Blackboard EMQs CVS Flashcards
48 yr old man presents with central chest pain on unusual exertion. Resting ECG is normal and there are no obvious risk factors. He would prefer not to take medication until a definitive diagnosis is made.
Choose the most appropriate initial management from the list of options A. Beta blockers B. Exercise ECG C. Long acting nitrates D. Nifedipine E. Angioplasty F. CABG G. Coronary angiography H. Thallium scan I. Ace inhibitors
B. Exercise ECG
This patient has presented with stable angina. Resting ECG is often normal however during exercise stress ECG (most often the Bruce Protocol) there will be ST segment depression during exercise indicative of ischaemia. Those unable to exercise to an adequate level may need stress myocardial perfusion imaging or stress echocardiography. 1st line treatment involves lifestyle changes and antiplatelet therapy with aspirin. Anti-anginal theray will also be given, first line being beta-blockade. Statin therapy, blood sugar control in diabetics and BP control with antihypertensives may also be necessary. Those with LMS disease, 3 vessel disease or a reduced EF may benefit from CABG. Single vessel disease may benefit from PCI.
55 yr old man is taking increasing doses of sublingual GTN for established stable angina. He also has COPD with a reduced PEFR. Coronary angiography has shown diffuse disease but he has refused intervention.
Choose the most appropriate initial management from the list of options A. Beta blockers B. Exercise ECG C. Long acting nitrates D. Nifedipine E. Angioplasty F. CABG G. Coronary angiography H. Thallium scan I. Ace inhibitors
D. Nifedipine
First line anti-anginal therapy for stable angina is a beta blocker such as metoprolol. However, this patient has COPD and beta blockers are relatively contraindicated due to bronchospasm (even those considered to be cardioselective). 2nd line treatment is with a CCB such as nifedipine. Long acting nitrates can be used as additional therapy or in patients where beta blockers and CCBs are contraindicated.
60 yr old man with stable angina is awaiting surgery. He is on the highest tolerated dose of beta blocker and CCB but is still symptomatic. BP is 170/95 mmHg.
Choose the most appropriate initial management from the list of options A. Beta blockers B. Exercise ECG C. Long acting nitrates D. Nifedipine E. Angioplasty F. CABG G. Coronary angiography H. Thallium scan I. Ace inhibitors
C. Long acting nitrates
Long acting nitrates such as isosorbide mononitrate or transdermal GTN is indicated as the patient is still symptomatic on beta blockers and CCBs. Appropriate nitrate-free periods will be needed to avoid tolerance. Severe hypotension may occur if combined with a phosphodiesterase-5 inhibitor.
50 yr old man presents with typical history of exertional angina with ischaemic changes on resting ECG. Coronary angiography shows 70% stenosis of the left anterior descending artery with no significant lesions elsewhere.
Choose the most appropriate initial management from the list of options A. Beta blockers B. Exercise ECG C. Long acting nitrates D. Nifedipine E. Angioplasty F. CABG G. Coronary angiography H. Thallium scan I. Ace inhibitors
E. Angioplasty
Those with LMS disease, 3 vessel disease or a reduced EF may benefit from CABG. Most single vessel disease can be adequately managed with PCI.
A 62 year old man, 3 months after an MI, taking asprin, atenolol and simvistatin, whose echocardigram shows worsening left ventricular function
Choose the best option for reducing CVS risk
A. Cholesterol lowering therapy with a statin
B. Aspirin therapy
C. Reduced alcohol intake
D. Antihypertensive drugs
E. Weight reduction and increased physical activity
F. Weight reduction and metformin therapy
G. Smoking cessation
H. Angiotensin converting enzyme inhibitor therapy
H. Angiotensin converting enzyme inhibitor therapy
This patient has worsening LV function in line with heart failure. First line treatment is with an ACE inhibitor which reduces morbidity and mortality associated with the condition. All patients with LV dysfunction should receive ACE inhibitors, whether symptomatic or not. Caution should be taken if the patient has renal impairment, cardiogenic shock or hyperkalaemia. All patients with chronic heart failure will also receive a beta blocker such as carvedilol.
A 46 year old woman, normal blood pressure, cholesterol and blood sugar, body mass index 32
Choose the best option for reducing CVS risk
A. Cholesterol lowering therapy with a statin
B. Aspirin therapy
C. Reduced alcohol intake
D. Antihypertensive drugs
E. Weight reduction and increased physical activity
F. Weight reduction and metformin therapy
G. Smoking cessation
H. Angiotensin converting enzyme inhibitor therapy
E. Weight reduction and increased physical activity
This woman is obese (BMI greater than or equal to 30) and needs to lose weight. Central obesity has a greater correlation with co-morbidities than peripheral obesity so arguably waist circumference is a better indicator of risk than body mass index. The mainstay of treatment is with diet and exercise. This patient is obese and drug therapy can be considered as an adjunct. This is primarily with orlistat which inhibits fat absorption by inhibiting lipases. For weight loss, the recommended intake is 1200-1500 kcal/day for men and 1000-1200kcal/day for women, producing a 500-1000kcal/day deficit.
A 77 year old man, normal blood pressure, not diabetic, who has had 3 episodes of transient left sided weakness in the last month
Choose the best option for reducing CVS risk
A. Cholesterol lowering therapy with a statin
B. Aspirin therapy
C. Reduced alcohol intake
D. Antihypertensive drugs
E. Weight reduction and increased physical activity
F. Weight reduction and metformin therapy
G. Smoking cessation
H. Angiotensin converting enzyme inhibitor therapy
B. Aspirin therapy
A TIA is colloquially called a ‘mini stroke’ with symptoms typically lasting under an hour. An antiplatelet drug such as aspirin is effective secondary prevention if the patient is not already anticoagulated. The patient will be anticoagulated if they have a likely or known cardioembolic source such as AF. Clopidogrel is an alternative in those who do not tolerate aspirin.
A 54 year old man, normal blood pressure, normal lipid profile, body mass index 28, random blood sugar 15 mmol/L, fasting blood sugar 8.5mmol/L
Choose the best option for reducing CVS risk
A. Cholesterol lowering therapy with a statin
B. Aspirin therapy
C. Reduced alcohol intake
D. Antihypertensive drugs
E. Weight reduction and increased physical activity
F. Weight reduction and metformin therapy
G. Smoking cessation
H. Angiotensin converting enzyme inhibitor therapy
F. Weight reduction and metformin therapy
This patient has DM. Symptomatic patients need a single random blood glucose of >11.1 or single fasting glucose of >7. Asymptomatic patients need two separate elevated readings for a diagnosis. Alternatively if there are borderline results, an OGTT can be conducted to see if plasma glucose is raised >11.1 two hours after an oral glucose load of 75g. A patient is said to have impaired fasting glucose if fasting glucose falls between 6.1-6.9. Impaired glucose tolerance is present if plasma glucose 2 hours after oral glucose load in OGTT falls between 7.8-11.0. First line intervention in this situation is diet and lifestyle advice and changes. Metformin will be added if there is no adequate response. In terms of this question, this option will reduce cardiovascular risk the most for this patient. Metformin is a biguanide and suppresses hepatic glucose production.
30 yr old man attends for a routine pre employment medical. On examination of the CVS system the doctor finds a soft ejection systolic murmur at the apex. He has no previous cardiac or respiratory problems, and has normal pulse and BP
Choose the most likely diagnosis A. Mixed aortic valve disease B. Mitral stenosis - rheumatic C. Infective endocarditis D. Innocent murmur E. Mixed mitral valve disease F. Mixed mitral and ahortic valve disease G. Mitral regurgitation- rheumatic H. Aortic regurgitation I. Hypertrophic obstructive cardiomyopathy J. Mitral incompetence K. Aortic stenosis
D. Innocent murmur
This is a functional murmur which is not caused by a structural cardiac defect. Functional murmurs tend to be systolic, occuring in an otherwise healthy individual with no symptoms. They are also characteristically position dependent and soft in nature. Ones that occur in children tend to disappear as the child grows. Benign paediatric murmurs include Still’s murmur.
60 yr old Irish woman comes to see you with a progressive one year history of shortness of breath and recent onset of paroxysmal nocturnal dyspnoea. She has been previously well apart from Sydenham’s chorea as a child. She had six normal pregnancies. Examination= plethoric cheeks, pulse is 110 bpm irregular and small volume. BP 128/80mmHg. The JVP is normal. The apex is in the 5th i.c.s. and m.c.l and tapping in nature. The 1st heart sound is loud and P2 accentuated. A low pitched mid-diastolic murmur is heard in the apex.
Choose the most likely diagnosis A. Mixed aortic valve disease B. Mitral stenosis - rheumatic C. Infective endocarditis D. Innocent murmur E. Mixed mitral valve disease F. Mixed mitral and ahortic valve disease G. Mitral regurgitation- rheumatic H. Aortic regurgitation I. Hypertrophic obstructive cardiomyopathy J. Mitral incompetence K. Aortic stenosis
B. Mitral stenosis - rheumatic
Sydenham’s chorea (St Vitus Dance) are dancelike movements seen in rheumatic fever. The major criteria for rheumatic fever can be remember by CASES: carditis, arthritis, Sydenham’s chorea, erythema marginatum and subcutaneous nodules. Practically every single case of mitral stenosis is caused by rheumatic heart disease. The process tends to also cause regurgitation. This is characteristically a grade 1-2 low pitch murmur heard in mid-diastole which has a rumbling nature and there is no radiation. There can be an associated malar flush, tapping apex beat and a diastolic thrill palpable at the apex, in the 5th intercostal space in the MCL. The first heart sound is also characteristically loud and often this is the most striking feature on ascultation. It is a difficult murmur to pick up so if you are ever asked at this stage to spot this murmur, it will most likely be based on the loud S1.
50 yr old man attends A&E with SOB, fever and hyperdynamic regular pulse of 100. BP 160/60 mmHg. He has a murmur at the left sternal edge. On further enquiry it is found he attended for a routine dental procedure 2 months ago.
Choose the most likely diagnosis A. Mixed aortic valve disease B. Mitral stenosis - rheumatic C. Infective endocarditis D. Innocent murmur E. Mixed mitral valve disease F. Mixed mitral and ahortic valve disease G. Mitral regurgitation- rheumatic H. Aortic regurgitation I. Hypertrophic obstructive cardiomyopathy J. Mitral incompetence K. Aortic stenosis
C. Infective endocarditis
Any patient presenting with fever and a new murmur should always make you think of bacterial endocarditis. The classic new or worsening murmur is actually rare. As are splinter haemorrhages, which this patient has. Other uncommon signs you may find include Janeway lesions (painless macular haemorrhagic plaques on the palms and soles) and Osler nodes (painful nodules on the pads of the fingers and toes). Roth spots may also be seen on fundoscopy. Three sets of bood cultures are required and this patient will have to go for an echocardiogram.The Duke criteria is used for diagnosis.
Personally I think aortic regurgitation is an acceptable answer here given the wide pulse pressure and location of the mumur.
80 yr old woman presents with recent onset of effort related chest pain. On examination: loud ejection systolic murmur and a low pulse pressure with a slow rising pulse.
Choose the most likely diagnosis A. Mixed aortic valve disease B. Mitral stenosis - rheumatic C. Infective endocarditis D. Innocent murmur E. Mixed mitral valve disease F. Mixed mitral and ahortic valve disease G. Mitral regurgitation- rheumatic H. Aortic regurgitation I. Hypertrophic obstructive cardiomyopathy J. Mitral incompetence K. Aortic stenosis
K. Aortic stenosis
Aortic stenosis can present with chest pain, dyspnoea and syncope. It is characterised by a harsh ejection systolic murmur heard loudest at the right upper sternal edge at end expiration, which radiates up towards the carotids. The pulse pressure is narrow and there may be an associated slow-rising and plateau pulse. Doppler echo is vital for diagnosis and shows a pressure gradient across the narrowed valve orifice. 20% of cases are due to a congenital bicuspid valve. The most common cause of aortic stenosis in adults is calcification of normal trileaflet valves. Clinically stable patients may be considered for surgical repair or TAVR.
65 yr old man had an inferior MI 10 days ago. His initial course was uncomplicated. He suddenly deteriorates with LVF. On examination pulse is regular 100bpm and normal volume and character. BP 110/160mmHg. Apex beat is dynamic. There is a loud grade III apical pan-systolic murmur radiating to the axilla.
Choose the most likely diagnosis A. Mixed aortic valve disease B. Mitral stenosis - rheumatic C. Infective endocarditis D. Innocent murmur E. Mixed mitral valve disease F. Mixed mitral and ahortic valve disease G. Mitral regurgitation- rheumatic H. Aortic regurgitation I. Hypertrophic obstructive cardiomyopathy J. Mitral incompetence K. Aortic stenosis
J. Mitral incompetence (same thing as regurgitation)
MR is loudest at the apex and radiates to the axilla and tends to be around grade 4. It is associated with a systolic thrill at the apex. TTE is the investigation of choice for diagnosis. Chronic MR is associated with a laterally displaced apex beat with LV dilatation. Mitral valve prolapse is a strong risk factor for development of MR.
33 year old woman complains of giddiness on standing & can no longer cross a road on her own as she is worried that she may pass out. She developed diabetes when age 12 & has had treatment to her eyes 2 years ago.
Match the cause of hypotension to the following case histories. A. Blood loss B. Addison’s disease C. Arrhythmia D. Autonomic neuropathy E. Drug induced F. Pulmonary embolus G. Cardiogenic shock H. Volume depletion I. Septicaemia
D. Autonomic neuropathy
Autonomic neuropathy is a complication of diabetic neuropathy. Symptoms of autonomic neuropathy include… resting tachycardia (late findings due to vagal impairment), impaired HR variation, erectile dysfunction (affects many diabetic men though is not solely due to autonomic neuropathy), decreased libido and dyspareunia, orthostatic hypotension (measure BP supine and then standing after 1, 2, 3 and sometimes 5 minutes – an abnormal drop when standing is indicative) and urinary symptoms of frequency, urgency, incontinence, nocturia, weak stream and retention. Other symptoms include constipation, faecal incontinence and sweating dysfunction. Fludrocortisone may be helpful in this woman.
76 year old woman was admitted with confusion. She had been increasingly unable to care for herself. On admission, she was found to have cool peripheries & her blood pressure was 100/70. Blood results showed plasma urea 25mmol/l & plasma creatinine 120umol/l.
Match the cause of hypotension to the following case histories. A. Blood loss B. Addison’s disease C. Arrhythmia D. Autonomic neuropathy E. Drug induced F. Pulmonary embolus G. Cardiogenic shock H. Volume depletion I. Septicaemia
H. Volume depletion
Volume depletion is a reduction in ECF volume due to salt and fluid losses which exceed intake. Causes include vomiting, bleeding, diarrhoea, diuresis and third space losses. Symptoms do not occur until large losses have alrady occured. Cool peripheries are a sign of peripheral shut down. Confusion may reflect poor cerebral flow or uraemia.Volume depletion has led to the low BP. Other symptoms include postural hypotension and tachycardia, weight loss and signs of shock. Serum urea and creatinine is elevated (you need to eyeball the patient when looking at creatinine – a very big body builder will have a much higher creatinine), indicating poor renal blood flow. This patient needs IV saline fluid replacement.
22 year old man presented with vomiting. He had not been feeling himself for some weeks. On examination, the skin creases of his hands were dark. Blood results showed plasma urea 8.5mmol/l, sodium 121mmol/l & potassium 5.1mmol/l.
Match the cause of hypotension to the following case histories. A. Blood loss B. Addison’s disease C. Arrhythmia D. Autonomic neuropathy E. Drug induced F. Pulmonary embolus G. Cardiogenic shock H. Volume depletion I. Septicaemia
B. Addison’s disease
Hyperpigmentation in the palmar creases points towards Addison’s disease. Hyperpigmentation due to excess ACTH production can be mucosal or cutaneous and is more pronounced in the palms, knuckles and around scars. MSH is a byproduct of the production of ACTH from the cleavage of POMC. Sodium is low and potassium elevated. Vomiting is present in 75% of patients and nausea is a common finding. Additionally, postural hypotension may be present. The presence of other autoimmune diseases is a risk factor for the development of Addison’s.
45 year old man presented with severe chest pain radiating down his left arm. He was pale, cold & sweaty. Blood pressure was 80/50mmHg, pulse rate was 100 & regular. JVP was raised by 3cm & auscultation of the chest revealed basal creps. Over the next few hours, he became progressively short of breath despite being given intravenous diuretics. Chest x-ray showed signs of pulmonary congestion.
Match the cause of hypotension to the following case histories. A. Blood loss B. Addison’s disease C. Arrhythmia D. Autonomic neuropathy E. Drug induced F. Pulmonary embolus G. Cardiogenic shock H. Volume depletion I. Septicaemia
G. Cardiogenic shock
Cardiogenic shock is pump dysfunction. This may occur, like in this case, after MI (shock complicates just under 10% of MIs) or may be due to cardiomyopathy, valve dysfunction or arrhythmias. This cause of shock in this patient is obviously apparent. Clinical signs of shock include stress responses of tachycardia and tachypnoea, hypotension (<90 systolic) with signs of hypoperfusion (for example, cold extremities). Raised JVP, basal crackles and pulmonary oedema support cardiac failure. Treatment begins with your ABCs. In this case, urgent revascularisation of the coronary arteries is indicated.
67 year old man was observed to be very drowsy 12 hours after an aortic aneurysm repair. There had been considerable blood loss & he had been given 4 units of blood during surgery. He had been written up for pethidine 50-100mg 3 hourly postoperatively & had had 3 doses. BP had been 150/80 post-operatively & was now 100/60 with a pulse rate of 75/minute. Oxygen saturation was low at 85%.
Match the cause of hypotension to the following case histories. A. Blood loss B. Addison’s disease C. Arrhythmia D. Autonomic neuropathy E. Drug induced F. Pulmonary embolus G. Cardiogenic shock H. Volume depletion I. Septicaemia
E. Drug induced
Opioid OD symptoms include CNS depression (drowsiness, sleepiness), respiratory depression and relative bradycardia. This patient needs ventilation prior to the administration of naloxone, titrated to patient response.
An 80 year old man with a history of ischaemic heart disease trips over a paving stone & fractures his hip. An ambulance takes him to A&E. 1 hour after arrival, he develops crushing central chest pain.
Choose the most useful investigation from the list of options. A. Coronary angiogram B. Thoracic spine x-ray C. Chest x-ray in expiration D. CT scan abdomen E. Exercise ECG F. Chest x-ray rib views G. Chest x-ray H. Barium swallow I. V/Q scan J. CPK (creatine phosphokinase) K. ECG L. Transthoracic echo M. Upper GI endoscopy
K. ECG
This patient’s crushing central chest pain sounds like an MI. Chest pain is classically severe and heavy in nature, located centrally with possible radiation to the left arm or jaw and lasts for >20 minutes. SOB due to pulmonary congestion and sweating due to high sympathetic output are common symptoms. Risk factors incorporate the standard set of cardiovascular risks such as smoking, high BP, DM, obesity and dyslipidaemia. An ECG is indicated. If ECG shows STEMI, new LBBB or confirmed posterior MI then PCI/thrombolysis is indicated. It is worth noting that RV infarction is present in 40% of inferior infarcts so if ST elevation is seen in II, III and aVF, right sided ECG leads should be obtained.
A 19 year old male medical student develops acute chest pain during a game of squash. On examination he is distressed there but examination is otherwise unremarkable. There is a family history of sudden death.
Choose the most useful investigation from the list of options. A. Coronary angiogram B. Thoracic spine x-ray C. Chest x-ray in expiration D. CT scan abdomen E. Exercise ECG F. Chest x-ray rib views G. Chest x-ray H. Barium swallow I. V/Q scan J. CPK (creatine phosphokinase) K. ECG L. Transthoracic echo M. Upper GI endoscopy
L. Transthoracic echo
This patient has likely HOCM. The patient’s young age makes it unlikely to be atherosclerotic coronary artery disease (unstable angina). HOCM is the most likely cardiomyopathy and the most frequent cause of sudden cardiac death in younger people. The FH of sudden death is suggestive of this diagnosis. This has a benign prognosis is most people though symptomatic patients are treated medically with beta blockade, CCBs or disopyramide. Chest pain on exertion (playing squash) is a common presentation in those who are symptomatic, as is dyspnoea on exertion, palpitations (such as due to AF) and a history of either pre-syncope or syncope (due to LV outflow obstruction). Inheritance is autosomal dominant with a variable penetrance.
Examination findings may be normal or may reveal an ejection systolic murmur which is positionally responsive and a double carotid or apex pulsation due to the transient interruption of CO. A fourth heart sound may also be heard due to hypertrophy. Echocardiography must be performed to establish a diagnosis, though ECG and CXR will also be done and may also show changes. Echo will show septal hypertrophy. There may also be MR.
A 55 year old obese female complains of a 6 month history of chest pain which radiated to the jaw and both shoulders. The pain is reported to be more severe at night. ECG and chest x-rays are normal.
Choose the most useful investigation from the list of options. A. Coronary angiogram B. Thoracic spine x-ray C. Chest x-ray in expiration D. CT scan abdomen E. Exercise ECG F. Chest x-ray rib views G. Chest x-ray H. Barium swallow I. V/Q scan J. CPK (creatine phosphokinase) K. ECG L. Transthoracic echo M. Upper GI endoscopy
M. Upper GI endoscopy
This patient has GORD characterised by heartburn and regurgitation of acid. It is more severe at night when the patient is lying flat and also when the patient is bending over. Risk factors include obesity and hiatus hernia. Diagnosis is generally clinical and can also be achieved by a diagnostic trial of a PPI. Normally an upper GI endoscopy is reserved for complications such as strictures, Barrett’s or cancer, or for atypical features. An OGD may show oesophagitis or Barrett’s (red velvety), however OGD may be normal. Manometry and pH monitoring may also be performed, but in this case, this patient will probably just have a therapeutic and diagnostic trial of a PPI instead of an OGD.
A 30 year old male alcoholic presents nausea and pain in the lower chest in a band radiating around to the back. The pain makes the patient curl up in a ball and movement worsens it. On examination there is decreased breath sounds on the left side which is stony dull to percussion at the base.
Choose the most useful investigation from the list of options. A. Coronary angiogram B. Thoracic spine x-ray C. Chest x-ray in expiration D. CT scan abdomen E. Exercise ECG F. Chest x-ray rib views G. Chest x-ray H. Barium swallow I. V/Q scan J. CPK (creatine phosphokinase) K. ECG L. Transthoracic echo M. Upper GI endoscopy
D. CT scan abdomen
This patient has acute pancreatitis. He has vomited and is describing mid-epigastric pain radiating around to the back which is relieved in the fetal position and is worse with movement. He is an alcoholic and alcoholic pancreatitis is seen more frequently in men usually after an average of 4-8 years of alcohol intake. Binge drinking also increases the risk. This patient also has nausea and may describe vomiting too, with agitation and confusion. The examination findings described here allude to a pleural effusion which is seen in half of patients with acute pancreatitis. Complicated haemorrhagic pancreatitis may exhibit Cullen’s sign, Grey-Turner’s sign and Fox’s sign. Make sure you know what these are and you are familiar with the causes of acute pancreatitis. Those caused by hypocalcaemia may display Chvostek’s sign and Trousseau’s sign.
Key to diagnosis is serum amylase or lipase levels which are massively elevated. Prognostic criteria are outlined in Ranson’s criteria applied on admission and after 48 hours, or the modified Glasgow score which you can find in your Oxford Handbook. An abdominal CT is however the most sensitive and specific study and findings may include enlargement of the pancreas with irregular contours, necrosis, pseudocysts and peripancreatic fat obliteration.
For interest, urinary trypsinogen-2 is now considered a better screening test than amylase but is not currently clinically used.
An 80 year old woman on corticosteroids develops acute chest pain while standing up. It is posteriorly sited, radiating anteriorly under the breast. The pain is worse on movement and there is tenderness on the back of the chest. Cardiovascular and respiratory examination are normal.
Choose the most useful investigation from the list of options. A. Coronary angiogram B. Thoracic spine x-ray C. Chest x-ray in expiration D. CT scan abdomen E. Exercise ECG F. Chest x-ray rib views G. Chest x-ray H. Barium swallow I. V/Q scan J. CPK (creatine phosphokinase) K. ECG L. Transthoracic echo M. Upper GI endoscopy
B. Thoracic spine x-ray
This patient likely has osteoporotic vertebral collapse/fracture which is compressing the intercostal nerve and causing her sudden pain in the back of her chest. The pain tends not to be related to traumatic activities and can occur on standing up or bending forwards, even coughing and sneezing. The history of corticosteroid use is associated with osteoporosis through multiple mechanisms. The thoracic spine plain x-ray would show loss of height in one of the thoracic vertebrae. Osteoporotic changes may also be seen such as osteopenia. Treatment depends on the extent of spinal involvement and the severity of the pain and whether it is complicated by spinal deformity such as kyphosis. For the diagnosis of osteoporosis, a DEXA scan is needed indicating a T score of less than or equal to -2.5.
A 62 year old gentleman presents with fatigue, breathlessness & anorexia. On examination his JVP is noted as being elevated, he has hepatomegaly & swollen ankles.
Choose the appropriate diagnosis. A. Decubitus angina B. Unstable angina C. Atrial flutter D. Myocardial infarction E. Left ventricular failure F. Constrictive pericarditis G. Atrial fibrillation H. Stable angina I. Congestive cardiac failure J. Bacterial endocarditis
I. Congestive cardiac failure
The key manifestation is dyspnoea and tiredness. CCF is a term used for patients who are breathless with oedema (signs of LVF and RVF). Elevated JVP, hepatomegaly and peripheral oedema are all signs of RVF. Initial investigations should include ECG, CXR, TTE and bloods including BNP levels. First line treatment is with an ACE inhibitor which reduces morbidity and mortality. Salt and fluid restriction is also beneficial. All patients with chronic heart failure will also receive a beta blocker such as carvedilol. Other adjuncts include spironolactone, diuretics, hydralazine and a nitrate, and digoxin. The NYHA classification criteria can be used based on symptoms to describe functional limitations and ranges from Class I to Class IV with symptoms occuring at rest. Many patients are asymptomatic for long periods of time because mild cardiac impairment is balanced by compensation.
A 55 year old gentleman with a history of systemic hypertension presents to A&E with breathlessness on exertion & orthopnoea. Examination reveals cardiomegaly & a displaced apex beat to the left.
Choose the appropriate diagnosis. A. Decubitus angina B. Unstable angina C. Atrial flutter D. Myocardial infarction E. Left ventricular failure F. Constrictive pericarditis G. Atrial fibrillation H. Stable angina I. Congestive cardiac failure J. Bacterial endocarditis
E. Left ventricular failure
This patient has no signs of RVF mentioned above. You should know the distinction between LVF and RVF. RVF leads to a backlog of blood and congestion of the systemic capillaries. This causes peripheral oedema and ascites and hepatomegaly may develop. Nocturia may be a symptom as fluid returns from the legs when the patient lies down flat. LVF causes congestion in the pulmonary circulation so the symptoms are respiratory. As seen in this patient, there is SOB on exertion and orthopnoea. This is why you can ask patients in a cardiac history how many pillows they sleep with. PND can also occur as well as ‘cardiac asthma’.
A diabetic, 66 year old lady presents to A&E with breathlessness, sweating, nausea & vomiting. She is feeling very distressed. She has no pain. On inspection she appears pale, sweaty & grey.
Choose the appropriate diagnosis. A. Decubitus angina B. Unstable angina C. Atrial flutter D. Myocardial infarction E. Left ventricular failure F. Constrictive pericarditis G. Atrial fibrillation H. Stable angina I. Congestive cardiac failure J. Bacterial endocarditis
D. Myocardial infarction
This diabetic is having a silent MI without chest pain. Silent MIs are more common in the elderly and those with DM probably due to autonomic neuropathy.
Tachycardia is a common feature of MI especially anterior wall MI. Chest pain of MI is classically severe and heavy in nature, located centrally with possible radiation to the left arm or jaw and lasts for >20 minutes. SOB due to pulmonary congestion and sweating due to high sympathetic output are common symptoms. This patient also has pallor which is due to a high sympathetic output. Risk factors incorporate the standard set of cardiovascular risks such as smoking, high BP, DM, obesity and dyslipidaemia. Patients with DM are at increased risk of CAD by a variety of mechanisms which are not fully known.
If ECG shows STEMI, new LBBB or confirmed posterior MI then PCI/thrombolysis is indicated. It is worth noting that RV infarction is present in 40% of inferior infarcts so if ST elevation is seen in II, III and aVF, right sided ECG leads should be obtained. Cardiac biomarkers include CK-MB and troponin.
A 49 year old man presents to A&E with a 2 week history of a ‘tight’ central chest pain radiating to the jaw experienced when he is lying down.
Choose the appropriate diagnosis. A. Decubitus angina B. Unstable angina C. Atrial flutter D. Myocardial infarction E. Left ventricular failure F. Constrictive pericarditis G. Atrial fibrillation H. Stable angina I. Congestive cardiac failure J. Bacterial endocarditis
A. Decubitus angina
Usually as a complication of heart failure. This patient has chest pain which occurs on lying down, which is decubitus angina by definition.
A 45 year old man comes to A&E with shortness of breath, giving a history of decreased exercise tolerance. On examination the patient is noted as having an irregular pulse, warm vasodilated peripheries, exopthalmos & a goitre.
Choose the appropriate diagnosis. A. Decubitus angina B. Unstable angina C. Atrial flutter D. Myocardial infarction E. Left ventricular failure F. Constrictive pericarditis G. Atrial fibrillation H. Stable angina I. Congestive cardiac failure J. Bacterial endocarditis
G. Atrial fibrillation
This patient has hyperthyroidism. More specifically, Graves’ disease (peripheral manifestations such as ophthalmopathy do not occur with other causes of hyperthyroidism). Treatment of Graves’ aims to normalise thyroid function and is achieved by radioactive iodine, antithyroid medications or with surgery. They are all effective and relatively safe options. Symptomatic therapy is given with beta blockers such as propranolol. This patient has AF which has occured as a result of his hyperthyroid state which affects around 10% of untreated patients. Irregular HR is the hallmark feature of AF. Have a think about what the ECG would show.
Mrs James is a 50 year old diabetic lady who complains of a tightness in her chest plus a cramping sensation in her jaw and neck after climbing 2 flights of stairs to her apartment.
For each patient below, choose the most likely cause of the symptom A. VSD B. HOCM (hypertrophic obstructive cardiomyopathy) C. Romano-Ward syndrome D. Infective endocarditis E. Pericarditis F. MI G. Congestive cardiac failure H. Left ventricular failure I. Angina J. ASD
I. Angina
A 45 year old man developed severe central chest pain, lasting for approximately 30 mins. He vomited with the pain, became acutely breathless & sweated profusely. For each patient below, choose the most likely cause of the symptom A. VSD B. HOCM (hypertrophic obstructive cardiomyopathy) C. Romano-Ward syndrome D. Infective endocarditis E. Pericarditis F. MI G. Congestive cardiac failure H. Left ventricular failure I. Angina J. ASD
F. MI
Chest pain of MI is classically severe and heavy in nature, located centrally with possible radiation to the left arm or jaw and lasts for >20 minutes. SOB due to pulmonary congestion and sweating due to high sympathetic output are common symptoms. N&V was believed to be associated with inferior wall infarction but this has been disputed. If ECG shows STEMI, new LBBB or confirmed posterior MI then PCI/thrombolysis is indicated. Risk factors incorporate the standard set of cardiovascular risks such as smoking, high BP, DM, obesity and dyslipidaemia.
Jean is a 35 year old lady who has recently given birth to her 3rd baby. 2 weeks ago she developed a fever, malaise & night sweats. She feels too tired to care for the baby & is losing weight. She attended her GP following the loss of control in her left arm. On examination there was weakness on the left side of her body. Her BP was normal, 120/80. Urinalysis showed small amounts of blood & auscultation revealed a loud pansystolic murmur plus bilateral basal crepitations. For each patient below, choose the most likely cause of the symptom A. VSD B. HOCM (hypertrophic obstructive cardiomyopathy) C. Romano-Ward syndrome D. Infective endocarditis E. Pericarditis F. MI G. Congestive cardiac failure H. Left ventricular failure I. Angina J. ASD
D. Infective endocarditis
Any patient presenting with fever and a new murmur should always make you think of bacterial endocarditis. The classic new or worsening murmur is actually rare. Other uncommon signs you may find include splinter haemorrhages, Janeway lesions (painless macular haemorrhagic plaques on the palms and soles) and Osler nodes (painful nodules on the pads of the fingers and toes). Roth spots may also be seen on fundoscopy. Septic embolic are common in IE and urinalysis may show active sediment. Three sets of bood cultures are required and this patient will have to go for an echocardiogram.The Duke criteria is used for diagnosis.
John is a 20 year old man with breathlessness and chest pain after exertion. 5 days ago he developed palpitations & fainted during a game of squash. Examination revealed a jerky pulse and a systolic murmur. His ECG showed changes of left ventricular hypertrophy.
For each patient below, choose the most likely cause of the symptom A. VSD B. HOCM (hypertrophic obstructive cardiomyopathy) C. Romano-Ward syndrome D. Infective endocarditis E. Pericarditis F. MI G. Congestive cardiac failure H. Left ventricular failure I. Angina J. ASD
B. HOCM
This patient has HOCM. The patient’s young age makes it unlikely to be atherosclerotic coronary artery disease (unstable angina). HOCM is the most likely cardiomyopathy and the most frequent cause of sudden cardiac death in younger people. This has a benign prognosis in most people though symptomatic patients are treated medically with beta blockade, CCBs or disopyramide. Chest pain on exertion (playing squash) is a common presentation in those who are symptomatic, as is dyspnoea on exertion, palpitations (such as due to AF) and a history of either pre-syncope or syncope (due to LV outflow obstruction). Inheritance is autosomal dominant with a variable penetrance and there may be a FH of sudden death. Examination findings may be normal or may reveal an ejection systolic murmur which is positionally responsive and a double carotid or apex pulsation due to the transient interruption of CO. The arterial pulse is described as ‘jerky’. A fourth heart sound may also be heard due to hypertrophy. Echocardiography must be performed to establish a diagnosis, though ECG and CXR will also be done and may also show changes. Echocardiography will show septal hypertrophy. There may also be MR.
