Cardio Key Flashcards

Question

[Example 3] A 62 YO man with Hx of smoking and HTN presents complaining of 25 minutes of left side constricting chest pain radiating to his left shoulder. He was given Aspirin 300 mg and trinitrates for the pain. ECG was then done and showed ST elevation in leads V1-V4. What is the most appropriate next step in management?

Answer 1

→ PCI “Percutaneous Coronary Intervention”. If not among the choices, pick → Alteplase “Thrombolysis”

Answer 2

In this case, 2 drugs should be given immediately: √ Aspirin 300 mg. √ LMWH or Fondaparinux. Pick the one that is given in the choices. “low-risk patients can be treated conservatively. However, if subsequent ischemia develops → coronary angiography with PCI”.

Answer 3

? → Emergency coronary angiography.

Answer 4

Do → Emergency coronary angiography.

Answer 5

o 75% in the left atrium. o Benign tumours o Tend to grow on the wall (inter-atrial septum). o 10% are inherited → Familial myxoma

Answer 6

◙ Obstruction of Mitral valve → Mid-diastolic murmur, Dyspnea, Syncope, Congestive HF. ◙ Small pieces may break off and travel to arteries causing (ischemia) of different parts of the body such as: ♦ Lung → Can cause PE (Pulmonary Embolism) →Can cause Stroke → Clubbing and Blue fingers. ◙ Atrial Fibrillation

Answer 7

Embolectomy

Answer 8

The likely Diagnosis → Cardiac Tamponade. The most appropriate management → Pericardiocentesis • Beck’s Triad: Hypotension, Muffled Heart Sounds, High JVP (Distended neck veins).

Answer 9

o If QRS in lead I is up (+ve) and in lead II is down (negative) → Left axis deviation o If QRS in lead I is down (-ve) and in lead II is up (+ve) → Right axis deviation

Answer 10

Inferior MI Wolff Parkinson White Syndrome Left Ventricular Hypertrophy Left Anterior Fascicular block (or hemiblock) Obese

Answer 11

Pulmonary Embolism Right Ventricular Hypertrophy Chronic Lung Disease Lateral MI Left Posterior Fascicular Block (or hemiblock) Thin, Tall, Children

Answer 12

o Congenital Heart Disease. o Left Ventricular Aneurysm.

Answer 13

P R interval > 0.2 seconds (Only prolonged PR intervals). (i.e., PR interval occupies more than 1 large square (or 5 small squares).

Answer 14

→ Progressive prolongation of the PR interval until a dropped beat occurs

Answer 15

→ PR interval is constant but the P wave is often not followed by a QRS complex.

Answer 16

• There is no association between P waves and QRS complexes.

Answer 17

◙ 1st Degree Heart Block and Mobitz type 1 usually → do not require treatment (as long as the patient is Asymptomatic). ◙ Mobitz type 2 and Complete heart block (3rd degree heart block) → require permanent pacemaker • Initially → Atropine (first choice for all symptomatic bradycardia). • Then → Transcutaneous pacing. (Used to buy time until transvenous pacing is done). • Then → Transvenous pacing. • Then → Permanent pacing (Pacemaker).

Answer 18

For your knowledge: • 1 small square • 1 large square contains 5 small squares = 0.04 sec. X 5= 0.2 sec.

Answer 19

• Atrial Flutter management → Cardioversion (Shock)

Answer 20

√ Ventricular tachycardia (VT) is broad-complex tachycardia originating from a ventricular ectopic focus. √ It can develop into ventricular fibrillation and therefore requires urgent treatment. √ P wave might be present or absent.

Answer 21

→ Ventricular tachycardia → Give Amiodarone He is stable!

Answer 22

→ DC cardioversion = shock. He is unstable but has a pulse.

Answer 23

→ Ventricular Fibrillation → Defibrillation = Asynchronized shock

Answer 24

[As the patient is still conscious and with a felt pulse, it is likely ventricular tachycardia; not ventricular fibrillation. However, remember that ventricular tachycardia is managed by amiodarone if the patient is stable and by cardioversion if unstable]. If No pulse → Immediate Defibrillation.

Answer 25

• Ventricular fibrillation is the most important shockable arrhythmia. • Hypokalemia (↓ K+) is the most important cause of ventricular tachycardia (VT) clinically.

Answer 26

◙ Beat-to-beat variations with no uniform pattern of ventricular contractions. ◙ Broad QRS (except in resting status), Prolonged QT, Fainting episodes, Patient might be a young athlete, Recurrent. ◙ Treatment → IV Magnesium Sulphate.

Answer 27

◙ Usually in young patients ◙ Presents with Palpitations, Light-headedness, Recurrent , Young ♠ Initial line → Valsalva manoeuvre, Carotid massage. ♠ Not improved? → Intravenous adenosine

Answer 28

Delta wave on the ECG

Answer 29

Lightheadness, hypotension, vertigo, syncope, dizziness. N.B. Sinus bradycardia is normal in young athletes. ◙ The first drug of choice for Symptomatic Bradycardia (Dizziness, feeling unwell) → Atropine

Answer 30

Physiological situation (exercise, stress, anger). Hx of infection.

Answer 31

VF Immediate defibrillation

Answer 32

‘’Fluttering Feeling in the chest’’, Sawtooth waves on the ECG → Synchronized ardioversion.

Answer 33

Regular and Fast rhythm. Ongoing lightheadness, Palpitations, Chest pain. → Give Amiodarone. If unstable (SBP <90, ↓ consciousness) → Immediate synchronized Cardioversion. Immediate defibrillation. If Pulseless VT → Defibrillation = Unsynchronized cardioversion “high”

Answer 34

‘’Fluttering Feeling in the chest’’, Sawtooth waves on the ECG → Synchronized ardioversion.

Answer 35

Palpitation, Tachycardia, Dyspnea, Fibrillatory waves on the ECG, Irregularly irregular rhythm → Give Beta-Blocker. If Asthmatic → Give Calcium Channel Blocker. If with hypotension → Cardioversion / IV amiodarone.

Answer 36

While loop diuretics (furosemide, bumetanide) and nitrates are important in the management of acute or decompensated cardiac failure, they have no effect on long-term survival.

Answer 37

• ACE-inhibitors • Beta-blockers • Angiotensin receptor blockers (ARBs) • Aldosterone antagonists (e.g. Eplerenone, Spironolactone) • Hydralazine with nitrates

Answer 38

How to manage CHF? (Important) • For all patient, for symptomatic relief and to reduce the volume overload → Diuretics (e.g., Furosemide ▐ Lasix ™) or (Bumetanide).

Answer 39

• Start with either an ACE inhibitor or Beta blocker (one drug at a time). • If the symptoms persist → Add the other one (ACEi or BB). • If the symptoms still persist → Add Spironolactone

Answer 40

• Increase the dose of the furosemide. • Switch the furosemide to either bumetanide or torsemide. • Consider admission for IV loop diuretics.

Answer 41

ACE inhibitors are reno-protective and thus beneficial for diabetic patients.

Answer 42

• If HF + AF → Digoxin

Answer 43

The answer is → No! • Thiazide and Loop Diuretics (e.g. Furosemide) → HypOkalemia. • ACEi (e.g., Ramipril) and Spironolactone → HypeRkalemia.

Answer 44

◙ In Acute Settings → MONA (Morphine, O2, Nitrates, Aspirin 300 mg) + Heparin (either unfractionated or LMW such as enoxaparin/ fondaparinux)

Answer 45

• If the patient presents within 12 hours of the onset of the symptoms → PCI (Percutaneous Coronary Intervention) ‘’The gold standard’’ • If Not, or PCI is unavailable → Thrombolysis (Alteplase).

Answer 46

Aspirin for life, Ticagrelor or Prasugrel for 12 months ‘’Clopidogrel previously’’, Beta Blockers (for 12 months), ACE inhibitors , Statins So, Long-term MI Rx = 5 Drugs: Aspirin, Clopidogrel, BB, ACEi, Statins AABC+S → Aspirin, ACE inhibitors, Beta-blockers, Clopidogrel + Statins

Answer 47

√ The foramen allows blood to pass from the right atrium to the left atrium. √ The opening is supposed to close soon after birth, but sometimes it does not. In about 1 out of 4 people, the opening never closes. If it does not close, it is called a PFO. √ In most of these individuals, the PFO causes no problems and remains undetected throughout life.

Answer 48

√ PFO has long been studied because of its role in paradoxical embolism (an embolism that travels from the venous side to the arterial side). This may lead to a stroke or transient ischemic attack . √ Transesophageal echocardiography is considered the most accurate investigation to demonstrate a patent foramen ovale. √ A patent foramen ovale may also be an incidental finding.

Answer 49

The important point to remember is: Trans-oesophageal Echocardiography (TOE) with bubble contrast is the gold standard in diagnosing Patent Foramen Ovale (PFO)

Answer 50

• This most commonly occurs due to patients developing ventricular fibrillation and is the most common cause of death following a MI. • Patients are managed as per the ALS protocol with defibrillation.

Answer 51

Chronic heart failure If the patient survives the acute phase, their ventricular myocardium may become dysfunctional resulting in chronic heart failure

Answer 52

Tachyarrhythmias ◙ Ventricular fibrillation, as mentioned above, is the most common cause of death following a MI. Other arrhythmias can also occur e.g. ventricular tachycardia. ◙ Management: 1) Check the patient’s pulse, if no pulse, commence the arrest protocol immediately (and deliver immediate defibrillation) 2) Administer O2.

Answer 53

◙ Management of Pericarditis (imp): √ A full-dose NSAID should be used (eg, aspirin, 2-4 g/d; ibuprofen 1200-1800 mg/d; indomethacin 75-150 mg/d); treatment should last at least 7-14 days. √ Colchicine (as an adjunct to NSAIDs to ↓ inflammation and recurrence)

Answer 54

Similar to mitral regurgitation but the pan-systolic murmur is heard over the lower left sternal border.

Answer 55

◙ Due to → Ischemia or rupture of the papillary muscles of the mitral valve. ◙ An early-to-mid systolic or Pansystolic murmur is typically heard at Apex. ◙ May present with Hypotension, Tachycardia, and Pulmonary edema. If with Pulmonary Edema → SOB (Dyspnea), Bi-basal Crackles, Tachycardia. ◙ To diagnose MR → Echocardiogram.

Answer 56

◙ Rupture of the interventricular septum usually occurs in the first week after a MI attack and is seen in around 1-2% of patients ◙ Features: acute heart failure associated with a pan-systolic murmur best heard at the left lower sternal border + Heart Failure (eg, bibasilar crackles) + Shock (hypotension, tachycardia). ◙ An echocardiogram is diagnostic and will exclude acute mitral regurgitation which presents in a similar fashion. ◙ Urgent surgical correction is needed.

Answer 57

◙ The underlying pathophysiology is thought to be an autoimmune reaction against antigenic proteins formed as the myocardium recovers. ◙ It is characterised by a combination of fever, pleuritic chest pain that worsens on inspiration and lying flat , pericardial effusion and a raised ESR. ◙ It is treated with NSAIDs. ◙ ECG: Widespread Saddle Shaped ST Elevation ± PR Depression

Answer 58

◙ This is typically associated with persistent ST elevation and left ventricular failure. ◙ A thrombus may form within the aneurysm increasing the risk of stroke . Patients are therefore anticoagulated. ECG → Persistent ST Elevation + Left Ventricular Failure. CXR → Enlarged heart with a bulge at the left heart border . Echo → Paradoxical movement of the ventricular wall.

Answer 59

” ◙ Similar to pericarditis in features but it tends to occur 2-6 weeks following a myocardial infarction. ◙ The underlying pathophysiology is thought to be an autoimmune reaction against antigenic proteins formed as the myocardium recovers. ◙ It is characterised by a combination of fever, pleuritic chest pain that worsens on inspiration and lying flat, pericardial effusion and a raised ESR. ◙ It is treated with NSAIDs. ◙ ECG: Widespread Saddle Shaped ST Elevation ± PR Depression.

Answer 60

◙ Pericarditis (Can occur as a Complication of MI, may develop shortly after MI within 2 days) and Dressler’s syndrome (presents 2-6 weeks after MI) both have the same features: → Pleuritic chest pain that worsens on lying flat and during inspiration, and improves on upright sitting forward. ± Pericardial rub, ± Widespread Saddle shaped ST elevation on the ECG. ◙ They can also lead to Pericardial effusion (Enlarged globular heart on chest X-ray) and if severe enough, Cardiac Tamponade can also develop (also enlarged globular heart of the X-ray + Beck’s Triad: Hypotension, Muffled Heart Sounds, High JVP).

Answer 61

→ Left main coronary artery [LMCA] occlusion → Emergency coronary angiography

Answer 62

TEMI: → Give MONA (Morphine, O2, Nitroglycerin, Aspirin) and then: → Send immediately for (Percutaneous Coronary Intervention). • If PCI is not obtainable → alteplase ie thrombolysis • If PCI and Alteplase are not given, pick →Streptokinase. [i.e. thrombolysis].

Answer 63

√ Oral Aspirin 300 mg ◙ Any patient presents with NSTEMI or Unstable angina: → After giving morphine, 2 medications should be given immediately: (+) √ SC Low molecular weight heparin “or” SC Fondaparinux.

Answer 64

i.e. (widespread ST depression + ST elevation in aVR): after giving morphine → Emergency coronary angiography.

Answer 65

→ Atropine Given 0.5 mg IV push and may be repeated up to a total dose of 3 mg). What if he was given atropine but no response? Next step would be → Temporary transcutaneous pacemaker. ◙ 2nd Line → Dopamine. ◙ 3rd Line → Epinephrine. ♠ N.B. If the question was “the next best step” (or) “the initial line”, the Answer will be → O2 (ABCD).

Answer 66

→ Cardiac Tamponade. → Echo for Dx and Pericardiocentesis for Rx

Answer 67

The initial step → Blood Culture √ Then → Echo Example: 6 weeks following MI, a 59-year-old patient presented with a 10-day history of intermittent fever and a new-onset of a soft high-pitched murmur at the apex. His ECG is normal. Fever + New-onset murmur, Think → infective Endocarditis

Answer 68

◙ A previous episode of endocarditis → the strongest risk factor. ◙ Rheumatic valve disease. ◙ Prosthetic valves. ◙ Congenital heart defects. ◙ Intravenous drug users (IVDUs: typically causing tricuspid lesion).

Answer 69

: - Staph. Aureus is the commonest cause of IE in general . - Staph. Epidermidis is the commonest cause after prosthetic valve surgery. - Strept. Viridans (especially sterpt. Mitis and strept. Sanguinis) are the commonest cause in people with poor dental hygiene or following a dental procedure.

Answer 70

Major criteria 1) Positive blood cultures ◙ Two positive blood cultures showing typical organisms consistent with infective endocarditis, such as Streptococcus viridans and the HACEK group, (Or) ◙ Persistent bacteraemia from two blood cultures taken > 12 hours apart or three or more positive blood cultures where the pathogen is less specific such as Staph aureus and Staph epidermidis Not to be confused, it is true that staph. Aureus is the commonest pathogen in IE; however, it is not specific for IE as it causes many other inflammations. 2) Evidence of endocardial involvement (i.e. +ve Echo for IE) ◙ Positive echocardiogram ( oscillating structures Abscess formation , new valvular regurgitation or dehiscence of prosthetic valves). (Or) ◙ New valvular regurgitation

Answer 71

1. Predisposing heart condition or intravenous drug use. 2. Microbiological evidence that does not meet the major criteria. 3. Fever > 38°C. 4. Vascular phenomena → Major emboli, Splenomegaly, Clubbing, Splinter haemorrhages, Janeway lesions, Petechiae or purpura. 5. Immunological phenomena → Glomerulonephritis, Osler’s nodes, Roth spots. N.B. - Osler’s Nodes: painful, red nodules on the hands or feet that can persist for hours to days. - Janeway lesions: Non-tender, small, erythematous or hemorrhagic macular or nodular lesions on the soles or palms. they occur due to septic micro- emboli that deposit the bacteria under the skin).

Answer 72

• Native valve endocarditis → - Amoxicillin + low-dose Gentamicin. (Or), - Vancomycin + low-dose Gentamicin ( If Penicillin allergic or MRSA Methicillin-Resistant Staph. Aureus” is suspected or Severe Sepsis). • If Hx of prosthetic valve endocarditis→ Vancomycin + low-dose Gentamicin + Rifampicin

Answer 73

The most important note to remember is that in any patient presenting with Fever + a new heart Murmur → suspect Infective Endocarditis and order Blood Culture until proven otherwise.

Answer 74

The likely Dx → The underlying cause of this condition → The next investigating step → Answers Infective Endocarditis. (Fever + New Murmur). infection. blood culture ( followed by Echo).

Answer 75

What is the most appropriate investigation? → Blood Culture These lesions are likely endocarditis). ♦ Likely → → Do Blood culture Janeway lesions (minor criteria of infective Infective endocarditis then Echocardiogram

Answer 76

“To determine the need to anticoagulants” . ◙ Give Warfarin or DOAC (Direct-Acting Oral AntiCoagulants, such as Apixaban, Rivaroxaban, Edoxaban, Dabigatran) To: √ All patients with score ≥ 2. √ Consider giving Warfarin or DOAC to Men who score ≥ 1.

Answer 77

Advantages of DOAC: o No need for INR Monitoring, o Faster Onset of Action (2-4 hours Reduces the risk of intracranial Hemorrhage. Disadvantages of DOAC: o No Antidote o Require strict compliance by the patients.

Answer 78

◙ The CHA2DS2-VASc score is used to determine the need to anticoagulants in a patient who has atrial fibrillation. √ important ◙ The ABCD2 score (Prognostic) is used to identify the risk of future stroke in patients who have had a suspected TIA in the following 7 days . √ Not advised to be used now according to the recent 2019 CKS guidelines. ◙ The HAS-BLED score estimates the risk of major bleeding for patients on anticoagulation for atrial fibrillation. ◙ The DRAGON score predicts the 3-month outcome in ischaemic stroke patients receiving tissue plasminogen activator (tPA) e.g. alteplase. The QRISK2 score is used to determine the risk of a cardiovascular event in the next 10 years

Answer 79

Mechanism: Often caused by congestive heart failure. When the heart is not able to pump efficiently → blood may return into the veins → then to the lungs. As the pressure in these blood vessels increases, fluid is pushed into the air spaces (alveoli) in the lungs. Features: Desaturation (Low O2 Sat.), Dyspnea (SOB), Orthopnea (SOB worsens when lying down), Auscultation → Crepitations “Crackles = rales”. Mostly bi-basal. Tachycardia.

Answer 80

Echocardiogram to be identified (e.g. Congestive Heart Failure, Complication of MI → Acute Mitral Regurgitation due to papillary rupture, Ventricular aneurysm, …etc.)

Answer 81

Therefore, pay attention to the question words! ◙ The Most Appropriate Investigation → Chest X-Ray. “imp √” ◙ The Investigation Needed to Identify the Underlying Cause → Echo. “imp √”

Answer 82

Management: MONA (But the last A -Aspirin- is replaced by F -Furosemide-): → Morphine, O2, Nitrates, Furosemide (Lasix). 1) Sit the patient up (Popup position) and give O2 (aim for O2 saturation of ≥ 95%, or ≥ 90% in COPD patients). 2) Spray 2 puffs of sublingual GTN (Glyceryl TriNitrates). 3) Give Furosemide (Lasix) 40 mg IV (Slowly). 4) Give Diamorphine ( 2.5-5 mg IV slowly) or Morphine (5-10 mg IV slowly) to relieve pain, anxiety and distress.

Answer 83

N.B. A good difference between Pulmonary Edema and Pulmonary Embolism is that Pulmonary Oedema can be diagnosed by Chest X-ray while Pulmonary Embolism needs CTPA (CT Pulmonary Angiogram).

Answer 84

Pulmonary Oedema → Kerley Lines + Bat’s wing hilar shadow

Answer 85

◙ The likely Dx → Pulmonary Oedema. ◙ The appropriate Initial investigation → Chest X-Ray. ◙ The best investigation to identify the cause → Echocardiography. ◙ Treatment → MONF (Morphine, O2, Glyceryl Trinitrates, FUROSEMIDE). Pulmonary Oedema → Kerley Lines (Expansion of the interstitial space by fluid)

Answer 86

Important: If pulmonary edema is cuased by existent hear failure, the patient needs to be discharged on either ACE inhibitor or a beta blocker (one drug at a time). If asthmatic → ACE inhibitor is preferred over BB as BB may worsen asthma

Answer 87

◙ Central Chest Pain or Epigastric pain or Substernal pain that is severe, sudden, crushing, pressuring, squeezing, constricting or burning. ◙ Radiates to arms, shoulders, neck or jaw. ◙ ± Sweating (Diaphoresis), Nausea, Vomiting, Fatigue and/or Palpitations. ◙ SOB “Shortness of breath”.

Answer 88

Although Dissecting aortic Aneurysm may have more or less a similar presentation to MI, to be chosen as an answer, there should be other clinchers pointing towards dissecting aneurysm such as: √ Unequal pulses in upper limbs. √ Hx of Marfan Syndrome (tall, long slender limbs and fingers). √ Hx of Ehlers-Danlos syndrome/ turner syndrome. √ Severe tearing chest pain that radiates to the Back. √ HTN is the most important risk factor. √ The patient presents with Hypotension, SOB, tachycardia, sweating.

Answer 89

• Aortic dissection is a rare but serious cause of chest pain. • Pathophysiology → tear in the tunica intima of the wall of the aorta. • Injury of the innermost layer of the aorta allows blood to flow between the layers of the aortic wall, forcing the layers apart. • In most cases, this is associated with a sudden onset of severe chest or back pain, often described as “tearing” in character. Also, vomiting, sweating, and lightheadedness may occur. • Other symptoms may result from decreased blood supply to other organs, such as stroke or mesenteric ischemia. • Aortic dissection can quickly lead to death from not enough blood flow to the heart or complete rupture of the aorta. • The transoesophageal echocardiogram (TEE) is a good test in the diagnosis of aortic dissection, with a sensitivity up to 98% and a specificity up to 97%. It has become the preferred imaging modality for suspected aortic dissection. • Other good investigations → CT scan with contras/ MRI. • In emergency settings → US or CT scan.

Answer 90

Stanford classification of Aortic Dissection: type A: ascending aorta, 2/3 of cases type B: descending aorta, distal to left subclavian origin, 1/3 of cases

Answer 91

• Type A → surgical management, but blood pressure should be controlled to a target systolic of 100-120 mmHg whilst awaiting intervention. • Type B → conservative management, bed rest, reduce blood pressure: IV labetalol to prevent progression

Answer 92

• Cardiac Tamponade can develop as a complication of MI After MI → Acute pericarditis → Pericardial effusion → Cardiac Tamponade • Trauma is the most important cause of cardiac tamponade

Answer 93

N.B. Chest X-ray that shows → Think of either enlarged globular heart Pericardial effusion (OR) Cardiac Tamponade. • Dx: Echocardiogram is diagnostic • Rx: Urgent pericardiocentesis.

Answer 94

Important! If the patient is in hypovolemic shock (severely low BP) and the question asks about the [INITIAL] treatment line and IV fluids is within the option, pick it! Cardiac Tamponade: Oxygenation and ventilation → 1 to 2 L IV fluid NS → bedside Pericardiocentesis

Answer 95

In the context of chest pain, new LBBB is significant as it is an indication for thrombolysis / percutaneous coronary intervention (PCI). LBBB features on ECG: ◙ Notched (M shaped) broad complex QRS: usually in Lead (I), aVL and V6 but not always. ◙ Deep inverted (Negative) QRS: usually in lead (V1). ◙ Left Axis Deviation (Not always) Important Note → A new onset LBBB is characteristic for Myocardial Infarction (MI)

Answer 96

◙ The classical picture: a triad of: Pain, Hypotension, pulsatile tender abdominal mass. - Sudden onset severe abdominal ± Lower back ± Flank pain. - Shock (Hypotension, Sweating, Fainting) - Absent Lower Limb Pulse, mottled skin. ◙ It is a surgical emergency; therefore, immediate Ultrasound is the most appropriate initial investigation. ◙ If no U/S in the options, go for CT scan abdomen.

Answer 97

: √ Men only. √ Once only. √ In 65th year. √ by Ultrasound.

Answer 98

The management would be: • For symptomatic relief and to reduce the volume overload, all patients should receive → Diuretics (e.g. loop diuretics e.g. Furosemide) • Start with either ACEi or BB. (one drug at a time) • If the symptoms persist → Add the other one (ACEi or BB). • If still symptomatic → Add spironolactone “potassium sparing diuretics”. • V. Imp. Note: If the patient with Heart Failure has Diabetes , we start with ACE inhibitors (e.g. Ramipril) instead of Beta-Blockers.

Answer 99

Right coronary artery (RCA) gives off the PDA • The artery that supplies the Posterior Descending Artery (PDA) determines the coronary dominance. of the population, the (Right Dominant). of the population, the • In 85% • In 15% left circumflex gives off the PDA (Left Dominant). ◙ Hence, the artery that has artery dominance is the (RCA), as it gives off the PDA in 85% of people.

Answer 100

It is characterised by a combination of fever, pleuritic pain worsens on inspiration and on lying flat, pericardial effusion and a raised ESR. ◙ ECG → Widespread Saddle Shaped ST Elevation + PR Depression ◙ It is treated by NSAIDs. ◙ Its features are more or less similar to acute pericarditis

Answer 101

◙ Spironolactone, ACE inhibitors, ARBs → ◙ Loop diuretics, Thiazide like diuretics → HypeRkalemia. HypOkalemia. ◙ The ECG changes in HypUkalemia → U Wave

Answer 102

U wave (hypokalemia) → an additional wave after (T-wave) Management of hypokalemia 1) Oral or IV potassium chloride (based on severity), e.g. 2) Stop/ Treat the cause (e.g. stop furosemide, thiazide like diuretics).

Answer 103

Loop Diuretics (e.g. Furosemide • Thiazide-like diuretics( e.g. bendroflumethiazide, indapamide) • Villous Adenoma Conn’s disease (1ry hyperaldosteronism) Vomiting and Diarrhea • Renal tubular failure • Cushing Syndrome

Answer 104

ACE inhibitors (e.g. enalapril) • ARBs (e.g. losartan). Potassium-sparing diuretics Eg. Spironolactone/ Eplerenone) • Congenital Adrenal Hyperplasia (CAH Addison’s (1ry Adrenal Insufficienc • CKD/ Acute renal failure

Answer 105

Remember: √ Severe vomiting can cause hypokalemia. √ Hypokalemia features include muscle weakness and cramping.

Answer 106

Management: imp √ ♠ Initial line → Valsalva manoeuvre, Carotid massage. ♠ Not improved? adenosine → Intravenous (6mg Rapid IV Bolus), still not improved? → give additional 12mg adenosine, still not improved? → give another 12mg adenosine

Answer 107

N.B. Adenosine is contraindicated in asthmatics → Verapamil (CCB) is the preferred option in SVT in a patient with Asthma. ♠ Still not improved? → Electrical DC “Cardioversion” • Prevention of future episodes → ß-Blockers or Radio-frequency ablation. IMPORTANT NOTE: If the patient is hemodynamically unstable (eg, hypotension, chest pain, shock, and or altered mental status) Proceed immediately to → electrical synchronised cardioversion. In summary: → Carotid Massage and Valsalva Manoeuvre → IV Adenosine 6 mg → IV Adenosine 12 mg → IV Adenosine 12 mg → Cardioversion (Shock). [ Important Note: Start with this step if chest pain, hypotension, and or altered mentation ie, hemodynamic unstable patient]

Answer 108

) ◙ Beat-to-beat variations with no uniform pattern of ventricular contractions. ◙ Broad QRS (except in resting status), Prolonged QT, Fainting episodes, Patient might be a young athlete, Recurrent. ◙ Treatment → IV Magnesium Sulphate. N.B. Verapamil should NOT be used in VT.

Answer 109

◙ Quick Important Note to Remember: High doses of can lead to Citalopram, (a SSRI), can cause prolonged QT intervals, which Torsade De Pointes

Answer 110

Pick → i.e. Alteplase “preferred” or Streptokinase (Tissue Plasminogen Activator) Thrombolysis.

Answer 111

→ Request Cardiac Enzymes, especially (Troponin) If Troponin is high → NON-STEMI Elevation MI → Give LMWH OR Fondaparinux + Aspirin 300 mg

Answer 112

The likely cause → Left Ventricular Aneurysm. (Persistent ST elevation post-MI → Think of: Left Ventricular Aneurysm) Left ventricular aneurysm ◙ The ischaemic damage sustained during a MI episode may weaken the myocardium resulting in a thin muscular layer; thus, aneurysm formation. ◙ This usually occurs 4-6 weeks post MI. ◙ This is typically associated with persistent ST elevation and left ventricular failure. ◙ A thrombus may form within the aneurysm increasing the risk of stroke. Patients are therefore anticoagulated. ECG → Persistent ST Elevation + Left Ventricular Failure. CXR → Enlarged heart with a bulge at the left heart border. Echo → Paradoxical movement of the ventricular wall.

Answer 113

Stage 1 Clinic BP ≥ 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP ≥ 135/85 mmHg Stage 2 Clinic BP ≥ 160/100 mmHg and subsequent ABPM daytime or hypertension HBPM average BP ≥ 150/95 mmHg

Answer 114

Stage 3 “Severe Clinic systolic BP ≥ 180 mmHg, hypertension” or clinic diastolic BP ≥ 110 mmHg

Answer 115

Keys: ABPM → Ambulatory Blood Pressure Monitoring. HBPM → Home Blood Pressure Monitoring. N.B. Clinic BP is usually higher than ABPM and HBPM because some people get stressed or feared while at a clinic → a slight increase in BP. Management of hypertension Lifestyle advice should not be forgot

Answer 116

Low salt diet. • Caffeine intake should be reduced. • Stop smoking. • Drink less alcohol. • Eat a balanced diet rich in fruits and vegetables. • Exercise more. • Lose weight.

Answer 117

♠ When to Treat Stage 1 Hypertension? • Treat if the patient’s age is < 80 years AND + any of the following: Target organ damage, established cardiovascular disease, renal disease, diabetes (DM) or a 10-year cardiovascular risk equivalent to ≥ 10%. ◙ Note: If a patient is completely free and has a stage 1 Hypertension → Lifestyle and Diet Modification + review (Follow up). ◙ Note: In a patient with stage 2 hypertension at a clinic (Clinic BP ≥ 160/100) → Before commencing antihypertensive drugs, record either ABPM or HBPM.

Answer 118

→ Consider a specialist referral to exclude secondary causes of the HTN

Answer 119

If ABPM or HBPM ≥ 150/95 mmHg (i.e., confirmed stage 2 or higher hypertension) → Always treat.

Answer 120

The Steps of The Management of Hypertension Step 1 • Patients < 55-years-old → start with ACE inhibitor (A) or ARBs. • Patients ≥ 55-years-old of Afro-Caribbean origin “of any age” → start with Calcium channel blocker. or In other words: • White + < 55 YO • —- ace inh or arb White + > 55 YO → start with ccb Afro-Caribbean + any age → start with ccb as a step 1 management of HTN.

Answer 121

• Both: ACE inhibitor + Calcium channel blocker (A + C)

Answer 122

→ start with both ACE inhibitor + Calcium Channel Blocker as a first step.

Answer 123

- It is reno-protective (unless eGFR is low; <30; in advanced CKD). - It has protection against diabetic retinopathy. - It has +ve effect on glucose metabolism.

Answer 124

→ If eGFR (Glomerular Filtration Rate) is low ; <30 as in advanced Chronic Kidney Disease → ACEi and ARBS should be avoided in this case.

Answer 125

→ ACE inhibitors (Ramipril). They can cause postural hypotension → thus falls. Anti-hypertensive medications as ACE inhibitors and Calcium channel blockers can cause postural hypotension → dizziness on standing → Falls. if there was no postural hypotension, we would suspect Zopiclone (Although rare, it can lead to falls by balance impairments).

Answer 126

Start with → (e.g. Enalapril). ACE inhibitor (Note, if the eGFR is 30 or below, ACEi and ARBS should be avoided).

Answer 127

Diagnosis? → Atrial Fibrillation. beta-blockers. Management? √ First line → beta blocker √ If asthmatic → Avoid beta-blockers and give √ ccb If the patient has associated HF → give digoxin

Answer 128

Apixaban, Rivaroxaban, Edoxaban, Dabigatran”

Answer 129

If haemodynamically unstable Cardioversion √ If the patient with AF is unstable (eg, SBP ≤ 90) → (Shock). (eg, hypotension) and the AF has just started and no cardioversion in the options, Pick → IV amiodarone. Imp √

Answer 130

Be careful, the reason of IE is → Infection “infective” endocarditis. - Staph. Aureus is the commonest cause of IE in general. - Staph. Epidermidis is the commonest cause after prosthetic valve surgery. - Strept. Viridans (especially sterpt. Mitis and strept. Sanguinis) are the commonest cause in people with poor dental hygiene or following a dental procedure.

Answer 131

◙ A sense of a missed/skipped beat, unsustained palpitation ± Dyspnea and Dizziness due to immature discharge of a ventricular ectopic focus which produces → an early and broad QRS complex. ◙ Causes → Ischemic heart disease (MI), Cardiomyopathy, Stress, Alcohol, Caffeine, Cocaine, Medications OR Naturally. ◙ Over half the population have silent, or asymptomatic ventricular ectopics which are discovered incidentally on a routine ECG. ◙ If there is No underlying Heart disease (e.g. IHD, Cardiomyopathy) → Benign; no clinical significance. ◙ If these ventricular ectopics are due to IHD or Cardiomyopathy → May precipitate to more life-threatening arrhythmias like Ventricular Fibrillation

Answer 132

◙ Central Chest Pain or Epigastric or Substernal pain that is severe, sudden, crushing, pressuring, squeezing or burning and radiates to arms, shoulders, neck or jaw. ◙ ± Sweating (Diaphoresis), Nausea, Vomiting, Fatigue and/or Palpitations.

Answer 133

- The likely cause of this patient’s gout → Thiazide like diuretics (e.g. bendroflumethiazide) or Loop Diuretics (Both can cause hyperuricemia (Gout) and both can be used to treat volume overload caused by Heart Failure) - The likely cause of this patient’s worsening of SOB and Orthopnea → NSAIDs (e.g. Ibuprofen) that was prescribed to treat his gout.

Answer 134

Never give NSAIDs (e.g. Ibuprofen) nor selective COX-2 inhibitors (e.g. Celecoxib) to the following patients: CKD, CHD, IHD (Chronic Kidney Disease, Chronic Heart Failure, Ischemic Heart Disease). ◙ These drugs can worsen the HF (worsening the SOB and Orthopnea) and also the renal function. ◙ Remember that NSAIDs inhibit the synthesis of prostaglandins → thus, decrease the eGFR, retain more salt and water (risk factor for HF). ◙ N.B. Thiazide like diuretics and Loop diuretics decrease the clearance of Uric Acid → leading to Gout (Hyperuricemia) ◙ N.B. NSAIDs such as Ibuprofen are used for the treatment of Gout. If given to a patient with chronic heart failure, they would worsen the HF symptoms (Orthopnea and Dyspnea).

Answer 135

Ring the emergency bell and call resuscitation team (Code Blue) first. Then → Start CPR 30:2. Then → Get defibrillator. Then → ALS when the resuscitation team arrives.

Answer 136

“preferred” or Pick → = i.e. Alteplase Streptokinase (Tissue Plasminogen Activator) Thrombolysis.

Answer 137

This is because they may not feel chest pain due to autonomic neuropathy.

Answer 138

AF Beta blocker Ccb if asthmatic

Answer 139

Remember: ◙ In → We firstly perform If this fails → We give Supraventricular tachycardia Carotid Massage (Narrow QRS Complex, absent p waves) and Valsalva Manoeuvre. IV Adenosine. IMPORTANT NOTE: If the patient is hemodynamically unstable ( eg, hypotension, chest pain, shock, altered mental status) Proceed immediately to → electrical synchronised cardioversion.

Answer 140

→ IV magnesium sulfate.

Answer 141

Hypotension, Muffled Heart Sounds, High JVP (Distended neck veins). • Trauma (e.g. stab in the chest) is the most important cause for cardiac tamponade. • Dx: Echocardiography is diagnostic. • Tx: Urgent pericardiocentesis.

Answer 142

◙ In Atrial Myxoma → Mitral valve obstruction → Mitral Stenosis → Early or Mid-diastolic murmur, Dyspnea, Syncope

Answer 143

Atrial myxoma

Answer 144

Points on Alcohol UK guidelines recommend that a person should drink - No more than 14 units a week, - No more than 3 units a day, - with at least 2 alcohol-free days a week.

Answer 145

→ Smoking Cessation Clinic. This is because his alcohol intake is insignificant as per NICE whereas his smoking is significant.

Answer 146

→ The likely Dx → → The likely Cause → Mitral Regurgitation. Rupture of Papillary Muscles. Acute mitral regurgitation (MR): “important √” pansystolic murmur ◙ Occurs 2-15 days after the MI (Mostly inferior MI). ◙ Due to → Ischemia or rupture of the papillary muscles of the mitral valve. ◙ An early-to-mid systolic or Pansystolic murmur is typically heard. ◙ May present with Hypotension, Tachycardia and Pulmonary edema. ◙ Dx → Echocardiogram. ◙ Treatment → vasodilator therapy but often requires emergency surgical repair

Answer 147

→ Acute Pericarditis. Post-MI Pericarditis “important √” ◙ Occurs within 2-3 Days after MI. ◙ Features → Pleuritic chest pain that is worse on lying flat and during inspiration ± Fever ± pericardial rub ◙ Pericardial effusion may develop leading to enlarged globular heart on chest X-ray and is confirmed by echocardiogram. ◙ ECG → Widespread Saddle Shaped ST Elevation with upward concavity + PR Depression. ◙ Management of Pericarditis (imp): √ A full-dose NSAID should be used (eg, aspirin, 2-4 g/d; ibuprofen 1200-1800 mg/d; indomethacin 75-150 mg/d); treatment should last at least 7-14 days. √ Colchicine (as an adjunct to NSAIDs to ↓ inflammation and recurrence).

Answer 148

→ IV Morphine. ◙ Remember the initial management for acute MI → (MONA): Morphine, Oxygen, Nitrates, Aspirin.

Answer 149

1) Glyceryl Trinitrate (GTN) sublingual or spray. 2) ± Opioids (INTRAVASCULAR): 2.5-5 mg Diamorphine or 5-10 mg Morphine. - N.B. Around 1/3 of the patients with MI have nitrate-resistant chest pain; therefore, morphine is given additionally to relieve chest pain. √ IM absorption is unreliable + √ If the patient receives thrombolysis later on, the site of IM injection might bleed.

Answer 150

Ventricular Fibrillation Old adult, Sudden collapse, Not breathing, Unconscious → Shock ‘’defibrillation’’

Answer 151

♠ An ECG showing broad complex tachycardia in a (still) conscious patient ± atrial activity → Ventricular tachycardia → IV Amiodarone. ♠ If the patient is hemodynamically unstable; i.e. unconscious, collapsed, not breathing → Ventricular Fibrillation → 1) Check the patient’s pulse, if no pulse, commence the arrest protocol immediately. 2) Administer O2. 3) If the patient is hemodynamically unstable: Shock followed by IV Amiodarone followed by further Shocks if needed. ◙ N.B. HypOkalemia is the most important cause of ventricular tachycardia (VT) clinically.

Answer 152

→ Pericardiocentesis.

Answer 153

→ Calcium Channel Blocker (CCB) (First Step Management of hypertension in African-Caribbean patients is CCB regardless of the age).

Answer 154

Any ethnicity + Any age + Diabetes → start with ACEi/ARBs as a step 1 management of HTN

Answer 155

Aortic stenosis Ejection systolic Right 2nd ic lateral to sternum Radiates to carotid artery Dyspnea on activity Angina chest pain Syncope

Answer 156

Early Diastolic left lower sternal border around the 3rd to 4th intercostal spaces Symptoms of Heart Failure

Answer 157

Ejection Systolic Left 2nd ICS just lateral to sternum, radiates to left shoulder of infraclavicular area Systemic cyanosis

Answer 158

Early-Diastolic Left 2nd ICS just lateral to sternum Symptom of right heart failure

Answer 159

Mid diastolic or late diastolic Apex left 5th ics mid clavicular line Symptoms of heart failure

Answer 160

Pansystolic Apex( left 5th ics midclavicular Radiates to axilla) Symptoms of chf oedema ascites

Answer 161

Diastolic rumble 4th to 5th ics over left sternal border Fluttering Discomfort in the neck

Answer 162

Pansystolic 4th -5th ics on left sternal border Symptoms of right sided heart failure

Answer 163

→ Mitral Regurgitation. → Request Echocardiogram.

Answer 164

The likely Dx→ Polymorphic Ventricular Tachycardia (Torsades de pointes) Polymorphic (Broad-Complex) Ventricular Tachycardia = Torsades De Pointes (TDP) ◙ Beat-to-beat variations with no uniform pattern of ventricular contractions. ◙ Broad QRS (except in resting status), Prolonged QT, Fainting episodes, Patient might be a young athlete. Recurrent. ◙ Treatment → IV Magnesium Sulphate. N.B. Verapamil should NOT be used in VT.

Answer 165

→ Mitral Stenosis. The most common cause of mitral stenosis → rheumatic fever, rheumatic fever and rheumatic fever. Pathogenesis of Mitral Stenosis: Mitral stenosis impedes left ventricular filling → increased left atrial pressure (Which will lead to left atrial hypertrophy; therefore, CXR shows Straight left side heart border) → Blood returns Back to lungs → Pulmonary Congestion → Right Ventricular Failure (Hepatomegaly, Ascites, Oedema) Features • Mid-late diastolic murmur (best heard on expiration) ‘’low pitched’’ • Loud S1, opening snap • Low volume pulse • Malar flush • Atrial fibrillation

Answer 166

Note: ◙ Left heart murmurs (Mitral and Aortic) are best heard during expiration ◙ Right heart murmurs (Tricuspid and Pulmonary) best heart in inspiration

Answer 167

Chest x-ray in MS • Left atrial enlargement (often) → Straightening the left border of the heart. ECG (may show): - Signs of Right ventricular hypertrophy - P mitrale (bifid P wave) - AF Echocardiography → (Thickening of Mitral valve leaflets)

Answer 168

→ ß-Blockers (e.g. Metoprolol)

Answer 169

Dilated Cardiomyopathy

Answer 170

Hypertrophic Cardiomyopathy.

Answer 171

Dilated Cardiomyopathy (DCM) Basics (For READING ONLY) • Dilated heart leads to systolic (± diastolic) dysfunction • All 4 chambers are affected but the Left Ventricle is more affected than the Right Ventricle. • Features include arrhythmias, emboli, mitral regurgitation • Absence of congenital, valvular or ischaemic heart diseas

Answer 172

• inherited • previous MI • infections e.g. Coxsackie B, HIV, diphtheria, parasitic • endocrine e.g. Hyperthyroidism • infiltrative e.g. Haemochromatosis, sarcoidosis • neuromuscular e.g. Duchenne muscular dystrophy • nutritional e.g. Kwashiorkor, pellagra, thiamine/selenium deficiency • drugs e.g. Doxorubicin

Answer 173

• alcohol: may improve with thiamine • postpartum • hypertension ◙ Other causes

Answer 174

• inherited • previous MI • infections e.g. Coxsackie B, HIV, diphtheria, parasitic • endocrine e.g. Hyperthyroidism • infiltrative e.g. Haemochromatosis, sarcoidosis • neuromuscular e.g. Duchenne muscular dystrophy • nutritional e.g. Kwashiorkor, pellagra, thiamine/selenium deficiency • drugs e.g. Doxorubicin ◙ Inherited dilated cardiomyopathy • around a third of patients with DCM are thought to have a genetic predisposition • a large number of heterogeneous defects have been identified • the majority of defects are inherited in an autosomal dominant fashion although other patterns of inheritance are seen

Answer 175

If the patient is → start with Valsalva manoeuvre and Carotid massage to stimulate the vagal tone (Parasympathetic which decreases the heart rate). - If still ill? → Give Adenosine 6 mg IV bolus. - If no response? → give another Adenosine double dose (12 mg). - If still no response? → give another Adenosine double dose (12 mg). - Unsuccessful yet? → Cardioversion. ♠ If the patient is haemodynamically Unstable → start with Cardioversion.

Answer 176

In AF: - Start with ß-Blockers (e.g. Metoprolol). - If Asthmatic patient → Calcium Channel Blockers. - If Associated Heart Failure → Digoxin.

Answer 177

If stable patient → IV Amiodarone. If unstable → Synchronized cardioversion (Shock)

Answer 178

Inherited dilated cardiomyopathy • around a third of patients with DCM are thought to have a genetic predisposition • a large number of heterogeneous defects have been identified • the majority of defects are inherited in an autosomal dominant fashion although other patterns of inheritance are seen

Answer 179

If the patient is → start with Valsalva manoeuvre and Carotid massage to stimulate the vagal tone (Parasympathetic which decreases the heart rate). - If still ill? → Give Adenosine 6 mg IV bolus. - If no response? → give another Adenosine double dose (12 mg). - If still no response? → give another Adenosine double dose (12 mg). - Unsuccessful yet? → Cardioversion. ♠ If the patient is haemodynamically Unstable → start with Cardioversion.

Answer 180

= (Torsade De Pointe) → Give IV MgSO4 (Magnesium Sulphate)

Answer 181

◙ In AF: - Start with ß-Blockers (e.g. Metoprolol). - If Asthmatic patient → Calcium Channel Blockers. - If Associated Heart Failure → Digoxin.

Answer 182

If stable patient → IV Amiodarone. If unstable → Synchronized cardioversion (Shock)

Answer 183

Analysis and Causes of Falls. Causes are usually: 1) Cardiac cause (e.g. Arrhythmia). 2) Postural (Orthostatic) Hypotension. 3) Hypoglycemia. 4) Seizure.

Answer 184

If the cause was hypoglycemia, he would have felt sweaty and dizzy before the episode. Plus, he would not have recovered until Glucose is administered. ◙ If it was a seizure, the stem has to include an eyewitness to describe the episode. Also, in seizure, there are usually post-ictal features such as confusion and drowsiness. However, the patient in the above stem did not feel any of these, he rather recovered completely. ◙ If it was Postural hypotension (Orthostatic hypotension), the fall usually follow a standing from a sitting position. In addition, the patient would have felt dizziness before the fall, Hx of difficult mobilisation, which are not mentioned here.

Answer 185

Long term medications post-Myocardial Infarction = 5 Drugs AABCS → Aspirin, ACEi, BB, Clopidogrel, Statin (e.g. Atorvastatin)

Answer 186

? → Echocardiogram. ◙ A Holter ECG (24-hour ECG) will not be beneficial as the ECG already shows Irregular Rhythm; hence, there is no point of using it again. Echo should be done to identify the underlying cause of this irregular rhythm so the treatment can be decided accordingly.

Answer 187

Haemodynamically Unstable → e.g. √ Hypotension (SBP < 90), √ Loss of Consciousness, Others: √ HR > 150. √ Severe dizziness or syncope. √ Ongoing chest pain. √ increasing SOB. → Synchronized DC Cardioversion. [Any arrhythmia in an unstable patient → DC Cardioversion]

Answer 188

The best Investigation → 12-lead ECG

Answer 189

Therefore, the likely cause here is arrhythmia (Cardiac cause), likely (Stokes Adam attack). This is also supported by the fact that the patient felt hot and flushed after recovery, which means that the blood has been, rapidly, pumped back to the already dilated vessels. ( Dilated due to hypoxia caused by the irregular rhythm) → 12-lead ECG monitoring is required. Stokes Adam attack [For Reading]: Sudden collapse into unconsciousness due to a disorder of heart rhythm in which there is a slow or absent pulse resulting in syncope (fainting) with or without convulsions. In this condition, the normal heartbeat passing from the upper chambers of the heart to the lower chambers is interrupted. This results in a condition called a “heart block.” When a heart block occurs, the heart rate usually slows considerably. This can cause inadequate blood flow to the brain and result in fainting.

Answer 190

- Preterm baby with continuous or machinery murmur → PDA (Patent Ductus Arteriosus).

Answer 191

→ TOF (Tetralogy of Fallot). Ejection systolic murmur here is due to pulmonary stenosis which is one of the four major features of TOF.

Answer 192

→ Tricuspid Atresia.

Answer 193

→ VSD (Others: Poor feeding and poorly gaining weight)

Answer 194

ASD VSD PDA COARCTATION KF AORTA

Answer 195

TRUNCUS ARTERIOSIS TRANSPOSITION OF GREAT ARTERIES TRICUSPID ATRESIA TETRALOGY OF FALLOT TOTAL ANOMOLOUS PULMONARY VASCULAR RETURN

Answer 196

√ PDA, ASD, VSD → Acyanotic. √ TOF, Tricuspid Atresia → Cyanotic. √ Pansystolic murmur = MR or TA or VSD.

Answer 197

• A form of congenital heart defect • generally classed as ‘acyanotic’ . (√) • connection between the pulmonary trunk and descending aorta • more common in premature (Preterm) babies. (√) • May close spontaneously

Answer 198

• left subclavicular thrill (sometimes rough systolic murmur along the left sternal border) • Continuous ‘machinery’ murmur (√) • large volume, bounding, collapsing pulse • wide pulse pressure Diagnosis → Echocardiogram

Answer 199

Management • Indomethacin / ibuprofen (NSAIDs) (ind=end=closes the duct) (inhibits prostaglandin synthesis) closes the connection in the majority of cases. (√) • If associated with another congenital heart defect amenable to surgery then prostaglandin E1 is useful to keep the duct open until after surgical repair. Indomethacin or ibuprofen → closes the duct. Prostaglandin → keeps the duct ope

Answer 200

. → Tetralogy of Fallot. The cause of ejection systolic murmur here is → pulmonary stenosis (one of the four criteria of TOF).

Answer 201

) Tetralogy of Fallot (TOF) is the most common cause of Cyanotic congenital heart disease **however, at birth, transposition of the great arteries is the more common lesion as patients with TOF generally present at around 1-2 months. ** It typically presents at around 1-2 months, although may not be picked up until the baby is 6 months old TOF is a result of anterior malalignment of the aorticopulmonary septum.

Answer 202

1) Ventricular septal defect (VSD) 2) Right ventricular hypertrophy (RVH) 3) Right ventricular outflow tract obstruction “pulmonary stenosis” (PS) → ejection systolic murmur 4) Overriding aorta

Answer 203

• cyanosis • causes a right-to-left shunt • ejection systolic murmur due to pulmonary stenosis (the VSD doesn’t usually cause a murmur) • a right-sided aortic arch is seen in 25% of patients • chest x-ray shows a ‘boot-shaped’ heart. • ECG shows right ventricular hypertrophy

Answer 204

• Surgical repair is often undertaken in two parts. • Cyanotic episodes may be helped by beta-blockers to reduce infundibular spasm.

Answer 205

Q) When to highly suspect it? 1) If Cholesterol is > 7.5 (Normal: <5 mmol/L) 2) Family History of “MI” in a first degree relative before the age of 60 or 2nd degree below 50

Answer 206

Sudden collapse Not breathing Unconscious No pulse Defibrillation

Answer 207

→ Ring the emergency bell and call the resuscitation team. First → Start CPR 30:2. → Get Defibrillator. → Commence ALS when the resuscitation team arrives.

Answer 208

◙ MR → Mitral Regurgitation. ◙ TR → Tricuspid Regurgitation. ◙ VSD → Ventricular Septal Defect.

Answer 209

◙ If small hole → Asymptomatic ± Left sternal pan-systolic murmur with systolic thrill. ◙ If large hole → • Pan-systolic murmur along the left sternal border. • Left sternal heave, and systolic thrill. • Pulmonary HTN → Dyspnea, Fatigue. • May develop a right-to-left shunt → Cyanosis

Answer 210

→ Backflow of the blood to the lungs → Pulmonary Oedema → Desaturation, Dyspnea, Orthopnea, Crepitations → Perform → Perform → chest X-ray to Diagnose —- to identify the Underlying cause of the Pulmonary Oedema we do, Echo MONF (Morphine, Oxygen, Nitrates, Furosemide is RX

Answer 211

→ Complete heart Block (3rd degree heart block).

Answer 212

→ (Give ARBs e.g., Losartan instead -important-). Other ARBs (Angiotensin II receptor blockers) that could be the valid answer → Losartan, Valsartan, Candesartan. √ One of the important and common side effects of ACE inhibitors is dry cough. If developed, shift to ARBs. √ Another side effect of ACEi to remember is → Hyperkalemia (↑ serum K+).

Answer 213

→ Mitral Regurgitation (MR). Notes: ◙ MR can occur 2ry to MI (Rupture of papillary muscles). ◙ MR can occur 2ry to Rheumatic fever. ◙ MR may lead to → Right-sided (Congestive) heart failure (Ascites, LL oedema). ◙ MR may lead to → Pulmonary oedema ◙ Rheumatic fever can lead to either Mitral Regurgitation or Mitral Stenosis. We can decide based on clinical features.

Answer 214

Mitral Stenosis Mid-Late Diastolic murmer with opening click Symptoms of heart failure 5th ics mcl at apex MR Pan-Systolic murmur At the Apex (left 5th ICS MCL), radiates to Axilla Symptoms of congestive Heart Failure; edema, Ascites

Answer 215

The likely underlying cause of the recurrent falls → Postural Hypotension. The patient is on multiple anti-hypertensive medications (CCB → Amlodipine ▐ Thiazide-like diuretics → indapamide ▐ ACEi → Enalapril). These Blood Pressure Lowering agents are known to cause orthostatic “Postural” hypotension. → Blood Pressure Monitoring + Review the patient’s medications.

Answer 216

→ Echocardiogram. ◙ A Holter ECG (24-hour ECG) will not be beneficial as the ECG already shows Irregular Rhythm; hence, there is no point of using it again. ◙ Echo should be done to identify the underlying cause of this irregular rhythm so the treatment can be decided accordingly. ◙ The most common Valvular heart disease that causes is →AS (ejection systolic murmur at the 2nd right ICS + Angina ± Dyspnea). Syncopal attack ◙ Syncope during or shortly after exertion → Exercise ECG.

Answer 217

This patient likely has AF causing TIA (syncope + irregular rhythm), and to determine the cause of his Atrial fibrillation, do Echo. ◙ Causes of AF: √ Endocardium → Endocarditis, Mitral valve disease. √ Myocardium → Cardiomyopathy. √ Pericardium → Constrictive pericarditis . √ HF, HTN, MI. √ Hyperthyroidism, excessive alcohol intake, chronic lung disease.

Answer 218

Ejection Systolic murmur Right 2nd ICS just lateral to sternum, radiates to Carotid artery Dyspnea on activity, Anginal chest pain, syncope

Answer 219

→ Tricuspid Atresia

Answer 220

→ TOF (Tetralogy of Fallot).

Answer 221

→ Tricuspid Atresia.

Answer 222

Acyanotic, Pan-systolic murmur → VSD ( Others: Poor feeding and poorly gaining weight)

Answer 223

Request → Serum Electrolytes and Urea Amiodarone Amiodarone is a class III antiarrhythmic agent used in the treatment of atrial, nodal and ventricular tachycardias. The main mechanism of action is by blocking potassium channels which inhibits repolarisation and hence prolongs the action potential.

Answer 224

• TFT (Thyroid), LFT (Liver), U&E (Serum electrolytes and Urea), CXR, ECG prior to treatment • TFT, LFT every 6 months • ECG every 12 months

Answer 225

• Thyroid dysfunction: both hypothyroidism and hyperthyroidism • Corneal deposits • Pulmonary fibrosis (The most serious)/pneumonitis • Liver fibrosis/hepatitis • Peripheral neuropathy, myopathy • Photosensitivity • ‘Slate-grey’ appearance (Grey skin) • Thrombophlebitis and injection site reactions (So, usually given via central veins) • Bradycardia • Prolonged QT interval

Answer 226

→ Reassurance.

Answer 227

Early- Diastolic Left 2nd ICS just lateral to sternum Symptoms of Right-Sided Heart Failure

Answer 228

After surgical correction of Tetralogy of Fallot early in life, the corrected pulmonary stenosis (one of the four criteria of TOF) can be complicated into Pulmonary regurgitation (diastolic murmur at the left upper sternal border) that can manifest many decades late

Answer 229

(stenosis as a child – due to TOF) Suspect pulmonary regurgitation (on top of the corrected pulmonary stenosis)

Answer 230

. New murmur + Fever → Investigation → Infective Endocarditis. Blood Culture then Echocardiogram.

Answer 231

→ Think of SVT (Paroxysmal Supraventricular Tachycardia) = Narrow Complex. → Valsalva manoeuvre and Carotid massage → IV Adenosine: 6 mg → 12 mg → 12 mg → Cardioversion N.B. Adenosine is contraindicated in asthmatics → Verapamil (CCB) is the preferred option in SVT in a patient with Asthma.

Answer 232

→ do not require treatment (as long as the patient is Asymptomatic).

Answer 233

→ require permanent pacemaker

Answer 234

. • Initially → Atropine (first choice for all symptomatic bradycardia). • Then → Transcutaneous pacing. (Used to buy time until transvenous pacing is done). • Then → Transvenous pacing. • Then → Permanent pacing (Pacemaker).

Answer 235

- The commonest valvular disease in the elderly (Over 65). - Usually Asymptomatic apart of exercise intolerance (often mild). - It can cause syncopal fainting. - Ejection systolic murmur at the right 2nd ICS, louder on sitting upright and during expiration, and radiates to carotid. A scenario of an elderly presents with mild exercise intolerance or is asymptomatic but visiting for the purpose of check-up is found to have ejection systolic murmur.

Answer 236

: 1) Irregular rhythm (Cardiac syncopal events): Usually abrupt, with rapid recovery and flushing → 12 Lead ECG. 2) Low blood pressure or postural drop → frequent falls, dizziness while trying to stand from a sitting position, Hx of taking multiple medications → Measure BP while lying and 3 minutes after standing (i.e. Blood Pressure Monitoring). 3) Seizures → need eyewitness to confirm, as there is usually post-ictal drowsiness or confusion. 4) Hypoglycemia → Hx of excessive alcohol intake, sweating, tachycardia, hypotension, confusion before falling → Check blood glucose

Answer 237

B. A vasovagal attack is usually due to overwarm environment, or prolonged standing period, or after visual stimuli e.g. seeing blood. The patients usually feel dizzy and ‘’tunnel vision’’ before the attack.

Answer 238

• Drop attacks → Sudden falls without losing consciousness. • Stokes Adam → Unconscious + Abnormal ECG. • Hypoglycemia → Unconscious (or) ↓ level of consciousness + Sweating, do not recover unless given glucose. • Vasovagal attacks → Unconscious + Hx of prolonged standing, straining, pooping, heavy weight lifting or after visual stimuli e.g. seeing blood. The patients usually feel dizzy and ‘’tunnel vision’’ before the attack . Usually in a YOUNG FEMALE (with NO chest pain, palpitation and with Normal ECG) • Epilepsy → Unconscious ± Post-seizure confusion

Answer 239

• GIT (Commonest): Nausea, Vomiting, Anorexia. • Neurological: Hallucination, Confusion. • Visual: Yellow green vision, (Yellow haloes), blurred vision. • Arrhythmias: Bradycardia, V tach, Premature contractions. Management: • Order Digoxin level • Digibind [DigiFab] = (digoxin immune FAB). • Correct Arrhythmia • Monitor Potassium

Answer 240

◙ Thiazide-like diuretics work by inhibiting sodium reabsorption at the beginning of the proximal part of the distal convoluted tubule (DCT) by blocking the thiazide-sensitive Na+ -Cl− symporter. ◙ The main use of bendroflumethiazide was in the management of hypertension but recent NICE guidelines now recommend other thiazide-like diuretics such as indapamide and chlortalidone. ◙ Remember that: Furosemide and Bumetanide (Loop diuretics) – inhibit the Na-K-Cl cotransporter in the thick ascending limb of the loop of Henle.

Answer 241

• Postural Hypotension. √ • HypOkalemia and HypOnatremia. √ • Gout (Hyperuricemia). √ • dehydration • impaired glucose tolerance • impotence • Thiazide diuretics can cause hypercalcaemia and hypocalciuria

Answer 242

→ Postural hypotension likely due to thiazide being used for hypertension.

Answer 243

As the patient is hemodynamically unstable (Hypotensive) → Cardioversion. If there was No pulse (Hypotensive) → Defibrillation. Remember: Defibrillation = Asynchronized cardioversion In 2 conditions: √ Ventricular Fibrillation. √ Pulseless Ventricular Tachycardia.

Answer 244

→ Acute Mitral Regurgitation. Acute mitral regurgitation (MR): “important √” pansystolic murmur Occurs 2-15 days after the MI (Mostly inferior MI). ◙ Due to → Ischemia or rupture of the papillary muscles of the mitral valve. ◙ An early-to-mid systolic or Pansystolic murmur at cardiac apex is typically heard. ◙ May present with Hypotension, Tachycardia and Pulmonary edema (SOB and bibasilar crackles). ◙ Dx → Echocardiogram. ◙ Treatment → vasodilator therapy but often requires emergency surgical repair

Answer 245

√ In the case of stable Angina, the pain is precipitated by predictable factors such as exercise and emotional stress. This is because while exercising, the Oxygen demand is more than the Oxygen supply. √ Stable Angina is relieved by Rest and GTN “Glyceryl Trinitrates”.

Answer 246

Occurs mostly at rest, unpredictable, random. It is an emergency.

Answer 247

Tricuspid atresia

Answer 248

VSD Tricuspid Atresia → Cyanotic. VSD → Acyanoti

Answer 249

The ECG shows → (Likely 2ry to Tall Tented T-Waves → Hyperkalemia ACE inhibitors being used to control his Hypertension)

Answer 250

Remember that: ◙ Spironolactone and ACE inhibitors and ARBs → hyperkalemia ◙ Loop diuretics, Thiazide diuretics → Hypokalemia

Answer 251

J wave (Osborn wave) in → Hypothermia U wave in → “HypUkalemia”, an additional wave after T wave. Hypokalemia Tall Tented T-wave [Peaked T-wave] in → Hyperkalemia Delta wave in → WPW syndrome (Wolff Parkinson White Syndrome) Widespread Saddle Shaped ST Elevation with upward concavity + PR Depression in → Pericarditis

Answer 252

Acute coronary Syndrome Aspirin (lifelong) & Ticagrelor or clopidogrel (12 months)

Answer 253

Aspirin (lifelong) & prasugrel or ticagrelor (12 months)

Answer 254

Aspirin 300 mg 2 weeks then Clopidogrel 75 mg (lifelong)

Answer 255

Aspirin 300 mg 2 weeks then Clopidogrel 75 mg (lifelong)

Answer 256

Aspirin 300 mg for 2 weeks then start Anticoagulation ( e.g. Warfarin or DOAC- apixaban, rivaroxaban)

Answer 257

Clopidogrel (lifelong)

Answer 258

? • All people with established cardiovascular disease ( stroke, TIA, ischaemic heart disease, peripheral arterial disease).2ndary prevention 80mg Primary prevention 20mg • following the 2014 update, NICE recommend anyone with a 10-year cardiovascular risk ≥ 10% should receive statin. • patients with type 2 diabetes mellitus should now be assessed using QRISK2 like other patients are, to determine whether they should be started on statins. • patients with type 1 diabetes mellitus who were diagnosed more than 10 years ago OR are aged over 40 OR have established nephropathy Statins should be taken at night as this is when the majority of cholesterol synthesis takes place. This is especially true for simvastatin which has a shorter half-life than other statins.

Answer 259

→ Cardioversion If not in the options → IV amiodarone (or IV flecainide) not oral! If stable → BB, (or CCB if he is asthmatic), ( or digoxin if associated heart failure)

Answer 260

The next step in management is → Immediate DC Cardioversion ◘ The patient has AF (Irregularly irregular rhythm, Tachycardia, Absent P waves). ◘ Since she is unstable (Confusion, severe Hypotension) → cardioversion.

Answer 261

. The most appropriate management → [Pericardiocentesis]. Cardiac Tamponade Accumulation of pericardial fluid under pressure • Beck’s Triad: Hypotension ▐ Muffled Heart Sounds ▐ High JVP (Distended neck veins). • Dx: Echocardiogram is diagnostic • Rx: Urgent pericardiocentesis

Answer 262

Old, Sudden collapse, confusion, severe hypotension, Not breathing, Unconscious ‘’defibrillation’’ → Deliver immediate Shock

Answer 263

Atrial fibrillation in an unstable patient → Immediate shock If stable → BB, (or CCB if he is asthmatic), ( or digoxin if associated heart failure)

Answer 264

The next step in management is → Immediate DC Cardioversion ◘ The patient has AF (Irregularly irregular rhythm, Tachycardia, Absent P waves). ◘ Since she is unstable (Confusion, severe Hypotension) → cardioversion. If cardioversion is not given, pick → IV amiodarone.

Answer 265

? without ST elevatuon → Order Cardiac Enzymes, especially (Troponin) √ If Troponin is high → NON-STEMI Elevation MI √ Immediate management → give LMWH or fondaparinux + Aspirin 300 mg.

Answer 266

→ Adenosine. (Remember that Valsalva maneuverer and Carotid massage are tried initially and IV Adenosine is then given). IMPORTANT NOTE: If the patient is hemodynamically unstable (eg, hypotension, chest pain, shock, and or altered mental status) Proceed immediately to → electrical synchronised cardioversion.

Answer 267

Gout Hyponatremia Hypokalemia

Answer 268

Hyponatremia Hyperkalemia Gynaecomastia

Answer 269

Hyperglycaemia Hyponatremia Hypokalemia Gout Postural hypotension

Answer 270

These lesions are likely endocarditis). Janeway lesions (minor criteria of infective ♦ Likely → Infective endocarditis → Do Blood culture then Echocardiogram.

Answer 271

This is likely a case of Hyperkalemia (Tall Tented T waves are seen on the ECG To prevent cardiac arrhythmia

Answer 272

Note, If severe hyperkalemia (> 6.5), and there is no hyperkalemic ECG changes, we still give Calcium carbonate as a next step to protect the heart.

Answer 273

→ Rivaroxaban (or any other DOAC e.g. Apixaban, Rivaroxaban, Edoxaban, Dabigatran) “Now preferred over Warfarin” This patient with TIA/ ischemic stroke will need to take Aspirin 300 mg for 2 weeks, then rivaroxaban (DOAC) and atorvastatin 80 mg for long-term management. If he did not have AF, clopidogrel will be given instead of DOAC.

Answer 274

√ with Atrial Fibrillation → DOAC (eg, apixaban) + Statins (eg, Atorvastatin). √ Without Atrial Fibrillation → Clopidogrel + Statins (eg, Atorvastatin). Important: What if a patient with a history of stroke is already on warfarin and presents with a new onset atrial fibrillation? Since he is already on an anticoagulant, he should continue on warfarin and should not be switched to DOAC (eg, Edoxaban) unless his INR is increased.

Answer 275

√ Control Blood Pressure. [To prevent further stroke in the future]. Remember, if he has DM, pick or add ACEi eg, ramipril. √ Statins (for All patients regardless of their cholesterol baseline level). √ Ani-platelets (or) Anti-coagulation: ( Based on presence or absence of AF): → Anticoagulants: Warfarin [or] DOAC (Dabigatran/ Apixaban/ Rivaroxaban/ Edoxaban). DOAC is now preferred. (Warfarin is almost obsolete nowadays. DOAC is recommended instead) → Antiplatelets: Clopidogrel 75 mg OD. Absense of AF • If there is Atrial Fibrillation • If No Atrial Fibrillation Important: What if a patient with a history of stroke is already on warfarin and presents with a new onset atrial fibrillation? Since he is already on an anticoagulant, he should continue on warfarin and should not be switched to DOAC (eg, Edoxaban) unless his INR is increased.

Answer 276

→ ABCD2 Score. ◙ The ABCD2 score (Prognostic) is used to identify the risk of future stroke in patients who have had a suspected TIA in the following 7 days. √ IMPORTANT: ABCD2 score is Not advised to be used now according to the recent 2019 CKS guidelines. Therefore, it will not be a valid answer anymore. Thus, this question is to not be considered. We have added it just in case!

Answer 277

→ Furosemide. (Loop diuretics such as furosemide can cause hypokalemia).

Answer 278

(a calcium channel Blocker). → Amlodipine √ This patient is likely taking CCB for his HTN. √ CCB can cause ankle swelling as it causes vasodilatation.

Answer 279

→ Serum Electrolytes and Urea.

Answer 280

(TFTs) Thyroid Function Tests, and: (KFTs) Kidney Function Tests.

Answer 281

→ Beta-blockers (eg, metoprolol, atenolol) ◙ Agents used to control rate (Rate Control) in patients with Atrial Fibrillation (AF): o Beta-blockers (eg, atenolol 50-100 mg PO OD, bisoprolol, metoprolol) → First line but Contraindicated in Asthma. o Calcium channel blockers [non-dihydropyridine = rate-limiting CCB] (eg, diltiazem, verapamil) → if Asthmatic patient.

Answer 282

o Digoxin → (not considered first-line anymore as they are less effective at controlling the heart rate during exercise. However, they are the preferred choice if the patient has coexistent heart failure). √ If haemodynamically unstable Cardioversion √ If the patient with AF is unstable (eg, SBP ≤ 90) → (Shock). (eg, hypotension) and the AF has just started and no cardioversion in the options, Pick → IV amiodarone. Imp √

Answer 283

◙ The first drug of choice for Symptomatic Bradycardia (Dizziness, feeling unwell) → Atropine (Given 0.5 mg IV push and may be repeated up to a total dose of 3 mg).

Answer 284

A. Amiodarone B. C. Co- Amoxiclav D. Insulin- Glucose infusion E. Sodium Bicarbonate Peaked T wave suggesting Hyperkalemia (2ry to kidney injury in this case). → IV calcium gluconate (or calcium chloride) to protect the heart should be given initially.

Answer 285

→ DC Cardioversion. Patient is unstable, SBP < 90 → (Cardioversion) Shock. ◘ Broad complex tachycardia + low BP (unstable) → Cardioversion ◘ Pulseless V. Tach or V. Fibrillation → Immediate Defibrillation.

Answer 286

New Murmur + Fever → IE. think of ± Malaise, Rigors, Fever The initial step → Infective Endocarditis (IE) Blood Culture. Then → Echo

Answer 287

◙ Pericarditis Dressler’s syndrome (A Complication of MI that can develop shortly after the MI within 2 days) and (presents 2-6 weeks after MI) both have t’e same features → Pleuritic chest pain that worsens on lying flat and during inspiration, Pericardial rub, Widespread Saddle shaped ST elevation on the ECG. ◙ They can also lead to Pericardial effusion (Enlarged globular heart on chest X-ray) and if severe enough, Cardiac Tamponade can also develop (also enlarged globular heart on the X-ray). ◙ Management of Pericarditis (imp): √ A full-dose NSAID should be used (eg, aspirin, 2-4 g/d; ibuprofen 1200-1800 mg/d; indomethacin 75-150 mg/d); treatment should last at least 7-14 days. √ Colchicine (as an adjunct to NSAIDs to ↓ inflammation and recurrence).

Answer 288

E) Alteplase. F) G) IV Glyceryl trinitrate (GTN). H) IV Morphine. Sc fondaparinux Since the ECG is normal, alteplase is wrong. Since ECG is normal and Troponin is high → Non-STEMI → Anti-coagulation (LMWH e.g. Dalteparin, Enoxaparin or Fondaparinux). + Oral Aspirin 300 mg.

Answer 289

The most common type of arrhythmia that develops in patients with alcoholic cardiomyopathy is → Atrial Fibrillation.

Answer 290

√ Acute alcohol intake can lead to → AF or flutter ((Holiday heart Syndrome)). √ AF presentation: Palpitation, Dyspnea, Dizziness or Syncope, Chest discomfort or pain, Stroke or TIC, Irregularly irregular pulse.

Answer 291

√ Oral √ SC Pick the one that is given in the choices. Aspirin 300 mg LMWH or Fondaparinux. “low-risk patients can be treated conservatively. However, if subsequent ischemia develops → coronary angiography with PCI”.

Answer 292

? → Emergency coronary angiography.

Answer 293

arrange an ECG The most appropriate next step is to to check for any electrocardiographic changes that may indicate life-threatening arrhythmias due to hyperkalemia. Explanation: Even though the potassium level of 6.0 mmol/L represents moderate hyperkalemia, the patient is asymptomatic. An ECG is necessary to assess for changes such as: • Peaked T waves. • Widened QRS complex. • Prolonged PR interval. These changes can indicate a risk for life-threatening arrhythmias. If ECG abnormalities are present, urgent treatment with calcium gluconate may be required to stabilize the cardiac membrane.

Answer 294

Summary: First, arrange an ECG, then in both scenarios (normal or abnormal ECG): • Discontinue ACE inhibitors like Ramipril. • Avoid ARBs, as they also contribute to hyperkalemia. (So, both ACE inhibitors and ARBs can cause hyperkalemia). • Switch to safer alternatives such as calcium channel blockers or thiazide- like diuretics. • Continue monitoring renal function and potassium levels to ensure effective management of hyperkalemia and maintain blood pressure control.

Answer 295

Answer: Start with an ACE inhibitor (e.g., Ramipril, Lisinopril) or an ARB (e.g., Losartan, Candesartan). Reasoning: For diabetic patients, ACE inhibitors or ARBs are the first-line treatment regardless of age or ethnicity due to their kidney-protective effects. The presence of diabetes takes precedence over ethnicity in this case.

Answer 296

. Answer: Recommend lifestyle modifications such as reducing salt intake, increasing exercise, and quitting smoking. Reasoning: In a healthy patient without risk factors or comorbidities, antihypertensive medication is not required for Stage 1 hypertension (clinic BP ≥ 140/90 mmHg but <160/100 mmHg). Lifestyle changes are the first recommendation unless there are additional risk factors like organ damage, diabetes, or cardiovascular disease.

Answer 297

Answer: Add a thiazide-like diuretic (e.g., Indapamide, Chlorthalidone). Reasoning: After trying an ACE inhibitor and a calcium channel blocker (Step 1 and Step 2), adding a third drug, such as a thiazide-like diuretic, is the next step to achieve better blood pressure control.

Answer 298

Answer: Start with an ACE inhibitor (e.g., Lisinopril, Enalapril). Reasoning: For patients under 55 years with Stage 2 hypertension (BP ≥ 160/100 mmHg), the first-line treatment is typically an ACE inhibitor unless there are contraindications. His age and absence of other risk factors point toward this approach. Note: If the patient were ≥55 years or Afro-Caribbean of any age, the first-line treatment would be a calcium channel blocker (CCB).

Answer 299

Answer: Individualized treatment based on overall health, considering her frailty. Reasoning: For patients over 80 years old, treatment decisions should be personalized. In this case, the patient's frailty means that the risks and benefits of medication need careful consideration, and lifestyle modifications might be a reasonable alternative if her health allows.

Answer 300

t. Answer: Start with a calcium channel blocker (e.g., Amlodipine, Diltiazem). Reasoning: For patients ≥55 years or Afro-Caribbean of any age, the first-line treatment for Stage 2 hypertension is a calcium channel blocker. This is because CCBs have been shown to be more effective in these populations compared to ACE inhibitors or ARBs.

Answer 301

Answer: Stop the calcium channel blocker due to the side effects and replace it with a thiazide-like diuretic (e.g., Indapamide, Chlorthalidone). Reasoning: Ankle swelling (peripheral edema) is a common side effect of calcium channel blockers. In this case, the CCB should be discontinued and replaced with a thiazide-like diuretic. The four most common side effects of calcium channel blockers are: 1. Peripheral edema (ankle swelling). 2. Gingival hyperplasia (gum overgrowth). 3. Headache. 4. Flushing.

Answer 302

Answer: According to NICE UK guidelines (NG136), if blood pressure remains uncontrolled after steps 1, 2, and 3, the next step in managing resistant hypertension (Step 4) involves the following: 1. Add Low-Dose Spironolactone: o If the patient’s potassium levels are ≤ 4.5 mmol/L, add spironolactone at a dose of 25 mg once daily. 2. Alternative Option: o If the patient’s potassium levels are > 4.5 mmol/L or if spironolactone is not tolerated, consider using an alpha-blocker (e.g., Doxazosin) or a beta- blocker (e.g., Atenolol). 3. Referral to Specialist: o If the blood pressure remains uncontrolled despite these interventions, refer the patient to a hypertension specialist for further evaluation and management. 4. Monitoring: o Regular monitoring of potassium levels and renal function is necessary, especially when using spironolactone. This approach is based on the NICE NG136 guidelines for managing resistant hypertension in adults.

Answer 303

Common Antihypertensive Examples: • ACE Inhibitors: Ramipril, Lisinopril. • Angiotensin II Receptor Blockers (ARBs): Losartan, Candesartan. • Calcium Channel Blockers (CCBs): Amlodipine, Diltiazem. • Thiazide-like Diuretics: Indapamide, Chlorthalidone.

Answer 304

Key Notes: • Patients with diabetes: Start with ACE inhibitors or ARBs, regardless of age or ethnicity, to protect kidney function. • Lifestyle Modifications: Encourage lifestyle changes in all patients, including: o Salt reduction. o Regular exercise. o Stress management. o Limiting alcohol intake. o Smoking cessation.

Answer 305

s: Step Patient Characteristics Treatment Options Step 1 Age <55 Start with ACE inhibitor. Age ≥55 or Afro-Caribbean origin Start with Calcium Channel Blocker (CCB). Step 2 BP uncontrolled in Step 1 Add a second drug: ACE inhibitor, CCB, or Thiazide-like diuretic . Step 3 BP uncontrolled in Step 2 Combine all three: ACE inhibitor + CCB + Thiazide-like diuretic.

Answer 306

Treat with antihypertensives if one or more of the following: - Target organ damage. - Cardiovascular disease. - Renal disease. - Diabetes. - 10-year cardiovascular risk ≥ 10%.

Answer 307

Individualized treatment based on overall health, frailty, and potential risks.

Answer 308

Advice on lifestyle modifications (e.g., diet, exercise, no smoking); no antihypertensive treatment unless high risk

Answer 309

Patients < 55 years Start with an ACE inhibitor Patients ≥ 55 years or Afro-Caribbean origin Start with a calcium channel blocker.

Answer 310

If BP remains >140/90 mmHg after initial treatment, move to step 2 treatment as in the following table. Ace inh Ccb Thiazide like diuretic Stepwise

Answer 311

1. Stage 1 Hypertension: o Clinic BP: ≥ 140/90 mmHg. o Confirmed by Ambulatory BP Monitoring (ABPM) or Home BP Monitoring (HBPM): Daytime average BP ≥ 135/85 mmHg. 2. Stage 2 Hypertension: o Clinic BP: ≥ 160/100 mmHg. o Confirmed by ABPM or HBPM: Daytime average BP ≥ 150/95 mmHg. 3. Stage 3 (Severe) Hypertension: o Clinic systolic BP: ≥ 180 mmHg OR o Clinic diastolic BP: ≥ 120 mmHg.

Answer 312

Overview: A 19-year-old male presents with recurrent episodes of syncope, particularly during exercise. His ECG reveals a prolonged QT interval, suggesting long QT syndrome (LQTS), which is associated with a high risk of ventricular tachyarrhythmias, such as torsades de pointes. This condition often presents in childhood and is triggered by physical activity, which can precipitate dangerous arrhythmias, leading to syncope or even sudden cardiac death.

Answer 313

Key Features: • Prolonged QT Interval: Identified on ECG, which increases the risk of life- threatening arrhythmias. • Syncope with Exercise: Episodes are commonly triggered by physical exertion in patients with LQTS. • Ventricular Tachyarrhythmias: The most likely arrhythmia in this case, associated with the prolonged QT interval and syncope.

Answer 314

Differential Diagnosis: • Sick Sinus Syndrome: Causes bradyarrhythmias and syncope due to slow heart rates, but not associated with prolonged QT intervals. • Ventricular Ectopics: Extra heartbeats that are common in young individuals and often benign. SThese are not linked to syncope or prolonged QT interval unless very frequent. In summary, this patient's presentation is highly suggestive of long QT syndrome, and the likely arrhythmia responsible for his symptoms is ventricular tachyarrhythmias such as torsades de pointes Early identification and management are crucial to prevent severe complications, including sudden cardiac death.

Answer 315

Important Note: Torsades de pointes is a type of ventricular tachyarrhythmia that is associated with a prolonged QT interval . It is the hallmark

Answer 316

Key Features: √ New Murmur: A characteristic pan-systolic murmur, best heard at the left lower sternal border (LLSB). √ Hemodynamic Instability: VSR often leads to cardiogenic shock, evidenced by hypotension (e.g., blood pressure 90/60 mmHg), diaphoresis, and jugular venous distension. √ Respiratory Symptoms: Pulmonary crackles on auscultation, indicating pulmonary edema due to the acute hemodynamic changes.

Answer 317

Diagnosis: → Echocardiography: This is the definitive diagnostic tool. It confirms the presence and severity of the septal rupture and helps in planning further management. Clinical Context: • VSR should be suspected in any patient who develops a new pan-systolic murmur a few days after an MI, especially if accompanied by signs of hemodynamic instability. • The murmur is typically loudest at the left sternal border. • Immediate intervention is crucial as the condition rapidly progresses, often requiring surgical repair. Differential Diagnoses: Acute Pericarditis: Usually presents with pleuritic chest pain and a pericardial rub, not a murmur. Dressler Syndrome: A form of post-MI pericarditis that occurs weeks after the event, presenting with fever and pleuritic chest pain. Left Ventricular Aneurysm: Occurs weeks to months post-MI, presenting with heart failure symptoms rather than a new murmur. Mitral Regurgitation: While it may present with a pan-systolic murmur, the murmur typically radiates to the axilla. In summary, VSR post-MI is a critical diagnosis characterized by a pan-systolic murmur at the left sternal border and hemodynamic instability. Early diagnosis and intervention are essential to prevent fatal outcomes

Answer 318

Start atorvastatin “regardless of lipid profile level”. Torsade De Pointes.

Answer 319

Think → Ventricular septal defect/ rupture. Why NOT tricuspid regurgitation (TR)? √ Tricuspid regurgitation can occur as a complication of MI, but it develops over weeks to months, not acutely and within a few days after MI. √ Also, hypotension and shock are another sign of ventricular septal defect, not TR.

Answer 320

Offer → ( Statin ) for 1ry prevention of CVD).

Answer 321

Think → Hypertrophic cardiomyopathy (HOCM).

Answer 322

→ Treat hyperkalemia first (by giving IV calcium gluconate or calcium carbonate or calcium chloride As initial intervention, treating hyperkalemia with IV calcium -which would stabilize the cardiac membrane and prevent cardiac arrest- is more critical than treating bradycardia with atropine. Notes: normal). • If K+ is ≥ 6.5 mmol/L (ie, severe) → treat with IV calcium (even if ECG is normal) • If K+ is 6 – 6.4 (ie, moderate) → treat with IV calcium (if there is ECG changes)

Answer 323

Management of hypokalemia 1) Oral or IV (potassium Chloride) based on severity), e.g. 2) Stop/ Treat the cause (e.g. stop furosemide, thiazide like diuretics

Answer 324

Ischemic stroke Long-term antiplatelet/anticoagulant drugs in: (or √ Ischemic stroke + AF TIA) → Aspirin for 2 weeks, then clopidogrel for life. → Aspirin for 2 weeks, then warfarin/DOAC for life. If he was already on warfarin (anticoagulant) and develops atrial fibrillation (AF), continue on warfarin and do not shift to DOAC unless his INR is poor. √ MI → Aspirin for life, clopidogrel (or ticagrelor) for 12 months.

Answer 325

AF + Stable patient → BB (eg, metoprolol) or CCB (if asthmatic) or Digoxin (if with HF

Answer 326

→ Cardioversion

Answer 327

→ Do not cardiovert; but give rate control (e.g. BB) + LMWH → Then: assess for long-term intake of Warfarin or DOAC (e.g. apixaban, rivaroxaban, dabigatran) upon discharge using CHA2Ds2-VASc score.

Answer 328

This patient has acute pulmonary edema 2ry to left ventricular failure. Pulmonary edema: Kerley B lines, bat’s wing hilar shadow, crepitations, SOB, low O2 sat. Echo in the stem shows left ventricular impairment (HF). HF can lead to → Pulmonary edema Remember, Management of HF: • Furosemide (for symptomatic relief) “was already given here”. • Start with either Beta-blocker or ACE inhibitor (one medication at a time). • If still? Add the other medication. • If still? Add spironolactone Since this patient is Asthmatic, we would begin with ACE inhibitors (e.g. lisinopril) instead of BB. BB is better to be avoided in asthma as it can cause bronchospasm and thus aggravates asthma. So, the answer is that this patient should be discharged on → ACE inhibitor (e.g. Lisinopril).

Answer 329

? √ Do not rush and pick papillary muscle rupture thinking it is mitral regurgitation (evidenced by the holosystolic murmur over the apex)! If MR, why there is fever? √ Note that papillary muscle rupture usually occurs 2-15 days after MI, not 6 months! √ Also, papillary muscle rupture is more common with inferior MI (II, III, aVR). √ Q waves here → permanent markers of necrosis (indicate previous MI), here, likely lateral MI (I, aVL, V5, V6). FEVER + NEW MURMUR → INFECTIVE ENDOCARDITIS!

Answer 330

→ Dual antiplatelets (Aspirin + Clopidogrel) + Fondaparinux + Blood transfusion. Notes: √ Triple vessel disease means that 3 big vessels (the left anterior descending, right coronary and circumflex arteries) have blockages from atherosclerotic plaques. √ This patient has ACS “acute coronary syndrome” secondary to anemia and the pre-existing triple vessel disease. √ Aspirin (oral) and fondaparinux (SC LMWH) are given whenever there is heart ischemia. √ Blood Transfusion is indicated if: ♠ Hb < 80 g/L + Symptoms of Anemia. Or: ♠ HB < 70 g/L + With or Without Symptoms of Anemia.

Answer 331

→ Aortic stenosis. Do → Echocardiogram.

Answer 332

→ request troponin. If troponin is elevated → Myocardial infarction (Non-ST Elevation MI).

Answer 333

→ ECG Measuring lying and standing blood pressure should also be done to R/O postural hypertension (Note that ambulatory blood pressure monitoring is used to diagnose hypertension, not postural hypertension. Thus, not useful in syncopal attacks).

Answer 334

◙ The QRISK3 score is used to determine the risk of a cardiovascular event in the next 10 years. ◙ If QRISK3 is > 10% and the age is < or = 84 → the patient needs to start on statins (atorvastatin) to reduce the risk of cardiovascular disease. ◙ If QRISK3 is 10%, this means that the patient has 10% chance of developing cardiovascular disease over the next 10 years.

Answer 335

Aortic Stenosis.

Answer 336

→ Mitral stenosis.

Answer 337

Think→ Mitral stenosis. (Remember, rheumatic fever is the commonest cause of mitral stenosis. Rheumatic fever is commonly found in developing countries e.g. Syria, Mozambique). ◙ Complications of MS: As the left atrium enlarges → Atrial fibrillation → Venous thromboembolism → Cerebral infarction. “imp √”. √ Note: left ventricular hypertrophy is a common complication of aortic stenosis.

Answer 338

→ Synchronized Cardioversion.

Answer 339

• Think → Congenital long QT syndrome (Congenital LQTS). • The most common arrhythmia associated with Congenital LQTS is → Ventricular tachyarrhythmia. There is risk of ventricular fibrillation. Thus, some patients use long-term beta blocker treatment.

Answer 340

Myocardial Ischemia. T wave

Answer 341

Although there is no ECG changes of hyperkalemia “tall tented T waves”, this patient has severe hyperkalemia (>6.5) and the initial step is to protect the heart and prevent cardiac arrest by giving a medication that antagonizes the cardiac membrane excitability as a temporary measure such as calcium Gluconate 10% or calcium chloride or calcium carbonate.

Answer 342

→ Perform an urgent catheter Embolectomy. • A piece of the atrial myxoma has broken off and caused left acute limb ischemia (sudden swollen painful left arm with a loss of radial pulse). • It has been only a few hours and the limb could be saved if embolectomy is performed urgently. • It is perfomed by a interventional radiologist who uses an angiogram in theatre and introduce a catheter to aspirate the emboli “embolectomy”. • Note that this is not a blood clot, but a piece of the benign tumor. Thus, thrombolysis and anticoagulation would not be suitable.

Answer 343

Next test → N-terminal (NT)-pro hormone BNP (NT-proBNP). If raised → Echocardiogram. • N-terminal (NT)-pro hormone BNP (NT-proBNP) is a non-active prohormone that is released from the same molecule that produces BNP. Both BNP and NT- proBNP are released in response to changes in pressure inside the heart. These changes can be related to heart failure and other cardiac problems. • Note: sometimes in heart failure, ECG may be normal.

Answer 344

→ Kidney function tests.

Answer 345

◘ Initial management → Atropine. What if he was given atropine but no response? Next step would be → Temporary transcutaneous pacemaker. ◘ Definitive management → Permanent pacemaker. • Bradycardia is a condition typically defined wherein an individual has a resting heart rate of under 60 beats per minute (BPM) in adults, although some studies use a heart rate of less than 50 BPM. Bradycardia typically does not cause symptoms until the rate drops below 50 BPM. • All symptomatic bradycardia should initially be treated with atropine. If no response → temporary pacemaker (in an emergency setting). • Atropine is given 0.5 mg IV push and may be repeated up to a total dose of 3 mg.

Answer 346

◙ 1st Degree Heart Block and Mobitz type 1 usually → do not require treatment (as long as the patient is Asymptomatic). ◙ Mobitz type 2 and Complete heart block (3rd degree heart block) → require permanent pacemaker. • Initially → Atropine (first choice for all symptomatic bradycardia). • Then → Transcutaneous pacing. (Used to buy time until transvenous pacing is done). • Then → Transvenous pacing. • Then → Permanent pacing (Pacemaker).

Answer 347

A) Refer to a cardiologist. B) Refer to a smoking cessation clinic. C) Refer to alcohol cessation services. D) Advise to reduce salt. √ His clinic BP is normal (<140/90). √ Smoking is the major risk factor here. √ His alcohol intake is within the recommended limit. (no more than 14 units a week with at least 2 days free). His salt intake is within the recommended limit. (Salt intake recommendation for adults in the UK is no more than 6 g per day which is around 1 teaspoon).

Answer 348

Think → Heart failure. Next test → N-terminal (NT)-pro hormone BNP (NT-proBNP). If raised → Echocardiogram. • N-terminal (NT)-pro hormone BNP (NT-proBNP) is a non-active prohormone that is released from the same molecule that produces BNP. Both BNP and NT- proBNP are released in response to changes in pressure inside the heart. These changes can be related to heart failure and other cardiac problems. • Note: sometimes in heart failure, ECG may be normal.

Answer 349

→ Kidney function tests.

Answer 350

◘ Initial management → Atropine. ◘ What if he was given atropine but no response? Next step would be → Temporary transcutaneous pacemaker. ◘ Definitive management → Permanent pacemaker.

Answer 351

Since his home blood pressure is ≥ 140/90, but < 150/95 mmHg. → He has stage (1) hypertension.

Answer 352

Answer → C. • He has a stage 2 hypertension. • Since he is < 55 YO → Start with ACE inhibitor (eg, ramipril).

Answer 353

? • Treat if the patient’s age is < 80 years AND + any of the following: Target organ damage, established cardiovascular disease, renal disease, diabetes (DM) or a 10-year cardiovascular risk equivalent to (QRISK2) ≥ 10%.

Answer 354

→ Lifestyle and Diet Modification + review (Follow up).

Answer 355

Discuss initiating antihypertensive therapy.

Answer 356

(Atrial fibrillation = narrow-complex irregularly irregular tachycardia). • First line (if hemodynamic stable) → Beta-blockers (eg, metoprolol). • If hemodynamic unstable (eg, hypotension, chest pain, altered mentation) → Start with electrical cardioversion. If still not improved → IV amiodarone.

Answer 357

Pan-systolic murmur over the apex Think → Mitral regurgitation. Pan-systolic murmur over the lower left sternal border Think → TR Or ventricular septal rupture. This is due to a possible dysfunction of papillary muscles of the valve

Answer 358

Ventricular septal defect occurs acutely (within a few days) after MI, and also presents with hypotension (shock). √ Tricuspid regurgitation tends to develop over weeks to months after MI, and hypotension is not a feature. - In both conditions, do → Echocardiogram.

Answer 359

→ Deliver a shock. (VT in a pulseless patient and VF requires immediate shock delivery).

Answer 360

→ Start CPR (Chest Compressions). Important: If CPR is not among the options, what’s to pick? → Give adrenaline (Epinephrine) 1 mg IV. (A flat ECG reading means asystole which is a non-shockable rhythm)

Answer 361

→ Deliver a shock. (VT in a pulseless patient and VF requires immediate shock delivery).

Answer 362

• One of the manifestations that would be seen in DKA is: → Hyperkalemia (ECG might show tall tented t waves)

Answer 363

(holiday heart syndrome). • The ECG in this case would be unremarkable. The best action is to → and decrease smoking would resolve palpitations completely). Advise on lifestyle modifications (decreasing alcohol)

Answer 364

Important: the investigation that would likely be abnormal in this case is → Urea and electrolytes. Urea and electrolyte panel includes: → Urea, creatinine, sodium, potassium, eGFR.

Answer 365

The right answer is ©: Stop clopidogrel and start a DOAC eg, edoxaban. • He did not have atrial fibrillation before, that’s why he was on clopidogrel (and not warfarin or DOAC). • Since he is now having atrial fibrillation, switch clopidogrel to an anticoagulant such as warfarin or DOAC (eg, edoxaban, apixaban). DOAC is preferred over warfarin. • His blood pressure is not mentioned so we assume it is controlled and therefore no need to add an additional antihypertensive (even if he is diabetic, he is already on amlodipine and controlled).

Answer 366

The right answer is (D): continue lercanidipine (CCB) and add ramipril (ACEi). • Since he is diabetic, ACEi is of choice to control HTN. • Since he is already on an antihypertensive (which is lercanidipine; a calcium channel blocker) and his hypertension is still uncontrolled, go to step 2 and add a second antihypertensive (ACE inhibitor eg, ramipril). • We do not shift from warfarin to DOAC unless his INR is not normal. Here, no mention of INR. Thus, continue on warfarin (option A is wrong). • Since he has AF, an anticoagulant (eg, warfarin, DOAC) is given; Not an antiplatelet (eg, clopidogrel).

Answer 367

• In patients with a history of ischemic stroke, the long-term management to prevent further stroke (2ry prevention of ischemic stroke) is as follows: √ Control Blood Pressure. Remember, if he has diabetes, pick or add ACEi eg, ramipril. √ Statins (for All patients regardless of their cholesterol baseline level). √ Ani-platelets (or) Anti-coagulation: (Based on presence or absence of AF): • If there is Atrial Fibrillation → Anticoagulants: Warfarin [or] DOAC (Dabigatran/ Apixaban/ Rivaroxaban/ Edoxaban). DOAC is now preferred. (Warfarin is almost obsolete nowadays. DOAC is recommended instead). • If No Atrial Fibrillation → Antiplatelets: Clopidogrel 75 mg OD. Important: What if a patient with a history of stroke is already on warfarin and presents with a new onset atrial fibrillation? Since he is already on an anticoagulant, he should continue on warfarin and should not be switched to DOAC (eg, Edoxaban) unless his INR is abnormal

Answer 368

is → IV atropine. (Given 0.5 mg IV push and may be repeated every 3-5 minutes up to a total dose of 3 mg). Rx is required if the patient is symptomatic even if the ECG shows first- degree heart block. As long as he has symptoms and bradycardic, start with atropine. • After initial stabilisation of the patient by atropine, he should then be prepared for temporary pacemaker and assessed for whether or not he needs a long-term permanent pacemaker.

Answer 369

Since the AF has just started and the patient is hypotensive (ie, haemodynamically unstable) → cardioversion • If cardioversion is not in the option → IV amiodarone • Another possible answer is IV Flecainide (IV, not Oral). (Careful: beta-blockers are first line in STABLE patients with AF)!

Answer 370

→ IV atropine. (Given 0.5 mg IV push and may be repeated every 3-5 minutes up to a total dose of 3 mg).

Answer 371

• Exercise ECG (stress test) is preferred for stable angina. Here, no chest pain! • Echo: could be requested if the current ECG is abnormal. Here, it is normal. • Also, if you think this might be aortic stenosis (AS) that requires Echo to be diagnosed, then you are mistaken. AS presents with ejection systolic murmur over the right second intercostal space + Fainting episodes (syncope) ± Dyspnea ± Angina (chest pain). None of these features are present! • This patient has dizziness and PALPITATIONS mostly during walking, which may indicate hidden arrhythmia which develops while walking. • The arrhythmia can be detected by ECG. However, the current ECG is normal. Thus, ambulatory 24-hour (Holter) ECG is needed.

Answer 372

Give → (When SGLT2 inhibitors are added to the medications of HF which are B-blockers, ACE inhibitors, Aldosterone antagonist → they reduce cardiovascular death). So, in DM with heart failure, use metformin and flozin family. SGLT2 inhibitors such as Dapagliflozin, Empagliflozin

Answer 373

). The most appropriate investigation to determine this mitral regurg is → Echocardiogram

Answer 374

→ Other features → syncope Dyspnea, Angina.

Answer 375

• Since his ambulatory BP is ≥ 150/95 ( His SBP is the high portion in this case) → he needs treatment. (Confirmed stage 2 HTN). (f ABPM or HBPM ≥ 150/95 mmHg (i.e., confirmed stage 2 or higher hypertension) → Always treat.) → Felodipine • Since he is ≥ 55 YO → the first step is Calcium channel blocker (CCB). (Felodipine is a CCB).

Answer 376

• The ECG shows PR prolongations followed by a dropped beat. • This is a second-degree heart block (Mobitz type 1). Also called (Wenckebach). • Asymptomatic patients with this type of heart block do not need specific Rx

Answer 377

Think → Rx → Acute pericarditis. NSAIDS (eg, Ibuprofen) + Colchicine. ◙ Other Criteria of Acute Pericarditis → Central sharp stabbing chest pain relieved by sitting up and leaning forward and worsened by lying down + Pericardial rub. ◙ Management of Pericarditis (imp): √ A full-dose NSAID should be used ( eg, aspirin, 2-4 g/d; ibuprofen 1200-1800 mg/d; indomethacin 75-150 mg/d); √ Colchicine (as an adjunct to NSAIDs to ↓ inflammation and recurrence). treatment should last at least 7-14 days.

Answer 378

→ Admit and repeat troponin level after 3 hours of the symptom’s onset. • The patient has arrived to the hospital after one hour of the beginning of the chest pain. So, the troponin level was taken only one hour after the chest pain. • Elevated troponin can be detected within 3 to 4 hours after the onset of myocardial injury. Serum levels can remain increased for 7 to 10 days for troponin I and 10 to 14 days for troponin T. • Therefore, a second troponin level is needed after 3 hours of the onset of the chest pain. Taking into consideration that he is Old + DM + HTN (All RFs for MI

Answer 379

If arrived > 3 hours of the chest pain onset: √ troponin is < 12 → ACS is unlikely → suspect stable angina and refer to cardiology outpatient or rapid access chest pain clinic. √ troponin is > 30 → correlate with ECG and Hx → treat as ACS.

Answer 380

Ambulatory 24-hour ECG. This is because the arrhythmia occurs in some Do → ambulatory 24 hour ecg periods of the day and so the ordinary ECG may be normal. We need ambulatory 24-hour ECG to try to detect the arrhythmia. Also known as an ambulatory ECG or EKG monitor, a Holter monitor records your heart’s activity over 24 to 48 hours or up to 2 weeks while you maintain a diary of your activity to help your doctor identify the cause of your symptom

Answer 381

→ Exercise ECG “stress test”.

Answer 382

The right option is → Indapamide (which is a thiazide like diuretic0 He has started with CCB (step 1) and cannot use it because of ankle edema S/E. Then stopped it and went for ACEi ramipril (step 2) Now, (step 3) is a thiazide like diuretic e.g., indapamide. Note that valsartan is ARBs. It is used instead of ACEi in some cases like those who develop dry cough as a side effect of ACEi.

Answer 383

• Increase the dose of the furosemide . • Switch the furosemide to either bumetanide or torsemide. • Consider admission for IV loop diuretics.

Answer 384

The likely occluded artery → LAD “left anterior descending artery”.

Answer 385

→ Ambulatory blood pressure monitoring (ABPM) is needed before starting lifestyle modifications and antihypertensive medications.