Cardiovascular SBA Flashcards
A 22yr old man of Vietnamese descent is rushed into A&E after an episode of syncope while out walking the dog. He makes recovers spontaneously and is discharged several days later, with no clear cause for his syncope being identified. Serial resting ECGs over several days shows coved ST elevation with no chest pain or elevated cardiac enzymes. There is no other abnormality on his ECG and ECHO is normal. He is referred to cardiology for further investigation. At clinic he reveals that two of his uncles have suddenly died at a very young age, and is very concerned the same may happen to him. He mentions that his girlfriend has woken him up several nights to check he is okay and his breathing ‘goes funny’ sometimes during the night. What is the most likely underlying condition to explain this man’s symptoms?
A. Hypertrophic cardiomyopathy
B. Brugada syndrome
C. STEMI
D. Long QT syndrome
E. Complete heart block
Correct answer: b
This case is suggestive of Brugada syndrome, with the hallmark coved ST elevation found on his ECG. Brugada is commonly found in young men, particularly of South Asian descent. The FH of sudden cardiac death, and abnormal nightime breathing (nocturnal agonal respiration) would fit the diagnostic criteria for Brugada syndrome. Long QT syndrome could cause syncope of unclear cause, however long QT syndrome is more common in women and is associated with increasing age and comorbidities (particularly cardiovascular, renal and liver), there is also no evidence of a long QT interval in this man’s ECG. Hypertrophic cardiomyopathy could explain both this man’s presentation and his family history; however it is often associated with other cardiac symptoms and is likely to have been seen on ECHO. A STEMI may explain ECG changes, but is unlikely to be present over several days in the there is no history of cardiac chest pain and troponins are not elevated, so the diagnostic criteria of a STEMI is not met. Complete heart block could cause syncope, but does fit the ECG findings
An 81yr old lady is brought into A&E following a collapse at home. She reports blacking out for a few seconds after feeling light headed when getting up from her chair. She denies chest pain, palpitations or short of breath. It is the first time this has happened, but she does often get light headed on standing. She has a PMH of HTN, IHD and is an ex-smoker. Her medication history is aspirin 75mg OD, bisoprolol 2.5mg OD, ramipril 5mg OD, amlodipine 10mg OD, bendroflumethiazide 2.5mg OD. Other than a few cuts and scrapes, her examination is grossly normal. Her ECG and blood tests including cardiac enzymes are all grossly normal, other than slightly low sodium. What is the most likely cause of her collapse?
A. Postural hypotension, most likely secondary to antihypertensives
B. Paroxysmal fast AF
C. Syncope due to severe aortic stenosis
D. Inferior NSTEMI
E. Posterior circulation stroke
Correct answer: a
The symptoms of dizziness on standing are classic of postural hypotension, and this lady has numerous causative medications. Therefore postural hypotension is the most likely cause. Paroxysmal AF is a possibility, but would commonly present with palpitations, and may also be seen on the ECG. Severe aortic stenosis can cause syncope, but you would most likely hear a significant ejection systolic murmur radiating to the carotids, which is not present in this lady. NSTEMIs can cause present atypically, particularly in elderly women. However a normal ECG and cardiac enzymes are reassuring that this is not an NSTEMI. Posterior circulation stroke can cause dizziness and collapse, but does not often cause loss of consciousness. You would also expect to see ongoing neurological signs. All of the above options are a possibility in this lady, but the symptoms are classic of postural hypotension and there are clearly causative medications, therefore it is the most likely.
A 67yr old man presents to A&E with central chest pain radiating up his jaw. He describes it as a ‘heaviness’ and feels sweaty. It started an hour ago and has got progressively worse. He has never had a pain like this before. He has a past medical history of hypertension and takes amlodipine and for it. He smokes 30 cigarettes a day and has a 70pack year history. His ECG shows significant ST depression in leads II, III and aVF. Blood tests on arrival to A&E including trop T are all normal. What is the most likely diagnosis?
A. Hypokalaemia
B. Anterior NSTEMI from thrombus in left anterior descending coronary artery
C. Inferior NSTEMI from thrombus in left circumflex artery
D. Inferior NSTEMI from thrombus in right coronary artery
E. Anterolateral STEMI from occlusion of the left anterior descending coronary artery
D
The history is suggestive of cardiac chest pain, and the ECG changes are consistent with an NSTEMI. Leads II,III and aVF are inferior leads. Inferior NSTEMIs are most commonly caused by thrombus to the right coronary artery. It is much less common for a thrombus in left circumflex to be responsible. Hypokalaemia can cause ST depression, but normal serum potassium would exclude that. Hypokalaemia would also be unlikely to cause this man’s symptoms.
A 27 year old man presents to A&E. He is clearly uncomfortable and he gestures to his chest as if to suggest pain. He has a history of imprisonment for the supply for opiates. On examination, he is visibly sweaty. He has some painful nodules on his hands. There are no dark streaks beneath the fingernails. Examination of the retina is completely unremarkable. He has some bruising and track marks in his antecubital fossa. His blood pressure is 100/70 and his heart rate is 120 bpm. His respiratory rate is 25/minute and his oxygen saturations are 96% on room air. He is currently slightly confused but manages to suggest that he passed some blood in his urine when he last visited the toilet. His tympanic temperature is 38.3 degrees Celsius. His ECG shows the presence of normal P waves and narrow QRS complexes. T waves are present and uninverted. There is unconvincing evidence of ST depression or elevation in any contiguous leads. Initial blood tests show the following: Hb: 130 g/L White Cells: 24 x109 /L Platelets: 400 x109/L CRP: >5 ESR: within normal limits What is the most likely diagnosis?
A. Granulomatosis with polyangiitis
B. Hand Foot and Mouth Disease
C. Infective Endocarditis
D. Myocardial Infarction
E. Secondary Syphilis
Correct answer: c
The patient is most likely to have infective endocarditis(IE). The picture of fever, shock and painful palmar nodes (Osler’s nodes) suggest this. IE has systemic manifestations including an, through the immune complex deposition and induction of a glomerulonephritis, can cause haematuria. Other manifestations of IE include septic emboli (can be cerebral or pulmonary). Though the patient is sweaty and nauseous, a myocardial infarction is unlikely in a patient of this age, especially with what is essentially a normal ECG (note that the patient is only tachycardic). You can develop a maculopapular rash with syphilis but there is no real hint at a mechanism for contracting syphilis in the case above. Granulomatosis with polyangiitis(GPA) is a small vessel vasculitis which can cause haematuria, as well as nasal bleeding/crusting, the latter features not being present. Furthermore, a normal ESR is unlikely to support this diagnosis. Hand foot and mouth disease can also create a maculopapular/vesicular rash on the hands, but there is no evidence of foot or mouth involvement.
A 14 year old girl presents to her GP with a productive cough and a fever. 7 years ago, she was admitted to hospital for bacterial pneumonia. She has always suffered with recurrent chest infections and a daily productive cough, the sputum of which is occasionally blood stained. Observations are normal albeit an elevated respiratory and a tympanic temperature of 37.7 degrees Celsius. Respiratory examination reveals widespread coarse crackles. A previous chest X-ray reveals a gastric bubble and cardiac apex on the right-hand side. What is the most likely diagnosis?
A. Alpha-1 anti-trypsin deficiency
B. Bronchiectasis
C. Cystic Fibrosis
D. Karteneger Syndrome
E. Viral Bronchiolitis
Correct answer: d
The most likely diagnosis is Karteneger Syndrome. This is a diagnosis to consider in a patient with ciliary dyskinesia (leading to recurrent infections), bronchiectasis and dextrocardia situs inversus (meaning that other visceral organs, such as the stomach, are also on the opposite side). Practical implications of dextrocardia include placing ECG leads on the opposite side of the body to aid interpretation. Even though this patient has bronchiectasis, the addition of dextrocardia makes you more suspicious of Karteneger’s. Cystic fibrosis also presents with recurrent infections but is not associated with dextrocardia. Viral bronchiolitis tends to present in younger children and is associated with a dry cough and bilateral crepitations. Alpha 1-antitrypsin deficiency tends to present later (e.g. early 20s onwards) with either pulmonary or hepatic problems. Pulmonary problems include early onset COPD, in the form of a panacinar emphysema (involvement of the whole acinus from respiratory bronchioles to the alveolar ducts/alveoli), as opposed to a centriacinar emphysema (more proximal acinar involvement: there is more respiratory bronchial involvement, rather than distal alveolar duct/alveolar involvement) typically seen in COPD. https://rarediseases.info.nih.gov/diseases/6815/kartagener-syndrome
Perry Halodol is a 67 year old man who presents to A&E with central chest pain, radiating up into his jaw. The pain has persisted for 30 minutes and he is visibly sweaty. He has a 40 pack year history of cigarette smoking, and he drinks about 12 units of alcohol each week. He has a past medical history of hypertension, type 2 diabetes, hypercholesterolaemia, asthma and GORD. An ECG shows 5mm ST elevation in leads aVF, II and III. As such he is sent to the catheter lab for treatment of a STEMI. Given Perry’s presentation and past medical history, in which of the following conditions is atherosclerosis most likely to play a role in the underlying pathophysiology?
A. Acute Pulmonary Embolism
B. Granulomatosis with Polyangiitis
C. Prinzmetal Angina
D. Renal Artery Stenosis
E. Type 2 Myocardial Infarction
Correct answer: d
Risk factors for renal artery stenosis are similar to those for coronary heart disease because they can both be caused by atherosclerosis. Renal artery stenosis can lead to chronic renal underperfusion and chronic renal failure. The manifestation of one atherosclerotic disease may signal the development of other atherosclerotic diseases (so this is a reason to ask about concomitant limb claudication in search of peripheral vascular disease in someone with coronary heart disease). Type 2 myocardial infarctions are caused by supply/demand problems not caused by coronary vessel obstruction with a ruptured atherosclerotic plaque and thrombus (type 1). The coronary vessels are likely to be clear, and infarction may be caused by coronary vasospasm, hypoperfusion (e.g. due to hypotension) or even diffuse microvascular disease (microvascular problems cannot be visualised on conventional angiography). Prinzmetal angina is induced by coronary vasospasm and not exertion on a background of atherosclerotic disease (stable angina). Finally, Granulomatosis with Polyangiitis(GPA) is a systemic, small vessel vasculitis associated with nasal crusting, nasosinusitis, a rapidly progressive glomerulonephritis, purpura and non-specific respiratory symptoms (including haemoptysis). Fundamentally, GPA’s disease process is not really driven by atherosclerosis. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3127560/ http://heart.bmj.com/content/heartjnl/103/1/10.full.pdf
A 27 year old man presents to A&E. He is clearly uncomfortable and he gestures to his chest as if to suggest pain. He has a history of imprisonment for the supply for opiates. On examination, he is visibly sweaty. He has some painful nodules on his hands. There are no dark streaks beneath the fingernails. Examination of the retina is completely unremarkable. He has some bruising and track marks in his antecubital fossa. His blood pressure is 100/70 and his heart rate is 120 bpm. His respiratory rate is 25/minute and his oxygen saturations are 96% on room air. He is currently slightly confused but manages to suggest that he passed some blood in his urine when he last visited the toilet. His tympanic temperature is 38.3 degrees Celsius. His ECG shows the presence of normal P waves and narrow QRS complexes. T waves are present and uninverted. There is unconvincing evidence of ST depression or elevation in any contiguous leads. Initial blood tests show the following: Hb: 130 g/L White Cells: 24 x109 /L Platelets: 400 x109/L CRP: >5 ESR: within normal limits What is the next most appropriate investigation?
A. Blood cultures
B. Transoesophageal echocardiogram
C. Urea and Electrolytes
D. Sputum culture
E. Urine Culture
Correct answer: a
This patient may have infective endocarditis, however, he is also septic. Therefore, you should initiate your “Sepsis 6” bundle, obtaining blood cultures before starting antibiotics within one hour of presentation. Subsequent investigations may include a transoesophageal echocardiogram in search of valve vegetations or new valvular regurgitation. https://academic.oup.com/bjaed/article/12/3/134/258704
