Circulatory System/Heart/Vessel Flashcards
Which one of the following is not a differential diagnosis for shoulder tip pain?
A. Pulmonary Embolism
B. Myocardial Infarction
C. Emphysema
D. Pneumothorax
E. Peptic Ulcer Disease
C. Emphysema
Shoulder-tip pain is an important clinical sign and can be caused by local musculoskeletal trauma or inflammation or referral. The following are the differential diagnoses of referred shoulder-tip pain:
- Pulmonary embolism
- Pneumothorax
- Myocardial infarction
- Perforation of peptic ulcer disease
- Diaphragmatic irritation
Emphysema is not a cause of shoulder-tip pain, unless a spontaneous pneumothorax occurs.
After percutaneous coronary intervention (PCI) in a patient with STEMI, which one of the following is the recommended period for anti platelet therapy?
A. Two weeks
B. Four weeks
C. Six weeks
D. 12 months
E. Lifelong
What are the common DAPTs?
In nearly all patients in whom intra-coronary drug-eluting stent is placed, dual antiplatelet therapy is indicated for at least 12 months. Dual therapy is with aspirin and any of the following:
- Clopidogrel
- Prasugrel
- Ticagrelor
Reference:
* RACGP - AFP - Dual antiplatelet therapy
Which one of the following is of predictive value for prognosis of a patient with systolic heart failure?
A. Jugular venous pressure.
B. Peripheral edema.
C. Shortness of breath.
D. Orthopnea.
E. Chest pain.
Which above is diagnostic and which is predictive?
A. JVP
Prognosis of systolic heart failure can be predicted by jugular venous pressure (JVP) and the third heart sound (S3). Increased JVP or the presence of S3 sound indicates poor prognosis.
Other options are of diagnostic, not predictive values.
Based on the culture results of a 42-year-old man with infective endocarditis, hemophilus ducreyi is found to be the causative organism. He is treated with a course of intravenous ceftriaxone. Which one of the following would be the most appropriate investigation in addition to treatment?
A. Colonoscopy.
B. Abdominal CT scan.
C. CT angiography.
D. Trans-thoracicechocardiography(TTE).
E. Trans-esophageal echocardiography (TEE).
C. CT angiography
Infective endocarditis (IE) can be uncommonly caused by HACEK group. HACEK group are oral gram-negative bacilli including Hemophilus, Aggregatibacter actinomycetmcomitans, Cardiobacterium hominis, Eikenella corrodens and Kingella kingae. HACEK organisms are most often associated with infective endocarditis, accounting for up to 10% of cases. They are also the most common cause of gram-negative endocarditis among persons who do not abuse intravenous drugs.
Generally, IE have several complications with embolic events being one of the most lethal ones.
A number of imaging studies have been used to identify infected aneurysms, including ultrasound, CT scan, MRI and digital subtraction angiography (DSA). Of these, CT angiography is the most useful one for diagnosing mycotic aneurysm. MRI angiography is the alternative when intravenous contrast is contraindicated.
Colonoscopy is considered in patients with Streptococcus bovis as the cause of their IE because Streptococcus bovis is found to be associated with increased risk of colon cancer. Abdominal CT scan is not useful for detection of microaneurysms.
Trans-thoracic or trans-esophageal echocardiography is not useful for detection of micoraneurysms.
You are called to see a 50-year-old Aboriginal woman with history of congestive heart failure, who has developed severe dyspnea and is in respiratory distress. On examination, she is pale and sweaty with a blood pressure of 110/75 mmHg and pulse rate of 120bpm. The respiratory rate is 26/min. Chest auscultation is significant for bilateral crackles. A chest X-ray shows bilateral whiteout of lungs from the lower lobes up to middle of the lung fields. An ECG shows no abnormality. Troponin level is normal on arrival and eight hours later. Which one of the following is the most likely diagnosis?
A. Acute right heart failure.
B. Acute pulmonary edema.
C. Pleural effusion.
D. Acute myocardial infarction.
E. Pulmonary embolism.
B. Acute pulmonary EDEMA - dyspnea, bibasilar coarse crackles, tachycardia, pallor and cold limbs due to hypoperfusion. The background history of CHF supports the diagnosis of pulmonary edema in this patient as the most likely diagnosis.
A. Acute RHF - ankle edema, raised JVP, hepatomegaly, shortenss of breath. With only lung congestion and no other findings that can be present in right heart failure, this diagnosis less likely.
C. Pleural effusion - progresses slowly and usually does not cause acute-onset symptoms. Even an acute pleural effusion takes hours to days to develop.
D. With acute MI - ECG changes and positive cardiac enzymes should have been present.
E. A massive pulmonary embolism (PE) can be the second likely diagnosis on the list differential diagnoses. PE presents with shortness of breath, tachypnea and tachycardia as the hallmark symptoms. Pleuretic chest pain or shoulder-tip pain may be other finding. ECG may be normal or show S1Q3T3 pattern (prominent S wave in lead I, Q wave and T wave inversion in lead III), sinus tachycardia, T wave inversion in leads V1 –V3 and right bundle branch block.
A 65-year-old woman presents with several episodes of acute lightheadedness, especially shortly after getting off the bed or a chair for the past 3 months. Her medical history is otherwise unremarkable. A table tilt test is arranged that is positive. Which one of the following would be the first-line management of this patient?
A. Oral fludrocortisones.
B. Oral hydrocortisone.
C. Intravenous fluids.
D. Increased salt and water intake.
E. Indomethacin.
D. Increased salt and water intake.
A positive table tilt test is highly suggestive of orthostatic (postural) hypotension
= Excessive fall in BP when an upright position is taken on. BP drop is >20mmHg in systolic pressure, 10mmHg in diastolic pressure or both. The condition may be acute or chronic.
= Most common acute causes include:
* Hypovolemia (e.g. blood lost)
* Drugs
* Prolonged bed rest
* Adrenal insufficiency
= Most common chronic causes:
* Age-related changes in blood pressure regulation
* Drugs
* Autonomic dysfunction
= Symptoms are related to diminished blood flow to central nervous system, especially the brain and include:
* Faintness
* Lightheadedness
* Confusion
* Blurred vision
* Syncope, falls or even seizures may be seen in severe cases
Too Long, Read Page 6/7
Conservative Management
should always be considered as the first-line management. These measures include increased sodium and water intake in the absence of heart failure or hypertension. This may expand intravascular volume and decreases the severity of symptoms. This approach carries the risk of heart failure, particularly in the elderly and patients with impaired myocardial function.
NOTE - development of dependent edema without heart failure is not a reason to stop the treatment.
Other conservative measures include:
* Patients requiring prolonged bed rest should be advised to sit up first on waking and exercise in bed when possible.
* Elderly patients should avoid prolonged standing. Sleeping with the head of the bed raised may relieve symptoms by promoting Na retention and reducing nocturnal diuresis.
* Patients should rise slowly from a recumbent or sitting position, consume adequate fluids, limit or avoid alcohol, and exercise regularly when possible, because modest-intensity exercise promotes overall vascular tone and reduces venous pooling.
* If the case is postprandial hypotension, it should be recommended that the size and carbohydrate content of meals be reduced. The patient must minimize alcohol intake and avoid sudden standing after meals.
* Waist-high fitted elastic hose may increase venous return, cardiac output, and BP after standing.
Medical Management
If conservative measures fails:
**Fludrocortisone **- being a potent mineralocorticoid, fludrocortisone exerts it effects through sodium retention, which results in volume expansion and relieving or decreasing the symptoms. It is only effective if sodium intake is adequate.
This drug may also improve the peripheral vasoconstrictor response to sympathetic stimulation. Supine hypertension, heart failure, and hypokalemia may occur; K supplements may be required.
Other drugs used include midodrine, NSAIDs, L-Dihydroxyphenylserine (a norepinephrine precursor), and propranolol or other beta blockers.
For this patient with no heart fialure, increased water and sodium intake will be the next best step in management.
John, 35 years old, presents to the emergency department with pain and swelling of his left thigh since this morning. Investigations establish the diagnosis of deep venous thrombosis for which he is started on heparin in hospital. He has diabetes and hypertension and his wife mentions that is very busy and distracted and always forgets to take the drugs he is prescribed for treatment of his hypertension and diabetes. Which one of the following options would be the most appropriate management for him after the course of heparin is completed?
A. No more treatment is needed.
B. Warfarin for 6 months.
C. Aspirin for 6 months.
D. Surgical intervention.
E. Caval filter.
DVT noncompliance
E. Caval Filter (Inferior Vena Cava (IVC) Filter)
As this patient is known be noncompliance with his medications he should have a inferior vena cava filter for prevention of PE.
Treatment of DVT starts with either unfractionated or low molecular weight heparin. Warfarin could be started at the same day (or within 48 hours). Heparin therapy should be continued for 5 days and stopped once INR is above 2 in two consecutive days.
NOTE - Since anticoagulation is contraindicated in the presence of a bleeding diathesis, the following tests should be performed prior to heparinization:
* APTT
* INR
* Platelet count
* Thrombophilia screen including: activated protein C resistance, fasting plasma homocysteine, prothrombin G20210A, antithrombin III, protein C, protein S, lupus anticoagulant, anticardiolipin antibody and lupus anticoagulant
Warfarin should be continued for at least 3 months or more depending on the patient’s risk of recurrent VTE.
The objectives of anticoagulation therapy are treating the current DVT and prevention of pulmonary embolism. Studies have shown that as many as 33% of patients may develop PE while receiving adequate anticoagulation therapy.
Cava filters are an alternative to systemic anticoagulation with warfarin (or heparin) in the following situation: DVT or PE in patients with contraindications to anticoagulation therapy; these patients include those with:
* Hemorrhagic stroke
* Recent neurosurgical procedure or other major surgery
* Major or multiple trauma
* Active internal bleeding (e.g. upper or lower gastrointestinal bleeding, hematuria, hemobilia)
* Intracranial neoplasm (either primary or metastatic)
* Bleeding diathesis (e.g. secondary thrombocytopenia, idiopathic thrombocytopenic purpura, hemophilia) Pregnancy
* Unsteady gate or tendency to fall (as seen in patients with previous stroke, Parkinson disease)
* Poor patient compliance with medications
…. long list not important.
Inferior Vena Cava (IVC) Filter
Due to the patient’s noncompliance with medication, an IVC filter should be used to prevent pulmonary embolism (PE).
DVT Treatment:
- Start with unfractionated or low molecular weight heparin.
- Begin warfarin on the same day or within 48 hours.
- Continue heparin for 5 days, stopping once INR is above 2 for two consecutive days.
Important Tests Before Starting Heparin (if anticoagulation is contraindicated):
- APTT
- INR
- Platelet count
- Thrombophilia screen (activated protein C resistance, fasting plasma homocysteine, prothrombin G20210A, antithrombin III, protein C, protein S, lupus anticoagulant, anticardiolipin antibody)
Warfarin Therapy:
- Continue for at least 3 months or longer, depending on the risk of recurrent VTE.
Goals of Anticoagulation Therapy:
- Treat current DVT
- Prevent PE (though 33% of patients may develop PE despite adequate therapy)
IVC Filters:
- An alternative to systemic anticoagulation in patients who cannot take anticoagulants.
- Use in patients with:
- Hemorrhagic stroke
- Recent neurosurgery or major surgery
- Major trauma
- Active internal bleeding (GI bleeding, hematuria, hemobilia)
- Intracranial tumors
- Bleeding disorders (thrombocytopenia, ITP, hemophilia)
- Pregnancy
- Unsteady gait or risk of falls (e.g., stroke, Parkinson’s disease)
This simplified approach ensures understanding of when to use IVC filters and the steps for DVT and PE prevention.
Which one of the following is not indicated in management of pulmonary edema?
A. Continuous positive airway pressure (CPAP).
B. Bilevel positive airway pressure (BiPAP).
C. Glyceryl trinitrate.
D. Oral forusemide.
E. Morphine.
D. ORAL Forusemide
Management of acute pulmonary oedema:
1. Oxygen 10-15 L/min by Hudson mask and reservoir bag.
2. Once the patient is stable continue oxygen 2-6 L/min by nasal cannula.
3. INTRAVENOUS forusemide - it is one of the most essential steps in treatment of pulmonary oedema by decreasing the volume overload. If taken orally, forusemide takes time to work and is not effective in treatment.
4. GTN – it reduces the preload; it is essential to titrate the dose to maintain systolic blood pressure above 100mmHg.
5. Morphine – by decreasing the sympathetic tone, it results in vasodilation and reduction of preload
6. CPAP and BiPAP – these non-invasive methods of ventilation are used to reduce alveolar and pulmonary edema by reducing the venous return and preload.
O2, reduce water, reduce preload/pain
A 76-year-old man comes to your clinic for a routine health check-up. He has blood pressure of 110/90 mmHg and a pulse rate of 92 bpm. He is on no medications except daily multivitamins. As a part of evaluation, an ECG is obtained which is shown in the following photograph. Which one the following is the next best step in management?
(ECG on page 12)
A. Aspirin.
B. Warfarin.
C. Reassurance.
D. Metoprolol.
E. Atropine.
C. Reassurance.
The ECG shows a sinus rhythm with increased PR interval characteristic of first-degree atrioventricular block. The condition can be caused by:
- Age-related fibrosis and degeneration of AV node – the most common cause
- Drugs: digoxin, beta blockers, calcium channel blockers
- Increased vagal tone.
First-degree heart block is characterized by PR interval > 200 ms (0.2 s) on ECG, normal QRS complexes in terms of duration and spacing, and the presence of a P wave before each QRS.
This is quite common among the elderly due to age-related fibrotic changes of the cardiac conductive system.
Asymptomatic patients do not need treatment and must be reassured.
With symptoms (e.g., dizziness, shortness of breath, chest pain, etc.) atropine or pacemaker (if unresponsive to atropine) is considered.
A 79-year-old man collapses on the floor while waiting in the Emergency Department and becomes unresponsive. He has a blood pressure of 84/47 mmHg and rapid and barely perceptible pulse. Cardiopulmonary resuscitation is started immediately. The rhythm, obtained by defibrillator is shown in the accompanying photograph. Which one of the following is the next best step in management?
(ECG on page 13)
A. Continue CPR until the patient regains consciousness.
B. Cardioversion.
C. Amiodarone infusion.
D. Intravenous adrenaline.
E. Defibrillation.
B. Cardioversion.
The first step in management of a collapsed patient is management is calling for help (if possible) and starting CPR with chest compression and ventilation. Once the defibrillator is available obtain the cardiac rhythm with the pedals. The rhythm of this patient is characteristic of ventricular tachycardia (VT). In patients with unstable hemodynamic status, the next best step in management is synchronized cardioversion if the patient has a pulse, or defibrillation if no pulse is detected.
Hemodynamic instability is manifested as:
* Chest pain
* Dyspnea
* Hypotension
* Perfusion-related confusion
* Collapse and/or unresponsiveness
Option A: Continuing the CPR without defibrillation is unlikely to help in this condition.
Option C: Amiodarone and other anti-arrhythmic drugs used for VT are indicated if the patient is hemodynamically stable.
Option D: IV adrenaline is the first step in management, in conjunction with chest compression and ventilation, in patients with asystole, or ventricular fibrillation after two attempts of DC shock fail to convert the rhythm.
Option E: Defibrillation is the option when there is ventricular fibrillation or if the patient has pulseless VT.
Which one of the following is NOT a contraindication to thrombolytics use in a patient with ST elevation myocardial infarction?
A. Ischemic stroke in the past 3 months.
B. Hemorrhagic stroke in the past 10 years.
C. Heavy menstrual bleeding.
D. Coagulation disorders.
E. Gastrointestinal bleeding within the past 4 weeks.
C. Heavy menstrual bleeding.
Absolute contraindications for fibrinolytic use in STEMI include the following:
* Prior intracranial hemorrhage (ICH)
* Known structural cerebral vascular lesion
* Known malignant intracranial neoplasm
* Ischemic stroke within 3 months
* Suspected aortic dissection
* Active bleeding or bleeding diathesis (excluding menses)
* Significant closed head trauma or facial trauma within 3 months Intracranial or intraspinal surgery within 2 months
* Severe uncontrolled hypertension (unresponsive to emergency therapy)
* For streptokinase, prior treatment within the previous 6 months
Relative contraindications for fibrinolytic use in STEMI include the following:
* History of chronic, severe, poorly controlled hypertension
* Significant hypertension on presentation (systolic blood pressure >180 mm Hg or diastolic blood pressure >110 mm Hg
* Traumatic or prolonged (>10 minutes) cardiopulmonary resuscitation (CPR) or major surgery less than 3 weeks previously
* History of prior ischemic stroke not within the last 3 months
* Dementia
* Recent (within 2-4 weeks) internal bleeding
* Noncompressible vascular punctures
* Pregnancy
* Active peptic ulcer
* Current use of an anticoagulant (e.g., warfarin) that has produced an elevated INR higher than 1.7 or a PT longer than 15 seconds
Of the given options, only heavy menstrul bleeding is not an absolute contraindication to thrombolytic therapy.
A 67-year-old man presents for assessment after he experienced an episode of vision loss of his right eye lasting 30 minutes 24 hours ago. The condition is resolved now. On examination, the visual acuity of the left and right eyes are 6/60 and 6/36, respectively. A systolic murmur is noted over the sternum. No carotid bruit is heard. Which one of the following is most likely to establish the cause of his condition?
A. CT scan of the brain.
B. Electroencephalography (EEG).
C. MRI of the brain.
D. Doppler ultrasound of carotid arteries.
E. Echocardiography.
D. Doppler ultrasound of carotid arteries
In adults, transient visual loss is a frequently encountered complaint that in most cases has an identifiable cause. The loss of vision may be monocular or bilateral and may last from seconds to hours. Episodes are usually ischemic in origin.
Ischemic causes of transient visual loss include:
-Giant cell arteritis
-Cerebrovascular ischemia
-Retinal arteriolar emboli
-Amaurosis fugax syndrome
Transient visual loss can be a symptom of a serious vision-threatening or even life-threatening condition, requiring urgent investigation and treatment, or it may have a more benign origin (e.g., migraine). Transient visual loss in children is less common than in adults and is more likely to have a benign origin. Causes of transient visual loss in children include migraine and epileptic seizure.
Embolic occlusions of the arteries supplying the eye are a common cause of transient visual loss in adults. Emboli causing circulatory compromise may originate from the heart or the carotid arteries. Embolic events are usually isolated; therefore, frequent episodes of visual loss are less likely to be caused by emboli.
In contrast to transient ischemic attacks (TIAs) involving the cerebral hemispheres, retinal ischemia is more commonly associated with emboli originating from carotid stenosis rather than the heart.
Diagnostic evaluation of transient visual loss (TVL):
The overlap in clinical presentations and grave prognosis of some potential diagnoses necessitates that some diagnostic testing is performed in most patients:
Ophthalmologic evaluation - A detailed fundoscopic evaluation is an important part of the evaluation of patients with transient visual loss. Ophthalmology referral is required for all patients with suspected giant cell arteritis, retinal vein disease, and ocular causes of visual loss.
Erythrocyte sedimentation rate (ESR) and C-reactive protein - All older patients (>50 years) with transient monocular or binocular vision loss should have an ESR and C-reactive protein to exclude giant cell arteritis (GCA). If these are elevated, or if the history is very suggestive, patients should proceed to a confirmatory temporal artery biopsy. Treatment with predniso(lo)ne should be started empirically.
Carotid imaging - Carotid Duplex Doppler ultrasound, magnetic resonance angiography (MRA), or computed tomographic angiography (CTA) should be ordered in all older patients (>50 years) and in younger patients with vascular risk factors (diabetes, hypertension, hyperlipidemia), who have experienced transient mono-ocular visual loss (TMVL).
Duplex ultrasound is the preferred initial modality because it is noninvasive, inexpensive and readily available with acceptable sensitivity and specificity.
Cardiac evaluation - Once GCA and carotid disease have been excluded, an evaluation to see if a cardiogenic source of embolism exists should follow in all older patients (and younger patients with risk factors), who have had TMVL. This is also indicated in patients with transient binocular visual loss (TBVL) due to posterior circulation ischemia. Testing may include Holter monitoring and echocardiography. A baseline electrocardiogram (ECG) should also be included in the evaluation of these patients because cardiac morbidity and mortality in patients with TMVL and central retinal artery occlusion is significant.
Brain MRI - Older patients with binocular visual symptoms (TBVL) with accompanying symptoms suggestive of vertebrobasilar ischemia should have a brain MRI.
Electroencephalography (EEG) - EEG is not a routine test for TVL, but should be performed in a patient with TBVL whose symptoms suggest possible seizure. EEG monitoring may increase the diagnostic yield, especially in patients with frequently recurring symptoms.
Hypercoagulable testing - When brain or ocular ischemia is the suspected cause of TVL, hypercoagulable testing should be performed in individuals who have suggestive histories (prior thrombosis, miscarriage, or family history), as well as in individuals with probable ischemia and otherwise negative workup. A full blood exam should also be obtained to screen for conditions such as polycythemia vera and essential thrombocythemia.
Of the options, the most important initial test to consider is Duplex Doppler ultrasonography of carotid arteries since most visual losses are due to carotid artery stenoses. Absence of carotid bruit does not exclude the possibility of carotid stenosis as the most likely cause of retinal ischemia in this patient.
A 70-year-old man presents to the Emergency Department with complaint of chest pain starting 15 minutes ago, central in location, and dull and aching in nature. He is given aspirin, sublingual glyceryl trinitrate, and oral antacid, and is put on supplemental oxygen by nasal cannula. These measures ameliorate the pain to a significant extent.
On examination, his blood pressure is 140/90mmHg, pulse 110 bpm, and respiratory rate 20 breaths per minute. A 12-lead ECG strip reveals no abnormality. He mentions that he has had these pains every time he exceeded a certain amount of physical activity, and that each time the pain subsides with rest or sublingual glyceryl trinitrate. He rates this current episode no more than the previous ones. Which one of the following is the most appropriate next step in management?
A. Reassure and discharge him home.
B. Book for an outpatient echocardiography.
C. Admit him to coronary care unit (CCU), measure cardiac enzymes and repeat the ECG.
D. Refer him for a stress ECG and echocardiography.
E. Refer him to a gastroenterologist.
D. Refer him for a stress ECG and echocardiography.
Central chest pain described as heaviness, dull and aching that may or may not radiate to the jaw, left arm, or epigastrium is more likely to be ischemic in nature. The duration of pain (< 20 minutes), being brought on by a predictable amount of exertion and relieved by rest or nitrates is characteristic of stable angina, a condition in which an increased oxygen demand of the heart, induced by activity, leads to ischemia because the stenotic coronary arteries cannot keep up with increased need for oxygen. On the other hand, unstable angina is defined as any new ischemic chest pain, or one with deviation from the typical pattern of previous pains, in terms of either duration, intensity, frequency, or decreased amount of exertion required for its reproduction.
The characteristics of the pain (duration, reversibility, and response to rest and nitrates), in addition to a normal ECG establishes the diagnosis of stable angina in this patient. In approaching to such patients, the next best step in management is urgently performing a stress test (either conventional treadmill, chemical, or nucleic) to establish the coronary artery stenosis if the ECG or diagnosis is equivocal (as is in this patient). A positive stress test (reproduction of the chest pain, ST segment depression>2mm or a drop in blood pressure>10mmHg) is then followed by angiography for further evaluation and treatment with either ballooning with or without stent placing or coronary artery bypass grafting surgery.
Option A: Reassuring and discharging the patient is not an appropriate action before the patient has been fully assessed.
Option B: Echocardiography may be a part of plan now or later on in outpatient setting, but is not the most appropriate management now.
Option C: Admission to CCU, cardiac enzymes and follow-up ECGs were indicated if the patient had any changes in the intensity of the pain or its duration, unresponsiveness to rest and nitrates, or aggravating or relieving factors.
Option E: Referring the patient to gastroenterologist is not correct because the pain is typical for cardiac ischemia.
A 50-year-old man presents to the Emergency Department with chest pain felt behind the sternum radiating to his jaw. A 12-lead ECG strip is obtained and is as the following photograph. You give him aspirin and sublingual nitroglycerine and start him on supplemental oxygen by nasal cannula. A troponin level is ordered which comes back negative. Which one of the following is the next best step in management of this patient?
(ECG on Page 16)
A. Repeat troponin in 8 hours.
B. Immediate reperfusion therapy.
C. Repeat the ECG in 6 hours.
D. Start him on beta blockers.
E. Serial ECGs.
B. Immediate reperfusion therapy.
With ST elevation in leads II, III, and aVF on the given ECG, this patient has sustained an inferior ST-elevation myocardial infarction (STEMI) for which the next best step in management is either immediate percutaneous coronary intervention (PCI) as the preferred option, or thrombolytic therapy if not contraindicated.
Option A: Even with negative troponin, ST elevation of more than 1mm in two or more contiguous leads and chest pain makes the diagnosis certain. In fact with chest pain and ECG changes, no troponin level was required to guide the management, and reperfusion therapy should have been performed even without waiting for the results.
Option C: This patient has acute inferior MI and should be treated immediately. Waiting for 6 hours to obtain an ECG is definitely an incorrect answer.
Option D and E: Serial ECGs are indicated as well to further assess the possible evolution of the myocardial infarction. Beta blockers are effective in reducing the mortality, but neither ECG, nor beta blockers takes precedence over PCI.
A 60-year-old man presents with complaints of increasing tiredness and abdominal distention for the past four months. His past medical history is remarkable for smoking 20 cigarettes a day for the past 20 years. On examination, there is bilateral ankle edema and ascites. The liver is palpated 3cm below the costal margin. His jugular pulse is noted to drop on expiration and rise on inspiration. Which one of the following is the most likely diagnosis?
A. Cardiac tamponade.
B. Budd- Chiari syndrome.
C. Superior vena cava obstruction.
D. Constrictive pericarditis due to TB in the past.
E. Hepatic cirrhosis.
What is the special sign seen here? Typically seen in what conditions?
D. Constrictive pericarditis due to TB in the past.
Drop of jugular pulse on inspiration and its rising during expiration is a normal physiologic response. Dropped jugular venous pressure (JVP) during expiration and its rise on inspiration is a pathological sign called Kussmal sign. Kussmal sign is seen in restrictive cardiomyopathy, constrictive pericarditis, and cardiac tamponade. Of the options, only constrictive pericarditis due to TB infection can present with Kussmal sign.
Option C: Superior vena cava (SVC) obstruction leads to edema of the face not ankle edema. On the other hand, although the JVP is raised in SVC obstruction, there is no pulsation of the jugular vein.
Option B: Budd-Chiari syndrome is associated with thrombus formation in the hepatic vein, leading to portal hypertension. It may present with fatigue, right upper quadrant pain, mild jaundice, and hepatosplenomegaly; however, JVP remains normal, without pulsation.
Option E: In hepatic cirrhosis , the liver is usually shrinked and not enlarged. Although fatigue, edema and ascites are commn findign, the Kussmal sign is not a feature.
Cardiac Tamponade p/w Beck’s Triad (hypotension, JV distension, muffled)
A 30-year-old man presents to the emergency department with chest pain that has started this morning and worsened over time. He mentions that deep breathing increases the pain intensity. On examination, pleuretic chest pain and a temperature of 38°C is noted. The BP is 140/85mmHg and the pulse 100bpm. He takes shallow breaths in a rate of 20/min. The rest of physical examination is inconclusive. A 12- lead ECG is obtained and is shown. Which one of the following is the most likely diagnosis?
(ECG on Page 18)
A. Myocardial ischemia.
B. Pulmonary embolism.
C. Infectious endocarditis.
D. Acute myocardial infarction.
E. Pericarditis.
E. Pericarditis.
The clinical picture of pleuretic chest pain (chest pain worsened with breathing), mildly elevated respiratory rate and a borderline pulse rate can be either to pericarditis or pulmonary embolism, but diffuse ST elevation in pericordial and limb leads favors pericarditis as the most likely diagnosis.
Option A: Although myocardial ischemia causes chest pain, the nature of the pain and the pattern of ST segment elevation makes this diagnosis less likely.
Option B: Pulmonary embolism can present similarly; however, the ECG changes are not consistent with this diagnosis.
Option C: Infectious endocarditis presents with a murmur and fever. The ST changes in the ECG are characterisitc for pericarditis. Infectious endocarditis does not cause such an ECG abnormality.
Option D: Acute myocardial infarction (MI) causes ST elevation in specific lead groups, depending on the coronary artery involved and its territory. The pleuretic nature of the chest pain, on the other hand, is against MI as a likely diagnosis.
A 70-year-old man in brought to the Emergency Department because of light-headedness for the past 4 hours. On examination, he is found to have bradycardia with an irregular pulse of 45 bpm and a blood pressure of 85/60 mmHg. Atropine is used as the treatment of symptomatic bradycardia but the pulse rate remains the same and the lightheadedness persists. An ECG strip is obtained which is shown in the following photograph. Which one of the following is the next best step in management?
A. Metoprolol.
B. Dopamine.
C. Intravenous pacemaker.
D. Permanent pacemaker.
E. Adrenaline.
C. Intravenous pacemaker.
The rather constant PR intervals, and ‘p’ waves that are not followed by a QRS complex seen on ECG is characteristic of Mobitz II AV block.
Symptomatic AV block should be initially be treated with temporary pacing. Percutaneous or intravenous pacemakers are often available in the emergency department and can be applied. If not, atropine is used instead.
In the following situations temporary pacemakers are the most appropriate option for the initial management:
* History of asystole
* Mobitz II AV block
* Complete heart block
* Ventricular standstill>3 seconds
Option A: Metoprolol is definitely the wrong option because using it in this situation can dramatically worsen the condition.
Option B: Dopamine is a drug used for increasing cardiac contractility and vascular tone and is not used in treatment of symptomatic bradycardias.
Option D: Permanent pacemakers are definitive treatment of such blocks and are considered after initial temporary pacing.
Option E: Adrenaline infusion is sometimes indicated to maintain an adequate heart rate after atropine, while waiting for pacemaker insertion.
See Page 19 for topic review on Second Degree (Mobitz) Heart Block.
Mobitz II AV Block: P and QRS doing its own thing
A 47-year-old man has developed central chest pain one hour ago. On examination in the Emergency Department he is sweating profusely, has a BP of 90/60 mmHg and a pulse rate of 50bpm. An ECG shows 2-mm ST elevation in leads II, III, and aVF. Which one of the following is the most common cause of death in pre-hospital setting in this condition?
A. Ventricular tachycardia.
B. Ventricular fibrillation.
C. Bradycardia.
D. Asystole.
E. Hypotension.
B. Ventricular fibrillation.
The clinical and ECG findings are characteristic of inferior ST-elevation myocardial infarction (STEMI).
Of all patients experiencing acute myocardial infarction (MI), usually in the form of ST-elevation MI, 25–35% will die of sudden cardiac death (SCD) before receiving medical attention, most often from ventricular fibrillation; however, ventricular tachycardia is the most common arrhythmia early in the course of MI.
Patients suspected of having STEMI should be connected to defibrillator on the way to the hospital. Most ventricular fibrillations occur in the first 24 hour post-MI, with a half occurring within the first hour.
A 59-year-old man in brought to the emergency department of a tertiary hospital with compressing chest pain that has started 30 minutes ago.The pain is central in location and radiates to his jaw and left arm. A 12-lead ECG is obtained and is as follows. Which one of the following is the most appropriate management of this patient?
(ECG on Page 22)
A. Fibrinolytic therapy.
B. Morphine.
C. Aspirin.
D. Cardiac catheterization.
E. Rescue angioplasty.
D. Cardiac catheterization.
The history is highly suggestive of angina pectoris. On ECG, there is ST elevation in leads I, aVl, V5 and V6 (lateral aspect of the heart) and ST elevation in V3 and V4 indicative of involvement of the anterior wall. The ECG is characteristic of an anterolateral ST-elevation myocardial infarction (STEMI).
The most appropriate management of patients with STEMI is emergency reperfusion therapy either by fibrinolytics or percutaneous coronary intervention (PCI) if the presentation is within 12 hours after the onset of chest pain. Since the patient is in a tertiary hospital, PCI is the preferred method of reperfusion therapy.
Provided that proper facilities and an experienced cardiac interventionist is available a PCI could be performed with 90 minutes after presentation. Cardiac catheterization is a general term that includes angioplasty, PCI, and balloon angioplasty.
Option A: Fibrinolytics are the preferred method if PCI cannot be performed and the patient has no major risk of bleeding.
Option B and C: Aspirin and morphine have to be administered for every patient with acute coronary syndrome as important steps but they are the primary steps and can be given while the patient is arranged to be transferred to catheterization laboratory. Aspirin could be the correct answer if the question asked about the next step.
Option E: Rescue angioplasty is a term used to describe emergency angiographic coronary intervention after fibrinolytics fail to control the ischemia.
Steven is a 65-year-old man, who is a known case of congestive heart failure. He had been stable on enalapril, metoprolol and digoxin until three weeks ago when his wife passed away from breast cancer. Since then, he stopped taking his medication. Today, he is brought to the emergency department by his son, with complaints of shortness of breath, night coughs and ankle edema. On examination, he has a blood pressure of 90/75mmHg, heart rate of 68 bpm, and respiratory rate of 26 breaths per minute. On auscultation, an S3 gallop is noted, but there is no crackle. You decide to start him on medication again. Which one of the following would be the best option to start with?
A. Start him on enalapril.
B. Start him on metoprolol.
C. Start him on digoxin.
D. Start him on enalapril, digoxin and metoprolol at the same time.
E. Start him on enalapril and metoprolol.
A. Start him on enalapril.
The case describes a patient, with congestive cardiac failure, who has been under control with three medications, but his heart condition has been decompensated due to drug withdrawal.
At this moment, and based on physical findings, the patient has not pulmonary edema (no comments on basal crackles).
Angiotensin converting enzyme (ACE) inhibitors (e.g. enalapril) improve prognosis in all patients in all grades of heart failure and should be used as initial therapy in all patients. Angiotensin II receptor blockers (ARBs) such as losartan are used when ACE inhibitors cannot be tolerated .
Diuretics are added to ACE inhibitors to help control congestive symptoms and signs.
Beta blockers should only be started when the patient is stable and euvolemic. As this patient has S3 gallop and ankle edema (signs of hypervolemia), any options suggesting beta blockers (e.g. metoprolol) as initial treatment would be incorrect.
Digoxin is used in patients with heart failure if:
* Heart failure is caused by atrial fibrillation (often in conjuction with beta blockers if the patient is euvolemic)
* In patients with heart failure, who have sinus rhythm, but medications such as ACE inhibitors, diuretics have not adequately controlled their symptoms
* In patients with significantly decreased ejection fraction (EF) (<35%)
Which one of the following drug groups is the mainstay of therapy in diastolic heart failure?
A. ACE inhibitors and beta blockers.
B. Beta blockers and calcium channel blockers.
C. Calcium channel blockers and diuretics.
D. Angiotensin receptor blockers and beta blockers.
E. Beta blockers and diuretics.
B. Beta blockers and calcium channel blockers.
Diastolic dysfunction is defined as decreased compliance of the left ventricle during the diastole, resulting in decreased cardiac output. A hypertrophied left ventricle due to chronic hypertension remains the leading cause of diastolic dysfunction. The disease is most common among the elderly women. Other causes of diastolic dysfunction include restrictive cardiomyopathy and constrictive pericarditis. Pericardial tamponade causes acute diastolic dysfunction. Ejection fraction essentially remains unaffected or even increases.
Mainstay of therapy in the diastolic dysfunction, also termed as ‘heart failure with preserved systolic function (HFPSF)’ largely depends on the underlying cause. Mainstay of pharmacotherapy is with cardiac selective beta blockers (e.g. atenolol, carvedilol, metoprolol) and/or calcium channel blockers. Beta blockers, by slowing the heart rate, give ventricles more time to fill and enhance cardiac output. Calcium channel blockers serve the same purpose and can be used as second-line treatment or added to beta blockers later in the course of treatment.
The following drugs should not be used in treatment of diastolic dysfunction:
* Diuretics – they may decrease the already prone-to-decrease cardiac output. They are indicated if there is pulmonary congestion and edema.
* Vasodilators (e.g. nitrates) – they decrease the venous return and decrease cardiac output.
* Arterial vasodilators (hydralazine) – they may cause dynamic obstruction against the left ventricle outflow.
* Digoxin and other inotropic drugs – there is no role for these drugs as the ejection fraction is normal or even elevated. Digoxin may be considered for co-existing atrial fibrillation (but not as the first-line therapy).
Option A: No clear evidence exists to support ACE inhibitor therapy for diastolic heart failure. There has been no direct improvement in overall morbidity and mortality in patients with diastolic heart failure associated with ACE inhibitors; however, ACE inhibitors may have an important role in the treatment of the diseases underlying diastolic heart failure. Moreover, patients with diastolic heart failure frequently have comorbidities such as renal insufficiency and care should be taken when using ACE inhibitors, as there is the risk of renal function deterioration.
Option C: Calcium channel blockers are useful for treatment of diastolic heart failure, but diuretics decrease the cadiac output and should be avoided, unless there is volume overload.
Option D: Beta blokcers are mainstay of therapy in patients with diastolic heart failure, but there is no clear evidence from randomized clinical trials that treatment with angiotensin receptor blockers directly improves overall morbidity or mortality, or diastolic function in patients with diastolic heart failure.
Option E: Diuretics should not be used in patients with diastolic dysfunction, unless in the presence of volume overload and congestion.
An 17-year-old girl sustained sudden loss of consciousness and collapsed while playing basketball at school. She is now in the emergency department. She mentions that her father died suddenly at the age of 37 years. Which one of the following investigations is most likely to establish the diagnosis of the underlying cause of her collapse?
A. ECG.
B. Cardiac biomarkers.
C. Angiography.
D. Chest X-ray.
E. Echocardiography.
E. Echocardiography.
Sudden loss of consciousness in a young person while on exertion is most likely due to either an arrhythmia or hypertrophic obstructive cardiomyopathy (HOCM). With a positive family history for sudden death at young age, HOCM would be considered as the most likely diagnosis.
CXR, ECG and electrocardiography are all part of the work-up for this patient, but among them, echocardiography is more likely to establish the diagnosis of HOCM. Echocardiography is the best tool for detecting structural cardiac abnormalities (e.g. valvular lesion, cardiomyopathies).
Patients with a variety of cardiac conditions may require special care in pregnancy. Which one of the following cardiac lesions is mots likely to cause problems during pregnancy?
A. Mitral stenosis.
B. Tricuspid regurgitation.
C. Mitral regurgitation.
D. Aortic regurgitation.
E. Ventricular septal defect.
A. Mitral stenosis.
Among given options, mitral stenosis (MS) is more likely to complicate a pregnancy. Plasma volume is increased by 50% during pregnancy leading to more pronounced left atrial congestion and backflow of blood to the lungs resulting in pulmonary congestion and its typical presentation (fatigue, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, pulmonary oedema, etc).
Other mentioned lesions are well tolerated during pregnancy owing to the fact that decreased peripheral vascular resistance causes accumulation of blood in the periphery. This eliminates a part of the work load the heart should have undergone if all that blood returned to the heart for recirculation.
A 70-year-old man, farmer by profession, presents to the Emergency Department after he experienced chest pain of 20 minutes duration following physical activity. When the pain started, he took 3 puffs of glyceryl trinitrate but there was no relief. In the Emergency Department though, the pain alleviated with oxygen. On further questioning, you realize that he is on aspirin, metoprolol and sublingual glyceryl trinitrate spray on an ‘as needed’ basis. During the past 6 months, he has had only 3 episodes of chest pain subsided just by rest. He saw his GP 6 months ago when he received his last prescription. Which one of the following is the most likely explanation of failure of glyceryl trinitrate to relieve his symptoms?
A. Onset of unstable angina.
B. Nitrate tolerance.
C. Reduced drug potency.
D. Poor absorption through the mouth.
E. Onset of myocardial infarction.
C. Reduced drug potency.
The given scenario is more likely due to expiration of the glyceryl trinitrate. It is important to remember to remind the patients to update their GTN sprays or pearls. Expired GTN has reduced potency and effect on relieving the ischemic pain. Since this patient has refilled his prescription 6 months ago, it is likely that the drug is past its expiry date and lost the desired potency.
Option B: Nitrate tolerance is a possibility and concern in patients who take GTN or other nitrates on a regular basis. After some time, resistance to nitrates develops and the ability of pain control diminishes. In this patient, however, tolerance is very unlikely, as he is not been a regular user of nitrates and has used them occasionally on an ‘as-needed’ basis.
Option A and E: In patients with unstable angina or myocardial infarction, the pain may not respond to nitrates. However, this patient is not likely to have these because it is unlikely for unstable angina or myocardial infarction to respond to oxygen but not to nitrates.
Option D: GTN adequately and effectively absorbs through the mouth.
A 25-year-old woman comes to your practice with complaints of ‘skipped heart beats’. On examination, she has a blood pressure of 110/85 mmHg and pulse of 88 bpm. Heart auscultation is remarkable for a mid-systolic click followed by a late systolic murmur. Echocardiography shows mitral valve prolapse (MVP). Which one of the following is correct about her condition?
A. MVP is more common in men.
B. Prophylaxis against infectious endocarditis is recommended.
C. MVP is present in up to 10% of population.
D. Risk of pulmonary embolism is high.
E. Ventricular arrhythmias do not occur.
C. MVP is present in up to 10% of population.
Mitral valve prolapse is seen in up to 10% of population and is more common in women. Although it is asymptomatic most of the time, it can present with palpitation and shortness of breath, or rarely even chest pain or more severe complications.
Option A: MVP is more common in women than men.
Option B: Antibiotic prophylaxis against endocarditis is no longer recommended for valvular lesions in the 2007 AHA guideline. Indications for prophylaxis antibiotic therapy include bicuspid aortic valve, acquired aortic or mitral valve disease (including mitral valve prolapse with regurgitation), and hypertrophic cardiomyopathy with latent or resting obstruction.
Option D: If MVP leads to atrial enlargement and blood stagnation, there is an increased risk of systemic thromboembolism; however, risk of pulmonary embolism is extremely low.
Option E: Although very rarely, supraventricular and ventricular tachyarrhythmias are found in patients with MVP.
A patient with aortic stenosis has undergone cardiac catheterization. You are told that the aortic systolic gradient is 55 mmHg. Which one of the following additional piece of information is necessary to determine the significance of the gradient?
A. Presence of coronary artery disease.
B. Left ventricular ejection fraction.
C. Left ventricular end-diastolic pressure.
D. Cardiac output.
E. Left atrial pressure.
D. Cardiac output.
An aortic systolic gradient of 55 mmHg means that during systole, the pressure in the aorta is 55 mmHg lower than the pressure in the left ventricle. A normal gradient is less than 10 mmHg.
With aortic stenosis, the cardiac output is diminished because the stenotic valve impedes blood outflow from the left ventricle. Therefore, cardiac output would be determinant as to whether immediate surgical valve replacement should be considered.
It should be born in mind that even in the presence of a normal cardiac output, a gradient more than 50 mmHg needs surgical replacement of the aortic valve.
AMC Handbok - Page 435
A 39-year-old woman presents with dizziness after she left the gym. An ECG is obtained and is as the accompanying photograph. Which one of the following is the next best step in management?
A. Reassurance.
B. Intravenous atropine.
C. Transcutaneous pacemaker.
D. Intravenous pacemaker.
E. Adrenaline.
B. Intravenous atropine.
The rhythm strip shows sinus bradycardia with a rate of 50 bpm. Asymptomatic bradycardias are usually left alone. If symptomatic, symptoms can include:
* Pre-syncope or syncope (faint)
* Shortness of breath
* Lightheadedness (dizziness)
* Chest pain
Every patient with symptomatic bradycardias should be managed as follows:
Medical management:
* Atropine (IV 500-600mcg – repeat every 3-5 minutes up to 3mg) – the best initial management
* Adrenaline (IV infusion 2-10 mcg/min) to maintain satisfactory heart rate – the second-line medical management
Consider pacemaker insertion for the following patients:
Patients who do not respond adequately to medical therapy
Patients at risk of asystole:
* History of recent asystole Mobitz II AV block on ECG
* 3rd degree AV block on ECG Pulse < 40bpm
* Ventricular standstill > 3s
The initial pacing is with percutaneous pacing in the emergency department. Intravenous pacemaker insertion needs specialist referral. Permanent pacing is then followed electively if needed.
A 70-year-old man presents to the Emergency Department with chest discomfort, shortness of breath and pre-syncope. An ECG is obtained and is as follows. Which one of the following is the most appropriate immediate management of this patient?
A. Atropine.
B. Adrenaline.
C. Transcutaneous pacemaker.
D. Synchronized DC cardioversion.
E. Intravenous fluids.
C. Transcutaneous pacemaker.
The ECG is suggestive of third-degree (complete) heart block. Although atropine is used as first-line therapy for symptomatic bradycardias, in complete heart block emergency rescue transcutaneous pacemaker is the management of choice. Atropine should be given if emergency pacing cannot be done immediately.
ECG features:
* Severe bradycardia due to absence of AV conduction.
* The ECG demonstrates complete AV dissociation, with independent atrial and ventricular rates.
A 4-year-old boy is brought to the Emergency Department after he told her mother ‘my head is light and I feel like falling down’. On examination, his blood pressure is 80/50 mmHg and he has a regular pulse rate of 60 bpm. An ECG is obtained which is shown in the following photograph. Which one of the following is the next best step in management?
A. Give him adenosine.
B. Give him amiodarone.
C. Give him atropine.
D. Immerse his face in cold water and massage his carotid sinus.
E. Cardioversion with DC shock.
C. Give him atropine.
They ECG shows a sinus rhythm at rate of 60bpm, rather** wide QRS complexes** and the presence of typical ‘delta waves’ characteristic of a pre- exciting syndrome (e.g., Wolff-Parkinson-White). Although a heart rate of 60 bpm is considered normal in adults, it definitely signifies bradycardia in a 4-year-old child (normal 80-120bpm). Since this child has symptomatic bradycardia (light-headedness), he should be treated initially with atropine.
The normal range of heart rate for different age group is as follow:
< 1 y/o: 100-160BPM
1-2 y/o: 90-150BPM
2-5 y/o: 80-140BPM
6-12 y/o: 70-120BPM
>12 y/o: 60-100BPM
Option A and D: Adenosine or immersion of the face in cold water and carotid sinus massage are treatment options for supraventricular tachycardias, which is not the case here.
Option B: Amiodarone is used for ventricular tachyarrhythmias; this child does not have tachycardia.
Option E: Cardioversion is the treatment of choice for tachyarrhythmias that have resulted in hemodynamic instability, namely chest pain, shortness of breath, hypotension or hypoperfusion-related confusional state.
A 28-year-old man has had several episodes of palpitations associated with mild dizziness and sweating over the past year. These attacks occur usually after exercise and last between 10 and 20 minutes, and often stop after he immerse his face in cold water. He now presents with an attack that has been going on for 2 hours. His ECG is shown in the following picture. Which one of the following medications is most likely to be effective?
A. Digoxin.
B. Quinidine.
C. Flecainide.
D. Verapamil.
E. Propranolol.
D. Verapamil.
The rhythm strip shows paroxysmal supraventricular tachycardia (PSVT) at a rate of almost 180 bpm. The mechanism of PSVTs is either a re-entry circuit or automatous focus involving the atria. The best initial step in management of PSVTs is performing maneuvers that suppress conductivity in atrioventricular (AV) node such as Valsalva maneuvers, immersion of the face in cold water, etc. If non-medical measures fails, preferred medical management is with intravenous adenosine (preferred) or verapamil as the first-line medications.
Option A: Digoxin is no more recommended for management of PSVT.
Option B and C: Quinidine and flecainide are antiarrhythmic drugs, but not used for management of PSVT.
Option E: Beta blockers such as metoprolol, propranolol and atenolol are second-line drugs.
A 78-year-old man presents to your clinic with a 3-week history of palpitation. On examination, he has a blood pressure of 135/80 mmHg and heart rate of 115 bpm and irregular. ECG reveals atrial fibrillation (AF). An echocardiography is arranged that shows an ejection fraction (EF) of 38%. Which one of the following is the most appropriate treatment option for him?
A. Electrical cardioversion.
B. Metoprolol.
C. Digoxin.
D. Flecainide.
E. Verapamil.
B. Metoprolol.
The main goals of treatment of patients with AF + heart failure are control of symptoms and prevention of arterial thromboembolism. In patients with heart failure, hemodynamic consequences of AF results in decreased exercise capacity and the decompensation of heart failure.
Similar to the general population either rate control or rhythm control are mainstay of therapy. Previously, rhythm control was considered the superior method for treatment of AF in patients with heart failure; however, recent data has challenged this approach. Currently, rate control is the most appropriate initial management in patients with AF and symptoms related to rapid ventricular response. Rate control to prevent rapid AF often leads to an improvement in symptoms in patients with heart failure. Moreover, slowing of the ventricular rate often leads to a moderate or even marked improvement in left ventricular function. Based on current evidence, cardiac-selective beta blockers (metoprolol, atenolol, carvedilol, bisoprolol) are preferred options to use for rate control in patients with AF and heart failure because they are also recommended for treatment of heart failure itself. Digoxin can be used as adjunctive therapy if beta blockers fail to adequately control the rate.
If rate control cannot be achieved with beta blockers or combination of beta blockers and digoxin, amiodarone may be effective either alone or in combination with other rate-slowing medications.
NOTE - Initiation or increase of beta blocker is contraindicated in patients with decompensated heart failure. If such patients need rate, digoxin is the recommended agent; however, digoxin often fails to control the rate when used alone, especially in patients with elevated sympathetic tone (hypertension, tachycardia, etc.).
Beta blockers are contraindicated if any of the following is present:
* Heart rate < 60 bpm
* Symptomatic hypotension
* Greater than minimal evidence of fluid retention: increased jugular venous pressure, pulmonary crackles indicative of interstitial pulmonary edema, presence of S3, S4 or both, or a new or changed murmur
* Signs of peripheral hypoperfusion
* PR interval>0.24seconds
* Second- or third-degree AV block
* History of asthma or reactive airways
* Peripheral artery disease with resting limb ischemia
NOTE - The non-dihydropyridine calcium channel blockers verapamil and diltiazem are not usually recommended due to risk of an exacerbation of heart failure. If their use is considered, extreme caution is required.
This patient has both AF and heart failure; however, there is no finding in history or on examination to indicate that his heart failure is decompensated. On the other hand, he has no contraindication to beta blockers. A reduced ejection fraction of 38% alone is not a contraindication for beta blockers. In fact, beta blockers, by reducing heart rate and cardiac oxygen demand, will add to benefits of their use in this patient for rate control as the most appropriate management option.
Option A: Electrical cardioversion is used as an initial emergency treatment only if any of the 4 following conditions are present:
* Active ischemia (symptomatic or electrocardiographic evidence)
* Evidence of organ hypoperfusion
* Severe manifestations of heart failure including pulmonary edema
* The presence of a pre-excitation syndrome that may lead to an extremely rapid ventricular rate due to the presence of an accessory pathway
This patient has none of the above conditions to necessitate such treatment.
Option C: Digoxin is the initial management of patients with AF and decompensated heart failure. This patient’s heart failure is not decompensated. Even so, digoxin is not likely to slow the rate in the first hours of treatment.
Option D: Flecainide is an option for conversion to or maintenance of sinus rhythm and is used for rhythm control. Unless the patient has severe symptoms caused by the arrhythmia rather than the rapid rate, cardioversion should be performed on an elective basis after adequate anticoagulation has been achieved.
Option E: Verapamil is a non-dihydropyridine calcium channel blocker. These agents are appropriate options for rate control in the general population but should be avoided in heart failure due to significant risk of myocardial suppression and worsening of the heart failure associated with their use.
In short,
* AF - CCB (verapamil, diltiazem)
* AF + HF - BB +/- digoxin … fail then amiodarone
* AF + DHF - Digoxin
* Severe AF - Cardioversion then add flecainide
Main Goals in Treating AF + Heart Failure:
- Control symptoms
- Prevent arterial thromboembolism
Hemodynamic Impact of AF in Heart Failure:
- Decreased exercise capacity
- Decompensation of heart failure
Therapy Options:
- Rate Control: Preferred initial management for patients with AF and rapid ventricular response.
- Beta Blockers: Cardio-selective beta blockers (metoprolol, atenolol, carvedilol, bisoprolol) are preferred because they also treat heart failure.
- Digoxin: Used if beta blockers alone are not effective.
- Rhythm Control: Previously favored but recent data suggest rate control is better for initial management.
If Rate Control Fails:
- Amiodarone: Effective alone or with other medications.
Notes on Beta Blockers:
- Contraindicated in decompensated heart failure.
- Do not use if:
- Heart rate < 60 bpm
- Symptomatic hypotension
- Significant fluid retention
- Signs of hypoperfusion
- PR interval > 0.24 seconds
- Second- or third-degree AV block
- History of asthma or reactive airways
- Peripheral artery disease with resting limb ischemia
Non-Dihydropyridine Calcium Channel Blockers:
- Verapamil and diltiazem are generally not recommended due to the risk of exacerbating heart failure.
Case-Specific Notes:
- Patient has AF and heart failure but no signs of decompensation.
- No contraindications to beta blockers.
- Beta blockers are beneficial even with a reduced ejection fraction (38%).
Management Options:
- Electrical Cardioversion: Only for emergencies if:
- Active ischemia
- Organ hypoperfusion
- Severe heart failure symptoms
- Pre-excitation syndrome
- Digoxin: Used for decompensated heart failure but not likely effective immediately.
- Flecainide: Used for rhythm control, not rate control.
- Verapamil: Avoid in heart failure.
Summary for Treatment Choices:
1. AF: Calcium channel blockers (verapamil, diltiazem)
2. AF + Heart Failure: Beta blockers +/- digoxin, if needed, amiodarone
3. AF + Decompensated Heart Failure: Digoxin
4. Severe AF: Cardioversion, then add flecainide if necessary
Super long explanation - to refine later on*
A 65-year-old man presents to the emergency department with complaints of palpitation for the past 3 days which is worse today. He is on thyroxin 50 mcg for hypothyroidism. On examination, he has a blood pressure of 140/90 mmHg and an irregular pulse. An ECG is obtained and is as shown in the picture. Which one of the following would be the next step in management?
A. Stop thyroxin.
B. Start him on metoprolol.
C. Arrange for measuring plasma TSH level. D. Give him intravenous atropine.
E. Place a percutaneous pacemaker.
B. Start him on metoprolol.
The clinical findings of palpitation and irregular pulse in conjunction with ECG establish the diagnosis of atrial fibrillation (AF). AF may be idiopathic or due to a variety of conditions, with chronic hypertension being the most common cause. Hyperthyroidism is another etiology for AF. For every patient with AF, TSH should be measured (option C) and an echocardiography performed, but these steps are considered once the patient is started on appropriate treatment. For patients with symptomatic AF, treatment either with rate control (preferred) with metoprolol or calcium channel blockers or rhythm control should be started immediately.
Considering anticoagulation for prevention of thromboembolic events is another important step for AF with more than 48-hour duration or of unknown duration. Investigation for reversible causes of AF is considered once the patient is given appropriate initial management.
Option A: A TSH level below the normal lower limit is associated with an increased risk of AF, as is hyperthyroid state associated with excess doses of thyroxin. Even in the presence of increased levels of T4 in the plasma due to excess thyroxin, stopping the thyroxin will not lead to rapid improvement of symptoms.
Option D and E: Atropine and pacemakers are used for treatment of symptomatic bradycardia, which is not the case here.
A 69-year-old man just had a syncopal episode in the background history of aortic valve stenosis. He is now in the Emergency Department. Which one of the following is the most immediate management?
A. Electrocardiography.
B. Electrocardiography and cardiac monitoring.
C. Chest X-ray.
D. Emergency echocardiography.
E. Stress test.
B. Electrocardiography and cardiac monitoring.
Every patient over the age of 65 with an underlying cardiac disease is at risk of developing fatal arrhythmias such as complete heart block, ventricular tachyarrhythmias, etc. Although aortic stenosis is frequently associated with episodes of loss of consciousness and falls due to decreased perfusion on activity, the patient’s condition should not be merely attributed to this pathophysiology. An ECG should be obtained and the patient placed on cardiac monitoring for detection of potential arrhythmias that might have not been present when the ECG was taken.
Option A: ECG alone may miss the causative arrhythmia if it is transient.
Option C: Chest X-ray is not useful in detecting physiologic or structural heart anomalies.
Option D: Echocardiography may be considered later for additional pieces of information but not urgently. It has no role in detecting an arrhythmia. On the other hand, the diagnosis of aortic stenosis as a possible cause of syncope is already made.
Option E: Stress test is not helpful for detection of an arrhythmia. It can cause myocardial ischemia in this patient due to aortic stenosis.
A 62-year-old woman is seen in the ward 24 hours after a non-ST segment elevation myocardial infarction (NSTEMI). She complains of light- headedness. The radial pulse is difficult to feel, blood pressure is 90/60 mmHg, heart sounds are muffled, and there is evidence of biventricular cardiac failure. Which one of the following rhythm strips would be of most concern in this situation?
Correct Answer: A
The clinical picture of weak pulses, tachycardia and lightheadedness are suggestive of a tachyarrhythmia of ventricular origin, i.e. **ventricular tachycardia (VT) **or ventricular fibrillation (VF). The latter is always associated with loss of consciousness; therefore, cannot be considered in this woman.
The only rhythm strip consistent with the clinical picture is option A, which shows VT. VT is the most common arrhythmia occuring after myocardial infarction (MI). They are in particular common in the first 24 hours post-MI.
By definition, which one of the following best describes the condition termed as acute coronary syndrome?
A. Non-ST elevation myocardial infarction and ST elevation myocardial infarction immediately following cardiac surgery.
B. Unstable angina, non-ST elevation myocardial infarction and ST elevation myocardial infarction.
C. Stable angina, unstable angina and non-ST elevation myocardial infarction.
D. Stable angina, unstable angina and ST elevation myocardial infarction.
E. Unstable angina.
ACS consists of (option B.) unstable angina, non-ST elevation myocardial infarction and ST elevation myocardial infarction. They all present with similar clinical symptoms.
Which one of the following is not associated with prolongation of QT interval?
A. Hypothyroidism.
B. Hypercalcemia.
C. Haloperidol.
D. Sotalol.
E. Methadone.
B. Hypercalcemia.
Hypercalcemia affects the QT interval by shortening it, not prolonging it. Here’s a brief explanation for each condition:
- Hypothyroidism: Can lead to prolonged QT interval due to metabolic changes affecting the heart’s electrical activity.
- Hypercalcemia: Increases calcium levels in the blood, which accelerates the repolarization phase of the heart’s electrical cycle, leading to a shortened QT interval.
- Haloperidol: An antipsychotic that blocks potassium channels, delaying repolarization and prolonging the QT interval.
- Sotalol: A beta-blocker and antiarrhythmic that blocks potassium channels, leading to prolonged repolarization and QT interval.
- Methadone: An opioid that can block potassium channels, delaying repolarization and causing QT interval prolongation.
So, while conditions like hypothyroidism, and drugs like haloperidol, sotalol, and methadone prolong the QT interval, hypercalcemia does the opposite by shortening it.
The following is a list of conditions that can cause QT prolongation:
* Hereditary syndromes (rare)
* Electrolyte/metabolic abnormalities including hypocalcemia, hypokalemia or hypomagnesemia Intrinsic cardiac disease
* Medications:
Antiarrhythmics: amiodarone, disopyramide, dofetilide, ibutilide, procainamide, quinidine, sotalol Antihistamines: astemizole, terfenadine
Antibiotics: clarythromycin, erythromycin, pentamidine, sparfloxacin
Anti-malarials: chloroquine, halofantrine
Anti-psychotics: chlorpromazine, haloperidole, mesoridazine, pimozide, thioridazine Gastrointestinal drugs: cisapride, domperidone
Opiate agonists: methadone, levomethadyl
Other: Arsenic trioxide, bepridil, droperidol, probucol
* CNS disorders Systemic illnesses Myocardial Infarction
* Hypercalcemia is associated with shortening of QT interval and does not cause QT interval prolongation.
A 60-year-old man presents to the Emergency Department with complaint of vague abdominal pain. On examination, there is mild abdominal tenderness in the epigastric area with a vaguely palpated abdominal mass. On auscultation, a bruit is heard over the mass. Which one of the following is the next step in management?
A. Aortogram.
B. Emergency bedside ultrasonography.
C. Non-contrast abdominal CT scan.
D. Erect and supine abdominal X-rays.
E. Immediate transfer of the patient to the operating room.
B. Emergency bedside ultrasonography.
The findings are consistent with provisional diagnosis of abdominal aortic aneurysm (AAA). Physical examination is only moderately sensitive for diagnosis; therefore, a bedside ultrasonography for confirming the diagnosis of AAA is the next best step in management. Ultrasonography is the preferred diagnostic method for AAAs with high accuracy.
Spiral CT scan gives visualization of the aneurysm and surrounding structures. It is only indicated prior to elective surgical repair. It is never used to make a diagnosis of AAA. CT angiography with intravenous contrast can be used for assessment, but non-contrast CT and abdominal X-rays are of no use to diagnose AAA.
A 55-year-old man with history of smoking and hypertension has been diagnosed with a 4.2 cm abdominal aortic aneurysm (AAA). Which one of the following is the investigation of choice for monitoring and surveillance of his AAA?
A. MRI angiography.
B. CT angiography.
C. Ultrasonography.
D. Digital subtraction angiography.
E. Non-contrast abdominal CT scan.
C. Ultrasonography.
Ultrasonography is the most accurate and the best investigation for diagnosing, screening, and surveillance of aortic abdominal aneurysms Ultrasonography is a noninvasive and readily available test with approximately 100% sensitivity and specificity. CT angiography is performed if elective surgical correction is planned, once the diagnosis is made by ultrasonography.
A 65-year-old man presents with history of two episodes of abdominal pain after meals. As a part of workup plan, an abdominal ultrasonography is performed, which showed gallstones in the gallbladder and a 3.8 cm abdominal aortic aneurysm (AAA). Which one of the following is the recommended management of this asymptomatic AAA?
A. Ultrasonography every 12 months.
B. CT scan every 12 months.
C. Ultrasonography every 24 months.
D. CT scan every 24 months.
E. CT scan or ultrasonography every 12 months.
C. Ultrasonography every 24 months.
Ultrasonography is the preferred method for screening and surveillance of asymptomatic AAA. The screening intervals depend on the size of the AAA and are according to the following table.
Given the size of the AAA (3.8 cm), it should be monitored every 24 months with ultrasonography.
Abdominal ultrasonography of a 68-year-old man for renal colic reveals an abdominal aortic aneurysm 4.5 cm in size as a chance finding. Which one of the following is the most appropriate management of his aneurysm?
A. Refer him for elective surgical repair of the aneurysm.
B. Repeat sonography in 6 months.
C. Repeat sonography in 12 months.
D. Repeat sonography in 24 months.
E. Arrange for CT angiography.
C. Repeat sonography in 12 months.
Ultrasonography is the preferred method for screening and surveillance of asymptomatic AAA. The screening intervals depend on the size of the AAA and are according to the following table.
Given the size of the AAA (4.5 cm), it should be monitored every 12 months with ultrasonography.
A 60-year-old man presents with leg pain for the past 6 months. The pain becomes worse with walking and is relieved when he rests. There is no pain at rest. He has smoked 20 cigarettes per day for the past 30 years. On examination, he is obese with a BMI of 31 and has a blood pressure of 160/110 mmHg on two readings 20 minutes apart. Distal pulses of the left lower limb, including dorsal pedis, are barely perceptible. The skin of the legs is shiny and hairless. Mild muscular atrophy of the leg is noted. Ankle-brachial index (ABI) is 0.7. Which one of the following would be the most appropriate management and advice?
A. Smoking cessation, exercise and follow-up in three months.
B. Smoking cessation, statins and ACE inhibitors.
C. Duplex Doppler venous ultrasonography.
D. Aspirin, metoprolol and statins.
E. Referral for vascular surgery.
B. Smoking cessation, statins and ACE inhibitors.
With intermittent calf claudication, presence of the risk factors and an ABI of 0.7, the diagnosis of chronic peripheral arterial disease is almost established. Management of peripheral arterial disease includes the following:
Smoking cessation - smoking is the most important predisposing factor for peripheral arterial disease (PAD). Smoking cesation alone is associated with an improvement in the distance of pain-free walk, doubled 5-year survival and better post-op outcomes.
Exercise – exercise on an as tolerated basis, improves the pain-free walking distance and time and should be advised for all patients.
ACE inhibitors – evidence suggests that ACE inhibitors may improve walking ability in patients with intermittent claudication. The ACE inhibitor with greatest evidence of benefit is ramipril. It is unknown if the improvement in walking distance associated with ramipril is due to a class effect of ACE inhibitors or whether it is specific to this medicine. The ABI does not seem to improved though.
Statins – statins improve revascularisation, pain-free walking distance and survival. Of all lipid-lowering agents, only statins have been proved to lower the mortality in patients with vascular diseases due to atherosclerotic changes. It should be started for patients with coronary artery disease, PAD, aortic disease (e.g. abdominal aortic aneurysm), carotid artery disease and diabetes mellitus.
Clopidogrel and aspirin – they are often prescribed to reduce the overall risk of myocardial infarction and stroke, but are not associated with improvement of PAD symptoms.
Beta blockers (e.g. metoprolol) are not indicated in the absence of cardiac disease. They have no effect on PAD.
More detailed management of PAD is highly dependent on the severity of the disease. ABI is the mostly used predictor for this purpose. ABI is interpreted as follow: (see attachement)
Among the given option, smoking cessation, statins, and ACE inhibitors are the best possible management and the advice for this patient.
A 28-year-old man develops rapid palpitations and mild light-headedness following a 20km run. He denies any cardiac disease and mentions that a he had a similar episode 3 months ago for which he underwent cardiovascular examination by another doctor but everything was normal. On examination, he has regular but rapid pulse of 180 bpm. Which one of the following rhythm strips would be expected for him?
D. Paroxysmal supraventricular tachycardia (PSVT).
An arrhythmia induced by exercise in a young, otherwise healthy person, presenting with a rapid regular pulse is very likley to be a paroxysmal supraventricular tachycardia (PSVT).
The presence of ventricular tachycardia (option A) in the absence of an underlying cardiac disease is unlikely, as are complete heart block (option E) and atrial flutter (option C).
Atrial fibrillation (option B) presents with irregular pulse.
You are assessing the risk of thromboembolism in a 75-year-old woman, who is booked for elective surgical replacement of her left knee joint. Which one of the following, if present in history, is the most significant risk factor for thromboembolism during her peri-operative stay?
A. History of colon resection due to toxic megacolon.
B. Irritable bowel syndrome.
C. Stage II kidney disease.
D. Transient ischemic attack with full recovery three years ago.
E. Heart failure.
E. Heart failure.
Peri-hospital risk assessment of a venous thromboembolic events (VTE) such as deep vein thrombosis or pulmonary embolism is stratified according to the following table:
Among the options, congestive heart failure and the surgery are of the highest risk for venous thromboembolism. None of the other options are risk factors for VTE.
A-79-year-old woman undergoes total hip replacement surgery. After 4 days, she develops a swollen right leg. The circumference of the right calf is 4 cm greater than that of the left leg. The right leg feels warm to touch and is slightly tender. Which one of the following is most appropriate diagnostic tool to use for a diagnosis?
A. Duplex Doppler ultrasound.
B. X-ray.
C. Contrast venography.
D. CT angiography.
E. D-dimer assay.
A. Duplex Doppler ultrasound.
This patient has suspected diagnosis of deep vein thrombosis (DVT) and requires urgent Doppler ultrasound to establish the diagnosis.
Doppler ultrasound is more than 90% sensitive and more than 95% specific for thromboses within the femoral and popliteal veins, but less accurate for iliac or calf vein thromboses.
D-dimer is used for assessment of patients with Well score of < 2.
A patient with symptoms and signs consistent with DVT should be assessed and the clinical (pretest) probability of acute DVT established by using a validated scoring system. If the clinical probability of DVT is low (< 2), a D-dimer assay should be performed; otherwise, the next step would be Doppler Duplex sonography.
See Modified Wells’ Score below.
This patient has been bedridden for more than 3 days (1 point), has localized tenderness (1 point) and the circumference of the affected leg is more than 3 cm greater than the unaffected leg (1 point). With a Wells’ score or 3, she has high probability diagnosis of DVT and needs Doppler ultrasonography of the leg as the next step.
If the Wells’ score was < 2 the next best step would have been D-dimer assay (option E). A negative D-dimer test excludes DVT (and pulmonary embolism), but positive values is only suggestive of DVT and further investigations would be needed.
Previously, contrast venography (option C) was the definitive test for the diagnosis of DVT but has been largely replaced by ultrasonography, which is noninvasive, more readily available; however, it still remains the gold-standard for diagnosis of DVT (not in practice). While a Doppler ultrasound can establish the diagnosis, there is no need for CT angiography (option D) unless accurated anatomical site of the thrombus is required for surgical intervention (very rarely indicated).
A 45-year-old man comes to your practice for a routine health check. He has no remarkable past medical history. On examination, you feel his pulse is irregular with an average rate of 84 bpm. The rest of the exam is unremarkable. He denies any history of lightheadedness, shortness of breath, palpitation or chest pain. An ECG is ordered which is shown in the accompanying photograph. Which one of the following is the most appropriate next step in management of this patient?
A. Start him on metoprolol.
B. Start him on warfarin.
C. Start him on digoxin.
D. Start him on aspirin.
E. Do an echocardiography.
D. Start him on aspirin.
The ECG shows atrial fibrillation (AF) without tachycardia, and the given scenario is that of an asymptomatic AF. The priority in management of patients with asymptomatic AF centers around prevention of thromboembolic events, until elective cardioversion is performed either medically or by application of synchronized cardioversion. Patients with AF in the setting of valvular heart disease should be started on warfarin. Other patients with AF should be stratified and managed based on CHA2DS2 - VASc index.
C: Congestive heart failure / Left ventricular dysfunction (1) H: Hypertension (1) A2: Age ≥75 years (2) D: Diabetes mellitus (1) S2: Previous history of stroke or TIA (2) V: Vascular disease i.e., peripheral arterial disease, previous MI, aortic plaques (1) A: Age 65-74 years (1) Sc: Sex category (i.e. female sex) (1) NOTE - maximum score is 9 since age may contribute 0, 1, or 2 points 9
This patient has a CHA2DS2 - VASc score of 0. For him both no anticoagulation phrophylaxis or anticoagulation therapy with low-dose aspirin are acceptable options. There is no option suggesting ‘no anticoagulation therapy’; therefore, the only acceptable option would be anticoagulation therapy with aspirin.
For symptomatic patients or older patients with no or mild symptoms, who have rapid response AF evident by tachycardia, rate control should be started with beta blockers (first-line) such as metoprolol (option A) or calcium channel blockers (second-line). Digoxin (option C) is no longer recommended for rate control.
Echocardiography (option E) and TSH are two most important steps considered for every patient with new onset or new diagnosed AF, but not as the next best step in management.
NOTE - *Rhythm control* (vs. rate control) may be considered in the following patients groups
- Patients with unacceptable arrhythmia-related symptoms
- Patients presenting for the first time with non-valvular disease
- AF secondary to an identifiable and correctable underlying cause
- Patients who are intolerant of rate-controlling medications
- Patients with congestive heart failure - Arrhythmia can decompensate CHF, or cause CHF in an already sick heart
- Patients < 65 years
**
Which one of the following is not associated with increased serum troponin level?
A. Acute sepsis.
B. Renal failure.
C. Pulmonary embolism.
D. Aortic dissection.
E. Bradyarrhythmias.
E. Bradyarrhythmias.
There is a long list of conditions that can lead to elevated serum troponin levels in the absence of acute coronary syndrome and myocardial infarction. Bradyarrhythmias do not cause elevated serum troponin levels.
The causes for elevation of serum troponin levels are summarized in the following table.
A 76-year-old woman presents with complaint of palpitation. She is a known case of persistent atrial fibrillation for the past one year and is on rate control medications. She is not diabetic and has never had a stroke or TIA. She denies any episode of chest pain or shortness of breath. On examination, her BP is 130/85 mmHg with an irregular pulse of approximately 90 bpm. An ECG shows atrial fibrillation (AF). Which one of the following is the most appropriate management regarding prevention of stroke in this patient?
A. Digoxin.
B. Metoprolol.
C. Aspirin.
D. Warfarin.
E. Heparin.
D. Warfarin.
AF is manage either by rate control as the preferred method using beta blockers (first choice) or calcium channel blockers (diltiazem, verapamil), or rhythm control with flecainide, or amiodarone. Systemic thromboembolism is the most feared complication of AF, as one out of five patients with AF will develop cerebrovascular accidents (stroke or TIA) in one year. For this reason, the risk of stroke should be assessed and prevention considered for every patient with AF longer than 48 hours. CHA2DS2 -VASc scoring system is used for this objective in patients
with AF without underlying valvulopathies.
C: Congestive heart failure / Left ventricular dysfunction (1) H: Hypertension (1) A2: Age ≥75 years (2) D: Diabetes mellitus (1) S2: Previous history of stroke or TIA (2) V: Vascular disease i.e., peripheral arterial disease, previous MI, aortic plaques (1) A: Age 65-74 years (1) Sc: Sex category (i.e. female sex) (1) NOTE - maximum score is 9 since age may contribute 0, 1, or 2 points 9
This woman is 76 years old (2 points), has no previous history of stroke or TIA (0) and is not diabetic (0) or hypertensive (0). There is no history of MI, peripheral arterial disease, or aortic plaque (0). She does not have congestive heart failure or left ventricle dysfunction (0). She receives one additional point for being female. Collectively, this woman has a CHA2DS2 - VASc score of 3; therefore, she should be started on warfarin as the most appropriate option. Heparin should also be started to counteract the initial prothrombotic effects of warfarin until INR is within the therapeutic range of 2-3.
NOTE - Although the cut-off point for type 1 hypertension is defined as a systolic blood pressure of 130 mmHg or higher by the American Heart Association (AHA), the cut-off value for hypertension in CHA2DS2 - VASc score remains 140mmHg or higher.
Option A: Digoxin is occasionally used for rate or rhythm control in AF. It does not prevent thromboembolic events.
Option B: Metoprolol is used for rate control not anticoagulation and thromboembolism prophylaxis.
Option C: Aspirin is used in patients with nonvalvular AF and a CHAD2S2 score of 0 or 1 (in carefully selected patients where anticoagulation outweighs the risk of bleeding).
Option D: Heparin is used initially in conjunction with warfarin and stopped once the INR is within the therapeutic range (2-3).
Worried parents of a 4-year-old boy bring him to the Emergency Department because he is breathless and his heart is racing. An ECG strip is obtained and is as follows. Which one of the following is the most appropriate immediate management of this child?
A. Reassure the parents as it is sinus tachycardia.
B. Intravenous adenosine.
C. Intravenous lignocaine.
D. Intravenous beta blockers.
E. Immerse the child’s face in cold water.
B. Intravenous adenosine.
Condition:
- Non-sustained wide QRS complex tachycardia: Episodes of fast heartbeats with wide QRS complexes (>0.09 seconds) that start and stop on their own.
- Can be ventricular tachycardia (VT) or supraventricular tachycardia (SVT) with aberrancy.
- In children, it’s often SVT with aberrancy, but treat as VT until proven otherwise.
When to Treat:
- Asymptomatic: Identify and correct the underlying cause.
- Symptomatic or sustained: Requires treatment.
Treatment Based on Hemodynamic Status:
-
Hemodynamically Unstable (e.g., hypotension, altered mental status, signs of shock):
- If there’s a pulse: Electrical cardioversion.
- If no pulse: Defibrillation.
-
Hemodynamically Stable (e.g., no hypotension, no altered mental state, no shock):
- In adults: Use an antiarrhythmic like amiodarone, lidocaine, or sotalol.
- In children: Start with intravenous adenosine if the rhythm is regular and QRS complexes are monomorphic, as it’s often SVT with aberrancy.
Why Adenosine for Children:
- Adenosine is effective for SVT with aberrancy.
- If adenosine doesn’t work, consider VT and use amiodarone or procainamide after consulting a specialist.
Options Explained:
- Option A (Reassurance): Not suitable. This child needs treatment and investigation.
- Option C (Amiodarone/Lidocaine): Use only if adenosine fails.
- Option D (Beta Blockers): Used orally for mild symptoms in an outpatient setting.
- Option E (Vagal Maneuvers): Effective for narrow QRS tachycardia, not wide QRS.
Summary:
- First-line treatment for symptomatic non-sustained wide QRS tachycardia in children: Intravenous adenosine.
The ECG shows episodes of tachycardia with wide monomorphic QRS complexes that do not sustain and terminate spontaneously. This is called non-sustained wide QRS complex tachycardia. A wide complex for this matter is defined as a QRS of >0.09 second (90 msec). Wide QRS complex tachycardia is either due to ventricular tachycardia or a supraventricular tachycardia (SVT) with aberrancy. While most wide QRS complexes in adults originate from ventricles, in children they often represent SVT with aberrancy. However, due to the potential progression of ventricular tachycardia (VT) to ventricular fibrillation and cardiac arrest, any wide QRS complex tachycardia should be considered VT and managed accordingly until proven otherwise.
Asymptomatic non-sustained wide QRS complex tachycardia does not often require treatment other than identifying and correction of the underlying cause. Symptomatic non-sustained wide QRS complex tachycardia and sustained wide QRS complex tachycardias whether symptomatic or asymptomatic require treatment.
Treatment options depend on the patient’s hemodynamic status:
* In patients with wide QRS complex tachycardia who are hemodynamically unstable, represented by hypotension, acutely altered mental status or signs of shock, the treatment is with electrical cardioversion if there is a pulse. Defibrillation is the choice in the absence of a pulse.
- In adult patients with sustained wide QRS who are asymptomatic or have symptoms other than those mentioned above, or non- sustained wide QRS complex tachycardia with symptoms other than those mentioned above, pharmacotherapy with an antiarrhythmic medication is the treatment of choice. Amiodarone is first-line. Lignocaine or sotalol can be used alternatively.
- In children with sustained wide QRS complex tachycardia who are asymptomatic, or have symptoms but are hemodynamically stable (no hypotension, no acutely altered mental state, no signs of shock), or in children who have non-sustained wide QRS complex tachycardia with symptoms other than those related to hemodynamic instability, it is recommended that treatment start with adenosine if the rhythm is regular and QRS complexes are monomorphic. The rationale behind this is the fact that such tachycardias are often SVTs with aberrancy; hence, responsive to adenosine. However, if there is no response to adenosine, VT should be considered and treated with amiodarone or procainamide after expert consultation or under expert supervision.
This child has symptomatic non-sustained wide QRS complex tachycardia but his symptoms are not any of those representing hemodynamic instability; so, the most initial treatment to consider for him must be intravenous adenosine.
Option A: This child has symptomatic non-sustained wide complex tachycardia, probably with an underlying pathology. His parents cannot be reassured, and this child’s tachycardia requires treatment as well as investigations for an underlying cause.
Option C: Lignocaine, amiodarone, procainamide, etc. will be considered after adenosine proved ineffective to control the tachycardia, and the wide QRS complex tachycardia is likely to be VT. These medications should be used after consultation or under supervision of an expert.
NOTE - of these medications, amdiodarone is the safest to use.
Option D: Oral (not intravenous) beta blockers are used as first-line in treatment of non-sustained wide QRS complex tachycardias in outpatient setting if the symptoms are mild or not representative of hemodynamic instability.
Option E: Vagal stimulation by maneuvers such as immersion of face in cold water, Valsalva maneuver, carotid massage etc. are used as the initial management for patients with *narrow QRS complex *tachycardia because such tachycardias are not likely to have ventricular origin. This child has wide QRS.
A 71-year-old man with a history of congestive heart failure for the past 10 years, controlled on perindopril and hydrochlorothiazide, presents to the Emergency Department with a one-day history of palpitation. He has a blood pressure of 135/90 mmHg, an irregular pulse rate of 98 bpm, and a respiratory rate of 18 breaths per minute. Lungs are clear to auscultation. No ankle edema or raised jugular venous pressure is noted. An ECG is obtained and is shown in the following photograph. Which of the following would be the next best step in management?
A. Aspirin.
B. Metoprolol.
C. Warfarin.
D. Digoxin.
E. Diltiazem.
B. Metoprolol.
The ECG is characteristic of atrial fibrillation (AF). The most appropriate initial management of AF in a patient with stable hemodynamic status is rate control. Rate control often leads to an improvement in symptoms in patients with heart failure. In addition, slowing of the ventricular rate often leads to moderate or, in some cases, marked improvement in left ventricular function.
Cardioselective beta-blockers (metoprolol, atenolol, and carvedilol) are first-line medications for this purpose. Anticoagulation should be considered if AF persists beyond 48 hours or if the duration is unknown. Digoxin should be added if a second agent is necessary to achieve adequate rate control. However, the efficacy of digoxin decreases with physical activity.
If rate control with either beta-blockers or a combination of beta-blockers and digoxin has not been achieved, amiodarone may be useful either alone or in combination with other rate-slowing agents.
It should be noted that in patients with decompensated heart failure the initiation or increase of beta blockers is contraindicated. In such patients, the use of digoxin is suggested. However, digoxin is often ineffective if used alone, especially in patients with an elevated sympathetic tone. Also, for patients with acute AF with the rapid ventricular response associated with heart failure, amiodarone may be helpful to slow the ventricular rate. Although usually used for rhythm control, amiodarone can also provide a degree of rate control while it is being loaded and thereafter. Amiodarone is not recommended as a chronic rate-control medication, but in the acute setting can assist with rate control as it is being loaded, or can be used as a temporary rate-control medication in a patient who is unable to tolerate other therapies.
Even though this patient has heart failure, since the heart failure is rather stable and not decompensated, beta-blockers (metoprolol) are the most appropriate next step in management.
NOTE - Acute decompensated heart failure (ADHF) can be defined as the sudden or gradual onset of the sign and/or symptoms of heart failure requiring unplanned office visits, emergency department visits, or hospitalization. Regardless of the underlying precipitant of the exacerbation, pulmonary and systemic congestion due to increased left- and right-heart filling pressure is nearly a universal finding in ADHF.
Acute decompensated heart failure (ADHF) may present with:
* Pulmonary edema
* Cardiogenic shock
* Weight gain and fluid retention
* Exertional dyspnea
* Orthopnea
* Raised jugular venous pressure
* Peripheral edema
Option A: Aspirin is used for patients in whom AF is not caused by a valvular lesion and has a CHA2DS2 - VASc score of zero (or 1 in selected cases).
Option C: Anticoagulation with warfarin (after reaching an INR of 2-3 by initial administration of heparin) is considered the second most important step in whom AF has lasted over 48 hours or is of unknown duration. With an AF of only one-day duration anticoagulation is not required for now.
Option D: Digoxin could have been an appropriate option if the patient’s heart failure was decompensated and beta blockers were contraindicated.
Option E: Although non-dihydropyridine calcium channel blockers (verapamil and diltiazem) are second-line medications for rate control in patients with AF, extreme caution should be considered in patients with heart failure, due to the risk of heart failure exacerbation and decompensation.
A 65-year-old woman presents to the Emergency Department after she collapsed at work. She was walking to her desk when she suddenly lost consciousness and fell down. According to her colleague, who is accompanying her, she was ‘out’ for only a few seconds, and regained consciousness shortly. One examination, she is overweight, has a blood pressure of 110/75 mmHg, pulse rate of 110 bpm and respiratory rate of 18 breaths per minute. You are arranging for an ECG when she collapses again. On a quick review, she is found to have a blood pressure of 80/45 mmHg. You feel no radial or carotid pulse. An ECG is obtained which is shown in the following photograph. Which one of the following is the most appropriate next step in management?
A. Intravenous bolus of normal saline.
B. Intravenous amiodarone.
C. Synchronized cardioversion.
D. Cardiopulmonary resuscitation and defibrillation.
E. Cardiac catheter ablation.
D. Cardiopulmonary resuscitation and defibrillation.
The ECG is typical for ventricular tachycardia (VT). In each lead, QRS complex are of same morphology; therefore, this patient has a monomorphic VT.
Approach to sustained VT (VT lasting more than 30 seconds) depends on the patient’s hemodynamic status. Those with hemodynamic instability are in emergency need for reversion of the rhythm to a sinus rhythm. In the presence of a palpable pulse, the initial management is by synchronized cardioversion if a pulse is palpable, and defibrillation (unsynchronized) if no pulse is felt.
Since this patient is pulseless, CPR should be immediately started and defibrillation performed when available and ready.
In patients with a shockable rhythm (ventricular fibrillation and pulseless VT), the first action is start chest compression while waiting for defibrillator to be ready. First defibrillation should be followed by 2 minutes of CPR. After the second defibrillation, adrenaline should be started and repeated every second cycle.
Hemodynamic instability is defined as the presence of any of the following:
* Chest pain
* Hypotension (systolic blood pressure < 90mmHg)
* Perfusion-related confusion or unconsciousness
* Unconsciousness
* Heart failure
Option A: In a patient with VT, the cause of hypotension is decreased cardiac output as result of pump failure not hypovolemia; therefore, intravenous fluids are useless.
Option B: Antiarrhythmic medications such as amiodarone are indicated as first-line management option in patients who are hemodynamically stable despite presence of VT, or for sustaining a sinus rhythm after treatment with cardioversion or defibrillation.
Option C: Synchronized cardioversion was initial management and the correct option if the patient had a palpable pulse.
Option E: Cardiac catheter ablation is the definite treatment in patients with regular supraventricular tachyarrhythmias if the cause is found to be an accessory pathway bypassing the normal cardiac conductive system e.g. Wolff-Parkinson-White syndrome.
A 54-year-old man presents to the emergency department with complaint of retrosternal chest pain that worse on inspiration and lying back and relieved by bending forward. On examination, he has a blood pressure of 138/97mmHg, pulse rate of 110bpm, shallow respiration at a rate of 26 breaths per minute and a temperature of 38.5°C. An ECG is obtained which is shown in the following photograph. Which one of the following is the most appropriate next step in management after administration of supplemental oxygen?
A. Non-steroidal inflammatory drugs (NSAIDs).
B. Corticosteroids.
C. Arrange for cath lab.
D. Heparin.
E. Thrombolysis.
A. Non-steroidal inflammatory drugs (NSAIDs).
The clinical picture and the ECG findings are characteristic of pericarditis as the most likely diagnosis. Pericarditis presents with pleuritic chest pain (worsening with respiration) that often intensifies on lying down and relieved by bending forward. A friction rub (not a given finding in this patient) may be present. Fever, often low-grade, can be a feature.
Pericarditis is an important differential diagnosis to consider in patients with chest pain. It is diagnosed in 5% of patients presenting to emergency departments with chest pain in the absence of a myocardial infarction. Viral infections and idiopathic pericarditis are the most common etiologies.
Troponin can be elevated in some patients; however, unlike in myocardial infarction, raised troponin levels in pericarditis are not associated with negative prognosis.
Pericardial effusion is common complication that can follow in as many as 60% of patients. Cardiac tamponade can be a serious life- threatening condition complicating pericardial effusion.
Findings in pericarditis can include diffuse PR depression and diffuse ST elevation with upward concavity. Unlike pericarditis, myocardial infarction typically produces ST elevation with upward convexity. ST elevation in pericarditis is often seen in pericardial and limb leads and involves more than one coronary vascular territory.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line medications for treatment of pericarditis. Of NSAIDs, ibuprofen is the drug of choice due to its favorable effect on the coronary flow and large dose range. Depending on severity and response, 300–800 mg every 6–8 hours may be initially required and can be continued for days or weeks, ideally until the effusion has disappeared. Gastrointestinal protection may be considered.
Colchicine (0.5 mg twice daily) added to an NSAID or as monotherapy also appears to be effective for the initial attack and the prevention.
The role of systemic corticosteroids (option B) in pericarditis is controversial. High dose corticosteroids (i.e., prednisolone 1 mg/kg/ day) with a 2–4-week taper is considered in pericarditis secondary to connective tissue disease, uremia or autoreactivity.
Referring the patient to cath lab (option C), heparin (option D), or thrombolytic agents (option E) may be considered for patients with myocardial infarction or other conditions within the spectrum of acute coronary syndrome. The pleuritic nature of the chest pain, presence of fever, and the characteristic ECG findings favors pericarditis with high index of certainty.
A 56-year-old man presents to the emergency department with complaints of chest pain and lightheadedness. On examination he has a blood pressure of 85/50mmHg, rapid and barely perceptible pulse of 160bpm and respiratory rate of 24 breaths per minute. An ECG is obtained which is shown in the accompanying photograph. Which one of the following is the most appropriate next step in management?
A. Atropine.
B. Intravenous diltiazem.
C. Intravenous metoprolol.
D. Pace maker insertion.
E. DC cardioversion.
E. DC cardioversion.
The ECG is characteristic of supraventricular tachycardia (tachycardia with regular and monomorphic QRS complexes and absence of P wave).
SVT is a common condition that occurs in individuals of all age groups and presents with a variety of clinical manifestations. Patients may be asymptomatic or may present with minor palpitations or more severe symptoms.
If symptomatic, symptoms can include:
Palpitations - >96%
Dizziness - 75%
Shortness of breath - 47%
Syncope - 20%
Chest pain - 35%
Fatigue - 23%
Diaphoresis - 17%
Nausea - 13%
Rare complications of paroxysmal SVT include myocardial infarction, congestive heart failure, syncope, and sudden death.
Acute management of supraventricular tachycardia (SVT) includes controlling the rate and preventing hemodynamic collapse. Patients with unstable hemodynamic status (hypotension, chest pain, dyspnea and perfusion-related confusion) should be treated with immediate cardioversion after sedation. This patient has a systolic blood pressure of less than 90 mmHg indicating hemodynamic instability. Lightheadedness per se is not a sign of instability.
If the patient is stable, vagal maneuvers can be used to slow the heart rate and to convert it sinus rhythm. If vagal maneuvers are not successful, adenosine can be used in increasing doses. If adenosine does not work, atrioventricular (AV) nodal blocking agents such as calcium channel blockers (diltiazem or verapamil) or beta-blockers (e.g. metoprolol) should be used, as most patients who present with SVT have AV nodal reentrant tachycardia (AVNRT) or AV reentrant tachycardia (AVRT). These arrhythmias depend on AV nodal conduction and therefore can be terminated by transiently blocking this conduction.
Option A and D: Atropine and pace maker are used for patients with symptomatic bradycardia which is not the case here.
A 65-year-old man presents to the Emergency Department with complaint of chest pain radiating to his jaw for the past 2 hours. The patient is given aspirin, sublingual nitroglycerine (TNG), and supplemental oxygen. With these measures the chest pain subsides. An ECG is obtained and is as follows. A troponin level is requested with the result still pending. Which one of the following is the next best step in management?
A. Send the patient home on aspirin.
B. Coronary angiogram and angioplasty.
C. Thrombolysis.
D. Admit and wait for the troponin results.
E. Perform stress test.
B. Coronary angiogram and angioplasty.
This patient as a typical ischemic chest pain as well as an ECG showing ST segment elevation in leads II, III, and aVF. With these, an inferior ST segment elevation myocardial infarction (STEMI) is a definite diagnosis prompting immediate treatment and reperfusion therapy.
Therapy should be started regardless of the troponin result because troponin may take up to 6-8 hours to become positive, and its negativity does not change the diagnosis and the management plan in this scenario. In other words, even with a negative troponin result, the diagnosis is still STEMI and urgent reperfusion therapy is required.
According to National Heart Foundation of Australia, Australian Clinical Guidelines for the Management of Acute Coronary Syndromes For patients with ST elevation myocardial infarction (STEMI) presenting within 12 hours of symptom onset, and in the absence of comorbidities that impact the individual’s overall survival, emergency reperfusion therapy with either primary percutaneous coronary intervention (PCI) (formerly called angioplasty) or fibrinolytic therapy is recommended.
Since this patient is still in the 12 hours window, angiography to located the coronary stenosis or blockage and stent placement to maintain the vessel patent is the first-line treatment choice. In case PCI cannot be performed with acceptable delay, thrombolysis using agents such as alteplase, tenecteplase or reteplase are the treatment of choice.
