Inhaled foreign body + palpitations + JVP

Question 1

What are the features of an inhaled foreign body?

Answer 1

• Cough
• Stridor
• Dyspnoea

Question 2

What are possible causes of palpitations?

Answer 2

• Arrhythmias
• Stress
• Increased awareness of normal heart beat / extrasystoles

Question 3

What are first-line investigations for palpitations?

Answer 3

12-lead ECG: this will only capture the heart rhythm for a few seconds and hence is likely to miss episodic arrhythmias. However, other abnormalities linked to the underlying arrhythmia (for example a prolonged QT interval or PR interval, or changes suggesting recent myocardial ischaemia) may be seen.

Thyroid function tests: thyrotoxicosis may precipitate atrial fibrillation and other arrhythmias

Urea and electrolytes: looking for disturbances such as a low potassium

Full blood count: anaemia

Question 4

How do you exclude episodic arrhythmias?

Answer 4

Holter monitoring:

• Portable battery operated device
• Continuously records ECG from 2-3 leads
• Usually done for 24 hours but may be used for longer if symptoms are less than daily
• Patients are asked to keep a diary to record any symptomatic palpitations. This can later be compared to the rhythm strip at the time of the symptoms
• At the end of the monitoring a report is generated summarising a number of parameters including heart rate, arrhythmias and changes in ECG waveform

Question 5

What do you do if no abnormality is found on the Holter monitor and symptoms continue?

Answer 5

• External loop recorder
• Implantable loop recorder

Question 6

How do you treat isolated systolic hypertension?

Answer 6

• Common in the elderly, affecting around 50% of people older than 70 years old
• 2011 NICE guidelines which recommends treating ISH in the same stepwise fashion as standard hypertension.

Question 7

What is ivabradine?

Answer 7

• Ivabradine is a class of anti-anginal drug which works by reducing the heart rate.
• It acts on the I_f (‘funny’) ion current which is highly expressed in the sinoatrial node, reducing cardiac pacemaker activity.

Question 8

What are the side effects of ivabradine?

Answer 8

• Visual effects, particular luminous phenomena, are common
• Headache
• Bradycardia, heart block

Question 9

What does the JVP show?

Answer 9

• Providing information on right atrial pressure, the jugular vein waveform may provide clues to underlying valvular disease.
• A non-pulsatile JVP = superior vena caval obstruction.
• Kussmaul’s sign describes a paradoxical rise in JVP during inspiration seen in constrictive pericarditis

Question 10

What is the ‘a’ wave?

Answer 10

Atrial contraction

• Large if atrial pressure e.g. tricuspid stenosis, pulmonary stenosis, pulmonary hypertension
• Absent in atrial fibrillation

Question 11

What are cannon ‘a’ waves?

Answer 11

• Caused by atrial contractions against a closed tricuspid valve
• Are seen in:
  
  • complete heart block
  • ventricular tachycardia/ectopics
  • nodal rhythm
  • single chamber ventricular pacing

Question 12

What is a ‘c’ wave?

Answer 12

• Closure of tricuspid valve
• Not normally visible

Question 13

What is a ‘v’ wave?

Answer 13

• Due to passive filling of blood into the atrium against a closed tricuspid valve
• Giant v waves in tricuspid regurgitation

Question 14

What is ‘x’ descent?

Answer 14

Fall in atrial pressure during ventricular systole

Question 15

What is ‘y’ descent?

Answer 15

Opening of tricuspid valve