Cardio SAQ

Question 1

48F female with intermittent palpitations lasting 3-5 mins with spontaneous resolution for 6 months. Thyroid, liver renal, baseline ECG all normal. Hx of hypertension on some medications (?)
At home ECG (with some leads only, not 12-lead ECG) on Holter during the episode showing NORMAL. After given ambulatory ECG device, one day she send you this photo saying she just experienced an episode of palpitation.
1. Describe the abnormality
2. Describe mechanism of flecainide
3. Give 2 contraindications of flecainide
4. What 2 complications of this arrhythmia?
5. What is hte other medication, with respect to 4.
6. Px cannot tolerate bradycardia effect of flecainide, suggest one other therapy

Answer 1

1. Afibrillation (no visible P waves). Not Aflutter as not all leads show flutter waves
2. Class 1c antiarrhythmics, sodium channel blocker
3. ischemic heart disease, hypertensin with LVH, congestive heart failure, hypertrophic cardiomyopathy, degree 2 and 3 AVB, complete BBB with significant liver and kidney disease.
4. Stroke, MI, heart failure tachycardia induced cardiomyopathy
5. Anticoagulant (DOAC)
6. Catheter ablation of ectopic foci

Question 2

76-year-old with syncope and back pain. Left arm BP 190/110, pulse 75 bpm, LSB 2/6 early diastolic murmur. Right arm weak pulse. Femoral pulse 2+.
1. ECG abnormality
2. What causes syncope in this gentleman
3. Three investigations to confirm the diagnosis
4. Describe your management

Answer 2

1. ST elevation over lead II, III, aVF. Reciprocal ST depression over leads I, aVL, V1-3. Q waves over leads II, III
2. Aortic regurgitation due to Type A aortic dissection
3. CXR, CT thorax with contrast (aortogram), echo (TEE), cTnT, CKMB
4. Bed rest, NPO, IV line
   IV labetolol and nitroprusside to manage HT
   IV analgesic
   Monitor vitals, maintain saO2 >90%
   Consult CTS for surgical repair of type A aortic dissection

Question 4

Man with pulse 58/min, ankle edema (features of heart failure) with following ECG
What is 1st line Mx?

Answer 4

Transvenous pacing as this complete heart block ( AV dissociation: no P to QRS complex matching –> decompensating into acute heart failure –> acute APO)

ACLS unstable bradycardia features: hypotension, altered mental state, ischemic chest discomfort, and acute heart failure

Question 5

Answer 5

a) ST elevation in leads II, III, aVF. ST depression in lead I, aVL (reciprocal leads) –> inferior STEMI
b) cTnT+ CKMB, CXR, R/LFT, lipid profile, HbA1c, aPTT+INR (baseline for thrombolytics treatment)
c) DAPT (aspirin and ticagrelor) + anticoagulant (enoxaparin), ACEI, B blocker, nitrates, statins
d) Arrhythmia: symptomatic sinus bradycardia, AV block, tachycarrhythmia, stable sustained monomorphic VT, sustained polymorphic VT
Pump failure: LV dysfunction, RV dysfunction
Mechanical complications: VSD, MR
Pericarditis

Question 6

Answer 6

Cause of palpitation: AF

Fast AF (ventricular rate >100bpm) : requires rate control diltiazem/verapamil
For persistent AF, anticoagulated for 3 weeks before conversion and continue for 4 weeks after (delayed cardioversion approach)
Amiodarone 150mg over 10 min then 1mg/min for 6 hours.
If failed cardioversion than do maintenance rhythm control: flecainide, procainamide

Non valvular AF: can be discharged with DOAC (dabigatran (thrombin inhibitor) or apixiban/rivaroxaban)

Question 7

Answer 7

a) Aspirin: secondary prevention of MI and CVD
Lisinopril: decreases the preload and reduces blood pressure. (improves peri MI cardiac remodelling)
Metoprolol: decreases myocardial workload and thus oxygen demand by reducing HR and BP
Atorvastatin: used to reduce cholesterol levels and atherosclerosis worsening
b)
aspirin AE: nausea, dyspepsia, peptic ulcer bleeding
lisinopril AE: dry cough, hyperK, angioedema, hypotension
metoprolol AE: bradycardia, bronchospasm, dizziness
Atorvastatin AE: myositis, arthralgia, hepatitis, hyperglycemia, rhabdomyolysis
c)
Multi compartment dose administration aids (pill boxes)
Polypill: multiple drugs in one pill (dont need to take so many pills)

Question 8

Answer 8

a) aortic stenosis
b) degenerative cause (elderly), bicuspid aortic valve
c) transesophageal echocardiogram
d) TAVR: balloon expanding stent or self expandible stent (improved outcome as less thrombus/calcification cracking)

Question 9

Answer 9

Correct underlying caues: hypoxia, electrolyte disorders, sepsis, thyrotoxicosis
If fast ventricular rate >100bpm –> do ventricular rate control. Diltiazem/verapamil.

Cardioversion with 3 weeks anticoagulant before cardioversion than continue 4 weeks post cardioversion. Or do immediate cardioversion but do TEE to rule out LA thrombus in LAA.
Cardioversion with IV/oral amiodarone.

Anticoagulant: secondary prevention of cardioembolic stroke –> DOAC: dabigatran

Question 10

Lady suddenly collapses. BP of 90/50mmHg and HR of 76bpm. spO2 91% on nasal cannula.
a. 3 findings on ECG
b. most likely cause of syncope?
c. 3 Ix to confirm dx?
d. 3 treatment options for her condition?

Answer 10

a) sinus tachycardia, right axis deviation, RBBB, R wave in lead V1, S1Q3T3, T wave inversion over leads V1-4
b) PE
c) 1st line is CTPA, D-dimer (rule out PE), VQ scan (only if renal dysfunction so cannot do CTPA)
d) LMWH, tPA, embolectomy

Question 11

Cardiologist for management of heart: clopidogrel, esomeprazole, simvastatin, losartan
HA for management of hypertension: lisinopril, amlodopine

a) Name 3 pairs of drugs that show drug drug interaction
b) specific AE for each pair of drug drug interaction
c) 4 ways to minimize AE

Answer 11

a)
* Losartan: lisinopril. AE: hyperK, postural hypotension. Swap one to K+ sparing diuretic (e.g. spironolactone, eplerenone)
* Simvastatin (CYP3A4 substrate): esomeprazole or amlodopine –> increased risk of myopathy/rhabdomyolysis. Avoid concomitant use and switch to a different statin with less interaction risk or limit simvastatin dose to 20mg/d
* Clopidorel: esomeprazole. AE: decreased effectiveness of clopidogrel (coverage of thrombus and stroke formation). Increase dosage of clopidogrel for adequate anticoagulant coverage

Question 12

A 60-year-old man presents with dizziness and shortness of breath. On examination, his blood pressure is 90/50 mmHg with heart rate of 35 beats per minute. There is no cyanosis, but jugular venous pressure showed cannon A wave. The apex beat is not displaced an in normal character. On auscultation, there is a variable first heart sound without any murmur. ECG shows complete heart block and 2 mm ST ele- vation over lead II, III and aVF.
(a) What is the most likely diagnosis causing his heart block?
(b) Briefly outline further investigations and management of his cardiac condition.

Question 13

2017 SAQ 1
A 78-year-old man complaining of palpitations for seven days is referred after an electrocardiogram shows atrial fibrillation.
(a) What causes do you need to consider? How could these be investigated?
(b) What are the principles of management of atrial fibrillation?

Answer 13

• Atrial dilatation: valvular diseases (mitral stenosis), HTN, HF, CAD, PE
• Chronic lung disease
• Hyperthyroidism (hyperdynamic state)
• Alcoholism
• Others e.g. cardiomyopathy, cardiac surgery, sepsis induced AF
• Lone AF: no structural heart disease
  Ix: CBC (infection/anemia), CXR, ECG, echocardiogram, TFT

Mx
If unstable do direct cardioversion
Acute rate control: metoprolol
Acute rhythm control: flecainide (class 1c), amiodarone (class 3)

Question 14

A 45-year-old man presents with sudden onset of chest pain with radiation to the back after walking uphill 4 hours ago. He enjoys good past health except blurring of vision due to partial lens dislocation over his right eye. On physical examination, he is thin and 6 feet tall, his blood pressure is
90/40 mmHg over his left arm but is not measurable over his right arm. His heart rate is 120 beats per minute and the jugular venous pressure is elevated. The apex beat is not displaced and is in normal character. On auscultation, the heart sounds are normal and a grade 2/6 early diastolic murmur is heard over the left sternal border. Electrocardiogram shows diffuse low voltage with ST segment elevation over all 12 leads. Please name the complete clinical diagnosis and outline your acute management of this man within the first 24 hours.

Question 15

A 65-year-old man presents with increasing breathlessness and ankle swelling over the previous 2 months. On examination, his pulse is 100/min regular, his blood pressure is 130/85, apex beat is dis- placed to the anterior axillary line, he has moderate bilateral ankle oedema, and chest auscultation re- veals fine crackles to the midzones. A clinical diagnosis of congestive heart failure is made.
(a) What further investigations are indicated?
(b) What treatment should he receive?
(c) Which of these treatments have been shown to result in improved survival?

Question 16

2015 SAQ 13
A 65-year-old man presents with progressive shortness of breath over 1 weeks. He claims that he has not been able to lie flat in bed for 3 days. He has no chest pain. He has previous history of anterior wall myocardial infarction 10 year ago. On examination, he is afebrile with respiratory rate of 22 breaths per min; his blood pressure is 120/70 mm Hg. The jugular venous pressure is 8 cm. The apex beat is in the left anterior axillary line. There are late inspiratory crackles throughout both lung fields. Chest x-ray shows upper lobe venous diversion. Please outline your acute management and pre-discharge manage- ment.

Answer 16

• Resuscitate patient by ABC: start on high flow oxygen therapy or mechanical ventilation if patient is not responsive to oxygen via nasal cannula
• Put patient to bed rest and propr up the bed. Fast the patient and restrict fluid intake
• Monitor BP, pulse, pulse oximetry and breathing rate of the patient. Monitor patients input/output chart. Set up cardiac monitor
• Give IV furosemide and ACEI to relieve pulmonary edema
• After stabilization arrange coronary angiogram or thallium scan to look for myocardial perfusion and correct any underlying ischemic heart disease to prevent recurrence of acute decompensation.
• Ix by taking CBC, L/RFT, clotting profile, cardiac enzymes and lipid profile. Perform echo do document dilatation or valvular defect

RF modication: HT, DM and HL. Upon finding of heart failure –> start patient on diuretics, reduce volume overload and BB or CCB to reduce cardiac work.

Question 17

A 75-year-old woman presents with an episode of syncope while walking uphill. She has history of diabetes on medications for 2 years. On examination, her blood pressure is 120/70 mmHg with a slow rising pulse and heart rate is 60 beats per minutes. There is bilateral ankle oedema with jugular venous pressure of 6cm. On auscultation, the second heart sound is soft and a grade 4/6 ejection systolic mur- mur is heard over the aortic area with radiation to neck. Examination of the chest shows bilateral basal crepitation. Electrocardiogram shows sinus rhythm with left bundle branch block pattern.
(a) What is the most likely diagnosis and name 3 possible causes for this condition?
(b) Briefly outline investigations to confirm your diagnosis.
(c) Describe the management of her condition.

Answer 17

(a) critical aortic stenosis causing heart failure
* Degenerative changes gives to calcification of aortic valve
* Rheumatic aortic valve disease
* Congenitally abnormal valve with superimposed calcification (unicuspid or bicuspid)
b) Ix to rule out metabolic and neurological causes of syncope
* ECG for LVH, ischemic changes of myocardium and concomitant AF
* CXR for cardiomegaly, pulmonary edema
* Echocardiogram: valve anatomy and structure, valve haemodynamics, aortic valve flow velocity and presssure gradient, diameter of stenosed aortic orifice
* Cardiac catheterization to assess aortic valve gradient useful for guiding treatment
* Excercise test or dobutamine stress test to assess for ischemic heart disease

Question 18

Regarding prophylaxis against infective endocarditis
(a) For a patient having a tooth extraction, list three categories of patients with cardiac disorders / conditions for which chemoprophylaxis is currently recommended.
(b) Other than resorting to the use of antimicrobials, list two other steps that could be implement- ed, particularly for patients with vulnerable cardiac lesions.


Answer 18

(a) indications for antibiotics
* Prosthetic heart valve
* Congenital heart disease: unrepaired cyanotic congenital heart disease
* repaired congenital heart disease with residual defects
* Completely repaired CHD w/prosthetic material within 6m
* Heart transplant with concomitant valvulopathy
* Previous IE

b) have good dental hygiene and regular dental checkup, attention to skin hygiene, good hospital hygiene

Question 19

A 56-year-old man presents with sudden onset of chest pain with radiation to the back after walking uphill 4 hours ago. He has history of hypertension on medications for 5 years. On examination, his blood pressure is 220/140 mmHg over his left arm but is 120/60 mmHg over his right arm. His heart rate is 110 beats per minute and the jugular venous pressure is normal. The apex beat is not displaced and is in normal character. On auscultation, the heart sounds are normal and a grade 3/6 early diastolic murmur is heart over the left sternal border. Electrocardiogram shows 1 mm ST segment elevation over lead II, III and aVF. Please outline your acute management of this man within the first 24 hours.

Answer 19

dx: aortic dissection complicated by retrograde extension causing inferior MI and aortic regurgitation
Immediate mx: resuscitation
* ABC
* IV fluid
* Life threatening complications: shock secondary to massive hemorrhage, severe HT, cardiac tamponade, AR, AMI. Others: CVA, AKI, bowel ischemia

Ix:
* T/S x surgical intervention
* Serial cardiac biomarker: cTnT/cTnI, CK
* Lactate x ischemic bowel
* RFT x AKI
* aPTT, INR x coagulopathy
* d-dimer
* amylase x pancreatitis
* Serial 12 lead ECG
* Imaging: CXR, echo, contrast CT thorax + abdomen, TEE x visualize aortic valve/thoracic aorta, pericardial effusion

NPO, low salt diet
Bed rest and admit to CCU
Close monitor vitals: BP, P, RR, sO2, continous cardiac monitor
O2
Analgesics morphine IV 2-5mg

Medical mx: IV nitroprusside and IV labetolol
Consult CTS for surgical operation (cardiopulmonary bypass)

Question 20

A 80-year-old man presents with dizziness and shortness of breath. On examination, his blood pressure is 90/50 mmHg with heart rate of 35 beats per minute. There is no cyanosis, but jugular venous pressure shows cannon A wave. The apex beat is not displaced and is in normal character. On auscultation, there is a variable first heart sound without any murmur.
(a) What is the most likely diagnosis and possible cause for this condition?
(b) Briefly outline investigations to confirm your diagnosis.
(c) Describe the management of his condition.

Answer 20

(a) heart failure with complete heart block possibly due to AMI
(b) bloods: cTnT/cTnI, RFT, ABG, BNP
12 lead ECG: signs of AMI (ST elevation, q wave, inverted T wave)
c) Mx: ABC and vital sign
set IV line: atropine
pacing (bridge with TCP)
Treat if AMI
Cardiac monitoring: continuous ECG, BP/P, spO2

Question 21

A 76-year-old man has been feeling unwell for 2 months. His family doctor has visited on three occa- sions over the last 2 weeks, recording a temperature between 37.2°C and 38.0°C. He is known to have had mild mitral regurgitation.
(a) Describe your differential diagnosis.
(b) For one of your possible diagnoses give up to six clinical signs you might expect to see.
(c) What would be your initial management?

Answer 21

a) infective endocarditis, infection (TB, syphilis), deep seated abscess. Malignancy: lymphoma, leukemia
b) signs of infective endocarditis. roth spot (eye), hands (splinter hemorrhage, janeway lesion, oslers node)
(c) bloods (3 venous cultures taken at different sites, separated by 30 mins), CBC, urine (proteinuria, microscopic haematuria, pyuria, RBC casts), ECG (AV block of conduction delays (indicate paravalvular extension to valve annulus/IV septum), ischemia). CXR. Echocardiogram (vegetations, abscess formation (TTE as initial screen)
d) High dose IV bacterial agents for empirical coverage: IV penicillin G and gentamicin for 2 weeks
Surgical tx: early surgical debridement + replacement indicated when
Heart failure sx due to valvular dysfunction
Left sided IE due to resistant organisms
Evidence of persistent bacteremia or fever >5-7d

Question 22

A 40-year-old man presents to his doctor with headache. In outpatients he is well but his blood pres- sure is found to be 240/150 mmHg.
(a) Describe what signs you might be particularly interested in at clinical examination.
(b) What would be your initial management?
(c) Name up to 6 investigations that would be of use.

Answer 22

a) end organ damage
Fundoscopy: hypertensive retinopathy stage 3 (cotton wool spots, hemorrhage) or stage 4 (papilledema)
CVS: LVH, murmur, basal rales, ankle edema
Aortic dissection: different BP between 2 arms
PVD: absent peripheral pulss or femoral/carotid bruit
Possible causes of secondary HTN: renal (renal bruit), ballotable kidneys, urinanalysis. Endocrine (cushingoid features (phaeochromocytoma)
CoA: radial femoral delay
b) recheck BP, admit bed rest
Ix: CBC, RLFT, cardiac enzyme, clotting profile, CXR, ECG, urinanalysis
Anti HTN: oral metoprolol, captopril for phaeochromocytioma
Treat RF
c) bloods: K+, Na+ (conns adenoma)
ECG: LVH for CoA
Imaging: CXR
Urine analysis: red casrt, protein
RAS: USG doppler renal artery
Cushing: overnight dexamethasone suppression test/24 hour urine cortisol and creatinine
Phaeochromocytoma: 24 hour urine catecholamines and creatinine
Primary aldosteronism: PRR ratio