eMedici - Cardiology 2/2 Flashcards
Presentation - A 68-year-old retired electrician, presents to the Emergency Department complaining of dyspnoea and chest discomfort. Johan first noticed his shortness of breath yesterday and it has been getting worse since then. His symptoms are constant and are worsened when Johan tries to exert himself, such as going up the two flights of stairs to his apartment. The chest discomfort is not similar in nature to his angina pain. In addition to these symptoms, he also has significantly swollen ankles.
Which of the following are likely differential diagnoses for this presentation?
In the absence of an elevated troponin, which one of the following is the most likely diagnosis to explain the patient’s illness?
- Congestive heart failure
- Myocardial infarction
- Pulmonary embolism
- Subacute cardiac tamponade
= Subacute cardiac tamponade
Physical examination - The registrar now considers cardiac tamponade to be the most likely diagnosis and, realising the serious nature of the condition, proceeds to a quick physical examination. Which of the following features, if present on physical examination, would support the diagnosis of tamponade?
Which of the following are causes of cardiac tamponade?
- Malignancy
- Mitral regurgitation
- Penetrating trauma
- Post-cardiac injury
- Recent thoracic surgery
- Uremia
Investigations - With subacute cardiac tamponade now the leading diagnosis for this patient, the cardiologist considers further investigations to order. While she knows the diagnosis of tamponade is largely clinical, certain investigations may help her to decide on a management plan for Johan.
Which of the following investigations are appropriate?
- ECG
- Echocardiogram
- Exercise stress test
ECG & Echocardiogram
ECG interpretation - An echocardiogram is performed on Johan. Which of the following echocardiogram descriptions would best confirm the diagnosis of cardiac tamponade?
= Moderate pericardial effusion with right atrium collapse at end-diastole
Which of the following is the most appropriate treatment at this stage?
- Inotropes
- Pericardial drainage
- Supportive fluid therapy
- Watchful waiting
= Pericardial drainage
Complications - The cardiologist explains the proposed treatment options to Johan. He agrees to undergo pericardiocentesis once she explains that the process would involve placing an ultrasound-guided needle and drain into the pericardial sac for removal of the fluid. The patient undergoes successful pericardiocentesis and returns to the ward for further monitoring with telemetry and frequent vital sign assessment. Johan is now asking about the possibility of complications after his procedure. Which of the following are possible complications of pericardiocentesis?
Which one of the following is the most likely cause of this woman’s presentation?
- Chronic Obstructive Pulmonary Disease (COPD)
- Iron deficiency anaemia
- Heart Failure
- Bronchial carcinoma
- Hypothyroidism
- Pulmonary embolism
- Asthma
= Heart Failure
Assessment - The New York Heart Association (NYHA) functional classification provides a simple way of grading a patient’s symptoms. Although it is difficult to predict prognosis in an individual, patients with symptoms at rest (NYHA class IV) have a 30-70% annual mortality rate, whereas patients with symptoms with moderate activity (NYHA class II) have an annual mortality rate of 5-10%. As a reminder: Mrs. Ellington’s history reveals that over the past 6 months she has been experiencing increasing shortness of breath and fatigue on walking to the shop (100 m) and hanging up her washing. Her ankles are always swollen by the end of the day. Based on this history provided which NYHA class does the patient belong?
NYHA II
Clinical signs - On physical examination, the patient is able to get onto the examination bed with no issues and is lying comfortably at 45 degrees. Her BP is 136/84 with HR of 84, regular and RR 15. Her JVP is elevated (measured at 4cm vertical height above the sternal angle). On examination of the praecordium, the apex beat is laterally displaced and a third heart sound (S3) is heard on auscultation. Bibasal crepitations are heard on auscultation of the posterior chest. Mild hepatomegaly is noted on abdominal examination and there is pitting oedema bilaterally to the mid shins. Which of the following clinical features are predominantly due to right-sided heart failure?
= Raised jugular venous pressure (JVP), Peripheral oedema, & Hepatomegaly
Investigations - In view of a probable diagnosis of heart failure, further investigations are required in confirming the diagnosis. Which of the following is the most appropriate investigation at this stage?
= Electrocardiogram
Investigations - An ECG is performed and demonstrates pathological Q waves (consistent with previous infarct) and evidence of left ventricular hypertrophy. There is no evidence of arrhythmia. Which of the following investigations should be undertaken at this point?
Assessment - Baseline bloods (as listed previously) are performed as well as a chest X-ray. CBE, EUC and LFTs are unremarkable. The HbA1c is 6.4% indicating adequate control. A chest X-ray (image) is performed and demonstrates cardiomegaly, bilateral hazy opacification (pulmonary oedema) and upper lobe pulmonary redistribution, in keeping with heart failure. Plasma natriuretic peptides are markedly elevated and are as follows: * NT-proBNP – 912 pg/mL * BNP – 486 pg/mL. Based on the above findings, an echocardiogram is performed and demonstrates left ventricular ejection fraction (LVEF) of 37% with no valvular abnormalities. What is the most appropriate classification of this patient’s heart failure?
Heart failure with reduced ejection fraction (HFrEF)
Management - A referral is made to a cardiologist who performs a clinical assessment and reviews the investigation results. Some thought now needs to be placed into how best Mrs. Ellington should be managed. In the absence of contraindications, which of the following management strategies should be recommended in ALL patients with HFrEF?
Management - Mrs. Ellington’s current medications are as follows:
- Ramipril 5mg daily
- Aspirin + clopidogrel 100mg/75mg daily
- Atorvastatin 40mg nocte
- Calcium carbonate 1000 mg daily
Considering the new diagnosis of HFrEF, what changes to her medications should now be made?
= Up-titrate ramipril, Commence beta-blocker, & Commence a loop diuretic.
Treatment - Beta-blockers form part of the first-line therapy in the management of HFrEF considering their synergistic effect with ACE-I in reducing mortality . In the absence of contraindications, a beta-blocker should be commenced in addition to an ACE-inhibitor in patients with HFrEF, for whom reduced mortality is an appropriate therapeutic goal. Which of the following are appropriate beta-blocker that could be commenced?
= Carvedilol, Metoprolol XR, Nebivolol, & Bisoprolol.
Contraindications - Each patient requires careful consideration of the risks and benefits of commencing a new medication. Which of the following is a contraindication for the use of a beta-blocker in heart failure?
= Asthma
Prognosis - Australia has an ageing population. What is the median survival following a diagnosis of heart failure?
= 3-4 years - The combination of an ageing population with advances in modern therapeutic interventions has resulted in an increasing incidence of many chronic diseases, including heart failure. Despite improvements in therapy, mortality in heart failure remains high. The two main causes of death in heart failure are sudden arrhythmic death and progressive pump failure with haemodynamic deterioration
Heart Failure:
- Definition?
- Epidemiology in Australia?
- Aetiology?
- Clinical signs?
Heart Failure
- Investigations?
- Echocardiography?
- Pharmacological Management?
Heart Failure
- Comprehensive Management Approach?
Presentation - You are the general practitioner on call in a small rural town and you receive a call at 10pm on a Friday night regarding a 67-year-old women reporting a ‘jumpy heart beat’. This patient has a reputation for presenting quite frequently with various ailments for which no cause is often found. The nurse on the other end of the telephone seeks your advice. This is not the first time you have been telephoned about this patient on a Friday evening. You have just settled down with a good book and are looking forward to a quiet evening. Which one of the following is the most appropriate advice before you assess the patient?
= Put the patient on an ECG monitor
ECG interpretation - You arrive in the Emergency Department and look around for the patient. You head for her cubicle but before you can ask the patient any questions, you are handed an ECG. What does the ECG show?
= Atrial fibrillation
How would you classify this patient’s atrial fibrillation?
- Paroxysmal atrial fibrillation
- Persistent atrial fibrillation
- Permanent atrial fibrillation
- Long-standing atrial fibrillation
= Paroxysmal atrial fibrillation
Risk factors - You realize that in the evaluation and management of this patient, it is important to consider whether or not there are any reversible risk factors underlying her AF, as it will also be important to manage these as well as the AF itself. Which of the following are potential risk factors/precipitants of atrial fibrillation?
= All of them
Investigations - Further questioning reveals no symptoms suggestive of acute infection, hyperthyroidism or acute coronary syndrome. She denies the use of illicit drugs or OTC medications and has not drunk alcohol for 30 years. She states she does sometime feel tired throughout the day and that her partner has commented that she snores in her sleep. What investigations should be undertaken (both immediately and also in the outpatient setting) in the evaluation of this patient with first-presentation atrial fibrillation?
Which of the following are the preferred rate-control medications for this patient?
- ACE-Inhibitors
- Beta-blockers
- Dihydropyridine calcium channel blockers
- Non-dihydropyridine calcium channel blockers
- Digoxin
= Beta-blockers & Non-dihydropyridine calcium channel blockers
Management - Stepping away from the current case of a stable patient presenting with AF, let us consider the case of another patient who has also presented with AF but with a BP of 92/52 and severe shortness of breath. Which of the following is the most appropriate immediate management in this patient?
= DC Cardioversion
Assessment - Now, back to the initial patient. Being a competent clinician, you understand that atrial fibrillation is a significant risk factor for thromboembolic complications (particularly stroke) and that the need for long-term anticoagulation is something that must be considered in all patients with AF. You recall that the CHA2DS2-VASc score is a useful method of determining whether or not the benefit of long-term anticoagulation will outweigh the risks in non-valvular atrial fibrillation. What are the components of the CHA2DS2-VASc score?
Assessment - As important as it is to be able to calculate a patient’s thromboembolic risk with the CHA2DS2-VASc score, the ability to determine the appropriate approach to anticoagulation based on a patient’s score is equally as important. Which of the following statements regarding long-term anticoagulation in non-valvular atrial fibrillation is correct (provided there are no contraindications to anticoagulation)?
Treatment - In consideration of the fact that this patient is female (1 point), has angina (1 point as this is a form of vascular disease) and is age 67 (1 point) you realize that long-term anticoagulation is warranted based on her CHA2DS2-VASc score. Regarding anticoagulation, which of the following pharmacologic treatments should she receive in the long-term?
Apixaban
Clinical assessment - Despite apixaban (5mg BD) being the preferred choice for long-term anticoagulation in atrial fibrillation, there are certain situations in which warfarin is preferred. Which of the following situations would prompt the use of warfarin over apixaban?
= Valvular AF, Creatinine clearance <25 mL/minute, & Patient preference
Which one of the following is the most appropriate next step in management?
- Erect chest X-ray
- Cardiac enzyme levels
- CT abdomen
- Electrocardiogram
- Urgent transfer to a metropolitan hospital for coronary angiography
- Pancreatic enzymes (amylase, lipase)
- Serum lactate
- Ultrasound of the upper abdomen
= Electrocardiogram
ECG interpretation - Whilst the nurse connects the ECG leads, you take a blood sample for some baseline investigations, which include a complete blood examination, EUC, lipid studies, blood glucose level and cardiac enzymes. Upon returning from the lab, the patient’s ECG is recorded and is shown below. What is the diagnosis?
- Anteroseptal STEMI
- Pericarditis
- Inferior STEMI
- Lateral STEMI
- Normal ECG
- NSTEACS
= Inferior STEMI
Management - In consideration of the ECG findings of an inferior STEMI, urgent decisions need to be made regarding the appropriate reperfusion strategy (fibrinolysis vs. PCI). Whilst fibrinolysis can be undertaken in Emergency Department, this small rural hospital is not equipped with a cardiac catheterization laboratory. You decide to contact the cardiology registrar on-call at the closest metropolitan hospital for advice. However, before this is done, some initial medical therapy should be commenced in this patient who remains in severe pain. What is the appropriate medical management to be initiated at this stage?
= Anticoagulation, Analgesia, & Dual antiplatelet therapy
Management - You are put through to the cardiology registrar on call at the closest metropolitan hospital (which is equipped with a catheterization laboratory). You present the pertinent points of the case and also what initial management has been started. The key decision at this point is the choice of reperfusion strategy for this patient. The registrar estimates that with an urgent transfer, the patient will reach the cath lab for PCI within 70 minutes. It has now been 90 minutes since the onset of pain. Which one of the following is the appropriate reperfusion strategy for this patient?
- Primary percutaneous coronary intervention
- Fibrinolysis
= Primary percutaneous coronary intervention
What are the absolute contraindications to the use of fibrinolysis?
Management
An urgent transfer is made to the nearby hospital where PCI is undertaken. Although there is flow down the distal vessel, the angiogram shows a >90% stenosis of the dominant right coronary artery (see image), which is successfully opened with a drug-eluting stent. He remains on the ward for a period of three days and is pain-free and stable. Advice is given regarding lifestyle modification (specifically smoking cessation, weight reduction and regular activity). He is also advised to follow-up with his general practitioner regarding ongoing diabetic control. What medical therapy should the patient be discharged with?
What is the Initial medical therapy for a STEMI?
What are the options for reperfusion in STEMI? When can you do PCI vs. Fibrinolysis?
Which one of the following is the most likely diagnosis?
- Aortic dissection
- Acute myocardial infarction
- Lower lobe pneumonia
- Biliary colic
- Spontaneous pneumothorax
- Oesophageal spasm
= Acute myocardial infarction
Investigations - Mr Walters attached to monitors to obtain a cardiac tracing and to measure his peripheral oxygen saturation. An intravenous line is inserted. He is pale and sweaty with a blood pressure of 86/62 mmHg and a pulse of 50/min. His apex beat is not displaced nor are there any added heart sounds. His jugular venous pressure is not raised and there are no bruits heard on auscultation of his neck vessels. The respiratory system is normal and abdominal palpation does not give any helpful information. He is given fentanyl for his pain. Which of the following investigations would be appropriate at this stage?
ECG interpretation
Whilst the history and physical examination proceed a formal electrocardiogram is performed. The ECG trace is shown. What does the ECG show?
- A normal pattern
- Acute Inferior myocardial infarction (STEMI)
- First degree heart block
- Mobitz type I
= Acute Inferior myocardial infarction (STEMI)
Management - The electrocardiography findings indicate that Mr Walter has acute inferior STEMI and complete heart block. Measures are taken to manage his myocardial infarction and arrangements are made for urgent angiography. The principles of treatment of myocardial infarction are discussed in the case ‘Chest pain in a 62-year-old man.’ The current case will focus on the problem related to the heart complete block. With regards to the heart block, which one of the following is the most appropriate next step in the management?
= Transcutaneous pacemaker
Complications - Mr Walter’s heart rate is brought under control with transcutaneous pacing. Whilst thought is given to the more long-term management of his complete heart block, some consideration must be given to possible complications. Which of the following are complications of complete heart block?
- Ventricular tachycardia or fibrillation
- Pneumothorax
- Cardiac failure
- Sudden cardiac death
Ventricular tachycardia or fibrillation, Cardiac failure, & Sudden cardiac death.
Which of the following diagnoses should be considered at this stage?
- Acute infective endocarditis
- Sub-acute infective endocarditis
- Pneumonia
- Acute rheumatic fever
- Myocardial infarction
= Acute infective endocarditis & Acute rheumatic fever
Investigations - With two potential cardiac conditions being uppermost in mind, some investigations need to be undertaken. Which of the following investigations would be appropriate at this stage?
The ECG confirms atrial fibrillation. Bloods are sent off for stand laboratory investigations and culture. Mr Wirl is septic and even thought the exact source of the sepsis is unknown and possible infective organisms have yet to be confirmed, empiric antibiotic therapy must be started.
Which of the following antibiotic regimens would be most appropriate?
= Gentamicin and vancomycin
Assessment - The next day, the laboratory results of Mr Wirl’s cultures come through and have grown Staphylococcus aureus and Streptococcus. The echocardiogram shows severe mitral regurgitation and a large, 1cm vegetation on the valve leaflet. The leaflets are thickened and abnormal, consistent with previous carditis and mitral valve damage. Mr Wirl now meets the Duke’s Criteria for a diagnosis of Infective Endocarditis. This is based on an integration of the clinical picture, microbiology results and imaging findings. Mr. Wirl is commenced on vancomycin and gentamicin. During his admission he has two episodes of acute pulmonary oedema; a trans-oesophageal echocardiogram shows partial destruction of the mitral valve leaflets and a 1cm vegetation attached to one of the leaflets It is decided that Mr. Wirl needs valve surgery. Which of the following clinical criteria would indicate the need for valve surgery.
= Valve regurgitation leading to cardiac failure, Fungal infection of the valve, & Presence of heart block
Follow up - Mr Wirl undergoes mitral valve replacement after he shows microbiological evidence of asepsis. He makes a steady and uneventful recovery from surgery. He is started on warfarin. Which of the following discharge arrangements will be required?
= Warfarin after discharge, Prophylactic antibiotics, & Medic alert bracelet
Which of the following investigations would be appropriate at this stage?
- Electrocardiogram
- Serum urea and electrolytes
- Fasting Blood glucose
- Liver function tests
- Lipid profile
- Endoscopy
What does the ECG show?
- A normal pattern
- Myocardial ischaemia
- Left ventricular hypertrophy
- Acute inferior myocardial infarction
= Left ventricular hypertrophy
Investigations - Mr Cecil does not appear to have had an ischaemic event. However, it would be prudent to consider if any further investigations should be arranged at this stage. Which of the following would be appropriate at this stage?
- Complete lipid profile
- Oral glucose tolerance test
- Global cardiovascular risk assessment
- Exercise stress test
- Coronary angiography
= Complete lipid profile & Global cardiovascular risk assessment
What does the ECG show?
= Acute anterior myocardial infarction
Which one of the following regimens would be most appropriate?
- Long term warfarin
- Clopidogrel alone for two years
- Aspirin alone for two years
- Aspirin and clopidogrel for two years
- Rivaroxaban
- Dabigatran
= Aspirin and clopidogrel for two years
History - Mr Perea is a 74-year-old man who presents to the Emergency Department of his local hospital with chest pain. He has a history of ischaemic heart disease and has experienced five episodes of central chest tightness in the last three days, each lasting between 5 - 10 minutes. Each of these episodes had been precipitated by some form of activity and was relieved by a combination of rest and using his GTN spray. None have occurred at rest. He does not have any chest pain currently but is sufficient concerned with the recent episodes that he wants some help. He describes these episodes of pain as similar to his usual angina pain but occurring more frequently. He also complains of worsening fatigue and shortness of breath of late. He is also now experiencing episodes of extreme shortness of breath which suddenly wake him from sleep. He also reports that his ankles swell throughout the day.
History - More information is sought from Mr Perea to find out about his previous health issues. In conjunction with his case notes it transpires that he has an extensive history of ischaemic heart disease. He suffered an inferior STEMI at the age of 40 and subsequently underwent a double coronary bypass (LCA and LAD) from his saphenous vein. Two years ago, his left anterior descending graft was stented. His last echocardiogram was in six months ago and this showed a subjective ejection fraction of 38%. From the history, Mr Perea’s current problem appears to be that of cardiac failure. Which one of the following is the most likely cause of his cardiac failure?
= Ischaemic cardiomyopathy
Which of the following would be reasonable explanations for the recent worsening of Mr Perea’s symptoms?
- Worsening ischaemic heart disease
- Anaemia
- Infection
- Arrhythmia
- Lack of adherence to medications
- Excessive salt or fluid intake
- Medication side-effects
- His recent weight gain
- Kidney dysfunction
There are a number of causes of an acute decompensation of chronic heart failure (5) and these include:
1. Excessive salt intake
2. Noncompliance with medication/fluid restriction
3. Medication adverse effect – NSAIDs, calcium channel blockers
4. Development of arrhythmia
5. Myocardial infarction
6. Infection
7. Anaemi
8. Renal impairment
9. Pulmonary embolism
Investigations - There are many possible explanations for Mr Perea’s recent deterioration in health and some investigations are required. Which of the following investigations would be appropriate at this stage?
Which of the following are the most appropriate next steps in his management?
- Thiazide diuresis
- Daily weighing
- 2L fluid restriction
- Fluid balance chart
- Continuous positive airways pressure (CPAP)
= Daily weighing & Fluid balance chart
Treatment - Mr Perea is placed on a 1.5L fluid restriction regimen and his fluid balance is charted. He is given 40mg of intravenous furosemide twice daily, as well as his regular medications. Over the first 24 hours he passes 2.7L of urine, and consumes 1.2L of fluid. His weight the following day is 135.6kg. Attention must now be given to medications that would be suitable for minimising the long-term progression of heart failure and reducing the risk of death. Which of the following medications would best fit with these aims?
ACE-inhibitors/Angiotensin receptor blockers, Aldosterone antagonists, & Beta-blockers
Medications - Mr Perea has previously been commenced on bisoprolol. Other beta-blockers are also effective in reducing mortality in patients with heart failure. Which of the following beta-blockers are effective in reducing mortality in patients with heart failure?
Carvedilol, Metoprolol, & Nebivolol
Which of the following are important non-pharmacological management options for a patient with cardiac failure?
- Daily fluid restriction <1.5L
- Daily weight monitoring
- Salt restriction <5g/day
- Protein restriction
- Influenza vaccination
= Daily fluid restriction <1.5L, Daily weight monitoring, & Influenza vaccination
Which of the following are common differential diagnoses for Anita’s presentation?
- Reflex (neurally mediated) syncope
- Subclavian steal syndrome
- Orthostatic hypotension
- Psychogenic pseudosyncope
- Cardiac syncope
- Cyanotic breath holding spell
- Subarachnoid haemorrhage
- Epileptic seizures
= Reflex (neurally mediated) syncope, Orthostatic hypotension, Cardiac syncope, Epileptic seizures
The history suggests that Anita has been suffering syncopal episodes. Reflex syncope is the most common cause of a transient loss of consciousness. Reflex syncope encompasses both vasovagal and situational syncope. Vasovagal syncope is a common cause of syncope in athletes. Situational syncope may also occur in this setting as specific scenarios appear to trigger a neural reflex such as straining or squatting. In this age group orthostatic hypotension must be considered. This would likely due to acute or subacute volume depletion. This is possible in athletes who become dehydrated during intense physical activity. Reduced intravascular volume may induce a presyncopal event similar to the features of reflex syncope. However, the symptom of syncope is unlikely in true isolated orthostatic hypotension.
True syncope occurring during the ‘full flight’ of exertion and not in the post exercise cooling down period is a feature of cardiac syncope. While less common than other causes of syncope, there must be a high index of clinical suspicion for a cardiac cause of syncope - even in a patient of this age group.
History - From the history certain red flags have been raised. Which of the following are red flag features on history for any person presenting with syncope?
ECG interpretation - From the history, it would appear that Anita has high cardiac risk syncope. On examination she is in no obvious distress and her pulse is regular and 62/min. Her supine blood pressure is 126/82 mmHg and on standing it is 122/76 mmHg. There are no signs of heart failure. The apex beat is non-displaced. There are two heart sounds with nil added. A full neurological examination is unremarkable. A 12 lead electrocardiogram (ECG) is performed. What is the diagnosis?
**Prolonged QT interval (presumed congenital) **- The patient has a prolonged QT interval which, in the absence of QT prolonging medications, is likely to be congenital. A tip is to see that the QT interval is greater than 1/2 the RR interval. This should raise suspicion for a prolonged QT interval. The QTc by Bazett’s formula is 0.712, much greater than the normal QTc <460 ms in women. For a diagnosis of WPW, a patient must have evidence of both pre-excitation and supra-ventricular tachycardia. This ECG does not demonstrate pre-excitation (short PR, delta wave).
Investigations - The combination of a prolonged QT interval with a probable family history and history of unheralded syncope makes congenital long QT syndrome likely. The practitioner contacts the cardiology team at the nearest tertiary referral centre who suggest transfer for inpatient evaluation in the context of her recurrent symptoms. This is arranged and after discussion with Anita and her family, she is transferred to the cardiology unit. Which of the following investigations should be performed initially by the cardiologist for further evaluation and exclusion of other differential diagnoses?
= Complete blood examination, Serum biochemistry, Chest X-ray, & Echocardiogram
Baseline laboratory investigations are important. Other than a baseline test, electrolyte abnormalities such as hypokalaemia and hypomagnesaemia can prolong the QT interval and this would need to be corrected. A chest X-ray may identify signs of heart failure (pleural effusion, pulmonary oedema) if present, and may identify cardiomegaly. It also doubles up as a baseline test.
An echocardiogram is imperative in this situation. While the ECG is extremely suggestive of a chanellopathy (congenital Long QT syndrome), structural abnormalities of the heart need to be excluded. These involve valvular pathologies, ventricular wall thickness abnormalities or regional wall motion abnormalities.
Management - Anita is deemed as a high likelihood of having congenital long QT syndrome (LQTS) and as such, she agrees to further genetic studies. These has the benefit of potentially identifying the common mutation associated with the disease or identifying a new gene to the disease. The tests come back as positive and consistent with congenital Long QT syndrome 1, a common genotype of this condition. Anita is worried about her condition and asks what would be appropriate management to prevent symptoms and cardiac events. Which of the following would be appropriate first-line interventions for Anita?
= Avoiding high stress and intense exercise activities & Commencing a beta blocker.
What are the 3 broad classes of syncope?
What history, exam and ECG features would you expect for a patient with syncope?
Which of the following diagnosis should be considered?
- Gastro-esophageal reflux disease
- Myocardial ischaemia
- Pulmonary embolism
- Lobar pneumonia
- Pericarditis
- Pneumothorax
- Oesophageal rupture
- Pulmonary barotrauma
Which one of the following is the most likely diagnosis?
- Aortic regurgitation
- Aortic stenosis
- Mitral regurgitation
- Pericardial friction rub
= Pericardial friction rub
Investigations - From the clinical assessment, a diagnosis of pericarditis heads the list. Which of the following investigations would be appropriate?
Which one of the following is most characteristic of acute pericarditis?
- ST Segment elevation and T wave inversion
- Convex ST segment elevation
- Localised ST segment elevation
- Diffuse ST segment elevation
= Diffuse ST segment elevation
Which one of the following is most characteristic of acute pericarditis?
- ST Segment elevation and T wave inversion
- Convex ST segment elevation
- Localised ST segment elevation
- Diffuse ST segment elevation
= Diffuse ST segment elevation
Treatment - The ECG shows a normal sinus rhythm and a rate of 75/min. There is widespread ST elevation. The ECG supports the clinical diagnosis of pericarditis and some treatment must now be considered. Which of the following should be part of the initial treatment?
= Ibuprofen & High dose aspirin
Management - Stefan is given a 10 day course of ibuprofen (800mg tds) and advised to go home and rest. He is instructed to return to the cardiac clinic if his condition does not improve over the next few days. Stefan initially appears to respond to treatment with ibuprofen and simple analgesia. However, his response is slow and seven days after his initial present he still has pleuritic chest pain and is beginning to run a low grade temperature. Which one of the following is the most appropriate plan of management?
= Look for a different cause
Which one of the following should be the first step in management?
- Aspirin
- Ticagrelor
- Supplemental oxygen
- Glyceryl trinitrate
- Tenecteplase
= Aspirin
With which one of the following diagnoses are the ECG changes most consistent?
- Pericarditis
- Anterolateral myocardial ischaemia
- Anterior myocardial ischaemia
- Brugada pattern
- Inferior myocardial ischaemia
- Lateral myocardial ischaemia
= Inferior myocardial ischaemia
Treatment - With the diagnosis now established, further managment decisions must be made. Which of the following should be included in the next stage of Karl’s management?
= Enoxaparin, Ticagrelor, Percutaneous coronary intervention, & Intravenous fluids
Management - The ECG has confirmed an inferior ST-segment elevation myocardial infarction. Karl is given a loading dose of clopidogrel and a Code STEMI is called. As Karl arrives in the catheter laboratory he becomes drowsy and is unable to speak in full sentences. He still has a pulse but his systolic blood pressure has dropped further to 50 mmHg. The cardiac monitor shows the following ECG trace (Image). Which one of the following is the most appropriate immediate management?
- Adenosine 6 mg IV
- Amiodarone 150 mg IV over 10 minutes
- Sedation and synchronised shock of 200J with a monophasic external defibrillator
- Sedation and synchronised shock of 400J with a monophasic external defibrillator
- Intravenous magnesium sulphate
= Sedation and synchronised shock of 200J with a monophasic external defibrillator
Which one of the following drugs or drug combinations should be started to minimise the risk of stent thrombosis?
- Aspirin and apixaban
- Enoxaparin
- Warfarin
- Dabigatran
- Aspirin and ticagrelor
= Aspirin and ticagrelor
Management - Karl is started on aspirin 100 mg daily and ticagrelor 90 mg twice daily. He has been given a drug-eluting stent, which is designed to reduce the risk of restenosis through the sustained local delivery of an antiproliferative drug such as everolimus. This reduces neointimal proliferation of the stented vessel. Drug eluting stents were developed after bare metal stents to combat the issue of restenosis; 20-30% of patients with a bare metal stent would go on to develop >50% restenosis of the stented vessel (3). Which one of the following is the most appropriate duration of time for which both the aspirin and ticagrelor should be continued?
6 - 12 months
Knowledge - Whilst drug-eluting stents reduce neointimal proliferation around the stent lumen and hence reduce the risk of restenosis and the need for further revascularisation procedures, there are some circumstances where a bare-metal stent might be a preferred option. Which one of the following is the most likely reason to choose a bare-metal stent over a drug-eluting stent?
= The patient has a history of poor medication compliance.
Other than early cessation of dual antiplatelet therapy, which one of the following factors would place patients at higher risk of stent thrombosis?
- Older age
- Concurrent malignancy
- Elective stenting
- Stenting of an isolated coronary lesion
- Use of a bare-metal stent
= Concurrent malignancy
Knowledge - Some nine months after his myocardial infarction Karl presents to his gastroenterologist with a referral letter from his general practitioner. Karl has noticed occasional red blood in his stools. He is currently otherwise asymptomatic, and has a Hb of 120 g/L. His GP is concerned as Karl’s father died of bowel cancer at the age of 58, and would like the gastroenterologist to perform a colonoscopy to work this up further. The gastroenterologist understands Karl needs to consider the risk of bleeding from a diagnostic colonoscopy against the risk of stent thrombosis if antiplatelet therapy is discontinued. Which of the following endoscopic procedures are considered to carry a high risk of bleeding?
= Endoscopic retrograde cholangiopancreatography (ERCP), Placement of a percutaneous endoscopic gastrostomy (PEG) feeding tube & Endoscopic or colonoscopic polypectomy
Management - Karl is quite anxious about the possibility he might have bowel cancer and wants the gastroenterologist to find out why he has had blood in his stools. He does understand that a colonoscopic procedure might be associated with a real risk of haemorrhage - particularly if a polyp was found and requires resection. Which one of the following would be the most appropriate plan of management?
= Discontinue clopidogrel for at least five days and then proceed to colonoscopy
