Cardio

Question 1

A 56 year old asian man is brought in by ambulance complaining of feeling like someone is sitting on his chest, making it diffiicult for him to breathe. He is very sweaty.

A - Acute Coronary Syndrome
B - Heart Failure
C - Aortic Stenosis
D - Pericarditis
E - Atrial Myxoma

Answer 1

Acute Coronary Syndrome -

ACS encompasses unstable angina, NSTEMI and STEMI. Clues in the question are ethnicity (higher demographic in Asian communities), pressure on the chest and sweating. Common risks: ethnicity, age, FH, smoking, obesity, hypertension. Investigations: ECG, troponin (cardiac necrosis/ischaemia leads to release of troponin from myocytes, usually 6 hours after chest pain if they have had an MI), creatine kinase (non-specific, increases after an hour). For treatment, use MONARCH: Morphine (10mg IV, must give with anti-emetic, e.g. metaclopramide 10mg IV), Oxygen, Nitrates (GTN spray), Aspirin (300mg oral/PR), Revascularisation (i.e. PCI, if within a 4-5hr window), Clopidogrel (300mg), low weight Heparin. Secondary prevention: monitor glucose (insulin sliding scale), beta block to reduce HR, ACEi, statin, possibly long-acting nitrate (vasodilator, reduces chest pain).

Question 2

An 80 year old man is brought to your GP clinic complaining of worsening shortness of breath on exercise. He also says it is worse when he lies flat. You notice that his legs are very swollen.

A - Chagas disease
B - Obstructive sleep apnoea
C - Fabry's disease
D - Congestive cardiac failure
E - Sarcoidosis

Answer 2

Congestive heart failure

Question 3

A 74 year old man complains of shortness of breath on exertion and occasional collapse in which he loses consciousness. On examination in GP practice he has an ejection systolic murmur.

A - Aortic regurgitation
B - Aortic stenosis
C - Mitral regurgitation
D - Mitral stenosis
E - Pulmonary regurgitation

Answer 3

Aortic stenosis

Question 4

What are the symptoms of aortic stenosis?

Answer 4

triad of syncope/dizziness, chest pain, SOB.

Question 5

What is the most common cause of aortic stenosis?

Answer 5

most commonly, age-related calcification of aortic valve.

Question 6

What are the risk factors of aortic stenosis?

Answer 6

age, diabetes, congenital biscuspid aortic valve (2 leaflets instead of normal 3, common in Marfan’s disease).

Question 7

What are investigations for aortic stenosis?

Answer 7

echo (valve area <1cm2 or mean gradient pressure across the valve greater than 40mmHg indicative of aortic stenosis).

Question 8

How would you treat aortic stenosis?

Answer 8

if the patient has the triad of symptoms, options include valve replacement (metal or biosynthetic)

Question 9

A 74 year old lady presents to her GP with a chest infection. The GP hears an ejection systolic murmur, loudest in the 2nd intercostal space, right sternal edge. The murmur does not radiate to the carotids. What is the diagnosis?

A - Aortic regurgitation
B - Aortic stenosis
C - Aortic sclerosis
D - Mitral stenosis
E - Coarctation of the aorta

Answer 9

Aortic sclerosis -

fibrous thickening of the aortic valve (as opposed to stenosis = narrowing). Presents with ejection systolic murmur, no radiation to the carotids, usually asymptomatic

Question 10

Mrs Patel is seen in her GP clinic for a regular follow up. The practice nurse takes her blood pressure which is 165/104 despite medication. She does not smoke, has no family history of medical complaints, is otherwise well.

A - Essential hypertension
B - MEN 2A
C - Phaeochromocytoma
D - Conn's disease
E - Cushing's disease

Answer 10

Essential hypertension -

All others are recognised causes of 2o hypertension. 90% of hypertension is essential.

Question 11

How do you diagnose hypertension / treat hypertension?

Answer 11

24hr ambulatory BP, or two measurements on the same day. Treatment: ACEi, calcium channel blocker, thiazide-type diuretic, ARB if ACEi not tolerated, alpha blocker

Question 12

Mr Shah is seen in A&E complaining of sharp left sided chest pain better on leaning forward. He was discharged from hospital 3 weeks ago following an STEMI. His ECG shows widespread ST elevation and PR depression.

A - STEMI
B - NSTEMI
C - Dressler's syndrome
D - Unstable angina
E - Chagas disease

Answer 12

Dressler’s syndrome

Question 13

What is Dressler’s syndrome?

Answer 13

an autoimmune form of pericarditis, specific to post-MI. CLUE: pressure is taken off pericardium when leaning forward.

Question 14

What is pericarditis?

Answer 14

very common. trauma, cancer, recent MI / surgery (Dressler’s), recent viral infection.

Question 15

What are the signs/symptoms of pericarditis?

Answer 15

sub-sternal pain, varies with respiration, increased with recumbency, relieved by learning forward, anxiety, anorexia, fever, pericardial friction rub

Question 16

Mrs Siddleton is seen in A&E complaining of palpitations and dizzyness. On examination she has an irregularly irregular heart beat.
A
Ventricular tachycardia
B
Ventricular Fibrillation
C
Atrial fibrillation with fast ventricular response
D
Complete heart block
E
First degree heart block

Answer 16

Atrial fibrillation with fast ventricular response

Question 17

What is AF and what are common causes?

Answer 17

Recurrent, uncoordinated contraction of atria.
Causes: IHD, hypertension, CAD, valvular heart disease, rheumatic heart disease, thyrotoxicosis. Also electrolyte imbalance dehydration

Question 18

How do you treat AF?

Answer 18

Rate vs Rhythm control, anticoagulation, CHADSVASC score (> or equal to 2, anticoagulate)
Can only cardiovert if <48hrs - electrical or chemical. Paroxysmal AF - self-limiting.

Question 19

A 75 year old presents with shortness of breath on exertion. On further questioning she is unable to lie flat due to breathlessness and has woken up during the night gasping for air. She has a history of hypertension. On examination there is bibasal crackles. The CXR reveals small bilateral pleural effusions, upper lobe diversion and bat wing oedema. What is the most likely diagnosis?

A - COPD
B - Pulmonary Oedema
C - Interstitial lung disease
D - Cryptogenic fibrosing alveolitis
E - Pneumonia

Answer 19

Pulmonary oedema

Question 20

What would you see on an x-ray of pulmonary oedema?

Answer 20

see photo from Helen Rimell

Question 21

A 81 year old male with a history of hypertension and inferior MI is seen in the cardiology clinic due to worsening angina and heart failure and 2 syncopal episodes. He is found to have an pan systolic murmur loudest at the apex. Which investigation will confirm the most likely diagnosis?

A - Echocardiography
B - ECG
C - Exercise tolerance test
D - Coronary angiography
E - Blood cultures

Answer 21

Echocardiography -

most likely diagnosis is mitral regurgitation, which can be detected though an echo.

Question 22

A 72 year old gentleman has recently had a mitral valve replacement. He is now complaining of fatigue and shortness of breath. On examination he is pale and his sclera appear yellow. Bloods reveal a low haemoglobin, increased bilirubin, increased reticulocyte count and fragmented red cells on blood film. What is the most likely diagnosis and why?

A - Infective endocarditis
B - iron deficiency anaemia
C - haemolytic anaemia
D - acute cholangitis
E - B12 deficiency

Answer 22

Haemolytic anaemia -

metal valves are longer lasting but increase risk of clots and haemolytic anaemia

Question 23

A 21 year old medical student is on his way back from home from a recent Wednesday night sports event. He suddenly feels palpitations, no SOB, no CP. He goes to ED and they diagnose supraventricular tachycardia with a HR of 170 bpm. They trial carotid sinus massage which does not work. What is your next step?

A - Repeat carotid sinus massage
B - IV verapamil
C - IV propranolol
D - IV adenosine
E - synchronised DC cardioversion

Answer 23

IV adenosine

Question 24

What is SVT?

Answer 24

regular, narrow QRS complexes

Causes: alcohol binge, can occur for no apparent reason.

Question 25

What is the management of SVT?

Answer 25

vagal manœuvres to try to make heart return to normal sinus rhythm. e.g. stick finger / syringe in mouth and blow

IV adenosine (6mg, then 12mg, then 12mg - couple of minutes in-between): this targets the SAN, causes systole and prevents any electrical activity going through their heart which can then “reboot” after 5-6 seconds (very quickly metabolised). If 3 lots of adenosine hasn’t worked, sedate and shock (chemically with amiodarone via a central line or with pads), can cardiac massage while placing central line (takes approx. 20mins).