Cardiology

Question 1

AVN re-entry tachycardia (Causes/Path/CF/ECG/Mx/Sub-types)

Answer 1

Causes: Commonest cause of palpitations in patients with strucurally normal hearts. Typically spontaneously or with provocation (exertion, caffeine, alcohol, beta-agonists (salbutamol) or sympathomimetics (amphetamines). W>M (75%).

Path: Functional re-entry circuit with the AVN.
• Normal- impulse travels down fast and slow pathways simultaneously, fast impulse enters distal end of slow pathway and they cancel each other out.
• Abnormal- One of the pathways is in it’s refractory period, so the impulse goes down the other pathway, this then cyles round, back up the other pathway then cycling round.

CF: Sudden onset rapid/regular palpitations, syncope, chest pain (think underlying coronary artery disease), dyspnoea, anxiety. Regular tachycardia 140-280

ECG: Regular tachycardia 140-280, narrow complex unless there is co-existing BBB/rate related aberrant conduction. P waves, if visible, inverted in II, III, aVF. May see ST depression and QRS alterans (large complex alternating sized complex).

Mx: Vagal rhythm, adenosine. May use CCBs/amiodarone, DC cardioversion rarely needed. If recurrent episodes not amenable to medical treatement could consider catheter ablation.

Subtypes:
• Slow-Fast- (80-90%), anterograde slow pathway, retrograde fast pathway- likely no visible P wave.
• Fast-Slow- (10%), anterograde fast pathway, retrograde slow pathway- P wave after QRS (long ventriculo-atrial interval)
• Slow-Slow- (1-5%), anterograde & retrograde slow pathway- P wave prior to QRS (similar to sinus tachycardia)

Question 2

Atrioventricular re-entry tachycardia (Path/ECG/Mx)

Answer 2

E.g. Wolff-Parkinson-White

Path: An accessory pathway allows electrical activity from the ventricles to pass to resting atrial myocytes.
• Orthodromic conduction- Via the AVN, anterograde, resulting in a regular narrow QRS comlpexes
• Antidromic- Via accessory pathway, going back through the AVN, producing a regular broad complex rhythm.

ECG:
• Orthodromic- 200-300 bpm, retrograde P waves, long RP interval, QRS <120 (unless pre-existing BBB or rate-related aberrant conduction, rate-related ischaemia is common. QRS alterans (QRS complexes large and alternating in size).
• Antidromic- 200-300 bpm, regular broad complexes
Mx:
• Orthodromic- If unstable DC cardiovert, if stable need to slow conduction via AVN, start with vagal manoeuvres then adenosine and/or verapamil. (note if verapamil used observe for at least 4 hours as may develop AF.)
• Antidromic- If any doubt if is VT treat accordingly, if stable try procainamide, Ibutilide/amiodarone second line., DC cardioversion if drug therapy fails.

Question 3

Focal atrial tachycardia (Path/CF/ECG/Mx/Associations)

Answer 3

Path: Rapid regular rhythm arising from a discrete area within the atira.

CF: Palpitations, fatigue, chest pain, syncope.

ECG: Regular atrial tachycardia with P wave morphology different from sinus tachycardia.

Mx: Adenosine, withdrawing causative agent/treatin underlying cause. Can require ablation.

Associations: Coronary artery disease, CCF, surgery, digoxin tocicity, catecolamines, cocaine and alcohol excess

Question 4

Sinus Tachycardia (Causes/Mx)

Answer 4

Causes:
1. Infection, pain, anxiety, dehydration, exercise, bleeding, systemic vasodilation( eg sepsis), anaemia, fever, PE, hyperthyroidism, pregnancy, hypercapnia, autonomic neuropathy (inappropriate sinus tachycardia)
2. Drugs- eg caffeine, nicotine, salbutamol
Mx:
1. If emergency treat as per ALS algorithm
2. Otherwise treat the underlying

Question 5

Narrow complex tachycardias- ALS

Answer 5

A-E
Give O2 to maintain SpO2
IV access
Blood gas/bloods- correct clear abnormalities

If signs of shock (Hypotension, chest pain, syncope or heart failure):
1. Synchronised DC shock (up to 3 attempts)
2. Amiodarone 300mg IV over 10-20 minutes
3. Repeat shock
4. Amiodarone 900mg over 24 hours
Regular:
1. Vagal manoeuvres (blow through syringe, ice on face, carotid massage)
2. Adenosine 6mg IV bolus, if no effect then a further 12mg then a further 12mg.
3. NSR achieved- probably re-entry paroxysmal SVT, consider prophylaxis
4. NSR not achieved- possible atrial flutter
Irregular:
1. Probable AF
2. Rate control- B-blocker or diltiazem, if in HF consider digoxin or amiodarone.
3. Assess thromboembolic risk and consider anticoagulation

Question 6

PE (RF/CF/Ix/Mx/Unprovoked PE)

Answer 6

RF: Recent surgery, thrombophilia, leg fracture, immobility, malignancy, pregnancy/post-partum, COCP/HRT and previous VTE.

CF:
1. Symptoms- acute SOB, pleuritic chest pain, haemoptysis, dizziness, syncope.
2. Pyrexia, cyanosis, tachypnoea, tachycardia, hypotension, raised JVP, pleural rub and pleural effusion.
Ix:
1. Bloods- Routine, D-dimer
2. ABG- T1RF
3. CXR- often normal, may show dilated pulmonary artery, linear atlectasis, small pleural effusion, wedge shaped opacities or cavitation(rare).
4. ECG- may be normal, often sinus tachy, also RBBB, right ventricular strain (TWI V1-V4), S1Q3T3 (deep S in I, pathological Q in III and TWI in III)
Mx:
1. Unstable- thrombolyse if massive/RHS, alteplase 10mg in 1 min then 90mg over 2 hours
2. Stable- DOAC (apixaban/rivaroxaban), can use warfarin (with LMWH bridging)
Unprovoked: If no known provoking factor consider Ix for malignancy/antiphospholipid/thrombophillia. Ix that can be done include: Bloods, CXR, breast exam, PSA and CT abdo/pelvis.

Question 7

Cardiac myxoma (path/CF/Ix/Mx)

Answer 7

Path: Rare benign cardiac tumor, F:M 2:1, usually sporadic, but may be familial (carney complex, cardiac/cutaneous myxomas)

CF:
1. Can mimic IE- fever, weight loss, clubbing, raised EDR and systemic emboli
2. Can mimic MS- left atrial obstruction and AF.
3. Tumour plop, symptoms may vary with posture.
Ix: ECHO

Mx: Excision

Question 8

Restrictive cardiomyopathy (causes/CF/Ix/Mx)

Answer 8

Causes: Idiopathic, amyloidosis, haemachromatosis, sarcoidosis, scleroderma, Loffler’s eosinophilic endocarditis, endomyocardial fibrosis.

CF: Features of RVF, raised JVP with prominent X/Y descents, hepatomegaly, oedema, ascities.

Ix: ECHO/MRI/cardiac catheterisation

Mx: Treat the underlying cause.

Question 9

Hypertrophic cardiomyopathy (Path/inheritance/CF/Ix/Mx/Prognosis)

Answer 9

Path: LV outflow obstruction fromasymmetrical septal hypertrophy. Leading cause of sudden cardiac death in the young. 0.2% prevalence with AD inheritance but 50% sporadic, 70% have mutations encoding B-myosin/a-tropomyosin and troponin T.

CF:
1. Sudden cardiac death- ask about family
2. Angina, SOB, palpitations, syncope, CCF, jerky pulse, A wave in JVP, double apex beat, systolic thrill left sternal edge, harsh ejection systolic murmur.
Ix:
1. ECG- LVH, progressive Twave inversion, deep Qwaves (inferior+lateral), AF, WPW syndrome, ventricular ectopics and VT.
2. ECHO- asymmetrical septal hypertrophy, small LV cavity with hypercontractile posterior wall, midsystolic closure of aortic valve, systolic anterior movement of mitral valve.
3. Cardiac catheterisation- can be helpful to assess severity, but can cause VT.
4. Exercise test +/- holter- useful to risk stratify
Mx:
1. B-blockers or verapamil for symptoms (aim to reduce compatability), amiodarone for arrythmias.
2. Anticoagulate for paroxysmal AF or systemic emboli
3. Septal myomectomy- surgical/chemical(alcohol), to reduce LV outlow tract gradient is reserved for severe symptoms
4. Consider implantible defibrillator
Prognosis: if <14 then 5.9%/year, if >14 then 2.5%/year. Poor prognostic factors- age <14, syncope at presentation and FH of sudden cardiac death.

Question 10

Dilated cardiomyopathy (Associations/CF/Ix/Mx/Prognosis)

Answer 10

Associations: Unknown cause, but associated with alcohol, high BP, chemotheraputics, haemochromatosis, viral infection, autoimmune, peri/postpartum, thyrotoxicosis, congenital (X-linked).

CF:
1. Fatigue, SOB
2. Pulmonary oedema, RVF, emboli, MR/TR, pleural effusion, oedema, jaundice, hepatomegaly, ascities, AF and VT.
3. Tachycardia, hypotension, raised JVP, diffuse apex S3.
Ix:
1. Bloods- High BNP, low Na (indicates poor prognosis.
2. CXR- Cardiomegaly, pulmonary oedema.
3. ECG- Tachycardia, non-specific T wave changes, poor R wave progression.
4. ECHO- globally dilated hypokinetic heart and low ejection fraction. MR/TR. LV mural thrombus.
Mx:
1. Bed rest
2. Diuretics, B-blockers, ACEi and anticoagulants
3. biventricular pacing/ICDs/LVAD/transplantation
Prognosis: Variable, mortalitiy ~40% in 2 years

Question 11

Acute myocarditis (Causes/CF/Ix/Mx/Prognosis)

Answer 11

Causes:
1. Idiopathic- 50%
2. Viral- Enteroviruses, adenoviruses, HHv6, EBV, CMV, influenza, hepatitis, mumps, rubela, Coxsckie, polio, HIV, HSV
3. Bacterial- Staph, Strep, Clostridia, diptheria, TB, meningococcus, mycoplasma, brucellosis, psittacosis
4. Spirochaetes- Leptospirosis, syphylsis, Lyme disease
5. Protozoa- Chagas, Leishmania, toxoplasmosis
6. Drugs- Cyclophosphamide, trastuzumab, penicillin, chloramphenicol, sulfonamides, methyldopa, spironolactone, phenytoin, carbamezapine.
7. Toxins- Cocaine, lithium, alcohol, lead, arsenic
8. Immunological- SLE, sarcoid, Kawaski, scleroderma, heart transplant rejection
CF: Chest pain, HF symptoms, palpitaions and tachycardia, soft S1 and S4 gallop.

Ix:
1. ECG- ST changes and T wave inversion, atrial arrythmias, transient AV block and QT prolongation
2. Bloods- CRP/ESR and troponin raised, send viral serology
3. ECHO- diastolic dysfunction, regional wall abnormalities
4. Cadiac MRI if stable
5. Endomyocardial biopsy is gold standard
Mx: Treat underlying cause, treat HF/arrythmias, avoid exercise as it can precipitate arrythmias, NSAIDs controversial.

Prognosis: 50% recover within 4 weeks, 12-25% will develop dilated cardiomyopathy and severe heart failure (can also develop years later).

Question 12

Tetralogy of fallot (Path/Features/CF/Ix/Mx/Prognosis)

Answer 12

Path: Most common cyanotic congenital heart disorder (3-6:10,000), 10% adult CHD. Thought to be due to abnormalities in the seperation of the truncus arteriosus into aorta and pulmonary arteries.

Features:
1. VSD
2. Pulmonary stenosis
3. RVH
4. Aorta overides the VSD accepting right heart blood.
CF:
1. Infants- may be acyanotic at work with pulmonary stenosis murmur, gradually become cyanotic after ductus arteriosus closeure with increasing right to left flow. Toddlers may squat as it increases peripheral vascular resistance, reducing R>L flow.
2. Adults- Often asymptomatic, if unoperated often have cyanosis.
3. Repaired patients- late symptoms include exertional dyspnoea, palpitations, clubbing, RV failure, syncope and sudden death.
Ix:
1. ECG- RVH with RBBB
2. CXR- normal or classical boot shaped heart
3. ECHO/cardiac CT/MRI- will show anatomy and provide information for surgery.
Mx: Surgery, usually done before 1 year old with closure of VSD and pulmonary stenosis.

Prognosis:

1. Without surgery- 95% death by 20.
2. After surgery- 85% survive to 35, with common issues being PR causing RV dilatation and failure, RV outflow tract obstructions, AR, LV dysfunction and arrythmias.

Question 13

Coarctation of the aorta (Path/Associations/CF/Ix/Mx/Complications)

Answer 13

Path: Congential narrowing of the descending aorta, ususally just distal to the origin of the left subclavian artery.

Associations: Bicuspid aortic valve, Turner’s syndrome.

CF: Radiofemoral delay, weak femoral pulse, HTN, scapula bruit, systolic murmur (best heard over left scapula), cold feet.

Ix: CT/MRI aortogram. CXR may show rib notching as blood diverts down intercostal arteries to reach lower body causing them to dilate.

Mx: Surgery or balloon dilatation +/- stenting

Complications: HF from high afterload, IE, intracerebral haemorrhage.

Question 14

Ventricular septal defects (Causes/CF/Ix/Mx/Complications)

Answer 14

Causes: Congential (1:2000), acquired- post MI

CF:
1. severe HF in infancy or asymptomatic.
2. Harsh pansystolic murmur at left sternal edge with a systolic thrill +/- parasternal heave (smaller holes give louder murmurs)
Ix:
1. ECG- Normal, can show LAD/LVH/RVH.
2. CXR- Normal heart size with mild pulmonary plethora (small VSD) or cardiomegaly with large pulmonary arteries and marked pulmoary pethora.
3. Cardiac catheterisation- raised O2 sats in right ventricle.
Mx: Initially medical management as many close spontaneously, indications for surgical closure are failed medical therapy, symptomatic, shunt >3:1, SBE/IE

Complications: AR, IE/SBE, pulmonary HTN, Eisenmenger’s complex, HF from volume overload.

Question 15

Atrial septal defect (ASD) (Types/CF/Ix/Mx/Complications)

Answer 15

Types:
1. Ostium secundum- 80%, often asymptomatic until adulthood when develop L>R shunt, typically 40-60 year olds.
2. Ostium primum- associated with AV valve anomalties (e.g. Down;s), present in childhood.
CF:
1. Chest pain, palpitaions, SOB, haemoptysis. Increased frequency of migraines.
2. Arrythmias (AF), pulmonary systolic flow murmur, wide fixed split S2, pulmonary HTN may predispose PR/TR
Ix:
1. ECG- RBBB with LAD(primum) or with RAD(secundum).
2. CXR- small aortic knuckle, pulmonary plethora, atrial enlargement
Mx: May close spontaneously. Primum should be closed in childhood, Secundum should be closed if symptomatic or RV failure. Transcatheter closure more common than surgical.

Complications:

1. Reversal of L>R shunt- (Eisenmenger’s complex), initial L>R shunt causes pulmonary HTN which increases RH pressures until they exceed left, at which point it reverses. Causes cyanosis as deoxygenated blood enters body.
2. Paradoxical emboli- go through shunt into arterial circulation. ( e.g strokes)

Question 16

Bicuspid aortic valve

Answer 16

Usually asymptomatic from birth.

Often develop AS +/- AR predisposing to IE/SBE/aortic dilatation/aortic dissection.

Intense exercise may cause acceleration, so yearly ECHOs on atheletes.

Question 17

Cardiac Tamponade (Path/CF/Diagnosis/Mx)

Answer 17

Pathophysiology: Pericardial effusion that raises intrapericardial pressure reducing ventricular filling and decreasing cardiac output, can rapidly lead to arrest.

CF: Tachycardia, hypotension, raised JVP, Kausmaul’s sign(JVP rising with inspiration), muffled heart sounds

Diagnosis:

1. Beck’s Triad (falling BP, rising JVP, muffled heart sounds).
2. ECG- low voltage QRS +/- electrical alternans.
3. ECHO- Echo free zone +/- diastolic collapse of RA/RV

Mx: Emergency pericentesis- send fluid for culture/staining

Question 18

Constricitive pericarditis (Causes/CF/Ix/Mx)

Answer 18

Causes: Idiopathic, TB or post pericarditis.

CF: RHF (raised JVP, Kaussmaul’s sign(JVP rising with inspiration), oedema, ascities, hepatosplenomegaly, quiet heart sounds, soft/diffuse apex beat).

Ix:
1. CXR- small heart +/-pericardial calcification
2. CT/MRI- to distinguish from restrictive cardiomyopathy
3. ECHO
Mx: Surgical excision, medical Mx of cause.

Question 19

Pericardial effusion (cause/CF/Ix/Mx)

Answer 19

Causes: Pericarditis, myocardial rupture, aortic dissection, pus, malignacy

CF: Dysponea, chest pain, signs of compression (hiccoughs/nausea/bronchial breathing in left base), muffled heart sounds

Ix:
1. CXR- enlarged globular heart if >300mls
2. ECG- low voltage QRS or alternating QRS morphologies
3. ECHO- echo-free zone surrounding heart
Mx: Treat the cause, pericardiocentesis with culture/ZN/TB stain and cytology.

Question 20

Pericarditis (Causes/CF/Ix/Mx)

Answer 20

Causes:
1. Idiopathic
2. Viruses- Coxsackie, echovirus, EBV, CMV, adenovirus, mumps, varicella, HIV
3. Bacteria- TB, Lyme disease, Q fever, pneumonia, rheumatic fever, Staph, Strep, mycoplasma, legionella
4. Fungi/Parasitic- very rare- immunocompromise
5. Autoimmune- SLE, RA, vascultis (Behcet, Takayasu), IBD, sarcoid, amyloid, Dressler’s
6. Druds- Procainamide, hydralazine, penicillin, isoniazid, anorexia, chemotherapy
7. Other- trauma, surgery, malignancy, MI, radiotherapy, chronic HF
CF: Central chest pain worse on inspiration/lying flat +/-relieved by sitting forward, pericardial friction rub may be heard, pericardial effusion/tamponade, pyrexia.

Ix:
1. ECG- concave (saddle shaped) ST elevation, PR depression, can be normal
2. Bloods- CK/Trop may be raised
3. CXR- cardiomegaly, pericardial effusion
Mx:
1. NSAIDs/aspirin +/- PPi for 2/52
2. Colchicine 500mg OD ro BD
3. Treat cause, if resistant or autoimmune consider steroids/immunosuppressants

Question 21

Rheumatic fever (Diagnosis/Mx)

Answer 21

Diagnosis: Needs evidence of recent strep infection with 2 major or 1 major and 2 minor criteria

Evidence of group A B-haemolytic strep
1. positive strep culture
2. rapid strep antigen test +ve
3. Elevated/rising strep antibody titre
4. Recent scarlet fever
Major:
1. Carditis- tachycardia, murmurs (MR/AR/carey coombs), pericardial rub, CCF, cardiomegaly
2. Arthritis- migratory, ‘flitting’ polyarthritis, usually affecting larger joints
3. Subcutaneous nodules- small, mobile and painless. On extensor surfaces of joints/spine
4. Erythema marginatatum- geographical-type rash, red-raised edges and clear centre, ususally on trunk/thighs/arms
5. Sydenham’s Chorea- (St Vitus dance), involuntary semi-purposeful movements, may be preceded by emotional lability/uncharicteristic behaviour
Minor:
1. Fever
2. Raised ESR/CRP
3. Arthralgia (but not if arthritis is one of the major criteria)
4. Prolonged PR interval (but not if carditis is major criteria)
5. Previous rheumatic fever
Management:
1. Bed rest- until CRP normal for 2 weeks
2. Benzylpenicillin IV STAT then Pen V PO for 10 days
3. Analgesia as needed- aspirin 100mg/kg for 2/7 then 70mg/kg for 6 weeks, alternative is NSAIDs
4. Immobilise joints in severe arthritis
5. Haloperidol/diazepam for chorea
6. Long term prophylaxis with Pen V
Prognosis- 60% with carditis develop chronic rheumatic HD, valvular incompetence (M>A>T>P) resulting in stenosis long term

Question 22

Complications of an MI

Answer 22

Cardiac arrest
Cardiogenic shock
LVHF

Bradyarrythmias:
1. Sinus bradycardia- in infarction of AV node may be atropine unresponsive
2. 1st degree HB- in inferior MI, 40% progress to higher blocks
3. Wenckebach phenomenon- generally tolerated
4. Mobitz tye II- needs pacing
5. Complete HB- Usually resolves after a few days, insert PPM
6. Bundle branch block- needs pacing
Tachyarrythmias: (Hypoxia/low K+/acidosis predispose, so correct)
1. Sinus tachycardia- treat causes and add B-blocker
2. SVT
3. AF/flutter- if unstable DC cardioversion, otherwise medical Mx
4. Frequent PVCs/non-sustained VT- common post MI, risk of sudden death. Correct low K+/Mg+ and start B-blocker
5. Sustained VT- Synchronized DC shocks, consider ablation +/- ICD
6. VF- Synchronized DC shocks +/- ICD
RVF/infarction- give fluids +/- inotropes, avoid vasodilators and diuretics

Pericarditis
Systemic embolism- warfarin for 3/12
Cardiac tamponade
Mitral regurgitation
Ventricular septal defect
Late malignant ventricular arrythmias- occurs 1-3 weeks, avoid hypokalaemia.
Dressler's syndrome
Left ventricular aneurysm- 4-6 weeks post MI, persistent ST elevation with LVF/angina/recurrent VT, anticoagualate and consider excision

Question 23

NSTEMI (initial/post acute)

Answer 23

Initial:

1. Oxygen if SATs <90%
2. Morphine 5-10mg IV + metoclopramide 10mg IV
3. GTN- spray, if not resolving can trial IV
4. Aspirin 300mg + Ticagrelor 180mg (can use clopidogrel 300mg)
5. Fondaparinux 2.5mg SC or LMWH 1mg/kg BD
6. B-blocker (bisoprolol)- unless in acute HF/cardiogenic shock
7. Cardiology r/v ?angiography- if on going pain then <2 hours

Post acute

1. PRN GTN
2. modify risk factors (diet/diabetes/exercise/mental illness/smoking cessation)
3. Aspirin 75mg OD + second anti-platelet for 12/12 (clopidogrel) +/- PPI
4. Fondaparinux until discharge
5. B-blocker, start low and increase (if contraindicated consider verapamil/diltiazem)
6. Atorvastatin 80mg
7. ECHO

Question 24

STEMI Mx (initial/post acute)

Answer 24

Initial:
1. Aspirin 300mg + Ticagrelor 180mg (or prasugrel 60mg, clopidogrel is last option 600mg)
2. Morphine 5-10mg IV, repeat as needed. Give with anti-emetic (metoclopramide 10mg IV or cyclizine 50mg IV)
3. Oxygen to keep SATs >95%
4. <12 hours- PCI (if not at PCI centre must be able to get to one within 2 hours, otherwise thrombolyse), will need anti-coagulation- Bivalirudin or enoxaparin
5. >12 hours- Fibrinolysis (ideally <30minutes from arrival), tissue plasminogen acitvators (tenecteplase, IV single bolus). Contraindications- previous intracranial haemorrhage, ischaemic stroke (<6/12), cerebral malignancy/AVM, major trauma/surgery/head injury (<3/52), GI bleed (<1/12), non-compressible punctures (<24hrs), bleeding disorder. Relative CI: TIA <6/12, anticoagulants, pregancy, refractory HTN, IE, advanced liver diease, active peptic ulcer, prolonged resuscitation.
6. If presenting >12 hours from symptom onset treat with fondaparinux
Post acute
1. PRN GTN
2. modify risk factors (diet/diabetes/exercise/mental illness/smoking cessation)
3. Aspirin 75mg OD + second anti-platelet for 12/12 (clopidogrel) +/- PPI
4. Fondaparinux until discharge
5. B-blocker, start low and increase (if contraindicated consider verapamil/diltiazem)
6. Atorvastatin 80mg
7. ECHO

Question 25

Angina (Classification/Types/Ix/Mx)

Answer 25

Classification: Symptomatic and reversible myocardial ischaemia, 3 cardinal features:
1. Cardiac chest pain
2. Symptoms brought on by exertion
3. Symptoms relieved within 5 minutes by rest or GTN
All 3- typical angina, 2- atypical angina, 1- anginal chest pain

Types:
1. Stable angina- Exertional, relieved by rest
2. Unstable angina- (crescendo), increasing frequency/severity or occuring on minimal exertion/rest, associated with increased risk of MI.
3. Prinzmetal angina- Vasospastic, coronary artery spasm.
Ix:
1. ECG- usually normal
2. Bloods- Trops normal, abnormal lipid profile
3. Can consider: angiography, exercise ECG or functional imaging
Mx:
1. PRN GTN
2. B-blocker or CCB, if unsuccessful can swap or combine these, if not controlled by one and other contraindicated/not tolerate can trial one of : long-acting nitrate/ivabradine/ranolazine, (also can use one of these if unable to use CCB or B-blocker).
3. Aspirin 75mg
4. Smoking cessation, dietary advice, adress hyperlipidaemia (statins), consider ACEi
5. Revascularisation- high risk/failed medical Mx

Question 26

Prinzmetal angina (Cause/Sx/Risks/Mx)

Answer 26

Vasospastic angina

Cause: Coronary artery vasospasm, can occur in normal arteries.

Symptoms: Angina chest pain, usually at rest.

Risks/Triggers: Smoking, recreational drugs (cocaine, amphetamines, weed), low magnesium and artery instrumentation (e.g. during angiography)

Mx: Avoid triggers. Replace magnesium. Smoking cesation. PRN GTN. Calcium channel blockers +/- long-acting nitrates. Avoid B-blockers, aspirin and triptans.

Question 27

Dressler’s Syndrome

Answer 27

Develops 2-10 weeks after MI/heart surgery/PPM insertion.

It is thought that myocardial injury stimulates autoantibody formation against the heart muscle.

Symptoms: Recurrent fever and chest pain. +/- pleural rub (from serositis).

Mx: Aspirin, NSAIDs or steroids.

Cardiac tamponade may occur, so avoid anticoagulants.