Cardiology

Question 1

Plasma levels of brain natriuretic peptide (BNP) correlate closely with the pressure and mural tension of the right ventricle and with pulmonary arterial pressure. The relationship between brain natriuretic peptide increase in acute pulmonary embolism (APE) and the increase in mortality and morbidity has frequently been suggested in small studies but its global prognostic performance remains largely undefined.

Answer 1

BNP levels were determined among the 30 consecutive patients arriving at the emergency department with shortness of breath and moderate to high probability of pulmonary embolism. All patients were subjected to a thorough clinical and physical examination, 12 lead electrocardiography, chest X-ray, echocardiography, laboratory tests including complete blood count, coagulation profile, renal and liver functions, brain natriuretic peptide and multiline computed tomography.

Results

20 patients were diagnosed with APE. Among them, 7 were diagnosed with massive embolism (group 1) and 13 had mild to moderate embolism (group 2). Among the first group 6 patients died while only 2 patients from the second group died. BNP levels were significantly higher in group 1 (130 ± 15 pg/ml) compared to group 2 (91 ± 7 pg/ml) (P < 0.05) and this was associated also with an increased mortality in group 1.

Conclusion

BNP levels can help predict the severity and possible outcome in patients with pulmonary embolism.

Question 2

Can antibiotic causes torsades de pointes?

A 69 year old gentleman was being treated for a chest infection with antibiotics. He has previous history of myocardial infarction and as well as the current antibiotic course he is also taking aspirin, atorvastatin and perindopril. He then collapses 2 days after the antibiotics began and was taken to A and E. When you examine him he has a BP of 130/80mmHg, heart rate of 80 bpm and he rest of his exam is unremarkable. You notice however on the cardiac monitor he is having short runs of torsade de points. What is the most likely antibiotic that he has been prescribed?

Answer 2

Antimicrobials. Macrolides (erythromycin, clarithromycin), fluoroquinolones, antifungals, and antimalarials have been implicated in predisposing to TdP as a result of QT prolongation

Macrolides such as clarithromycin and erythromycin have been associated with QT prolongation and TdP [Lee et al. 1998; Ray et al. 2004]. In animal studies, erythromycin was found to have similar effects to class III antiarrhythmic agents with prolongation of QT interval, induction of EAD and transmural dispersion.

Torsades de Points is a ventricular tachycardia which is polymorphic and occurs with QT prolongation. Macrolides e.g. erythromycin, clarithromycin and quinolones lead to prolongation of QT interval. Erythromycin should be avoided with simvastatin due increased risk of rhabdomyolysis.

Question 3

A 23 year old female who has history of a cardiac condition wants to start a family with her husband and has been referred to the cardiology clinic for advice. What condition is an absolute contra indication to pregnancy?

Answer 3

Pulmonary hypertension is the only absolute contraindication as it can rapidly deteriorate during pregnancy. MVP and bicuspid aortic valve should be monitored. PFO and ASD are not contraindications.

Question 4

A 68 year old asthmatic presents with shortness of breath. She also has a PMH of hypertension for which she is prescribed ramipril. On examination she is found to have a BP of 130/80mmHg, pulse of 90 irregularly, irregular and bilateral wheeze and normal heart sounds. A CXR reveals cardiomegaly. What is the most appropriate treatment of her AF?

Answer 4

Rate control is the most appropriate in this case. Digoxin should be utilised due to the cardiomegaly and history of asthma which means verapamil and atenolol should be avoided due to potential of precipitating heart failure and worsening asthma respectively.

Why digoxin shud be used ? What’s the moa.
Why verapamil and atenolol should be avoided

Question 5

A 60 year old male presents with general malaise, pyrexia and night sweats. They have a past history of rheumatic heart disease. On examination there is evidence of a pansystolic murmur. Which is a new clinical finding. What organism is the most likely to have caused these symptoms?

Answer 5

The most common organism to lead to infective endocarditis on a native valve is Strep Viridans. Staph Aureus and staph epidermidis are most likely to be the causative agents in prosthetic valve endocarditis. HACEK ad MRSA are both more rare causes.

Question 6

Which of the following is not a feature of hypokalaemia on an ECG?

Answer 6

DELTA WAVE

Question 7

patient presents with chest pain and shortness of breath. She has rheumatoid arthritis. She is tachycardic and hypotensive. She has a raised JVP and an ECG shows low QRS voltages. What is the most likely diagnosis?

Answer 7

CARDIAC TAMPONADE

Also recall causes of raised jvp mnemonic

Question 8

Which of the following suggests more severe mitral regurgitation?

Answer 8

As mitral regurgitation becomes more severe, the left ventricle enlarges and the apex beat displaces and a systolic thrill can develop.

Recall back heaves and thrill in PE

Question 9

An echocardiogram is performed on a patient prior to surgery and reveals a very small pericardial effusion but no other abnormalities. He is asymptomatic. What should be done regarding this prior to surgery?

Answer 9

Answer is proceed to Surgery , nothing to be done prior. Why ?
If large effusion need to do pericaridiocentesis , if minor no need just proceed .

Pericardiectomy or pericardial window: A surgeon makes an incision in the chest, reaches in, and cuts away part of the pericardium. This drains the pericardial effusion and usually prevents it from coming back. The procedure requires general anesthesia and is riskier than pericardiocentesis.

Question 10

A 35 year old gentleman has collapsed twice in the last month. He has a brother and uncle who died in their 20s of sudden cardiac death. An ECHO reveals features of HCOM and a 24 hour ECH shows several short runs of non sustained VT. How do you manage the non sustained VT?

Answer 10

Due to evidence of the non sustained VT he is at increased risk of sudden cardiac death and therefore an ICD is appropriate. Amiodarone was previously utilised for medical management but ICDs are now becoming management of choice.

All this while I tought VT means amiadanore only.
The implantable cardioverter defribelator ICD WILL DETECT THE RYTHM IF TACHY MEANS IT WILL GIVE SHOCK BY ITSELF. Like the normal shock we give in the algorithm

Question 11

A 23 year old present with palpitations intermittently. She is known to suffer from anxiety attacks. However on auscultation of the heart there is evidence of a late systolic murmur with a mid systolic click. It is worsened by the standing position. What is the most likely diagnosis?

Answer 11

The late systolic murmur with mid systolic click is indicative of mitral valve prolapse where the posterior leaflets bulge during systole. It has been associated with Ehlers Danlos syndrome and Marfans syndrome amongst others. It can very rarely lead to problems such as embolic events. Mitral stenosis causes a diastolic murmur and may be associated with other features such as haemoptysis. AS leads to an ejection systolic murmur. An atrial myxoma is a cardiac tumour and may lead to a mid diastolic murmur and tumour plop.
In contrast to most other heart murmurs, the murmur of mitral valve prolapse is accentuated by standing and valsalva maneuver (earlier systolic click and longer murmur) and diminished with squatting (later systolic click and shorter murmur).

Question 12

A 70 year old female has had several syncopal episodes. On auscultation there is an ejection systolic murmur radiating to the carotids. What is the most likely diagnosis?

Answer 12

Aortic stenosis leads to an ejection systolic murmur radiating to the carotids. It can lead to anginal symptoms and syncopal episodes as in this case and heart failure. There has been some association with haemorrhagic telangiectasia and GI bleeding. MR leads to a pansystolic murmur radiating to the axillae. An arrhythmia may be occurring but given the presence of a murmur aortic stenosis is more likely.
U STUDIED THIS IN CVS PHYSICAL EXAMINATION.

Question 13

A 45 year old male presents with palpitations. He had been drinking heavily the night before. His heart rate is about 140 bpm and is irregularly irregular. What is the most likely diagnosis?

Answer 13

Given the history of alcohol excess and irregularly irregular pulse this is highly indicative of Atrial fibrillation which commonly can occur after alcohol or caffeine excess.

Question 14

In a patient with chest pain with some t wave flattening, which investigation will confirm an NSTEMI?

Answer 14

Troponin I and troponin T are specific for myocardial infarction and are elevated within 6-12 hours. AST and LDH are elevated following an MI however these are not specific. CK-MB was previously utilised however troponin is more sensitive and specific.

Question 15

A 29 year old male presents with a history of intermittent palpitations. He is normally fit and well. He is a non smoker and takes little alcohol. These episodes can last for a few minutes to an hour. He is aware of his heart racing, it feels regular but very fast and he feels dizzy and short of breath. He has not noticed any triggering factors. There is no family history of any heart disease. Examination is normal Which of the following is the most likely diagnosis?

Answer 15

The history of a regular fast tachycardia with no history or structural heart disease makes the most likely diagnosis an SVT. It can occur in young people although the risk does increase with age. The risk of developing SVT also increases with previous myocardial infarction, MVP, pericarditis, alcoholism and chronic lung disease. If the palpitations were irregular then PAF would be suspected. Usually ectopics are described by patients as their hearts skipping a beat.
THIS IS A BONUS QUESTION U STUDIED THIS. Remember which is regular and irregular and point their differences.

Question 16

A 65 year old woman during prep assessment is found to have a small pericardial effusion. She is asymptomatic. The rest of her examination, ECG and other investigations are normal. How do you manage this patient?

Answer 16

The answer is is just reassure because
This patient can be reassured as there is no need for pericardiocentesis is the patient is asymptomatic and is haemodynamically stable. It is indicated if there is symptoms or haemodynamic compromise or fluid is required for diagnosis.

Question 17

A 52 year old gentleman is 5 days post STEMI when he starts to develop chest pain. It is pleurtic in nature and worse on lying down. He is pyrexial and generally unwell. On examination he is tachycardic and there is evidence of a pericardial friction rub. On ECG there is widespread ST elevation. What is the most likely diagnosis?

Answer 17

This patient presents with symptoms and signs of Dresslers syndrome. It is thought to be an immunological reaction which leads to pericarditis and presetns normally 2 to 5 days following MI but can present up to 3 months. As well as chest pain the patient is often suffering from malaise and pyrexia. There may a leucocytosis , eosinophilia and raised ESR. AS with any other causes of pericarditis pericardial; friction rub and widespread ST elevation may be evident.

Dressler’s syndrome is a type of pericarditis — inflammation of the sac surrounding the heart (pericardium). Dressler’s syndrome is believed to be an immune system response after damage to heart tissue or to the pericardium, from events such as a heart attack, surgery or traumatic injury. Symptoms include chest pain, which may be similar to chest pain experienced during a heart attack.

Dressler’s syndrome may also be called postpericardiotomy syndrome, post-myocardial infarction syndrome and post-cardiac injury syndrome. With recent improvements in heart attack treatment, Dressler’s syndrome is less common than it used to be.

Symptoms
Symptoms are likely to appear weeks to months after a heart attack, surgery or injury to the chest. Symptoms might include:

Chest pain
Fever

Dressler’s syndrome is associated with an immune system response to heart damage. Your body reacts to the injured tissue by sending immune cells and proteins (antibodies) to clean up and repair the affected area. Sometimes this response causes excessive inflammation in the pericardium.

Postpericardiotomy syndrome might affect 10 to 40 percent of people who have had heart surgery.

Question 18

A 50 year old female presents with shortness of breath, fatigue and peripheral oedema. On examination she has a raised JVP, pitting oedema, hepatomegaly and ascites. An echo is organised and reveals globally thickened walls including the interatrial septa with atrial dilatation but the ventricles were not dilated. There is an increased scintillation pattern (granular speckling). There is a normal ejection fraction. An ECG shows low voltage complexes. What is the most likely diagnosis?

Answer 18

FUCKINGN STUDY DILATED AND HYPERTROPHIC CARDIOMYOPATHY. I have seen few questions already.

The most likely diagnosis is restrictive cardiomyopathy given the clinical features and echo findings. The clinical findings are similar to those of constrictive pericarditis however the echo in this condition would reveal thickened calcified pericardium and normal wall thickness. Due to the atrial dilatation thrombus formation can occur and patients may present with embolic symptoms. The other options may be excluded from the echocardiogram findings. In HOCM patients tend no to present with features of right heart failure and on arrhythmogenic right ventricular cardiomyopathy would present with a ventricular arrhythmia. Amyloidosis is the most common cause of restrictive cardiomyopathy and the interatrial septal hypertrophy and granular speckling are suggestive of this as the underlying cause however are not specific and may be seen in other causes. Other causes include sacoidosis and Loefflers endocarditis.