eMedici - Cardiology 1/2 Flashcards
1
Q
- Cardiac failure?
- Pulmonary embolism?
- Psychogenic?
- Myocardial ischaemia?
- Asthma?
A
= Cardiac failure
2
Q
What does this ECG show?
- A normal examination?
- Right bundle branch block?
- Recent myocardial infarct?
- Complete heart block
A
= Right bundle branch block
3
Q
Which one of the following is the most appropriate next investigation?
- Chest X-ray
- Echocardiogram
- CT pulmonary angiogram
- Exercise stress test
- Histamine challenge test
- Depression screen questionnaire
A
= Echocardiogram
4
Q
Which one of the following is the most likely diagnosis?
- Ventricular septal defect
- Pulmonary hypertension
- Chronic thromboembolic pulmonary hypertension
- Atrial septal defect
A
= Atrial septal defect
5
Q
Which one of the following is the most appropriate management option?
- Medical therapy
- Cardiac surgery
- Percutaneous therapy
A
6
Q
List 7 congenital cardiac defects that could present with breathlessness?
A
7
Q
What are the major cyanotic cardiac conditions? How are they usually managed?
A
8
Q
Do Implantable occluder devices for congenital heart defects require a defined period of prophylaxis?
A
9
Q
- A. Intravenous glyceryl trinitrate infusion
- B. Administer high-flow oxygen by Hudson mask
- C. Intravenous metoprolol 2mg
- D. Perform an ECG
- E. Subcutaneous morphine
A
D. Perform an ECG
10
Q
A 13 year old girl presents with a history of fainting at school during biology class, where they have been studying animal biology and have been performing dissections. What is the most appropriate form of management in this patient?
- A. Reassure the patient, and educate them about neurally-mediated syncope
- B. Initiate cardiac pacing
- C. Encourage sleeping with 10-15 degrees of head-up tilt in bed
- D. Fludrocortisone 0.1-0.2mg daily plus sodium chloride supplementation
- E. Sustained release potassium chloride 600mg daily
A
Reassure the patient, and educate them about neurally-mediated syncope
11
Q
A 50-year-old man presents to the emergency department 5 months after aortic valve replacement with a mechanical valve. He has flu-like symptoms, fever, rigors and feels unwell. On examination there are splinter haemorrhages and digital infarctions present in both hands. There is clinical evidence of anaemia. His blood cultures are positive for Streptococcus viridans.
Which one of the following is the most likely diagnosis?
A
Infective endocarditis
12
Q
An 84-year-old man is recovering from surgical intervention for a type III dissecting aneurysm. Prior to discharge he is counselled about potential complications of the dissection. Which one of the following is the most likely complication?
A
= Aneurysmal degeneration
13
Q
A 70-year-old woman develops new, acute onset congestive cardiac failure secondary to chordal rupture and mitral valve regurgitation. Which one of the following is the most appropriate initial step in management?
A
Oral loop diuretics and ongoing supportive care
14
Q
A 18-year-old man presents with a history of recurrent palpitations. His ECG is shown below. Which one of the following is the most likely diagnosis?
- A. Wolf-Parkinson White syndrome
- B. Brugada syndrome
- C. Long QT syndrome
- D. Arrhythmogenic right ventricular dysplasia
- E. Short QT syndrome
A
- A. Wolf-Parkinson White syndrome
15
Q
A 4-year-old boy is brought in to the hospital following a routine visit to his medical practitioner where a widely split S2 heart sound was heard. The boy runs around at home for a minute or so at a time before becoming short of breath. He is meeting all developmental milestones. On examination the JVP is normal, as is the right ventricular impulse. There is mild hepatomegaly. A thrill is felt at the left upper sternal border. Which one of the following is the most appropriate diagnostic investigation?
A
Doppler echocardiography
16
Q
Dilated cardiomyopathy has characteristic findings on ECG examination. Which one of the following would be most characteristic of this diagnosis?
A
Non-specific ST-T wave changes and Q wave changes
17
Q
A 23-year-old woman presents with a four week history of increasing breathlessness and lethargy. Finger clubbing is evident and on cardiac auscultation the first heart sound is split with a predominant tricuspid component. Third and fourth heart sounds are audible and there is a pansystolic murmur at the left parasternal edge.
Which one of the following is the most likely diagnosis?
A
= Ebstein’s anomaly
18
Q
Coarctation of the aorta can occur in isolation or in association with other defects.
With which one of the following is coarctation of the aorta most frequently associated?
A
Turner syndrome
19
Q
A mother brings her 4-year-old son to see her general practitioner. She is concerned that her son may have Marfan syndrome, as she has an 8-year-old daughter with the condition. She asks if there is a screening test that could be done to exclude this condition.
Which one of the following would be most appropriate?
A
= Genetic analysis for fibrillin-1 gene mutation
20
Q
Page 12
A 59-year-old man presents to the Emergency Department with acute onset of palpitation and shortness of breath. He is alert, with a blood pressure of 130/90 mmHg and has an oxygen saturation of 98% breathing room air. His ECG is shown. Which one of the following is the most likely diagnosis?
- A. Left bundle branch block
- B. Right bundle branch block
- C. Atrial fibrillation
- D. Non ST elevation myocardial infarction
- E. Normal sinus rhythm
A
= Atrial fibrillation
21
Q
A 67-year-old man with diabetes is scheduled for coronary angiography and stenting.
Which one of the following will most effectively reduce the risk of contrast-induced nephropathy?
A
= N-acetylcysteine
22
Q
A 29-year-old man presents to the Emergency Department with acute onset of palpitations. On examination, his blood pressure is 130/80mmHg and his ECG is shown. Which one of the following should be given immediately?
- A. Aspirin
- B. Digoxin
- C. Amiodarone
- D. Metoprolol
- E. Adenosine
A
= Adenosine
23
Q
A 39-year-old man presents to his general practice with a six month history of palpitations. This has been diagnosed as paroxysmal atrial fibrillation. The patient is intolerant to digoxin and is being treated for asthma. Which one of the following medications is the most appropriate treatment to control his atrial fibrillation?
A
= Verapamil
24
Q
A 57-year-old woman presents to the Emergency Department of a metropolitan hospital with acute onset of dull central chest pain for 20 minutes. On examination, her blood pressure is 120/85mmHg, saturation 97% on room air and her ECG is shown below. She is given oxygen and aspirin. Which one of the following is the most appropriate management?
- A. Percutaneous coronary intervention
- B. Thrombolysis
- C. Coronary artery bypass grafting
- D. Emergency temporary pacing
- E. Intravenous adenosine
A
= Percutaneous coronary intervention
25
A 34-year-old man presents to the Emergency Department with shortness of breath. He has become increasingly breathless over the past two days, and is now complaining of chest discomfort. On examination, his blood pressure is 115/80 mmHg and pulse rate 120/min. His heart sounds are muffled and his JVP is visible 3 cm above the sternal angle. His chest radiograph is shown. Which one of the following is the most likely diagnosis?
- A. Left lower lobe pneumonia
- B. Acute myocardial infarction
- C. Pericardial effusion
- D. Para-oesophageal hernia
- E. Aortic dissection
Pericardial effusion
26
- Aspirin
- Simvastatin
- Clofibrate
- Nicotinic acid
- Ezetimibe
Simvastatin
27
A 74-year-old man presents to the Emergency Department with acute onset of chest pain. On examination, his blood pressure is 167/95 mmHg and heart rate 110/mn. The heart sounds are normal and his chest is clear. The ECG shows sinus tachycardia with non-specific ST changes. A CT with contrast is performed. Which one of the following is the most likely diagnosis?
- Left renal artery stenosis
- Acute pulmonary embolism
- Pericardial effusion
- Para-oesophageal hernia
- Aortic dissection
Aortic dissection
28
A 55-year-old man presents to his general practice with increasing shortness of breath. His symptoms are now such that they prevent him from cooking his dinner. He is no longer able to do any work on his farm as he finds it too physically demanding. Which one of the following is the most approximate measure of his symptoms according to the New York Heart Association classification?
Class III
29
A 65-year-old man at ED, unresponsive. What is the diagnosis?
- Ventricular Tachycardia
- Sinus Bradycardia
- Complete Heart Block
- Atrial Fibrillation
- Ventricular Fibrillation
**Ventricular Fibrillation** - Whenever there is coarse baseline with no clear QRS (narrow or widen), this is ventricular fibrillation. This requires immediate CPR, calling for help, and early AED access for defibrillation.
30
A 45-year-old man presents to the ED, complaining of palpitations. What is the diagnosis?
- Ventricular Tachycardia
- Sinus Bradycardia
- Complete Heart Block
- Atrial Fibrillation
- Ventricular Fibrillation
**Ventricular Tachycardia** - Wide QRS with the ventricular rate above 100/min is most likely ventricular tachycardia. Sometimes, p wave can be seen hidden inside the QRS wave in the long ECG strip. Differential diagnosis could be atrial tachycardia with bundle branch block.
31
A 55-year-old man at ED, complaints of central chest pain for 20 mins. What is the diagnosis?
- Hyperkalaemia
- Acute anterior STEMI
- Ventricular Tachycardia
- Acute pulmonary embolism
- Acute pericarditis
Acute anterior STEMI - There is significant ST elevations seen in V1 to V6. Therefore STEMI in anteriorlateral LV = extensive MI.
32
A 55-year-old woman in the medical ward, complaints of chest discomfort for 30 mins. What is the diagnosis?
- Atrial Fibrillation
- Ventricular Tachycardia
- Sinus Bradycardia
- Complete Heart Block
- Atrial flutter
**Atrial Fibrillation** - An irregularly irregular narrow QRS rhythm with a coarse baseline is likely to be atrial fibrillation.
33
A 25-year-old woman comes to the ED with a complaint of shortness of breath of 30 mins. What is the diagnosis?
**Sinus tachycardia** - There is a PQRST at every beat which appears regularly, as the heart rate is roughly 150bpm, its sinus tachycardia as the PR interval is normal and QRS duration narrow and normal.
34
A 45-year-old man presents to the ED with syncope.
**Torsades de pointes (TdP)** - This is a classical polymorphic VT with changes in amplitude around an isoelectric line, sometimes described as a party streamer look (twisting of the axis). Although 50% of patients are asymptomatic, some patients can present like above with syncope and palpitations.
35
35-year-old man presents to the ED with chest pain for 2 hours. What is the diagnosis?
- Ventricular Tachycardia
- Acute anterior STEMI
- Hyperkalaemia
- Acute pulmonary embolism
- Acute pericarditis
**Acute pericarditis **- Classic global concave ST elevation + Mild PR segment elevation with reciprocal change in the aVR. To be exact this is the early stage of acute pericarditis, history can also help differentiate this from an MI.
36
A 75-year-old man presents to the ED with SOB and signs of heart failure. What is the diagnosis?
Second degree Type 1 heart block - This is a Mobitz I heart block as noticed that the PR interval progressively gets longer and eventually disappears (dropped QRS following the P wave). In contrast a Mobitz type 2 will have dropped QRS complexes.
37
A 75-year-old man presents to the Emergency Department with dyspnoea and signs of heart failure. What is the diagnosis?
= **Atrial flutter** - This provides the classic saw tooth pattern. The constant height and duration of the waves and constant rate of 300bpm instead of being higher at 400-600 bpm rules out the possibility of a coarse atrial flutter.
38
A 75-year-old man presents to the ED with palpitations. What is the diagnosis?
**Supraventricular tachycardia** - As there is no P preceding the QRS ,cannot be sinus rhythm. Narrow QRS = not from the ventricles. Regularly tachycardic at 220 bpm which is >100 bpm
39
A 65-year-old woman presents to the ED with chest discomfort.
**Normal pacemaker rhythm** - Verticle spikes of ~2ms preceding the P wave firing at a fixed rate. The other spike precedes the wide bizzare paced QRS. With these 2 information its likely a sequential pacemaker at Atrial paced and ventricular paced rhythm.
40
A 25-year-old woman presents to the ED with palpitations. What is the diagnosis?
**Ventricular ectopic (premature) beats**
Occasional broad QRS that happens without any sinus P wave + discordant ST segment and T wave, going the opposite direction of the QRS + compensatory pause that is double the previous R-R interval. As there is only 1 type seen here, this is a unifocal PVC with a trigeminy pattern.
41
A 60-year-old man had an ST elevation myocardial infarction two days ago, and was treated with a percutaneous coronary intervention. He has been started on aspirin. On the ward he develops a sharp chest pain that appears to change with position. An ECG is performed. Which one of the following is the most appropriate management for this patient?
- Subcutaneous low molecular weight heparin
- Naproxen
- Clopidogrel
- Warfarin
- Intravenous heparin infusion
Naproxen
42
A 30-year-old man presents with a history of apparent fainting. It is thought that these episodes of syncope are neurally mediated. Which one of the following would be most supportive of this hypothesis?
- Sudden onset without prodrome
- Presence of severe structural heart disease
- Fainting with arm exercise
- Presence of autonomic neuropathy
- Fainting at the sight of blood
Fainting at the sight of blood
43
10%
20%
50%
70%
90%
= 90%
44
There are several factors that determine the haemodynamic compromise that may occur in atrial fibrillation.
Which one of the following is the most important?
Ventricular contractility
45
A 50-year-old woman has dyspnoea on minor exertion. On examination she has a water-hammer pulse, a wide pulse pressure and an early diastolic, decrescendo mumur best heard over the second right intercostal space on expiration. Echocardiography reveals a left ventricular ejection fraction of 38%.
Which one of the following is the most appropriate therapeutic intervention?
Aortic valve replacement
46
An otherwise fit 77-year-old man attends his general practice with a three week history of palpitations. On examination, he has an irregularly irregular pulse as his only abnormal sign. His ECG shows absent p waves and an irregular ventricular rate averaging 75/min, but no other abnormalities.
Which one of the following is the most appropriate initial step in management?
Assess the haemodynamic status
47
An 85-year-old Indigenous woman with diabetes mellitus presents to the Emergency Department of a rural hospital with three days of progressive dyspnoea on a background of a two month history of fatigue. She has crepitations in both lung bases and her hands appear abnormally cold for the weather. Her medical history includes hypertension and childhood acute rheumatic fever.
Which one of the following is the most likely diagnosis?
Congestive cardiac failure
48
A 68-year-old man presents to the emergency department with a two-hour history of sudden onset, searing chest pain, worse between the shoulder blades. His history includes hypertension for which he takes perindopril. On examination he looks unwell with a blood pressure of 160/100mmHg, pulse rate of 90/min and temperature 37.2C. The rest of the physical examination is unremarkable. He is given oxygen by face mask and an ECG is performed. Which one of the following is the most appropriate next investigation?
CT angiography chest and abdomen
49
A 60-year-old man with a high probability of ischaemic heart disease has an exercise stress test. Four minutes into the test utilising the Bruce protocol he develops ST depression in leads II, III and aVF.
Which one of the following is the most appropriate initial step in management?
Coronary angiography
50
A 68-year-old man presents to the emergency department with sudden onset left sided crushing chest pain. He has jugular vein distension during inspiration and a systolic blood pressure of 70mmHg by palpation with clear lung fields. An ECG is performed. Which one of the following is the most important next step in management?
- 250-500 ml isotonic saline rapidly
- Intravenous dobutamine
- Intravenous morphine
- Intravenous frusemide
- Intravenous nitroglycerine
250-500 ml isotonic saline rapidly
51
A 56-year-old man presents with a three week history of increasing shortness of breath on exertion, orthopnoea and fatigue. On examination, an s3 gallop rhythm is present. There is jugular venous distension, peripheral oedema, basal crackles on auscultation of both lung bases. ECG shows a low limb lead voltage, wide QRS complexes and left bundle branch block. P mitrale is present. The chest X-ray shows an enlarged cardiac shadow.
Which one of the following is the most appropriate next investigation?
Transthoracic echocardiogram
52
A 23-year-old woman presents with a history of increasing breathlessness and lethargy. She is cyanosed with digital clubbing and a split second heart sound. On transthoracic echocardiogram, intravenous administration of a solution of agitated saline demonstrates "bubbles" in the left ventricle.
Which one of the following is the most likely diagnosis?
Eisenmenger syndrome
53
A 60-year-old man presents to the emergency department with complaints of palpitations. His blood pressure is 90/60mm Hg. His initial ECG is shown below. (Image) Shortly after his initial assessment the patient becomes unresponsive with a pulse. Which one of the following is the most appropriate next step in management?
- High flow oxygen and assisted ventilation if necessary
- Establish venous access and give 150 mg amiodarone
- Defibrillation with 360J
- Synchronised cardioversion at 100J
- Establish venous access and give intravenous lidocaine
High flow oxygen and assisted ventilation if necessary
54
A 30-year-old man presents seeking advice on some forthcoming dental treatment. He had a ventricular septal defect repair in childhood and has a history of premature ventricular ectopic beats. He is attending his local dental practice next week for root canal work. Which one of the following is the most appropriate advice?
No antibiotic prophylaxis is required
55
During a routine examination an 11 year old boy is found to have a blood pressure of 130/90mmHg in both upper limbs. Blood pressure measurement at his lower limbs reveals a blood pressure of 105/60mmHg. Radial pulses are synchronous, but a radio-femoral delay is present. Pulses are diminished in both lower limbs. Which one of the following is the most appropriate diagnostic investigation?
MRI aorta
56
A previously well 17-year-old man presents with sudden onset of marked palpitations which have persisted over the previous two hours. His ECG shows prolonged QT intervals and broad-based T waves. There is no evidence of any previous cardiac events. Which one of the following is the most appropriate plan of management?
Lifestyle modification. monitoring and metoprolol
57
The acute coronary syndrome is initiated by a specific pathophysiological event.
Which one of the following most accurately describes this event?
Rupture of a vulnerable plaque
58
A 29-year-old man presents to the Emergency Department with acute onset of palpitations. On examination, his blood pressure is 130/80mmHg and his ECG is shown. Which one of the following is the most likely diagnosis?
- Multifocal atrial tachycardia
- Atrial flutter
- Atrial fibrillation
- Supraventricular tachycardia
- Sinus tachycardia
Supraventricular tachycardia
59
A 35-year-old man with a prosthetic value requires antibiotic prophylaxis for a dental procedure. He is allergic to penicillin. Which one would be the most appropriate choice?
Clarithromycin
60
A 63-year-old man presents to the emergency department with sudden onset of shortness of breath. He is breathless at rest and only able to speak in short sentences. His blood pressure is 130/85 mmHg, pulse rate 100/min and oxygen saturation on room air is 93%. His chest X-ray is shown. Which one of the following is the most likely diagnosis?
- Left-sided pneumothorax
- Right middle lobe pneumonia
- Acute pulmonary oedema
- Cardiac tamponade
- Left pleural effusion
- Acute pulmonary oedema
61
= 3
Franz's Glasgow Coma Scale (GCS) is 3 and is calculated using 3 categories (Image). Eye response, verbal response and motor response. In this case the patient scored:
Eye response 1: no eye opening.
Verbal response 1: no verbal response
Motor response 1: no motor response
62
Non-shockable rhythms are asystole and pulseless electrical activity (PEA). Patients with PEA may have some mechanical myocardial contractions but they are too weak to produce a detectable pulse or blood pressure.
Survival following a cardiac arrest with asystole or PEA is unlikely unless a reversible cause can be found and treated quickly and effectively (ALS, 2016).
63
- The default level on a defibrillator for adults is set to 200 J.
- If the first shock is unsuccessful, and the defibrillator is capable of delivering shocks of higher energy, it is reasonable to deliver subsequent shocks at a higher level.
- Biphasic waveforms are recommended to be used for defibrillation as they are more effective in converting VF back to sinus rhythm. In the absence of biphasic defibrillators, monophasic defibrillators are acceptable.
64
- In a non-shockable rhythm adrenaline 1mg (1mL of 1:1000 or 10 mL of 1:10,000) IV should be given and continue CPR
- In a shockable rhythm adrenaline 1mg (1mL of 1:1000 or 10 mL of 1:10,000) IV should be given after the second shock
65
Airway control
The paramedics provide the following information: Intravenous adrenaline was given twice on scene and then again once en route. Franz's airway was very soiled with initially frothy fluid, then blood stained fluid. Intubation was attempted, but unsuccessful because the fluid in the upper airway obscured any clear view of vocal cords. A laryngeal mask airway (LMA) was inserted successfully and required constant suction through it to keep airway clear.
1. Rescue airway in a failed intubation
2. To improve oxygenation as part of rapid sequence airway approach
3. Ventilation for elective anaesthesia in fasted patients with low risk of regurgitation
66
The reversible causes of a cardiac arrest need to be considered.
Which of the following are reversible causes of a cardiac arrest?
= All except sepsis
67
- A. non depolarising acetylcholinesterase antagonist, which act at the neuromuscular junction preventing depolarisation of the muscle membrane
- B. depolarising acetylcholinesterase antagonist, which acts at the neuromuscular junction preventing depolarisation of the muscle membrane.
- C. CNS depressant which acts at the GABA receptor. May also shorten channel opening times at nicotinic acetylcholine receptors and sodium channels in the cerebral cortex.
- D. Potentiates the action of neurotransmitter GABA at multiple sites in the CNS.
= A. non depolarising acetylcholinesterase antagonist, which act at the neuromuscular junction preventing depolarisation of the muscle membrane.
Rocuronium is a non-depolarising acetylcholinesterase antagonist. It is used for skeletal muscle relaxation in anaesthesia and intensive care.
68
What is the diagnosis?
The ECG shows evidence of an anterior STEMI.
The heart rate is 89/min and sinus rhythm, with ST elevation in anterior leads, left axis deviation, right bundle branch block (bifascicular block).
69
he clinical findings and the ECG findings are consistent with a diagnosis of an anterior STEMI. Which of the following are the most appropriate management options for a STEMI?
The basic management plan for an acute STEMI should include:
1. PCI or fibrinolysis
2. Dual antiplatelet (aspirin + prasugrel OR ticagrelor OR clopidogrel; choice depends on hospital protocol)
3. Anticoagulant: Heparin or enoxaparin.
70
Franz is awaiting transfer to the cardiac catheterisation laboratory.
Which of the following are priorities in post resuscitation care?
71
What are the most common rhythms of arrest?
72
Presentation - A 75-year-old man comes to see his general practitioner for a routine check-up. Karl is currently asymptomatic and reports no episodes of syncope or pre-syncope, chest pain or unexplained dyspnoea. As part of the physical examination, Karl's pulse is found to be irregularly irregular, ranging between 80 - 110/min. What further information should be sought to determine his risk of having a thrombo-embolic stroke?
73
Treatment Options - On questioning, Karl states that he has high blood pressure for which he takes perindopril arginine (Coversyl) 5mg daily. His blood pressure over the past year has been ‘around 140’. Otherwise he has no previous relevant medical history and that the only other medication he is taking is aspirin 75mg daily.
Cease aspirin and start an oral anticoagulant
74
After counselling Karl on his options regarding anticoagulation, it is decided to commence him on apixaban and cease his aspirin. He has no evidence of renal impairment and he is started on 5mg twice daily.
= No monitoring tests required for DOACs
75
Patient Education - Now that a decision has been made to stop the aspirin and start one of the newer oral anticoagulants (apixaban), it will be important to counsel Karl on some of the important aspects of taking the medication and some of the potential problems he might face.
= Seek medical attention if Karl has a fall, minor bleeds can lead to catastrophe outcomes
76
Complications - Karl returns to the clinic six months later as he has recently been admitted to hospital for a fall and was found to have a small sub-dural haematoma (Image). His apixaban was ceased and the discharge letter requests that you manage his anticoagulation. He has currently been off his apixaban for five days. Which one of the following is the most appropriate next step in management?
- Continue without anticoagulation and review in four weeks
- Restart the apixaban at half the previous dose
- Restart the apixaban at the full dose
- Assess the risk of a further major bleed
- Change to warfarin
= Assess the risk of a further major bleed
77
Balancing Risks - It is calculated that Karl has a moderate risk of having a major bleed (4.1%). The risk of a major bleed must be weighed up against his risk of a stroke (5.9%). Both these risks appear very similar.
= When anticoagulation is ceased, there is a high risk of strokes in the interim (<30days)
78
What is CHADS2?
79
What is HASBLED?
80
Presentation - Talia is a 12-year-old indigenous girl who is brought by her mother to her rural GP with a three day history of pain in her right knee. She is unable to walk due to the pain. This has never occurred before. Talia does not recall any trauma to the area and does not report any pain in other joints, skin changes to the area, or existing medical conditions. Her mother notes that her daughter's forehead felt hot to touch this morning.
= Rheumatic fever
81
Major and Minor criteria for Rheumatic fever?
82
History - Further history reveals that Talia has been hot and sweaty, feels unwell and has had sharp stabbing chest pain for the past few days. Her right knee is extremely tender and warm to palpate and she is unable to weight bear. On further prompting, Talia remembers having a sore throat two weeks ago that seemed to resolve on its own.
= Chorea
83
Physical examination - On physical exam Talia is a young indigenous girl who appears unwell and anxious. No choreiform movements are observed. She does not have any skin rashes on her trunk or limbs. Her pharynx and tonsils do not appear erythematous but her cervical lymph nodes are palpable and tender. Her HR is 80bpm, BP is 125/80 mmHg sitting, RR 14 and she has a temperature of 38.5˚C. On auscultation of her chest, both heart sounds are heard and are of equal intensity however there is a grade I apical pansystolic murmur present.
= Mitral regurgitation
84
Clinical criteria - The history and examination findings are suggestive of acute rheumatic fever. The 2020 Australian criteria for acute rheumatic fever (ARF) can be used to make a diagnosis.
85
Investigations
Based on the provisional diagnosis of rheumatic fever, Talia is transferred to the nearest hospital for monitoring, and the cardiologist on call orders several investigations. Her CBE shows an elevated white cell count. Talia also has an elevated ESR and CRP but negative blood cultures. Her ECG is normal. Echocardiogram shows annular dilation and chordal elongation consistent with acute carditis, and mild mitral regurgitation (Image). There is no evidence of pericarditis, pericardial effusion or impaired left ventricular function. An aspiration of her knee joint shows no organisms on gram stain or culture, and no crystals.
= Anti-streptolysin O titre
86
The cardiologist discusses the diagnosis with Talia and her mother. The doctor is aware that there are several options for initial treatment in rheumatic fever dependent on which clinical features are present, although these treatments do not alter the disease process.
= Single dose benzathine penicillin
87
Management of acute carditis - Thalia is suffering from acute cardiac complications of rheumatic as demonstrated by the echocardiographic findings.
= Bed rest & Corticosteroids
88
Secondary prophylaxis - Thalia is provided with good symptomatic relief from her medications and recovers quickly in hospital. However after talking with the patient’s mother, the cardiologist finds out that, due to their poor socioeconomic status, Talia and her family of eight live in a house of poor quality far away from the hospital. Talia and her three younger siblings share a bed. Being aware that socioeconomic and environmental disadvantage, overcrowding, and limited access to infrastructure are all risk factors for rheumatic fever, the cardiologist is worried that the patient is likely to re-present with the disease.
= Benzathine penicillin G
89
1. Impaired LVEF <60%
2. Left ventricular end-systolic diameter >40mm
3. New onset atrial fibrillation
4. Pulmonary hypertension >50mmHg
90
What is Acute rheumatic fever?
What are 6 Differentials for knee pain and fever?
91
Clinical features of rheumatic fever?
Pharmacological treatment of rheumatic fever?
92
Long-term complications of rheumatic fever?
5 Management options once rheumatic heart disease has occurred?
93
Which one of the following would be the most accurate?
- A. The airway is intact, breathing is intact, circulation is intact, disability is abnormal.
- B. The airway is intact, breathing is intact, circulation is unable to be assessed, disability normal.
- C. The airway is intact, breathing is intact, circulation is normal, disability is normal.
**C. The airway is intact, breathing is intact, circulation is normal, disability is normal** - Elena is speaking in full sentences to the nurse which requires a patent airway and adequate respiration. She was able to walk in which indicates adequate perfusion to her brain and extremities, and she had no disability as she is fully conscious and coordinated. It would be highly unlikely that she is hypoglycaemic without symptoms and she is currently not on any medication. The next step would be to obtain a full set of observations.
94
Even though Elena has a tachycardia, she does not appear to have an acute problem. However, an ECG will be required. The nurse puts on a 12 lead ECG and prints it out. What does the ECG show?
- A. Junctional tachycardia
- B. Torsades de Pointes
- C. Atrial flutter
- D. Atrial fibrillation
= D. Atrial fibrillation
95
Aetiology - The ECG confirms that Elena is in atrial fibrillation (AF). The rest of the observations show a blood pressure of 138/72 mmHg and oxygen saturation is 96% on room air. Elena is understandably anxious about the alarms. She denies having an irregular rhythm previously. Which of the following are reversible causes of atrial fibrillation that currently need to be considered in this patient?
= Myocardial infarction, Hyperthyroidism, Pulmonary embolism, Alcohol, Electrolyte disturbance.
96
**Management** - On further questioning, Elena has no chest pain or shortness of breath. She has never felt palpitations before and her only medical history is hypertension and high cholesterol. On examination, she is an elderly lady, lying comfortably in bed. Her heart sounds are dual with no added sounds. Her respiratory examination is unremarkable and her JVP is not elevated. Her calves are soft and non-tender, without any swelling. Some laboratory tests are arranged, including a complete blood examination, MBA20, magnesium, and thyroid function tests. At a later stage serum troponin, creatine kinase, and D-dimer may be indicated, but there is no urgency with these investigations as Elena’s clinical signs and symptoms suggest a low probability of myocardial infarction or pulmonary embolism. A chest X-ray is arranged. Some action must be taken in respect of the tachycardia and atrial fibrillation. Which of the following would be appropriate management options?
97
Management - It is important to consider the effects of rate control (controlling the heart rate) and rhythm control (reverting the heart rhythm to sinus rhythm). Converting Elena to sinus rhythm without knowing the duration of atrial fibrillation could be dangerous as any thrombus in the left atrial appendage could be dislodged during the reversion and cause a stroke. Additionally, clinical trials show that rate control has similar outcomes to rhythm control. The anaesthetist elects to choose rate control to treat the patient. Understandably, that whilst all this assessment has been going on, the surgeon is keen to get on with the list and would like to proceed to deal with Elena's skin lesions. 'Can we proceed?' He asks. Which of the following would be appropriate responses?
98
Definition - The skin lesions are removed under local anaesthetic and Elena is admitted to the recovery ward post surgery for observations and investigation of her AF. Her complete blood examination, white cell count, thyroid function tests and chest X-ray return back normal. She has had a recent previous echocardiogram 3 months earlier which was normal and an ECG done five days prior to surgery was also normal. Which of the following most accurately describe this type of atrial fibrillation?
99
List and score the risk factors involved in the CHA₂DS₂-VA score.
100
Management - The next critical management choice after rate control would be the prevention of stroke. Which one of the following strategies would be most appropriate?
**= Anticoagulation**
During atrial fibrillation, the absence of organized atrial contractions promotes blood stasis in the atria, particularly the atrial appendage. Blood stasis is a strong risk factor for clot formation (a coomponent of Virchow’s triad) and subsequently atrial fibrillation is a big risk factor for stroke. The stroke risk for paroxysmal AF is the same as persistent or permanent AF, hence they all require consideration of anti-coagulation even if the patient is in sinus rhythm. The evidence is less clear for patients with a clear trigger for atrial fibrillation – the trigger may have caused atrial fibrillation but the patient is predisposed to atrial fibrillation in order for the trigger to cause this.
101
Management - It is decided that Elena should be anticoagulated. There are currently several options for anticoagulation: warfarin and direct oral anticoagulants (DOACS). Which of the following would be appropriate?
= DOAC.
102
What is the main morbidity to AF due to? (5)
103
How is AF categorised?
It is divided into two categories of valvular and non-valvular AF. This is then split into further categories of paroxysmal, persistent, and permanent AF based on duration. Lone AF describes patients without underlying heart disease. The risk of stroke in paroxysmal vs permanent AF is the same and hence anticoagulation is important to consider in the various subtypes. The evidence is less clear for AF that is triggered by a stimulus such as an infection or other causes.
104
What are the priorities of management in atrial fibrillation?
105
Presentation - A 65-year-old man presents to the Emergency Department with a two hour history of central crushing chest pain. Nik has never had anything like this before and at first thought it was a bad attack of acid reflux. He has suffered with heartburn for many years and takes esomeprazole regularly. He took some of his liquid antacid preparation which did not make any difference to his symptoms and his concerned wife drove him directly to the hospital. Nik has other health issues including hypertension (perindopril) and type 2 diabetes (metformin). He had an appendicectomy twenty years ago and has a 40 pack-year smoking history, ceasing two years ago. He does not take any other medications. An acute coronary syndrome is suspected, and cardiogenic shock must be excluded.
Which of the features of the physical examination would raise suspicions of cardiogenic shock?
= Tachycardia, Hypotension, Cool, clammy peripheries, & Bibasal coarse crackles
106
Management - On examination Nik is in pain, sweaty and anxious. His blood pressure is 130/90 mmHg, pulse rate 100/min and temperature 37.2C. His chest is clear and his JVP not elevated. He is obese (BMI 34) and the remainder of the physical examination is unremarkable. Nik is attached to a cardiac monitor. Pulse oximetry shows an oxygen saturation of 96%. His condition remains stable. A myocardial infarction is suspected. Which of the following should be part of the initial management?
107
Complications - The ECG show changes consistent with an acute anterior myocardial infarction. The QR pattern suggests right ventricular conduction delay. Serial troponin estimations show a rise confirming the clinical and electrocardiographic diagnosis. Nik is transferred to the catheter laboratory and a drug-eluting stent is inserted into his left anterior descending coronary artery.Which one of the following complications is most common after acute myocardial infarction?
- Mural thrombus formation
- Pericarditis
- Arrhythmias
- Aneurysm formation
- Left ventricular free wall rupture
= Arrhythmias
108
Management - You must now consider Nik's ongoing management. This includes minimising his risk of stent thrombosis. Which one of the following drug combinations would be most effective in reducing this risk?
**= Aspirin and ticagrelor** Although aspirin is still the mainstay of therapy in patients with acute coronary syndromes, it has been shown that the addition of another antiplatelet agent can reduce morbidity and mortality in selected patients. Ticagrelor has become the preferred agent in combination with aspirin.
109
Treatment - Immediately following the stent insertion, Nik is started on aspirin and ticagrelor. The patient asks how long he will need to take these drugs for. For how long should ticagrelor ideally be continued in a patient with a second generation drug eluting stent?
= 12 months
110
Risk assessment
Six weeks after this procedure, Nik presents again to the Emergency Department with severe right upper quadrant pain and vomiting. An abdominal ultrasound reveals a thick-walled, dilated gallbladder containing two large gallstones, with one obstructing the neck of the gallbadder (Image). A diagnosis of acute cholecystitis is made with a recommendation for surgery. However, Nik is still on dual anti platelet therapy. His attending physicians now face what is an increasingly common clinical dilemma. The risk of surgical haemorrhage needs to be weighed up against the risk of stent thrombosis. Dual antiplatelet therapy (DAPT) clearly increases a patient's risk of bleeding. If DAPT is discontinued, there will be an increased risk of post-operative myocardial infarction. Which one of the following most closely approximates to this increased risk?
- 2x increased risk
- 2-4x increased risk
- 5-10x increased risk
- 10-15x increased risk
- >15x increased risk
**= 5-10x increased risk**
Withdrawal of DAPT for surgery increases the risk of postoperative MI and death 5 - 10 fold. Additionally, if DAPT is stopped within the first six weeks after a stent is placed, perioperative cardiovascular mortality is as high as 71%, compared with 5% if DAPT is continued.
111
Management - In some surgical circumstances it may be necessary to cease DAPT. Which one of the following best approximates the minimum length of time ticagrelor would need to be ceased for the bleeding risk to return to baseline?
**= 3 days**
The lifespan of a platelet averages 7-10 days. However, as the actions of ticagrelor are reversible, a minimum of 3 days is required for cessation preoperatively. In contrast, as the actions of aspirin on the platelet are irreversible, a new generation of platelets must be allowed to regenerate and replace the affected ones (ie 7 days).
112
Management - Managing DAPT in the surgical patient can be a complex clinical dilemma, and can vary quite significantly depending on the surgical procedure being performed. For which of the following surgeries does the Cardiac Society of Australia and New Zealand (CSANZ) recommend the holding of DAPT where possible?
The following are recommended where DAPT should be held:
1. Spinal
2. Intracranial
3. Extra-ocular
4. Transurethral resection of the prostate
5. Major plastic reconstructive procedures
113
Management - There are significant risks when operating on patients currently prescribed DAPT, regardless of whether you stop or continue their medication. It is therefore preferred to avoid the situation where possible. For how long should elective procedures ideally be delayed after the insertion of a drug-eluding stent?
= 12 months
114
Which of the following diagnoses need to be considered?
- Epidural abscess
- Cauda equina syndrome
- Sciatica
- Osteoarthritis
- Osteomyelitis
- Spinal fracture due to osteoporosis
- Urosepsis
- Ankylosing spondylitis
115
Investigations - The clinical picture would fit for a caudal equina syndrome with a septic element. Some investigations will be required. Which of the following investigations would be appropriate?
116
Which of the following risk factors are likely to be present?
- Intravenous drug abuse
- Dental procedures
- Diabetes
- Valvular heart disease
- Immunosuppression
- Prosthetic heart valve
Dental procedures & Valvular heart disease
117
Diagnosis - On further questioning, Rudi says that he has had three dental procedures performed in the past 12 months, and the last one was three months ago (root canal). His General Practitioner is contacted and confirms that Rudi has had an ejection systolic murmur for many years thought to be aortic stenosis. Since admission, this murmur has not changed. Which of the following pieces of information support the diagnosis of infective endocarditis.
Rudi has a fever, probable native valvular heart disease, recent dental work and the finding of Streptococcus gordonii on blood culture. These are supportive of a diagnosis of infective endocarditis. None of the other listed pieces of information are relevant to this diagnosis.
118
Which of the following investigations would be appropriate?
- Transthoracic Echocardiogram/TTE
- Transesophageal
- Echocardiogram/TOE
- Abdominal USS
- Gallium scan
- Lumbar puncture
- MRI lumbar spine
- CT head
119
Which of the following are the complications that can be associated with IE?
- Heart failure
- Perivalvular abscess
- Sciatica
- Urinary retention
- Splenic abscess
- Dental abscess
- Brain abscess
- Constipation
- Septic arthritis
120
What features of the ECG are suggestive of atrial fibrillation?
- Absent P waves
- Varying R-R intervals
- A “saw-tooth” pattern
- Presence of fibrillatory waves
- Atrial fibrillation is always associated with a rapid ventricular response
* Absent P waves – p waves are absent in an ECG of a patient in atrial fibrillation.
* Varying R-R intervals – there are irregularly irregular QRS complexes, which can also be described as varying R-R intervals. This represents the irregularly irregular ventricular rate.
* A “saw-tooth” pattern – flutter waves (“saw-tooth” pattern) cannot be seen in this ECG. Moreover, a “saw-tooth” pattern is suggestive of atrial flutter.
* Presence of fibrillatory waves – fibrillatory waves can be seen, also described as ‘f’ waves.
* Atrial fibrillation is always associated with a rapid ventricular response – atrial fibrillation will not always have a rapid ventricular response/rate. Indeed, this ECG demonstrates a rate of 78/min. The ventricular rate will depend on the degree of atrioventricular (AV) node conduction, with a slower ventricular rate during atrial fibrillation seen in patients on digoxin, beta blocker or calcium channel blocker or those with various degree of AV block.
* In this patient the goal is to have a pulse rate of less than 90/min, this has been achieved with metoprolol.
121
Investigations - Further reading from her file shows that Dorothy's pulse is usually regular and there is no previous recorded hearing of a murmur. An ECG taken two years ago before she underwent a minor operative procedure shows sinus rhythm with a rate of 68/min. Some investigations should be considered to determine any possible underlying causes of Dorothy’s atrial fibrillation. Which of the following investigations would be appropriate?
122
Risk assessment
It is explained to Dorothy that she has atrial fibrillation and that this is associated with an increased risk of stroke. She will need to take some medication to decrease this risk and that the medications have potential risks as well. The decision to take medication will come down to balancing the risks and benefits for Dorothy. Use of a risk calculator will help provide advice about what medication she should take. The CHA2DS2VASC tool will help determine the risk of stroke. Which risk factors are used in the CHA2DS2VASC tool?
123
Risk assessment - Reviewing Dorothy's medical history: she is a 76-year-old woman with atrial fibrillation, hypercholesterolaemia, type 2 diabetes mellitus, and hypertension. Her medication list includes 20mg atorvastatin, 500mg metformin, 10mg perindopril, and 5mg amlodipine. She is an ex-smoker (10 pack-year history, quit at age 30). Her mother was known to be on warfarin. Which one of the following correctly identifies Dorothy’s score using the CHA2DS2VASC tool?
- Low
- Medium
- High risk
124
Contraindications - Dorothy's case is discussed with the local cardiologist. She agrees that Dorothy has developed atrial fibrillation, is high risk and needs to be started on anticoagulation therapy. She should have a cardiac echo performed to exclude a valvular lesion and whilst that is awaited she should be started on warfarin therapy. It is important to review whether there are any possible contraindications to this medication for Dorothy.
Which of the following scenarios are contraindications to warfarin?
125
Medications - Upon reviewing Dorothy’s medical history there are no contraindications to warfarin therapy and this medication is started. Dorothy is reviewed by the cardiologist, who makes the assessment of permanent atrial fibrillation, requiring rate control with metoprolol. An echocardiogram excludes any valve disease. She is reviewed six months after her initial presentation. Over the past several months, she has had difficulty attending for regular INR monitoring as she says that it is too far for her to travel. As a result, her cardiologist has recommended Dorothy trial a different anticoagulant medication that may be more practical. Dorothy has non-valvular atrial fibrillation and is high risk, according to her CHA2DS2VASC score of five. Which of the following medications would be appropriate?
= Dabigatran, Apixaban, & Rivaroxaban
126
Dabigatran - Dorothy’s cardiologist decided to switch her to dabigatran. Which of the following are true with regards to dabigatran therapy in non-valvular atrial fibrillation?
