PM Cardio Questions Flashcards
B-type natriuretic peptide is released in response to what?
B-type natriuretic peptide is released in response to ventricular strain.
Different classes of anti-arrhythmics:
Cardiac action potential refresher
Quinidine, Lidocaine, Flecainide and procainamide are examples of what class of drug?
Class 1 Na+ sodium channel blockers (anti-arrhythmics).
What is pulsus paradoxus?
A greater than the normal (10 mmHg) fall in systolic blood pressure during inspiration → faint or absent pulse in inspiration.
What is pulsus paradoxus a sign of?
Severe asthma, cardiac tamponade
What is the treatment for a patient unstable in VT?
A synchronised cardioversion is the treatment for a unstable patient in VT
Ehler’s danlos is associated with what cardiac problem?
Aortic dissection
What is diagnostic of aortic dissection?
Transoesophageal echocardiogram
What is the immediate management of a PE?
Patients with a suspected pulmonary embolism should be initially managed with a direct oral anticoagulant (DOAC)
(apixaban or rivaroxaban)
What are the different types of aortic dissection?
Aortic dissection
type A - ascending aorta - control BP (IV labetalol) + surgery
type B - descending aorta - control BP(IV labetalol)
What is the treatment for stable aortic dissection?
Aortic dissection
type A - ascending aorta - control BP (IV labetalol) + surgery
type B - descending aorta - control BP(IV labetalol)
What are the four red flag symptoms of fast AF?
Syncope, heart failure, myocardial ischaemia, and shock.
What is the treatment of fast AF with decompensation?
In AF with decompensation the correct management is synchronised DC cardioversion.
Thiazide diuretics can cause what electrolyte abnormality?
Thiazide diuretics can cause hypercalcaemia and hypocalciuria.
What are the features of hypokalemia on ecg?
ECG features of hypokalaemia
U waves
small or absent T waves (occasionally inversion)
prolong PR interval
ST depression
long QT
Pulsus parodoxus =
cardiac tamponade
What is the immediate management of acute heart failure?
O - oxygen
My - Morphine
Fucking - IV Furosemide
God - GTN
Sit up
Diagnosis in this patient: a very tall patient with long fingers who presents with a tearing chest pain radiating to his back…
Aortic dissection secondary to marfan’s.
How is aortic dissection classified?
type I - originates in ascending aorta, propagates to at least the aortic arch and possibly beyond it distally.
type II - originates in and is confined to the ascending aorta.
type III - originates in descending aorta, rarely extends proximally but will extend distally
Type A = 2/3 involved
Type B = 1/3 involved
What are risk factors for aortic dissection?
hypertension
trauma
bicuspid aortic valve
collagen disorders
Turner’s and Noonan’s syndrome
pregnancy
syphilis
Marfan’s
Aortic dissection on imaging:
- what is most diagnostic for aortic dissection?
TOE - transoesophageal echocardiogram
What are the management options for aortic dissection?
Manage BP with IV labetalol + surgery if Type a (ascending aorta).
What are the complications of aortic dissection?
▪Aortic incompetence/ regurgitation
▪MI: inferior pattern is often seen due to right coronary involvement
▪unequal arm pulses and BP
▪stroke
▪renal failure
What are the side effects of starting a patient on warfarin?
haemorrhage
teratogenic, although can be used in breastfeeding mothers
skin necrosis: when warfarin is first started biosynthesis of protein C is reduced. This results in a temporary procoagulant state after initially starting warfarin, normally avoided by concurrent heparin administration. Thrombosis may occur in venules leading to skin necrosis
purple toes
What are the indications for giving warfarin?
venous thromboembolism: target INR = 2.5, if recurrent 3.5
atrial fibrillation, target INR = 2.5
mechanical heart valves, target INR depends on the valve type and location. Mitral valves generally require a higher INR than aortic valves.
What is Amiodarone used for?
Amiodarone is a class III antiarrhythmic agent used in the treatment of atrial, nodal and ventricular tachycardias.
What is the mechanism of action of Amiodarone?
The main mechanism of action is by blocking potassium channels which inhibits repolarisation and hence prolongs the action potential. Amiodarone also has other actions such as blocking sodium channels (a class I effect).
How long should dual antiplatelet therapy be continued for following ACS event?
Post acute coronary syndrome (medically managed): add ticagrelor to aspirin, stop ticagrelor after 12 months.
What are the featuures of mitral stenosis?
This woman presents with mitral stenosis. The features in the examination which point to this diagnosis are mitral facies, atrial fibrillation due to left atrial dilatation, raised JVP, peripheral oedema and a characteristic diastolic murmur with an opening snap. The most common cause of mitral stenosis (up to 95%) is rheumatic heart disease. Other causes are far less common, including congenital disease, degenerative calcification, Libman-Sacks endocarditis, rheumatoid arthritis and amyloidosis.
The cardiac arrest team is called to the bedside of a 67-year-old male patient, 2 days post-myocardial infarction. Two nurses are currently performing chest compressions and a manual defibrillator has just been attached. Chest compressions are paused briefly so that the rhythm can be analysed: pulseless electrical activity is observed.
Given the above, which of the following should happen in this scenario?
Adrenaline should be given immediately.
ALS - give adrenaline in non-shockable rhythm as soon as possible.
What class of drug is Doxazosin and what is it used for?
Doxazosin is a selective a1-blocker that is used to treat hypertension.
When should use of GTN spray be avoided in ACS patients?
Administering sublingual glyceryl trinitrate is incorrect as nitrates should be avoided in patients with hypotension. Nitrate-induced hypotension may lead to syncope.
After a beta blocker used a first line in treatment for fast AF what is used next?
Digoxin can be added as a second line treatment for rate control in atrial fibrillation
Which valve defect is associated with PKDS?
Mitral valve prolapse is associated with polycystic kidney disease.
What is the mechanism of action of alteplase?
Activates plasminogen to form plasmin.
NICE guidelines for treatment of hypertension:
First line management for someone aged 45 and hypertensive with no PMH.
Ace inhibitor / angiotensin receptor blocker
First line management for someone aged 65 and hypertensive with no PMH.
CCB
First line management for someone aged 65 and hypertensive with type 2 diabetes.
Angiotensin receptor blocker / Ace inhibitor
Any black African / afro carribean should be offered with as first line for hypertension?
CCB
NSTEMI guidelines
What type of murmur does mitral stenosis cause?
Mitral stenosis typically causes a mid-diastolic murmur with an opening snap.
Wendy, 48, presents to the Emergency Department after feeling faint earlier that day. She is found to be in atrial fibrillation. She is known to have structural heart disease as a result of an ill-functioning mitral valve, but is otherwise fit and healthy. What is the most appropriate treatment if pharmacological cardioversion is agreed upon?
If pharmacological cardioversion has been agreed on clinical and resource grounds for new-onset atrial fibrillation, offer:
Flecainide or amiodarone if there is no evidence of structural or ischaemic heart disease or
Amiodarone if there is evidence of structural heart disease.
Note: Atenalol and diltiazem are both used for rate control.
Treatment for a patient in cardiac arrest in ventricular fibrilation:
The Resuscitation Council has clear guidelines on how to manage cardiac arrest (Adult advanced life support guidelines). In the shockable rhythms - ventricular fibrillation (VF) and pulseless ventricular tachycardia (pVT), CPR should be immediately provided and the patient defibrillated as soon as possible. Therefore the correct answer is defibrillation.
How do Thiazide diuretics work and what are they used for?
Thiazide diuretics work by inhibiting sodium reabsorption at the beginning of the distal convoluted tubule (DCT) by blocking the thiazide-sensitive Na+-Cl− symporter. Potassium is lost as a result of more sodium reaching the collecting ducts. Thiazide diuretics have a role in the treatment of mild heart failure although loop diuretics are better for reducing overload.
Treats hypertension.
Common adverse side effects of thiazide diuretics:
dehydration
postural hypotension
hyponatraemia, hypokalaemia, hypercalcaemia*
gout
impaired glucose tolerance
impotence
A 64-year-old man presents to the respiratory clinic for a scheduled review of his pulmonary hypertension. He was diagnosed with pulmonary hypertension ten years previously. His comorbidities include type 2 diabetes mellitus and heart failure. His medications include bosentan, metformin, sitagliptin, ramipril and bisoprolol.
On examination, he is slightly overweight; he has mild peripheral oedema; his lungs are clear; and there is a high-pitched, pansystolic murmur, heard loudest at the lower left sternal edge, which is loudest on inspiration.
Which underlying pathology is most likely to explain his murmur?
Tricuspid regurgitation becomes louder during inspiration, unlike mitral stenosis.
You are the first to arrive at a 45-year-old man who has become unconscious following elective surgery earlier that day. An attached ECG shows that he is in sinus tachycardia, but there is no carotid pulse. The nurse has already put out a crash call. The airway is being maintained and the nurse has begun ventilating with bag and mask, pupils equal and reactive to light, with no external signs of injury
Whilst awaiting senior help, what should you do?
The absence of a carotid pulse in the presence of sinus tachycardia indicates that this is a non-shockable rhythm, and the appropriate algorithm should be followed as explained below. The only shockable rhythms are ventricular fibrillation and ventricular tachycardia.
A 55-year-old woman suffers from shortness of breath on exertion and orthopnoea. Her echocardiogram shows dilation of all four chambers. There are no regional wall motion abnormalities but the left ventricular ejection fraction is poor.
Which of the following is a risk factor for this condition?
Chronic alcohol use may cause dilated cardiomyopathy.
Total cessation of alcohol is associated with improvement of symptoms and even reversal of DCM in some cases.
A 24-year-old rugby player is suddenly collapses during a game. After being rushed to hospital it is suspected that he has hypertrophic obstructive cardiomyopathy.
Which of the following signs can be classically elicited on examination of someone with this condition?
S4
HOCM = 4 letters = S4
S4 hit the floor
Mid diastolic murmur =
Mitral stenosis
How does Wolff-Parkinson White present on an ECG?
The ECG shows a short PR interval associated with a slurred upstroke (delta wave). Note the non-specific ST-T changes which are common in Wolff-Parkinson White and may be mistaken for ischaemia.
Tricuspid regurgitation often occurs secondary to what and has what sound on auscultation?
Functional tricuspid regurgitation often occurs secondary to pulmonary hypertension as a result of chronic lung disease such as chronic obstructive pulmonary disease (COPD) producing a loud pulmonary component of the second heart sound, raised jugular venous pressure and a pansystolic murmur in the left lower sternal edge.
Other secondary causes of tricuspid regurgitation involve mitral valve stenosis and regurgitation as well as pulmonary thromboembolism.
Name the murmur:
Auscultation of the heart revealed an ejection systolic murmur, loudest at the 2nd intercostal space right sternal edge. The murmur showed radiation to the carotids.
Aortic stenosis
Why are nitrates contraindicated in aortic stenosis?
Nitrates are contraindicated in severe aortic stenosis because of the theoretical yet unproven risk of precipitating profound hypotension.
Coarctation of aorta effects on bp:
The most common type of coarctation of the aorta seen in adults is the postductal variety, i.e. the aortic narrowing is distal to the ductus arteriosus. This means that the upper limb blood pressure is greater than that in the lower limbs as the narrowing occurs after the left subclavian artery branches from the aorta.
What would you see on an ECG for:
First degree heart block
Second degree heart block
type 1 (Mobitz I, Wenckebach):
type 2 (Mobitz II):
Third degree (complete) heart block
First degree heart block
PR interval > 0.2 seconds
Second degree heart block
type 1 (Mobitz I, Wenckebach): progressive prolongation of the PR interval until a dropped beat occurs
type 2 (Mobitz II): PR interval is constant but the P wave is often not followed by a QRS complex
Third degree (complete) heart block
there is no association between the P waves and QRS complexes
A 35-year-old man, normally fit and well, presents to the emergency department with a 1 day history of chest pain. He describes it as left sided chest pain radiating into his neck, and is associated with shortness of breath. The chest pain worsens on lying down flat, and eases on sitting up and leaning forwards. He also describes feeling feverish and having a cough recently.
What’s the diagnosis?
Pericarditis
Chest pain due to pericarditis is often relieved by sitting/leaning forward.
Causes of pericarditis:
- viral infections (Coxsackie)
- tuberculosis
- uraemia (causes ‘fibrinous’ pericarditis)
- trauma
- post-myocardial infarction, Dressler’s syndrome
- connective tissue disease
- hypothyroidism
- malignancy
What investigations are done for pericarditis?
Investigations
- ECG changes
the changes in pericarditis are often global/widespread, as opposed to the ‘territories’ seen in ischaemic events
‘saddle-shaped’ ST elevation
PR depression: most specific ECG marker for pericarditis
all patients with suspected acute pericarditis should have transthoracic echocardiography.
What is the management of pericarditis?
Management
Treat the underlying cause.
A combination of NSAIDs and colchicine is now generally used for first-line for patients with acute idiopathic or viral pericarditis.
What are the indications for aortic valve replacement?
In general, aortic valve replacement is indicated in symptomatic patients with severe aortic stenosis. The presence of symptoms is associated with a mortality of 2-3 years. The triad of symptoms is dyspnoea, chest pain and syncope. Valve replacement in asymptomatic patients is more controversial.
What are the common side effects of thiazide diuretics?
Bendroflumethiazide is a thiazide diuretic. Common side effects of this class of drugs includes; constipation, diarrhoea, dizziness and dry mouth.
Common side effects of ACE inhibitors:
Ramipril is an ACE inhibitor. A common side effect of ramipril is a dry cough.
Long term heartfailure management:
The first-line treatment for all patients is both an ACE-inhibitor and a beta-blocker
Generally, one drug should be started at a time. NICE advise that clinical judgement is used when determining which one to start first.
Beta-blockers licensed to treat heart failure in the UK include bisoprolol, carvedilol, and nebivolol.
ACE-inhibitors and beta-blockers have no effect on mortality in heart failure with preserved ejection fraction.
Second-line treatment is an aldosterone antagonist
These are sometimes referred to as mineralocorticoid receptor antagonists. Examples include spironolactone and eplerenone.
It should be remember that both ACE inhibitors (which the patient is likely to already be on) and aldosterone antagonists both cause hyperkalaemia - therefore potassium should be monitored.
Note: Also give annual influenza vaccine.
CHADsVAS score
HASBLED score
Ejection systolic murmur louder on inspiration
Pulmonary stenosis
How does warfarin work?
Warfarin causes a prolonged prothrombin-time.
Warfarin affects factor X, IX, VII and II. The extrinsic pathway, affecting the PT, involves factor VII. The intrinsic pathway, affecting the APTT, involves factors XII, XI, IX, VIII. Because Warfarin reduces the levels of factor VII, the PT is prolonged with therapeutic doses of Warfarin.
1972
What is Wolff-Parkinson White (WPW) syndrome?
Wolff-Parkinson White (WPW) syndrome is caused by a congenital accessory conducting pathway between the atria and ventricles leading to a atrioventricular re-entry tachycardia (AVRT). As the accessory pathway does not slow conduction AF can degenerate rapidly to VF is caused by a congenital accessory conducting pathway between the atria and ventricles leading to a atrioventricular re-entry tachycardia (AVRT). As the accessory pathway does not slow conduction AF can degenerate rapidly to VF
How does WPW present on an ECG?
Possible ECG features include:
short PR interval
wide QRS complexes with a slurred upstroke - ‘delta wave’
left axis deviation if right-sided accessory pathway*
right axis deviation if left-sided accessory pathway*
What is the management of WPW syndrome?
Management
definitive treatment: radiofrequency ablation of the accessory pathway
medical therapy: sotalol***, amiodarone, flecainide
What effect can ace inhibitors have on electrolytes?
ACE inhibitors can cause hyperkalaemia
What is the acute management of SVT?
Acute management
vagal manoeuvres: e.g. Valsalva manoeuvre, carotid sinus massage
intravenous adenosine 6mg → 12mg → 12mg: contraindicated in asthmatics - verapamil is a preferable option
electrical cardioversion
What medications improve mortality in heart failure patients?
ACE inhibitors, beta blockers, and spironolactone all help to reduce long-term mortality and slow disease progression and therefore patients should make sure they continue these medications even when symptoms subside.
What is Rheumatic fever caused by?
Rheumatic fever is caused by group A Streptococcus species (GAS). While typically associated with bacterial pharyngitis, GAS can cause ongoing complications, such as rheumatic fever and later rheumatic heart disease, as well as post-streptococcal glomerulonephritis. The incidence of rheumatic fever is increased if antibiotic treatment is not adequate. Rheumatic fever is rare in the developed world, but patients from indigenous populations in central Australia, such as this patient, remain at increased risk.
You are working in a GP practice. Your next patient is a 27-year-old female who has just found out she is 6 weeks pregnant. She has a past medical history of familial hypercholesterolaemia, type 1 diabetes and asthma. What should your next step in management be?
Stop atorvastatin.
Pregnancy is a contraindication to statin therapy
Treatment of a large PE with hypertension =
Massive PE + hypotension - thrombolyse e.g with Ateplase
Persistent ST elevation following MI may be suggestive of what?
Persistent ST elevation after previous MI, is very suggestive of a left ventricle aneurysm. Blood stagnates around a left ventricle aneurysm, thereby promoting platelet adherence and thrombus formation. Embolisation of left ventricular thrombi can lead to embolic stroke or other systemic embolisms.
What is used to reverse bleeding on dabigatran?
Bleeding on dabigatran? Can use idarucizumab to reverse
pulmonary stenosis - What murmur is likely to be heard on examination?
Pulmonary stenosis causes an ejection systolic murmur that is louder on inspiration.
What is the most common ECG change seen in a PE?
The most common ECG change in PE is sinus tachycardia
Cause of mitral stenosis = 99%
RHEUMATIC FEVER
Patients treated with PCI for MI are experiencing pain or haemodynamic instability post PCI should receive what treatment?
If patients treated with PCI for MI are experiencing pain or haemodynamic instability post PCI, urgent coronary artery bypass graft (CABG) is recommended.
Initial management of a suspected PE?
Patients with a suspected pulmonary embolism should be initially managed with a direct oral anticoagulant (DOAC).
Beta blocker side effects:
- bronchospasm
- cold peripheries
- fatigue
- sleep disturbances, including nightmares
- erectile dysfunction
Notching of the inferior border of the ribs is a specific feature of what condition?
Notching of the inferior border of the ribs is present in around 70% of adults with coarctation of the aorta.
Explain how cardioversion of AF is assessed:
If acute (<48 hrs) and unstable - electrical cardioversion.
If acute but stable - then decide between electrical or pharmalogical cardioversion.
If chronic (>48 hrs) - electrical cardioversion after 3 weeks of anti coagulation and rhythm control in the interim.
For cardioversion of AF: patients must either be anticoagulated or have had symptoms for < 48 hours to reduce the risk of stroke.
What are the causes of postural hypotension?
Postural hypotension may be defined as a fall of systolic blood pressure > 20 mmHg on standing.
Causes
- hypovolaemia
- autonomic dysfunction: diabetes, Parkinson’s
- drugs: diuretics, antihypertensives, L-dopa, phenothiazines, antidepressants, sedatives
- alcohol
Common side effects of GTN spray?
Intense headache
Dizziness
Post MI how long should a patient be on DUAC
75mg for 12 months - then drop clopidogrel / ticagrelor and continue asprin for life long.
SCARB + consider ppi for gastro protection against multiple antiplatelets.
Common side effects of statins + contraindication:
Myalgia and muscle weakness.
Contraindicated in pregnancy.
Turners syndrome is associated with what cardiac abnormality?
Co-arctation of the aorta.
What medication is contra-indicated in HOCM?
ACE-inhibitors should be avoided in patients with HOCM.
Collapsing pulse is associated with what valvular defect?
Collapsing pulse describes a rapid upstroke and a sharp descent. This is seen in chronic aortic regurgitation and other hyperdynamic states e.g. anaemia, thyrotoxicosis, fever, exercise/pregnancy.
You are asked to review a 28-year-old woman who has just presented to the Emergency Department. She has been in a road traffic accident and has sustained significant blunt trauma to her chest wall. Despite aggressive fluid resuscitation, her blood pressure remains 70/30 mmHg and her heart rate remains 125 bpm. You note that her JVP is elevated at 5 cm. Her peripheries are cool and clammy and she is deteriorating rapidly. Portable chest X-ray demonstrates left pleural effusion with no cardiomegaly. What is the most likely cause of her symptoms?
Consider cardiac tamponade in elevated JVP, persistent hypotension and tachycardia despite fluid resuscitation in a patient with chest wall trauma.
Becks Triad - Raised JVP, hypotension, muffled heart sounds.
NSTEMI management: fondaparinux should be given in addition to aspirin to all patients unless high bleeding risk
NSTEMI management: fondaparinux should be given in addition to aspirin to all patients unless high bleeding risk
First line investigation for aortic dissection:
CT angiography is the investigation of choice for suspected aortic dissection (depending on stability of patient).
Unstable patient with aortic dissection what is the first line investigation?
TOE
Angina management:
If angina is not controlled with a beta-blocker, a calcium channel blocker should be added.
Medication
All patients should receive aspirin and a statin in the absence of any contraindication
Sublingual glyceryl trinitrate to abort angina attacks
NICE recommend using either a beta-blocker or a calcium channel blocker first-line based on ‘comorbidities, contraindications and the person’s preference’.
What is the conservative management of an NSTEMI?
NSTEMI (managed conservatively) antiplatelet choice
aspirin, plus either:
ticagrelor, if not high bleeding risk
clopidogrel, if high bleeding risk
Organisms associated causing infective endocarditis:
The reasons as to why the other answers are less likely are as follows:
1 - Streptococcus viridans - classically linked to poor dental hygiene or following a dental procedure
2 - Streptococcus bovis - most commonly linked with colorectal cancer
3 - Coxiella burnetti - causes Q fever, an infection caught most commonly from farm animals. So, consider in any farmer or abattoir worker.
-
Staphylococcus aureus is the most common cause of infective endocarditis, even more so amongst intravenous drug users.
5 - Staphylococcus epidermis - most commonly associated with patients who have undergone previous prosthetic valve surgery
You are called to see a 64-year-old woman on the surgical ward who has a heart rate of 160 bpm and a blood pressure of 80/50 mmHg. She is alert and seems unaware of her fast heart rate. An electrocardiogram (ECG) shows a narrow-complex tachycardia with a rate of 174 bpm. You look at her notes and see she was deemed medically fit for discharge earlier in the day after an umbilical hernia repair a week ago. Her past medical history includes asthma and hypertension.
What immediate treatment should this woman receive?`
In the context of a tachyarrhythmia, a systolic BP < 90 mmHg → DC cardioversion.
This woman has a narrow-complex tachycardia with adverse signs - despite the fact that she is currently alert, she is in shock with a blood pressure of 80/50 mmHg which is highly dangerous. She needs urgent DC cardioversion which involves getting the resuscitation trolley, an anaesthetist, a medical registrar and nursing colleagues on hand as soon as possible if they are not already present. She will first need some midazolam to sedate her, so this can be drawn up, and pads can be placed on her chest while expert help is awaited. A large-bore cannula in a large vein will need to be sited - preferably she needs access in both arms. You can take blood at the same time, including for potassium, magnesium and calcium.
Vagal manoeuvres would be the appropriate first step in managing a narrow-complex tachycardia if she were not showing adverse signs. Due to her shock, this is incorrect for the scenario.
Adenosine would be given if vagal manoeuvres had failed in a non-asthmatic patient. This woman is asthmatic and is showing adverse clinical signs so adenosine is inappropriate.
Verapamil would be the correct drug in this patient if vagal manoeuvres had failed and she was not showing adverse signs. Due to her shock, this is an incorrect answer.
Amiodarone is not an appropriate first-line option here. DC cardioversion should be trialled immediately. If this does not restore her to sinus rhythm and she has no electrolyte imbalances, amiodarone can be given.
A 78-year-old man is brought in to the emergency department by ambulance following a collapse at a restaurant. His ECG (electrocardiogram) shows third-degree heart block with a ventricular rate of 39 bpm. He is given a dose of atropine 500 micrograms IV by the on-call anaesthetist. His heart rate remains the same.
Which of the following is the most appropriate next step in management?
Transcutaneous pacing - External pacing is used for symptomatic bradycardia if atropine fails.
When should you being anti-coagulation in a patient that has AF and has just had an acute stroke?
Why?
A patient with AF + an acute stroke (not haemorrhagic) should have anticoagulation therapy started two weeks after the event.
Hemorrhagic transformation of an ischemic infarct occurs within 2-14 days post ictus, usually within the first week. It is more commonly seen following cardioembolic strokes and is more likely with larger infarct size. Therefore; if you used an anticoagulant during this time you put the patient at an increased risk of massive intracranial bleeds.
Management of a patient on warfarin with INR of 6.1?
INR 5.0-8.0 (no bleeding) - withhold 1 or 2 doses of warfarin, reduce subsequent maintenance dose
What is the first line investigation for someone with stable angina?
CT angiography is the first-line investigation for stable chest pain caused by ischaemic heart disease.
A 56-year-old woman is recovering on the ward following percutaneous coronary intervention (PCI) treatment for an ST-elevated myocardial infarction (STEMI).
She had been recovering well until 9-days following the STEMI, when she reports sudden onset chest pain and feeling acutely short of breath, particularly when lying flat.
Examination reveals a raised jugular venous pressure (JVP) and muffled heart sounds. No murmurs are audible. Recording of the patient’s blood pressure reveals a pressure of 110/70mmHg, with a pattern of pulses paradoxus.
Based on the information provided, which of the following pathologies is the most likely explanation for this patient’s current presentation?
Sudden heart failure, raised JVP, pulsus parodoxus, recent MI - left ventricular free wall rupture.
What pulse deficits may be seen in aortic dissection?
In aortic dissection, a pulse deficit may be seen:
Weak or absent carotid, brachial, or femoral pulse
Variation in arm BP
Management of heart block following inferior MI?
Reassure and monitor.
Transcutaneous pacing is only needed in cases of an anterior MI.
What should be added if angina is not controlled with a beta blocker?
If angina is not controlled with a beta-blocker, a calcium channel blocker should be added.
A 65-year-old lady trips over the carpet and falls. She presents to the emergency department with an externally rotated right leg which is shorter than the left.She has a past medical history of heart failure and hypertension. She takes ramipril, simvastatin, nifedipine, indapamide and furosemide. A DEXA scan confirms osteoporosis and serum calcium is low. She is treated under the orthopaedic department. Which of the following drugs is most likely responsible for the deterioration in bone health?
Ramipril?
Nifedipine?
Furosemide?
Indapamide?
Simvastatin?
Furosemide - Hypocalcemia is a side effect of loop diuretics.
When is new onset AF eligible for cardioversion?
New onset AF is considered for electrical cardioversion if it presents within 48 hours of presentation.
What is first line for symptomatic bradycardia?
Atropine
How does atropine work?
Atropine is a clinically relevant anticholinergic drug, which blocks inhibitory effects of the parasympathetic neurotransmitter acetylcholine on heart rate leading to tachycardia.
What is the Bishops score used for?
To determine whether a woman needs an induction for labour.
What is Kussmaul’s sign?
In constrictive pericarditis, the JVP will rise on inspiration; this is known as Kussmaul’s sign.
JVP should normally fall during inspiration.
What are the symptoms of hypercalcemia?
Symptoms can be remembered by the rhyme “stones, bones, groans and psychic overtones”. Abdominal pain, constipation and increased confusion and lethargy are common symptoms of hypercalcaemia.
Torsades de pointes
Torsades de pointes (‘twisting of the points’) is a form of polymorphic ventricular tachycardia associated with a long QT interval. It may deteriorate into ventricular fibrillation and hence lead to sudden death.
What is used to treat torsades de pointes?
IV magnesium sulfate is used to treat torsades de pointes
A patient develops acute heart failure 5 days after a myocardial infarction. A new pan-systolic murmur is noted on examination - what does this signify?
A patient develops acute heart failure 5 days after a myocardial infarction. A new pan-systolic murmur is noted on examination - ventricular septal defect
Complete heart block following an MI. Management depends on what key feature?
Complete heart block following an inferior MI is NOT an indication for pacing, treat with atropine.
Anterior MI needs transcutaneous pacing.
What is Cor Pulmonale?
Cor pulmonale describes the hypertrophy of the right ventricle and right heart failure that are caused by pulmonary arterial hypertension. In COPD, hypoxia induces pulmonary vasoconstriction, eventually causing pulmonary hypertension.
Symptoms of symptomatic aortic stenosis?
‘SAD’ (syncope, angina, dyspnoea on exertion)
Eisenmenger’s syndrome
Eisenmenger’s syndrome describes the reversal of a left-to-right shunt in a congenital heart defect due to pulmonary hypertension. This occurs when an uncorrected left-to-right leads to remodeling of the pulmonary microvasculature, eventually causing obstruction to pulmonary blood and pulmonary hypertension.
A 65-year-old man calls an ambulance as he has central crushing chest pain that radiates to his left arm and jaw. As he arrives at the emergency department his heart rate is found to be 50/min. An ECG is performed which shows ST elevation and bradycardia with a 1st-degree heart block.
Given the history, which of the following are the leads will most likely show the ST elevation?
II, III and AVF
This question is asking about the presentation of an ST-elevated myocardial infarction. The patient has presented 1st-degree heart block following his MI and so we can work out that his MI has most likely affected the inferior leads (right coronary arteries also provide blood supply to the AV node). Therefore the question requires you to know that leads II, III and aVF represent the inferior heart and the right coronary artery.
A right coronary infarct supplies the AV node so can cause arrhythmias after infarction.
A 30-year-old Asian woman presents with a history of headaches, claudication and having unequal blood pressure in both her arms.
What is the diagnosis?
Takayasu’s arteritis
Takayasu’s arteritis
Takayasu’s arteritis is a large vessel vasculitis. It typically causes occlusion of the aorta and questions commonly refer to an absent limb pulse. It is more common in females and Asian people
Features
- systemic features of a vasculitis e.g. malaise, headache
- unequal blood pressure in the upper limbs
- carotid bruit
- intermittent claudication
- aortic regurgitation (around 20%)
JVP rising on inspiration is a key sign of what?
Kussmauls sign - indicative of constrictive pericarditis.
What condition is mitral regurge associated with?
Mitral regurgitation is associated with collagen disorders such as Marfan’s Syndrome and Ehlers-Danlos syndrome.
Management of heartfailure in people with reduced ejection fraction?
Offer a mineralcorticoid receptor antagonist, in addition to an ACE inhibitor (or ARB) and beta-blocker, to people who have heart failure with reduced ejection fraction if they continue to have symptoms of heart failure
STEMI management if patient is having a PCI, what medications are given?
STEMI management: if patient is having PCI then prasugrel is given in addition to aspirin. If patient is on an anticoagulant then clopidogrel used instead
What are the main side effects of ACE inhibitors?
A - Angieodema
C - Cough
E - Elevated potassium
What is the treatment for symptomatic bradycardia once multiple atropine bolus’ have failed?
External pacing is used for symptomatic bradycardia if atropine fails
Thiazide diuretics can cause what electrolyte abnormality?
Thiazide diuretics can cause hypercalcaemia and hypocalciuria
