Cardiology Flashcards
A 78 year old man presents to the emergency department with severe, crushing chest pain and shortness of breath. He is seen immediately and, among other investigations, an ECG is performed. You are the F1 in the department and your registrar says the ECG shows tall R waves in leads V1 and V2.
What is this man suffering from? (A) Anterior Myocardial Infarction (B) Cardiac Tamponade (C) Inferior Myocardial Infarction (D) Pericarditis (E) Posterior Myocardial Infarction
(E) Posterior Myocardial Infarction - Posterior MIs typically present on ECG with tall R waves in leads V1 and V2. This would be typical of a left coronary artery occlusion. An anterior MI would have ST elevation in leads V1-V4, inferior would have ST elevation in II, III and aVF. Pericarditis would cause widespread ST elevation and cardiac tamponade will have a phenomenon called ‘electric alternans’ - beat to beat variation in electrical amplitude.
A 67 year old man (may or may not be called Geoff) with a history of hypertension presents to the emergency department with a 24 hour history of dyspnoea and palpitations. He also complains of mild chest discomfort. On examination, you note an irregularly irregular pulse of 115 beats per minute, blood pressure of 95/70mmHg and a respiratory rate of 20 breaths/minute. He denies any regular medication and insists he has never experienced anything like this before. An ECG shows absent P waves with QRS complexes at irregularly irregular intervals.
What is the most appropriate management?
(A) Clopidogrel (B) Direct Current (DC) Cardioversion (C) Bisoprolol (D) IV Adenosine (E) Digoxin
(B) Direct Current (DC) Cardioversion - new onset atrial fibrillation is considered for electrical cardioversion if it presents within 48 hours of presentation. The low blood pressure in a patient with a history of hypertension who is not currently taking any regular medication is concerning and suggests he is haemodynamically unstable. The most appropriate treatment for new onset AF within 48hrs is DC cardioversuon if unstable or either DC cardioversion or pharmacological cardioversion. Beta blockers can be used for rate control. Clopidogrel is not a treatment for AF. Bisoprolol would be a suitable alternative if the patient was more stable. Digoxin is ideal for patients with AF and heart failure. IV Adenosine is a treatment for narrow complex supraventricular tachyarrhythmias.
A 72 year old woman presents to the emergency department with severe shortness of breath. She complains of a productive cough which started yesterday. Her past medical history includes hypertension and two recent myocardial infarctions. On examination, she appears to be anxious, breathless and sweaty. Jugular Venous Pressure (JVP) is increased. Auscultation of the chest reveals widespread end-inspiratory crackles. Her pulse rate is 120 beats per minute, respiratory rate is 33 breaths/minute and her oxygen saturations are 88% on room air.
Based on the likely diagnosis, which of the following is the best pharmacological treatment for this patient?
(A) IV Diuretics (B) Oral Diuretics (C) IV Nitrates (D) Sublingual Nitrates (E) Oral Antibiotics
(A) IV Diuretics - Acute pulmonary oedema is a complication of myocardial infarction. The most likely diagnosis is acute pulmonary oedema or heart failure due to the past medical history of Myocardial Infarction. Intravenous diuretics such as furosemide is the best pharmacological treatment for this patient as this method of administration has better bioavailability since the patient is severely dyspnoeic with poor vital signs. IV Diuretics are also recommended by NICE guidelines for the treatment of acute heart failure. Nitrates are not routinely offered. Oral antibiotics are not required as there are no signs of infection and the clinical presentation is in keeping with acute pulmonary oedema.
A 78 year old man is brought to the emergency department with sudden onset severe chest pain. He has an ECG which shows ST elevation mainly in leads I and aVL and slightly in V5 and V6 too.
Which coronary artery is most likely affected?
(A) Left anterior descending (LAD) (B) Left coronary (C) Left Circumflex (D) Right coronary (E) Right Circumflex
(C) Left Circumflex
Lateral MI is generally caused by a left circumflex artery lesion.
This is a lateral myocardial infarction (MI) - sudden onset chest pain with ST elevation in I, aVL, V5 and V6. Lateral MIs are caused by a lesion in the left circumflex artery. A lesion in the left anterior descending will cause an anterolateral MI, right coronary will cause an inferior MI. There is no right circumflex artery.
A 65 year old woman with a history of COPD (Chronic Obstructive Pulmonary Disease) is reviewed in the emergency department. She has presented with a sudden worsening of her dyspnoea with associated haemoptysis. What is the most suitable initial imaging investigation to exclude a pulmonary embolism (PE)?
(A) Ventilation - Perfusion scan (B) Echocardiogram (C) Pulmonary Angiography (D) CTPA (Computed Tomographic Pulmonary Angiography) (E) MRI Thorax
(D) CTPA (Computed Tomographic Pulmonary Angiogram) - for PE, CTPA is the first-line investigation. However it is still common in U.K. Hospitals, despite guidelines, for a ventilation-perfusion scan to be done first-line.
A 60 year old homeless woman is brought into the emergency department by the paramedics. They have found her unconscious and an ECG reveals a broad complex polymorphic tachycardia indicative or Torsades De Pointes. Which of the following could be a cause of this woman’s arrhythmia?
(A) Hypothermia (B) Hypercalcaemia (C) Hyoerthyroidism (D) Hypermagnesia (E) Hypoglycaemia
(A) Hypothermia
Hypothermia is a cause or Torsades De Pointes. The question is asking about a patient presenting with a broad complex polymorphic tachycardia. This is characteristic of a Torsades De Pointes, therefore the answer is hypothermia which is a known cause.
Hypocalcaemia, Hypomagnesia (and also hypokalaemia) are all causes of Torsades De Pointes, not their ‘Hyper’ counterparts listed above.
There is no link between hypoglycaemia or hyperthyroidism and Torsades De Pointes.
A 65 year old man with heart failure presents to his GP with some questions regarding his medication. He would like to know which of his drugs will help him live longer and not just improve his symptoms.
What is the most appropriate response?
(A) ACE Inhibitors, Beta blockers and Spironolactone
(B) ACE Inhibitors, Beta blockers, Spironolactone and Furosemide
(C) ACE Inhibitors, Beta blockers and Furosemide
(D) ACE Inhibitors, Spironolactone and Furosemide
(E) Beta Blockers, Spironolactone and Furosemide
(A) ACE Inhibitors, Beta Blockers and Spironolactone
Diuretics only improve he symptoms of heart failure and have no effect on mortality.
The question is asking about the medications that reduce the mortality in heart failure. Many medications can be used in heart failure, however the use of furosemide is for symptomatic control alone. Other medications listed above e.g. ACE Inhibitors, beta blockers and spironolactone all help to reduce long term mortality and slow disease progression and therefore patients should make sure they continue these medications even when symptoms subside.
A 69 year old man presents to his GP. He complains of chest pain and shortness of breath on exertion. He is unable to lie flat because of his breathlessness. He requires three pillows to sleep at night. Auscultation of the heart reveals an ejection systolic murmur, loudest at the second intercostal space at the right sternal edge. The murmur shows radiation to the carotid. His recent blood tests show high triglycerides and low-density cholesterol. You decide you are going to refer him to cardiology for further management. In the meantime you would like to alleviate his symptoms.
Which of the following is the most suitable medication to alleviate his symptoms?
(A) Glyceryl Trinitrate (GTN) Spray (B) Isosorbide Dinitrate (C) Furosemide (D) Aspirin (E) Simvastatin
(C) Furosemide - Nitrates are contra-indicated in aortic stenosis.
The history and examination are consistent with aortic stenosis. Symptomatic aortic stenosis should be considered for valve replacement. The BNF has stated that nitrates are contra-indicated in aortic stenosis due to the theoretical risk of profound hypotension. GTN spray and isosorbide dinitrate are both nitrates. Aspirin and simvastatin may reduce the risk of myocardial infarction (MI) but this is unlikely to help with symptoms. Furosemide will be helpful especially in relieving orthopnoea and shortness of breath on exertion (barn door pulmonary oedema present).
A patient with heart failure is being reviewed by the cardiologist. Their symptoms are under control at rest although the patient comments that waking to the shops can make him quite breathless. He says that 5 years this would not have been a problem. He doesn’t struggle to make breakfast or move around his house. He does mention though that more intense household chores such as cleaning are a struggle.
According to the NYHA classification, what stage of heart failure is this patient at?
(A) Stage I (B) Stage II (C) Stage III (D) Stage IV (E) Stage v
(B) Stage II
NYHA Class II Heart Failure causes slight discomfort with ordinary activity. No symptoms at rest.
Stage I - No limitation on ordinary activity (incorrect)
Stage II - Normal at rest. Ordinary physical activity causes breathlessness (correct)
Stage III - Normal at rest. Less than ordinary activity causes breathlessness (incorrect)
Stage IV - Symptoms at rest (incorrect)
There is no such thing as Stage V.
Making breakfast and moving around the house are not especially intense forms of activity and may still be achievable with no problem in Stage II NYHA of heart failure. If he was unable to do these things he would be classified as Stage III.
A 67 year old Caucasian man (Geoffers) is found to have a blood pressure measurement of 155/95mmHg on routine measurement in his GP surgery. On subsequent measurements in the GP surgery it is always found to be around the 150/90mmHg mark. He has home blood pressure monitoring (HBPM) which shows an average of 145/85mmHg. He is otherwise fit and well, no known past medical history and a QRISK2 score of 9%.
What is the most appropriate management of this man’s blood pressure?
(A) Amlodipine (B) Lifestyle Advice (C) Lisinopril (D) Losartan (E) Thiazide Diuretic
(B) Lifestyle Advice
For a person under the age of 80 with Stage 1 Hypertension, only treat medically if: diabetic, renal disease, QRISK2 greater than 20%, established coronary vascular disease or end-organ damage.
This man has stage 1 hypertension and thus, combined with he fact he has no other diseases, a QRISK2 score of less than 20% and he is under 80 years of age means he only requires lifestyle advice and monitoring. Lifestyle advice would include reducing salt intake, reducing caffeine intake, stopping smoking, reducing alcohol intake, eating a balanced diet rich in fruit and vegetables, exercising more and losing weight.
A 33 year old woman presents to the emergency department with abdominal pain. She has a past medical history of Hypertension.
On examination, she has a palpable mass on the left side of her abdomen, and on auscultation of the heart, a murmur is heard. An ultrasound scan shows multiple cysts in her left kidney.
Which one of the following abnormalities is commonly associated with her condition?
(A) Pulmonary Stenosis (B) Tricuspid Regurgitation (C) Mitral Stenosis (D) Mitral Valve Prolapse (E) Aortic Stenosis
(D) Mitral Valve Prolapse - is associated with polycystic kidney disease.
This patient has polycystic kidney disease. Patients with PKD have an increased occurrence of cardiac valve abnormalities, with mitral valve prolapse and mitral valve regurgitation being the most common. As many as 1 in 4 adults with PKD develop mitral prolapse.
Since mitral valve prolapse is the most common valvular abnormality associated with polycystic kidney disease, the other answers are incorrect.
A 40 year old man presents to his GP with a noted abnormality around his right eye. It is a clear case of xanthomata.
What is the most likely diagnosis? (A) Hypertriglyceridaemia (B) Hypercholesterolaemia (C) Hypothyroidism (D) Wilson's Disease (E) Diabetes Mellitus
(B) Hypercholesterolaemia
The patient has developed xanthalasma secondary to hypercholesterolaemia.
A 23 year old man is given IV Adenosine to treat a supraventricular tachycardia. What is the approximate half-life of Adenosine?
(A) 10 seconds (B) 1 minute (C) 10 minutes (D) 2 hours (E) 6 hours
(A) 10 seconds
Patients who are given Adenosine will experience unpleasant but short-lived side effects. Adenosine acts by causing transient heart block in the AV nice. As an agonist of the A1 receptor which inhibits adenylyl cyclase, it reduces cAMP and causes hyperpolarisation by increasing potassium efflux. Adenosine has a very short half-life.
Adverse effects include chest pain, bronchospasm and the potential to enhance conduction down accessory cardiac pathways resulting in increased ventricular rate (e.g. Wolff-Parkinson-White Syndrome).
A 50 year old man complains of central constricting chest pain. Walking up the stairs triggers the pain, which goes away with rest. He experiences some shortness of breath but denies any syncope or palpitations. He suffers from hypertension and diabetes. He takes verapamil for migraine prophylaxis. His other medications include GTN spray, aspirin, metformin, atorvastatin and ramipril. On examination, his rhythm seems irregular. There is no murmur on auscultation of the heart and no tenderness of the chest wall on palpation.
He is asking for a medication that would be helpful to prevent the chest pain from occurring. What would be the most appropriate treatment?
(A) Bisoprolol (B) Digoxin (C) Metoprolol (D) Nicorandil (E) Ibuprofen
(D) Nicorandil
Beta blockers such as Bisoprolol should not be used with verapamil due to the risk of bradycardia, heart block and congestive cardiac failure.
This is a typical angina history. Beta blockers are a first line angina prophylaxis. However this man is taking verapamil for his migraines. Verapamil should not be used with a beta blocker, therefore Bisoprolol and metoprolol are incorrect answers. Ibuprofen and digoxin do not reduce the frequency of angina. Therefore the next line for prophylaxis of angina ha is Nicorandil.
