PassMed Learning Points Flashcards
A 65-year-old man is undergoing coronary bypass surgery. To gain access to his thoracic cavity, the surgeon divides the patient’s sternum in the midline.
Which of the following vessels lies closest to the posterior aspect of the manubrium of the sternum at the midline and so is vulnerable when this bone is divided?
Brachiocephalic trunk
Left brachiocephalic vein
Left common carotid artery
Right internal thoracic vein
Superior vena cava
A 65-year-old man is undergoing coronary bypass surgery. To gain access to his thoracic cavity, the surgeon divides the patient’s sternum in the midline.
Which of the following vessels lies closest to the posterior aspect of the manubrium of the sternum at the midline and so is vulnerable when this bone is divided?
Brachiocephalic trunk
Left brachiocephalic vein
Left common carotid artery
Right internal thoracic vein
Superior vena cava
When starting statin treatment, how often should you monitor cholesterol levels? [1]
Every 3 months
What is the rule about age and deciding hypertension treatment? [1]
If over 55: CCB
What is the treatment aim when starting treatment to reduce lipid levels? [1]
Reduction of 40%
In primary prevention of cardiovascular disease, atorvastatin is started at [] mg once at night.
In primary prevention of cardiovascular disease, atorvastatin is started at 20 mg once at night.
A male with known angina currently managed on glyceryl trinitrate (GTN) spray presents to the Emergency Department with crushing central chest pain. A 12-lead electrocardiogram reveals ST depression and flat T waves. He is managed as acute coronary syndrome without ST elevation.
Which of the following options is most likely to be used in his immediate management?
Furosemide
Paracetamol
Warfarin
Simvastatin
Fondaparinux
A male with known angina currently managed on glyceryl trinitrate (GTN) spray presents to the Emergency Department with crushing central chest pain. A 12-lead electrocardiogram reveals ST depression and flat T waves. He is managed as acute coronary syndrome without ST elevation.
Which of the following options is most likely to be used in his immediate management?
Furosemide
Paracetamol
Warfarin
Simvastatin
Fondaparinux
Which changes to JVP waveform indicate a patient might have mitral stenosis? [2]
A wave absent
J wave prominent
Malar flush is associated with
mitral regurgitation
mitral stenosis
aortic stenosis
aortic regurgitation
Malar flush is associated with
mitral regurgitation
mitral stenosis
aortic stenosis
aortic regurgitation
It is advisable to stop [drug class] in patients with heart disease, as they have negative inotropic effects (reducing the contractility of the heart), exacerbating the condition.
It is advisable to stop calcium-channel blockers in patients with heart disease, as they have negative inotropic effects (reducing the contractility of the heart), exacerbating the condition.
The normal size of the aortic valve area is more than [] cm2, in mild AS it is more than [] cm2, in moderate AS it is from [] to []cm2, and in severe AS < [] cm2.
The normal size of the aortic valve area is more than 2 cm2, in mild AS it is more than 1.5 cm2, in moderate AS it is from 1.0 to 1.5 cm2, and in severe AS < 1 cm2.
A 64-year-old male is admitted to hospital following an episode of chest pain. There is no ST elevation on his initial electrocardiogram (ECG). His cardiac troponins come back elevated. Whilst in the Coronary Care Unit, he develops the following ECG:
His blood pressure begins to fall and he is haemodynamically unstable.
What is the best management for this condition?
- Emergency direct current (DC) cardioversion
- Intravenous adenosine
- Intravenous amiodarone
- Intravenous lidocaine
- Insertion of a temporary pacemaker
A 64-year-old male is admitted to hospital following an episode of chest pain. There is no ST elevation on his initial electrocardiogram (ECG). His cardiac troponins come back elevated. Whilst in the Coronary Care Unit, he develops the following ECG:
His blood pressure begins to fall and he is haemodynamically unstable.
What is the best management for this condition?
- Emergency direct current (DC) cardioversion
The ECG displays a wide-complex tachycardia consistent with ventricular tachycardia (VT). The differential diagnosis is a supraventricular tachycardia with bundle branch block. Management of VT depends on the haemodynamic status of the patient. If the patient is haemodynamically compromised, then emergency DC cardioversion must be considered first, which is the correct management choice for this patient.
If the patient is haemodynamically stable, chemical rather than electrical cardioversion is recommended. The drugs of choice are intravenous lidocaine or amiodarone. DC cardioversion may be necessary if medical therapy is unsuccessful.
How do you decided if chemical c.f. electrical cardioversion is preferred? [1]
If the patient is haemodynamically stable, chemical rather than electrical cardioversion is recommended. The drugs of choice are intravenous lidocaine or amiodarone. DC cardioversion may be necessary if medical therapy is unsuccessful.
Patients with hypertrophic obstructive cardiomyopathy (HOCM) often exhibit a characteristic [shape] left ventricular cavity
Patients with hypertrophic obstructive cardiomyopathy (HOCM) often exhibit a characteristic ‘banana-shaped’ left ventricular cavity
Which of the following best describes when the microscopic changes of acute MI first become visible?
Immediately after the infarct occurs
3-6 hours after infarct occurs.
12-24 hours after the infarct
3-10 days
4-6 weeks
Which of the following best describes when the microscopic changes of acute MI first become visible?
Immediately after the infarct occurs
3-6 hours after infarct occurs.
12-24 hours after the infarct
3-10 days
4-6 weeks
A 65-year-old male with hypertension and hypercholesterolaemia suffered severe central chest pain lasting one hour. His electrocardiogram in the ambulance shows anterolateral ST-segment elevation. His symptoms stabilised with medical treatment in the ambulance, but suddenly he died while on the way to hospital.
What is the most likely cause of his deterioration and death?
Mural thrombosis
Myocardial wall rupture
Papillary muscle rupture
Pulmonary oedema
Ventricular arrhythmia
A 65-year-old male with hypertension and hypercholesterolaemia suffered severe central chest pain lasting one hour. His electrocardiogram in the ambulance shows anterolateral ST-segment elevation. His symptoms stabilised with medical treatment in the ambulance, but suddenly he died while on the way to hospital.
What is the most likely cause of his deterioration and death?
Ventricular arrhythmia
Beck’s triad of signs pathognomonic for tamponade are? [3]
a low blood pressure, a raised JVP and muffled heart sounds.
Describe the size of syringe and needle for peridcardiocentesis [2]
Treatment is urgent pericardiocentesis, with a 20-ml syringe and 18G needle, to aspirate the pericardial fluid
IVDUs most commonly experience [] valve endocarditis, which produces the [] murmur.
IVDUs most commonly experience tricuspid valve endocarditis, which produces the pan-systolic murmur.
An 86-year-old female presents with intermittent claudication.
Which investigation will be most helpful in determining whether she is a suitable candidate for bypass surgery?
Ankle-brachial pressure index
Electrocardiogram (ECG)
Urea and electrolytes
Contrast arteriography
Digital subtraction arteriography
Digital subtraction arteriography
What is the most appropriate investigation for an AAA?
X-ray
Ultrasound
Computerised tomography (CT) scan
Intravenous (IV) arteriogram
No imaging required – this is a clinical diagnosis
What is the most appropriate investigation for an AAA?
X-ray
Ultrasound
Computerised tomography (CT) scan
Intravenous (IV) arteriogram
No imaging required – this is a clinical diagnosis
A 65-year-old man with type 2 diabetes has just been started on insulin. His past medical history includes a heart attack 2 years ago for which he takes a beta-blocker, calcium channel blocker, ace-inhibitor, statin and has GTN-spray prescribed. Which of his medications could lead to a reduced awareness of the symptoms of a hypoglycemic event following his insulin use?
Beta-blocker
Calcium channel blocker
Ace-inhibitor
Statin
GTN-spray
A 65-year-old man with type 2 diabetes has just been started on insulin. His past medical history includes a heart attack 2 years ago for which he takes a beta-blocker, calcium channel blocker, ace-inhibitor, statin and has GTN-spray prescribed. Which of his medications could lead to a reduced awareness of the symptoms of a hypoglycemic event following his insulin use?
Beta-blocker
Beta-blockers can suppress all of the adrenergically mediated symptoms of hypoglycemia and thus can lead to unawareness of hypoglycemic events.
Beta Blockers can cause which effects in an overdose? [4]
Hypotension
Bradycardia
HYPOGLYCEMIA
Hypothermia
Is a paradoxical stroke more likely in VSD or ASD? [1]
Explain your answer [2]
Paradoxical stroke is much more likely in an ASD”
- the pressure gradient between the two atrial chambers is much smaller
- so blood (and clots) can flow from right to left occasionally.
- the left ventricular pressure is usually much greater than the right, so blood flow across a VSD is usually only left to right, so paradoxical embolism is much rarer (but can still happen).
Describe the differences in causes of damage to papillary muscle and chorde tendinae [2]
Papillary muscle, like the cardiac muscle, is just as susceptible to hypoxia and necrosis
- common complication of MI (it also happens in infective endocarditis for a similar reason).
Chordae tendinae is less susceptible to hypoxia
- more often damaged by infective endocarditis and rheumatic due to inflammation.
Which valvular pathology is an acute complication of MI? [1]
How long after an MI does this occur? [1]
Acute mitral regurgitation is a complication of myocardial infarction (MI):
- which most commonly occurs 2 to 7 days after
If pain was felt in the buttocks and gluteal region with a patient with PAD, where in the arterial system would the issue be? [1]
Internal iliac artery
External iliac artery
If pain was felt in the bilateral leg and buttocks, in a patient with PAD, where in the arterial system would the issue be? [1]
Aorta
What are the three Ps of vasovagal syncope? [3]
Prodromal symptoms:
- sweating or feeling warm/hot before TLoC
Posture
- prolonged standing, or similar episodes that have been prevented by lying down
Provoking factors
- such as pain or a medical procedure
Which of the following is most likely to be the cause of a large JVP v-wave (giant v-wave)?
Atrial fibrillation
Cardiac tamponade
Obstruction of the superior vena cava
Tricuspid regurgitation
Ventricular tachycardia
Which of the following is most likely to be the cause of a large JVP v-wave (giant v-wave)?
Atrial fibrillation
Cardiac tamponade
Obstruction of the superior vena cava
Tricuspid regurgitation
Ventricular tachycardia
Which of the following is most likely to be the cause of a loss of a JVP a wave?
Atrial fibrillation
Cardiac tamponade
Obstruction of the superior vena cava
Tricuspid regurgitation
Ventricular tachycardia
Which of the following is most likely to be the cause of a loss of a JVP a wave?
Atrial fibrillation
Cardiac tamponade
Obstruction of the superior vena cava
Tricuspid regurgitation
Ventricular tachycardia
Describe the murmur in mitral stenosis [1]
The characteristic murmur of mitral stenosis is a mid-diastolic rumbling murmur following an opening snap after the second heart sound
What is an absolute contraindication to thrombolysis?
Blood pressure of 180/100 mmHg
Active peptic ulceration
Advanced liver disease
Pregnancy
Brain neoplasm
What is an absolute contraindication to thrombolysis?
Brain neoplasm
The rest are all relative contraindications
Describe how often you monitor different sized AAAs [4]
If the initial scan shows an AAA of < 3 cm, they are discharged.
If it is between 3 and 4.4 cm, they are invited back for yearly screening.
If it is between 4.5 and 5.4 cm, they receive an ultrasound scan every 3 months
Above 5.5 cm, they are referred to a vascular surgeon for consideration for repair.
An 80-year-old man develops a bundle branch block during an acute myocardial infarction.
Which of the following arteries is most likely to be involved?
Left anterior descending artery
Circumflex branch of the left coronary artery
Acute marginal branch of the right coronary artery
Obtuse marginal branch of the circumflex artery
Atrioventricular nodal branch of the right coronary artery
An 80-year-old man develops a bundle branch block during an acute myocardial infarction.
Which of the following arteries is most likely to be involved?
Left anterior descending artery
Which branch of the coronary arteries supplies the left atrium of the heart?
Sinoatrial (SA) nodal artery
Left anterior descending artery
Circumflex artery
Left marginal artery
Posterior interventricular branch
Circumflex artery
A 61-year-old man with peripheral arterial disease is prescribed simvastatin. What is the most appropriate blood test monitoring? [1]
LFTs at baseline, 3 months and 12 months
[] is the intervention of choice for severe mitral stenosis
Percutaneous mitral commissurotomy is the intervention of choice for severe mitral stenosis
Which of the following arteries is most likely to be involved in aortic dissection?
Superior mesenteric artery
Inferior mesenteric artery
Coeliac artery
Right renal artery
Left renal artery
Left renal artery
Dissection of the descending aorta tends to propagate proximally and distally along the left lateral side of aorta. The renal arteries are lateral branches of the abdominal aorta. Therefore, the ostium of the left renal artery may be involved in aortic dissection.
State the most likley cause of aortic stenosis in:
- patients under 70 [1]
- patients over 70 [1]
Under the age of 70:
- bicuspid valve.
Over the age of 70:
- Calcific aortic stenosis
muffled heart sounds and pulsus paradoxus are associated with which cardiac condition? [1]
Cardiac tamponade
A 68-year-old male is started on amiodarone for atrial fibrillation.
What investigations should be performed before starting treatment?
Liver function tests (LFTs), urea and electrolytes (U&Es), thyroid function tests (TFTs) and chest X-ray
LFTs, U&Es, peak expiratory flow rate (PEFR)
TFTs, chest X-ray and pulmonary function test
LFTs, U&Es, TFTs and nerve conduction studies
Chest X-ray, LFTs, U&Es and visual field studies
A 68-year-old male is started on amiodarone for atrial fibrillation.
What investigations should be performed before starting treatment?
Liver function tests (LFTs), urea and electrolytes (U&Es), thyroid function tests (TFTs) and chest X-ray
Diffuse ST segment elevations are seen on ECG, which can be confused with myocardial infarction can be associated with which cardiac condition? [1]
Pericarditis
What are the limits of the normal cardiac axis?
0 to 90 degrees
0 to -90 degrees
-30 to 60 degrees
-30 to 90 degrees
30 to -60 degrees
What are the limits of the normal cardiac axis?
0 to 90 degrees
0 to -90 degrees
-30 to 60 degrees
-30 to 90 degrees
30 to -60 degrees
The patient undergoes primary percutaneous coronary intervention (PCI), during which an occlusion is found within a vessel lying within the coronary sulcus.
Which of the following structures is most likely to be the site of occlusion?
Anterior interventricular (left anterior descending) artery
Coronary sinus
Right coronary artery
Right (acute) marginal artery
Left coronary artery
The patient undergoes primary percutaneous coronary intervention (PCI), during which an occlusion is found within a vessel lying within the coronary sulcus.
Which of the following structures is most likely to be the site of occlusion?
Anterior interventricular (left anterior descending) artery
Coronary sinus
Right coronary artery
Right (acute) marginal artery
Left coronary artery
Describe the treatment algorithm for AF where symptoms have been present for over 48hrs [4]
Patients with symptoms for over 48 hours or duration of onset is uncertain:
* Rate control is the preferred mode of management:
* beta-blockers (except sotalol) or diltiazem/verapamil are first-line for rate control (2021 NICE updates)
* digoxin may be used if the patient is sedentary or if other rate‑limiting drug options unsuitable due to comorbidities or the person’s preferences (2021 NICE update).
* If symptoms are not controlled with monotherapy, a combination of two drugs may be used.
* If AF has been present for more than 48 hours and cardioversion is required, electrical cardioversion is preferred: it should not be attempted until the patient has been fully anticoagulated for at least three weeks.
When treating AAA, explain how the location of the aneurysm may determine the treatment used [2]
Standard EVAR techniques cannot be used to treat aneurysms that occur above the level of the renal arteries, and, in these cases, open repair is the only available option
Above the renal arteries, there is not an adequate length of the normal aorta to attach the graft, increasing the risk of blood leaking around the graft (an endoleak).
A 38-year-old male presents with central chest pain, which is worse when he leans backwards and when he breathes in deeply. There is no previous cardiac history and he is a non-smoker. Over the past few days, he has had a fever with cold and flu-like symptoms.
On examination, his blood pressure is 135/80 mmHg, and he has an audible pericardial rub.
What is the most likely diagnosis? [1]
Acute pericarditis
How do women present differently with when having an MI? [3]
Atypical symptoms:
- shortness of breath
- weakness
- fatigue
(rather than the typical substernal chest pain)
[] is an important differential to keep in the back of the mind for younger adults with poorly controlled hypertension
Coarctation of the aorta is an important differential to keep in the back of the mind for younger adults with poorly controlled hypertension
Describe how coarctation of the aorta may present in adults? [4]
- hypertension
- weak or absent femoral pulses
- heart failure
- left ventricular hypertrophy
Describe the classical findings of a patient with ASD [3]
Explain why these findings occur [2]
- Prominent right ventricular cardiac impulse
- A systolic ejection murmur heard best in the pulmonic area and along the left sternal border
- Fixed splitting of the second heart sound.
These findings are due to an abnormal left-to-right shunt through the defect, which creates a volume overload on the right side. This increase in volume on the right side creates a flow murmur, dilatation of the right-sided chambers, and delayed closure of the pulmonic valve, all of which are seen in this presentation. Small atrial septal defects are usually asymptomatic.
Wenckebach’s phenomenon is typically benign, particularly in patients with normal haemodynamics.
Wenckebach’s phenomenon is accompanied by [3], what treatment is indicated? [1]
Wenckebach’s phenomenon is typically benign, particularly in patients with normal haemodynamics.
If Wenckebach’s phenomenon is accompanied by acute myocardial infarction, complete heart block or symptomatic Mobitz type II block, temporary pacing is indicated
Which pathology does Beck’s triad refer to? [1]
What makes up Beck’s triad? [3]
Cardiac tamponade
- muffled or distant heart sounds
- low systolic blood pressure
- distended JVP
What does Kussmauls sign indicate? [2]
constrictive pericarditis or restrictive cardiomyopathy.
What is a positive Kussmaul’s sign? [2]
Kussmaul’s sign is a paradoxical rise in jugular venous pressure (JVP) on inspiration due to impaired filling of the right ventricle.
Describe the difference in x and y descent in JVP waveform in constrictive pericarditis c.f. cardiac tamponade [2]
cardiac tamponade:
- jugular veins have a prominent x descent and an absent y descent
Constrictive pericarditis:
- there will be a prominent x and y descent.
Describe what each part of the JVP waveform indicates [6]
a wave: Atrial contraction
X1 descent: relaXation of the atrium and closure of the tricuspid valve
c wave: ventricular Contraction and bulging of the tricuspid valve
X2 descent: due to eXtra space within the pericardium to allow atrial filling
v wave: increase in Volume of the right atrium due to filling
y descent: emptYing of the right atrium with tricuspid valve opening
This waveform relates to
Cardiac tamponade
Constrictive pericarditis
Atrial fibrillation
Atrial septal defect
Tricuspid regurgitation
This waveform relates to
Cardiac tamponade
Constrictive pericarditis
Atrial fibrillation
Atrial septal defect
Tricuspid regurgitation
This waveform relates to
Cardiac tamponade
Constrictive pericarditis
Atrial fibrillation
Atrial septal defect
Tricuspid regurgitation
This waveform relates to
Cardiac tamponade
Constrictive pericarditis
Atrial fibrillation
Atrial septal defect
Tricuspid regurgitation
This waveform relates to
Cardiac tamponade
Constrictive pericarditis
Atrial fibrillation
Atrial septal defect
Tricuspid regurgitation
This waveform relates to
Cardiac tamponade
Constrictive pericarditis
Atrial fibrillation
Atrial septal defect
Tricuspid regurgitation
This waveform relates to
Cardiac tamponade
Constrictive pericarditis
Atrial fibrillation
Atrial septal defect
Tricuspid regurgitation
This waveform relates to
Cardiac tamponade
Constrictive pericarditis
Atrial fibrillation
Atrial septal defect
Tricuspid regurgitation
Describe why this JVP abnormality may occur [2]
State two pathologies that might cause this [2]
A ‘cannon’, ‘giant’ or ‘large’ A wave is seen when there is simultaneous atrial and ventricular activation leading to contraction of the right atrium against a closed tricuspid valve
- This leads to a sharp, and pronounced, elevation in the JVP pressure.
They occur due to rhythmic dissociation between atria and ventricle: e.g. complete heart block, ventricular tachycardia.
Describe why this JVP abnormality may occur [1]
State a pathology that might cause this [1]
Giant ‘cv’ waves or tall ‘v’ waves are due to tricuspid regurgitation.
Blood regurgitates through the tricuspid valve during ventricular systole (i.e. when the right ventricle contacts). If severe, the c wave obliterates the v wave leading to the term ‘cv’ wave.
What is missing from this JVP waveform? [1]
Why might this occur? [1]
The a wave represents atrial contraction. Therefore, in conditions such as atrial fibrillation when there is rapid, chaotic, atrial firing these waves are absent.
Describe why this JVP abnormality may occur [2]
State a pathology that might cause this [1]
When filling of the right ventricle is impaired following the opening of the tricuspid valve, this may lead to a slow or absent y descent.
Examples include tricuspid stenosis or pericardial tamponade because there is equalisation of pressure across all chambers.
A patient with idiopathic pericarditis becomes increasingly unwell, with hypotension, jugular venous distension and muffled heart sound on auscultation. Echocardiogram confirms a pericardial effusion.
At which of the following sites does this effusion occur?
Between the visceral pericardium and the myocardium
Between the visceral pericardium and the parietal pericardium
Between the parietal pericardium and the fibrous pericardium
Between the fibrous pericardium and the mediastinal pleura
Between the fibrous pericardium and the central tendon of the diaphragm
A patient with idiopathic pericarditis becomes increasingly unwell, with hypotension, jugular venous distension and muffled heart sound on auscultation. Echocardiogram confirms a pericardial effusion.
At which of the following sites does this effusion occur?
Between the visceral pericardium and the myocardium
Between the visceral pericardium and the parietal pericardium
Between the parietal pericardium and the fibrous pericardium
Between the fibrous pericardium and the mediastinal pleura
Between the fibrous pericardium and the central tendon of the diaphragm
What is the first line investigation for aortic dissection? [1]
Computed tomography (CT) thorax with intravenous (IV) contrast
A low sodium diet contains < [] g of sodium daily.
A low sodium diet contains < 2 g of sodium daily.
Describe what a cardiac myxoma is [3]
Rare, benign tumour that arises from connective tissue, found in most commonly in left atrium
Often grow from a stalk and swing freely with the flow of blood, as a tetherball does.
As they swing, they may move in and out of the nearby mitral valve
This swinging motion may plug and unplug the valve over and over again, so that blood flow stops and starts intermittently.
Describe the signs and symptoms of myxoma [+]
Blockage of the flow through the mitral valve can also lead to:
- Syncopal episodes
- Dyspnea
- Pulmonary oedema
- JVP distension
- Afib - due to electrical disruption
- Clubbing
- TIAs
- CXR: unusual intra-cardiac calcification within the left atrium
What heart sounds would a myxoma cause?
Loud first heart sound and a plopping sound in early diastole are heard.
Precordial findings may mimic mitral stenosis. The first heart sound (S1) may be loud and widely split because of the delay in the closure of the mitral valve due to the prolapse of the tumour into the mitral valve orifice.
Name three causes of cardiac clubbing? [3]
Infective endocarditis
Cyanotic congential heart disease
Atrial myxoma
A 74-year-old female presents to her General Practitioner (GP) for a routine check-up. On examination, she appears slight breathless at rest. Her pulse is 74 bpm and irregularly irregular, and her blood pressure is 124/76 mmHg. Systems examination reveals nothing of concern. There is no significant medical history, and the patient is not on any regular medication.
What is the most likely cause of this lady’s atrial fibrillation (AF)?
Thyrotoxicosis
Ischaemic heart disease
Hypertension
Alcohol excess
Lone AF
A 74-year-old female presents to her General Practitioner (GP) for a routine check-up. On examination, she appears slight breathless at rest. Her pulse is 74 bpm and irregularly irregular, and her blood pressure is 124/76 mmHg. Systems examination reveals nothing of concern. There is no significant medical history, and the patient is not on any regular medication.
What is the most likely cause of this lady’s atrial fibrillation (AF)?
Thyrotoxicosis
Ischaemic heart disease
Hypertension
Alcohol excess
Lone AF
What is Carvallo’s sign? [1]
What pathology does it indicate? [1]
Pansystolic murmur that gets louder with inspiration
Indicates tricuspid regurgitation
State a pathological consequence of right heart failure in the liver [1]
How can you detect this? [1]
Right heart failure can lead to hepatomegaly due to increased back pressure
Detectable due to pulstatile hepatomegaly
The most common cause of a pulsatile liver is []
The most common cause of a pulsatile liver is tricuspid incompetence.
The descending thoracic aorta lies in which of the following compartments of the mediastinum?
Superior only
Posterior only
Middle only
Middle and superior
Superior and posterior
The descending thoracic aorta lies in which of the following compartments of the mediastinum?
Superior only
Posterior only
Middle only
Middle and superior
Superior and posterior
In acute heart failure, describe how the LV is impacted with regards to contraction / relaxation; EDV and ESV if the clinical findings suggest diastolic dysfunction as the underlying cause?
Impaired LV relaxation – increased LV end-diastolic pressure – normal LV end-systolic volume
In acute heart failure, describe how the LV is impacted with regards to contraction / relaxation; EDV and ESV if the clinical findings suggest systolic dysfunction as the underlying cause?
- e.g. from cardiomyopathy
Impaired LV contraction – increased LV end-diastolic pressure – increased LV end-systolic volume
Impaired LV contraction results in LV dilation (increased end-systolic and end-diastolic volumes) and increased LV end-diastolic pressure.
Explain the effect of cardiac tamponade on chamber pressures [2]
- Because the pericardial sac isn’t very compliant, when it becomes full of liquid it doesn’t expand much
- Therefore the pressures inside the heart chambers equalise as the ventricles have less room to fill during diastole
- Therefore EDV, SV & BP decrease
Define pulsus paradoxus [1]
Explain what is meant by pulsus paradoxus in cardiac tamponade [4]
Pulsus paradoxus:
* Auscultation of heart sounds in the inspiration associated with a drop in systolic blood pressure of > 10 mmHg
Pathophysiology:
* During inspiration, get decrease in intrathoracic pressure
* However, in cardiac tamponade you have an increased return to RA (due to equalised chamber pressures)
* This means that increase in RV filling
* Causes expansion into septal side & into the LV
* Thereby reducing stroke volume and blood pressure.
What is the upper age limit for a lung or heart transplant? [1]
For heart-lung transplant? [1]
Usually, 65 years is the upper limit for consideration of single, double lung or heart transplants, and 55 years for both heart and lung transplants.
List contraindications for a lung transplant [5]
- >65
- end-stage liver or kidney disease
- bone marrow failure
- active smoking
- debilitating psychiatric disease
List contraindications for cardiac transplantations [5]
- irreversible renal dysfunction (estimated glomerular filtration rate < 30 ml/min/1.73 m2),
- clinically severe symptomatic cerebrovascular disease
- tobacco and substance misuse
- active malignancy
- severe irreversible pulmonary hypertension.
Define hereditary hemorrhagic telangiectasia [1]
State 3 complications of it [3]
Hereditary hemorrhagic telangiectasia:
- Telangiectasias are a type of arteriovenous malformation (AVM). They are small, dilated blood vessels that occur close to the surface of skin or mucous membranes.
- AVMs in the lungs can lead to low blood oxygen levels and AVMs in the brain can cause seizures or headaches.
- The most common clinical features are nosebleeds and telangiectases on the lip, oral mucosa and hands.
- High-output cardiac failure is a rare complication of HHT usually caused by shunting of blood through AVMs in the liver
Define what is meant by Buerger’s disease [1]
Name a key risk factor [1]
Buerger’s disease (thromboangiitis obliterans):
- a distinct vascular disorder characterised by segmental thrombosing inflammation in medium-sized and small arteries
- Long term smoking big RF
Describe the typical presentation of Buerger’s syndrome [1]
These ECG changes would indicate which pathology? [1]
concave ST-segment elevation and PR depression in I, II, III, aVL, aVF and precordial leads (V2–V6), with reciprocal ST-segment depression and PR elevation in aVR (± V1)
Acute pericarditis
Describe the ECG changes seen
What pathology is likely to have caused these ECG changes? [1]
Acute pericarditis
* Widespread concave ST elevation and PR depression is present throughout the precordial (V2-6) and limb leads (I, II, aVL, aVF).
* There is reciprocal ST depression and PR elevation in aVR.
Describe how you would differentiate between:
- Subendocardial infarction
- Transmural infarction
Subendocardial infarction:
- setting of shock
- affects most ECG leads.
Transmural infarction:
* limitation of ST elevation to a few leads
A 65-year-old male with a past history of hypertension, hypercholesterolaemia, peripheral vascular disease and bilateral carotid endarterectomy developed sudden pain in his right foot with a dusky colour change. On examination in the Emergency Department, he has a cold, blue, painful foot with an absent dorsalis pedis and posterior tibial pulse.
Which of the following is the most appropriate investigation?
Ankle–brachial pressure index (ABPI)
Lower limb ultrasound with Doppler
Echocardiogram
Focused assessment with sonography for trauma (FAST) scan of the abdomen
Lower limb angiography
Lower limb angiography
Angiography is not performed when the clinical picture suggests complete occlusion, as it introduces a delay in revascularisation. In an incomplete occlusion, angiography uses stent placement to open the vessels.
The patient’s presentation of a long-term history of hypertension and complaints of a painful, burning sensation in both legs suggest []
Describe the pathophysiology of this disease [3]
The patient’s presentation of a long-term history of hypertension and complaints of a painful, burning sensation in both legs suggest coarctation of the aorta.
Pathophysiology:
* In this condition, patients typically present with hypertension in the upper extremities and hypotension in the lower extremities, as the aortic lumen narrows just distal to the branches of the aortic arch.
- Therefore, blood shunts preferentially through the arch vessels, and little flow passes through the descending aorta
- Furthermore, these patients can suffer from symptoms of lower extremity claudication due to low oxygen delivery to those regions
A 65-year-old female with no significant medical history develops a paradoxical embolic stroke following a deep vein thrombosis.
What embryological problem is most likely to explain this?
Bicuspid aortic valve
Patent foramen ovale
Tetralogy of Fallot
Transposition of the great arteries
Triscuspid atresia
A 65-year-old female with no significant medical history develops a paradoxical embolic stroke following a deep vein thrombosis.
What embryological problem is most likely to explain this?
Patent foramen ovale
Paradoxical emboli occur when venous thromboses avoid clot capture by the lungs and enter the systemic circulation by way of a shunt by a septal defect. Patent foramen ovale occurs in up to 30% of adults and results in failure of the septum primum and secundum to fuse, preventing the normal creation of the inter-atrial septum.
A patient has DMT2, which is their first line antihypertensive treatment? [1]
Describe why [1]
ACE inhibitor:
- Angiotensin-converting enzyme (ACE) inhibitors such as Ramipril have been shown to reduce proteinuria in diabetic nephropathy
Name a drug that is prognostically beneficial in heart failure? [1]
Spironolactone
Which is the first line investigation for: [3]
- Intermittent claudification
- CLI
- ALI
Intermittent claudification:
- ABPI
CLI:
- Duplex US
ALI:
- Doppler US
What is the first line investigation for varicose veins? [1]
Duplex ultrasound
This imaging would be given by [Duplex/Doppler]
This imaging would be given by Duplex
This imaging would be given by [Duplex/Doppler]
Doppler
Sudden onset tachycardia with recovery of normal sinus rhythm after carotid sinus massage or adenosine
This is most likely which pathology? [1]
Paroxysmal SVT:
- Most common type is AVNRT
What is the common cause of death from an MI? [1]
The most common cause of death within the first hour after the onset of symptoms is a lethal arrhythmia such as ventricular fibrillation
A 73-year-old female attends her General Practitioner post discharge from hospital. She was admitted three weeks ago with chest pain and diagnosed with a non-ST elevation myocardial infarction. While admitted, she was started on several new medications to prevent further cardiac events and would now like some more advice.
What is the most appropriate advice to give on her dose of statin?
Simvastatin 40 mg od
Simvastatin 80 mg od
Atorvastatin 20 mg od
Atorvastatin 40 mg od
Atorvastatin 80 mg od
A 73-year-old female attends her General Practitioner post discharge from hospital. She was admitted three weeks ago with chest pain and diagnosed with a non-ST elevation myocardial infarction. While admitted, she was started on several new medications to prevent further cardiac events and would now like some more advice.
What is the most appropriate advice to give on her dose of statin?
Simvastatin 40 mg od
Simvastatin 80 mg od
Atorvastatin 20 mg od
Atorvastatin 40 mg od
Atorvastatin 80 mg od
A 78-year-old male has had surgery to remove his left lung after being diagnosed with advanced non-small cell lung cancer.
Which of the following complications of this management is most likely to have the highest mortality?
Anastomotic dehiscence
Arrhythmias
Pneumonia
Pulmonary embolism
Pulmonary oedema
Pulmonary oedema
Name differentials for scenarops where patients may present with interarm blood pressure discrepancy >10mm Hg [3]
- Aortic dissections
- atherosclerosis
- PAD
A patient has dilated cardiomyopathy. Describe how you would expect to find their heart on CXR [1]
Balloon shaped
Aortic dissection
Haemophilus influenzae pneumonia
Describe how you would radiographically detect the adult form of coarctation of the aorta [1
Enlarged intercostal arteries produce notching of the inferior margins of the ribs, which can be detected by radiography and is diagnostic of this condition.
The adult form of aortic coarctation is caused by stenosis in the aortic arch, just distal to the left subclavian artery. This leads to hypertension proximal to, and hypotension distal to, the stenotic segment. Hypertension in the upper part of the body manifests with headache, dizziness and other neurologic symptoms. Hypotension in the lower part of the body results in signs and symptoms of ischaemia, most often claudication, i.e. recurrent pain due to ischaemia of leg muscles. In addition, collateral arteries between the pre-coarctation and post-coarctation aorta (e.g. the intercostal and internal mammary arteries) enlarge and establish communication between aortic segments proximal and distal to the stenosis. Enlarged intercostal arteries produce notching of the inferior margins of the ribs, which can be detected by radiography and is diagnostic of this condition. Remember that the infantile form of aortic coarctation is associated with patent ductus arteriosus, whereas the adult form is not.
A patient presents with hypotension, distended neck veins and muffled heart sounds.
What is the most likely diagnosis? [1]
Pericardial effusion
hypotension, distended neck veins and muffled heart sounds: Beck’s triad
A patient presents 48hrs post MI with hypotension, oliguria and pulmonary oedema.
What is the most likely diagnosis? [1]
cardiogenic shock secondary to an acute myocardial infarction
What is a temporary treatment option for a patient with cardiogenic shock secondary to an acute MI? [1]
intra-aortic balloon pump
- provides ventricular support without compromising the blood pressure. It is inserted by a cardiac surgeon and increases blood pressure via a ball–valve effect in the proximal aorta. This is a temporising measure to allow recovery or as a bridge to transplant.
A 76-year-old female presents to the General Practitioner complaining of ‘bulging blue veins’ on her legs. While examining the patient’s legs, you note the presence of tortuous, dilated veins, accompanied by brown patches of pigmentation and dry, scaly plaques of skin. A diagnosis of varicose veins is made.
Which vein is most likely to be affected?
Cephalic vein
Femoral vein
Long saphenous vein
Popliteal vein
Short saphenous vein
A 76-year-old female presents to the General Practitioner complaining of ‘bulging blue veins’ on her legs. While examining the patient’s legs, you note the presence of tortuous, dilated veins, accompanied by brown patches of pigmentation and dry, scaly plaques of skin. A diagnosis of varicose veins is made.
Which vein is most likely to be affected?
Long saphenous vein
Which term describes the tapering of the legs above the ankles (“inverted champagne bottle”) in patients with chronic venous disease?
Haemosiderin deposition
Atrophie blanche
Lipodermatosclerosis
Thrombophlebitis
Lipodermatosclerosis
Which investigation should be performed prior to compression bandaging for varicose veins?
Peripheral pulse oximetry
MRSA skin swab
Ultrasound for deep vein thrombosis
Ankle-brachial pressure index
Which investigation should be performed prior to compression bandaging for varicose veins?
Ankle-brachial pressure index
Prior to compression bandaging being applied, the patient needs to have their ABPI to ensure there will be no compromise to the arterial supply to the limb
What is meant by the term ‘saphena varix’? [1]
How do they typically present? [2]
A saphena varix is a dilatation of the saphenous vein at the saphenofemoral junction in the groin.
It typically presents as a lump around 2-4cm inferior-lateral to the pubic tubercle.
It often has a bluish tinge, is soft to palpate and will vanish when the patient lies down which can help differentiate it from an inguinal hernia.
What is the main differential for a sapehna varix? [1]
Femoral hernia
Explain the electrolyte picture with an ruptured AAA [2]
Ruptured AAAcauses acidosis with a raised anion gap
- Reduced tissue perfusion leads to inadequate oxygenation, despite normal PaO2
- Widespread and significant anaerobic metabolism of glucose to lactic acid and possible impairment of hepatic metabolism (that would convert lactate back to glucose)
- If renal perfusion is compromised (i.e. due to hypotension), the ability of the kidney to excrete excess H+ may also be impaired.
A patient presents with chronic AF.
What pacemaker device would be suitable? [1]
VVI (Ventricular pacing)
A patient presents with this ECG.
What are your top two differentials? [2]
Explain how you would try and work out which one is causing the complaint [3]
- Anterior ST elevation myocardial infarction (STEMI)
-
Pericarditis
ST elevation in both
Pericarditis:
- chest pain relieved by leaning forwards
- commonly follows a viral illness
- PR depression and saddle shaped ST
Which jugular vein is commonly the best measure of central venous pressure (CVP)?
Right anterior
Right internal
Right external
Left internal
Left external
Which jugular vein is commonly the best measure of central venous pressure (CVP)?
Right anterior
Right internal
Right external
Left internal
Left external
A 25-year-old intravenous drug user is found to have a systolic murmur best heard at the left sternal edge at the fifth costal cartilage.
Disease at which one of the following anatomical sites is the most likely cause of the murmur?
Aortic valve
Interatrial septum
Interventricular septum
Mitral valve
Tricuspid valve
A 25-year-old intravenous drug user is found to have a systolic murmur best heard at the left sternal edge at the fifth costal cartilage.
Disease at which one of the following anatomical sites is the most likely cause of the murmur?
Tricuspid valve
- This regurgitation is likely caused by infective endocarditis, resulting in the formation of vegetations and destruction of the valve leaflets, leading to valve leakage. The patient’s history as an intravenous drug user increases the likelihood of right-sided heart involvement, as microbes can be introduced through injection into veins.
Explain the murmur heard in a patient with HOCM [2]
Ejection systolic murmur decreased by squatting
- This obstruction causes a reduction in the amount of blood the heart can pump out to the body, leading to decreased cardiac output
A patient has HOCM. What is their most likely murmur?
Early diastolic murmur at the end of expiration
Pansystolic murmur increased by squatting
Pansystolic murmur unaffected by position
Ejection systolic murmur increased by squatting
Ejection systolic murmur decreased by squatting
Ejection systolic murmur decreased by squatting
Explain why HOCM presents suddenly and now with progressive fatigue [1]
HOCM:
- Systolic function is preserved, whilst diastolic function is impaired by the increased septal growth
- The abnormal diastolic function is responsible for most symptoms.
Describe the ECG changes seen specifically in a posterior MI in leads V1-3 [4]
In posterior myocardial infarction, distinct ECG changes are observed in leads V1 through V3, which are opposite in pattern compared to an anterior/anteroseptal myocardial infarction.
Consequently, ST depression is commonly seen in these leads, reflecting the ischemic involvement of the posterior wall of the heart.
Which valvular pathology is most likely to cause syncope? [1]
Aortic stenosis
Aortic stenosis can lead to which of the following
Haemophilia
DIC
VWD
Polycythaemia rubra vera
T
Aortic stenosis can lead to which of the following
VWD
Turbulent flow across the stenotic aortic valve can lead to an acquired von Willebrand deficiency
High shear forces inducing structural changes in the shape of the protein leading to clotting abnormalities.
This is most likely associated with
Aortic regurg
Aortic stenosis
Mitral regurg
Mitral stenosis
This is most likely associated with
Aortic regurg
Aortic stenosis
Mitral regurg
Mitral stenosis
Angiodysplasia
A patient has low-gradient AS. Which is the most appropriate next imaging technqiue to use?
MCST
Dobutamine stress echocardiogram
CXR
Exercise stress test
A patient has low-gradient AS. Which is the most appropriate next imaging technqiue to use?
MCST
Dobutamine stress echocardiogram
CXR
Exercise stress test
How do you determine if an asymptomatic patient has AS? [1]
MCST
Dobutamine stress echocardiogram
CXR
Exercise stress test
How do you determine if an asymptomatic patient has AS? [1]
MCST
Dobutamine stress echocardiogram
CXR
Exercise stress test
Heyde’s syndrome is a combination of angiodysplasia causing anaemia, acquired coagulapathy and which valvular pathology?
Aortic regurg
Aortic stenosis
Mitral regurg
Mitral stenosis
Heyde’s syndrome is a combination of angiodysplasia causing anaemia, acquired coagulapathy and which valvular pathology?
Aortic stenosis
Heyde’s syndrome is a partly a result of which type of VWD? [1]
Acquired Type II VWD
What is meant by Tri-fascicular block? [3]
Combination of:
- RBBB
- left anterior fascicular block (LAFB): which shows LAD; prolonged PR waves
Explain what happens in the elcectrophysiology of left anterior fascicular block (LAFB)
In LAFB:
- Impulses are conducted to the left ventricle (LV) via the posterior fascicle, which inserts into the inferoseptal wall of the LV along its endocardial surface
Water hammer pulse is associated with which valvular pathology? [1]
A
(aka collapsing pulse)
Aortic regurgitation
LBBB is most asscociated with
- Aortic regurgitation
- Mitral regurgitation
- Aortic stenosis
- Mitral stenosis
LBBB is most asscociated with
Aortic stenosis
Afib is most asscociated with
- Aortic regurgitation
- Mitral regurgitation
- Aortic stenosis
- Mitral stenosis
Afib is most asscociated with
- Aortic regurgitation
- Mitral regurgitation
- Aortic stenosis
- Mitral stenosis
double-density sign is most asscociated with
- Aortic regurgitation
- Mitral regurgitation
- Aortic stenosis
- Mitral stenosis
double-density sign is most asscociated with
- Aortic regurgitation
- Mitral regurgitation - Aortic stenosis
- Mitral stenosis
shock and flash pulmonary oedema is most associated with:
- Aortic regurgitation
- Mitral regurgitation
- Aortic stenosis
- Mitral stenosis
- Acute mitral regurgitation
‘spike and dome’ pulse in carotid arteries may indicate which pathology? [1]
HOCM
Extreme pain preceded by skin changes indicates which pathology? [1]
NSTI
What does this AXR indicate? [1]
Gasless abdomen:acute mesenteric ischaemia
Name 4 causes of a positive Kussmaul’s sign [4]
Normally due to RH failure:
- constrictive pericarditis
- restrictive cardiomyopathy
- tricuspid stenosis
- pulmonary hypertension (PH)
In ALS, if IV access cannot be achieved then drugs should be given via the [] route ?
In ALS, if IV access cannot be achieved then drugs should be given via the intraosseous route (IO) - the tracheal route is no longer recommended
Is the most appropriate first-line anti-anginal for stable angina in a patient with known heart failure, if there are no contraindications?
A. Verapamil
B. Amlodipine
C. Nifedipine
D. Bisoprolol
E. Nicorandil
F. Isosorbide mononitrate
Is the most appropriate first-line anti-anginal for stable angina in a patient with known heart failure, if there are no contraindications?
A. Verapamil
B. Amlodipine
C. Nifedipine
D. Bisoprolol
E. Nicorandil
F. Isosorbide mononitrate
Patients may develop tolerance to this medication necessitating a change in dosing regime
A. Verapamil
B. Amlodipine
C. Nifedipine
D. Bisoprolol
E. Nicorandil
F. Isosorbide mononitrate
Patients may develop tolerance to this medication necessitating a change in dosing regime
A. Verapamil
B. Amlodipine
C. Nifedipine
D. Bisoprolol
E. Nicorandil
F. Isosorbide mononitrate
Describe what is meant by Buerger’s syndrome [1]
It is an inflammatory condition that causes thrombus formation in the small and medium-sized blood vessels in the distal arterial system (affecting the hands and feet).
Describe the two of the key diagnostic criteria for Buerger’s disease [2]
What is the usual population who suffer from Buerger’s disease? [2]
Younger than 50 years
Not having risk factors for atherosclerosis, other than smoking
Usually men 25-35 who have smoked heavily
Describe angiogram findings in Buerger’s disease [1]
Corkscrew collaterals
Describe the presentation of Buerger’s disease [2]
extremity ischaemia
* intermittent claudication
* ischaemic ulcers
superficial thrombophlebitis
Raynaud’s phenomenon
What is the main management of Buerger’s disease? [2]
- Complete cessation of smoking
- Intravenous iloprost (a prostacyclin analogue that dilates blood vessels).
Buerger’s disease
TOM TIP: The key presentation to remember for your exams is a []. The exam question may ask the diagnosis (Buerger disease or thromboangiitis obliterans) or ask the most important aspect of management ([]).
TOM TIP: The key presentation to remember for your exams is a young male smoker with painful blue fingertips. The exam question may ask the diagnosis (Buerger disease or thromboangiitis obliterans) or ask the most important aspect of management (completely stopping smoking).
The [] criteria are used for definitive diagnosis of infective endocarditis
The Duke criteria are used for definitive diagnosis of infective endocarditis
The Duke criteria are used for definitive diagnosis of []
The Duke criteria are used for definitive diagnosis of infective endocarditis
Infective endocarditis:
Acute endocarditis is most commonly caused by []
Subacute cases are most commonly caused by [] .
Acute endocarditis is most commonly caused by Staphylococcus
Subacute cases are most commonly caused by Streptococcus species.
What medication should be avoided in this patient?
The ECHO also reports left ventricular outflow tract.
Amiodarone
Atenolol
Disopyramide
Ramipril
Verapamil
What medication should be avoided in this patient?
Amiodarone
Atenolol
Disopyramide
Ramipril
Verapamil
ACE-inhibitors should be avoided in patients with HOCM
Name the ECG alteration shown [1]
What pathology is it pathognomic for? [1]
Electrical alternans
- Alternating loud and soft QRS complexes during to variation in fluid around the heart in each beat
- is suggestive of cardiac tamponade
According to the British National Formulary (BNF) and Resuscitation Council UK guidelines, [] is recommended as the first-line pharmacological treatment in cases of broad-complex tachycardia, particularly when the arrhythmia is suspected to be ventricular tachycardia (VT).
According to the British National Formulary (BNF) and Resuscitation Council UK guidelines, IV amiodarone is recommended as the first-line pharmacological treatment in cases of broad-complex tachycardia, particularly when the arrhythmia is suspected to be ventricular tachycardia (VT).
Describe the ECG changes you would expect in a person with hypothermia [4]
- Bradycardia (< 60bpm) and not tachycardia
- J waves
- Prolonged PR, QT and QRS intervals
- Shivering artefacts
- VT, VF or asystole
What is the management for the problem causing this ECG? [1]
IV magnesium sulphate
(ECG showing torsades de pointes)
How do posterior MIs present on an ECG? [3]
Tall, broad R waves (>30ms)
- ST DEPRESSION in V1, V2, V3 - most important
Upright T waves.
Dominant R wave (R/S ratio > 1) in V2.
Name this [1]
A double pulse felt in systole is called a bisferiens pulse or pulsus bisferiens.
Bisferiens pulse
A patient has chronic heart failure. You trial and ACEI but the patient is intolerant.
You then trial an ARB, but the patient is still intolerant.
What treatment should you consider nexr? [1]
Hydralazine and nitrate
A patient has chronic heart failure.
You iniate an ACEin and a BB as first line treatment. This does not resolve their EF.
You next trial and aldosterone antagonist. This does also not help.
They are Afro-Carribean.
What is the appropriate third line treatment?
- Ivabradine
- sacubitril-valsartan
- digoxin
- hydralazine in combination with nitrate
- cardiac resynchronisation therapy
- hydralazine in combination with nitrate
A patient has chronic heart failure.
You iniate an ACEin and a BB as first line treatment. This does not resolve their EF.
You next trial and aldosterone antagonist. This does also not help.
They have LVEF < 35% and symptomatic
What is the appropriate third line treatment?
- Ivabradine
- sacubitril-valsartan
- digoxin
- hydralazine in combination with nitrate
- cardiac resynchronisation therapy
A patient has chronic heart failure.
You iniate an ACEin and a BB as first line treatment. This does not resolve their EF.
You next trial and aldosterone antagonist. This does also not help.
They have LVEF < 35% and symptomatic
What is the appropriate third line treatment?
sacubitril-valsartan
Describe the abnormalities of this ECG [2]
U waves are visible in leads V2 and V3, and QT interval prolongation
An 87-year-old woman presents to the emergency department with confusion and generalised malaise following a syncope. On examination, she looks pale and clammy, her pulse is regular and slow. Her vital signs show the following: heart rate 45/min, respiratory rate 7/min, blood pressure 87/55 mmHg and temperature 35.9 ºC. She has a past medical history of amyloidosis and types two diabetes mellitus, usually well controlled.
Which one of the following management options is the most appropriate for this patient?
DC cardioversion
Transcutaneous pacing
IV adrenaline
IV adenosine
IV atropine
An 87-year-old woman presents to the emergency department with confusion and generalised malaise following a syncope. On examination, she looks pale and clammy, her pulse is regular and slow. Her vital signs show the following: heart rate 45/min, respiratory rate 7/min, blood pressure 87/55 mmHg and temperature 35.9 ºC. She has a past medical history of amyloidosis and types two diabetes mellitus, usually well controlled.
Which one of the following management options is the most appropriate for this patient?
DC cardioversion
Transcutaneous pacing
IV adrenaline
IV adenosine
IV atropine
A 14-year-old boy presents to the Emergency Department as he is unable to control his facial muscles and arm movements. For the last 5 weeks, following a throat infection, he has been experiencing ongoing fever, worsening shortness of breath and joint pains, mainly in his legs which have not been effectively managed. What is the most likely cause of the patient’s recent symptoms?
Huntington’s chorea
Chorea gravidarum
Wilson’s disease
Drug-induced chorea
Sydenham’s chorea
A 14-year-old boy presents to the Emergency Department as he is unable to control his facial muscles and arm movements. For the last 5 weeks, following a throat infection, he has been experiencing ongoing fever, worsening shortness of breath and joint pains, mainly in his legs which have not been effectively managed. What is the most likely cause of the patient’s recent symptoms?
Huntington’s chorea
Chorea gravidarum
Wilson’s disease
Drug-induced chorea
Sydenham’s chorea
Describe the treatment algorithm for ALS
- CPR 30:2
- Attach defibrillator
- Assess rhythm:
- If shockable (VF / Pulseless VT): one shock, then resume CPR for 2 min then assess rhythm again and repeat
- If non-shockable: immediately resume CPR for 2 mins and assess rhythm again
Adrenaline:
- 1 mg as soon as possible for non-shockable rhythms
- during a VF/VT cardiac arrest, adrenaline 1 mg is given once chest compressions have restarted after the third shock
- repeat adrenaline 1mg every 3-5 minutes whilst ALS continues
amiodarone:
* 300 mg should be given to patients who are in VF/pulseless VT after 3 shocks have been administered.
* a further dose of amiodarone 150 mg should be given to patients who are in VF/pulseless VT after 5 shocks have been administered
thrombolytic drugs:
* should be considered if a pulmonary embolus is suspected
* if given, CPR should be continued for an extended period of 60-90 minutes
Describe what is meant by Brugada syndrome [2]
Form of inherited cardiovascular disease with may present with sudden cardiac death
- autosomal dominant
- mutation in gene that encodes the myocardial sodium ion channel protein
- more common in males
What ECG changes do you see in Brugada syndrome? [2]
- convex ST segment elevation > 2mm in > 1 of V1-V3 followed by a negative T wave
- partial right bundle branch block
Define what is meant by a pulselss electrical activity [1]
organised or semi-organised electrical activity of the heart persists but the product of systemic vascular resistance and the increase in systemic arterial flow generated by the ejection of the left ventricular stroke volume is not sufficient to produce a clinically detectable pulse
Why are VSDs associated with aortic regurgitation? [1]
poorly supported right coronary cusp resulting in cusp prolapse
How do you differentiate between a posterior and anterior MI on an ECG?
Anterior MI
- ST-segment elevation in the precordial leads V1-V4
Posterior MI
- tall R waves V1-3 PosteRioR contains 2 tall Rs
- Horizontal ST depression in V1-3
How do you confirm a posterior MI? [1]
Posterior infarction is confirmed by ST elevation and Q waves in posterior leads (V7-9)
Describe what is meant by Wellen’s syndrome [2]
What does Wellen’s syndrome suggest? [1]
What is important to note about the presentation of Wellen’s syndrome?
Wellens Syndrome is a clinical syndrome characterised by biphasic or deeply inverted T waves in V2-3, plus a history of recent chest pain now resolved.
It is highly specific for critical stenosis of the left anterior descending artery (LAD)
ECG pattern present in pain-free state is part of the diagnostic criteria
‘V2 & V3 T wave inversion on an ECG + a pain free state’
This suggests which pathology? [1]
Wellen’s syndrome - suggests stenosis in LAD
*
Kartagener’s syndrome is associated with which cardiac condition? [1]
How does this present on an ECG? [3]
Kartagener’s syndrome - linked to dextrocardia
Dextrocardia is associated with an inverted P wave in lead I, right axis deviation, and loss of R wave progression
Describe what is meant by Takayasu’s arteritis [1]
Which vessels does it mainly affect? [2]
Takayasu’s arteritis:
- large vessel vasculitis.
- It mainly causes causes occlusion of the aorta and its branches. It can also affect the pulmonary arteries.
How do you diagnose Takayasu’s arteritis? [2]
Diagnosis involves CT angiography or MRI angiography.
vascular imaging of the arterial tree is required to make a diagnosis of Takayasu’s arteritis
Which of the following causes GI ulceration?
Bisoprolol
Diltiazem
Isosorbide mononitrate
Nicorandil
Ranolazine
Which of the following causes GI ulceration?
Bisoprolol
Diltiazem
Isosorbide mononitrate
Nicorandil
Ranolazine
Describe the different classes of antiarrhythmics [4]
Class I:
- Na blockers
Class II:
- Beta blockers
Class III:
- K blockers
Class IV
- Ca blockers
What are the three reasons for arrhythmogenesis [3]
Arrhythmogenesis may be due to increased automaticity, re-entry or triggered activity.
What ECG change would you expect to see with digoxin treatment? [1]
Curved ST segment depression
Describe the form of ventricular tachycardia that can occur in digoxin intoxication [1]
Bidirectional ventricular tachycardia:
- electrical axis shifting from L to R from one beat to the next
Describe the three different classes of Class I AA drugs [3]
Which phase of the action potential do class I AA work at? [1]
1A
- Phase 0: Depress
1B
- Phase 0: Depress
1C
- Phase 0: Markedly depress
Which stage of the cardiac action potential do Class I anti-arrythmics work on?
Phase 0
Phase 1
Phase 2
Phase 3
Phase 4
Which stage of the cardiac action potential do Class I anti-arrythmics work on?
Phase 0
Phase 1
Phase 2
Phase 3
Phase 4
Which stage of the cardiac action potential do Class II anti-arrythmics work on?
Phase 0
Phase 1
Phase 2
Phase 3
Phase 4
Which stage of the cardiac action potential do Class II anti-arrythmics work on?
Phase 0
Phase 1
Phase 2
Phase 3
Phase 4
Which stage of the cardiac action potential do Class III anti-arrythmics work on?
Phase 0
Phase 1
Phase 2
Phase 3
Phase 4
Which stage of the cardiac action potential do Class III anti-arrythmics work on?
Phase 0
Phase 1
Phase 2
Phase 3
Phase 4
Which stage of the cardiac action potential do Class IV anti-arrythmics work on?
Phase 0
Phase 1
Phase 2
Phase 3
Phase 4
Phase 0
Phase 1
Phase 2
Phase 3
Phase 4
Label which class anti-arrythmics work at each stage of the cardiac action potential [4]
A: Class 1 - Na channel blocker
B. Class 4 - Ca 2+ channel blocker
C. Class 3 - K+ channel blocker
D: Class 2 - Beta blocker
Flecainide works at which of the following
A
B
C
D
Flecainide works at which of the following
A - Class 1
B
C
D
Propanalol works at which of the following
A
B
C
D
Propanalol works at which of the following
A
B
C
D
Amiodarone works at which of the following
A
B
C
D
Amiodarone works at which of the following
A
B
C
D
Verapamil and Diltiazem work at which of the following
A
B
C
D
Verapamil and Diltiazem work at which of the following
A
B
C
D
Which class of anti-arrythmics cause an extension of the refractory period as their action? [1]
Class III
When performing ALS, under which conditions do you give 300mg amiodarone? [2]
Shockable rhythms:
- Amiodarone should be given to patients in ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) AFTER they’ve recieved three shocks
- a further dose of amiodarone 150 mg should be given to patients who are in VF/pulseless VT after 5 shocks have been administered
When performing ALS, under which conditions do you give adrenaline? [1]
Non-shockable rhythms:
- adrenaline 1 mg as soon as possible
Shockable rhythms:
- adrenaline 1 mg is given once chest compressions have restarted after the third shock
repeat adrenaline 1mg every 3-5 minutes whilst ALS continues
How can you elicit a louder [1] and quieter [1] murmur for a patient with HOCM? [1]
HOCM may present with ejection systolic murmur, louder on performing Valsalva and quieter on squatting
erythema marginatum is a sign of what cardiac disease? [1]
Rheumatic fever
The CT shows a large saddle embolus where the pulmonary trunk splits to form the right and left pulmonary arteries.
- big grey line in the pulmonary vessels
Describe what is meant by Arrhythmogenic right ventricular cardiomyopathy
Form of inherited cardiovascular disease which may present with syncope or sudden cardiac death:
* inherited in an autosomal dominant pattern with variable expression
* the right ventricular myocardium is replaced by fatty and fibrofatty tissue
* around 50% of patients have a mutation of one of the several genes which encode components of desmosome
