Investigations

Question 1

Aortic Stenosis Heart Sound

Answer 1

• Cresendo-decresendo intensity
• Peaking in mid-systole
• Loudest on right sternal edge 2nd intercostal space
• Radiates to carotids

Question 2

Aortic Regurgitation Heart Sound

Answer 2

• Decresendo pattern in early diastole

- Loudest on left sternal edge 4th intercostal space with patient sitting forwards, holding breath in expiration

Question 3

Mitral Regurgitation Heart Sound

Answer 3

• Same intensity throughout systole
• Loudest at the apex
• Radiates to axilla

Question 4

Mitral Stenosis Heart Sound

Answer 4

• Rumbling, decrescendo murmur starting after an opening snap in diastole
• Loudest at the apex, with bell of stethoscope, with patient in left lateral position

Question 5

ECG changes in CAD

Answer 5

1. Pathological Q waves usually indicate current or prior MI. Q waves are pathological if:
   - > 40ms (1mm) wide
   - >2mm deep
   - > 25% of depth of QRS complex
   - Seen in leads V1-3
2. LBBB
   - Broad QRS (>3 small squares/0.12 secs) and
   - Deep S wave in V1
   - No Q wave in V5/V6
3. ST segment and T wave abnormalities (e.g. ST segment depression or T wave flattening or inversion)

Question 6

ACS Investigation

Answer 6

GOLD STANDARD: Cardiac troponin I and T testing as they reflect myocardial cellular damage.
They rise within 24 hours and may be elevated for 2 weeks.

Question 7

ACS Management

Answer 7

Coronary angiography

Question 8

ACS Risk Scores

Answer 8

Ischaemic risk - GRACE score
Bleeding risk - CRUSADE score

Question 9

Ischaemic Endocardium on ECG

Answer 9

ST interval is depressed. Cardiac tissue isn’t dying but is starved of oxygen.

Question 10

Infarcting Endocardium on ECG

Answer 10

ST interval is elevated (STEMI). T waves are inverted - signals cardiac event is occurring/occurred.
V1, V2 + V3 capture anterior part of the heart. If ST depression this could mean posterior MI as flipped it would be ST elevation.

Question 11

ECG Changes in ACS

Answer 11

• ST depression
• Transient ST elevation
• T wave changes, mostly T wave inversion

Question 12

Ventricular Tachycardia ECG

Answer 12

• Regularly rhythm
• Rate is just under 300
• QRS is wide/broad (>3 small squares)
• No clear P waves

Question 13

Supraventricular Tachycardia ECG

Answer 13

• Regularly rhythm
• Rate is just under 300
• QRS is narrow (<3 small squares)
• No clear P waves (it is difficult to tell if those are P or T
  waves)

Question 14

1st Degree Heart Block ECG

Answer 14

• Regular rhythm
• Rate is around 90
• QRS is narrow (< 3 small squares)
• P waves before every QRS
• PR interval is constantly prolonged (> 5 small
  squares)

Question 15

2nd degree heart block Mobitz I ECG

Answer 15

• Regularly irregular rhythm
• Rate is around 60 occasionally dropping to 33
• QRS is narrow (<3 small squares)
• P waves
• P-R interval is ever increasing until a QRS complex
  is missed

Question 16

2nd degree heart block Mobitz II

Answer 16

• Regularly irregular rhythm
• Rate is around 85 occasionally dropping to 38
• QRS is narrow (<3 small squares)
• There are P waves
• P-R interval is constant until a QRS complex is
  missed