac precipitant I'd use CHAMP: Coronary, Hypertension, Arrhythmia, Mechanical and Pulmonary.

Here she describes three weeks of worsening breathlessness, worse lying flat, now sleeping in her chair, breathless on any household activity, with significant leg swelling.

I'd perform a full cardiovascular examination to place her in one of the heart-failure categories: warm or cold (well or poorly perfused) and wet or dry (overloaded or euvolaemic). I'd focus on her breathing, heart rate and sounds, blood pressure, JVP and peripheral oedema. Around 90% of heart-failure admissions are wet and warm and need offloading. A smaller group are wet and cold, overloaded but peripherally shut down, and these patients often need level 2 care for inotropic support before diuresis.

Bedside: repeat observations, a urine dip and sputum sample for an infective precipitant, and an ECG for every patient to look for a cause of decompensation. Bloods: full blood count (anaemia can cause high-output failure), renal and bone profiles, liver function and clotting (deranged in congestive hepatic failure), NT-proBNP, troponin for an ACS precipitant, lipids and HbA1c, an iron profile, and an ABG. Imaging: a chest X-ray for signs of pulmonary oedema such as Kerley B lines, effusions and cardiomegaly, and an urgent echocardiogram given the change in her clinical status. As an inpatient she'd need a strict fluid-balance chart and daily weights.

She's wet and warm, fluid overloaded with a good blood pressure. I'd sit her upright and give IV diuretics: in a diuretic-naive patient, 40 to 80mg of furosemide is a reasonable start, and for someone already on diuretics I'd double their usual dose, remembering IV furosemide has roughly double the bioavailability of oral. I'd monitor with fluid-balance and weight charts alongside a fluid restriction, and escalate oxygen to a non-rebreathe mask or CPAP if needed. If the oedema persists despite diuresis I'd consider vasodilators such as GTN under close monitoring on a cardiology or level 2 bed. If she were cold and wet, or her blood pressure couldn't sustain diuresis, I'd discuss ultrafiltration with HDU or ITU.

She improves with IV diuresis and reaches her dry weight, with a heart rate of 80 and stable renal function. Her inpatient echo shows an LVEF of 40%.

Conservative measures include smoking cessation, vaccinations (COVID, flu and pneumococcal) and cardiac rehabilitation. For heart failure with reduced ejection fraction, the prognostic medications are beta-blockers, ACE inhibitors or ARBs, ARNIs such as sacubitril/valsartan, mineralocorticoid receptor antagonists, ivabradine and SGLT2 inhibitors. It's also important to establish the cause: if there are acute ECG changes and a significant troponin rise this may be ACS with flash pulmonary oedema, warranting inpatient coronary angiography, otherwise a cardiac MRI helps define the aetiology. I'd involve the heart-failure team to optimise her guideline-directed therapy as an outpatient, with patient education on weight, fluid restriction and adherence. If her EF later falls below 35% with a widened QRS and bundle branch block, I'd consider cardiac resynchronisation therapy.