Cardiology

All patients with suspected upper GI bleed require an endoscopy within

24 hrs of admission

how many weeks of driving with CAGB

4 WEEKS OFF 1 WEEK IF SUCCESSFULLY TREATED BY ANGIOPLASTY

diagnose infective endocarditis

2 major 1 major + 3 minor 5 minor criteria

A 66-year-old male has an unprovoked ventricular fibrillation cardiac arrest in hospital. After successful resuscitation and recovery, an implantable cardiac defibrillator is inserted. How long must he wait until he can drive a car again?

6 months This is the length of time that a patient should not drive if they have had an implantable cardiac defibrillator inserted for secondary prevention as was the case in this scenario 40%

subclinical hypothyroidism mx

6 months levo trial

4 features of hypercalcaemia

'bones, stones, groans and psychic moans' corneal calcification shortened QT interval on ECG hypertension

bisferiens pulse means...

'double pulse' - two systolic peaks mixed aortic valve disease can suggest HOCM

bisferiens pulse

'double pulse' - two systolic peaks mixed aortic valve disease

shockable vs non shockable rhythms

'shockable' rhythms: ventricular fibrillation/pulseless ventricular tachycardia (VF/pulseless VT) 'non-shockable' rhythms: asystole/pulseless-electrical activity (asystole/PEA)

A 52-year-old gentleman, a current smoker with multiple cardiovascular risk factors, is brought urgently to the A&E by ambulance following an episode of central crushing chest pain radiating to the left shoulder and jaw. The chest pain does not radiate to the back. He has profuse sweating and is feeling nauseous. He does not complain of chills or a cough, and has no other risk factors for venous thromboembolism. An ECG performed in the ambulance showed prominent ST-segment elevation in leads V3 to V6, I and avL. Reciprocal ST-segment depression was seen in lead III and avF. Which of the following options below represents the cardiac axis that is most likely seen in this gentleman's ECG?

+120 degrees This gentleman is most probably suffering from an anterolateral myocardial infarct. In terms of the cardiac axis, this is a common cause of a right axis deviation. Recall that this is when the cardiac axis lies between +90 degrees to +180 degrees. Other causes of a right axis deviation include right ventricular hypertrophy, pulmonary embolism, left posterior hemiblock, Wolff-Parkinson White Syndrome with an accessory pathway on the left. A quick and easy way to determine if there is axis deviation on an ECG can be determined by leads I and II as follows: I and II are positive, the axis is normal (-30 degrees to +90 degrees) I is positive and II is negative, there is a left axis deviation (-30 degrees to -90 degrees) I is negative and II is positive, there is right axis deviation (+90 degrees to +180 degrees) I and II are negative, there is extreme axis deviation (-90 degrees to -180 degrees, not commonly seen) 27%

A 68-year-old gentleman, with a past medical history of metastatic colon cancer, is brought urgently to the A&E by ambulance following sudden-onset pleuritic chest pain and shortness of breath. He has no cardiovascular risk factors and is a non-smoker. On examination, no hyper-resonance was noted on percussion. He did not report a cough or any chills. After multiple investigations, he is diagnosed with a pulmonary embolism. Which of the following options below represents the cardiac axis that is most likely seen in this gentleman's ECG?

+135 degrees This gentleman is most probably suffering from a pulmonary embolism. In terms of the cardiac axis, this is a common cause of a right axis deviation. Recall that this is when the cardiac axis lies between +90 degrees to +180 degrees. Other causes of a right axis deviation include anterolateral myocardial infarct, right ventricular hypertrophy, left posterior hemi-block, Wolff-Parkinson White Syndrome with an accessory pathway on the left. A quick and easy way to determine if there is axis deviation on an ECG can be determined by leads I and II as follows: I and II are positive, the axis is normal (-30 degrees to +90 degrees) I is positive and II is negative, there is a left axis deviation (-30 degrees to -90 degrees) I is negative and II is positive, there is right axis deviation (+90 degrees to +180 degrees) I and II are negative, there is extreme axis deviation (-90 degrees to -180 degrees, not commonly seen) 31%

A 60-year-old gentleman with multiple cardiovascular risk factors is brought urgently to the A&E by ambulance following an episode of central crushing chest pain radiating to the left shoulder and jaw. The chest pain does not radiate to the back. He has diaphoresis and is feeling nauseous. He does not complain of chills or a cough, and has no other risk factors for venous thromboembolism. An ECG performed in the ambulance showed ST-segment elevation in leads II, III and avF. A relative bradycardia of about 45 beats per minute was also seen, although no obvious conduction defects were not present. Which of the following options below represents the cardiac axis that is most likely seen in this gentleman's ECG?

-60 degrees This gentleman is most probably suffering from an inferior myocardial infarct. In terms of the cardiac axis, this is a common cause of a left axis deviation. Recall that this is when the cardiac axis lies between -30 degrees and -90 degrees. Other causes of a left axis deviation include left ventricular hypertrophy, left anterior hemi-block, Wolff-Parkinson White Syndrome with an accessory pathway on the right. A quick and easy way to determine if there is axis deviation on an ECG can be determined by leads I and II as follows: I and II are positive, the axis is normal (-30 degrees to +90 degrees) I is positive and II is negative, there is a left axis deviation (-30 degrees to -90 degrees) I is negative and II is positive, there is right axis deviation (+90 degrees to +180 degrees) I and II are negative, there is extreme axis deviation (-90 degrees to -180 degrees, not commonly seen) 32%

drugs that can cause torsades de pointes

-antiarrhythmics - amiodarone, sotalol, class 1a antiarrhythmic drugs. - TCAs - anti-psychotics - chloroquine - terfenadine - erythromycin

normal QRS complex

0.12 seconds

A 68-year-old female is admitted to the hospital with a posterior ST-elevation myocardial infarction. She is treated successfully with primary percutaneous coronary intervention and there are no other urgent procedures planned for her. Before discharge, she has an echocardiogram which shows a left ventricular ejection fraction of 48%. How long must she wait until she can drive a car again?

1 week Following successful angioplasty (e.g. pci), a patient must stop driving for 1 week unless another urgent intervention is planned or if their left ventricular ejection fraction is less than 40%, in which case they would need to stop driving for at least 1 month. Furthermore, if a patient has heart attack that is not treated by angioplasty, they should not drive for one month 22%

how many weeks of driving with angioplasty

1 week off

causes of secondary HTN: A 28-year-old who is 10 weeks pregnant is noted to be hypertensive on her booking visit. Blood show a potassium of 2.9 mmol/l. Clinical examination is unremarkable A 39-year-old man presents with headaches and excessive sweating. He also reports some visual loss. Visual fields testing reveal loss of temporal vision bilaterally. A 68-year-old with a history of ischaemic heart disease is seen in the hypertension clinic. Despite four antihypertensives his blood pressure is 172/94 mmHg. An abdominal ultrasound shows

1. At 10 weeks gestation pregnancy-induced hypertension is not a possibility. The booking visit may represent the first time this patient has had her blood pressure checked, revealing an long-standing disorder. The low potassium points to a diagnosis of primary hyperaldosteronism (of which Conn's syndrome is a subtype) 2. Features of acromegaly include: coarse facial appearance, spade-like hands, increase in shoe size large tongue, prognathism, interdental spaces excessive sweating and oily skin features of pituitary tumour: hypopituitarism, headaches, bitemporal hemianopia 3. A 68-year-old with a history of ischaemic heart disease is seen in the hypertension clinic. Despite four antihypertensives his blood pressure is 172/94 mmHg. An abdominal ultrasound shows asymmetrical kidneys = RAS

first line ix for stable chest pain of suspected coronary artery disease aetiology

1. CT coronary angiography 2. non-invasive functional imaging (looking for reversible MI) 3. invasive coronary angiography

A 60-year-old man is admitted with severe central chest pain to the resus department. The admission ECG shows ST elevation in leads V1-V4 with reciprocal changes in the inferior leads. Which one of the following is most likely to account for these findings?

100% occlusion of the left anterior descending artery - widespread ST elevation in this territory implies a complete occlusion of the left anteiror descending artery

BP target for T2DM

140/90

stage 2 HTN clinic BP target

140/90

What dose of adrenaline should be given during a cardiac arrest?

1mg

A 76-year-old lady is admitted to the stroke ward after being diagnosed with a right-sided infarct. She was thrombolysed in resus. The patient has a past medical history of diabetes mellitus, hypertension, and COPD. The admission ECG shows an absent p wave and an irregular pulse. She was not on any prior anticoagulation.When should this patient be commenced on anticoagulation?

2 weeks after event

what investigation is indicated for people with multiple episodes of loss of consciousness with quick recovery times.

24 hour ecg

A 34-year-old man presented to the emergency department. He looked unwell and has a temperature of 38.2ºC. He is normally fit and well without any past medical condition. He is an iv drug user. He drinks 10 units of alcohol per week and smokes 1 pack a day.Examination of the cardiovascular and respiratory system revealed a pansystolic murmur in the left lower sternal edge and enlarged cervical lymph nodes.Which of the following will be most helpful to make the diagnosis?

3 sets of blood cultures are recommended in the investigation of infective endocarditis In someone with fever and heart murmur, consider infective endocarditis. In this patient, the pansystolic murmur auscultated over the tricuspid valve area is indicative of tricuspid regurgitation. In the context of an IV drug user and in the presence of fever and systemic upset, infective endocarditis is the most likely diagnosis.To diagnose infective endocarditis, Duke Criteria should be relied upon. The two major criteria require blood cultures and an echocardiogram. Other options will not help to diagnose infective endocarditis although may be helpful in excluding other (less likely) pathology.

You are reviewing the latest INR results for your patients. A young woman with antithrombin III deficiency who has had two previous deep vein thromboses and one previous pulmonary embolism has an INR of 2.4. The last two episodes of venous thromboembolism happened whilst she was warfarinised. What should her target INR be?

3.5

A patient is brought to the Emergency Department in cardiac arrest. The monitor shows that he is in ventricular fibrillation. The paramedics have already given three cycles of cardiopulmonary resuscitation and intravenous adrenaline. You decide to give amiodarone. What is the correct dose of amiodarone to give initially?

300mg

Normal QT interval

350-450ms

how to tell if something is a 3rd degree heart block

3rd-degree heart block There are several abnormalities in this ECG. 1. The QRS complexes are abnormally shaped (they're widened) 2. There is a bradycardia of 30 bpm. 3. There is no relationship between the P waves and the QRS complexes. If you look carefully, the rate of the p waves and the QRS complexes are constant, they are simply not related to each other. This ECG appearance is consistent with third-degree heart block 67%

reversible causes of cardiac arrest

4 Hs and 4Ts Hypoxia Hypovolaemia Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia and other metabolic disorders Hypothermia Thrombosis (coronary or pulmonary) Tension pneumothorax Tamponade - cardiac Toxins

ow long can you not drive for if you have had an icd

6 months

half life of adenosine

8-10 seconds this is why patients who are given adenosine will experience unpleasant, but short-lived side effects

A 55-year-old man visits his GP for a routine blood pressure (mmHg) check. After obtaining a reading the GP tells him he may have stage 1 hypertension and will need ambulatory blood pressure monitoring (ABPM).What reading is the GP likely to have obtained?

>140/90

stills murmur

A Still's murmur, also known as an 'innocent murmur' or 'vibratory murmur' is a common quiet systolic murmur heard in young children. Unlike in this vignette, Still's murmur do not progress to give symptoms and generally cannot be heard into adulthood.

what does asymmetric dosing regime for standard release isosorbide mononitrate mean and what does it prevent

A dosage regimen of one tablet twice daily, 7 hours apart is the correct option. The BNF recommends a dose of 10 mg twice daily initially for patients who have never had nitrates before, increased up to 120 mg daily if necessary. Long-acting standard-release nitrates should be prescribed following an asymmetric dosing regimen to prevent the development of tolerance. This involves having 6-8 hours between doses, to ensure the patient has a nitrate-free period.

A 63-year-old man is brought to the emergency department by ambulance with shortness of breath. He was admitted to the hospital 10 days earlier with an ST-elevation myocardial infarction, which was managed with percutaneous coronary intervention.On examination, he has a raised JVP, diminished heart sounds, and on inspiration, his systolic blood pressure drops by 20 mmHg.Given the above, what is the most likely cause of his presentation?

A patient develops acute heart failure 10 days following a myocardial infarction. On examination he has a raised JVP, pulsus paradoxus and diminished heart sounds - left ventricular free wall rupture

A 57-year-old man has undergone ambulatory blood pressure monitoring (ABPM) after it was found that he had raised blood pressure during a routine GP check-up.His average blood pressure recorded is 164/108 mmHg. His GP calculates his QRisk score to be 12%.The patient has no known past medical history but he takes regular ibuprofen for lower back pain.Given this patient's investigation findings, what is the most appropriate next step in his management?

A patient over 55 years with stage 2 hypertension and a QRisk score of >10% requires a calcium channel blocker, atorvastatin and lifestyle advice as first-line therapy

Mary is a 76-year-old woman with a history of well-controlled hypertension. She presented to the emergency department yesterday with a 5-hour history of an irregular racing sensation in her chest. Mary tells you that although she doesn't regularly drink alcohol, she did consume around 16 units yesterday while attending a friend's wedding. An ECG is performed which shows absent P waves and an irregularly irregular rhythm. Since admission, Mary had continuous cardiac telemetry and spontaneously returned to sinus rhythm.Does Mary require anticoagulation?

A single episode of paroxysmal atrial fibrillation, even if provoked, should still prompt consideration of anticoagulation

A 66-year-old man attends his GP surgery for a routine health check. During the consultation, his blood pressure is noted to be 152/86 mmHg. He is asymptomatic and examination is unremarkable. He has no significant past medical history except for mild arthritis of the knee, for which he takes paracetamol.The blood pressure is repeated and is recorded as 155/82 mmHg.What should be done next?

ABPM

The following drugs have all been shown to reduce mortality in patients with left ventricular failure:

ACE-inhibitors Beta-blockers Angiotensin receptor blockers Aldosterone antagonists Hydralazine and nitrates

A 67-year-old man attends to see the GP for a review of his blood pressure following a random clinic pressure of 156/101 mmHg. Past medical history includes type 2 diabetes and COPD managed using inhalers. His blood pressure recordings taken at home over the last week have shown an average reading of 142/98 mmHg.What is the most appropriate first-line intervention?

ACEi

moderate-severe aortic stenosis is a contraindication to what medication

ACEi

A 61-year-old Caucasian man with a background of hypertension and gout attended the surgery seeking advice regarding his blood pressure control. He has had high blood pressure readings at home over the last 7 days with an average reading of 150/95mmHg. He is currently well and does not complain of any chest symptoms. He does not smoke or drink alcohol. His current medication includes amlodipine and allopurinol which he has tolerated well. There is no history of any drug allergies. next line mx for HTN

ACEi Poorly controlled hypertension, already taking a calcium channel blocker - add an ACE inhibitor or an angiotensin receptor blocker or a thiazide-like diuretic

A 49-year-old male presents to his general practitioner because he has noticed an increase in his blood pressure. He routinely measures it as he is known to have bilateral renal artery stenosis. The doctor measures his blood pressure in the clinic, the result is 160/101 mmHg. He is otherwise feeling well in himself, and he is not taking any drugs routinely.Which one of the following antihypertensive drugs is contraindicated for this patient?

ACEi - CI in patients with renovascular disease

A 65-year-old man with heart failure presents to his GP with some questions about some of his medications. He would like to know which of his drugs will help him to live longer and not just improve his symptoms.What is the most appropriate response?

ACEi, BB and spironolactone diuretics only improve symptoms of heart failure and have no effect on mortality

when is oxygen given in people with ACS

ACS management: oxygen should only be given if the patient has oxygen saturations < 94%

A 60-year-old man presents to the emergency department with a sudden central chest pain. He has a past history of diabetes mellitus. On examination, he is alert but appears to be in pain and feeling nauseous. He has a pulse rate of 96 beats per minute and a blood pressure of 85/60 mmHg. ECG shows an ST-depression in the inferior leads.Which of the following medications is contraindicated in this patient?

ACS: Nitrates are contraindicated in patients with hypotension (< 90 mmHg)

HOCM inheritance pattern

AD

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?

ALS - give adrenaline in non-shockable rhythm as soon as possible

A 12-year-old girl with a background of Down syndrome presents for review. She looks and feels well. However, upon examination, she is found to have an ejection systolic murmur, louder during inspiration, with fixed splitting of the second heart sound. Her observations are all within normal range.Which of the following is the most likely cause?

ASD

A 45-year-old woman presents to the Emergency Department with sudden onset weakness on the right side of her body. It started without warning half an hour ago. Her vision is unaffected but her speech is confused and slurred. This has never happened before. She felt well until the weakness started.She has no significant past medical history. Her only medication is the combined oral contraceptive pill. She has a 40 pack-year smoking history and drinks two bottles of wine per week.She works as a receptionist and returned from Thailand four days ago.On examination, she is clinically stable. Neurological examination reveals 2/5 power down her right side. Examination of the cardiovascular system reveals peripheral cyanosis and clubbing with an ejection systolic murmur at the left upper sternal edge radiating through to the back and fixed splitting of the second heart sound. There is also erythematous tender enlargement of the right calf.Which of the following is the patient most likely to have?

ASD allows a 'paradoxical' stroke where an embolism from peripheral veins may bypass pulmonary circuation This lady presents with symptoms consistent with a stroke. She also has several risk factors for clots and has clinical signs consistent with deep vein thrombosis. Further, there is a clinical suggestion of cyanotic heart disease. In this particular case, there is a source of an embolism that would usually not explain the cranial involvement. Typically, peripheral embolisms lodge in the pulmonary circulation.However, there are some circumstances where a paradoxical embolisation can occur. One of these is an atrial septal defect (ASD) which is suggested here by the systolic murmur radiating through to the back with fixed S2 splitting. Even in the presence of an ASD, there must be a right-left shunt to allow paradoxical embolisation to occur. This can occur transiently with Valsalva manoeuvre or coughing. It can also occur more permanently in Eisenmenger's syndrome where the pressure in the right ventricle has raised sufficiently over time. Eisenmenger's is a cyanotic condition and can cause clubbing.

A 62-year-old lady was referred for a routine ECG by her GP after reporting intermittent palpitations. The ECG showed no discernable p waves and irregularly irregular rhythm. Otherwise, the heart rate was approximately 70 beats per minute, the QRS complexes were not broadened. No saw-tooth baseline was seen. The GP diagnoses her with atrial fibrillation. Which single most likely JVP waveform is expected to be seen in this patient?

Absent A-wave The A-wave signifies atrial contraction. As a result of uncoordinated atrial activity, the A-wave will not be seen. Knowledge of the JVP waveform is important for theory exams and viva components in the OSCE 48%

A 78 year old male patient with a past medical history of ischaemic heart disease following an anterior myocardial infarction last year and hypertension presents to the emergency department with shortness of breath and palpitations. He takes regular aspirin 75mg once daily, ramipril 2.5mg once daily and atorvastatin 20mg once daily. On examination he is overtly tachypnoeic with a respiratory rate of 24 breaths/min and oxygen saturations of 94% on 2l, he has a heart rate of 107bpm and a blood pressure of 118/68mmHg. His chest has bilateral crackles to the mid zone and his heart sounds are normal. He is afebrile and alert. His ECG shows sinus tachycardia with a broad complex QRS at 130ms His markers of infection are normal on his blood tests and he has a stage 1 AKI with a mild hyponatraemia. Which of the following is the most likely diagnosis?

Acute decompensated heart failure This is the classical presentation of a patient in acute decompensated heart failure. His impaired left ventricle secondary to ischaemic heart disease is unable to meet the demands of his body, this has resulted in lack of forward flow to the kidneys causing an AKI and back pressure through the pulmonary veins into the lung parenchyma which is causing the alveolar oedema on his chest and driving the tachypnoea. He should be diuresed with an IV loop diuretic and requires an urgent chest xray and echocardiogram to assess LV function 72% Ventricular tachycardia Patient's with ischaemic heart disease and previous myocardial infarcts are more likely to experience VT due to the electrical wavefront propagating around the scar formation in the ventricle, however this gentleman is normotensive, alert and most importantly has a ventricular rate that is almost certainly too slow for VT and would not cause the pulmonary congestion 22%

A 71-year-old woman comes for review. She was diagnosed with angina pectoris recently and is currently taking aspirin 75mg od, simvastatin 40mg on and atenolol 100mg od. If her anginal symptoms are not controlled on this medication, what is the most appropriate next step?

Add a long-acting dihydropyridine calcium-channel blocker

A 76-year-old man is seen by his GP. He recently had an ambulatory blood pressure monitor which showed frequent readings above 160/95 mmHg. The man has a background of well controlled heart failure (New York Heart Association stage 2) and chronic kidney disease. He takes ramipril, bisoprolol and atorvastatin; he has been established on this regime for one year and doses have been optimised.What would be the most appropriate next step? should you add nifedipine or indapamide

Adding nifedipine is incorrect. Nifedipine should be avoided in heart failure due to risk of symptom exacerbation; amlodipine is the only calcium channel blocker licensed for use in heart failure.

MOA and side effects of adenosine

Adenosine is most commonly used to terminate supraventricular tachycardias. The effects of adenosine are enhanced by dipyridamole (antiplatelet agent) and blocked by theophyllines. It should be avoided in asthmatics due to possible bronchospasm.Mechanism of action causes transient heart block in the AV node agonist of the A1 receptor in the atrioventricular node, which inhibits adenylyl cyclase thus reducing cAMP and causing hyperpolarization by increasing outward potassium flux adenosine has a very short half-life of about 8-10 seconds Adenosine should ideally be infused via a large-calibre cannula due to it's short half-life,Adverse effects chest pain bronchospasm transient flushing can enhance conduction down accessory pathways, resulting in increased ventricular rate (e.g. WPW syndrome)

which arrythmia is treated with adenosine

Adenosine is used to treat regular narrow complex tachycardias. If this patient was known to have supraventricular tachycardia (SVT) with bundle branch block then his broad complex tachycardia could be treated with adenosine, and adenosine is not contraindicated in broad complex tachycardias.

A 58-year-old man attends the emergency department with palpitations, reporting a 'racing heart' for four days, but denies any pre-syncope or chest pain. Usually, he is fit and well. On assessment, his ECG reveals an irregularly irregular pulse, with a ventricular rate of 105 bpm. He is haemodynamically stable. He is given oral bisoprolol, and his heart rate drops to 68 bpm. He is not keen to take medications long-term.What is the most appropriate management strategy?

Administer 4 weeks of anticoag and beta blocker prior to elective cardioversion. If a patient has been in AF for more than 48 hours then anticoagulation should be given for at least 3 weeks prior to cardioversion. An alternative strategy is to perform a transoesophageal echo (TOE) to exclude a left atrial appendage (LAA) thrombus. He is stable so there is no need for immediate cardioversion.

A 21-year-old man was brought in by police to the psychiatry unit due to reports of him behaving strangely in public place. On arrival, the clerking doctor gets a full history which shows evidence of paranoid ideation, thought insertion, withdrawal and broadcasting. He has no previous medical history and he is not on any regular medication. He denies illegal substance use and urine drug screen results were negative. The consultant psychiatrist feels the top differential diagnosis is first episode psychosis and recommends initiation of a daily anti-psychotic. Before prescribing this class of drugs, an initial assessment must include?

An ECG to assess for cardiovascular abnormalities including QT interval prolongation

Rhuematic Fever

Definition Rheumatic fever is a systemic complication of Lancefield group A beta-haemolytic streptococcal infection (typically a pharyngitis) that occurs two to four weeks post infection. Antibodies formed as a result of the infection cross-react with the myocardial tissue, causing the effects of rheumatic fever. Epidemiology The incidence of RF in developed countries is low. It is more common in developing countries, particularly where there is overcrowding and poor access to healthcare. Clinical findings Rheumatic fever typically presents with various clinical findings. To aid diagnosis, findings are classified by the Jones criteria into major and minor manifestations. Jones Criteria A diagnosis is considered likely if there is: Evidence of recent streptococcal infection (eg, history of scarlet fever, positive throat swab or rising or increased antistreptolysin O titre (ASOT) >200 U/mL or DNase B titre). Plus two major criteria; or One major and two minor criteria. Major Jones criteria Arthritis Usually the earliest manifestation, typically a "flitting" or migratory polyarthritis affecting one joint then others in quick succession. Most commonly affected joints are the knees, ankles, elbows and wrists. Pancarditis Affects all layers of the myocardium, however endocardial inflammation may predominate causing valvulitis. This may manifest clinically as a tachycardia, new murmur or new conduction defect. Sydenham's chorea Neurologic disorder consisting of abrupt, non-rhythmic, involuntary movements along with muscular weakness and emotional disturbance. They are most frequently marked on one side and cease during sleep. Erythema marginatum Geographical pink/red, nonpruritic rash involving mainly the trunk, thighs and arms. Characteristically, the rash has raised, sharp outer edges with a diffuse clear centre, making a ring (and contributing to its alternate name, erythema annulare). Subcutaneous nodules Firm, mobile painless lesions Minor Jones criteria Fever Arthralgia (unless if arthritis meets major criterion) Raised acute phase proteins (ESR and CRP) Prolonged PR interval on ECG (except if carditis meets major criterion) Management Management of rheumatic fever involves multiple goals: Eradication of group-A beta-haemolytic streptococcal infection STAT dose of IV Benzylpenicillin, with a ten day course of Phenoxymethylpenicillin to follow Analgesia for arthritic symptoms Aspirin or non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen. Aspirin should be used with caution in young children due to the small risk of Reye syndrome. There is no evidence to suggest that NSAIDs help with outcomes related to carditis. If carditis is complicated by heart failure Glucocorticoids (e.g. Prednisolone) can provide benefit (NSAIDs should be stopped concurrently). Diuretic treatment may also be necessary, and valve surgery if severe. Sydenham's chorea is self-limiting and does not require treatment, however Haloperidol or Diazepam may be used for distressing symptoms or risk of harm. Erythema marginatum is associated with rheumatic fever is temporary and doesn't require treatment, although antihistamines can help with pruritus. Mechanism of valve complications Rheumatic heart disease is a major cause of valvulopathy in children and young adults in the developing world. The most recent study in 2015 suggests that year there were over 30 million cases worldwide. Streptococcal antigens secondary to bacterial infection cross-reacts with the valve tissue, causing damage. Progressive damage commonly occurs in the years following acute rheumatic fever. Mitral disease occurs in 70% of cases and is the most common affected valve; aortic valves are involved in 40% (most commonly regurgitation), tricuspid valves in 10% and pulmonary valves in 2%. Common presentations of valve defects secondary to rheumatic heart disease Mitral stenosis - isolated mitral stenosis it is the most commonly encountered single valve lesion secondary to rheumatic heart disease Mitral regurgitation Mixed mitral stenosis and regurgitation Aortic regurgitation Aortic stenosis (rare in isolation) Tricuspid regurgitation or stenosis

differentiate lead poisoning from acute intermittent porphyria

Along with lead poisoning, acute intermittent porphyria should be considered in patients presenting with a combination of abdominal pain and neurological signs. In lead poisoning, raised serum and urine levels of delta aminolaevulinic acid may be seen making it sometimes difficult to differentiate from acute intermittent porphyria. However, in this case, the normal delta aminolaevulinic acid levels favour the diagnosis of lead poisoning.

A 73 year old man is seen in the community for high blood pressure. On this visit, his blood pressure is measured to be 178/82 mmHg. Ambulatory blood pressure monitoring reveals an average blood pressure of 168/76 mmHg. He declines treatment. Six months later, he develops sudden onset weakness in his right arm, a right facial droop and slurred speech. He presents to hospital three hours after symptom onset. His heart rate is 88 bpm, blood pressure is 178/80 mmHg, temperature is 36.8°C and respiratory rate of 22 breaths per minute. mx

Alteplase 60mg IV This is the correct answer. This man has presented with an acute ischaemic MCA stroke, which is a complication of uncontrolled hypertension (along with acute haemorrhagic stroke). The CT shows loss of differentiation between the grey and white matter and oedema affecting the left frontal and parietal lobes. Patients presenting within 4.5 hours of symptom onset are eligible for thrombolysis with Alteplase. This man meets the criteria. Blood pressure should be reduced below 185/110 mmHg before treatment 39%

amiodarone

Amiodarone is a class III antiarrhythmic agent used in the treatment of atrial, nodal and ventricular tachycardias. 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)The use of amiodarone is limited by a number of factors very long half-life (20-100 days). For this reason, loading doses are frequently used should ideally be given into central veins (causes thrombophlebitis) has proarrhythmic effects due to lengthening of the QT interval interacts with drugs commonly used concurrently (p450 inhibitor) e.g. Decreases metabolism of warfarin numerous long-term adverse effects (see below) Monitoring of patients taking amiodarone TFT, LFT, U&E, CXR prior to treatment TFT, LFT every 6 months Adverse effects of amiodarone use thyroid dysfunction: both hypothyroidism and hyper-thyroidism corneal deposits pulmonary fibrosis/pneumonitis liver fibrosis/hepatitis peripheral neuropathy, myopathy photosensitivity 'slate-grey' appearance thrombophlebitis and injection site reactions bradycardia lengths QT interval

which arrythmia is treated with amiodarone

Amiodarone is the recommended treatment for regular broad complex tachycardia (300mg IV over 20-60 minutes then 900mg over 24 hours).

A 44 year old presents to the emergency department with a four week history of malaise, fevers and recent concerns over painful purple spots on his fingertips. He has been treated by his GP for a lower respiratory tract infection with a short course of doxycycline but this has done little to abate his symptoms. He is otherwise fit and well and takes no regular medications. On examination he has raised, red and painful lesions on his fingertips and an ejection systolic murmur on auscultation of his chest. His lung fields are clear and he has non-swollen calves bilaterally. His blood tests show a raised white cell count and a high C-reactive protein An ECG shows normal sinus rhythm Blood cultures have grown gram positive cocci in two different bottles What would be the most appropriate antibiotic regimen for this gentleman?

Amoxicillin 2g 4-6 hourly Amoxicillin at high dose, sometimes with the addition of gentamicin at twice daily dosing, is the initial optimal management out of the options given. The high dose amoxicillin will provide good gram positive cover against the suspected pathogen. Treatment course would be discussed with a microbiologist but often runs to between 6 and 8 weeks with re-imaging at this point 46%

A 60 year old man has a two month history of progressive shortness of breath, swollen legs, arms and abdomen. He currently has to sleep with three pillows to feel comfortable, and often wakes in the night feeling short of breath. Over the past two weeks, he has also had occasional bouts of palpitations lasting around one hour, which self resolve. These are not associated with chest pain or dizziness. On examination, he is comfortable at rest. His JVP is visible 6cm above the sternal angle. Auscultation of his chest reveals bilateral reduced breath sounds at the bases. Heart sounds are audible without murmurs or added sounds. He has significant abdominal distension with shifting dullness, and pedal oedema extending to his knees. Blood tests show the following: BNP = 1023 ng/L A trans-thoracic echocardiogram is performed which shows a restrictive systolic pattern, with a left ventricular ejection fraction of 65% and reduced left ventricular cavity size. The myocardial wall has a "sparkling" appearance. Which of the following is the most likely cause of this man's presentation?

Amyloidosis This is the correct answer. AL amyloidosis (primary amyloidosis) results in amyloid protein deposition in various tissues in the body, such as kidneys and the heart. It can lead to a restrictive cardiomyopathy that appears "sparkling" on an echocardiogram. This man has presented with symptoms of heart failure with a preserved ejection fraction (HFpEF). Amyloid deposition also causes arrhythmias and conduction disturbances. Amyloidosis also causes renal dysfunction, leading to nephrotic range proteinuria which likely contributes to his significant oedema 49%

An 85 year old man has attended surgery to discuss an ambulatory blood pressure monitoring reading of 142/84 mmHg. He has no past medical history of coronary heart disease, renal disease or diabetes, and his only regular medication is lansoprazole. His 10-year cardiovascular risk score was recently calculated to be 8%. Management should include follow up with which one of the following?

An ambulatory blood pressure reading of greater than or equal to 135/85 mmHg confirms a diagnosis of stage 1 hypertension. However, the National Institute for Clinical Excellence (NICE) suggest that antihypertensive treatment should be offered only if the person is: aged less than 80 years with stage 1 hypertension with one or more of, target organ damage, established cardiovascular disease, renal disease, diabetes, and/or a 10 year cardiovascular risk of 10% or more. If stage 2 hypertension is diagnosed then antihypertensive medication should be started regardless of age. Lifestyle advice should be reinforced in all patients.

A 52-year-old male presents with tearing central chest pain. On examination, he has an aortic regurgitation murmur. An ECG shows ST elevation in leads II, III and aVF. What is the likely explanation?

An inferior myocardial infarction and AR murmur should raise suspicions of an ascending aorta dissection rather than an inferior myocardial infarction alone. Also the history is more suggestive of a dissection. Other features may include pericardial effusion, carotid dissection and absent subclavian pulse.

A 62-year-old man is being considered for clozapine treatment for treatment-refractory schizophrenia. As part of the initial work-up, he has an electrocardiogram (ECG) done on the ward.The cardiac electrophysiologist explains that his ECG shows an irregular, broad complex tachycardia of 120 beats per minute.He is currently stable, and his vital signs are within normal range. He has had no previous health issues and is not currently on any medication.What is the next most appropriate step in the management of his arrhythmia?

An irregular broad complex tachycardia is a rare rhythm, which would not be expected to be treated or handled without expert help. It is likely due to a composition of problems, such as atrial fibrillation with pre-existing bundle branch block or aberrant conduction. Due to their complexity, management should be handled by an expert cardiologist, and therefore their input is necessary here. There is no indication that he is clinically unwell currently, and therefore as he does not need any immediate intervention, it is sensible to seek help first.

ACEi

Angiotensin-converting enzyme (ACE) inhibitors are now the established first-line treatment in younger patients with hypertension and are also extensively used to treat heart failure. They are known to be less effective in treating hypertensive Afro-Caribbean patients. ACE inhibitors are also used to treat diabetic nephropathy and have a role in the secondary prevention of ischaemic heart disease.Mechanism of action: inhibit the conversion angiotensin I to angiotensin II ACE inhibitors are activated by phase 1 metabolism in the liver Side-effects: coughoccurs in around 15% of patients and may occur up to a year after starting treatmentthought to be due to increased bradykinin levels angioedema: may occur up to a year after starting treatment hyperkalaemia first-dose hypotension: more common in patients taking diuretics Cautions and contraindications pregnancy and breastfeeding - avoid renovascular disease - may result in renal impairment aortic stenosis - may result in hypotension hereditary of idiopathic angioedema specialist advice should be sought before starting ACE inhibitors in patients with a potassium >= 5.0 mmol/L Interactions patients receiving high-dose diuretic therapy (more than 80 mg of furosemide a day)significantly increases the risk of hypotension Monitoring urea and electrolytes should be checked before treatment is initiated and after increasing the dosea rise in the creatinine and potassium may be expected after starting ACE inhibitorsacceptable changes are an increase in serum creatinine, up to 30% from baseline and an increase in potassium up to 5.5 mmol/l.significant renal impairment may occur in patients who have undiagnosed bilateral renal artery stenosis

Vaccinations for HF

Annual influenza vaccination and single pneumococcal vaccination should be given to patients with chronic respiratory and heart conditions, including severe asthma, chronic pulmonary disease, and heart failure.Meningococcal vaccination is not given routinely to patients in heart failure. It is indicated in patients with asplenia or splenic dysfunction (including due to sickle cell and coeliac disease) as well as those with complement disorder.Pneumococcal vaccination is given as a booster every 5 years after the first dose for patients with splenic dysfunction and chronic kidney disease.

wellens syndrome

Anterior wall This is the correct answer. The patient's ECG is consistent with Wellen's syndrome which is associated with a high risk of anterior wall infarction from severe stenosis of the LAD. There is a biphasic pattern of the T waves in the anterior leads with T wave inversion. These patients often require PCI given the high risk of a large infarct 73%

The pain began three hours ago, which he described as central, sharp and radiating toward the back. It was associated with sweating, nausea and the sensation of near collapse. It is not exacerbated by inspiration or movement. He also complains of severe shortness of breath and is extremely uncomfortable at rest. On examination, he appears to be distressed, is pale and sweaty and has a thready pulse. Auscultation of his chest reveals bilateral inspiratory crepitations to the mid zones, and a low-pitched, rumbling mid-diastolic murmur heard loudest at the lower left sternal edge. His saturations are 92% on 10L of oxygen, respiratory rate is 36 breaths per minute, blood pressure is 102/55 mmHg, pulse is 120 bpm and temperature is 36.5°C.

Aortic dissection This is the correct answer. This man is presenting with symptoms typical of aortic dissection (central sharp pain radiating toward his back). He is also displaying features of acute aortic regurgitation (a rumbling mid-diastolic murmur characteristic of an Austin Flint murmur, cardiogenic shock and acute heart failure). Aortic dissection is the most common cause of acute aortic regurgitation. This leads to acute heart failure (suggested by respiratory distress) and CXR findings of pulmonary oedema 65%

Collapsing pulse indicates

Aortic regurgitation

A 54-year-old woman with a history of tertiary syphilis and severe rheumatoid arthritis on immunosuppressants was referred to the respiratory clinic following her complaint of dyspnoea. On physical examination, a new soft high-pitched diastolic murmur was auscultated. She was discussed with cardiology who advised the team to perform a routine echocardiogram. What condition is the echocardiogram most likely to show?

Aortic regurgitation typically causes an early diastolic murmur and is seen in tertiary cardiovascular syphilis and rheumatoid arthritis. Aortic regurgitation is the most frequent complication of syphilitic aortitis, occurring in 60% of those with cardiovascular syphilis. Aortic incompetence secondary to connective tissue diseases including rheumatoid arthritis has a relatively accelerated course rapidly leading to severe left ventricular failure.

A 59-year old presenting with a "tearing" sensation in his chest and back has been diagnosed with aortic dissection. A CT angiography is performed, and the patient is shown to have a Stanford Type A dissection. Which of the following is the most likely course of definitive management for this condition?

Aortic root replacement Stanford Type A aortic dissection are those which involve the ascending aorta, for which the management is surgical and an aortic root replacement may be needed to preserve perfusion to the carotid and subclavian arteries

A 68-year-old man with a past history of aortic stenosis is reviewed in clinic. Which one of the following features would most guide the timing of surgery?

Aortic stenosis management: AVR if symptomatic, otherwise cut-off is gradient of 40 mmHg

A 69-year-old female on the respiratory ward was admitted with a pulmonary embolism one week ago. This was her second pulmonary embolism, the first one occurring two months ago. She had been on warfarin prior to her admission. Her current dose of warfarin is 5mg and he INR today is 2.6. She has a past medical history of aortic stenosis and has a bioprosthetic aortic valve in situ.What is the most appropriate action to take?

As the patient suffers from recurrent pulmonary embolisms, her target INR is 3.5. Therefore the patients warfarin dose should be increased to 5.5mg.With regards to bioprosthetic valves, long-term warfarin is not required in absence of atrial fibrillation. However patients with bioprostheses in the mitral position should receive oral anticoagulants to achieve an INR of 2.5 for the first 3 months. Oral anticoagulants are not required for valves in the aortic position in patients in sinus rhythm, although many centres anticoagulate patients for 3-6 months after any tissue valve implant. Discuss (6)Improve

A 78 year old man is seen in the emergency department complaining of central chest pain radiating to the jaw. On examination he is tachypneic and sweaty. He has a past medical history of hypertension, gastric ulcers and type 2 diabetes. His troponin is raised at 105ng/mL and his ECG shows lateral T wave inversion. What is the next best initial step in management?

Aspirin 300mg, Clopidogrel 300mg and Glyceryl Trinitrate spray This is the correct answer. The patient's ECG shows lateral T wave inversion which is consistent with a non ST elevation infarction- NSTEMI. Dual antiplatelet therapy and GTN spray are indicated as well as morphine and oxygen if saturations are <94%. In this case, the patient is elderly and has a risk factor for bleeding (gastric ulcers) and therefore should not be given fondaparinux or ticagrelor 32%

A 74 year old man presents to their GP for a routine blood pressure check. Whilst checking his blood pressure you notice that his pulse rate is 64 but it is not regular. On further questioning he reveals he has had palpitations intermittently for 6 months. He does not have any chest pain and he has not felt short of breath or dizzy. His only medical history is diabetes, for which he is on metformin, and asthma, for which he takes inhalers. You arrange for him to have an ECG straightaway with the practice nurse. The ECG shows an irregularly irregular rhythm at a rate of 65 bpm. What is the most appropriate next step in management?

Assess his CHADSVASC score As there are no worrying features and his heart rate is in an acceptable range, the most appropriate next step in management is to assess his risk factors for stroke using the CHADSVASC score don't need to give a rate limiting mediciation because his rate is less than 80

A 35-year-old man presented to the primary care due to bouts of palpitations and shortness of breath on exertion. He is otherwise well. On examination, there was an ejection systolic murmur. An echocardiogram was arranged. This showed an asymmetric hypertrophy most marked in the septal region.Subsequent cardiovascular MR (CMR) confirmed this finding and found a systolic anterior movement of the anterior leaflet of the mitral valve.What is the most likely diagnosis?

Asymmetric septal hypertrophy and systolic anterior movement (SAM) of the anterior leaflet of mitral valve on echocardiogram or cMR support HOCM

A 15-year-old boy collapses and dies whilst playing football at school. He had no past medical history of note. Post-mortem examination reveals asymmetric hypertrophy of the interventricular septum. Given the likely underlying diagnosis, what is the individual risk his sister will also have the same underlying disorder?

Asymmetric septal hypertrophy and systolic anterior movement (SAM) of the anterior leaflet of mitral valve on echocardiogram or cMR support HOCM 50% chance

A 20 year old male patient presents to the emergency department with a syncopal episode whilst playing football. He has regained consciousness on arrival to the emergency department. He has no past medical history of note. His father died suddenly 2 years ago from a 'heart condition', but the patient is unsure of the name. Physical examination reveals a harsh ejection systolic murmur that decreases in intensity on squatting. Which of the following echocardiogram findings is consistent with the most likely diagnosis?

Asymmetric septal hypertrophy, diastolic dysfunction This is the correct answer. The patient presents with clinical features and a family history consistent with hypertrophic ostructive cardiomyopathy (HOCM). HOCM typically causes diastolic dysfunction due to impaired relaxation of the thickened left ventricle during diastole. This results in impaired filling of the left ventricle 46%

A 67-year-old man presents to the emergency department with dizziness and palpitations. The symptoms started 15 minutes ago and did not seem to subside.On examination, his blood pressure is 110/82 mmHg, heart rate 150/min, and respiratory rate 22/min. His pulse is irregularly irregular. He does not have any past medical history and is a keen athlete.An ECG shows an irregular trace with a QRS complex of 130 ms.What is the most likely cause of his presentation?

Atrial fibrillation with bundle branch block is the most likely cause of an irregular broad complex tachycardia in a stable patient

Jason, a 50-year-old man presents to the cardiac ward following a stroke. After further questioning, he reports a 4-month history of weight loss and fever. He is later examined and found to have a diastolic murmur for which he is sent for an echocardiogramThe report comes back as follows:'A pedunculated heterogeneous mass attached to the interatrial septum of the left atrium. Mitral valve obstruction also noted'Given the report, which of the following is the most likely diagnosis?

Atrial myxoma is a benign tumour most commonly occurring in the left atrium. It can present with the triad of mitral valve obstruction, systemic embolisation and constitutional symptoms such as breathlessness, weight loss and fever. In this case, the patient had all three, with a recent stroke, signs of mitral stenosis and the constitutional symptoms listed above.

what is the atrial myxoma and what are its features?

Atrial myxoma is the most common primary cardiac tumour.Overview 75% occur in left atrium, most commonly attached to the fossa ovalis more common in females Features systemic: dyspnoea, fatigue, weight loss, pyrexia of unknown origin, clubbing emboli atrial fibrillation mid-diastolic murmur, 'tumour plop' echo: pedunculated heterogeneous mass typically attached to the fossa ovalis region of the interatrial septum

management of bradycardia

Atropine (500mcg IV) is the first line treatment in this situation.If there is an unsatisfactory response the following interventions may be used: atropine, up to maximum of 3mg transcutaneous pacing isoprenaline/adrenaline infusion titrated to response Specialist help should be sought for consideration of transvenous pacing if there is no response to the above measures.

A 57-year-old man attended the GP 2 weeks ago due to persistent pain in his right hip. Whilst there, the GP decided to check his blood pressure, which was found to be 143/91mmHg.He was subsequently sent home with home blood pressure monitoring (HBPM) and today he returns to the GP for the results. His HBPM is 148/93mmHg.His past medical history is significant for a previous myocardial infarction.Given the result, what action should the GP take?

Ca channel blocker as he is over 55

first line for HF with reduced LVEF

BB and ACEi

features of AR

early diastolic murmur: intensity of the murmur is increased by the handgrip manoeuvre collapsing pulse wide pulse pressure Quincke's sign (nailbed pulsation) De Musset's sign (head bobbing) mid-diastolic Austin-Flint murmur in severe AR - due to partial closure of the anterior mitral valve cusps caused by the regurgitation streams

A 50 year old female presents to the Emergency Department with sudden onset of weakness in her right arm and leg. She has a 3 day history of fever and night sweats. Examination reveals an early diastolic murmur loudest over the 3rd left intercostal space. Blood cultures grew Gram positive cocci in chains. Which is the best choice of treatment?

Benzylpenicillin and gentamicin This is the treatment for infective endocarditis due to Streptococcus, which stains as Gram positive cocci in chains 29%

when are BB stopped

Beta-blockers should only be stopped in acute heart failure if the patient has heart rate < 50/min, second or third degree AV block, or shock

A 68-year-old with a history of hypertension has been diagnosed with heart failure. Which of the following medications has been shown to improve prognosis in patients with heart failure with reduced ejection fraction?

Bisoprolol Bisoprolol, carvedilol and metoprolol have been shown to have a survival benefit in patients with heart failure. 59%

A 76-year-old man is brought to the emergency department following a fall. He recently had a hip replacement and regularly takes atorvastatin, metformin, and dabigatran. CT imaging of the brain has revealed a subdural haematoma.What antidote should be administered?

Bleeding on dabigatran? Can use idarucizumab to reverse

A 34-year-old man with a history of intravenous drug abuse is admitted due to infective endocarditis. Blood cultures are obtained that show growth of Candida albicans. ECG of the patient shows PR shortening. A decision to perform urgent valve replacement is made.What aspect of this patient's history is an indication for surgery?

Blood culture finding Infective endocarditis - indications for surgery: severe valvular incompetence aortic abscess (often indicated by a lengthening PR interval) infections resistant to antibiotics/fungal infections cardiac failure refractory to standard medical treatment recurrent emboli after antibiotic therapy

A 52-year-old male presents with central chest pain and vomiting. He has drunk a bottle of vodka. On examination there is some mild crepitus in the epigastric region.

Boerhaave syndrome - the mackler triad: vomiting, thoracic pain, subcut emphysema. it commonly presents in middle aged men with a background of alcohol abuse

Side effects of amiodarone

Bradycardia Hyper/hypothyroidism pulmonary fibrosis/pneumonitis liver fibrosis/hepatitis jaundice taste disturbance persistent slate grey skin discolouration raised serum transaminases nausea constipation (particularly at the start of treatment) Uncommon side effects: arrhythmias peripheral neuropathy peripheral myopathy Very rare side effects: alopecia aplastic anaemia ataxia benign intracranial hypertension

brugada syndrome

Brugada syndrome is a genetic condition caused by sodium channelopathies. Epidemiology There is a high incidence of the condition in Southeast Asian males and a common cause of sudden cardiac death. Clinical features Patients may be asymptomatic or present with palpitations and syncope due to arrhythmias such as AV nodal re-entrant tachycardias (AVNRTs), VT or VF. Diagnostic criteria The condition is usually diagnosed by characteristic ECG changes and at least one clinical criterion. Examples include: VF or polymorphic VT Family history of sudden cardiac death under the age of 45 Syncope, ECG signs in the family Inducible VT Nocturnal agonal breathing Investigations Genetic testing, family history and special provocation tests eg ajmaline, are also used for diagnosis. Risk factors Certain risk factors can increase the risk of arrhythmia. Patients should be warned to avoid them or take prompt action like taking paracetamol if any fever. Fever Excess alcohol intake Dehydration Medicationanti dysrhythmics like flecainideverapamilantidepressants like amitriptyline Electrolyte abnormalities Management Definitive management is an ICD to reduce the risk of sudden death from arrhythmias such as VT/VF.

A 72-year-old man has been admitted to hospital with acute congestive cardiac failure and community-acquired pneumonia. He now complains of dizziness and yellow discolouration of his vision. He has a background of atrial fibrillation and ischaemic heart disease. On admission, he was taking apixaban, bisoprolol and digoxin. Which of the following newly prescribed medications may have precipitated his current symptoms?

Bumetanide The patient is describing symptoms of digoxin toxicity, which can be precipitated by hypokalaemia. Bumetanide is a loop diuretic and can cause hypokalaemia. 37%

A 70-year-old woman is prescribed bumetanide for congestive cardiac failure. Where is the site of action of bumetanide?

Bumetanide, like furosemide, is a loop diuretic. Furosemide - inhibits the Na-K-Cl cotransporter in the thick ascending limb of the loop of Henle

MVP

Mitral valve prolapse is midsystolic rather than ejection systolic and is louder on expiration rather than inspiration.

if someone has a high wells score, what is the next best step in this patients management? - is it CTPA or commence anticoagulation therapy

CT pulmonary angiogram (CTPA) is the correct answer. Based on the information provided, we can calculate her 2-level PE Well's score to be at least 4.5 (heart rate>100 + evidence of DVT). An alternative diagnosis is also less likely as the ECG and chest X-ray is largely unremarkable. Because she has a Well's score >4, the next best step in her management would be to perform a CTPA immediately, to diagnose a potential pulmonary embolism (PE).Commencing anticoagulation therapy is incorrect. This may be considered if the CTPA is delayed and interim anticoagulation is required. Anticoagulation is the mainstay of treatment in the management of PE. However, the next best immediate step would be to arrange a CTPA. There is no indication that there would be a delay in management and therefore anticoagulation is not currently indicated.

what do you need to in all AFib patients to determine their need for anticoagulation

CHA2DS2-VASc score

A 55-year-old woman presents to the emergency department with a one-hour history of sudden onset abdominal pain. The pain is constant and poorly localised, with 10/10 severity requiring opiate analgesia. Upon further questioning, there is a 2-month history of malaise, night sweats and spiking fevers. There is a past medical history of mitral valve replacement. Physical examination reveals a temperature of 38 degrees, nil abdominal findings, linear red streaks in her nails, and a pansystolic murmur heard loudest over the cardiac apex in held expiration. Which of the following is the single best investigation for a definitive diagnosis of the abdominal pain?

CT angiography This is the correct answer. This patient has subacute infective endocarditis, with acute mesenteric ischaemia due to septic emboli as a complication. CT angiography is the definitive diagnostic method for acute mesenteric ischaemia 54%

A 31-year-old male presents to the emergency department with sudden-onset 'tearing' pain in his chest. On examination, his heart rate is 70 beats per minute, respiratory rate is 16 breaths/min, temperature is 36.7ºC, oxygen saturations are 100% on room air, blood pressure is 165/82mmHg in the right arm and 138/70mmHg in the left arm. He has no past medical history but on examination, you note he has a tall stature, pectus excavatum and joint hypermobility.Chest x-ray is performed which shows a widened mediastinum.What is the most appropriate investigation?

CT angiography thorax, abdomen and pelvis is the investigation of choice for suspected aortic dissection

A 43-year-old lady presents with central chest pain, worse on deep inspiration, and shortness of breath. After her history and examining her, you suspect a pulmonary embolus (PE). Her Wells' score is 9. You plan to do a CTPA, but the radiologists request you order one further investigation prior to a CTPA. What investigation is this likely to be?

CXR

investigations for aortic dissection

CXR - widened mediastinum CT angiography of the chest, abdomen and pelvis - this is suitable for stable patients and for planning surgery. A false lumen is a key finding in diagnostic aortic dissection. TOE - more suitable for unstable patients who are too risky to take to a CT scanner

A 45-year-old gentleman presented to his local A&E with shortness of breath, palpitations and dizziness. He was previously diagnosed with Lyme disease but was non-compliant with his medication. He is otherwise fit and well normally. An urgent ECG performed by the attending physician revealed a complete heart block. Which single most likely JVP waveform is expected to be seen in this patient?

Cannon A-wave The A-wave signifies atrial contraction. A cannon A-wave is seen when an atrium contracts against a closed tricuspid valve during AV dissociation such as in this case of complete heart block. It is also seen in ventricular tachycardia or extrasystoles. Note that a cannon A-wave is more obvious than a prominent A-wave. These terms are based on historical convention. Knowledge of the JVP waveform is important for theory exams and viva components in the OSCE 43%

A 57 year old woman has a one month history of fevers and feeling "under the weather". Upon further questioning, she also reports having lost 10kg of weight unintentionally over the past ten weeks. Her only significant medical history is a pituitary adenoma resected twenty years previously. She has a pulse rate of 78bpm, blood pressure of 118/70mmHg, respiratory rate of 18 breaths per minute, saturations of 97% on room air and a temperature of 37.9°C. On examination, her finger nails are clubbed. Auscultation of her chest reveals a murmur which is variably audible depending on her position. Which of the following conditions is most likely responsible for her presentation?

Cardiac myxoma This is the correct answer. Cardiac myxomas are primary cardiac tumours, associated with systemic and local signs and symptoms. Systemic effects include fever, weight loss and malaise, and fingernail clubbing. On examination, a tumour "plop" may be heard, alongside a murmur variable with position (resulting from atrial outflow obstruction). Cardiac myxomas may be associated with the "Carney complex", alongside skin pigmentation. Schwannomas, skin myxomas and endocrine tumours such as pituitary adenomas, may also occur 44%

Pulmonary A pressure = low CO = low SVR = high

Cardiac output is lowered in hypovolaemia due to decreased preload.

criteria for giving CRT in someone with HF

Cardiac resynchronisation therapy This patient is symptomatic despite adequate medical therapy for congestive cardiac failure. He fulfils the criteria for consideration of CRT- cardiac resynchronisation therapy: LBBB on ECG LVEF <30% NYHA Class III 38%

A 75 year old male presents to the outpatient cardiology clinic complaining of worsening shortness of breath on exertion for the past 6 months. He has a history of heart failure secondary to ischaemic heart disease and takes the following medications: Ramipril 5mg once daily, bisoprolol 5mg twice daily, eplerenone 25mg once daily, furosemide 40mg twice daily, ivabradine 5mg twice daily. On examination his observations are all within range and he has fine crackles at bilateral bases on auscultation of his chest with normal heart sounds and no evidence of peripheral oedema. His ECG shows a sinus rhythm with a QRS duration of 135ms and an echocardiogram shows an left ventricular ejection fraction of 30%. What should the next step be in the management of this gentleman's heart failure?

Cardiac resynchronisation therapy device Patients with a wide QRS and an ejection fraction of <35% are indicated for CRT devices if they are not stabilised with the medications that this patient is already on. The two options are CRT-D or P. D stands for defibrillator and will shock the patient back into sinus rhythm should malignant rhythms occur such as VT and P stands for pacing and gives pure pacing capabilities without the defibrillator function see quesmed

A 39 year old male patients presents to the emergency department with a 2 hour history of palpitations and dizziness. Electrocardiogram (ECG) shows a short PR interval and narrow complex tachycardia which responds to intravenous adenosine. The ECG is repeated when the patient is in sinus rhythm and shows intermittent QRS complexes with pre-excitation. Following discharge, the patient continues to have several episodes of symptomatic tachycardia. Which of the following is the definitive management for the most likely diagnosis?

Catheter ablation of the accessory conduction pathway This is the correct answer. The patient presents with features suggestive of Wolff-Parkinson-White (WPW) syndrome. Catheter ablation of the accessory atrio-ventricular pathway is the treatment of choice following acute treatment 65%

xanthomata

Characteristic xanthomata seen in hyperlipidaemia:Palmar xanthoma remnant hyperlipidaemia may less commonly be seen in familial hypercholesterolaemia Eruptive xanthoma are due to high triglyceride levels and present as multiple red/yellow vesicles on the extensor surfaces (e.g. elbows, knees)Causes of eruptive xanthoma familial hypertriglyceridaemia lipoprotein lipase deficiency Tendon xanthoma, tuberous xanthoma, xanthelasma familial hypercholesterolaemia remnant hyperlipidaemia

A 65-year-old gentleman with a 6-month history of anorexia and nausea. On examination, his JVP was raised, there was tender smooth hepatomegaly, pitting oedema. No ascites was noted. The apex beat was not displaced, his lung bases were clear on auscultation. Which of the following diagnoses is the most likely underlying cause?

Chronic obstructive pulmonary disease (COPD) COPD or any chronic lung disease can result in cor pulmonale, defined as a deterioration in the function and/or structure of the right ventricle caused by respiratory pathology. The above clinical picture is consistent with isolated right ventricular failure; all other options are causes of left ventricular failure (which can eventually result in right ventricular failure) 32%

A concerned mother brings her one-week-old baby due to poor feeding. He was born at 38 weeks gestation with no complications. There is no central cyanosis. Vital signs include a slight tachycardia, tachypnoea and hypertension measured in the upper extremity. Oxygen saturations are measured at 99% on air. Auscultation of the chest reveals a systolic murmur heard loudest at the left sternal edge and bilateral femoral pulses are weak.What is the most likely underlying diagnosis?

Coarctation of the aorta is a congenital abnormality where there is a narrowing of the aorta leading to hypoperfusion of the lower body. Patients can present with cardiac failure and symptoms such as poor feeding, lethargy and shortness of breath. Neonates typically present with a systolic murmur with the maximum intensity in the left sternal edge. As well as this, due to the poor perfusion, the lower extremity pulses may be weakened.

A 64 year old man presents with a five day history of fevers, night sweats and malaise, on a background of six months of 10 kg weight loss and fatigue. He has a background of a metallic aortic valve replacement two years ago, a result of aortic stenosis secondary to a bicuspid valve. On examination, there is evidence of clubbing and splinter haemorrhages in his nails. Metallic heart sounds are audible with no murmurs or added sounds. A trans-oesophageal echocardiogram is performed which confirms infective endocarditis of his prosthetic valve. Two separate blood cultures return positive for the organism streptococcus bovis. Which of the following investigations is further warranted by this finding?

Colonoscopy This is the correct answer. Strep. bovis is an organism known to cause infective endocarditis, and a common source of it is from the gastrointestinal tract - patients with inflammatory bowel disease or colonic tumours are more likely to grow this type of bacteria. Patients with Strep bovis endocarditis should have a screening colonoscopy 45%

A 68 year old lady presents with a 2 month history of fever, night sweats and weight loss. She also reports a recent change in bowel habit and painless rectal bleeding. Her past medical history includes hypertension. On examination she has conjunctival pallor and an early diastolic murmur is noted. Rectal examination reveals fresh blood. Otherwise examination findings are unremarkable. Her blood tests show the following: Hb = 80g/L (115-160) WCC = 14 x 10^9/L (4-11) MCV = 71fL (80-100) Platelets = 150 x 10^9/L (150-400) What is the most likely explanation for this patient's rectal bleeding?

Colorectal cancer This is the correct answer. This patient gives a classic history of streptococcus bovis infection which predisposes patients to both infective endocarditis and colorectal cancer. This patient has symptoms of both providing a unifying diagnosis 62%

ide effects of thiazide diuretics

Common adverse effects dehydration postural hypotension hyponatraemia, hypokalaemia, hypercalcaemia* gout impaired glucose tolerance impotence Rare adverse effects thrombocytopaenia agranulocytosis photosensitivity rash pancreatitis

A 74-year-old male presents to the Emergency Department with acute, severe, central chest pain radiating down his left arm, and breathlessness. An ECG (electrocardiogram) shows ST elevation in leads II, III, and aVf and a blood test reveals a raised troponin level. His only past medical history is hypertension for which he is on amlodipine.His observations are as follows: Blood pressure 154/97 mmHg Heart rate 84 beats/min Temperature 36.9 ºC SpO 2 96% on air Whilst being assessed in resus his heart rate drops to 43 beats/min. A subsequent ECG shows complete heart block.What is the most appropriate management for his low heart rate?

Complete heart block following an inferior MI is NOT an indication for pacing, unlike with an anterior MI Atropine is the correct answer. This is because AV (atrioventricular) block and bradyarrhythmias are usually transient (hours to days) when caused by inferior myocardial infarction (MI). They are treated with atropine in the acute setting and usually respond well.External pacing is not usually needed when an inferior MI, unlike when the heart block is caused by an anterior MI - which is more likely to cause prolonged or permanent arrhythmia.

A 70 year old man patient presents to the general medical clinic for review. He has a past medical history of haemorrhagic stroke 2 years ago, hypertension, chronic kidney disease stage IIIa and liver cirrhosis. He admits to drinking half a bottle of wine per day. On physical examination there is a long-standing right-sided hemiplegia, and an irregularly irregular pulse is also noted. The examination is otherwise unremarkable and vital signs are within normal range. Electrocardiogram (ECG) reveals absent P waves with irregular QRS complexes. Which of the following is the most suitable long-term management plan regarding anti-coagulation?

Consider avoiding anti-coagulation given higher risk of bleeding This is the correct answer. This patient is likely to have chronic atrial fibrillation (AF). Use of anti-coagulation (to reduce the risk of cardio-embolic stroke) should be balanced against the risk of bleeding. In patients with a HAS-BLED score of 3 or more (this patient scores 6), the bleeding risk is higher so this risk needs to be shared with the patient and appropriate specialist opinion sought with consideration of balancing the risks vs the benefits of anti-coagulation 38%

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

A 78 year old man has a six week history of gradually increasing shortness of breath following a recent ST-elevation myocardial infarction (STEMI). He has a pulse rate of 88bpm, respiratory rate of 32 breaths per minute, blood pressure of 108/64 mmHg, saturation of 96% on room air and temperature of 37.1°C. His JVP is elevated at 6cm, and rises with inspiration. Heart sounds are quiet with a third heart sound present, and on auscultation he has bilateral basal inspiratory crepitations. His liver is palpable, and is pulsatile, smooth and non-tender. He has pedal oedema to his mid thighs bilaterally. An echocardiogram is performed, which shows diastolic dysfunction with an ejection fraction of 55%. Which of the following is most likely to be responsible for this man's presentation?

Constrictive pericarditis This is the correct answer. This man has presented with signs and symptoms suggestive of right heart failure (pulsatile hepatomegaly, peripheral oedema, dyspnoea), following a myocardial infarction (MI). Additional signs include quiet heart sounds and a third heart sound. These findings are consistent with constrictive pericarditis, causing diastolic heart failure (or heart failure with preserved ejection fraction, HFpEF). Dressler's syndrome describes pericarditis following an MI, which can be complicated by constrictive pericarditis not ischemic heart failure = this is more likely to present with a systolic dysfunction

A 35 year old man presents to the emergency department with severe central chest pain and shortness of breath whilst he was on a run this morning. He mentions that this has happened before and the pain is relieved by rest. The patient is not on any prescribed drugs, but admits to taking cocaine with his friends recently. On examination he is distressed and sweating. His pulse rate is 115 beats per minute and blood pressure is 118/68 mmHg. His respiratory rate is 28 breaths per minute with normal breath sounds in both sides of the chest. An ECG is conducted and shows only sinus tachycardia. What is the most likely diagnosis?

Coronary artery vasospasm Correct - coronary artery vasospasm presents with central chest pain on exertion and is strongly associated with the use of cocaine 73%

murmur grading

Grade 1 - Very faint murmur, frequently overlooked Grade 2 - Slight murmur Grade 3 - Moderate murmur without palpable thrill Grade 4 - Loud murmur with palpable thrill Grade 5 - Very loud murmur with extremely palpable thrill. Can be heard with stethoscope edge Grade 6 - Extremely loud murmur - can be heard without stethoscope touching the chest wall

You are doing the discharge summary for a 56-year-old man who is being discharged following a ST-elevation myocardial infarction (MI) for which he was treated with a percutaneous coronary intervention. He has no past medical history of note. Following NICE guidance, which of the following best describes the medications which he should be taking?

dual antiplatelet therapy, BB, ACEI and statin

A 34-year-old IVDU presented to the Emergency Department due to fever, chills and feeling unwell. Examination revealed vesicular breath sounds, S1 & S2 heart sounds with a murmur.Given the most likely diagnosis, which of the following criteria is helpful?

duke criteria - definitive diagnosis of invective endocarditis

A 62-year-old man presents to the emergency room with central chest pain radiated to his left arm. He underwent percutaneous coronary intervention (PCI) which was successful and he was later admitted to the ward. Five days following PCI the man experiences chest pain similar to before. which blood test is more useful in this situation

Creatine kinase (CK-MB) remains elevated for 3 to 4 days following infarction. Troponin remains elevated for 10 days. This makes CK-MB useful for detecting re-infarction in the window of 4 to 10 days after the initial insult

A 59-year-old patient presents with acute central chest pain that she first noticed 8 hours ago. She explains that she was recently discharged following a non-ST-elevation myocardial infarction that occurred 6 days previously. Following a thorough history and examination, you suspect re-infarction and wish to investigate further.What biomarkers would be most useful in confirming the diagnosis?

Creatine kinase (CK-MB) remains elevated for 3 to 4 days following infarction. Troponin remains elevated for 10 days. This makes CK-MB useful for detecting re-infarction in the window of 4 to 10 days after the initial insult

managing a stroke in a patient with AFib

Current NICE guidance (CG68) recommend 2 weeks of aspirin 300mg OD before consideration of anti-coagulation in cases of ischaemic stroke and atrial fibrillation. Currently, there is no evidence of other anti-platelets aside from aspirin (e.g. clopidogrel monotherapy or in combination with aspirin) in the acute phase of an ischaemic stroke to improve patient outcomes. This patient would then require lifelong anti-coagulation with either warfarin or a direct oral anti-coagulant to prevent the risk of further strokes. NICE issued guidelines on atrial fibrillation (AF) in 2006. They included advice on the management of patients with AF who develop a stroke or transient-ischaemic attack (TIA).Recommendations include: following a stroke or TIA, warfarin or a direct thrombin or factor Xa inhibitor should be given as the anticoagulant of choice. Antiplatelets should only be given if needed for the treatment of other comorbidities in acute stroke patients, in the absence of haemorrhage, anticoagulation therapy should be commenced after 2 weeks. If imaging shows a very large cerebral infarction then the initiation of anticoagulation should be delayed

what happens to creatinine when using ACEi and what should you do about it

Current guidelines state that when starting an ACE inhibitor, renal function and electrolytes should be measured before starting therapy and monitored during treatment. An increase in creatinine up to 30% from baseline and an increase in K+ up to 5.5mmol/L is acceptable after starting an ACE inhibitor. In this case, the creatinine has risen by approximately 28%, and K+ is <5.5mmol/L, therefore it is safe for this patient to continue taking ramipril. Bloods should be repeated in a further 2 weeks.

mx of someone with VT who has a pulse

DC cardioversion The ECG of this patient shows monomorphic ventricular tachycardia. This patient has had two episodes of collapse, this is one of the adverse features that must be considered when assessing any patient with a tachyarrhythmia. As this patient is compromised, cardioversion, as opposed to medical treatment is the most important management. As this patient still has a pulse, then DC cardioversion and not unsynchronised cardioversion is the most appropriate management 51%

which drugs in HF dont imporve morality

DD - digoxin and diuretics (ecxept spironolocatone)

which medication is given first line to reduce stroke risk in AF patients

DOACs

Pulmonary A pressure = low CO = high SVR = low

Decreased SVR is a major feature of sepsis. A hyperdynamic circulation is often present. This is the reason for the use of vasoconstrictors.

When is defibrillation indicated?

Defibrillation is indicated in cardiac arrest for ventricular tachycardia or ventricular fibrillation. This patient is very much alive and therefore defibrillation not indicated..

This patient is presenting with a short history of diarrhoea and fatigue. His blood results demonstrate mild anaemia, a calcium, phosphate and vitamin D deficiency combined with an isolated rise in ALP. This picture is indicative of anaemia combined with osteomalacia. The low Hb shows mild anaemia. Then, the low levels of calcium, phosphate and vitamin D indicate osteomalacia. what is the likely diagnosis

Diarrhoea, fatigue, osteomalacia → ?coeliac disease

when would you have dofferent bps in arms in

Difference of more than 20mmHg between the left and right arm This is correct. Although this presence of this finding will depend on exactly where the dissection is, if the dissection involves either the right brachiocephalic trunk or the left subclavian arteries blood flow (and therefore pressure) to the arms will be different 89%

use for: - doxazosin - prochlorperazine - isoprenaline - dobutamine

Doxazosin is a selective a1-blocker that is used to treat hypertension. This medication will worsen orthostatic hypotensions. Prochlorperazine is used in vertigo. Isoprenaline and dobutamine are ionotropic agents, that are sometimes used for patients in shock. They are not used for orthostatic hypotension.

A 56-year-old man attends the emergency department with a 3-day history of sharp left-sided chest pain and intermittent fevers. His past medical history includes hypercholesterolaemia and a non-ST elevation myocardial infarction (NSTEMI) 4 weeks ago.On examination, he has a heart rate of 88bpm and a blood pressure of 121/71mmHg. His heart sounds are muffled. His jugular venous pressure is normal and there is equal air entry bilaterally.Bedside echo: 1.2cm pericardial effusion.Investigations: Hb144 g/L(135-180)WBC11.1 * 109/L(4.0 - 11.0)ESR78 mm/hr< 28 What is the most likely diagnosis?

Dressler's syndrome is correct. This is an autoimmune reaction against antigenic proteins that form following myocardial recovery post-myocardial infarction. There is an overlap of symptoms compared to pericarditis including pleuritic chest pain, fever and raised WCC and ESR. In pericarditis, there may also be a pericardial effusion causing muffled heart sounds. However, Dressler's syndrome is a form of secondary pericarditis that typically occurs 2-6 weeks following a myocardial infarction, whereas pericarditis tends to develop within 48 hours.

ix for IE

ECG Chest X-ray Blood tests: FBC, U&E, LFT, CRP At least 3 sets of blood cultures should be taken at different times from various sites. Transthoracic echocardiogram is the first line imaging investigation Transoesophageal echocardiogram is the most sensitive diagnostic test

aortic stenosis ecg

Ejection systolic murmur heard loudest in the 2nd intercostal space, right sternal border This ECG shows a widened QRS complex in V6, in particular, the R wave looks notched. There is also a deep S wave in V1. This is an ECG finding consistent with LBBB. This is the murmur of aortic stenosis. Aortic stenosis is a well-documented cause of LBBB. The reason is that the calcification that leads to aortic stenosis can extend beyond the valve into the conduction system of the heart (i.e. the left bundle branch) 45%

A 26-year-old male presents via ambulance to the emergency department of your local hospital following a motor vehicle accident. He was a restrained passenger. The paramedics have secured his c-spine before transporting him. He is complaining of chest pain and shortness of breath. A primary and secondary survey are undertaken and the following pertinent findings are reported:Young, otherwise healthy looking male in clear pain and respiratory distress.Glasgow coma scale (GCS) of 14.Heart rate of 104/min.Blood pressure of 94/50mmHg.Respiratory rate of 24/min.Oxygen saturation: 99% on 15L non-rebreather.Temperature: 36.8 degrees.There is a tender contusion on the anterior chest. No abnormal chest movements. JVP can been seen at the level of the earlobe. Auscultation reveals soft heart sounds and bibasal crepitations. There is air entry throughout both lung fields.An ECG is performed.Which of the following ECG findings is most likely to be reported in this patient?

Electrical alternans is suggestive of cardiac tamponade

A 30 year old man presents to the emergency department after a syncopal episode at home. He has a long-standing history of palpitations. An ECG is consistent with Brugada syndrome, which is confirmed with an ajmaline provocation test and ambulatory ECG monitoring. Which of the following features should be treated urgently to prevent an arrhythmia?

Fever Fever can increase the risk of life-threatening arrhythmia in Brugada syndrome. It should be promptly treated with antipyretics such as paracetamol. Certain medications, excess alcohol and strenuous exercise should also be avoided 19%

ecg changes when first diagonal branch of the left ant descending artery isa ffected first diagnal branch is the circumflex

First diagonal branch of the left anterior descending artery This is the correct answer. The diagonal artery is a branch of the LAD supplying part of the lateral wall. There is ST elevation in leads I and aVL with reciprocal ST changes in leads III and aVF, consistent with a high lateral STEMI 41%

A 73-year-old woman is recovering in hospital a few days after a myocardial infarction (MI). Over a couple of hours, she develops significant shortness of breath and a cough productive of frothy sputum.On examination, she has coarse crackles bilaterally in the lungs and a pansystolic murmur best heard at the apex. Her heart rate is 112/min and regular, BP 95/70 mmHg, oxygen saturations 86% on air, respiratory rate 33/min and temperature 37.3ºC.What post-MI complication is most likely to have occurred?

Flash pulmonary oedema can occur after acute mitral valve regurgitation due to myocardial infarction

medical management of orthostatic hypotension

Fludrocortisone increases renal sodium reabsorption and increases the plasma volume. This helps to counteract the physiological orthostatic vasovagal reflex. Its efficacy is supported by 2 small observational studies and one small double-blind trials. The European Society of Cardiology has given a Class IIa recommendation to FludrocortisoneManagement of orthostatic hypotension (ESC 2018): education and lifestyle measures such as adequate hydration and salt intake discontinuation of vasoactive drugs e.g. nitrates, antihypertensives, neuroleptic agents or dopaminergic drugs if symptoms persist, consider compression garments, fludrocortisone, midodrine, counter-pressure manoeuvres, and head-up tilt sleeping

focal seizure mx in man and woman

Focal seizures: lamotrigine or levetiracetam are first-line

A 66-year-old man who has recently suffered a stroke has come to see you today for follow up. He reports that he was watching the football with his son last week when he noticed that he had lost sensation in the right side of his body. An ambulance was immediately called following the incident and he was taken to hospital where a left sided ischaemic stroke was confirmed on a CT scan. He has no other past medical history.Which one of the following antiplatelet medications should he be given following the stroke?

Following a stroke all patients should be offered an antiplatelet drug unless the person has an indication for an anticoagulant.According to NICE guidelines:Aspirin 300 mg daily for 2 weeks should be given immediately after an ischaemic stroke is confirmed by brain imaging. Following this, clopidogrel 75 mg daily should be given long-term -if it can be tolerated and is not contraindicated.If clopidogrel is contraindicated or not tolerated, then the patient should be given modified-release dipyridamole alongside low dose aspirin.

during a peri-arrest rhythm when is someone given synchronised DC shocks?

Following basic ABC assessment, patients are classified as being stable or unstable according to the presence of any adverse signs: shock: hypotension (systolic blood pressure < 90 mmHg), pallor, sweating, cold, clammy extremities, confusion or impaired consciousness syncope myocardial ischaemia heart failure If any of the above adverse signs are present then synchronised DC shocks should be given. Up to 3 shocks can be given; after this expert help should be sought.Treatment following this is given according to whether the QRS complex is narrow or broad and whether the rhythm is regular or irregular.

A 70-year-old male is brought to the emergency department complaining of a 40-minute history of central crushing chest pain.Observations reveal tachycardia, with a normal respiratory rate and oxygen saturations. An electrocardiogram (ECG) reveals ischaemic changes without ST elevation, and a troponin blood sample is reported as raised, leading to the diagnosis of a non-ST-elevated myocardial infarction (NSTEMI).He is administered morphine and nitrates for his pain, alongside anti-platelet and anticoagulant therapy. He is also started on a beta-blocker. His Global Registry of Acute Coronary Events (GRACE) score is calculated as 6%.Based on the information provided, what additional treatment is indicated for this patient?

Following the diagnosis of an NSTEMI, a patient's risk of a repeat event should be calculated, most commonly using the Global Registry of Acute Coronary Events (GRACE) score. A risk higher than 3% (as is the case with this patient) indicates that the patient should undergo PCI within 72 hours of hospital admission. They should also receive unfractionated heparin and a glycoprotein IIB/IIIA receptor antagonists prior to this PCI.

for <80 when do you start antihypertensives

For a person < 80, with stage 1 hypertension, only treat medically if: diabetic, renal disease, QRISK2 >10%, established coronary vascular disease, or end organ damage

when to start antihypertensives in <80

For a person < 80, with stage 1 hypertension, only treat medically if: diabetic, renal disease, QRISK2 >10%, established coronary vascular disease, or end organ damage

A middle-aged lorry driver presents with central chest pain and ST elevation on electrocardiogram. He is treated for myocardial infarction with Percutaneous Coronary Intervention (PCI) and a stent is deployed to his left circumflex artery to good effect. He is now asymptomatic and has been started on secondary prevention medications. He is keen to get back to work. What guidance should he be given on discharge?

For a private vehicle, patients do not need to notify the DVLA following PCI and may resume driving after 4 weeks providing they don't have any other disqualifying condition.For a Group 2 vehicle (bus or lorry), patients must notify the DVLA, and may not drive for at least 6 weeks. After 6 weeks the DVLA will assess to determine if the requirements for exercise or other functional tests are met and to ensure there is no disqualifying condition. Only then will the license to drive a Group 2 vehicle be reinstated.In this case, the most important factor is that the patient is obligated to tell the DVLA about his condition, and this is not a task for the medical team. Discuss (5)Improve

A 55-year-old man presents for review. He is of Afro-Caribbean descent and has been taking amlodipine 10mg daily. On review of his blood pressure readings, he has had an average of 154/93 mmHg over the last 2 months. The blood pressure today is 161/96 mmHg. Further management is discussed with the patient and he is keen to get his blood pressure under control.What is the best treatment to commence in this situation?

For patients of black African or African-Caribbean origin taking a calcium channel blocker for hypertension, if they require a second agent consider an angiotensin receptor blocker in preference to an ACE inhibitor

A 62-year-old man of black African descent is seen by the GP for a hypertension review. He already takes amlodipine with good adherence, but ambulatory blood pressure monitoring has shown readings consistently above 150/91mmHg. He also takes atorvastatin for high cholesterol.What is the most appropriate next step in management?

For patients of black African or African-Caribbean origin taking a calcium channel blocker for hypertension, if they require a second agent consider an angiotensin receptor blocker in preference to an ACE inhibitor

A 66-year-old man presented to his general practitioner with a longstanding history of leg swellings is now also complaining of becoming short of breath when walking. He has a background of chronic obstructive pulmonary disease, ischaemic heart disease and diabetes mellitus. He recently stopped smoking after doing so for the last 40 years and is now retired at home living with his wife in a two-bedroom house. Upon examination, he had a pansystolic murmur loudest at the left sternal edge with peripheral pitting oedema to the shins and a clear chest when auscultated. He appeared comfortable at rest and was not in any distress.What is the most likely cause for his murmur?

Functional tricuspid regurgitation often occurs secondary to pulmonary hypertension

MOA and side effects of loop diuretics

Furosemide and bumetanide are loop diuretics that act by inhibiting the Na-K-Cl cotransporter (NKCC) in the thick ascending limb of the loop of Henle, reducing the absorption of NaCl. There are two variants of NKCC; loop diuretics act on NKCC2, which is more prevalent in the kidneys.As loop diuretics work on the apical membrane they must first be filtered into the tubules by the glomerulus before they can have an effect. Therefore patients with poor renal function may require escalating doses to ensure a sufficient concentration is achieved within the tubules. Indications heart failure: both acute (usually intravenously) and chronic (usually orally) resistant hypertension, particularly in patients with renal impairment Adverse effects hypotension hyponatraemia hypokalaemia, hypomagnesaemia hypochloraemic alkalosis ototoxicity hypocalcaemia renal impairment (from dehydration + direct toxic effect) hyperglycaemia (less common than with thiazides) gout

what type of drug is bumetanide and what type of drug is spironolactone

Furosemide and bumetanide are loop diuretics that act by inhibiting the Na-K-Cl cotransporter (NKCC) in the thick ascending limb of the loop of Henle, reducing the absorption of NaCl. There are two variants of NKCC; loop diuretics act on NKCC2, which is more prevalent in the kidneys.As loop diuretics work on the apical membrane they must first be filtered into the tubules by the glomerulus before they can have an effect. Therefore patients with poor renal function may require escalating doses to ensure a sufficient concentration is achieved within the tubules. spironolactone is an aldosterone antagonist

loop diuretics

Furosemide and bumetanide are loop diuretics that act by inhibiting the Na-K-Cl cotransporter (NKCC) in the thick ascending limb of the loop of Henle, reducing the absorption of NaCl. There are two variants of NKCC; loop diuretics act on NKCC2, which is more prevalent in the kidneys.As loop diuretics work on the apical membrane they must first be filtered into the tubules by the glomerulus before they can have an effect. Therefore patients with poor renal function may require escalating doses to ensure a sufficient concentration is achieved within the tubules.Indications heart failure: both acute (usually intravenously) and chronic (usually orally) resistant hypertension, particularly in patients with renal impairment Adverse effects hypotension hyponatraemia hypokalaemia, hypomagnesaemia hypochloraemic alkalosis ototoxicity hypocalcaemia renal impairment (from dehydration + direct toxic effect) hyperglycaemia (less common than with thiazides) gout

A 58 year old man presents to the GP complaining of ongoing exertional chest pain. A recent myocardial perfusion scan has shown reversible ischaemia confirming a diagnosis of coronary artery disease. He is obese but has no other past medical history. The GP gives lifestyle advice and secondary prevention medication to reduce his cardiovascular disease risk. What is the next best step to manage his symptoms?

GTN spray and bisoprolol This is the correct answer. First line management in stable angina after optimising risk factors is a beta blocker or a rate-limiting calcium channel blocker and a short term nitrate- GTN spray 37%

A 72-year-old woman is due to have a tooth extracted next week.Her past medical history is significant for an aortic valve replacement 2 years previously.What antibiotic prophylaxis is recommended prior to this procedure?

General oral hygiene advice is correct. NICE guidance from 2008 recommended that patients undergoing dental procedures are not routinely offered infective endocarditis prophylaxis. This includes those deemed 'at risk' due to cardiac conditions such as valve replacement or structural heart disease.

A 50-year-old man presents to the GP with a 3-month history of worsening lower back pain radiating into his buttocks. The pain is worse on exertion and straining and is not relieved when lying down. He has a history of hypercholesterolaemia and recently had a few episodes of haemoptysis and weight loss. He has smoked 35 cigarettes daily for the last 30 years and works as a builder.On examination, power in the lower limb is reduced, and there is diminished pinprick sensation. The anal sphincter tone is intact.What is the most appropriate next step for the GP to take? lumbar mri or neoplastic scc or arrange urgent hospital admission

Give dexamethasone and arrange urgent hospital admission is correct. NICE recommends that all patients with suspected neoplastic spinal cord compression should be given an immediate dose of dexamethasone and referred to secondary care for an urgent MRI within 24 hours of presentation and an urgent oncological assessment for consideration of surgery or radiotherapy. Given that this consultation is taking place in a GP setting, the most appropriate action for the GP to take is to give an immediate dose of dexamethasone as long as this does not delay patient transport to hospital and admission for a full workup.

An 83-year-old male presents with recurrent episodes of collapse with associated loss of consciousness lasting a few minutes. These episodes occur at rest and on exertion. He has no previous cardiac history and takes no regular medications. Resting 12-lead ECG shows normal sinus rhythm.Observations on admission are within normal limits. No significant deficit between lying and standing blood pressure.What would be the most helpful investigation to determine the underlying cause of the recurrent collapse?

Given the recurrent episodes of collapse and a normal resting ECG, a 24-hour Holter monitor would be pertinent to investigate for any abnormal arrhythmias causing recurrent collapse. Findings on a 24-hour Holter may reveal; sinus pauses, abnormal bradycardia, supraventricular tachycardia or non-sustained ventricular tachycardia. Further investigations will be guided on the 24-hour Holter monitor findings. For example recurrent episodes of non-sustained ventricular tachycardia may warrant a coronary angiogram to investigate for underlying coronary artery disease as a potential precipitant.Lying and standing blood pressure is an important and simple test to rule out postural hypotension as a potential cause; however episodes occurring at rest and on exertion with associated loss of consciousness make this diagnosis unlikely.

golden s sign cxr

Golden S sign This is not the correct answer. This is caused by a central mass that causes right upper lobe atelectasis. It is not associated with heart failure 0%

A 5-day old infant presents to the paediatric assessment unit with poor feeding, tachypnoea and drowsiness.He was born at 38 weeks via normal vaginal delivery and was discharged within 24 hours after a newborn check was normal.On examination, he was also tachycardic with weak femoral pulses bilaterally. The lungs were clear and the liver was enlarged by 2cm.An echocardiogram was performed which confirmed a diagnosis of coarctation of the aorta.What is the most appropriate next step in management after resuscitation?

Growth failure, tachycardia and tachypnoea in the context of weak femoral pulses - coarctation of the aorta should be considered Coarctation of the aorta is the most commonly missed congenital heart disease.As illustrated by this case, a normal newborn examination does not definitively rule out congenital heart disease.While surgery is the only definitive treatment, IV prostaglandins are used in neonates to maintain a patent ductus arteriosus to allow adequate circulation until it is possible to attempt corrective surgery.IV NSAIDs are used to close a patent ductus arteriosus.

A third-year medical student is working in a hospital when they sustain a needle stick injury. Blood tests from the patient reveal that the patient has an active hepatitis B infection. Luckily, they were vaccinated against hepatitis B during their first year of medical school.The student visits occupational health and they advise that their blood test after vaccination showed the following: anti-HBs9(>10) Given these results, what should be done next?

HBIG + a booster vaccine is correct. The medical student in this case has been exposed to blood from a hepatitis B-positive patient. Although the student has had a full course of hepatitis B vaccinations, they have had blood tests that have shown they are a vaccine non-responder. We can tell this as the anti-HBs levels are below 10. Therefore, this patient requires HBIG and a booster vaccination to minimise the chance of hepatitis transmission.

A 57-year-old caucasian man with known heart failure attends the clinic for his regular follow-up. Unfortunately, despite treatment with an ACE-inhibitor, a beta-blocker, and an aldosterone antagonist, his ejection fraction has continued to fall and is now at 22%. His ECG showed a left bundle branch block with a rate of 70bpm. He is not currently symptomatic.What would be the most appropriate next step to reduce mortality in this patient?

HF not responding to ACEi, BB and aldosterone antagonist therapy, a widened QRS complex favours cardiaac resynchronisation therapy

'jerky' pulse

HOCM

common cause of sudden death in young patients and would not cause these changes on echocardiogram

HOCM

jerky pulse means...

HOCM

What is HOCM and what are the features?

HOCM is an autosomal dominant disorder of muscle tissue caused by defects in the genes encoding contractile proteins. the estimated prevalence is 1 in 500. HOCM is important as it is the most common cause of sudden death in the young. pathophysiology: the most common defects involve a mutation in the gene encoding β-myosin heavy chain protein or myosin-binding protein C results in predominantly diastolic dysfunctionleft ventricle hypertrophy → decreased compliance → decreased cardiac output characterized by myofibrillar hypertrophy with chaotic and disorganized fashion myocytes ('disarray') and fibrosis on biopsy features: often aymptomatic exertional dyspnoea angina syncope - usually following exercise, due to subaortic hypertrophy of the ventricular septum, resulting in functional aortic stenosis sudden death (usually due to ventricular arrhythmias), arrhythmias, HF jerky pulse, large a waves, double apex beat ejection systolic murmur = increases with valsava manoeure and decreases on squatting hypertrophic cardiomyopathy may impair mitral valve closure, thus causing regurgitation

A 20-year-old male had a recent collapse while playing football with his friends. He was then referred to a cardiologist and diagnosed with hypertrophic obstructive cardiomyopathy. An ECG is done which shows a PR interval of 100ms with a wide QRS complex.Which of the following conditions is the patient most likely to have?

HOCM is associated with WPW

ORBIT score

Haemoglobin <130 g/L for males and < 120 g/L for females, or haemtocrit < 40% for males and < 36% for females2Age > 74 years1Bleeding history (GI bleeding, intracranial bleeding or haemorrhagic stroke)2Renal impairment (GFR < 60 mL/min/1.73m2)1Treatment with antiplatelet agents1 0-2 = low risk 3 = medium 4-7 = high

A 49-year-old man is brought into ED after he was found on the side of the road unconscious. The paramedics give a history of alcohol abuse. You ask the nurse to perform a set of basic observations, capillary blood glucose (CBG) and an ECG.His basic observations are: a temperature of 35.9ºC, blood pressure 190/110 mmHg, heart rate 51 beats/min, respiratory rate is 24 breaths/min (Cheyne-Stokes breathing), oxygen saturations 95% on air. His Glasgow coma scale is 4/15 (E1V1M2).Capillary blood glucose comes back as 10.1.The ECG shows T wave inversion in all leads and QT prolongation.What is the most likely diagnosis?

Head injury - given the scenario, it is very likely the patient in question has had a fall secondary to alcohol intoxication. His observations represent Cushing's triad (hypertensive, bradycardic, tachypnoeic with signs of Cheyne-Stokes breathing) and are a sign of brain herniation. This is also confirmed by the ECG showing widespread T wave inversion, also known as 'cerebral T waves'. QT prolongation is another finding on this ECG that is in keeping with the clinical picture. 'Global' T wave inversion (not fitting a coronary artery territory) - think non-cardiac cause of abnormal ECG

You are asked to urgently review a 61-year-old female on the cardiology ward due to difficulty in breathing. On examination, she has a raised JVP with bilateral fine crackles to the mid zones. Blood pressure is 100/60 mmHg and the pulse is 140-150 and irregular. An ECG confirms atrial fibrillation. A review of her notes and previous ECGs show no prior history of atrial fibrillation.What is the most appropriate management?

Heart failure is one of the adverse signs indicating the need for urgent synchronised DC cardioversion Discuss (2)Improve

falsely low BNP results

Heart failure is unlikely if BNP levels are low (<100). However, aldosterone antagonists, ACE inhibitors, angiotensin-II receptor antagonists, beta-blockers and diuretics can all falsely lower BNP levels, as can obesity.

what causes high levels of BNP

High levels of BNP can have causes other than heart failure: age over 70 years, left ventricular hypertrophy, ischaemia, tachycardia, right ventricular overload, hypoxaemia (ie pulmonary embolism), renal dysfunction (eGFR less than 60 ml/minute/1.73 m2), sepsis, chronic obstructive pulmonary disease, diabetes, or cirrhosis of the liver).

what type of cardiomyopathy does hereditory haemochromotosis cause

Hereditary haemachromatosis This is incorrect. Hereditary haemochromatosis (HH) is a condition which results in iron deposition in a number of organs including the heart, pancreas, joints, liver, skin, pituitary and adrenal glands. It tends to result in dilated cardiomyopathy rather than restrictive cardiomyopathy, but both do occur. It is unlikely to cause significant oedema elsewhere, and this man does not display any other symptoms of HH 17%

A 47 year old man is referred to the cardiology clinic for poor exercise tolerance, pedal oedema and weight gain. He complains of worsening exertional shortness of breath over the last year, to the point where he is now breathless on mild exertion. His legs have become grossly swollen and blisters and he reports 10kg weight gain over the last six months. On examination, he has a pulse rate of 82bpm, blood pressure of 120/77mmHg, respiratory rate of 20 breaths per minute, saturations of 93% on room air and a temperature of 37.0°C. He has bilateral basal inspiratory crepitations to the mid zones of his chest, and pitting oedema to the knees. A third heart sound is audible. On examination of his abdomen there is a smooth, non-pulsatile hepatomegaly and tense abdominal distension with shifting dullness. He has a background of diabetes mellitus and bilateral arthritis of the knees and wrists, but has no other medical problems and has never been seen by cardiology. He denies alcohol or recreational drug use. An echocardiogram is arranged, which shows a globally dilated, hypokinetic heart with poor left ventricular function (EF = 10%). Which of the following is the most likely underlying cause for this man's presentation?

Hereditary haemochromatosis This is the correct answer. This man has presented with signs and symptoms of heart failure, confirmed by echocardiogram which shows evidence of dilated cardiomyopathy. He also has diabetes mellitus, joint pain, evidence of hepatomegaly and ascites. These presenting features are consistent with hereditary haemochromatosis (HH) where iron deposition affects the liver, pancreas, joints and heart. It also affects the skin, pituitary and adrenal glands 33%

A 69 year old African lady is seen in the cardiology clinic. She complains of shortness of breath on minimal exertion and reduced exercise tolerance. Her echocardiogram shows an ejection fraction of 35% and moderate aortic stenosis. On examination, she is dyspneic and has bilateral pitting oedema to the mid calf. Her current medication includes ramipril, bisoprolol and aspirin. Spironolactone was recently stopped due to hyperkalaemia. What is the next best step in management?

Hydralazine This is the correct answer. An ACE-inhibitor, beta blocker and aldosterone antagonist is indicated in heart failure patients with left ventricular systolic dysfunction. This patient is symptomatic and unable to tolerate spironolactone, therefore the next step is to consider hydralazine. This confers a mortality benefit and is especially indicated in Afro-Caribbean patients with moderate-severe heart failure 40%

A 42-year-old man presents a two-month history of steatorrhoea, abdominal discomfort, and diarrhoea. He is particularly worried, as three years ago, he required colonic resection following ischaemic colitis, leaving him with short bowel syndrome. He also reports paraesthesia and feeling unsteady on his feet. The endoscopic appearance of the small bowel is unremarkable. Biopsy samples show non-specific eosinophilia. Colonoscopy is also unremarkable. Abdominal examination is unremarkable, and his weight has remained stable.What investigation is most likely to be diagnostic?

Hydrogen breath test is the correct answer. Small bowel overgrowth syndrome (SBOS) is where excessive microbes colonise the bowel. As in this case, anatomic disorders can predispose to SBOS due to intestinal stasis. In the majority of cases, it presents as bloating and steatorrhoea. In patients with vitamin B12 deficiency, neurological symptoms can also co-exist. The diagnosis can be established with a positive hydrogen breath test. The mucosal histology is variable, and may include modest villous blunting accompanied by increased lamina propria and epithelial inflammation. It is often normal.

u&e's which has J waves

Hypercalcaemia A J-wave (or Osborne wave) is classically associated with hypercalcaemia. This is when a positive deflection is seen occurring at the junction between the QRS complex and the ST-segment. Other causes include hypothermia or an intra-cranial bleed such as a sub-arachnoid haemorrhage. The other main ECG finding associated with hypercalcaemia is a shortened QT interval 57%

Your next patient is a 74-year-old woman who is known to have type 2 diabetes mellitus. Her blood pressure has been borderline for a number of weeks now but you have decided she would would benefit from treatment. Her latest blood pressure is 146/88 mmHg, HbA1c is 58 mmol/mol and her BMI is 25 kg/m^2. What is the most appropriate drug to prescribe?

Hypertension in diabetics - ACE inhibitors/A2RBs are first-line regardless of age

A 27-year-old man attends his GP complaining of intermittent episodes of palpitations. This feels as though his heart is racing for a few seconds before resolving spontaneously. He sometimes feels light-headed during an episode, especially if he is exercising at the time. He has no chest pain or dyspnoea and a cardiovascular examination is normal. He has no medical history and is unsure of his family history.His ECG is shown below: Ventricular hypertrophy - while this ECG does not meet the voltage criteria for LVH, there are generalised hypertrophic changes suggested by increased amplitudes of R waves in the inferior limb leads and increased amplitude of both R and S waves in the septal and anterior precordial leads. Non-specific T wave inversions - note the T wave in V3 appears biphasic. Deep Q waves in leads II and III

Hypertrophic cardiomyopathy

A 32-year-old man presents to his GP with shortness of breath. He describes a 2 month history of increasing breathlessness, which is worse on lying down and during the night.His past medical history is significant for hypertrophic obstructive cardiomyopathy, for which he has an implantable cardioverter-defibrillator.On examination, he has bilateral basal crepitations. There is no evidence of peripheral oedema.What is the most likely diagnosis?

Hypertrophic obstructive cardiomyopathy (HOCM) has various possible complications. One of them is heart failure. HOCM is a pathology affecting the musculature of the left ventricle, reducing the lumen of the left ventricle and preventing it fully filling with blood. This can create a backlog, leading to left-sided heart failure and pulmonary congestion, which explains this man's respiratory symptoms. Since there is no problem with the outflow, or the pumping action itself, this is a diastolic filling problem. There will be an equal reduction in both ejection systolic and end-diastolic volumes, therefore leading to a normal ejection fraction. This is termed as heart failure with preserved ejection fraction (HF-pEF), and therefore this is the correct answer.

sudden cardiac death in young athelets is usually due to what

Hypertrophic obstructive cardiomyopathy - is associated with sudden death in young athletes due to ventricular arrhythmia

where is IM adrenaline injected

IM adrenaline should be injected in the anterolateral aspect of themiddle third of the thigh = anterolateral quadriceps

A 65-year-old man presents to the emergency department with an episode of rectal bleeding that resolves spontaneously in 15 minutes. He is taking warfarin for atrial fibrillation (AF). He is estimated to have lost approximately 50 ml of blood. A rectal examination shows external haemorrhoids with evidence of fresh bleeding. His observations show a heart rate of 80/min, blood pressure of 130/90 mmHg, oxygen saturations of 98% on air and a respiratory rate of 18/min. His haemoglobin is found to be within the normal range.As he is taking warfarin, his INR is checked. INR7.2 Given this raised INR, his warfarin is stopped and he is given intravenous vitamin K 2mg.When should his warfarin be restarted?

INR 5-8 (minor bleeding) - stop warfarin, give IV vit K 1-3mg, restarct when INR <5

A 25-year-old woman attends the haematology day unit for a blood transfusion. She has a history of acute lymphoblastic leukaemia, and her last haemoglobin, taken 2 days ago, was 69 g/dL. Two units of blood have been prescribed.As the first unit of blood is transfused, she develops shortness of breath.On examination, she has a temperature of 37.5ºC with a heart rate of 99 beats/min and a blood pressure of 90/55mmHg. Her oxygen saturations are 96% on air with a respiratory rate of 22 breaths/min. There is a bilateral wheeze on auscultation.What complication is the most likely explanation of this patient's symptoms?

Hypotension, dyspnoea, wheezing, angioedema during a blood transfusion → anaphylaxis

A 72-year-old man presents to the emergency department with a wound to his left hand. He was gardening earlier today and accidentally cut his ring finger with a secateurs. The finger is wrapped in a clean tea towel, and he has tried applying compression and elevating the wound but it has not stopped bleeding for the past 4 hours.Cardiovascular examination is normal. INR is 5.6.He has a history of atrial fibrillation, hypercholesterolemia, hypertension and benign prostatic hypertrophy. His current medications include warfarin, atorvastatin, amlodipine and tamsulosin.What is the most appropriate management regarding his anticoagulation?

INR 5.0-8.0 (minor bleeding) - stop warfarin, give intravenous vitamin K 1-3mg, restart when INR < 5.0

lateral MI - what are the lead changes and which artery is affected

I, aVL +/- V5-6 left circumflex artery

lateral stemi

I, aVL, V5, V6

ICD CRT Pacemaker

ICD: to stop tachyarrhytmias CRT: re-synchronise the ventricles Pacemaker: takeover electrical conduction

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 A right coronary artery infarct supplies the AV node so can cause arrythmias after infarction

A 15 year old girl has a fever. Her symptoms began three weeks ago with a swollen red tongue and a fine rash across her trunk. Her rash has now resolved, but her fever is persistent. On examination, there is an audible pan-systolic murmur, loudest at the apex. Her blood tests reveal a C-reactive protein (CRP) of 124 mg/L. What is the most appropriate initial treatment for this patient?

IV Benzylpenicillin This is the correct answer. Rheumatic fever is precipitated by Group A beta-haemolytic streptococcal infection, so an important part of treatment involves eliminating infection. While these organisms are highly virulent, they are also highly sensitive to simple antibiotics - a STAT dose of Benzylpenicillin is usually effective 53%

A 35-year-old man is on the acute medical unit with a new diagnosis of hypertrophic obstructive cardiomyopathy. He is on cardiac monitoring, and the emergency buzzer is pulled after he is noted to become very tachycardic. An ECG shows a regular, broad complex tachycardia. The patient has a GCS of 15, blood pressure is 123/81mmHg and he reports feeling well.What is the most appropriate management?

IV amiodarone is the first line treatment for regular broad complex tachycardia without adverse features. The patient is likely having a ventricular tachycardia, denoted by the regular and brought complexed tachycardia, and high risk given his cardiomyopathy. He is showing no adverse features (shock, syncope, myocardial ischaemia or heart failure) and therefore should be managed with IV amiodarone, as per the adult advanced life support algorithm.

A 72-year-old woman presents to the emergency department with severe shortness of breath. She complained of a productive cough which started yesterday. Her past medical history includes hypertension and two recent episodes of myocardial infarction. On examination, she appears to be anxious, breathless and sweaty. Jugular venous pressure is increased. Auscultation of the chest reveals widespread end-inspiratory crackles. Her pulse rate is 120 beats per minute, respiratory rate is 33 breaths per minute and oxygen saturation is 88% on room air.Based on the likely diagnosis, which of the following is the best pharmacological treatment for this patient?

IV diuretics - acute pulmonary oedema is a complication of MI

A 65-year-old man presents to the Emergency Department (ED) with sudden onset crushing chest pain and diaphoresis. The pain has persisted for around 25 minutes and an ECG reveals ST depression in the inferior leads. On assessment, the patient's blood pressure is noted to be 210/90. Which of the following is the single most appropriate method to lower the patient's blood pressure?

IV glyceryl trinitrate (GTN) This patient has a hypertensive emergency which is defined as a sudden increase in blood pressure that is associated with target organ damage, in this case likely acute coronary syndrome (ACS). Other examples of target organ damage include aortic dissection, acute pulmonary oedema, ischaemic or haemorrhagic stroke, hypertensive encephalopathy and acute renal failure. Hypertensive emergencies should be managed using IV medication with the aim of lowering the blood pressure by about 15-20%, within minutes to hours. The target blood pressure should be around 160/100. In the context of ACS, the first-line treatment of a hypertensive emergency is IV GTN as in addition to lowering the blood pressure, it will lead to coronary vasodilatation and help provide pain relief 24%

A 62-year-old male presents to the emergency department with tearing chest pain that is radiating to his back. He has a past medical history of hypertension for which he takes amlodipine. On examination, the patient has weak radial pulse. On auscultation of the heart, you hear a high-pitched, blowing early diastolic murmur at the 2nd intercostal space right sternal boarder. It is loudest when the patient sits up, leans forward and breathes out.What is the most likely management for this patient?

IV labetalol and surgery type A - ascending aorta - control BP (IV labetalol) + surgery type B - descending aorta - control BP(IV labetalol)

management of SVT after vagal manoeuvres if someone has asthma

IV verapamil

assessment of a patient presenting with suspected cardiac chest pain

Immediate management of suspected acute coronary syndrome (ACS) glyceryl trinitrate aspirin 300mg. NICE do not recommend giving other antiplatelet agents (i.e. Clopidogrel) outside of hospital do not routinely give oxygen, only give if sats < 94%* perform an ECG as soon as possible but do not delay transfer to hospital. A normal ECG does not exclude ACS Referral current chest pain or chest pain in the last 12 hours with an abnormal ECG: emergency admission chest pain 12-72 hours ago: refer to hospital the same-day for assessment chest pain > 72 hours ago: perform full assessment with ECG and troponin measurement before deciding upon further action *NICE suggest the following in terms of oxygen therapy: do not routinely administer oxygen, but monitor oxygen saturation using pulse oximetry as soon as possible, ideally before hospital admission. Only offer supplemental oxygen to: people with oxygen saturation (SpO2) of less than 94% who are not at risk of hypercapnic respiratory failure, aiming for SpO2 of 94-98% people with chronic obstructive pulmonary disease who are at risk of hypercapnic respiratory failure, to achieve a target SpO2 of 88-92% until blood gas analysis is available.

mx of mitral stenosis

If left untreated, the mechanical obstruction in mitral stenosis can lead to raised left atrial pressures, and subsequently raised pressures in the pulmonary vasculature and the right heart. Optimal timing of intervention is crucial as many cases can remain asymptomatic and stable, and may not require treatment at all. However, delay can lead to irreversible pulmonary hypertension and right heart failure. For this reason, patients with asymptomatic MS should undergo regular follow up echocardiography to assess progression. Patients with atrial fibrillation should be anticoagulated and rate-controlled. Diuretics and β blockers can provide symptomatic relief in decompensated states due to illness, or for stabilisation prior to intervention. Medical management however is not an alternative to definitive interventional treatment. For symptomatic patients, there are three treatment options: Balloon valvuloplasty - only appropriate if valve is pliable and non-calcified Percutaneous mitral valvotomy - for patients with moderate disease Open valve repair/replacement - for patients with severe disease who are not too high risk for surgery but are not candidates for percutaneous intervention, due to valve morphology or otherwise. Valves are more likely to be metal than bioprosthetic. Treatment is difficult in patients with severe disease or inadequate valve morphology who are poor candidates / high risk for open surgery.

A 64-year-old woman presents at the GP practice with increased shortness of breath (SOB). She is SOB on exertion and when lying down at night. Her symptoms have been gradually worsening over the last few weeks. She is an ex-smoker and is on no regular medication. On examination she is comfortable at rest, heart sounds are normal and there are bibasal crackles. She has pitting oedema to the mid-calf bilaterally. Observations are taken and show: pulse 89 bpm, oxygen saturations 96%, respiratory rate 12/min, blood pressure 192/128mmHg.What is the most appropriate management plan?

If new BP >= 180/120 mmHg + new-onset confusion, chest pain, signs of heart failure, or acute kidney injury then admit for specialist assessment

A 69-year-old man attends his GP for a check-up. Upon his visit, his blood pressure was measured. The first reading was 190/125 mmHg on his left arm, and the second reading was 200/130 mmHg on his left arm. His right arm also produced readings of >180/120 mmHg. The patient is asymptomatic and was not previously on any medications.What is the most appropriate next step in his management?

If new BP >= 180/120 mmHg + no worrying signs then the first step is urgent investigations for end-organ damage

guidelines on giving warfarin in emergency surgery

If surgery can wait for 6-8 hours - give 5 mg vitamin K IV If surgery can't wait - 25-50 units/kg four-factor prothrombin complex The guidance is to stop warfarin before elective or emergency surgery, so options 3 and 5 are incorrect Because this is emergency surgery, reversal of anticoagulation is necessary so option 2 is incorrect

what classifies someone as being haemodynamically stable warranting DC cardioversion

If the patient displays adverse features (shock, syncope, myocardial ischaemia, or heart failure) emergency synchronised direct current shock should be administered, followed by intravenous amiodarone. HF signs - bibasal crackles on auscultation BP less than 90 or 65

A 28 year old man presents to the emergency department after a syncopal episode at home. His GP diagnosed him with a viral upper respiratory tract infection due to coryzal symptoms and a temperature of 39°C. He has a long standing history of palpitations that have worsened since the viral infection. An ECG shows a coved ST elevation >2mm in V1-2 with subsequent negative T waves. What is the definitive treatment for the most likely cause of his presentation?

Implantable cardiac defibrillator The ECG is characteristic of type 1 Brugada syndrome. An ICD is the definitive management in patients with Brugada syndrome who have ECG changes or who are symptomatic. The Brugada sign is evident in leads V1-2: a coved ST elevation >2mm with subsequent negative T waves 34%

A 51 year old lorry driver suffers an out of hospital cardiac arrest for which he receives a stent via percutaneous coronary intervention to his left anterior descending. He is transferred to ITU and makes a good recovery however suffers recurrent episodes of ventricular tachycardia whilst in hospital. He has a past medical history of hypercholesterolaemia and hypertension and takes bisoprolol 5mg twice daily, atorvastatin 40mg once nightly and Ramipril 5mg once daily. On examination his observations are all within range and he has not suffered ventricular tachycardia for a number of days. He has normal heart sounds, a clear chest and a soft abdomen. Which therapy should be instituted prior to his discharge from hospital?

Implantable cardiac defibrillator This patient has likely suffered an episode of ventricular tachycardia which may have degenerated into ventricular fibrillation and caused the out of hospital arrest. Whilst medications will be somewhat protective against this, he needs a therapy capable of cardioverting him back into sinus rhythm should it happen again. This would take the form of an ICD. He would also not be able to drive lorries again without one long term amiodarone has lots of side effects - thyroid and hepatotoxicitiy so not used long term

A 66-year-old man suffers an ST-elevation myocardial infarction and is admitted to the coronary care unit. Shortly afterward, he worsens and then goes into cardiac arrest. The doctor on the ward puts out a cardiac arrest call and begins cardiopulmonary resuscitation. The defibrillator recognises a shockable rhythm and so the team follows the appropriate ALS guidelines. After the third shock, the patient remains in ventricular fibrillation and the team is now looking to administer some medication.What is the next appropriate treatment plan?

In ALS, amiodarone 300 mg should be given to patients who are in VF/pulseless VT after 3 shocks have been administered.

A 65-year-old man has an ST-elevation myocardial infarction and is admitted to the coronary care unit. He goes into cardiac arrest and cardiopulmonary resuscitation is initiated. A defibrillator is attached and shows ventricular tachycardia however no pulse can be palpated. Three shocks have been administered with chest compressions in between, however, the patient remains in ventricular tachycardia. Therefore, 1mg of adrenaline is administered. However, the nurses report that the other drug needed is not in the crash trolley.Which drug could be used in its place?

In ALS, lidocaine may be used instead of amiodarone if it is not available

A 42-year-old woman presents to the emergency department complaining of shortness of breath and chest pain. A CT pulmonary angiogram is requested however before this can be completed, the patient arrests. The rhythm check shows organised electrical activity but there is no pulse. The arrest team start cardiopulmonary resuscitation (CPR) and 1mg adrenaline is given intravenously.What stage should adrenaline next be given?

In ALS, once adrenaline has been initially given it should be repeated every 3-5 minutes whilst ALS continues

A 35-year-old male presents with pain in both legs for the last two weeks. He has noted that the pain occurs after he has walked for ten minutes during his morning walk and is relieved when he sits for some time. There is no swelling but has noted that his toes turn white, then blue and red during the cold. There is no history of trauma. He does not drink alcohol but has been smoking three to four packs of cigarettes per day for ten years.Which of the following is the most likely diagnosis?

In Raynaud's phenomenon with extremity ischaemia think Buerger's disease

A 65-year-old man with a background of hypertension is brought in by ambulance to the emergency department with sudden-onset ripping chest pain and associated diaphoresis and arm weakness. On examination he appears apprehensive and distressed with pain not managed even by IV morphine. The blood pressure in his left arm is 184/102 mmHg, whilst in his right arm it is 147/97 mmHg.Which of the following examination findings would you possibly expect to find based on your differential diagnosis?

In aortic dissection, a pulse deficit may be seen: weak or absent carotid, brachial, or femoral pulse variation in arm BP

A 23-year-old man is brought to the emergency department following submersion. The patient has a temperature of 26 degrees centigrade and is found to be in ventricular fibrillation (VF) on ECG.You have so far been performing ALS and have given three defibrillation shocks. You have also begun active and passive rewarming. The patient remains in VF.What should your ongoing management be?

In cases of hypothermia causing cardiac arrest, defibrillation is less effective and only 3 shocks should be administered before the patient is rewarmed to 30 degrees centigrade

A 61-year-old man attends the emergency department with a one-hour history of palpitations and chest pain. His observations are as follows: heart rate 168 beats per minute, respiratory rate 22 per minute, oxygen saturations 98% on air, blood pressure 88/59 mmHg and temperature 37.1ºC. His ECG confirms the above heart rate and shows a regular broad complex tachycardia.Which of the following would be the most appropriate treatment?

In the context of a tachyarrhythmia, a systolic BP < 90 mmHg → DC cardioversion

A 65-year-old male on the high dependency unit has just undergone a complex hip arthroplasty 12 hours ago. They are now complaining of feeling their heart pounding out of their chest and has become short of breath 30 minutes ago. An electrocardiogram (ECG) showed supraventricular tachycardia (SVT). The patient attempted blowing into a syringe with the guidance of a doctor and this terminated the SVT.A short while later, the patient has another episode of palpitations and breathlessness and again has visible SVT on an ECG. His temperature is noted to be 37.2 ºC, with oxygen saturations of 98% on air, a heart rate of 180 beats per minute, a respiratory rate of 24 breaths per minute, and a blood pressure of 85/65 mmHg.What is the appropriate immediate management of this patient?

In the context of a tachyarrhythmia, a systolic BP < 90 mmHg → DC cardioversion

A 56-year-old woman visits her GP to discuss her ischaemic heart disease, which was diagnosed 8 months ago. On questioning, she reports that her chest pain is ongoing, despite starting medications for her disease.An electrocardiogram (ECG) is performed and shows no acute changes. She is currently taking 5mg bisoprolol once daily and glyceryl trinitrate (GTN) spray as required for the chest pain. She also takes daily aspirin, atorvastatin and ramipril.What is the most appropriate next step in her management?

In this scenario, this patient's stable angina is not controlled by a beta blocker alone. The next step in her management would be combination therapy of a beta blocker and a calcium channel blocker. A long-acting calcium channel blocker (such as modified release nifedipine) is preferred in combination therapy. When used in monotherapy for stable angina, a rate-limiting calcium channel blocker such as verapamil is preferred. Isosorbide mononitrate (long-acting nitrate) may be a future options for this patient. This may be indicated when combination therapy of a beta blocker and calcium channel blocker has failed to control symptoms and the patient is waiting referral for bypass graft.Nicorandil (potassium channel activator) is an alternative option to isosorbide mononitrate to use on failure of combination therapy of a beta blocker and calcium channel blocker, once the patient has been referred for a bypass graft.The option of 'no change' to the treatment of this patient's ischaemic heart disease would be inappropriate at this stage. She is having ongoing symptoms, suggesting her disease is not controlled by beta blockers alone. Failure to control her condition would increase her risk of an acute coronary event.

A 48-year-old man has heart failure. He attends the emergency department because he feels short of breath and has gained 11kg in weight. His blood pressure is 88/48 mmHg, heart rate 112 bpm, and is requiring 2L of oxygen. Capillary refill time is 3 seconds, and you can feel his liver edge 6cm below the costal margin. Regular medications include 40mg furosemide twice per day and ramipril.His renal profile last month was normal. What is the management

Increased doses of loop diuretics may be required in patients with poor renal function to ensure sufficient concentration is achieved within the tubules = therefore give pt 160mg IV furosemide infusion This man has a cardiorenal syndrome. This occurs when the cardiac output drops sufficiently to result in renal dysfunction. In this case, renal hypoperfusion has likely occurred due to the progression of his cardiomyopathy. Note features of low cardiac output or 'pump failure', such as hypotension, tachycardia, reduced peripheral perfusion, and hepatic congestion. The hyponatraemia seen is dilutional (extra water in the serum) and the low blood pressure is because of cardiac overload. Whilst it is often thought that in renal dysfunction, nephrotoxic agents need to be withheld and doses of diuretics tapered. In this case, it is the hypervolaemic state that has contributed to reduced cardiac output (shifting the Frank-Starling curve). This means that increased doses of diuretics are required to improve cardiac contractility, improve cardiac output, and thus increase renal perfusion. It would be sensible to start an infusion of furosemide at a reasonably high dose.

what thiazide is given in HTN

Indapamide Indapamide is a thiazide like diuretic which works to decrease blood pressure by blocking re-uptake of sodium in the distal convoluted tubule. It is usually given as either a standard release of modified release preparation and can be given in a combination tablet with ACE inhibitors such as Peridnopril. It is recommended by NICE third line in control of essential hypertension. It has moved to replace thiazide-type diuretics such as Bendroflumethiazide due to decreased rates of stroke and cardiovascular events in comparative meta analyses. It is contra-indicated in severe renal failure 47%

indications for cabg

Indications NICE offer useful guidance regarding the management of stable angina. Re-vascularisation should be considered in patients with stable angina whose symptoms are not satisfactorily controlled with optimal medical treatment. Additional investigation (e.g. angiography) is typically required to guide the treatment decision. Patients with stable angina should be considered for re-vascularisation (with CABG or PCI) if their symptoms are not satisfactorily controlled on optimal medical treatment and there is complex 3 vessel disease or significant left main stem stenosis. Note that PCI may be more cost-effective than CABG, but CABG has a mortality advantage over patients who: are over 65 years old, have diabetes, or who have anatomically complex 3 vessel disease (with or without left main stem stenosis). Examination You may find patients on the wards who have previously had coronary artery bypass surgery. Common signs on examination include a mid-line sternotomy scar and a longitudinal graft scar in either leg.

indications for surgical repair of infective endocarditis

Indications for surgical repair Haemodynamic instability Severe heart failure Severe sepsis despite antibiotics Valvular obstruction Infected prosthetic valve Persistent bacteraemia Repeated emboli Aortic root abscess Common exam question: PR interval prolongation in a patient with Infective Endocarditis is an indication for surgery as it can be secondary to aortic root abscess

A 70-year-old man presents to the emergency department with a 2 hour history of sudden onset shortness of breath. He has had a 1 week history of fever and fatigue.Observations are as follows:BP = 94/66 mmHg, heart rate = 112 beats per minute, temperature = 38.9ºC, oxygen saturations = 92% on room air, respiratory rate = 24 breaths/min.Examination reveals bibasal inspiratory crackles with decreased air entry bilaterally. A new murmur was documented: a pan-systolic, 4/6 murmur loudest in the axilla.Repeat blood cultures identify Staphylococcus aureus on 2 tests.Chest X-ray revealed marked interstitial oedema. Echocardiography revealed mitral valvular insufficiency with multiple mitral valve vegetations, with an ejection fraction of 35%.What is the definitive management in this patient?

Infective endocarditis causing congestive cardiac failure is an indication for emergency valve replacement surgery

what is dukes criteria for infective endocarditis

Infective endocarditis diagnosed if pathological criteria positive, or 2 major criteria, or 1 major and 3 minor criteria, or 5 minor criteria pathological criteria = Positive histology or microbiology of pathological material obtained at autopsy or cardiac surgery (valve tissue, vegetations, embolic fragments or intracardiac abscess content) major criteria = Positive blood cultures: - two positive blood cultures showing typical organisms consistent with infective endocarditis, such as Streptococcus viridans and the HACEK group, or - persistent bacteraemia from two blood cultures taken > 12 hours apart or three or more positive blood cultures where the pathogen is less specific such as Staph aureus and Staph epidermidis, or - positive serology for Coxiella burnetii, Bartonella species or Chlamydia psittaci, or - positive molecular assays for specific gene targets Evidence of endocardial involvement: - positive echocardiogram (oscillating structures, abscess formation, new valvular regurgitation or dehiscence of prosthetic valves), or - new valvular regurgitation minor criteria: - predisposing heart condition or intravenous drug use - microbiological evidence does not meet major criteria - fever > 38ºC - vascular phenomena: major emboli, splenomegaly, clubbing, splinter haemorrhages, Janeway lesions, petechiae or purpura - immunological phenomena: glomerulonephritis, Osler's nodes, Roth spots

what is a good differential for atrial myxoma

Infective endocarditis is a differential for atrial myxoma, and thus they share many features. Infective endocarditis could cause the embolisation, fever and a new/changing murmur, all of which could explain the presentation above. However the presence of a mass on echocardiogram would not be noted, and this alone can be used to differentiate the two (even if you did not know that atrial myxoma typically caused the pedunculated heterogeneous mass as described above)

A 35 year old woman has a three month history of fatigue and shortness of breath on exertion. She describes no symptoms of orthopnoea, cough, palpitations, chest pain or syncope. On examination, she is comfortable at rest. Her chest is clear, however there is an audible "blowing" ejection systolic murmur which is audible in all areas. Her calves are soft and non-tender, and there is no evidence of peripheral oedema. She has a medical history of menorrhagia, and several members of her extended family with Marfan syndrome. An ECG and a chest X-ray are performed, which show no abnormalities. Her blood tests are as follows: Haemoglobin = 88 g/L White blood cell count = 4.5 x 10^9 cells/L CRP = 4 mg/L D-dimer = 10 ng/mL (normal < 250 ng/mL) Which of the following is most likely responsible for his heart murmur?

Innocent flow murmur This is the correct answer. Innocent murmurs are murmurs not associated with any valvular pathology. They are typically loudest in the pulmonary area, have a "blowing" quality and vary positionally (may disappear and reappear). Flow murmurs are innocent murmurs resulting from increased flow across the aortic and pulmonary valves — caused by conditions like anaemia, pregnancy and thyrotoxicosis. This woman has anaemia which can explain her murmur. She is asymptomatic, and her murmur type does not fit with any particular pattern of pathology 21%

A 68-year-old woman is brought into the emergency department with shortness of breath. She has a past medical history of left ventricular systolic dysfunction with an ejection fraction of 20%. A chest x-ray confirms acute pulmonary oedema which is treated immediately with high dose IV furosemide. Her repeat observations are oxygen saturation 94% on 15L oxygen, heart rate 124 beats per minute, respiratory rate of 28 breaths per minute and blood pressure 74/50 mmHg.What management option should be considered next?

Inotropic support on the high dependency unit (HDU) is the correct answer. In acute pulmonary oedema, the primary aim of management is diuresis to offload excess fluid. In patients who have cardiogenic shock, diuresis would lower blood pressure further and worsen the picture of shock. Inotropes should therefore be considered in this patient group to promote increased cardiac contractility and support blood pressure whilst diuresis is ongoing.

A 62-year-old female presents to the Emergency Department with chest pain and shortness of breath. She says the pain came on after she fell in her home after tripping over. The pain is a 6/10 but is an 8 when she breathes in.Given her history, the doctor wants to rule out a pulmonary embolus (PE). A 2-level PE Wells score is calculated as 1.5 (for a previous DVT) hence the doctor arranges for a D-dimer test and starts the patient on anticoagulation, expecting the test results to take over 4 hours to return.The patient's chest x-ray is clear and her D-dimer result comes back as negative.What is the most appropriate next step?

Investigating suspected PE: if 2-level PE Wells score is ≤ 4 and D-dimer is negative then stop anticoagulation and consider alternative diagnosis

On a ward round you see a 70-year-old female who's recently had a resection of her bowel for colon cancer, and has been bed bound for several days. She complains of a sore, red calf, and a feeling of breathlessness. A pulmonary embolism is suspected, and a CT-pulmonary angiogram (CTPA) is ordered, however it comes back negative for a pulmonary embolism (PE).What is the next most appropriate action to aid diagnosis?

Investigating suspected PE: if the CTPA is negative then consider a proximal leg vein ultrasound scan if DVT is suspected

ix for stable angina

Investigations Once atypical/typical angina pain is suspected and ECG and routine blood tests should be taken, such as FBC to exclude anaemia, TFTs to exclude hyperthyroidism which can exacerbate angina. 1st line investigations CT coronary angiography is indicated for atypical or typical angina pain or if ECG shows ischaemic changes in chest pain with <2 angina features. Functional imaging can be used if CTCA is inconclusive. 2nd line investigations Myocardial perfusion SPECT Stress ECHO MRI for regional wall motion abnormalities 3rd line investigations Coronary angiogram can be performed if there are inconclusive results from non-invasive testing. Source: NICE guidelines on assessing and diagnosing suspected stable angina

adrenaline dose after atropine for bradycardia

Isoprenaline 5 micrograms per minute IV Atropine can be given to a maximum cumulative dose of 3mg. Once this dose is reached there are several options including transcutaneous pacing, isoprenaline 5micrograms per minute, adrenaline 2-10 micrograms per minute 21%

A 65-year-old man presents to a rural medical assessment unit with recurrent episodes of syncope. He is admitted into the hospital in the cardiology ward for a work-up.Two hours into his admission he complains of dizziness and is mildly disorientated. On examination, his airway is patent, 15 breaths/minute, oxygen saturation 96% on air, blood pressure is 90/50 mmHg, and heart rate is 40 beats per minute. He is found to have an anaphylactic allergy to atropine on record.What management option is most appropriate?

Isoprenaline/adrenaline infusion is an alternative treatment to atropine/transcutaneous pacing for a symptomatic bradycardia

A 19-year-old student is brought to the Emergency Department by her friends. Around one hour ago she 'collapsed' whilst playing hockey. Her friends describe her complaining that she felt light-headed and then 'fainting' to the ground. She lost consciousness for a few seconds before returning to normal quite quickly. There is no past medical history of note other than the use of Microgynon 30 (a combined oral contraceptive pill). For the past 4-5 days the patient has experienced shortness-of-breath and a central chest pain which is worse when she coughs. On examination her pulse is 120/min, blood pressure 96/60 mmHg and chest auscultation reveals scattered wheezes.

It is usual taught that pulmonary embolism (PE) presents with pleuritic chest pain, dyspnoea and haemoptysis. This combination of symptoms is however only found in less than 20% of cases. As PE is a potentially life-threatening condition it is important to be aware of the wide variety of symptoms and signs that may accompany cases.A lot of patients who develop a PE have risk factors. There is one present in this case - combined oral contraceptive pill use. Tachycardia is also a common sign.

A 60 year old male patient with a history of heart failure with a reduced ejection fraction and ischaemic heart disease presents to the outpatient clinic with worsening shortness of breath on moderate exertion over the past 3 month and a slight increase in ankle swelling. He is adhering to cardiac rehab and currently takes Ramipril 5mg once daily, bisoprolol 2.5mg twice daily, eplerenone 25mg once daily and furosemide 20mg once daily. His observations are as follows: respiratory rate 16 breaths/min, 98% sats on room air, heart rate 86bpm, blood pressure 131/76 mmHg, afebrile On examination he has a clear chest, normal heart sounds and a soft non tender abdomen His echocardiogram shows a left ventricular function of <35% Which would be the most appropriate next medication to add in for prognostic management of his heart failure?

Ivabradine Ivabradine is a funny channel inhibitor which acts to slow ionic depolarisation through the pacemaker cells and therefore slow heart rate, allowing for more filling time (hence why it is only given to those with HR over 75bpm as per ESC guidance). It is used as a fourth line medication for those with an impaired left ventricular systolic function and a higher heart rate prior to considering device therapy. Trials which support it's usage are BEAUTIFUL and SHIFT 37%

An 84-year-old man is seen in the clinic for follow up of heart failure with reduced ejection fraction. The remainder of his past medical history includes hypertension and hypercholesterolaemia.He reports dyspnea on mild exertion, but not at rest. He is quite fatigued but denies any other symptoms. His examination is unremarkable with no signs of volume overload.An echocardiogram is performed and reported as 'LVEF of 30-35% with no wall motion abnormalities. His ECG shows sinus rhythm with a heart rate of 79 bpm.His medications are as follows: Furosemide 40mg OD Ramipril 10mg OD Bisoprolol 5mg OD Eplerenone 50mg OD Which of the following agents should be considered for the treatment of this man's chronic heart failure?

Ivabradine should be considered in heart failure if the patient has sinus rhythm > 75/min and a LVEF < 35% and have not responded to to ACE-inhibitor, beta-blocker and aldosterone antagonist therapy

use for: jones criteria duke criteria fraser criteria GRACE QRISK

Jones criteria are used to diagnose rheumatic fever after a streptococcal infectionDuke criteria are used to diagnose infective endocarditis (See notes below for detailed information on the Duke criteria)Fraser criteria are used to determine if contraception is appropriate for a young adultGRACE score is used to risk-stratify NSTEMI patients. High-risk NSTEMI patients would receive urgent invasive coronary angiogram.QRISK score is used to estimate the 10-year risk of cardiovascular disease. if this is at least 10%, statins should be commenced.

Kaussmaul sign

Kussmaul's sign Physiologically, the jugular venous pulsation should reduce and not rise when the intrapulmonary pressure reduces in inspiration. This is due to an inability of the right ventricle to fill with blood and instead the blood backs up into the venous system and causes a raised jugular venous pulsation 61%

which ecg trace is always abnormal

LBBB

A 61-year-old man with peripheral arterial disease is prescribed simvastatin. What is the most appropriate blood test monitoring?

LFTs at baseline, 3 months and 12 months. a fasting lipid profile may also be checked during monitoring to assess response to treatment.

what type of anticoagulant is enoxaparin

LMWH

what leads are affected if there is an MI in: Left circumflex A Left main coronary artery RCA septal branch of left ant descending artery

Left circumflex artery is incorrect. The left circumflex artery supplies the lateral part of the heart, resulting in ST-segment changes in the left lateral leads when occluded. These are leads I and aVL. Left main coronary artery is incorrect. The left main coronary artery gives off the left circumflex artery and the left anterior descending artery. When occluded, widespread ST-segment depression is seen, predominantly in V4-V5, I, II, and aVL. Acute left main coronary artery infarction is virtually non-survivable. Right coronary artery is incorrect. The right coronary artery supplies the inferior wall of the heart in 90% of people (right coronary artery dominance). This results in ST-segment changes in the inferior leads, including leads II, III, and aVF. Septal branch of left anterior descending artery is incorrect. Whilst the septal branches do supply the anterior 2/3rds of the interventricular septum, occlusion of just one of these vessels is unlikely to result in the clinical picture described. The deep T waves in V2 and V3 are pathognomonic for Wellen's syndrome, critical stenosis of the left anterior descending artery. DiscussImprove

An elderly man with aortic stenosis is assessed. Which one of the following would make the ejection systolic murmur quieter?

Left ventricular systolic dysfunction will result in a decreased flow-rate across the aortic valve and hence a quieter murmur.

An 18-year-old man is undergoing a 12-lead ECG as part of a medical fitness check for the armed forces. A predominantly negative QRS complex is seen in lead I and a negative P wave is present in lead I. The computer says it has identified right-axis deviation. The physician dismisses this and reports a normal ECG. What is the most likely cause of this?

Left-right-arm lead reversal Incorrect lead placement such as left-right arm reversal leads to a negative complex in lead I with a negative P wave in lead I, as is seen in this patient. It is one of the commonest causes of right-axis deviation on an ECG. Although this was recognised by the physician, it should be repeated to confirm that this was the cause. 45%

A 78-year-old man presents to the emergency department with a rapid loss of balance which occurred whilst walking the dog. In the department, he has difficulty sitting upright without veering to the left side.On examination, he has nystagmus with both horizontal and rotational components. On sensory assessment, he has reduced sensation to painful stimulus on the right side.What is the most likely additional finding on examination?

Left-sided ptosis is correct. This patient has cerebellar signs (ataxia and nystagmus) and contralateral spinothalamic deficit signs. This is suggestive of a left-sided lateral medullary syndrome caused by a posterior inferior cerebellar artery (PICA) lesion. The lesion also classically leads to a deficit in the supply to the descending sympathetic nervous system, which leads to an ipsilateral Horner's syndrome presenting with left-sided ptosis and miosis.

A 65 year old male has his blood pressure checked at his local general practice and it comes back as 150/94mmHg. The doctor therefore decides the patient should perform ambulatory blood pressure measurements. The patient agrees and completes this task. Following this, the doctor decides to check the patient's blood pressure every five years with no need for daily anti-hypertensive medication. What were the results of the ambulatory blood pressure measurements?

Less than 135/85mmHg Correct - if the patient's blood pressure is less than 135/85 mmHg, the patient does not require any treatment and their blood pressure should be monitored once every five years 76%

long QT syndrome

Long QT syndrome (LQTS) is an inherited condition associated with delayed repolarization of the ventricles. It is important to recognise as it may lead to ventricular tachycardia/torsade de pointes and can therefore cause collapse/sudden death. The most common variants of LQTS (LQT1 & LQT2) are caused by defects in the alpha subunit of the slow delayed rectifier potassium channel. A normal corrected QT interval is less than 430 ms in males and 450 ms in females.Causes of a prolonged QT interval: congenital: Jervell-Lange-Nielsen syndrome (includes deafness and is due to an abnormal potassium channel) Romano-Ward syndrome (no deafness) drugs: amiodarone, sotalol, class 1a antiarrhythmic drugs tricyclic antidepressants, selective serotonin reuptake inhibitors (especially citalopram) methadone chloroquine terfenadine** erythromycin haloperidol ondanestron other: electrolyte: hypocalcaemia, hypokalaemia, hypomagnesaemia acute myocardial infarction myocarditis hypothermia subarachnoid haemorrhage Features may be picked up on routine ECG or following family screening Long QT1 - usually associated with exertional syncope, often swimming Long QT2 - often associated with syncope occurring following emotional stress, exercise or auditory stimuli Long QT3 - events often occur at night or at rest sudden cardiac death Management avoid drugs which prolong the QT interval and other precipitants if appropriate (e.g. Strenuous exercise) beta-blockers*** implantable cardioverter defibrillators in high risk cases *the usual mechanism by which drugs prolong the QT interval is blockage of potassium channels. See the link for more details **a non-sedating antihistamine and classic cause of prolonged QT in a patient, especially if also taking P450 enzyme inhibitor, e.g. Patient with a cold takes terfenadine and erythromycin at the same time ***note sotalol may exacerbate long QT syndrome

A 70 year old gentleman presents to his GP with central crushing chest pain which started 4 hours ago. He is transferred urgently to a secondary care facility after having been given dual anti-platelet therapy with aspirin and Ticagrelor. Upon arrival to the hospital his observations are stable and the pain has eased somewhat with morphine given by the ambulance crew His high sensitivity troponin drawn at 4 hours after onset of chest pain is 888ng/l NSETMI What other anticoag should be given

Low molecular weight heparin In patients suffering from non-ST elevation myocardial infarction (NSTEMI) (as above) there is little benefit to immediate percutaneous coronary intervention unless they are unstable or at high risk and the patient should be therapeutically anti-coagulated for at least 48h. NICE guidance suggests the use of 1mg/kg BD of Low molecular weight heparin such as Enoxaparin / Fondaparinux (synthetic LMWH). 45%

echo findings with HOCM

MR SAM ASH mitral regurgitation (MR) systolic anterior motion (SAM) of the anterior mitral valve leaflet asymmetric hypertrophy (ASH)

which arrythmia is treated with MgSO4

Magnesium sulphate 2g intravenously over 10 minutes is the treatment for torsades de pointes. Whilst magnesium sulphate is not the first-choice treatment for monomorphic VT, it is unlikely to be harmful in this patient and is not contraindicated.

dukes criteria for infective endocarditis

Major Dukes criteria Blood culture positive for IE Typical microorganisms consistent with IE (S viridans, S bovis, HACEK organisms, S aureus without other primary site, enterococcus), from two separate blood cultures Microorganisms consistent with IE from persistently positive blood cultures (>= 2 blood cultures drawn > 12 hours apart, all of three blood cultures, or majority of four or more blood cultures) Single positive blood culture for Coxiella burnetti or positive antibody titre Imaging positive for IE Echocardiogram positive for IE e.g. vegetation, abscess, partial dehiscence of prosthetic valve, new valvular regurgitation Abnormal activity around site of prosthetic valve implantation on PET-CT Paravalvular lesions on cardiac CT Minor Dukes criteria Predisposition e.g. predisposing heart condition or intravenous drug use Fever > 38.0°C Vascular phenomena e.g. arterial emboli, infarcts, mycotic aneurysms, intracranial or conjunctival haemorrhages, Janeway lesions Immunological phenomena e.g. glomerulonephritis, Osler's nodes, Roth's spots, rheumatoid factor Microbiological evidence e.g. blood culture not meeting major criteria, or serological evidence of active infection with organism consistent with IE

A 79-year-old woman presents to the emergency department with a new left-sided weakness. She has a history of atrial fibrillation and takes warfarin. Her INR on admission is 2.5. A CT head shows left basal ganglia intracerebral haemorrhage.What action is required with regards to her warfarin?

Major bleeding - stop warfarin, give intravenous vitamin K 5mg, prothrombin complex concentrate

A 65 year old male patient presents to the general practitioner with a 2 month history of shortness of breath on exertion. He has also noticed a few episodes of waking up at night gasping for breath. His past medical history is significant for a myocardial infarct 2 year ago. On physical examination the jugular venous pressure is elevated 3 cm above normal and there is pitting oedema to the mid-shins. Which of the following is the most appropriate next step in the management?

Measure B-type natriuretic peptide (BNP) and refer for trans-thoracic echocardiogram if elevated According to recent NICE guidance, BNP should be measured before referral for echocardiogram. BNP has a high negative predictive value, so a low BNP makes the diagnosis of congestive cardiac failure highly unlikely NO LONGER URGENT REFERRAL TO TOE BECAUSE HE HAD A PREV MI

methotrexate causes what anaemia

Methotrexate therapy may result in a megaloblastic macrocytic anaemia secondary to folate deficiency

MR

Mitral regurgitation gives a pansystolic murmur, rather than an ejection systolic murmur and is louder on expiration rather than inspiration.

A 35-year-old lady presents to cardiology for investigation of a pansystolic murmur. She has hypermobility of large and small joints bilaterally and marked striae on her abdomen and chest.What is the most likely cause of this murmur?

Mitral regurgitation is associated with collagen disorders such as Marfan's Syndrome and Ehlers-Danlos syndrome

A 55-year-old woman presents with progressively worsening dyspnoea on exertion for the past few years. She also noticed that she requires more pillows for the past one year when she sleeps to prevent her from getting breathless. However, she recently wakes up in the middle of the night feeling breathless even though she uses three pillows to sleep. On auscultation, a loud first heart sound with an opening snap and a diastolic murmur can be heard.Based on the most likely diagnosis, what is the most common cause of this patient's condition?

Mitral stenosis - most common cause of it is rheumatic fever. This patient suffers from progressive cardiac failure secondary to mitral stenosis. She presents with exertional dyspnoea, orthopnoea and paroxysmal nocturnal dyspnoea, in keeping with left-sided heart failure. Findings upon auscultation of the heart are in keeping with mitral stenosis, which is most commonly caused by rheumatic fever.

Mitral stenosis

Mitral stenosis describes the obstruction of blood flow across the mitral valve from the left atrium to the left ventricle. This leads to increases in pressure within the left atrium, pulmonary vasculature and right side of the heart. It is said that the causes of mitral stenosis are rheumatic fever, rheumatic fever and rheumatic fever. Rarer causes that may be seen in the exam include mucopolysaccharidoses, carcinoid and endocardial fibroelastosis. Features dyspnoea↑ left atrail pressure → pulmonary venous hypertension haemoptysis due to pulmonary pressures and vascular congestion may range from pink frothy sputum to sudden haemorrhage secondary to rupture of thin walled and dilated bronchial veins mid-late diastolic murmur (best heard in expiration) loud S1, opening snap low volume pulse malar flush atrial fibrillation secondary to ↑ left atrail pressure → left atrial enlargement Features of severe MS length of murmur increases opening snap becomes closer to S2 Chest x-ray left atrial enlargement may be seen Echocardiography the normal cross-sectional area of the mitral valve is 4-6 sq cm. A 'tight' mitral stenosis implies a cross-sectional area of < 1 sq cm Management patients with associated atrial fibrillation require anticoagulation currently warfarin is still recommended asymptomatic patients = monitored with regular echocardiograms percutaneous/surgical management is generally not recommended symptomatic patients = percutaneous mitral balloon valvotomy mitral valve surgery (commissurotomy, or valve replacement)

mitral stenosis

Mitral stenosis describes the obstruction of blood flow across the mitral valve from the left atrium to the left ventricle. This leads to increases in pressure within the left atrium, pulmonary vasculature and right side of the heart.It is said that the causes of mitral stenosis are rheumatic fever, rheumatic fever and rheumatic fever. Rarer causes that may be seen in the exam include mucopolysaccharidoses, carcinoid and endocardial fibroelastosisFeatures dyspnoea↑ left atrail pressure → pulmonary venous hypertension haemoptysisdue to pulmonary pressures and vascular congestionmay range from pink frothy sputum to sudden haemorrhage secondary to rupture of thin walled and dilated bronchial veins mid-late diastolic murmur (best heard in expiration) loud S1, opening snap low volume pulse malar flush atrial fibrillationsecondary to ↑ left atrail pressure → left atrial enlargement Features of severe MS length of murmur increases opening snap becomes closer to S2 Chest x-ray left atrial enlargement may be seen Echocardiography the normal cross-sectional area of the mitral valve is 4-6 sq cm. A 'tight' mitral stenosis implies a cross-sectional area of < 1 sq cm Management patients with associated atrial fibrillation require anticoagulationcurrently warfarin is still recommended asymptomatic patientsmonitored with regular echocardiogramspercutaneous/surgical management is generally not recommended symptomatic patientspercutaneous mitral balloon valvotomymitral valve surgery (commissurotomy, or valve replacement)

MM u&e

Myeloma without metastasis is characterised by high calcium, normal/high phosphate and normal alkaline phosphate

Mr Smith has been admitted to hospital with chest pain and is being treated for a suspected myocardial infarction. While he is being reviewed by the admitting team, he suddenly gets very short of breath. On examination, he had bilateral crackles throughout the entire lung fields, his oxygen saturations have dropped to 92% and his blood pressure is low at 90/50 mmHg.What is the most likely cause of Mr Smith's deterioration?

Myocardial infarction can cause acute mitral valve regurgitation due to rupture of the tendinous cords that usually hold the valve in place. Regurgitation then causes backflow of blood from the left ventricle (LV) into the left atrium (LA) during systole. This causes increased pressures in the LA and LV, which prevent the pulmonary veins (low pressure) from draining into the LA. This, in turn, causes pulmonary congestion, which causes pulmonary oedema.

A 78 year old man presents to the GP complaining of chest pain. He describes the pain as 'tight band' across the chest, exacerbated by physical activity but is relieved by rest. An ECG shows sinus rhythm with no ischaemic changes and the observations are within normal limits. His troponin level is 4ng/L (<14ng/L). He has a past medical history of severe osteoarthritis and is on haemodialysis, with a baseline eGFR of 12. Which is the next best diagnostic investigation to request?

Myocardial perfusion imaging This is the correct answer. This patient has presented with 3 typical features of anginal pain with a negative troponin indicating stable angina. 1st line diagnostic investigation would be CT Coronary angiography, however this is contraindicated. His renal impairment increases the risk of contrast induced nephropathy, therefore appropriate second line functional imaging such as stress echo, MRI for regional wall motion abnormalities or myocardial perfusion scan with SPECT can be used This patient has presented with 3 typical features of anginal pain with a negative troponin indicating stable angina. 1st line diagnostic investigation would be CT Coronary angiography, however this is contraindicated because of his renal impairment. There is an increased risk of contrast induced nephropathy, therefore appropriate second line functional imaging such as stress echo, MRI for regional wall motion abnormalities or myocardial perfusion scan with SPECT can be used 49%

difference between myocarditis and pericarditis

Myocarditis can manifest as new-onset congestive heart failure (due to inflammation reducing the contractile strength of the heart), as evidenced by the presence of orthopnea and pulmonary oedema on chest x-ray. Whilst myocarditis and pericarditis present similarly and may co-exist, isolated pericarditis would not cause left ventricular failure.

Myocarditis

Myocarditis describes inflammation of the myocardium. There are a wide range of underlying causes. It should be particularly considered in younger patients who present with chest pain.Causes viral: coxsackie B, HIV bacteria: diphtheria, clostridia spirochaetes: Lyme disease protozoa: Chagas' disease, toxoplasmosis autoimmune drugs: doxorubicin Presentation usually young patient with an acute history chest pain dyspnoea arrhythmias Investigations bloods↑ inflammatory markers in 99%↑ cardiac enzymes↑ BNP ECGtachycardiaarrhythmiasST/T wave changes including ST-segment elevation and T wave inversion Management treatment of underlying cause e.g. antibiotics if bacterial cause supportive treatment e.g. of heart failure or arrhythmias Complications heart failure arrhythmia, possibly leading to sudden death dilated cardiomyopathy: usually a late complication

Patients presenting with stable chest pain

NICE define anginal pain as the following: 1. constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms 2. precipitated by physical exertion 3. relieved by rest or GTN in about 5 minutes patients with all 3 features have typical angina patients with 2 of the above features have atypical angina patients with 1 or none of the above features have non-anginal chest pain For patients in whom stable angina cannot be excluded by clinical assessment alone NICE recommend the following (e.g. symptoms consistent with typical/atypical angina OR ECG changes): 1st line: CT coronary angiography 2nd line: non-invasive functional imaging (looking for reversible myocardial ischaemia) 3rd line: invasive coronary angiography Examples of non-invasive functional imaging: myocardial perfusion scintigraphy with single photon emission computed tomography (MPS with SPECT) or stress echocardiography or first-pass contrast-enhanced magnetic resonance (MR) perfusion or MR imaging for stress-induced wall motion abnormalities

patients presenting with stable chest pain

NICE define anginal pain as the following: 1. constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms 2. precipitated by physical exertion 3. relieved by rest or GTN in about 5 minutes patients with all 3 features have typical angina patients with 2 of the above features have atypical angina patients with 1 or none of the above features have non-anginal chest pain For patients in whom stable angina cannot be excluded by clinical assessment alone NICE recommend the following (e.g. symptoms consistent with typical/atypical angina OR ECG changes): 1st line: CT coronary angiography 2nd line: non-invasive functional imaging (looking for reversible myocardial ischaemia) 3rd line: invasive coronary angiography Examples of non-invasive functional imaging: myocardial perfusion scintigraphy with single photon emission computed tomography (MPS with SPECT) or stress echocardiography or first-pass contrast-enhanced magnetic resonance (MR) perfusion or MR imaging for stress-induced wall motion abnormalities

This patient has recently been diagnosed with atrial fibrillation. His CHA2DS2-VASc score is 0. This indicates no clinical need for anticoagulation. what should you do

NICE guidelines indicate the need to perform an echocardiogram, to exclude valvular heart disease. If the echocardiogram shows a valvular defect, then anticoagulation should be started even with a low CHA2DS2-VASc score, as valvular heart disease in combination with atrial fibrillation is an absolute indication for anticoagulation.

chronic HF drug management

NICE issued updated guidelines on management in 2018, key points are summarised hereWhilst loop diuretics play an important role in managing fluid overload it should be remembered that no long-term reduction in mortality has been demonstrated for loop diuretics such as furosemide.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 remembered that both ACE inhibitors (which the patient is likely to already be on) and aldosterone antagonists both cause hyperkalaemia - therefore potassium should be monitored Third-line treatment should be initiated by a specialist. Options include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin and cardiac resynchronisation therapy ivabradinecriteria: sinus rhythm > 75/min and a left ventricular fraction < 35% sacubitril-valsartancriteria: left ventricular fraction < 35%is considered in heart failure with reduced ejection fraction who are symptomatic on ACE inhibitors or ARBsshould be initiated following ACEi or ARB wash-out period digoxindigoxin has also not been proven to reduce mortality in patients with heart failure. It may however improve symptoms due to its inotropic propertiesit is strongly indicated if there is coexistent atrial fibrillation hydralazine in combination with nitratethis may be particularly indicated in Afro-Caribbean patients cardiac resynchronisation therapyindications include a widened QRS (e.g. left bundle branch block) complex on ECG Other treatments offer annual influenza vaccine offer one-off pneumococcal vaccineadults usually require just one dose but those with asplenia, splenic dysfunction or chronic kidney disease need a booster every 5 years

You are a junior doctor in the cardiology clinic. A 57-year-old woman is referred due to chest pain. She is currently free of chest pain but has experienced a constricting discomfort in front of the chest in the past 2 months. She could only walk for 200m before getting breathless on walking due to her COPD. She does not think that walking triggers the chest discomfort as the pain starts randomly and does occur at rest. She suffers from hypertension, COPD and type 2 diabetes mellitus. There is a family history of premature coronary artery disease'. She is an ex-smoker.She is apyrexial. On examination, heart sounds are normal with no murmur. Resting ECG shows non-dynamic T-wave inversion in the lead V1-4. Auscultation of the lungs reveals reduced breath sound and scattered wheeze throughout. Palpation of the chest does not reveal any tender areas.What is the next step in the investigation of this lady's chest discomfort?

NICE recommends contrast-enhanced CT coronary angiogram for someone presenting with non-cardiac chest pain but whose resting ECG shows signs of ischaemia e.g. Q wave abnormality, ST-T wave changes

prophylaxis for infective endocarditis

NICE recommends the following procedures do not require prophylaxis: dental procedures upper and lower gastrointestinal tract procedures genitourinary tract; this includes urological, gynaecological and obstetric procedures and childbirth upper and lower respiratory tract; this includes ear, nose and throat procedures and bronchoscopy The guidelines do however suggest: any episodes of infection in people at risk of infective endocarditis should be investigated and treated promptly to reduce the risk of endocarditis developing if a person at risk of infective endocarditis is receiving antimicrobial therapy because they are undergoing a gastrointestinal or genitourinary procedure at a site where there is a suspected infection they should be given an antibiotic that covers organisms that cause infective endocarditis It is important to note that these recommendations are not in keeping with the American Heart Association/European Society of Cardiology guidelines which still advocate antibiotic prophylaxis for high-risk patients who are undergoing dental procedures.

AFib rate control and maintenance of sinus rhythm

NICE updated its guidelines on the management of atrial fibrillation (AF) in 2021. The following is also based on the joint American Heart Association (AHA), American College of Cardiology (ACC) and European Society of Cardiology (ESC) 2012 guidelines Patients presenting acutely with AF If a patient has signs of haemodynamic instability (e.g. hypotension, heart failure) they should be electrically cardioverted, as per the peri-arrest tachycardia guidelines.For haemodynamically stable patients, the management depends on how acute the AF is: < 48 hours: rate or rhythm control ≥ 48 hours or uncertain (e.g. patient not sure when symptoms started): rate controlif considered for long‑term rhythm control, delay cardioversion until they have been maintained on therapeutic anticoagulation for a minimum of 3 weeks Rate control Rate control should be offered as the first‑line treatment strategy for atrial fibrillation except in people: whose atrial fibrillation has a reversible cause who have heart failure thought to be primarily caused by atrial fibrillation with new‑onset atrial fibrillation (< 48 hours) with atrial flutter whose condition is considered suitable for an ablation strategy to restore sinus rhythm for whom a rhythm‑control strategy would be more suitable based on clinical judgement Medications Agents used to control rate in patients with atrial fibrillation beta-blockersa common contraindication for beta-blockers is asthma calcium channel blockers digoxinnot considered first-line anymore as they are less effective at controlling the heart rate during exerciseshould only be considered if he person does no or very little physical exercise or other rate‑limiting drug options are ruled out because of comorbiditiesmay have a role if there is coexistent heart failure Rhythm control Agents used to maintain sinus rhythm in patients with a history of atrial fibrillation beta-blockers dronedarone: second-line in patients following cardioversion amiodarone: particularly if coexisting heart failure Catheter ablation NICE recommends the use of catheter ablation for those with AF who have not responded to or wish to avoid, antiarrhythmic medication.Technical aspects the aim is to ablate the faulty electrical pathways that are resulting in atrial fibrillation. This is typically due to aberrant electrical activity between the pulmonary veins and left atrium the procedure is performed percutaneously, typically via the groin both radiofrequency (uses heat generated from medium frequency alternating current) and cryotherapy can be used to ablate the tissue Anticoagulation should be used 4 weeks before and during the procedure it should be remember that catheter ablation controls the rhythm but does not reduce the stroke risk, even if patients remain in sinus rhythm. Therefore, patients still require anticoagulation as per their CHA2DS2-VASc scoreif score = 0: 2 months anticoagulation recommendedif score > 1: longterm anticoagulation recommended Outcome notable complications includecardiac tamponadestrokepulmonary vein stenosis success ratearound 50% of patients experience an early recurrence (within 3 months) of AF that often resolves spontaneouslylonger term, after 3 years, around 55% of patients who've had a single procedure remain in sinus rhythm. Of patients who've undergone multiple procedures around 80% are in sinus rhythm

first line ix for chronic heart failure

NT-proBNP

A patient with heart-failure is being reviewed by the cardiologist. Their symptoms are under control at rest although the patient comments that walking to the shops can make him quite breathless. 5-years-ago, he says, this would not have been a problem. He doesn't struggle, though, making breakfast in the morning or moving around his house. He does mention though that more intense house-chores such as cleaning are a struggle.According the the NYHA classification, what stage is this patient at?

NYHA Class II Heart failure causes slight discomfort with ordinary activity. No symptoms on resting

A 40-year-old woman is admitted to the acute medical unit with a 2-month history of difficulty in walking and falls. She complains of paraesthesia in her lower limbs that has progressed from her feet to her upper shins. Her legs feel weaker than usual and she also reports increased irritability and a reduced ability to concentrate for prolonged periods of time. Her past medical history includes type 1 diabetes mellitus.On examination, there is increased spasticity in her lower limbs with reduced power and sensation.What is the most likely diagnosis?

Neurological features of pernicious anaemia may include peripheral neuropathy, subacute combined degeneration of the spinal cord and neuropsychiatric disorders

A 67-year-old man with a history of hypertension presents to the emergency department with a 24hr history of dyspnoea and palpitations. He also complains of mild chest discomfort. On examination, you note an irregularly irregular pulse of 115 beats per minute, blood pressure 95 / 70 mmHg and a respiratory rate of 20 breaths/min. He denies any regular medication and insists he has never experienced anything like this before. An ECG shows absent P waves with QRS complexes irregularly irregular intervals. What is the most appropriate management?

New onset AF is considered for electrical cardioversion if it presents within 48 hours of presentation

Mr Jain is a 57-year-old patient who has recently seen the practice nurse for his type 2 diabetes annual review. She found his blood pressure (BP) to be raised and he has subsequently borrowed a friend's BP monitor and has done some home readings which he has brought to show you on a spreadsheet. He has already worked out the average BP, which is 141/90mmHg. He has been reading about it on the internet and is keen to commence medication to reduce his cardiovascular risk, especially as he already has diabetes.Which antihypertensive does NICE recommend for Mr Jain?

Newly diagnosed patient with hypertension who has a background of type 2 diabetes mellitus - add an ACE inhibitor or an angiotensin receptor blocker regardless of age

main side effect of nicorandil

Nicorandil may cause ulceration anywhere in the gastrointestinal tract However, it has been associated with gastrointestinal ulceration, which can occur in different locations in the same patient, ranging from aphthous ulcers in the mouth down to anal ulcers.These ulcers can develop at any time after initiating the drug and may be refractory to treatment. If they develop, nicorandil should be rapidly and permanently discontinued.Ulceration can lead to further complications such as perforation, gastrointestinal haemorrhage, fistula or abscess formation. Patients with existing diverticular disease may be at particular risk of fistula formation or bowel perforation when taking nicorandil.

A 65-year-old man is found to have an ejection systolic murmur and narrow pulse pressure on examination. He has experienced no chest pain, breathlessness or syncope. An echo confirms aortic stenosis and shows an aortic valve gradient of 30 mmHg. How should this patient be managed?

No action should be taken at present as he is currently asymptomatic. If the aortic valve gradient > 40 mmHg or there is evidence of significant left ventricular dysfunction then surgery is sometimes considered in selected asymptomatic patients Discuss (3)Improve

A 65-year-old man presents to the emergency department with three days of cough and fever. He has no past medical history. He is a retired roofer.Observations: Heart rate 88 beats per minute Oxygen saturation 96% on room air Respiratory rate 18/minute Blood pressure 131/72 mmHg Temperature 37.8C The examination is unremarkable.A chest-x-ray demonstrates multiple calcified plaques in the lower zones but no consolidation.He is treated with oral antibiotics.What is the appropriate management of the radiographic findings?

No follow-up required is the correct answer. The patient has an incidental finding of multiple lower zone calcified plaques while being investigated for a lower respiratory tract infection. In the context of his profession as a retired roofer, these are likely to represent pleural plaques as a consequence of asbestos exposure. They are benign and do not require specific follow-up

A 65 year old woman is seen in cardiology clinic. She has a past medical history of rheumatic fever during childhood and hypertension. On examination, she has a rumbling mid-diastolic murmur heard best at the apex, in the left lateral position using the bell of the stethoscope. An echo shows a mitral valve area of 1.9cm2 and her ECG shows sinus rhythm. What is the most appropriate management option for this patient's valve disease?

No specific therapy This is the correct answer. The has the examination findings of the mitral stenosis. Previous rheumatic fever is a significant risk factor for this. The patient is asymptomatic and the mitral valve area is >1.5 cm2, therefore surgical intervention would provide no benefit 37%

oslers sign

Osler's sign of pseudohypertension This is not the correct answer. Osler's sign of pseudohypertension is a falsely elevated blood pressure reading which occurs due to calcification of blood vessels which prevents them from being compressed. This typically occurs in elderly patients and is associated with an elevated cardiovascular risk. It is not associated with infective endocarditis, unlike Osler's nodes (discovered by the same person) which are associated with infective endocarditis 16%

what does thiazide diuretics do and what electrolyte abnormalities does it cause

Of the abnormalities listed, hypercalcaemia is correct. Thiazide diuretics work by blocking the Na-Cl symporter in the distal convoluted tubule. This indirectly also leads to hypercalcaemia. Remember, as more calcium is being reabsorbed, less is being excreted in the urine - i.e. hypocalciuria. As such, these drugs are useful for the prevention of calcium-based kidney stones.Hyperkalaemia is incorrect - the opposite, hypokalaemia, occurs. This is due to more sodium reaching the collecting ducts, causing further potassium loss.Hyponatraemia, rather than hyper-, occurs with thiazide use. This is due to the primary effect of the drug - blockage of the Na-Cl symporter.

A 20-year-old woman presents for an insurance medical examination. On feeling the woman's radial pulse, the doctor can feel 2 separate systolic beats, as if there was a double pulse.Which of the following conditions may be a cause of this woman's physical findings?

Of the above conditions, only hypertrophic obstructive cardiomyopathy is associated with a bisferiens pulse (double pulse). This double pulse occurs due to subaortic stenosis as a result of the HOCM.In general, a bisferiens pulse is a sign of problems with the aortic valve, such as aortic stenosis and aortic regurgitation.Hypertrophic obstructive cardiomyopathy (HOCM) is an autosomal dominant disorder with a prevalence of around 1 in 500. While it is often symptomatic it is a differential for sudden death in younger people.

A 30 year old female patient is referred to the cardiology clinic with episodic palpitations. She reports 4 episodes in the last year, each episode lasting approximately 2 days. She has no past medical history of note but admits to drinking half a bottle of wine per day. At present physical examination reveals no abnormalities and the electrocardiogram (ECG) is normal. A previous ECG taken during an episode of palpitations revealed absent P waves with irregular QRS complexes. Which of the following is the most suitable management for this patient?

Oral flecainide This is the correct answer. Young patients with paroxysmal atrial fibrillation and no heart disease or hypertension should be treated with oral flecainide or sotalol (the 'pill in the pocket' strategy) 46%

where is short saphenous vein

Originates at the 5th digit where the dorsal vein merges with the dorsal venous arch of the foot, which attaches to the great saphenous vein. It passes around the lateral aspect of the foot (inferior and posterior to the lateral malleolus) and runs along the posterior aspect of the leg (with the sural nerve) Passes between the heads of the gastrocnemius muscle, and drains into the popliteal vein, approximately at or above the level of the knee joint.

orthostatic hypotension

Orthostatic hypotension can be diagnosed when there is a drop in SBP of at least 20 mmHg and/or a drop in DBP of at least 10 mmHg after 3 minutes of standing

A 65-year-old gentlemen presents to the General Practitioner (GP) with shortness of breath, fatigue, and a malar flush on his cheeks. Cardiovascular examination reveals a regular, low-volume pulse and a mid-diastolic murmur loudest with the patient leaning to his left-hand side.What ECG change might the GP expect to see in this patient?

P Mitrale represents left atrial hypertrophy/strain e.g. in mitral stenosis

A 26-year-old Caucasian male is on the general surgical ward. Three days post-operatively, he has been complaining of sudden onset of shortness of breath and a dry cough. He has a body mass index of 36kg/m² and is still using his Patient Controlled Analgesia (PCA) for pain relief. he has alkalosis

PE

most specific ecg finding in acute pericarditis

PR depression

PR prolongation on ecg - what pathology other than heart block may this be

PR prolongation, indicate heart block. RCA supplies AVN, RCA occlusion = inferior MI

primary polycythaemia

PRV

beaded appearance of bile ducts

PSC

A 70 year old male patient presents to the cardiology clinic for review. 2 weeks earlier he had a single chamber right ventricular pacemaker inserted for complete heart block. He is recovering well and is asymptomatic at present. Physical examination reveals no abnormalities. Which of the following electrocardiogram (ECG) findings are most consistent with this patient's presentation?

Pacing spikes preceding the QRS complexes. Broad QRS complexes with an RSR pattern in V5-6 This is the correct answer. In ventricular pacing the pacing spike precedes the QRS complex. In right ventricular pacing the QRS morphology is similar to left bundle branch block (remember WILLIAM MARROW - M-shaped QRS complexes in V5-6) 28%

IE monitoring

Perivalvular aortic abscess This is the correct answer. Perivavlular or aortic root abscesses are a potential complication of infective endocarditis. They manifest through prolongation of the PR interval on the ECG, which can be followed by higher degrees of heart block. Patients with infective endocarditis are monitored for this complication through daily ECGs 47%

patients on warfarin should avoid which types of food

Patients taking warfarin should avoid foods high in vitamin K, such as sprouts, spinach, kale and broccoli

A 64-year-old-man is admitted to the cardiology ward for routine catheter ablation to treat his atrial fibrillation. His wife asks whether he needs to continue his longterm apixaban.What is the correct advice to give her and the patient?

Patients who've had a catheter ablation for atrial fibrillation still require long-term anticoagulation as per their CHA2DS2-VASc score

Fawzia is a 76-year-old woman with a history of hypertension who undergoes catheter ablation to treat her atrial fibrillation. She is subsequently found to be in sinus rhythm. Prior to this, she was taking warfarin for stroke prevention.What is the correct longterm management of her anticoagulation?

Patients who've had a catheter ablation for atrial fibrillation still require long-term anticoagulation as per their CHA2DS2-VASc score. stay on warfarin

A patient in the emergency department waiting room collapses after feeling unwell. When he is brought through to resus he is found to have a heart rate of 38bpm and a blood pressure of 86/60mmHg.What is the first management step for this patient?

Patients with bradycardia and signs of shock require 500micrograms of atropine (repeated up to max 3mg)

You are called to see a 74-year-old patient who is complaining that her heart is racing. On examination, her heart rate is 209bpm and she appears breathless. Cardiac monitoring confirms a rapid narrow complex tachycardia. She states that she is now experiencing chest pain.What is the most appropriate management step?

Patients with tachycardia and signs of shock, syncope, myocardial ischaemia or heart failure should receive up to 3 synchronised DC shocks

A 68-year-old woman is followed up in the cardiology clinic for her aortic stenosis. She has a repeat echocardiogram and her cardiologist explains that the decision of whether to perform an operation depends on whether she has severe aortic stenosis or not. What parameter on the echocardiogram indicates severe aortic stenosis?

Peak trans-valvular pressure gradient >40mmHg An elevated pressure gradient >40 mmHg across the valve indicates severe aortic stenosis 48%

A 65 year-old man presents with new onset atrial fibrillation. He is started on warfarin for stroke prevention. He has a past medical history of alcoholism, epilepsy, and depression. Last week, he was diagnosed with a peptic ulcer. He takes phenytoin for his epilepsy as well as citalopram for his depression. Which of the following factors means that warfarin is contraindicated in this patient?

Peptic ulcer disease This is correct. Warfarin is contraindicated in those with peptic ulcer disease. This is because there is significant risk of gastrointestinal (GI) bleeding if you anti-coagulate those already with peptic ulcers. Other contraindications to warfarin treatment include bleeding disorders, severe hypertension and pregnancy (as warfarin is teratogenic) 57%

A 64-year-old male presents with a 30-minute history of crushing central chest pain radiating down into his left arm and jaw. He has a past medical history of hypertension, type 2 diabetes mellitus, and hyperlipidaemia. He is currently taking metformin, ramipril, and atorvastatin. He denies any allergies. His ECG report shows ST elevation in leads II, III, and aVF. It is decided that he is amenable for percutaneous coronary intervention.Which of the options below is the most appropriate medication to give prior to this procedure?

Percutaneous coronary intervention (PCI) can be offered to this patient as he is presenting with an STEMI within 12 hours of onset of symptom onset. The preferred method of PCI is via radial access with a drug-eluting stent. Prior to PCI, the patient should be given dual antiplatelet therapy. As the patient is not on any current oral anticoagulation, he should be given aspirin and prasugrel. 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

A 56-year-old man is seen in clinic with several months of progressive breathlessness on exertion that is worsening.On examination, a mid-late diastolic murmur is heard, which is heard better in expiration. S1 is also loud. An ECG is performed which shows sinus rhythm.What is the most appropriate step in his management?

Percutaneous mitral commissurotomy is the intervention of choice for severe mitral stenosis

A 35-year-old man is brought to the emergency department after a road traffic accident. He has a past medical history of COPD and smokes 30 cigarettes daily. His temperature is 37ºC, heart rate is 128/min, respiratory rate is 27/min, blood pressure is 80/43 mmHg, and GCS is 15. On examination he has right-sided chest bruising and tenderness to palpation, but chest movements are equal. His neck veins are distended but do not change with breathing and his trachea is central with heart sounds that are distant and quiet. There are also cuts and grazes seen on his hands and legs.What is the next step in his management?

Pericardial needle aspiration is correct. The presence of Beck's triad (hypotension + muffled (distant) heart sounds + elevated JVP) is characteristic of cardiac tamponade. This patient needs urgent aspiration of the pericardium to prevent further haemodynamic compromise. Although the patient is likely to have associated rib fractures, it essential to manage the cardiac tamponade first as it poses the biggest threat to his life in this scenario.

acute pericarditis

Pericarditis is one of the differentials of any patient presenting with chest pain. Features chest pain: may be pleuritic. Is often relieved by sitting forwards other symptoms include non-productive cough, dyspnoea and flu-like symptoms pericardial rub tachypnoea tachycardia Causes viral infections (Coxsackie) tuberculosis uraemia (causes 'fibrinous' pericarditis) trauma post-myocardial infarction, Dressler's syndrome connective tissue disease hypothyroidism malignancy 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 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

mx of sinus pause or sinus arrest >3secs

Permanent pacemaker The gentleman's ECG above shows a sinus pause or sinus arrest of longer than 3 seconds. This is an indication for the implantation of a permanent pacemaker. The pacemaker once implanted will be set to pace the heart at a minimum base rate to avoid this happening again and the patient dying in their sleep or having further pre-syncopal episodes 48%

A 65-year-old male presents with left sided hemiparesis, and decreased level of consciousness. On examination he has a blood pressure of 145/75 mmHg and pulse 110 beats per minute (regular). On auscultation he has crepitations to the mid zones and mild ankle oedema. He has a past medical history of a myocardial infarction 4 months previously. An ECG confirms persistent ST elevation in leads V1-V4.What is the most likely cause of the stroke?

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.

Pityriasis Rosea

Pityriasis rosea describes an acute, self-limiting rash which tends to affect young adults. The aetiology is not fully understood but is thought that herpes hominis virus 7 (HHV-7) may play a role.Features in the majority of patients there is no prodrome, but a minority may give a history of a recent viral infection herald patch (usually on trunk) followed by erythematous, oval, scaly patches which follow a characteristic distribution with the longitudinal diameters of the oval lesions running parallel to the line of Langer. This may produce a 'fir-tree' appearance Management self-limitingm - usually disappears after 6-12 weeks

What is porphyria cutanea tarda?

Porphyria cutanea tarda is a rare disorder characterised by painful, blistering skin lesions that develop on sun-exposed skin (photosensitivity). It does not present with visceral involvement as seen in this case, making it an unlikely diagnosis.

A 62-year-old man presents to the emergency department feeling acutely unwell with chest pain and palpitations. He reports a 4-week history of 4-kg weight loss and night sweats. He reports no recent travel history, does not smoke or drink and has worked as a farmer for all his life. At triage, he is noted to have splinter haemorrhages and painless macular lesions on the palmar surfaces of the hands. A diastolic murmur is auscultated over the right sternal border in the second intercostal space. Which of the following features on presentation would be most suggestive of a diagnosis of infective endocarditis?

Positive blood culture for Coxiella burnetii Endocarditis is a common presentation of Q fever, caused by the obligate intracellular bacteria Coxiella burnetii. Human infection usually results from aerosol inhalation of contaminated animal faeces, milk and birth products. A single positive blood culture for C. burnetii is a major Duke criteria. 38%

st depression in v1-v3

Posterior MI RCA

An 80-year-old man presents with sudden-onset difficulty walking and a droopy eyelid. He noticed slurred speech a few weeks ago, but as this resolved after 10 minutes he did not seek medical attention.On general examination, he has an ataxic gait and loss of sensation in his right arm and leg. On examination of his cranial nerves, he has nystagmus to the left, ptosis, meiosis and loss of sensation on the left-hand side of the face.Where is the likely arterial lesion?

Posterior inferior cerebellar artery (PICA) is the correct answer. Left-sided Horner's syndrome depicted here with cerebellar signs and a contralateral sensory loss of the limbs is consistent with a left-sided PICA infarct. The lateral brainstem signs involve the sympathetic outflow tract, (hence Horner's with ptosis and meiosis), spinocerebellar tract (hence cerebellar signs), the sensory nucleus of cranial nerve V (hence the sensation over the left-hand side of the face would be affected) and spinothalamic tract (hence pain and temperature loss on the contralateral, right side in this case).

A 59-year-old man attends the emergency department with chest pain. He states that his pain is central, heavy and non-radiating. He has hypertension and high cholesterol. His regular medications are amlodipine and atorvastatin. He has a 40 pack year smoking history and reports drinking one bottle of whisky a week.His observations are as follows: heart rate 98 beats per minute, blood pressure 164/92mmHg, temperature 37.8ºC, oxygen saturations 96% on room air and a respiratory rate of 20/minute.ECG findings are as follows. Sinus tachycardia. Leads V1, V2, and V3 show horizontal ST depression. Leads V1 and V2 show tall R waves.What is the likely cause for the abnormality seen on the ECG?

Posterior myocardial infarction is the correct answer. Posterior infarctions are often missed so it is important to be aware of them. A posterior MI can cause reciprocal changes on an ECG. This is commonly ST depression and tall R waves in the anterior leads. A good way to think about reciprocal change is an 'upside down' ST elevation seen in leads opposite to the site of infarction.

A 70 year old male patient presents to the emergency department with a 8 day history of palpitations. He has a past medical history of congestive cardiac failure and mitral stenosis. Electrocardiogram (ECG) reveals absent P waves and irregular QRS complexes at a rate of 120/minute. Electrical cardioversion is attempted but is unsuccessful. Which of the following management plans is most suitable in this patient?

Prescribe digoxin, carvedilol, and warfarin This is the correct answer. The patient has permanent atrial fibrillation (rhythm control has failed to restore sinus rhythm). Patients with heart failure benefit from the combination of carvedilol (for rate control) with digoxin (which may improve ejection fraction). A warfarin is important for stroke prophylaxis in those with valvular AF and is required in this patient as the CHA2DS2-VASc score is 2 37%

A 60-year-old man presents to the emergency department with acute left-sided weakness and dysphagia, which resolves 25 minutes later and he becomes asymptomatic. A CT head is normal. He has a past medical history of hypertension and takes amlodipine.He is subsequently referred to a specialist clinic where investigations are performed. An ECG shows absent P-waves and an irregularly irregular rhythm. A diffusion-weighted MRI shows no pathology. The patient does not smoke or drink alcohol and denies any other symptoms.What is the most appropriate step in his long-term management?

Prescribe lifelong apixaban now This patient has had a transient ischaemic attack (TIA) characterised by his brief period of focal neurological defects, which have resolved, along with the diffusion-weighted MRI showing no pathology, including ischaemia or haemorrhage. The ECG has demonstrated absent P-waves and an irregularly irregular rhythm, which indicates this patient may have atrial fibrillation (AF), which is likely to have contributed to his TIA. Prescribe lifelong apixaban now is correct. The NICE guidelines state that after a TIA, all patients with AF should be given anticoagulation immediately once imaging has excluded a haemorrhage, as AF can predispose patients to further TIAs and strokes. The anticoagulants of choice are direct-acting oral anticoagulants (DOACs), such as apixaban as they are more efficacious in patients with AF.

What do these ecg changes mean? J wave prolonged QT Tall tented T waves U waves

Presence of a J-wave is typically seen in hypothermia and not in hypercalcaemia. Prolonged QT interval is a feature of hypocalcaemia and not hypercalcaemia. Tall tented T waves are a feature characteristic of hyperkalaemia and not hypercalcaemia. U-waves are present in hypokalaemia and not in hypercalcaemia.

A 66-year female is admitted to hospital due to an ST-elevation myocardial infarction. She continues to have pain and has presented 2 hours after the symptoms began. What is the most appropriate intervention?

Primary percutaneous coronary intervention (PCI) If a patient with an ST-elevation myocardial infarction presents within 12 hours of symptom onset and there is ongoing pain or cardiovascular instability, then they are eligible for primary percutaneous coronary intervention. Ideally, PCI should be performed within 120 minutes of the time when fibrinolysis could have been given 83%

A 35-year-old lady, known intravenous drug user, presents to A&E with a fever. On examination, a new murmur was heard on auscultation that was later confirmed to be tricuspid regurgitation on an echocardiogram. Which single most likely JVP waveform is expected to be seen in this patient?

Prominent V-wave The V-wave signifies passive filling of the ventricle. A prominent V-wave (technically a C-V wave) is seen in tricuspid regurgitation, when the tricuspid valve fails to close completely such that blood shoots back into the right atrium during right ventricular contraction. Knowledge of the JVP waveform is important for theory exams and viva components in the OSCE 28%

A 43-year-old lady presents with severe chest pain. Investigations demonstrate a dissecting aneurysm of the ascending aorta which originates at the aortic valve. What is the optimal long term treatment?

Proximal aortic dissections are generally managed with surgical aortic root replacement. The proximal origin of the dissection together with chest pain (which may occur in all types of aortic dissection) raises concerns about the possibility of coronary ostial involvement (which precludes stenting). There is no role for attempted suture repair in this situation.

A 68-year-old man is admitted with severe community acquired pneumonia. A diagnosis of sepsis secondary to pneumonia is made. The sepsis 6 protocol is initiated however the patient unfortunately goes into cardiac arrest. Prompt CPR is initiated. An ECG shows pulseless electrical activity.What should be the next step in management?

Pulseless electrical activity and asystole are non-shockable rhythms and therefore are unresponsive to defibrillation. The patient should immediately receive 1mg of intravenous adrenaline whilst continuing high-quality CPR. The cause of the cardiac arrest should be identified and treated accordingly. Further adrenaline 1 mg IV should be given every 3-5 min (during alternate 2-min loops of CPR).

pulses alternans association

Pulsus Alternans This is the correct answer. The patient presents with features of left heart failure. Pulsus alternans (an alternating strong and weak pulse) is associated with severe left heart failure 41%

T wave inversion v1-v4, III and aVF

Pulmonary embolism Pulmonary embolism can present with chest pain and shortness of breath. The patient is tachycardic, hypoxic and has a low grade tempature also consistent with PE. The ECG shows evidence of right ventricular strain, in particular right ventricular dilation secondary to massive PE: T wave inversion in leads V1-V4, III and aVF 33%

ecg for pe

Pulmonary embolism (PE) is the correct answer. The ECG in the vignette shows sinus tachycardia (120bpm) with regular rate and sinus rhythm. There is evidence of right axis deviation (negative QRS complex in lead I and positive QRS complex in lead II and aVF). There is evidence of acute right heart strain (small R wave, large S wave, and slightly convex ST segment, with T wave inversion in the anterior leads (V1-V4) and inferior T leads (III and aVF)). There is also evidence of incomplete left bundle branch block (borderline prolonged negative QRS in V1 with a normal QRS complex duration in V6). The features of acute heart strain and tachycardia are consistent with a diagnosis of PE. Although an S1Q3T3 pattern (deep S in lead I, pathological Q waves in lead III, and T wave inversion in lead III) is present, this finding is not specific or sensitive to PE. The patient in the vignette is on the combined oral contraceptive, and one of its rare but serious side effects is the development of a PE.

A 44-year-old female presents with right-sided pleuritic chest pain of sudden onset. The pain is 8/10 severity, constant, and does not radiate to anywhere. She has a past medical history of hypertension, type 2 diabetes, stage 4 chronic kidney disease, hypercholesterolaemia. She does not have any known allergies. On examination, she has a respiratory rate of 24/min, heart rate 120 bpm, temperature of 37.6ºC. There is reduced air entry and inspiratory crackles in the right lower zone. An ECG shows sinus tachycardia and right-sided bundle branch block. D-dimer is reported as elevated. Given the likely diagnosis, what is the diagnostic investigation of choice?

Pulmonary embolism and renal impairment → V/Q scan is the investigation of choice

when to use the PERC criteria and when to use wells criteria

Pulmonary embolism rule-out criteria (PERC) is incorrect. This is done in patients with a low risk of PE, where more reassurance that a PE is less likely is desired. This patient has clear risk factors for PE (using oral oestrogen-containing contraceptives) and typical symptoms of PE; therefore, this scoring system is not appropriate. The two level Well's score can be used in patients presenting with signs and symptoms suggestive of PE to guide the next investigation

What is trifascicular block?

RBBB +left anterior or posterior hemiblock + 1st-degree heart block = trifasicular block

what is trifascular block

RBBB +left anterior or posterior hemiblock + 1st-degree heart block = trifasicular block

what medication should be avoided in people with HOCM

Ramipril is the correct answer. Angiotensin-converting enzyme (ACE) inhibitors are contraindicated in hypertrophic obstructive cardiomyopathy (HOCM) with left ventricular outflow tract (LVOT) obstruction. ACE inhibitors can reduce afterload which may worsen the LVOT gradient. The patient in this scenario has the characteristic signs of HOCM on his echocardiogram; mitral regurgitation, systolic anterior motion of the anterior mitral valve leaflet, asymmetric hypertrophy.

what medication should you stop 36 hours before commencing sacubitril valsartan

Ramipril is the correct answer. It is an angiotensin-converting enzyme inhibitor (ACE inhibitor). There should be a 36-hour 'washout' period between stopping ACE inhibitor therapy and starting sacubitril-valsartan to minimise the risk of angioedema. Co-administration of sacubitril (a neprilysin inhibitor) with an ACE inhibitor potentiates the levels of plasma bradykinin as they both inhibit bradykinin degradation, resulting in a higher risk of angioedema. In order to reduce this risk a 36 hour washout period is required to prevent the accumulation of bradykinin.

A 59-year-old patient is brought in by ambulance to the Emergency Department with severe, central chest pain, shortness of breath and diaphoresis.The ECG performed on scene by the paramedics shows ST depression in V1-V3 with tall, broad R waves and upright T waves.What is the next appropriate course of action?

Record a posterior ECG is the correct answer. This patient has presented with features suggestive of myocardial infarction (MI), chest pain, dyspnoea and diaphoresis. The ECG carried out on scene shows changes that should alert the clinician to the need to perform a posterior ECG. This involves placing leads V4-V6 on that patient's back to make leads V7-V9. V7 should be placed in the left posterior axillary line, V8 at the tip of the left scapula and V9 in the left paraspinal region, all in the same horizontal plane as V4-6. ST-elevation and Q waves in these leads confirm posterior infarction and the patient should be transferred for primary percutaneous coronary intervention as soon as possible. Posterior MIs are often missed so it is important to have a high index of suspicion and a low threshold for getting a posterior ECG. Remember to hand-write on the print-out that leads V4-6 are actually V7-9.

A 61 year old female patient is being treated for infective endocarditis on the cardiology ward. She has been on antibiotics for the past 5 days but has suddenly become acutely short of breath whilst mobilising to the toilet. She has a proven mitral valve vegetation on trans oesophageal echocardiogram and s.viridans positive blood cultures from 2 different sites. On examination she is acutely short of breath and is saturating 94% on 3 litres of oxygen with a respiratory rate of 25 breaths/min, she has bilateral crackles on lung auscultation and her JVP is elevated. Her heart rate is 107 bpm and her blood pressure 111/63 mmHg with a pan systolic murmur audible at the apex which you think is louder than on previous days. She is afebrile. What would be your next management step with this patient?

Referral for mitral valve replacement The above situation represents that of acute mitral regurgitation, likely secondary to a known vegetation present upon this patient's mitral valve. This represents an indication for urgent mitral valve surgery (mitral regurgitation with NYHA III or IV heart failure symptoms) and therefore she either needs referral to a surgical centre or to be seen by the surgeons that day 58%

Westermark sign x-ray

Regional oligemia in lung distal to pulmonary artery thrombus

A 75-year-old woman presents with fatigue, dyspnoea and ankle swelling on a background of hypertension, osteoarthritis, gout and type 2 diabetes mellitus. On examination, her cheeks appear erythematous. She has an irregularly irregular pulse and a raised JVP. There is peripheral oedema up to the knees bilaterally. On auscultation, the 1st heart sound is loud, and there is an added low, rumbling diastolic murmur.Which is the following is the most likely cause of this woman's presentation?

Rheumatic fever is the most common cause of mitral stenosis

A 68 year old man presents with increasing shortness of breath on exertion. His exercise tolerance has reduced from 100 metres to 10 metres over the course of one year. On examination, he is comfortable at rest with flushed cheeks. Auscultation of his chest reveals a mid-diastolic murmur with an early snap, rumbling in nature, loudest with the patient lying at on his left. His pulse rate is 102 bpm and is irregularly irregular. His blood pressure is 130/78mmHg, respiratory rate is 20 breaths per minute, saturations are 95% on room air and temperature is 37.3°C. What is the most likely underlying cause of this man's presenting features?

Rheumatic heart disease This is the correct answer. This man's symptoms and signs - a rumbling mid-diastolic murmur with an opening "snap", malar flush and atrial fibrillation - are consistent with mitral stenosis (MS). The commonest cause of MS is rheumatic heart disease. Streptococcal antigens secondary to bacterial infection cross-react with the valve tissue, causing damage. It is nowadays rarely found in developed countries 65%

cause of prolonged PR interval

Right coronary artery disease The most obvious abnormality shown in this ECG is a prolonged PR interval. A prolonged PR interval is considered anything >220ms (or 6 small squares on an ECG strip). 1st-degree heart block is caused by a delay in conduction from the SA node into the ventricles. As the AV node is supplied by the right coronary artery in 85% of individuals, disease in this artery may lead to first-degree heart block 13%

what needs transvenous pacing

Risk factors for asystole in bradycardia (? needs transvenous pacing) complete heart block with broad complex QRS recent asystole Mobitz type II AV block ventricular pause > 3 seconds

A 59-year-old man is admitted to the ward following primary percutaneous coronary intervention (PCI) for an acute inferoposterior myocardial infarction. He is recovering as expected until day 5 of his admission when he complains to the nurse that he is feeling suddenly short of breath.His observations reveal a pulse rate of 118/min , respiratory rate of 24/ min, temperature of 36.8ºC and blood pressure of 90/60 mmHg.On examination, an early-to-mid systolic murmur is audible and radiates to the axilla.What is the most likely explanation for this man's current symptoms?

Rupture of the papillary muscle due to a myocardial infarction → acute mitral regurgitation → widespread systolic murmur, hypotension, pulmonary oedema acute mitral regurgitation is the most common complication following an inferoposterior MI. it presents acutely with hypotension and features of pulmonary oedema.

what is an early sign of left ventricular failure

S3 is correct. The patient presents with shortness of breath and orthopnoea in association with bilateral crackles extending to the midzone with evidence of respiratory failure. On a background of ischaemic heart disease, this is likely caused by left ventricular failure. An S3 gallop rhythm is an early sign of left ventricular failure.

ecg changes for thrombolysis or PCI

ST elevation of > 2mm (2 small squares) in 2 or more consecutive anterior leads (V1-V6) OR ST elevation of greater than 1mm (1 small square) in greater than 2 consecutive inferior leads (II, III, avF, avL) OR New Left bundle branch block

A 65-year-old gentleman, with long-standing type 2 diabetes, is brought urgently to the A&E by ambulance following a 1-hour episode of severe nausea and profuse sweating. There is no chest pain. He does not complain of chills or a cough, and has no other risk factors for venous thromboembolism. An ECG performed in the ambulance showed prominent ST-segment elevation in leads V3 to V6, I and avL. Reciprocal ST-segment depression was seen in lead III and aVF. What are the ECG criteria for ST-segment elevation such that this patient is considered as having an ST-segment elevation myocardial infarct (STEMI)?

ST-segment elevation > 1 mm in 2 contiguous limb leads OR > 2 mm in 2 contiguous chest leads In UK clinical practice, a STEMI based on ECG findings is defined as above. This forms part of the requirement for the local STEMI protocol to be activated. There are slight differences in the magnitude of ST-segment elevation in the chest leads for men under 40-years-old (≥ 2.5 mm in leads V2-3) and for women (≥ 2.5 mm in leads V2-3). Note that apart from ST-segment elevation, a new-onset LBBB or hyperacute T-waves are also indicative of a STEMI. These ECG findings, or any investigation findings for that matter, should always be appropriately interpreted in the context of clinical history and examination. In this case, the patient has suffered a silent MI without chest pain, likely due to neuropathy secondary to his diabetes mellitus 40%

what is IV adenosine used for

SVTs

A 63-year-old gentleman with hypertension presents to A&E on a Monday at 11:00am with a history of new-onset palpitations. The attending physician immediately performs an ECG which shows atrial fibrillation with fast conduction of approximately 125 beats per minute. He is haemodynamically stable, has no chest pain or shortness of breath and oriented to time and place. On examination, his JVP is not raised, lung bases are clear and no ankle oedema was noted. What is the earliest possible time this gentleman's new-onset atrial fibrillation could have started such that rhythm control can be considered without the required delay for anticoagulation?

Saturday at 11:00am According to 2014 NICE guidelines, the maximum amount of time that acute atrial fibrillation can last for such that it still qualifies for rhythm control without delay is 48 hours. Based on the current time point of 11:00am on a Monday, the earliest possible time such an atrial fibrillation could have started is Saturday at 11:00am 67%

A 31-year-old woman complains of abdominal pain, bloating, flatulence and diarrhoea for 2 months. Her past medical history includes asthma, Raynaud's disease, and hyperthyroidism which are well-controlled on salbutamol, nifedipine, and carbimazole.On examination, her heart rate is 89/min, blood pressure is 132/88 mmHg. She is afebrile. Her abdomen is soft and non-tender and there are small, widened blood vessels around her mouth.A hydrogen breath test confirms the diagnosis.What increases the risk of developing this condition?

Scleroderma is correct. This patient presents with small bowel bacterial overgrowth syndrome. This commonly presents with features similar to inflammatory bowel syndrome, including abdominal pain, bloating, flatulence and diarrhoea. It is confirmed by the hydrogen breath test. Risk factors include diabetes, hypothyroidism, and scleroderma. Scleroderma occurs in limited cutaneous systemic sclerosis, which this patient is also showing signs of. She demonstrates two features of CREST syndrome (Raynaud's and telangiectasia). Others include calcinosis, oesophageal dysmotility, and sclerodactyly.

A 60-year old man presents to the Emergency Department with a weeklong history of intermittent dizziness. He reports fainting the day before. His ECG shows intermittently non-conducted P waves, there is no sign of PR elongation or shortening of the waves that are conducted. What is the most likely diagnosis?

Second-degree heart block (Mobitz type II) Correct. The PR interval is constant and there are intermittently non-conducted P waves. Mobitz type II is also known as Type 2 heart block. Definitive management is with a permanent pacemaker as these patients are at risk of risk of complete heart block and becoming haemodynamically unstable 59%

A 63-year-old female attends the outpatient cardiology department for an elective permanent pacemaker as she has had syncopal episodes due to a heart arrhythmia. She has an ECG which shows sinus bradycardia and a rate of 36. The PR interval and QT interval are within the normal range and a QRS complex follows every P wave. A brief sinus pause is also noted. Blood tests performed previously, including thyroid function tests, were all unremarkable. What is the most likely diagnosis?

Sick sinus syndrome This condition causes symptomatic bradycardia and is an indication of a permanent pacemaker. ECG may also reveal sinus pauses and spells of tachycardia 72%

does thaizide like diuretcis cause hypercalcaemia or is that loop diuretics

Side effects of furosemide include hypokalaemia, hyponatraemia and hypomagnesia. In contrast to thiazide diuretics, loop diuretics such as furosemide cause a hypocalcaemia.

illhouette sign

Silhouette sign This is not the correct answer. This manifests as a loss of the normally seen structural borders and typically occurs in pneumonia rather than heart failure 11%

when taking clarithromycin or erythromycin what medication should be stopped

Simvastatin is correct. According to the BNF, clarithromycin increases systemic exposure to simvastatin, leading to an increased risk of myopathy.

small bowel bacterial overgrowth syndrome: risk factors features dx mx

Small bowel bacterial overgrowth syndrome (SBBOS) is a disorder characterised by excessive amounts of bacteria in the small bowel resulting in gastrointestinal symptoms.Risk factors for SBBOS neonates with congenital gastrointestinal abnormalities scleroderma diabetes mellitus It should be noted that many of the features overlap with irritable bowel syndrome: chronic diarrhoea bloating, flatulence abdominal pain Diagnosis hydrogen breath test small bowel aspiration and culture: this is used less often as invasive and results are often difficult to reproduce clinicians may sometimes give a course of antibiotics as a diagnostic trial Management correction of the underlying disorder antibiotic therapy:rifaximin is now the treatment of choice due to relatively low resistance. Co-amoxiclav or metronidazole are also effective in the majority of patients.

NYHA classification

Stage I - No limitation on ordinary physical activity (incorrect)Stage II - Normal at rest. Ordinary physical activity causes breathlessness (correct)Stage III - Normal at rest. Less-than-ordinary activity causes breathlessness (incorrect)Stage IV - Symptoms at rest. (incorrect)

most common causes of endocarditis

Staphylococcus aureus Staphylococcus epidermidis if < 2 months post valve surgery

A 35-year old male presents to the emergency department with a one week history of fever, general malaise and night sweats. On further questioning he reveals he is an intravenous drug user and has been for many years. On examination he is febrile and tachycardiac with an audible murmur loudest over the right upper sternal border. A provisional diagnosis of infective endocarditis is made. Which organism is most likely to be responsible?

Staphylococcus aureus This is the most common pathogen responsible for causing endocarditis in an intravenous drug user 80%

A 60-year-old male who recently underwent cardiac surgery presents with fever, fatigue, and weight loss. The patient was discharged after a successful mitral valve replacement 4 months ago and as such an urgent echocardiogram is performed.The echo confirms the presence of a new valvular lesion, and a diagnosis of endocarditis is made. Three sets of blood cultures are taken.Which organism is most likely to be responsible for the patient's diagnosis?

Staphylococcus aureus is now the most common cause of infective endocarditis particularly in acute presentations and intravenous drug users. Although the patient has recently undergone valve replacement surgery it was over 2 months ago and so the spectrum of organisms that cause endocarditis return to normal. Therefore, Staphylococcus epidermidis not the most likely organism.

PR interval

Start of P-wave to the start of the QRS complex This is by definition the PR interval. It is important to note whether the interval is based on the start or the end of a wave or complex, as this can significantly change the results. Please note that the other important interval, the QT interval, is defined as the start of the QRS complex to the end of the T-wave 41%

statins

Statins inhibit the action of HMG-CoA reductase, the rate-limiting enzyme in hepatic cholesterol synthesis.Adverse effects myopathy: includes myalgia, myositis, rhabdomyolysis and asymptomatic raised creatine kinase. Risks factors for myopathy include advanced age, female sex, low body mass index and presence of multisystem disease such as diabetes mellitus. Myopathy is more common in lipophilic statins (simvastatin, atorvastatin) than relatively hydrophilic statins (rosuvastatin, pravastatin, fluvastatin) liver impairment: the 2014 NICE guidelines recommend checking LFTs at baseline, 3 months and 12 months. Treatment should be discontinued if serum transaminase concentrations rise to and persist at 3 times the upper limit of the reference range there is some evidence that statins may increase the risk of intracerebral haemorrhage in patients who've previously had a stroke. This effect is not seen in primary prevention. For this reason the Royal College of Physicians recommend avoiding statins in patients with a history of intracerebral haemorrhage Contraindications macrolides (e.g. erythromycin, clarithromycin) are an important interaction. Statins should be stopped until patients complete the course pregnancy Who should receive a statin? all people with established cardiovascular disease (stroke, TIA, ischaemic heart disease, peripheral arterial disease) following the 2014 update, NICE recommend anyone with a 10-year cardiovascular risk >= 10% patients with type 2 diabetes mellitus should now be assessed using QRISK2 like other patients are, to determine whether they should be started on statins patients with type 1 diabetes mellitus who were diagnosed more than 10 years ago OR are aged over 40 OR have established nephropathy Statins should be taken at night as this is when the majority of cholesterol synthesis takes place. This is especially true for simvastatin which has a shorter half-life than other statins.NICE currently recommends the following for the prevention of cardiovascular disease:: atorvastatin 20mg for primary preventionincrease the dose if non-HDL has not reduced for >= 40% atorvastatin 80mg for secondary prevention

donepezil effect on heart

Stop Donepezil, and refer urgently to A&E for external pacing This ECG shows a complete heart block. Donepezil is an anticholinesterase inhibitor, it is licensed for the use in mild-to-moderate dementia. As it increases acetylcholine levels, it can contribute to or lead to heart block. It is therefore important to stop this drug, as it may be the underlying cause of this patient's ECG. It is, however, necessary to also refer this patient to A&E - as complete heart block increases the risk of ventricular pause and sudden cardiac arrest. The emergency management of complete heart block is via external pacing 39%

A 5 year old girl is brought to the GP because she has been complaining of aches in her knees. Four weeks ago, she had similar aches in her ankles, along with a pink rash on her abdomen and legs. Her mother has also noticed some strange bumps around her elbows. On examination, her knees appear mildly erythematous and oedematous. There are scattered nodules across the elbows that are not tender on palpation. On auscultation, there is a 'swishing' sound on auscultation of the chest. What infection is this child likely to have had 6 weeks previously?

Streptococcus pharyngitis This child with migratory polyarthritis, subcutaneous nodules and pericarditis has rheumatic fever. Rheumatic fever is a delayed reaction to a streptococcal A infection, most commonly pharyngitis, in the preceding 2-6 weeks 61%

A 30 year old female presents to A&E with sudden onset of weakness in her right arm and leg. She has a 5 day history of fever and night sweats. She has a past medical history of rheumatic fever. Examination reveals clubbing and a pansystolic murmur in the mitral region. Growth on blood agar reveals partial haemolysis. What is the most likely causative organism?

Streptococcus viridans This typically causes a subacute presentation of infective endocarditis in patients with existing cardiac disease. It is one of the alpha haemolytic Streptococci and causes partial haemolysis on agar 32%

A 46-year-old man presents acutely unwell to the accident and emergency department. On examination, he has a temperature of 40ºC, rigours and an ejection systolic murmur located on the right second intercostal space. His dental hygiene is very poor.He has no other significant medical history. Blood cultures are taken from this patient and gram stained to show contain purple-coloured chains of coagulase-negative micro-organisms.What is the most likely micro-organism identified from this patient's blood culture?

Streptococcus viridans is correct. This patient is presenting with signs and symptoms consistent with infective endocarditis: fever and a new heart murmur (in this case due to aortic stenosis). For any patient presenting with these signs, infective endocarditis should be a top differential.The purple colour on the gram stain indicates that the species of micro-organism cultured is gram-positive, a pink/red colour would reveal the presence of a gram-negative species of microorganism. Coagulase is an enzyme responsible for the conversion of fibrinogen to fibrin. The presence of this enzyme is utilised clinically to distinguish between staphylococci species. For instance, Staphylococcus aureus is coagulase-positive and Staphylococcus epidermidis is coagulase-negative.Streptococcus viridans does not refer to a specific bacteria itself but rather a pseudo taxonomic term referring to different types of Streptococcus viridans species (e.g. Streptococcus mitis). This group of bacteria are commonly found in the mouth and is associated with poor dental hygiene or undertaking a dental procedure.

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 The presentation of this patient is classic for left ventricular free wall rupture following a myocardial infarction (MI). Left ventricular free wall rupture is caused by the infarction causing a weakening in the wall. The rupture leads to bleeding into the pericardium, resulting in cardiac tamponade. Hence the examination signs are consistent with the triad noted in cardiac tamponade of any cause (raised JVP, pulses paradoxus and muffled/quiet heart sounds). Pulses paradoxus refers to a fall in systolic blood pressure of greater than 10mmHg with inspiration and can be measured using manual blood pressure recordings. Patients often experience chest pain preceding symptoms of acute heart failure, such as breathlessness. This complication of an MI is associated with particularly high mortality (around 60%). It requires urgent pericardiocentesis and thoracotomy.

A 66 year old woman attends cardiology clinic with exertional dyspnoea, which has been worsening for the previous three months. She is currently able to walk 60 metres, after which she is limited by extreme breathlessness. Her baseline one year ago was over 100 metres, and she is normally functionally independent in her activities of daily living. She has no significant medical history. On examination, auscultation reveals few basal inspiratory crepitations bilaterally, with the rest of her chest being clear. She also has a loud ejection systolic murmur which is also heard in the carotid region. The second heart sound is soft. There is no peripheral oedema. She is comfortable at rest. Her saturations are 96% on room air, respiratory rate is 16 breaths per minute, blood pressure is 128/90 mmHg, pulse rate is 75 bpm and she is afebrile. A trans-thoracic echocardiogram is done, which shows a left ventricular ejection fraction of 50% and severe stenosis of the aortic valve. Which of the following is the most appropriate management option for this woman?

Surgical aortic valve replacement This is the correct answer. This woman has aortic stenosis, characterised by worsening dyspnoea and an ejection systolic murmur radiating to her carotids. She is otherwise healthy. Although her ejection fraction is preserved, she should receive intervention as she is symptomatic. Surgical aortic valve replacement is the ideal option for patients who are able to tolerate open heart surgery 49%

A 72 year old woman presents to cardiology clinic with a six month history of worsening shortness of breath and poor exercise tolerance. Her function has now deteriorated from a baseline of being able to walk unhindered, now to being extremely short of breath while moving around her house. She has no other significant medical history. On examination, she is comfortable at rest but becomes easily breathless transferring from the chair to the bed. Auscultation reveals an early diastolic murmur, which is loudest at the lower left sternal edge and is made louder by leaning forward and holding her breath in expiration. There are also bilateral inspiratory crepitations at the bases of her chest, with minimal peripheral oedema. A trans-thoracic echocardiogram is performed which confirms the diagnosis of aortic regurgitation. Based on her current condition, which is the most appropriate treatment option to offer her?

Surgical aortic valve replacement This is the correct answer. This woman has worsening symptoms of heart failure, secondary to aortic regurgitation. Because she is symptomatic, she should be offered intervention. Surgical valve replacement is the most appropriate because she is well enough to tolerate surgery and surgical replacement is more ideal compared to transcatheter implantation (TAVI) 39%

when to do surgical mx for someone with aortic regurgitation

Surgical intervention in aortic regurgitation (AR) is indicated in the following situations:Significant enlargement of the ascending aortaSymptomatic ARAsymptomatic AR with the following parameter findings:Poor left ventricular ejection fraction (<= 50%)Left ventricular end diastolic diameter > 70mm or left ventricular end systolic diameter > 50mmInfective endocarditis refractory to medical therapy

A 25-year-old lady, with a known past medical history of Wolff-Parkinson-White syndrome and waiting for definitive treatment, develops sudden-onset palpitations. She also reported chest pain and momentarily lost consciousness and was brought to A&E by ambulance. The attending physician performed an ECG which showed a regular rhythm with narrow QRS complexes with a heart rate of 140 beats per minute. P-waves are not seen. On examination, her blood pressure is 125/85 mmHg, her JVP is not raised and no pedal oedema was noted. What is the single most initial appropriate management in this patient?

Synchronised electrical cardioversion This patient has supraventricular tachycardia with adverse features such as syncope and chest pain. Based on the 2015 Resuscitation Council UK tachycardia algorithm, she requires urgent synchronised electrical cardioversion (up to 3 attempts) 28%

A 74-year-old obese man with a past medical history of chronic kidney disease, advanced COPD and type 2 diabetes mellitus presents with exertional chest pain and dizziness. On examination, he is found to have a loud ejection systolic murmur with absent S2.An echocardiogram shows severe aortic stenosis with associated left ventricular hypertrophy.What is the most suitable definitive management?

Symptomatic aortic stenosis: surgical AVR for low/medium operative risk patients transcatheter AVR for high operative risk patients

A 78-year-old gentleman presents to A&E with a 3-day history of a productive cough and chills. He also notes recent-onset palpitations. The attending physician performed an ECG which shows atrial fibrillation with fast conduction of approximately 130 beats per minute. On examination, his blood pressure is 89/68 and pitting ankle oedema is noted. What is the single best initial management for this patient?

Synchronised electrical cardioversion This patient has atrial fibrillation with adverse features such as heart failure and shock. Based on the 2015 Resuscitation Council UK tachycardia algorithm, he requires urgent synchronised electrical cardioversion (up to 3 attempts) not Unsynchronised electrical cardioversion Whilst electrical cardioversion can be used in controlling atrial fibrillation in the acute setting, it is vital it is synchronised to the patient's heart rhythm on ECG. This avoids the R-on-T phenomenon, which is the superimposition of the ectopic beat from the cardioversion on the T-wave of the preceding beat generated by the patient's heart. This can result in sustained ventricular tachyarrhythmias which are dangerous and potentially fatal. Unsynchronised electrical cardioversion is however used in Advanced Life Support, as the R-on-T phenomenon does not apply to ventricular tachyarrhythmias i.e. pulseless ventricular tachycardia or ventricular fibrillation 7%

A 54-year-old male with no past medical history is found to be in atrial fibrillation during a consultation regarding a sprained ankle. He reports no history of palpitations or dyspnoea. After discussing treatment options he elects not to be cardioverted. Examination of the cardiovascular system is otherwise unremarkable with a blood pressure of 118/76 mmHg. According to the latest NICE guidelines, if the patient remains in chronic atrial fibrillation what is the most suitable treatment to offer?

The CHA2DS2-VASc score for this man is 0. NICE therefore recommend that he does not require anticoagulation.

classification of syncope

Syncope may be defined as a transient loss of consciousness due to global cerebral hypoperfusion with rapid onset, short duration and spontaneous complete recovery. Note how this definition excludes other causes of collapse such as epilepsy.The European Society of Cardiology published guidelines in 2009 on the investigation and management of syncope. They suggested the following classification: Reflex syncope (neurally mediated) vasovagal: triggered by emotion, pain or stress. Often referred to as 'fainting' situational: cough, micturition, gastrointestinal carotid sinus syncope Orthostatic syncope primary autonomic failure: Parkinson's disease, Lewy body dementia secondary autonomic failure: e.g. Diabetic neuropathy, amyloidosis, uraemia drug-induced: diuretics, alcohol, vasodilators volume depletion: haemorrhage, diarrhoea Cardiac syncope arrhythmias: bradycardias (sinus node dysfunction, AV conduction disorders) or tachycardias (supraventricular, ventricular) structural: valvular, myocardial infarction, hypertrophic obstructive cardiomyopathy others: pulmonary embolism Reflex syncope is the most common cause in all age groups although orthostatic and cardiac causes become progressively more common in older patients. Evaluation cardiovascular examination postural blood pressure readings: a symptomatic fall in systolic BP > 20 mmHg or diastolic BP > 10 mmHg or decrease in systolic BP < 90 mmHg is considered diagnostic ECG carotid sinus massage tilt table test 24 hour ECG

syncope and its types

Syncope may be defined as a transient loss of consciousness due to global cerebral hypoperfusion with rapid onset, short duration and spontaneous complete recovery. Note how this definition excludes other causes of collapse such as epilepsy.The European Society of Cardiology published guidelines in 2009 on the investigation and management of syncope. They suggested the following classification:Reflex syncope (neurally mediated) vasovagal: triggered by emotion, pain or stress. Often referred to as 'fainting' situational: cough, micturition, gastrointestinal carotid sinus syncope Orthostatic syncope primary autonomic failure: Parkinson's disease, Lewy body dementia secondary autonomic failure: e.g. Diabetic neuropathy, amyloidosis, uraemia drug-induced: diuretics, alcohol, vasodilators volume depletion: haemorrhage, diarrhoea Cardiac syncope arrhythmias: bradycardias (sinus node dysfunction, AV conduction disorders) or tachycardias (supraventricular, ventricular) structural: valvular, myocardial infarction, hypertrophic obstructive cardiomyopathy others: pulmonary embolism Reflex syncope is the most common cause in all age groups although orthostatic and cardiac causes become progressively more common in older patients.Evaluation cardiovascular examination postural blood pressure readings: a symptomatic fall in systolic BP > 20 mmHg or diastolic BP > 10 mmHg or decrease in systolic BP < 90 mmHg is considered diagnostic ECG carotid sinus massage tilt table test 24 hour ECG

JVP increases with inspiration

The JVP increasing with inspiration is known as Kussmaul's sign and can be a feature of constrictive pericarditis. It is caused by impaired filling of the right ventricle due to a poorly compliant myocardium or pericardium. The JVP should fall with inspiration due to reducing pressure in the thoracic cavity.

baseline tests prior to starting someone on amiodarone

TFT + LFT + U&E + CXR A baseline chest x-ray is required due to the risk of pulmonary fibrosis / pneumonitis in patients treated with amiodarone. Urea and electrolytes are suggested by the BNF to detect hypokalaemia which may increase the risk of arrhythmias developing.

TOE/TTE for aortic dissection

TOE

patients with suspected acute pericarditis should be investigated with what

TOE

ix in unstable patients for suspected aortic dissection

TOE - transoesophageal echo

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 younger females (e.g. 10-40 years) and Asian people.Features systemic features of a vasculitis e.g. malaise, headache unequal blood pressure in the upper limbs carotid bruit and tenderness absent or weak peripheral pulses upper and lower limb claudication on exertion aortic regurgitation (around 20%) associations - RAS management - steroids

A 45-year-old woman suffered from sudden onset central crushing chest pain. Her electrocardiogram showed ST-segment elevation. Troponin is slightly raised. She was rushed for an emergency invasive angiogram but this revealed slight wall irregularities with no luminal obstruction. Subsequently, cardiovascular MR (CMR) showed an apical ballooning of the myocardium resembling an octopus pot.She did not have any significant past medical history. There is a family history of premature coronary artery disease. Her partner recently passed away of prostate cancer.What is the most likely cause of the ST-segment elevation?

Takotsubo cardiomyopathy is a differential for ST-elevation in someone with no obstructive coronary artery disease The differential diagnosis for ST-elevation: myocardial infarction pericarditis/myocarditis normal variant - 'high take-off' Takotsubo cardiomyopathy Left ventricular aneurysm Prinzmetal angina Subarachnoid haemorrhage Takotsubo cardiomyopathy also known as 'Broken heart syndrome' and 'Takotsubo apical ballooning syndrome' describes a cardiomyopathy induced by severe stressful triggers (e.g. emotional upset). It is commoner in women. In this scenario, we assume that the patient is in bereavement which precipitated the stress cardiomyopathy.Takotsubo is a Japanese word that describes an octopus trap; this is used to describe the appearance of the heart on left ventriculogram, CMR or echocardiogram. This apical ballooning appearance occurs due to severe hypokinesis of the mid and apical segments with preservation of activity of the basal segments. In simple terms, the bottom of the heart (the apex) does not contract and therefore appears to balloon out. However, the area closer to the top (the base) continues to contract (creating the neck of the octopus trap).

Takotsubo cardiomyopathy

Takotsubo cardiomyopathy is a type of non-ischaemic cardiomyopathy associated with a transient, apical ballooning of the myocardium. It may be triggered by stress.Pathophysiology Takotsubo is a Japanese word that describes an octopus trap the apical ballooning appearance occurs due to severe hypokinesis of the mid and apical segments with preservation of activity of the basal segments. In simple terms, the bottom of the heart (the apex) does not contract and therefore appears to balloon out. However, the area closer to the top (the base) continues to contract (creating the neck of the octopus trap) Features chest pain features of heart failure ECG: ST-elevation normal coronary angiogram Treatment is supportive.Prognosis the majority of patients improve with supportive treatment

A 48-year-old woman presents to the emergency department with severe central crushing chest pain, palpitations and shortness of breath that has come on over the last two hours. She was involved in a high-speed road traffic accident three weeks ago and required a leg amputation due to irreparable injuries. She is a non-smoker with a normal BMI and was healthy and active before her accident.An ECG demonstrates global ST elevation, most evident in the precordial leads and inverted T waves. The following blood result is recorded: Troponin 9ng/l. likely diagnosis

Takotsubo cardiomyopathy is correct. Also known as broken heart syndrome, this is a stress-related heart disease characterised by ballooning and temporary left ventricle dysfunction. It is often seen in recently bereaved patients, but anything that causes intense physical or emotional distress, e.g. an accident, natural disaster or significant illness/injury, can induce this disorder. Signs and symptoms appear similar to myocardial infarction, and ECG findings are similar. There is often a moderate troponin rise, but it is usually <15 ng/L compared to MI which usually presents with a significantly raised troponin >30 ng/L.

A 35-year-old male is brought into the emergency department by paramedics. He was a pedestrian hit by a car 20 minutes prior and lost consciousness immediately upon impact. His Glasgow coma scale (GCS) score was 5 on arrival.An initial assessment found no significant traumatic injury. He was intubated and attached to vital signs monitoring including an ECG. A subsequent x-ray of his chest and abdomen demonstrated no apparent injury.Thirty minutes later, the patient was noticed to have sinus tachycardia and hypotension with profuse sweating. An examination revealed asymmetrical chest expansion and tracheal deviation. Moments later, a nurse notices he has no pulse.Which arrest rhythm is likely to be seen in this patient?

Tension pneumothorax is a reversible cause of PEA in cardiac arrest resulting from trauma

per-arrest rhythms: bradycardia management

The 2015 Resuscitation Council (UK) guidelines emphasise that the management of bradycardia depends on: 1. identifying the presence of signs indicating haemodynamic compromise - 'adverse signs' 2. identifying the potential risk of asystole adverse signs: The following factors indicate haemodynamic compromise and hence the need for treatment: shock: hypotension (systolic blood pressure < 90 mmHg), pallor, sweating, cold, clammy extremities, confusion or impaired consciousness syncope myocardial ischaemia heart failure Atropine (500mcg IV) is the first line treatment in this situation.If there is an unsatisfactory response the following interventions may be used: atropine, up to maximum of 3mg transcutaneous pacing isoprenaline/adrenaline infusion titrated to response Specialist help should be sought for consideration of transvenous pacing if there is no response to the above measures. potential risk of asystole: The following are risk factors for asystole. Even if there is a satisfactory response to atropine specialist help is indicated to consider the need for transvenous pacing: complete heart block with broad complex QRS recent asystole Mobitz type II AV block ventricular pause > 3 seconds

An 83-year-old woman is admitted with a left intertrochanteric neck of femur fracture. On examination the patient is found to have an ejection systolic murmur loudest in the aortic region. There is no radiation of the murmur to the carotid arteries. Her ECG is normal. what is the cause of the murmur

The most likely diagnosis is aortic sclerosis. The main differential diagnosis is of aortic stenosis, however as there is no radiation of the murmur to the carotids and the ECG is normal, this is less likely.

what does new york heart association classify and what are the classifications

The New York Heart Association (NYHA) classification is widely used to classify the severity of heart failure:NYHA Class I no symptoms no limitation: ordinary physical exercise does not cause undue fatigue, dyspnoea or palpitations NYHA Class II mild symptoms slight limitation of physical activity: comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea NYHA Class III moderate symptoms marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms NYHA Class IV severe symptoms unable to carry out any physical activity without discomfort: symptoms of heart failure are present even at rest with increased discomfort with any physical activity

A 37-year-old woman presents to the emergency department with pleuritic chest pain and shortness of breath. There is nil past medical history of note and urine pregnancy test is negative. Her vital signs are all in the normal range. A CTPA shows a small peripheral pulmonary embolism. Her pulmonary embolism severity index (PESI) score is calculated and is class 1 - very low risk. She is keen to avoid a hospital admission.Which of the following management options is most appropriate at this time?

The Pulmonary Embolism Severity Index (PESI) score is recommended by BTS guidelines to be used to help identify patients with a pulmonary embolism that can be managed as outpatients therefore do outpaient management with rivaroxaban.

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 injuryWhilst 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.

Travelling and DVT prophylaxis

The most recent CKS guidelines advise that we take a risk based approach. For example, a patient with no major risk factors for VTE (i.e. the average person) then no special measures are needed.Patients with major risk factors should consider wearing anti-embolism stockings. These can either be bought by the patient or prescribed (class I). Clearly if the risk is very high (e.g. a long-haul flight following recent major surgery) then consideration should be given to delaying the flight or specialist advice sought regarding the use of low-molecular weight heparin.All guidelines agree there is no role for aspirin in low, medium or high risk patients.

A 64-year-old man with a history of type 2 diabetes mellitus is admitted with chest pain to the Emergency Department. An ECG shows ST elevation in the anterior leads and he is thrombolysed and transferred to the Coronary Care Unit (CCU). His usual medication includes simvastatin, gliclazide and metformin. How should his diabetes be managed whilst in CCU?

The benefits of tight glycaemic control following a myocardial infarction were initially established by the DIGAMI study. These findings were not repeated in the later DIGAMI 2 study. However modern clinical practice is still that type 2 diabetics are converted to intravenous insulin in the immediate period following a myocardial infarction.NICE in 2011 recommended the following: 'Manage hyperglycaemia in patients admitted to hospital for an acute coronary syndrome (ACS) by keeping blood glucose levels below 11.0 mmol/litre while avoiding hypoglycaemia. In the first instance, consider a dose-adjusted insulin infusion with regular monitoring of blood glucose levels.' Discuss (4)Improve

symptoms of hypercalcaemia

The combination of polyuria and polydipsia, constipation and abdominal pain, depression, weakness and fatigue all indicate hypercalcaemia as the likely diagnosis.

A 53-year-old female with advanced lung cancer presents to the emergency department with worsening generalised abdominal pain. The patient appears anxious and explains to you that she also has been suffering from nausea, constipation, and bony pain.What is this patient's admission ECG likely to show?

The correct answer is 'shortening of the QT interval'. This patient is presenting with classical signs of hypercalcemia of malignancy (bones, stones, and psychiatric moans). A common ECG finding in hypercalcemia is QT interval shortening, making this the correct answer. For reference, management of acute hypercalcemia is usually with rehydration.

A 67-year-old woman is being monitored on the coronary care unit (CCU) due to Mobitz type I atrioventricular (AV) block. She has had 2 episodes of syncope in the last 24 hours. Her current heart rate is 37 beats per minute. So far, she has received 3mg of intravenous (IV) atropine.What is the next step in management?

The correct answer is 'transcutaneous pacing'.This patient is suffering from Mobitz type I AV block and has adverse features present in the form of syncope. The presence of adverse features are suggestive of haemodynamic compromise and mean that she requires treatment. She has already received 3mg of atropine, which is the maximum dose allowed. The next step in management would be to initiate transcutaneous pacing.

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?

The correct answer is IV atropine 500mcg. This patient is presenting with signs and symptoms of bradycardia with shock. Bradycardia is defined as a heart rate inferior to 60/min and usually does not require any treatment. When the patient starts showing signs of hemodynamic compromise, then it requires an intervention. In this case, the syncope, clamminess, and hypotension are all signs of hemodynamic compromise. Atropine 500mcg IV is the first-line treatment in this situation. If the patient does not respond, then up to 3mg of atropine can be given. If this fails as well, transcutaneous pacing can be considered. Amyloidosis is a risk factor for the development of severe bradycardia.

A 57-year-old man presents to the emergency department complaining of fever and painful joints, with occasional shortness of breath.On examination, his heart rate is 110/min, respiratory rate 20/min, blood pressure 125/92 mmHg and temperature 39.2 ºC. A cardiorespiratory examination highlights an early diastolic murmur.He had never experienced similar symptoms before and was previously healthy, except for a sore throat he had three weeks ago. He is a known intravenous drug user with no fixed abode.What is the most likely cause of his murmur?

The correct answer is aortic regurgitation. This patient suffers from a textbook presentation of rheumatic fever, an immunological reaction to a recent Streptococcus pyogenes infection. This condition can cause different valvulopathies but in this case, the murmur is described as an early diastolic murmur. It can be easily mistaken for other conditions such as infective endocarditis, but in this case, it is important to focus on the description of the murmur, which gives the key to the correct diagnosis.

digoxin toxicity ecg

The correct answer is digoxin therapy. This ECG shows the classic effects of digoxin therapy, in a patient with atrial fibrillation. There is a 'scooped' ST depression in leads II, III, aVF, v5, and V6. The presence of this 'scooping' or 'reverse-tick sign' is a typical finding in patients taking digoxin.

A 64-year-old female attends the GP practice with a headaches, dizziness and fatigue. She has a past medical history of hypertension and mild asthma. She currently takes bendroflumethiazide and occasionally uses a salbutamol inhaler. The patient is investigated and blood tests are performed.Which of the following electrolyte abnormalities is most likely in this patient?

The correct answer is hyponatraemia. Thiazide diuretics work by inhibiting sodium reabsorption in the distal convoluted tubule. They are not used as widely anymore for hypertension; thiazide-like diuretics are generally used in preference nowadays - this patient's use of bendroflumethiazide is likely historic.

A 63-year-old man presents to his general practitioner for a blood pressure check. Ambulatory blood pressure readings are constantly above 140/90 mmHg. His past medical history includes gout and types two diabetes mellitus, for which he takes metformin and allopurinol. He is of black African ethnicity.What drug is the most appropriate to prescribe him?

The correct answer is irbesartan. This medication is an angiotensin II receptor blocker (A2RB). It is used to manage hypertension in diabetic patients, as it has a renoprotective effect.Black African and Afro-Caribbean patients are prescribed calcium channel blockers first-line for hypertension. However, as the patient is diabetic, ACE inhibitors/A2RBs are preferred due to their renoprotective effect. In black African and Afro-Caribbean patients, A2RBs are preferred over ACE inhibitors.

A 22-year-old woman presents to the clinic after being referred by her GP. She has a six-month history of unexplained malaise and headaches. She feels fatigued and finds walking for long distances extremely challenging as her legs start aching after she walks more than 100m.On examination, her radial pulse is weaker on the right side. Her dorsalis pedis and posterior tibial pulses are absent bilaterally. An early diastolic decrescendo murmur heard is present. She is a non-smoker, and she is otherwise healthy.Given the most likely diagnosis, what investigation is needed to confirm it?

The correct answer is magnetic resonance angiography. This patient is presenting with the characteristic features of Takayasu's arteritis leading to absent peripheral pulses (as in this case) or uneven blood pressure and pulses (as shown in the radial pulse). Additionally, the occlusion can cause symptoms similar to claudication due to the reduced blood flow, described as aching legs. It has been associated with aortic regurgitation (an early diastolic decrescendo murmur) in 20% of the cases. Vascular imaging is required to confirm the diagnosis; in this case, magnetic resonance angiography (MRA) is the only viable option.

A 60-year-old man undergoes percutaneous coronary intervention for an ST-elevation myocardial infarction.After 12 hours he becomes pale, clammy, and bradycardic. The ECG shows complete disassociation between the atria and ventricles.What coronary artery is most likely to have been affected?

The correct answer is the right coronary artery. Infarction of this vessel is associated with complete heart block as it supplies the atrioventricular node in the majority of people (90%). Infarction of the AV node leads to a loss of the normal conduction pathway from the atria to the ventricles. This is a well-known complication post-MI.

A 56-year-old man is admitted to the emergency department with an infective exacerbation of COPD.The patient has a background of atrial fibrillation, anti-coagulated with warfarin, and COPD.He has previously been treated in the community with steroids and antibiotics by his GP, one week before admission.The clerking doctor performs some blood tests, some of which are found below: International normalised ratio (INR)6.9(<1.5) Prothrombin time (PT)20 secs(10-14 secs) Activated partial thromboplastin time (APTT)21 secs(25-35 secs) He has no current symptoms or signs of bleeding.What is the next most appropriate step in the management of this patient?

The correct answer is to withhold warfarin for 1-2 days and restart at a lower dose.This is because the patient has an INR between 5.0-8.0 and NO bleeding, therefore you need to withhold the warfarin for 1-2 days and then reduce the maintenance dose until the INR is within the therapeutic range.It is important to note in this history, and in any patient with a prolonged INR on warfarin the recent drug history. This patient has recently been treated for an infective exacerbation of COPD with an antibiotic - clarithromycin is commonly used for this, which can inhibit CYP40 liver enzymes responsible for metabolising warfarin, causing raised INR.

A 64-year-old man is brought to the emergency department after being involved in a road traffic accident. He denies any recent illness and takes no regular medications.On examination, he appears breathless and has a visibly raised jugular venous pressure. Heart sounds are muffled on auscultation and he is hypotensive and tachycardic. A bedside echocardiogram is subsequently performed which confirms the likely diagnosis.Which of the following ECG findings is most likely to be seen?

The diagnosis here is cardiac tamponade, likely a result of the trauma from the accident. Beck's triad is present - muffled heart sounds, hypotension and raised jugular venous pressure - which suggests tamponade. The diagnosis is confirmed by an echocardiogram. The correct answer here is therefore electrical alternans, which is seen in tamponade. It describes consecutive, normally-conducted QRS complexes that alternate in height, due to the heart swinging back and forth in a fluid-filled pericardium.

A 76-year-old female is admitted after being found on the floor at her home. On examination she has a core temperature of 30ºC. Her serum electrolytes are within normal range. Which one of the ECG findings is most likely to be seen?

The following ECG changes may be seen in hypothermia bradycardia 'J' wave (Osborne waves) - small hump at the end of the QRS complex first degree heart block long QT interval atrial and ventricular arrhythmias

advanced life support

The following is based on the 2015 Resus Council guidelines. Please see the link for more details, below is only a very brief summary of key points.It should be remembered that the algorithm divides patients into those with: 'shockable' rhythms: ventricular fibrillation/pulseless ventricular tachycardia (VF/pulseless VT) 'non-shockable' rhythms: asystole/pulseless-electrical activity (asystole/PEA) Major points include: chest compressionsthe ratio of chest compressions to ventilation is 30:2chest compressions are now continued while a defibrillator is charged defibrillationa single shock for VF/pulseless VT followed by 2 minutes of CPRif the cardiac arrested is witnessed in a monitored patient (e.g. in a coronary care unit) then the 2015 guidelines recommend 'up to three quick successive (stacked) shocks', rather than 1 shock followed by CPR drug deliveryIV access should be attempted and is first-lineif IV access cannot be achieved then drugs should be given via the intraosseous route (IO)delivery of drugs via a tracheal tube is no longer recommended adrenalineadrenaline 1 mg as soon as possible for non-shockable rhythmsduring a VF/VT cardiac arrest, adrenaline 1 mg is given once chest compressions have restarted after the third shockrepeat adrenaline 1mg every 3-5 minutes whilst ALS continues amiodaroneamiodarone 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 administeredlidocaine used as an alternative if amiodarone is not available or a local decision has been made to use lidocaine instead thrombolytic drugsshould be considered if a pulmonary embolus is suspectedif given, CPR should be continued for an extended period of 60-90 minutes Other points atropine is no longer recommended for routine use in asystole or pulseless electrical activity (PEA) following successful resuscitation oxygen should be titrated to achieve saturations of 94-98%. This is to address the potential harm caused by hyperoxaemia

A 35-year-old male presents his general practice with pain in his foot and lower limb which is worse at night. He describes that the pain improves when he hangs his leg over the edge of the bed. On further questioning, he also notes that he has been getting 'pins and needles' in his fingers and they feel very cold. He has no past medical history but smokes 25 cigarettes per day.Based on the history, what is the most likely underlying diagnosis?

The likely diagnosis in this case is Buerger's disease (thromboangiitis obliterans). Buerger's disease is a non-atherosclerotic vasculitis affecting predominantly medium-sized arteries. It most commonly affects young males who smoke. Common symptoms include paraesthesia/cold sensation in the fingers or limbs, rest pain and ulceration/gangrene may occur.

A 73-year-old male attends the emergency department with progressive shortness of breath and fatigue. He finds that his shortness of breath is worse when lying flat, and denies any chest pain or loss of consciousness. He has a past medical history of hypertension for which he takes amlodipine, and he had rheumatic fever 30 years ago.On examination, he has a displaced apex beat, collapsing pulse, and nailbed pulsation is visible. A murmur is audible on auscultation.Based on the most likely underlying diagnosis, which type of murmur would you expect to hear?

The likely diagnosis, in this case, is aortic regurgitation (AR). It is likely that this patient has developed chronic aortic regurgitation over many years due to a previous history of rheumatic fever, which is a strong risk factor for AR. There are several clinical examination findings that also point towards this diagnosis: the presence of a collapsing pulse, left ventricular hypertrophy leading to a displaced apex beat, Quincke's sign (visible nailbed pulsation) and an audible murmur. The murmur heard in aortic regurgitation is diastolic, and may be early or mid-late, depending on the severity. In mild AR, the murmur is typically early diastolic, and in severe AR, the murmur may be mid-late diastolic.

You attend a trauma call in resus of a 63-year-old lady with a past medical history of acute myeloid leukaemia treated with chemotherapy as a child. As such the patient has very difficult vascular access in her arms. During the arrest call, the medical registrar asks you to site a cannula because there is a delay in siting intraosseous access. The ITU SHO offers to assist you in performing a venous cutdown of one of the veins in her ankle, passing anterior to the medial malleolus. What is the name given to this vessel?

The long saphenous vein passes anterior to the medial malleolus and is commonly used for venous cutdown The long saphenous vein passes anterior to the medial malleolus and is commonly used for venous cutdown in cases where vascular access is difficult such as trauma, hypovolaemic shock or if the patient is known to have poor access. Regarding the other options: the short saphenous vein passes posterior to the lateral malleolus. The dorsalis pedis vein accompanies the dorsalis pedis artery on the anterior foot; and the posterior tibial vein is part of the deep venous system accompanying the posterior tibial artery. There is no significant sural vein (there is however a sural nerve), but the sural veins accompany the sural arteries and drain to the popliteal vein.

drug management of Angina Pectoris

The management of stable angina comprises lifestyle changes, medication, percutaneous coronary intervention and surgery. NICE produced guidelines in 2011 covering the management of stable angina 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' if a calcium channel blocker is used as monotherapy a rate-limiting one such as verapamil or diltiazem should be used. If used in combination with a beta-blocker then use a long-acting dihydropyridine calcium-channel blocker (e.g. modified-release nifedipine). Remember that beta-blockers should not be prescribed concurrently with verapamil (risk of complete heart block) if there is a poor response to initial treatment then medication should be increased to the maximum tolerated dose (e.g. for atenolol 100mg od) if a patient is still symptomatic after monotherapy with a beta-blocker add a calcium channel blocker and vice versa if a patient is on monotherapy and cannot tolerate the addition of a calcium channel blocker or a beta-blocker then consider one of the following drugs: a long-acting nitrate, ivabradine, nicorandil or ranolazine if a patient is taking both a beta-blocker and a calcium-channel blocker then only add a third drug whilst a patient is awaiting assessment for PCI or CABG Nitrate tolerance many patients who take nitrates develop tolerance and experience reduced efficacy NICE advises that patients who take standard-release isosorbide mononitrate should use an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimise the development of nitrate tolerance this effect is not seen in patients who take once-daily modified-release isosorbide mononitrate

if upper limb pressure is greater than the pressure in the lower limbs what does this means

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.

A 25-year-old female is found to have a left hemiparesis following a deep vein thrombosis. An ECG shows RBBB with right axis deviation. What is the most likely underlying diagnosis?

The ostium secundum in this patient has allowed passage of an embolus from the right-sided circulation to the left causing a stroke

A 24-year-old air stewardess presents to the emergency department complaining of pleuritic chest pain and shortness of breath, after arriving to London from Bangkok. On examination she has a swollen left calf, with tenderness over the deep venous system. Her observations are as follows: heart rate 101 bpm, blood pressure 108/73 mmHg, sats 94% on room air and temperature 37.5ºC. Chest xray is unremarkable.You request a CTPA as you are concerned about a pulmonary embolus. The radiologist agrees but states it will be about 90 minutes until the scan can happen. What should you do next?

The patient has a history suggestive of a pulmonary embolus (PE) and a Wells' score of at least 7.5 (DVT clinically, heart rate greater than 100 bpm and PE most likely diagnosis) from the information provided. NICE guidance is that with a Wells' score of greater than 4 they should have a CTPA or V/Q scan, and if this is delayed the patient should be treated as if a PE has been confirmed.A D-Dimer is not required in this situation, as a positive or negative result, will not change the management plan.

A 28-year-old man presents with shortness of breath on exertion which has progressively worsened over the last few weeks. On examination his heart rate is regular at 115 beats per minute, blood pressure 125/45 mmHg, and SpO2 94% on room air. On examination, you note bibasal coarse crepitations and an early diastolic murmur. A chest x-ray demonstrates evidence of pulmonary oedema.What condition is associated with the likely underlying cardiac defect?

The presence of an early diastolic murmur and wide pulse pressure make aortic regurgitation (AR) the most likely diagnosis.Causes of AR can be due to valve disease (e.g. bicuspid aortic valve, aortic dissection, spondyloarthropathies (e.g. ankylosing spondylitis) and connective tissue disease) or due to aortic root disease (e.g. rheumatic fever, calcific valve disease, infective endocarditis and connective tissue diseases). Therefore the most likely diagnosis is ankylosing spondylitis.

pulmonary artery occlusion pressure monitoring

The pulmonary artery occlusion pressure is an indirect measure of left atrial pressure, and thus filling pressure of the left heart. The low resistance within the pulmonary venous system allows this useful measurement to be made. The most accurate trace is made by inflating the balloon at the catheter tip and 'floating' it so that it occludes the vessel. If it is not possible to occlude the vessel in this way then the measurement gained will be the pulmonary artery end diastolic pressure. When combined with measurements of systemic vascular resistance and cardiac output it is possible to accurately classify patients.Systemic vascular resistanceDerived from aortic pressure, right atrial pressure and cardiac output.SVR=80(mean aortic pressure-mean right atrial pressure)/cardiac output

Causes of infective endocarditis

The strongest risk factor for developing infective endocarditis is a previous episode of endocarditis. The following types of patients are affected: previously normal valves (50%, typically acute presentation)the mitral valve is most commonly affected rheumatic valve disease (30%) prosthetic valves congenital heart defects intravenous drug users (IVDUs)e.g. typically causing tricuspid lesion) others: recent piercings Causes Staphylococcus aureusnow the most common cause of infective endocarditis particularly common in acute presentation and IVDUs Streptococcus viridans historically Streptococcus viridans was the most common cause of infective endocarditis. This is no longer the case, except in developing countriestechnically Streptococcus viridans is a pseudotaxonomic term, referring to viridans streptococci, rather than a particular organism. The two most notable viridans streptococci are Streptococcus mitis and Streptococcus sanguinisthey are both commonly found in the mouth and in particular dental plaque so endocarditis caused by these organisms is linked with poor dental hygiene or following a dental procedure coagulase-negative Staphylococci such as Staphylococcus epidermidiscommonly colonize indwelling lines and are the most cause of endocarditis in patients following prosthetic valve surgery, usually the result of perioperative contamination.after 2 months the spectrum of organisms which cause endocarditis return to normal (i.e. Staphylococcus aureus is the most common cause) Streptococcus bovis associated with colorectal cancerthe subtype Streptococcus gallolyticus is most linked with colorectal cancer non-infectivesystemic lupus erythematosus (Libman-Sacks)malignancy: marantic endocarditis Culture negative causes prior antibiotic therapy Coxiella burnetii Bartonella Brucella HACEK: Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella)

cardioversion for Afib

There are two scenarios where cardioversion may be used in atrial fibrillation: electrical cardioversion as an emergency if the patient is haemodynamically unstable electrical or pharmacological cardioversion as an elective procedure where a rhythm control strategy is preferred. Electrical cardioversion is synchronised to the R wave to prevent delivery of a shock during the vulnerable period of cardiac repolarisation when ventricular fibrillation can be induced.The notes below refer to cardioversion being used in the elective scenario for rhythm control. The wording of the 2014 NICE guidelines is as follows: offer rate or rhythm control if the onset of the arrhythmia is less than 48 hours, and start rate control if it is more than 48 hours or is uncertain. Onset < 48 hours If the atrial fibrillation (AF) is definitely ofless than 48 hoursonset patients should be heparinised. Patients who have risk factors for ischaemic stroke should be put on lifelong oral anticoagulation. Otherwise, patients may be cardioverted using either: electrical - 'DC cardioversion' pharmacology - amiodarone if structural heart disease, flecainide or amiodarone in those without structural heart disease Following electrical cardioversion if AF is confirmed as being less than 48 hours duration then further anticoagulation is unnecessary Onset > 48 hours If the patient has been inAF for more than 48 hours then anticoagulation should be given for at least 3 weeks prior to cardioversion. An alternative strategy is to perform a transoesophageal echo (TOE) to exclude a left atrial appendage (LAA) thrombus. If excluded patients may be heparinised and cardioverted immediately.NICE recommend electrical cardioversion in this scenario, rather than pharmacological.If there is a high risk of cardioversion failure (e.g. Previous failure or AF recurrence) then it is recommend to have at least 4 weeks amiodarone or sotalol prior to electrical cardioversionFollowing electrical cardioversion patients should be anticoagulated for at least 4 weeks. After this time decisions about anticoagulation should be taken on an individual basis depending on the risk of recurrence

what drugs help with gout: atorvastatin bendroflumethiazide naproxen levothyroxine methotrexate

Thiazide diuretics reduce uric acid excretion from the kidneys

Thiazide diuretics - MOA - side effects

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. The main use of bendroflumethiazide was in the management of hypertension but recent NICE guidelines now recommend other thiazide-like diuretics such as indapamide and chlortalidone.Common adverse effects dehydration postural hypotension hyponatraemia, hypokalaemia, hypercalcaemia* gout impaired glucose tolerance impotence Rare adverse effects thrombocytopaenia agranulocytosis photosensitivity rash pancreatitis

A 55-year-old female presents to the emergency department with an eight-hour history of heart palpitations. She has a heart rate of 200 beats per minute and an ECG shows regular QRS complexes of 0.08 seconds. She has not had any chest pain or episodes of syncope and has no signs of heart failure. Her blood pressure is 130/90 mmHg and her oxygen saturations are 97% on air. What should you do first?

This female has a regular narrow complex tachycardia with no adverse features. The first step in this instance would, therefore, be to try vagal manoeuvres, for example, a carotid sinus massage. If this is unsuccessful, IV adenosine should be given (6mg at first, followed by 12mg if no response, and then by a further 18mg if again no response). If this is unsuccessful consider atrial flutter as the diagnosis and treat as appropriate.

A 38-year-old man presents to the Emergency Department with sudden onset of uncontrollable epistaxis and chest pain. He is severely anxious and has already vomited on the way to hospital. The medical history reveals that he is a long-term user of recreational drugs especially amphetamine. His blood pressure reading is 205/110 mmHg and fundoscopy reveals retinal bleeding with papilloedema. Which of the following is the most likely cause of this man's symptoms?

This is a hypertensive emergency, or malignant hypertension, where the blood pressure is extremely high and there are potentially life-threatening symptoms indicative of acute impairment of one or more organ systems eg the kidneys, heart or eyes.Signs and symptoms include: Papilloedema (must be present before a diagnosis of malignant hypertension can be made) Retinal bleeding Increased cranial pressure causing headache and nausea Chest pain due to increased workload on the heart Haematuria due to kidney failure Nosebleeds which are difficult to stop Diagnosis: Systolic blood pressure >= 180mmHg or diastolic blood pressure >= 120mmHg. Evidence of acute organ damage

You are seeing John, a 50-year-old man who is complaining of central constricting chest pain. Walking up the stairs triggers the pain. The pain goes away with resting. He experiences some shortness of breath but denies any syncope or palpitations. He suffers from hypertension and diabetes. He takes verapamil for migraine prophylaxis. His other medications include GTN spray, aspirin, atorvastatin, Ramipril and metformin. On examination, his rhythm seems to be irregular. There is no murmur on auscultation of the heart. There is no tenderness on chest wall palpation.He is asking for a medication that would be helpful to prevent the chest pain from occurring. What is the most appropriate treatment?

This is a typical angina history. Beta-blocker is a first line Angina prophylaxis. However, this man is taking verapamil for his migraine. Verapamil should not be used with beta blocker due to the risk of bradycardia, heart block or even congestive cardiac failure. Therefore, bisoprolol and metoprolol are incorrect answers. Ibuprofen and digoxin do not reduce the frequency of angina. Therefore, the next line for prophylaxis of angina is Nicorandil.

A 45-year-old man presents to the emergency department with chest pain that radiates to his back. On questioning he says in the last couple of days the chest pain has started, and it is much worse on inspiration. On examination you notice that when the patient breaths in, his jugular venous pulse (JVP) rises.What is the most likely cause of this man's pain?

This is a typical history of two of the options- constrictive pericarditis and cardiac tamponade. They present with very similar symptoms, but there are a few signs to differentiate the two. Kussmaul's sign- JVP rise on inspiration, is typical of constrictive pericarditis. Pericarditis often occurs after non-specific viral illness.

A 44-year-old woman with a known history of asthma presents to the emergency department with sudden onset shortness of breath and pain on inspiration. Her heart rate is 110 beats per minute, her respiratory rate is 23 per minute, her saturations are 93% on air, and her temperature is 36.4 ºC. On examination, she appears to be in respiratory distress but is able to speak in full sentences. On auscultation, air entry is equal bilaterally and there are no added sounds.What is the most likely diagnosis?

breathing problems with clear chest - think PE

what is the most common bacterial cause of endocarditis?

This micro-organism is a gram and coagulase-positive bacteria. It is the most common cause of infective endocarditis, in particular for those patients who inject drugs. Streptococcus viridans is the most common cause of infective endocarditis in those with poor dental hygiene.

in which people is staph epidermis the most common cause of infective endocarditis?

This micro-organism is a gram-positive coagulase-negative bacteria. Prosthetic valve surgery is a key risk factor for developing infective endocarditis due to this bacteria.

management of SVTs

This patient has a supraventricular tachycardia. If vagal manoeuvres fail to terminate the arrhythmia adenosine should be given. Whilst strictly speaking the term supraventricular tachycardia (SVT) refers to any tachycardia that is not ventricular in origin the term is generally used in the context of paroxysmal SVT. Episodes are characterised by the sudden onset of a narrow complex tachycardia, typically an atrioventricular nodal re-entry tachycardia (AVNRT). Other causes include atrioventricular re-entry tachycardias (AVRT) and junctional tachycardias.Acute management vagal manoeuvres:Valsalva manoeuvre: e.g. trying to blow into an empty plastic syringecarotid sinus massage intravenous adenosinerapid IV bolus of 6mg → if unsuccessful give 12 mg → if unsuccessful give further 18 mgcontraindicated in asthmatics - verapamil is a preferable option electrical cardioversion Prevention of episodes beta-blockers radio-frequency ablation

side effects of beta blockers

bronchospasm cold peripheries fatigue sleep disturbances, including nightmares erectile dysfunction

A 78-year-old man presents to the emergency department with shortness of breath. He is not experiencing chest pain. He has a past medical history of angina and two myocardial infarctions. On examination there is bibasal crepitations of the lungs and bilateral pitting oedema of the lower extremities. An ECG shows a sinus bradycardia of 35 beats per minute.What should be the next step in management?

This patient has a sinus bradycardia. As per the Resuscitation Council bradycardia guidelines, since this patient has adverse features, he should receive 500 micrograms of intravenous atropine.

A 64-year-old woman is admitted to the respiratory ward with shortness of breath on a background of a saddle pulmonary embolus. During her admission, she becomes unresponsive and stops breathing. Cardiopulmonary resuscitation is started.At the first rhythm check, the defibrillator shows pulseless ventricular tachycardia. A shock is administered but the patient remains in pulseless ventricular tachycardia. An alteplase infusion is started.Given the above, how long must cardiopulmonary resuscitation continue?

This patient has been admitted with a new diagnosis of a pulmonary embolus prior to having a cardiac arrest. As part of the ALS algorithm, the reversible causes (4H's and 4T's) should be explored to look for a reversible cause of the arrest. It seems likely that the pulmonary embolus is the cause of the cardiac arrest in this patient, making thrombolysis with alteplase the most appropriate option at this stage. Whilst alteplase is being given, cardiopulmonary resuscitation should continue for further 60-90 minutes to allow for the drug to take effect. In most resuscitation departments, this is achieved by automated chest compression devices such as the LUCAS.

if someone has a single episode of paroxysmal AFib, even if provoked how are they now managed

This patient has had an episode of paroxysmal atrial fibrillation. According to National Institute of Clinical Excellence (NICE) CKS guidance, his CHA2DS2-VASc score should be calculated, and a DOAC considered if the score is 1 or more. His CHA2DS2-VASc is 1 (as he is 65). Therefore, you should calculate his ORBIT score (to calculate his risk of bleeding). If appropriate, you should then have a conversation with him regarding starting a DOAC.

A 55-year-old woman presents to the GP with a 3-month history of breathlessness on exertion, fatigue and ankle swelling. She reports that she requires 2 pillows to sleep at night. Her past medical history is significant only for a feverish illness 4-months previously. On examination, there is a mid-diastolic murmur present and a loud S1 opening snap consistent with mitral stenosis. You also notice an annular erythematous rash on her chest. On further investigation, her ECG reveals signs of right ventricular hypertrophy and P-mitrale.Which is the most likely cause of her clinical findings?

This patient has mitral stenosis characterised by her signs of heart failure, mid-diastolic murmur and loud S1 opening snap. Her ECG findings of right ventricular hypertrophy and P-mitrale further support the diagnosis.The underlying cause of mitral stenosis in this patient is most likely to be rheumatic fever. This is suggested by the prodromal illness and the annular (ring-like) erythematous rash, commonly known as erythema marginatum. The rash commonly affects the trunk and inner surfaces of the arms and legs and can persist for several months. The rings are barely raised and are non-pruritic. Erythema marginatum is pathognomonic for rheumatic fever. Please note, the face is generally spared.Complications of rheumatic fever include valvulitis which can lead to valvular damage, particularly stenosis of the mitral valve.

symptoms of hypercalcaemia

This patient has symptoms of hypercalcaemia. 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.

An 80-year-old man presents to accident and emergency with leg swelling. He has been more fatigued recently. His past medical history includes diabetes and chronic obstructive pulmonary disease. He has been on metformin and inhalers for many years.On examination, you note a barrel chest, elevated jugular venous pressure, and a systolic murmur over the 4th intercostal left parasternal region. You ask him to take a deep breath in and the murmur becomes louder. You listen over the carotids but hear no murmurs. Lungs are vesicular with no wheezes or crackles. You examine his legs which show bilateral pitting oedema. Heart rate 85 and blood pressure 130/80mmHg.What valvular pathology is present in this patient's heart?

This patient has tricuspid regurgitation as evidenced by the following:1- Systolic murmur.2- Loudest in the 4th intercostal left parasternal region.3- Louder on inspiration.4- The patient has chronic obstructive pulmonary disease and is developing signs of core pulmonale.

A 55-year-old man presents to the emergency department of a tertiary hospital with central crushing chest pain which resolves after 60 minutes. His past medical history is significant for hypertension and hyperlipidaemia.On examination, he appears well with stable vital signs and no evidence of fluid overload. An ECG taken on admission demonstrates new ST depression in leads II and III with no elevation elsewhere. He has a troponin rise to 0.9ng/mL and his GRACE score is calculated at a 4% risk of mortality at 6 months.What is the most appropriate treatment option for this patient?

This patient has typical cardiac chest pain and a positive troponin rise with no ST elevation on ECG, which is diagnostic for an NSTEMI. As part of NSTEMI management, patients with a GRACE score >3% should have coronary angiography within 72 hours of admission. This patient has a GRACE score of 4%, therefore, a coronary angiogram within 72 hours of admission is indicated. This allows for early diagnosis of coronary artery narrowing and potential therapeutic intervention with percutaneous coronary intervention is required.

A 59-year-old man is brought into the emergency department with a 2-hour history of dizziness and palpitations. He denies chest pain or shortness of breath. His past medical history includes hypertension and stable angina.His observations are as follows: Temperature 36.7ºC Heart rate 44bpm Blood pressure 90/51mmHg Respiratory rate 18 breaths/min Oxygen saturations 94% on air On examination, he has a regular pulse bilaterally. His calves are soft and non-tender. On auscultation, vesicular breath sounds are heard and heart sounds are normal.ECG: sinus rhythm, PR interval 210ms (120-200ms).What is the most appropriate next step in the management of this patient?

This patient is bradycardic and hypotensive. The ECG findings show a prolonged PR interval in keeping with first-degree heart block. In the management of bradycardia with adverse signs (e.g. shock or heart failure), atropine is used first-line. Atropine is a muscarinic antagonist that acts to increase the heart rate. It can be administered in 500 microgram boluses up to a maximum dose of 3mg. If atropine alone fails to control a patient's bradyarrhythmia, alternative options include isoprenaline infusions or transcutaneous pacing.

aortic dissection features

This patient is having an aortic dissection. The classical history of severe chest pain radiating to the back is given here. A history of hypertension is common and high blood pressure may be seen on clinical examination. Other features include a prolonged capillary refill time, absent peripheral pulses, narrow pulse pressure and diastolic murmur. It is common to see a raised D-dimer with a normal troponin. Additionally, in aortic dissection, ST-elevation can be seen in the inferior leads secondary to dissection of the right coronary artery. The imaging of choice is a CT aortic angiogram.

A 71-year-old woman with heart failure attends a review appointment. She has been feeling progressively more breathless since having a myocardial infarction seven months ago. The dyspnoea is now present during even minimal exertion, but not at rest. She is currently taking furosemide 40mg daily, ramipril 10mg daily and bisoprolol 10mg daily. An echocardiogram from six months ago reports that her ejection fraction is 30%.What is the most appropriate medication to add to her management?

This patient is having persistent and progressive symptoms of heart failure despite being on first-line medications. As such, she should be started on a mineralocorticoid receptor antagonist such as spironolactone, which is the next add-on therapy in heart failure with reduced ejection fraction. This reduces mortality and morbidity in patients with heart failure with reduced ejection fraction following myocardial infarction. One contraindication to spironolactone is hyperkalaemia, but this patient has a normal potassium level. 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

A 59-year-old man attends a cardiology outpatient clinic 4 weeks after sustaining a myocardial infarction (MI). He reports feeling a little more tired than previously and has felt his heart racing occasionally. He denies any cough, fever, or chest pain. He has a past medical history of hypertension and hypercholesterolaemia.On examination, he has bibasal crackles and is noted to have a third and fourth heart sound. His ECG is reported as ST elevation in the precordial leads alongside some well-formed Q waves.What is the most likely diagnosis?

This patient is presenting 4 weeks following a myocardial infarction (MI) with bibasal crackles (due to heart failure) and additional heart sounds (paradoxical splitting of S2 and a new S3 heart sound). The persistence of ST-segment elevation supports a diagnosis of left ventricular aneurysm. Usually, ST segments return to the near-baseline within the 2 weeks after an MI and T waves may become inverted. Left ventricular aneurysm occurs due to incomplete reperfusion of the left ventricle post-MI and transmural scar formation causing impaired conduction and contractility. Left ventricular aneurysm can lead to ventricular arrhythmias, congestive cardiac failure, and mural thrombus formation.

A 56-year-old obese male patient presents to the emergency department of his local district general hospital with sudden onset, heavy central chest pain. He is nauseated and clammy. He has a past medical history of hypertension, type two diabetes mellitus, and hyperlipidaemia. His observations were taken showing oxygen saturation of 98% on room air, respiratory rate 16/min, heart rate 117/min, blood pressure 131/68mmHg, temperature 36.8ºC. His ECG shows ST-segment depression in the inferior leads and tachycardia.What is the most appropriate management choice for this patient?

This patient is presenting with symptoms consistent with non-ST elevated myocardial infarction (NSTEMI). He is presenting at his local district general hospital emergency department where there is unlikely to be a cardiac centre available to administer angiography immediately. Due to this, the most appropriate management is aspirin and fondaparinux .

A 72-year-old male presents to the cardiology clinic with persistent symptoms of reduced exercise tolerance, peripheral oedema and paroxysmal nocturnal dyspnoea. He suffered an ST-elevation myocardial infarction (STEMI) five years previously from which he developed heart failure shortly afterwards. He is currently taking candesartan and bisoprolol. An echocardiogram shows a left ventricular ejection fraction of 35%.Which of the following would be most appropriate long-term therapy to prescribe this patient?

This patient is presenting with symptoms of chronic heart failure. His echocardiogram confirms this diagnosis. Management of heart failure with reduced ejection fraction is initially with an angiotensin-converting enzyme (ACE) inhibitor (or angiotensin receptor blocker (ARB), as is the case in this patient) and a beta-blocker. As both of these have been prescribed and the patient's symptoms are not controlled, spironolactone (a mineralocorticoid receptor antagonist) should be added.

where is long saphenous vein

This vein may be harvested for bypass surgery, or removed as treatment for varicose veins with saphenofemoral junction incompetence. Originates at the 1st digit where the dorsal vein merges with the dorsal venous arch of the foot Passes anterior to the medial malleolus and runs up the medial side of the leg At the knee, it runs over the posterior border of the medial epicondyle of the femur bone Then passes laterally to lie on the anterior surface of the thigh before entering an opening in the fascia lata called the saphenous opening It joins with the femoral vein in the region of the femoral triangle at the saphenofemoral junction Tributaries Medial marginal Superficial epigastric Superficial iliac circumflex Superficial external pudendal veins

A 55-year-old man presents to the emergency department with chest pain. Before he can be seen, he collapses. There is no pulse and cardiopulmonary resuscitation (CPR) is started.A defibrillator is attached which shows ventricular fibrillation. The man is treated per the shockable advanced life support algorithm. After three shocks, there are still no signs of life and the patient remains in ventricular fibrillation.What is the most appropriate next action?

This patient remains in ventricular fibrillation, meaning he should continue to be treated per the shockable advanced life support algorithm. This means that, after the third shock, both amiodarone and adrenaline should be given intravenously. CPR should continue whilst this is being given. Amiodarone is given after the 3rd shock and again after the 5th shock. Adrenaline is given every 3-5 minutes, with the first dose being given after the 3rd shock in the shockable algorithm and straight away in the non-shockable algorithm.

A 25-year-old woman is reviewed in clinic after experiencing 3 unprovoked episodes of sudden bilateral upper and lower limb limpness and falling. Each episode lasts for 10 seconds and she does not lose consciousness. She denies any incontinence and is able to carry on her activity after a few minutes.She has no past medical history and denies any head trauma. Her mother had similar problems in the past.Given the likely diagnosis, what is this patient most likely to be started on?

Tonic or atonic seizures: lamotrigine is first-line for females

A 28-year-old woman presents to the emergency department after receiving a call from her GP. The GP had called her to say her renal function has fallen dramatically, after commencing ramipril and she should go to the hospital immediately.On examination, she has weak radial pulses bilaterally and an early diastolic murmur on auscultation. Her blood pressure is 156/82mmHg.What investigation is most likely to be diagnostic of her underlying condition?

This patient's worsening renal function following ramipril, an ACE inhibitor, is suggestive of renal artery stenosis. Combined with weak radial pulses and likely aortic regurgitation, this is suggestive of a large-vessel vasculitis, such as Takayasu's arteritis, which is more common in young women.CT angiography of the large vessels is correct as this is the diagnostic test of choice in Takayasu's arteritis. Another investigation that may be considered is magnetic resonance imaging (MRA). These visualise the blood vessels involved in sufficient enough detail to make a diagnosis.

A 60-year-old man presents with a 2-week history of dyspnoea and leg swelling. On examination, he has a raised JVP that doesn't fall with inspiration. His lung bases are clear and a pericardial knock is heard on auscultation. His only past medical history is angina for which he was recently investigated with a coronary angiogram.Given this presentation, which of the following is the most likely cause of his presentation?

This question is about a man presenting with dyspnoea, peripheral oedema and a positive Kussmaul's sign (the raised JVP that doesn't fall with inspiration). These are all classic features of constrictive pericarditis. While the history is fairly short for constrictive pericarditis, it is not that uncommon, with most cases developing over months but sometimes days. Another factor that indicates constrictive pericarditis is his recent history of cardiac catheterisation for his coronary angiogram. Recent cardiac surgery (including cardiac catheterisation) is a common cause for constrictive pericarditis.

A 23-year-old man attends a routine military physical. He is planning to sign up to the army and requires a medical examination beforehand. On auscultation, the army doctor finds a third heart sound, however, the rest of the examination is normal. He is otherwise well with no symptoms or past medical history. Which of the following may be causing this?

This question is asking about the cause of a third heart sound in an otherwise well 23-year-old. In this case, the most likely cause is physiological extra heart sounds, which can be normal up to the age of 30.

A 19-year-old woman presents to the emergency department with new-onset chest pain and shortness of breath.The pain started today and is centrally located, sharp in nature and doesn't change with breathing or position.She has been unwell for the past week, with fever and joint pains.She has no past medical history of note.On examination, she has bibasilar crackles, with dull heart sounds with no added sounds. Her vital signs are normal apart from a respiratory rate of 24/min.An ECG is performed and shows diffuse T-wave inversion.What is the most likely diagnosis?

This young woman presents with new-onset chest pain and shortness of breath following a recent viral illness. The chest pain does not appear ischaemic in nature and does not change with position or breathing. This is a typical presentation of myocarditis, which is an inflammation of the heart muscle itself. There may be non-specific ECG changes to the ST segment or to the T wave. The dull heart sounds are due to the myocardium being inflamed and thickened. The shortness of breath and bibasilar crackles are likely due to myocardial dysfunction causing pulmonary congestion.

A 44 year old male attends the emergency department due to general malaise and having felt feverish over the past week. He denies shortness of breath, chest pain or palpitations. He has a past medical hisotry of intravenous drug use, having last injected heroin three days ago, epilepsy and hepatitis C. He takes the following medications regularly; sodium valproate 100mg BD and adcal D3 1 tab twice daily. His observations are as follows: respiratory rate 20 breaths/min, saturations 98% room air, heart rate 101 bpm sinus rhythm, blood pressure 112/64mmHg and temperature 37.7 degrees Celsius. On examination, he has track marks bilaterally, multiple splinter haemorrhages on his fingernails and purple discolouration on the pulps of his fingers. An ejection systolic murmur is heard on auscultation of his chest, his lung fields are clear and his abdomen is soft and non-tender His ECG shows sinus tachycardia. His chest x-ray is clear. A trans-thoracic echocardiogram (TTE) cannot rule out a mass on his aortic valve Blood cultures are taken and routine bloods show raised inflammatory markers Which investigation should be performed next?

Trans-oesophageal echocardiogram (TOE) A TOE allows for a better understanding of the make up of this gentleman's heart valves and specifically as to whether any vegetation exists upon his aortic valve given the presenting history. If infective endocarditis is suspected then antibiotics should be commenced given that this patient is unwell, however a TOE would guide management with regards to surgical intervention and prognosis 75%

An 82-year-old man has been followed up in the cardiology clinic for the past 5 years due to his aortic stenosis. In one follow-up clinic, he is wheeled into the room in a wheelchair as he has recently developed severe breathlessness which affects him even with the smallest movements. An urgent echocardiogram provides further evidence that he has severe aortic stenosis. He is haemodynamically stable. Which of these is the most appropriate treatment for the management of his aortic stenosis?

Transcatheter aortic valve implantation (TAVI) In symptomatic or aortic stenosis classified as severe via echocardiogram, if patients are fit enough for surgery, then they should undergo an aortic valve replacement. For patients over the age of 75, it is preferable to perform a TAVI procedure rather than a more invasive surgical aortic valve replacement 61%

An 89-year-old female presents to the emergency department following a collapse. On arrival, an ECG is performed which shows a complete heart block with a heart rate of 35 bpm. The patient also complains of feeling lightheaded. She is given 500 micrograms of IV atropine which shows no change. This is repeated another five times, and her heart rate does not rise above 40 bpm. Transcutaneous pacing is attempted but is ineffective.Which of these is the next management step according to the Resuscitation Council (UK) guidelines?

Transvenous pacing should be considered if a bradycardia doesn't respond to drugs or transcutaneous pacing

unstable patients investigation for aortic dissection

Transoesophageal echocardiography (TOE) more suitable for unstable patients who are too risky to take to CT scanner

ecg treatment with digoxin

Treatment with digoxin On this ECG the only evident abnormality (apart from the AF) is the down-slopping ST segments seen in leads V4-V6, I and aVL. These down-slopping ST-segments (or reverse ticks) are characteristic of digoxin treatment. It can be difficult to distinguish this appearance from ST depression associated with an NSTEMI. In NSTEMI the ST depression is horizontal (not down-slopping). Digoxin is often used in the treatment of atrial fibrillation (especially if there's co-existing heart failure) in the elderly population 45%

A 35 year old male patient presents to the GP with a 1 week history dysphagia to solids and liquids. He also reports fatigue. He has recently returned to the United Kingdom after having lived in Brazil for 10 years. He has no other past medical history. On physical examination the jugular venous pressure is raised 3 cm above normal, there are bibasal fine crackles on auscultation, and there is bipedal pitting oedema. Which of the following tests will confirm the most likely underlying diagnosis?

Trypanosomal serology This is the correct answer. The patient presents with clinical features suggestive of Chagas' disease, an infection caused by the protozoan parasite Trypanosoma cruzi. The first line test to confirm the diagnosis of chronic-phase disease is with serology 11%

management of type A and type B dissections - mnemonic

Type A - Ascending aorta - ASSAortic root replacementSystolic BP target 100-120SurgeryType B - BooBsBed rest and Beta blockers

hypokalaemia ecg

U waves small or absent T waves (occasionally inversion) prolong PR interval ST depression long QT In Hypokalaemia, U have no Pot and no T, but a long PR and a long QT

A 31 year old man presents to the emergency department after experiencing a syncopal episode whilst playing football. He has no prior history of syncope but describes intermittent palpitations and chest pain for several years. An ECG shows left ventricular hypertrophy, atrial fibrillation with occasional ventricular ectopics. An echocardiogram is consistent with a diagnosis of hypertrophic cardiomyopathy. Which clinical feature is a risk factor for sudden cardiac death?

Unexplained syncope This is the correct answer. A personal history of unexplained syncope is a risk factor for sudden death in patients with hypertrophic cardiomyopathy (HCM). Although a significant proportion of patients are asymptomatic, exertional syncope suggests left ventricular outflow obstruction with or without ventricular dysrhytmia 46%

You are part of the cardiac arrest team and are called to see a 72-year-old man who was admitted to the care of the elderly ward. He presented with shortness of breath, productive cough and hypoxia. He was being treated for community-acquired pneumonia with IV antibiotics. His early warning score has continued to worsen throughout the day and then he became unresponsive. There were no signs of life, therefore, chest compressions were commenced by the ward staff and the crash call was put out. The first rhythm check shows the patient is in ventricular fibrillation.Apart from restarting chest compressions, what should be the next step taken as part of the advance life support algorithm?

VF/pulseless VT should be treated with 1 shock as soon as identified. Adrenaline is given after the 3rd shock if following the 'shockable rhythm' pathway (AF/pulseless VT) or immediately if on the 'non-shockable rhythm' pathway (asystole or pulseless electrical activity).

A 65-year-old man has a cardiac arrest two days after being admitted to hospital following a myocardial infarction

VFib

difference between VT and VFib on ecg

VFib is smaller

most common congenital ardiac malformation

VSD

broad complex tachycardia following an MI

VT

which arrythmias do vagal maneuvers treat

Vagal manoeuvres are used to treat regular narrow complex tachycardias. If this patient was known to have an SVT with bundle branch block then his broad complex tachycardia could be treated with vagal manoeuvres.

A 34 year old female IV drug user is admitted to the emergency department with a two week history of fevers and malaise. She last injected heroin 3 days ago. She has a past medical history of HIV on no anti retroviral therapy and takes no other regular medications. On examination she has raised, red and painful lesions on her palms and a pan systolic murmur on auscultation of her chest. Her lung fields are clear and she has non-swollen calves bilaterally. Her blood tests show a raised white cell count and a high C-reactive protein An ECG shows normal sinus rhythm with a long PR interval Blood cultures have grown staph aureus in two different sets What would be the most appropriate antibiotic regimen for this patient?

Vancomycin This patient has proven staphylococcal endocarditis, this pathology carries an extremely high mortality rate and therefore an initial management of vancomycin, often with a second agent added in for synergistic effect would be warranted. Vancomycin has good gram positive coverage and good penetrance against resistant staph aureus making it the correct choice 36%

The on-call junior doctor is called to review a 58-year-old male inpatient on the cardiology ward. He was admitted 5 days ago for a myocardial infarction and underwent percutaneous coronary intervention. Over the past few hours, he has reported becoming increasingly breathless.On examination, the patient looks breathless and uncomfortable. There are bilateral basal crackles on the chest, and a new pan-systolic murmur is heard upon auscultation of the heart - there is no previous documentation of this murmur. JVP is visibly elevated, and there is some pitting oedema of both ankles.After starting initial treatment, the on-call cardiologist is urgently bleeped and comes to review the patient. She performs a bedside echocardiogram which demonstrates, on colour flow Doppler, a clear left-to-right shunt.What is the likely diagnosis?

Ventricular septal defect (VSD) is the correct answer. The history of acute heart failure developing several days post-myocardial infarction, along with the new pan-systolic murmur and the demonstration of the shunt on echocardiogram, strongly points to this diagnosis, which occurs in 1-2% of patients in this timeframe. With regards to post-MI VSD, urgent surgical correction is required, as mortality without surgery is extremely high.

A 63 year old female patient presents to the general practitioner for regular review. She has a past medical history of osteoarthritis and asthma. She is well at present, and systems review is unremarkable. On physical examination her pulse rate is 104 beats per minute and she has an irregularly irregular pulse. Vital signs are otherwise within normal range. Electrocardiogram (ECG) reveals absent P waves and irregular QRS complexes. Blood tests, including FBC U&E LFT TFTs, are normal. Which of the following is the most appropriate management strategy for this patient?

Verapamil, no anti-coagulation required This is the correct answer. The patient is likely to have persistent/permanent atrial fibrillation which can be managed with rate or rhythm control. Given the patient is asymptomatic rate control is a sensible option. The patient is asthmatic so a non-dihydropyridine calcium channel blocker (such as verapamil) should be used rather than a Beta-blocker. The CHA2DS2-VASc score is 1 (female sex) so anti-coagulation is not required 39%

Patients with very poor dental hygiene may develop endocarditis secondary to

Viridans streptococci e.g. Streptococcus sanguinis

A 32 year old Afro Caribbean woman presents to the acute medical unit with a 3 day history of chest pain worse on inhalation, temperature and general malaise. On examination heart sounds are normal and a pericardial friction rub is heard. Troponin is 1200ng/L. She is haemodynamically stable. What is most likely aetiology of the condition she has presented with?

Viral This patient has presented with features of acute pericarditis of which the most common cause is idiopathic/viral. Viral causes include EBV, HIV, CMV, Coxsackie virus A/B, Echo 8, VZV Systemic lupus erythematosus Systemic lupus erythematosus - SLE is a recognised cause of pericarditis however, there is no mention of any symptoms pointing to lupus such as facial rash, arthritis, renal, anaemia impairment etc. Other systemic causes include rheumatoid arthritis, systemic sclerosis, inflammtory bowel disease and vasculitis 25%

what is wellens syndrome

Wellen's syndrome is an ECG pattern that is typically caused by high-grade stenosis in the left anterior descending coronary artery.The patient's pain may have resolved at the time of presentation and cardiac enzymes may be normal/minimally elevated.ECG features biphasic or deep T wave inversion in V2-3 minimal ST elevation no Q waves

VT management

Whilst a broad complex tachycardia may result from a supraventricular rhythm with aberrant conduction, the European Resuscitation Council advise that in a peri-arrest situation it is assumed to be ventricular in originIf the patient has adverse signs (systolic BP < 90 mmHg, chest pain, heart failure, syncope) then immediate cardioversion is indicated. In the absence of such signs antiarrhythmics may be used. If these fail, then electrical cardioversion may be needed with synchronised DC shocks.Drug therapy amiodarone: ideally administered through a central line lidocaine: use with caution in severe left ventricular impairment procainamide Verapamil should NOT be used in VT.If drug therapy fails electrophysiological study (EPS) implant able cardioverter-defibrillator (ICD) - this is particularly indicated in patients with significantly impaired LV function

A 63-year-old male has a cardiac arrest prior to coronary angiography, while in the catheter laboratory. His heart rate is 164 beats per minute and the 12-lead ECG monitor shows ventricular tachycardia. You begin to assess him but cannot palpate a pulse and call for help.Which of the following should be done next?

Witnessed cardiac arrest while on a monitor - up to three successive shocks before CPR If not witnessed - 1 shock then commence CPR

Wolff-Parkinson-White 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 VFPossible 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* Differentiating between type A and type B** type A (left-sided pathway): dominant R wave in V1 type B (right-sided pathway): no dominant R wave in V1 Associations of WPW HOCM mitral valve prolapse Ebstein's anomaly thyrotoxicosis secundum ASD Management definitive treatment: radiofrequency ablation of the accessory pathway medical therapy: sotalol***, amiodarone, flecainide *in the majority of cases, or in a question without qualification, Wolff-Parkinson-White syndrome is associated with left axis deviation**there is a rare type C WPW, WPW in which the delta waves are upright in leads V1-V4 but negative in leads V5-V6***sotalol should be avoided if there is coexistent atrial fibrillation as prolonging the refractory period at the AV node may increase the rate of transmission through the accessory pathway, increasing the ventricular rate and potentially deteriorating into ventricular fibrillation

Wolff-Parkinson-White 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 VFPossible 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* Differentiating between type A and type B** type A (left-sided pathway): dominant R wave in V1 type B (right-sided pathway): no dominant R wave in V1 Associations of WPW HOCM mitral valve prolapse Ebstein's anomaly thyrotoxicosis secundum ASD Management definitive treatment: radiofrequency ablation of the accessory pathway medical therapy: sotalol***, amiodarone, flecainide *in the majority of cases, or in a question without qualification, Wolff-Parkinson-White syndrome is associated with left axis deviation**there is a rare type C WPW, WPW in which the delta waves are upright in leads V1-V4 but negative in leads V5-V6***sotalol should be avoided if there is coexistent atrial fibrillation as prolonging the refractory period at the AV node may increase the rate of transmission through the accessory pathway, increasing the ventricular rate and potentially deteriorating into ventricular fibrillation

Xanthelasma

Xanthelasma are yellowish papules and plaques caused by localized accumulation of lipid deposits commonly seen on the eyelid. They are also seen in patients without lipid abnormalities.Management of xanthelasma, options include: surgical excision topical trichloroacetic acid laser therapy electrodesiccation

A 56-year-old gentleman with a past medical history of mitral stenosis secondary to rheumatic heart disease is at a cardiology appointment for his newly-diagnosed atrial fibrillation. He is currently on rate control and is being considered for anti-coagulation. Should he be anti-coagulated, and what is his CHA2-DS2-VASc score?

Yes, CHA2-DS2-VASc score is 0 All patients with valvular disease and atrial fibrillation should be on anti-coagulation, regardless of CHA2-DS2-VASc score i.e. the patient's CHA2-DS2-VASc score is a distraction as it is irrelevant. Atrial fibrillation is considered valvular generally if the patient has a heart valve disorder or a prosthetic heart valve. Such patients should be anticoagulated only with vitamin K antagonists like warfarin - direct oral anticoagulants are not licensed with for non-valvular atrial fibrillation, whereby they are the mainstay of treatment now 11%

A 37-year-old man presents to his general practitioner with new-onset symptoms. He has been noticing inflamed veins bulging on both of his calves and non-healing ulcers forming on his legs. Additionally, he has been perceiving strong pain in his legs after walking long distances. He has a 20 pack-year history of smoking. He has a family history of systemic lupus erythematosus on his mother's side.His heart rate is 77/min, respiratory rate 13/min, blood pressure 137/70 mmHg and temperature 36.7 ºC. A random blood glucose test shows a result of 7.4 mmol/L.Which one of the following is the most likely diagnosis?

Young male smoker with symptoms similar to limb ischaemia - think Buerger's disease

A 62-year-old man with a background of chronic obstructive pulmonary disease (COPD) attends for his annual check-up. He is on 1 litre of home oxygen for 15 hours a day. His treatment for COPD includes salbutamol, Symbicort (budesonide/formoterol) and tiotropium inhaler.On examination, you can hear scattered wheeze with no crackles. You also note pitting oedema in both legs. When you listen to his heart sound, you suspect that he may have pulmonary hypertension.Which of the following features would support this diagnosis?

a loud second heart sound

A 26-year-old female is admitted to hospital with palpitations. ECG shows a shortened PR interval and wide QRS complexes associated with a slurred upstroke seen in lead II. What is the definitive management of this condition?

accessory pathway ablation

moa of alteplase

activates plasminogen to form plasmin

CI to thrombolysis

active internal bleeding recent haemorrhage, trauma or surgery (including dental extraction) coagulation and bleeding disorders intracranial neoplasm stroke < 3 months aortic dissection recent head injury severe hypertension

A 63-year-old woman presents to the emergency department with a two-hour history of vomiting, shortness of breath, and sweating. She has no chest pain. She has a past medical history of type II diabetes, hypertension, alcohol dependence, and chronic kidney disease. Her medications include metformin and ramipril. Her blood pressure is 155/74 mmHg, heart rate 94 bpm, oxygen saturation 95% on room air, and respiratory rate 22 breaths per minute. Her ECG shows inferolateral ST depression. VBG is normal. what does she have?

acute MI - diabetic patients with an MI can present without chest pain

A 71-year-old man presents to the emergency department with an abnormal cardiac rhythm. After various unsuccessful attempts of restoring normal cardiac rhythm, the team decides to administer him a drug. After the administration, he complains of severe chest pain, which is self-limiting and terminates quickly.What drug has this patient been given?

adenosine

A 47-year-old female presents to the emergency department with palpitations and lightheadedness. Her symptoms started four days ago after exercising, but seem to be worsening. She has a past medical history of hypertension, managed with ramipril. On examination, she has a fast, irregular pulse but she looks alert. The doctor performs an electrocardiogram which shows she is in AFib. what is the appropriate management

administer apixaban and schedule an appointment for electrical cardioversion

drugs causing long QT

amiodarone, sotalol, class 1a antiarrhythmic drugs tricyclic antidepressants, selective serotonin reuptake inhibitors (especially citalopram) methadone chloroquine terfenadine** erythromycin haloperidol ondanestron

meds prolonging QT

amiodarone, sotalol, class 1a antiarrhythmic drugs tricyclic antidepressants, selective serotonin reuptake inhibitors (especially citalopram) methadone chloroquine terfenadine** erythromycin haloperidol ondanestron

where does furosemide act

ascending loop of henle

infective endocarditis causing congestive cardiac failure is managed how?

by emergency valve replacement surgery

A 56-year-old man has presented to his GP. He complains of having a headache that has been bothering him since yesterday. This headache is worse when he leans forwards. He also mentions that his vision has blurred on occasions over he past few days. On fundoscopy, the GP notes the presence bilaterally of retinal haemorrhages and papilloedema. The GP measures his blood pressure, which is 190/120 mmHg.What is the next appropriate step?

admit for specialist assessment

If new BP >= 180/120 mmHg + new-onset confusion, chest pain, signs of heart failure, or acute kidney injury - what do you do

admit the patient for specialist assessment

no p waves =

afib

poor prognostic factors for ACS

age development (or history) of heart failure peripheral vascular disease reduced systolic blood pressure Killip class* initial serum creatinine concentration elevated initial cardiac markers cardiac arrest on admission ST segment deviation

ecg features of wellens syndrome

biphasic or deep T wave inversion in V2-3 minimal ST elevation no Q waves

A 78-year-old woman with dementia presents to the emergency department feeling unwell and reports shortness of breath over the last 24 hours. Her carer reports that she has been distressed over the last three days. Medical history includes ischaemic stroke, hypertension, and stage IV chronic kidney disease.Heart rate is 105 bpm, blood pressure 146/79 mmHg, respiratory rate 18/minute, and temperature 36.5ºC. A 12-lead ECG confirms atrial fibrillation. Her inflammatory markers, chest x-ray, and urine dipstick were normal. She is started on apixaban.What other medication should be given?

bisoprolol

A 78-year-old man presents to the emergency department after telling his daughter this morning that he has had palpitations for the past 3 weeks. He has had some dizziness but denies any loss of consciousness or near-syncope. He has a past medical history of hypertension for which he takes ramipril and has no known allergies. Observations show heart rate 150/min, BP 135/89mmHg, temperature 36.9ºC, 98% saturations in room air. His ECG report shows no visible P waves and an irregularly irregular narrow QRS complex.What is the most appropriate management option?

anticoag for 3 weeks then consider cardioversion

A 67-year-old male presents to the emergency department with sudden onset chest pain. The pain is located in his central chest, and started an hour ago. The pain was maximal at onset, and is not exacerbated with deep breaths. He describes it as the most intense pain he's ever experienced. He has not had any similar episodes previously.He has a past medical history of hypertension (for which he takes ramipril and bendroflumethiazide). He has a 15-pack-year smoking history.On examination he appears drowsy. He has left-sided ptosis and miosis of his left pupil.What is the most likely cause of this presentation?

aortic dissection - it can present with neurological complaints. In this scenario, this man is presenting with symptoms of Horner's syndrome (classically ptosis, miosis and anhidrosis) due to compression of the sympathetic trunk by the expanding aortic dissection.

when is collapsing pulse found

aortic regurgitation

which murmur is associated with marfans syndrome

aortic regurgitation

collapsing pulse means

aortic regurgitation patent ductus arteriosus hyperkinetic states (anaemia, thyrotoxic, fever, exercise/pregnancy)

collapsing pulse

aortic regurgitation patent ductus arteriosus hyperkinetic states (anaemia, thyrotoxic, fever, exercise/pregnancy)

slow rising pulse/plateau

aortic stenosis

slow rising/plateau pulse means..

aortic stenosis

A 65 year old female patient presents to the emergency department with a 24 hour history of palpitations and dizziness. She has a past medical history of hypertension. She drinks a bottle of wine per day. Electrocardiogram (ECG) reveals absent P waves and irregularly irregular QRS complexes at a rate of 104 per minute. Which of the following clinical signs is consistent with the most likely underlying diagnosis?

apical radial pulse deficit Apical to radial pulse deficit This is the correct answer. The patient presents with features consistent with fast atrial fibrillation. Apical to radial pulse deficit occurs as not all atrial impulses (palpable at the apex) are mechanically conducted to the ventricles (palpable as a peripheral pulse) 31%

how is IV adenosine given for SVT if valsava maneuvers fail

as a rapid IV bolus

NSTEMI management

aspirin + IV morphine/GTN as required + calculate GRACE score

A 59-year-old man is brought into the emergency department with a 5-hour history of central chest pain, radiating to his left arm and jaw. He is sweating profusely and complains of feeling nauseated. His past medical history includes chronic kidney disease stage 3.On examination, his heart rate is 113 beats/min with a blood pressure of 89/58 mmHg. Chest sounds are clear with saturations of 94% on air and heart sounds are normal. His calves are soft with no pitting oedema.ECG: ST-depression in leads I, aVL, V5 and V6.A decision is made to treat the patient medically instead of with percutaneous coronary intervention.Given the likely diagnosis, what is the most appropriate immediate treatment to initiate for this patient?

aspirin + ticagrelor + fondaparinux no nitrates as he is hypotensive

NSTEMI conservative mx

aspirin, plus either: ticagrelor, if not high bleeding risk clopidogrel, if high bleeding risk and fondaparinux

A 61-year-old man presents with a two-months history of palpitation. He describes the sensation of his heart skipping a beat regularly but is otherwise well in himself with no reports of dizziness, orthopnoea, shortness of breath, chest pain or collapse.On examination, his chest is clear with an oxygen saturation of 97%. His heart sound is normal. There is no sign of peripheral oedema. His blood pressure is 122/60mmHg and his ECG shows irregularly irregular rhythm with the absence of P waves and a heart rate of 84/min.What is the most appropriate next step management option for this patient?

assessment using ORBIT risk tool and CHA2DS2-VASc

what can chronic mitral regurgitation cause

atrial fibrillation

what method of inheritance does HOCM have

autosomal dominant

A 59-year-old woman presents to the emergency department complaining of a three-day history of new-onset palpitations. She has no structural or ischaemic heart disease. Her heart rate is 120bpm, and she shows no signs haemodynamic compromise. Her ECG shows an irregularly irregular rhythm with the absence of p waves. The consultant recommends elective cardioversion for this patient. Which one of these management plans is the most appropriate for this patient?

bisoprolol and oral anticoagulant therapy for 3 weeks and the electrical cardioversion

first line investigation for stable chest pain that is suspected to be of suspected coronary artery disease aetiology

contrast enhanced CT angiogram

He has a BP of 139/82mmHg, heart rate of 93/min and respiratory rate of 18/min. His chest x-ray is normal. By the time of his examination, his pain has resolved without any treatment. However, ECG shows deeply inverted T waves in leads V2 and V3 but no other changes.

because it is just in leads V2 and V3 - it is due to a critical stenosis of left anterior descending artery (wellens syndrome) not complete occlusion

how to measure QT interval

beginning of QRS to end of T wave

A 75-year-old woman is brought to the Emergency Department by her family. She has been getting more short-of-breath over the last 6 weeks and says her energy levels are low. An ECG on arrival shows atrial fibrillation at a rate of 114 / min. Blood pressure is 128/80 mmHg and a chest x-ray is unremarkable. What is the appropriate drug to control the heart rate?

beta blocker This question reiterates an important point which frequently comes up in exams - digoxin is no longer first-line for rate control in atrial fibrillation. Her shortness-of-breath is likely to be rate related and does not necessarily mean that she is in heart failure. This is supported by a normal chest x-ray.

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? - BB - CCB - ACEi - statin - GTN spray

beta blockers

which anti-anginal causes sexual dysfunction?

beta blockers

A 74-year-old man presents to the emergency department with a fall after tripping over a step outside his house. There were no preceding presyncopal symptoms. He sustained a head injury but did not lose consciousness. His past medical history includes atrial fibrillation, hypertension and type 2 diabetes. He takes dabigatran, amlodipine and metformin.His observations on arrival were heart rate 84 beats per minute, blood pressure 132/77 mmHg, respiratory rate 18/minute, oxygen saturations 96% on air and temperature 36.4ºC. He was alert with a Glasgow coma scale of 15/15. A neurological examination was normal. There was evidence of an external head injury with some bruising.A CT head demonstrates a small subdural haematoma. There is no midline shift or mass effect.What is the most appropriate medication to administer at this point?

bleeding on dabigatran = use idarucizumab to reverse. Given that the patient has sustained a subdural haematoma as a consequence of trauma and anticoagulant treatment with dabigatran, we need to reverse the effect of dabigatran. While tranexamic acid is an anti-fibrinolytic medication that reduces bleeding in a variety of situations, it is not the specific reversal agent in this circumstance.Idarucizumab is the correct answer. This is a monoclonal antibody used as a reversal agent for dabigatran. As this patient has suffered a potentially life-threatening complication of anticoagulant treatment, the anticoagulant effect of the medication should be reversed.

what is IV atropine used for?

bradycardia

An 82-year-old man is referred to cardiology by his GP with increasing dyspnoea on exertion and a systolic murmur. Examination demonstrates a blood pressure of 100/80 mmHg and a slow rising pulse. What is the most likely cause of his underlying condition?

calcification of the aortic valve.

A 65-year-old patient with a known history of stable angina is presented to his GP with poor control of his symptoms. He is taking atenolol for the angina. The patient's allergy notes indicate that he had developed ankle oedema when tried on nifedipine in the past for hypertension. According to NICE guidelines, which of the following drugs can be added to help control his symptoms?

cant use amlodipine = use ivabradine

complications following an MI

cardiac arrest most commonly occurs due to patients developing VF and is the most common cause of death following a MI. patients are managed as per the ALS protocol with defib. cardiogenic shock = If a large part of the ventricular myocardium is damaged in the infarction the ejection fraction of the heart may decrease to the point that the patient develops cardiogenic shock. This is difficult to treat. Other causes of cardiogenic shock include the 'mechanical' complications such as left ventricular free wall rupture as listed below. Patients may require inotropic support and/or an intra-aortic balloon pump. chronic HF = As described above, if the patient survives the acute phase their ventricular myocardium may be dysfunctional resulting in chronic heart failure. Loop diuretics such as furosemide will decrease fluid overload. Both ACE-inhibitors and beta-blockers have been shown to improve the long-term prognosis of patients with chronic heart failure. tachyarrhythmias = Ventricular fibrillation, as mentioned above, is the most common cause of death following a MI. Other common arrhythmias including ventricular tachycardia. bradyarrhythmias = Atrioventricular block is more common following inferior myocardial infarctions. pericarditis = Pericarditis in the first 48 hours following a transmural MI is common (c. 10% of patients). The pain is typical for pericarditis (worse on lying flat etc), a pericardial rub may be heard and a pericardial effusion may be demonstrated with an echocardiogram.Dressler's syndrome tends to occur around 2-6 weeks following a MI. The underlying pathophysiology is thought to be an autoimmune reaction against antigenic proteins formed as the myocardium recovers. It is characterised by a combination of fever, pleuritic pain, pericardial effusion and a raised ESR. It is treated with NSAIDs. left ventricular aneurysm = The ischaemic damage sustained may weaken the myocardium resulting in aneurysm formation. This is typically associated with persistent ST elevation and left ventricular failure. Thrombus may form within the aneurysm increasing the risk of stroke. Patients are therefore anticoagulated. left ventricular free wall rupture = This is seen in around 3% of MIs and occurs around 1-2 weeks afterwards. Patients present with acute heart failure secondary to cardiac tamponade (raised JVP, pulsus paradoxus, diminished heart sounds). Urgent pericardiocentesis and thoracotomy are required. ventricular septal defect =Rupture of the interventricular septum usually occurs in the first week and is seen in around 1-2% of patients. Features: acute heart failure associated with a pan-systolic murmur. An echocardiogram is diagnostic and will exclude acute mitral regurgitation which presents in a similar fashion. Urgent surgical correction is needed. acute MR = More common with infero-posterior infarction and may be due to ischaemia or rupture of the papillary muscle. Acute hypotension and pulmonary oedema may occur. An early-to-mid systolic murmur is typically heard. Patients are treated with vasodilator therapy but often require emergency surgical repair.

A 17-year-old female presents with recurrent attacks of collapse. These episodes typically occur without warning and have occurred whilst she was running for a bus. There is no significant past medical history and the only family history of note is that her father died suddenly when he was 38-years-old. What is the likely cause?

cardiogenic syncope sudden death, unusual collapse in young person -- HOCM

why may a third heart sound be present

caused by diastolic filling of the ventricle considered normal if < 30 years old (may persist in women up to 50 years old) heard in left ventricular failure (e.g. dilated cardiomyopathy), constrictive pericarditis (called a pericardial knock) and mitral regurgitation

aortic regurgitation causes

causes due to valve disease: rheumatic fever: the most common cause in the developing world calcific valve disease infective endocarditis connective tissue diseases e.g. rheumatoid arthritis/SLE bicuspid aortic valve (affects both the valves and the aortic root) causes of AR due to aortic disease: bicuspid aortic valve (affects both the valves and the aortic root) aortic dissection spondylarthropathies (e.g. ankylosing spondylitis) hypertension syphilis Marfan's, Ehler-Danlos syndrome

investigating palpitations

causes: - arrhythmias - stress - increased awareness of normal heart beat/extrasystoles. first line investigations include: 12-lead ECG: this will only capture the heart rhythm for a few seconds and hence is likely to miss episodic arrhythmias. However, other abnormalities linked to the underlying arrhythmia (for example a prolonged QT interval or PR interval, or changes suggesting recent myocardial ischaemia) may be seen. thyroid function tests: thyrotoxicosis may precipitate atrial fibrillation and other arrhythmias urea and electrolytes: looking for disturbances such as a low potassium full blood count capturing episodic arrythmias: First-line investigations are often normal in patients complaining of palpitations. The next step is to exclude an episode arrhythmia.The most common investigation is Holter monitoring portable battery operated device continuously records ECG from 2-3 leads usually done for 24 hours but may be used for longer if symptoms are less than daily patients are asked to keep a diary to record any symptomatic palpitations. This can later be compared to the rhythm strip at the time of the symptoms at the end of the monitoring a report is generated summarising a number of parameters including heart rate, arrhythmias and changes in ECG waveform If no abnormality is found on the Holter monitor, and symptoms continue, other options include: external loop recorder implantable loop recorder

posterior MI on ecg

chest pain with tall R waves in V1+V2. This would be typical of a left coronary artery occlusion.

A fifty-year-old man collapses, whilst visiting his wife on the ward. He is found to be pulseless and unresponsive so advanced life support (ALS) is commenced. The defibrillator displays ventricular fibrillation (VF). After three cycles of CPR and three shocks, he remains in VF. It is decided that adrenaline should be administered.What is the correct dose to give?

during ALS - 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

You are a doctor attached to a cardiology clinic. You are about to see a 55-year-old male who has recently presented with progressive exertional dyspnoea, orthopnoea, and pitting ankle oedema.He went on to have an echocardiogram which showed dilation of all four chambers, thinning of both ventricular walls, tricuspid regurgitation, mitral regurgitation and a reduced ejection fraction.Which is the following is the most likely cause for this patients condition?

chronic alcohol use may cause dilated cardiomyopathy The history is suggestive of heart failure. The echo findings are suggestive of dilated cardiomyopathy (DCM). In DCM, the walls of the heart thin leading to dilation of the chambers. As the ventricles dilate they pull the AV valve leaflets apart leading to a degree of regurgitation. DCM is a systolic heart failure (where systolic contraction is poor), this leads to a reduced ejection fraction. DCM is most commonly idiopathic. Other causes include alcoholism, cocaine abuse, various infections, heamochromatosis, sarcoidosis, and pregnancy. There are many more causes these are some of the most common. Chronic alcoholism is correct. This is a common cause of DCM and is related to thiamine deficiency. It is a less well known, but equally important, reason to manage thiamine deficiency in alcoholics.

where is the pain in type A and type B aortic dissections

classically chest pain is more common in type A dissection and upper back pain is more common in type B dissection - there is, however, considerable overlap

A 45-year-old woman presented to the emergency department. She complained of a sudden-onset chest pain that radiated down her left arm. This started when she was cleaning the house. She denied any other symptoms such as nausea, sweating, vomiting, or shortness of breath. Cardiovascular examination was unremarkable. Her point of care troponin was raised. Upon seeing her ECG, the on-call cardiologist decided to offer her immediate invasive coronary angiogram. The invasive coronary angiogram confirmed a critical stenosis of the left anterior descending artery. Which of the following ECG findings is compatible with the scenario?

deep T wave inversion or biphasic T waves in V2-3. ECG finding of deeply inverted or biphasic waves in V2-3 in a person with the previous history of angina is characteristic of Wellen's syndrome. This is highly specific for a critical stenosis of the left anterior descending artery

what is the s2 heart sound and what does it mean if it is soft

closure of aortic and pulmonary valves soft in aortic stenosis splitting during inspiration is normal

what is the s1 heart sound, what if it is soft or loud

closure of mitral and tricuspid valves soft if long PR or mitral regurgitation loud in mitral stenosis

first line management of acute pericarditis

combination of NSAID and colchicine

investigations for aortic dissection

computeriised tomography angiography of the chest, abdo and pelvis

causes of torsades de pointes

congenitalJervell-Lange-Nielsen syndromeRomano-Ward syndrome antiarrhythmics: amiodarone, sotalol, class 1a antiarrhythmic drugs tricyclic antidepressants antipsychotics chloroquine terfenadine erythromycin electrolyte: hypocalcaemia, hypokalaemia, hypomagnesaemia myocarditis hypothermia subarachnoid haemorrhage

A 73 year old woman presents to the Emergency Department with progressive shortness of breath. On examination the patient has an S3 gallop rhythm, bibasal crepitations and pitting oedema up to both knees. An ECG shows signs of left ventricular hypertrophy and a chest X-ray shows small bilateral pleural effusions, cardiomegaly and upper lobe diversion. what is the likely diagnosis

congestive heart failure

management of type A aortic dissection

consists of hypertension control with intravenous (IV) labetalol and surgical repair, which is usually thoracic endovascular aortic repair.

first line ix for stable chest pain in suspected coronary artery disease

contrased enhaned CT cronary angiography

This patient's decreased GCS and abnormal posturing (with fixed flexion of both arms, called the 'mummy baby' pose), on the background of a subdural haemorrhage, is highly concerning for brain herniation.This patient likely has uncal herniation as a result of raised intracranial pressure. In this case, as the subdural haemorrhage pushes the brain through the tentorium, uncal herniation is causing damage to what cranial nerve

cranial nerve III - eye goes down and out

A 72-year-old man is admitted with chest pain. He has associated nausea and vomiting. On examination he is pale and sweaty. An ECG shows ST elevation in V3-V6. A diagnosis of ST elevation myocardial infarction is made. The patient unfortunately deteriorates and goes into cardiac arrest. Prompt CPR is initiated. One cycle of CPR is completed before a heart tracing is obtained. The ECG shows monomorphic ventricular tachycardia. The patient still has no pulse.What should be the next step in management?

defib

coarctation of the aorta

describes a congenital narrowing of the descending aorta. - more common in males (despite association with turners syndrome) features: infancy: heart failure adult: hypertension radio-femoral delay mid systolic murmur, maximal over back apical click from the aortic valve notching of the inferior border of the ribs (due to collateral vessels) is not seen in young children associations: Turner's syndrome bicuspid aortic valve berry aneurysms neurofibromatosis

first line for angina when bb is ci

diltizem or verpamil - rate limiitng CCBs

features of heart failure

dyspnoea cough: may be worse at night and associated with pink/frothy sputum orthopnoea paroxysmal nocturnal dyspnoea wheeze ('cardiac wheeze') weight loss ('cardiac cachexia'): occurs in up to 15% of patients. Remember this may be hidden by weight gained secondary to oedema bibasal crackles on examination

rheumatic fever

develops following an immunological reaction to recent (2-6 weeks ago) strep pyogenes infection. Pathogenesis Streptococcus pyogenes infection → activation of the innate immune system leading to antigen presentation to T cells B and T cells produce IgG and IgM antibodies and CD4+ T cells are activated there is then a cross-reactive immune response (a form of type II hypersensitivity) thought to be mediated by molecular mimicry the cell wall of Streptococcus pyogenes includes M protein, a virulence factor that is highly antigenic. It is thought that the antibodies against M protein cross-react with myosin and the smooth muscle of arteries this response leads to the clinical features of rheumatic fever Aschoff bodies describes the granulomatous nodules found in rheumatic heart fever diagnistic criteria: diagnosis is based on evidence of recent strep infection accompanied by: - 2 major criteria - 1 major with 2 minor criteria. Evidence of recent strep infection: raised or rising streptococci antibodies, positive throat swab, positive rapid group A streptococcal antigen test Major criteria: - erythema marginatum - sydenhams chorea: this is often a late feature - polyarthritis - carditis and valvulitis (e.g. pancarditis): The latest iteration of the Jones criteria (published in 2015) state that rheumatic carditis cannot be based on pericarditis or myocarditis alone and that there must be evidence of endocarditis (the clinical correlate of which is valvulitis which manifests as a regurgitant murmur) - subcut nodules Minor criteria: -raised ESR or CRP -pyrexia -arthralgia (not if arthritis a major criteria) - prolonged PR interval Management: antibiotics: oral penicillin V anti-inflammatories: NSAIDs are first-line treatment of any complications that develop e.g. heart failure

> 80 and stage 1 HTN management

diagnose stage 1 HTN and advise about lifestyle changes

A 55-year-old man presents for a review of his treatment. Despite treatment, he is still experiencing recurrent episodes of dyspnoea and palpitations. His heart rate is 85 bpm, his blood pressure is 125/75 mmHg, and his chest is clear with normal heart sounds. An ECG shows absent p-waves and an irregularly irregular rhythm.He has a history of asthma and takes salbutamol and beclometasone inhalers and does very little exercise. He has been given diltiazem which has been trialled for a few weeks but has been ineffective and he is still symptomatic.What additional drug would be most appropriate to prescribe?

digoxin

A 65-year-old gentleman with known diabetes and heart failure is currently admitted to the general medical wards suffering from atrial fibrillation (AF). He presented with a fast AF with a tachycardia of 130 beats per minute. He has been given atenolol but this has not yet reduced his heart rate below 120/min.Which of the following can be added as a second-line medication to help control his heart rate?

digoxin can be added as a second line treatment for rate control in AFib. Amlodipine is not recommended as the second line treatment for AF. Only non-dihydropyridine calcium channel blockers such as Verapamil can be used due to their atrioventricular node blocking actions Discuss (15)Improve

An 84 year old man is seen in a cardiology clinic for annual review. He has been symptomatic for the past two years with breathlessness on mild exertion, inability to lie flat and occasional episodes of palpitations. These symptoms have worsened slightly. On examination, he is comfortable at rest with pedal oedema to the mid-shins and sparse bilateral basal crackles. He has a pulse rate of 64bpm (irregularly irregular) and blood pressure of 128/77mmHg. Echocardiogram demonstrates an ejection fraction of 25%. ECG indicates atrial fibrillation with left bundle branch block (LBBB), QRS duration 160ms. Blood tests are within normal limits. His current medications include Enalapril, Bisoprolol, Eplerenone, Atorvastatin, Furosemide, Aspirin, and Apixaban. Which of the following treatments should be offered to this patient?

digoxin in sinus rythm heart failure he is eligible for CRT - he needs to be trialed this because you can give him left ventricular assist device

A 71-year-old woman presents to the emergency department as her smartwatch ECG recorder has indicated that she has had atrial fibrillation for the last three days. She has become slightly short of breath on exertion in the previous 24 hours. On assessment, her heart rate is irregular, with a heart rate of 98 bpm. Her blood pressure is maintained at 130/72 mmHg. She is not known to have atrial fibrillation and only takes amlodipine for grade I hypertension.What is the most appropriate treatment approach?

discharge on bisoprolol and apixaban and cardiovert in 4 weeks.

A 75-year-old man presents to the clinic with persisting shortness of breath, reduced exercise tolerance, and peripheral oedema over the last month. At night, he sometimes wakes up short of breath and has been sleeping poorly. He suffered from an ST-elevation myocardial infarction 3 years previously. He is currently taking aspirin, ramipril, bisoprolol, and atorvastatin. An echocardiogram shows a left ventricular ejection fraction of 37%.What drug would be the most appropriate for improving this patient's prognosis?

diuretics only improve symptoms of heart failure and have no effect on mortality so furosemide not givem. Spironolactone is correct. This patient has signs and symptoms consistent with chronic heart failure, characterised by shortness of breath, peripheral oedema, paroxysmal nocturnal dyspnoea, and reduced ejection fraction. They are already taking the first-line options for the management of heart failure, but are still symptomatic. The next step would be to add an aldosterone antagonist (e.g. spironolactone or eplerenone). Aldosterone antagonists decrease the morbidity and mortality associated with symptomatic chronic heart failure by reducing the risk of volume overload and increased strain on the heart, therefore improving its prognosis.

in AF if a CHA2DS2-VASc score suggests no need for anticoagulation what do you do

do an echo to exclude valvular heart disease

digoxin toxicity on ecg

down-sloping ST depression ('reverse tick', 'scooped out') flattened/inverted T waves short QT interval arrhythmias e.g. AV block, bradycardia

Mr Smith is a 59-year-old man who presents to the walk-in clinic complaining of central chest pain that is sharp in nature and is associated with a low-grade fever of 37.9ºC. He complains that it is worse when he goes to bed at night and better when he sits forward. He denies any recent infections or trauma to the chest. Upon reading the patient's notes the following entry is found dated 2 weeks previously. It reads as follows: Mr Smith presented to the emergency department with central crushing chest pain that radiated to his jaw that started 40 minutes ago. The admitting ECG revealed marked ST-elevations in leads II, III, and AVF. He was sent directly for percutaneous coronary intervention where a stent was inserted into the right coronary artery... Given the history and the current presenting complaint, what is the most likely diagnosis?

dresslers syndrome: The notes suggest that 2 weeks after a confirmed myocardial infarction, Mr Smith developed chest pain suggestive of pericarditis.Dressler syndrome fits the presentation and the time frame in this instance. It is a condition characterised by an autoimmune response mounted by the body after an injury to the myocardium or pericardium, in the case of this gentleman - a myocardial infarction. The condition comprises of fever, pericarditis, pleuritic pain +/- pericardial effusion. Dressler syndrome usually occurs between 2 -3 weeks after the initial injury, but can also present a few months later.

following an ACS, what medications should all patients be offered

dual antiplatelet therapy (aspirin plus a second antiplatelet agent) ACEi BB statin

A 65-year-old man presents in the early hours of the morning to the Emergency Department with a sudden onset of shortness of breath and reducing levels of consciousness. The medical history reveals that he has been stabbed in his chest with a knife following an altercation with a stranger outside a nightclub. On examination, his heart rate is 127 beats/min and blood pressure is 97/62 mmHg. The veins in his neck are markedly distended and auscultation of the heart proves to be difficult as the heart sounds are quiet. What is the most appropriate diagnostic test for this man's condition?

echo

investigation for cardiac tamponade

echocardiogram - shows enlarged pericardium or collapsed ventricles.

investigation for AR

echocardiography

what is allowed to happen to egfr and creatinine when on acei

egfr is allowed to decrease from pre-treatment line by about 25% creatinine is allowed to increase by about 30%

A 25-year-old man presents to cardiology clinic. He remembers his mother telling him he had a 'heart murmur' in childhood, but never had any operations or further investigations performed as they moved around a lot. He now feels increasingly fatigued and breathless, especially when he exercises. On examination, an audible ejection systolic murmur, which is louder on inspiration is head. There is no finger clubbing.What is the most likely diagnosis?

ejection systolic murmur heard loudest on inspiration = ASD Many atrial septal defects (ASD) are asymptomatic in childhood, and only progress to give symptoms if they remain untreated to adulthood, as in this vignette. The typical murmur of ASD is also described in this vignette; an ejection systolic murmur louder on inspiration.

how to differentiate unstable angina and NSTEMI

elevated troponin = NSTEMI

A 78-year-old patient has been undergoing treatment for symptomatic bradycardia.After several boluses of atropine, the patient remains unwell with a blood pressure of 84/53mmHg, heart rate of 34 beats per minute, respiratory rate of 23 breaths per minute, oxygen saturation of 97%, and a temperature of 37.2ºC. The patient is confused and sweating, with cold and clammy extremities.What is the most appropriate next step in the management of this patient?

external pacing is sued for symptomatic bradycardia if atropine fails. It is a temporary measure that delivers pacing of the heart through the chest wall until more permanent pacing may be established.

side effect of indapamide

erectile dysfunction

After starting an ACE inhibitor, significant renal impairment may occur, why?

if the patient has undiagnosed bilateral renal artery stenosis

first line mx of absence seizures including in men

ethosuximide

when is fibrinolysis offered in STEMI

fibrinolysis should be offered within 12 hours of onset of symptoms if primary PCI cannot be delivered within 120 minutes

A 24-year-old attends her routine medical examination prior to starting her job as a professional footballer. She is fit and well with no significant family history.On examination, her chest is clear and she has normal heart sounds. Her pulse is 62 beats per minute. Her ECG shows sinus rhythm with a prolonged PR interval of 215ms.How should her ECG findings be managed?

first degree heart block is a normal variant in an athlete. it does not require intervention.

what medication is given to individuals undergoing fibrinolysis for a STEMI

fondaparinux

ntemi to be managed by PCI what anticoagulant should they be given

if the patient is not taking an oral anticoagulant: prasugrel or ticagrelor if taking an oral anticoagulant: clopidogrel

which diuretic causes ototoxicity

furosemide

Which one of the following treatments have not been shown to improve mortality in patients with chronic heart failure?

furosemide - whilst useful in managing the symptoms of acute and chronic HF furosemide offers no prognostic benefits

patients on warfarin therapy who are undergoing emergency surgery what should you do

give 4 factor prothrombin complex concentrate.

A 67-year-old woman is reviewed in the afternoon GP surgery. She describes a 20 minute episode heavy central chest pain shortly after getting up from bed this morning, about 7 hours ago. This has not happened before and she has been pain free since the morning. Clinical examination is normal but the ECG shows T wave inversion in the inferior leads. What is the most appropriate action?

give aspirin + arrange an emergency admission (immediate ambulance)

during CPR if PE is suspected what do you do

give thrombolytic drugs such as alteplase

how is IV amiodarone give and what does this reduce the risk of

given into central veins to reduce risk of injection site reactions

what is used to determine who is given glucocorticoid therapy in alcoholic liver failure

glucocorticoids (e.g. prednisolone) are often used during acute episodes of alcoholic hepatitis = Maddrey's discriminant function (DF) is often used during acute episodes to determine who would benefit from glucocorticoid therapy = it is calculated by a formula using prothrombin time and bilirubin concentration

the vast majority of cases of bacterial endocarditis are caused by what type of bacteria

gram positive cocci

What does pulsus paradoxus indicate?

greater than the normal (10 mmHg) fall in systolic blood pressure during inspiration → faint or absent pulse in inspiration severe asthma, cardiac tamponade

pulsus paradoxus

greater than the normal (10 mmHg) fall in systolic blood pressure during inspiration → faint or absent pulse in inspiration severe asthma, cardiac tamponade

A 76-year-old male patient is brought to the hospital after he has crushing chest pain. He is found to have an ST-elevation myocardial infarction and he receives percutaneous coronary intervention. Following the procedure, he is kept on cardiac telemetry and the emergency buzzer sounds when he develops ventricular tachycardia on the monitor. He is haemodynamically stable, although he has a slight discomfort in his chest. What is the most appropriate management?

haemodynamically stable VT is managed with amiodarone

You are asked to perform a cardiovascular examination on a 67-year-old woman who presents with shortness of breath and orthopnoea. By the bedside, she has flushed cheeks and neck vein distension. On auscultation, you hear a rumbling mid-diastolic murmur heard loudest over the apex. The murmur was louder during expiration. Her ECG shows normal sinus rhythm. Her heart rate is 90 bpm, respiratory rate 18 breaths per minute, blood pressure is 145/84 mmHg, oxygen saturation is 97% on room air and she is apyrexial.Given the likely cause of her condition, what other sign or symptom could she potentially have?

haemoptysis can be a common smyptom of mitral stenosis. so can dyspnea and orthopnoea.

A 75-year-old man presents with a one-month history of dyspnoea, palpitations and dizziness. However, within the last few days, he has developed a productive cough with blood-streaked frothy white sputum. On examination, a low-pitch, rumbling, mid-diastolic murmur, is heard loudest at the apex and bilateral crepitations at the lung bases.What is the most likely diagnosis?

haemoptysis can be a symptom of mitral stenosis.

side effect of thrombolysis

haemorrhage hypotension - more common with streptokinase allergic reactions may occur with streptokinase

side effects of warafrin

haemorrhage teratogenic, although can be used in breastfeeding mothers skin necrosiswhen warfarin is first started biosynthesis of protein C is reducedthis results in a temporary procoagulant state after initially starting warfarin, normally avoided by concurrent heparin administrationthrombosis may occur in venules leading to skin necrosis purple toes

A 50-year-old man complains of central, pleuritic chest pain 24 hours after being admitted with an anterior myocardial infarction. The pain is eased when he sits upright.

he has early pericarditis. Dressler's syndrome is a seperate clinical phenomenon and is not generally seen in the first two weeks following a myocardial infarction.

cardioascular effects of lyme disease

heart block peri/myocarditis

A 47-year-old man with no fixed abode is brought into the emergency department by ambulance. On examination he looks extremely pale and is shivering. His speech is slurred and has a minimally-reduced level of consciousness. His Glasgow coma scale score (GCS) is 13 and his body temperature is 34.1ºC. The senior house office (SHO) has requested bloods, an electrocardiogram (ECG) and a CT head.In keeping with the clinical findings, what would you expect to see on the ECG?

heart rate of 45/min and J waves. The ECG changes associated with hypothermia include: Bradycardia (<60bpm) and not tachycardia J waves Prolonged PR, QT and QRS intervals Shivering artefacts VT, VF or asystole

mx of post MI dresslers syndrome

high dose aspirin (post viral pericarditis is mx with nsaids or colchicine)

massive GI bleed --> bilateral pitting oedema, elevated JVP. What happened?

high output heart failure --> anaemia

A 52-year-old male presents to the emergency department (ED) with chest pain radiating down the left arm. His observations show: Blood pressure 75/40mmHg Heart rate is 117 beats per minute Respiratory rate 24/min Temperature 37.1ºC Oxygen saturations 96% On examination, he appears diaphoretic and in a significant amount of discomfort, an ECG reveals new T wave inversion in leads V1-4.What is the best next step in the management of this patient?

immediate coronary angiography with percutaenous coronary intervention

A 75-year-old Afro-Caribbean male with a known diagnosis of heart failure attends a cardiology clinic for specialist review. He is struggling with breathlessness after minimal activity as well as ankle oedema. His temperature was 37ºC, oxygen saturation 96% on air, heart rate 64 beats per minute, respiratory rate of 18 breaths per minute and blood pressure 145/85 mmHg.His current medications include ramipril, bisoprolol and spironolactone.What other medications may be prescribed to improve the patient's symptoms?

hydralazine and nitrate

most commonest association with aortic dissection

hypertension

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?

hypocalcaemia is a side effect of loop diuretics

becks triad

hypotension, JVD, muffled heart sounds for cardiac tamponade

A 58-year-old woman presents to the emergency department with palpitations and dizziness which began suddenly 20 minutes ago. An ECG is performed which suggests she has atrioventricular nodal re-entry tachycardia (AVNRT). Minutes later, once the patient has received treatment, she complains of severe sudden onset chest pain.What is the most likely cause of this chest pain?

iatrogen (adenosine) may cause chest pain

management of aortic stenosis

if asymptomatic then observe the patient is a general rule if symptomatic then valve replacement if asymptomatic but valvular gradient > 40 mmHg and with features such as left ventricular systolic dysfunction then consider surgery options for aortic valve replacement (AVR) include:surgical AVR is the treatment of choice for young, low/medium operative risk patients. Cardiovascular disease may coexist. For this reason, an angiogram is often done prior to surgery so that the procedures can be combinedtranscatheter AVR (TAVR) is used for patients with a high operative risk balloon valvuloplastymay be used in children with no aortic valve calcificationin adults limited to patients with critical aortic stenosis who are not fit for valve replacement

when is staph epidermis the cause of endocarditis

if it has been < 2 months post valve surgery

Alan is a 66-year-old man who comes to see you complaining of a new-onset headache which started 2 weeks ago. Alan's past medical history includes type 2 diabetes and hypercholesterolaemia, and he has a body mass index of 31kg/m².As part of your examination, you check Alan's blood pressure which is 196/122 mmHg. A repeat reading is 188/120 mmHg. You carry out fundoscopy which shows evidence of retinal haemorrhage.What is the most appropriate initial management?

if new BP >= 180/120 + retinal haemorrhage or papillodema - refer for same day specialist assessment

This afternoon, a Cardiology patient underwent percutaneous coronary intervention (PCI) after presenting to the emergency department with severe chest pain secondary to an ST-elevation myocardial infarction (STEMI).It has been four hours since the PCI, and the patient is now complaining of increasing, severe chest pain.What is the single most appropriate treatment option?

if patients treated with PCI for MI are experiencing pain or haemodynamic instability post PCI, urgent CABG is recommended

when is PCI offered in STEMI

if presents within 12 hours of onset of symptoms

when to do surgery for aortic stenosis

if symptomatic then valve replacement if asymptomatic but valvular gradient > 40 mmHg and with features such as left ventricular systolic dysfunction then consider surgery options for aortic valve replacement (AVR) include:surgical AVR is the treatment of choice for young, low/medium operative risk patients. Cardiovascular disease may coexist. For this reason, an angiogram is often done prior to surgery so that the procedures can be combinedtranscatheter AVR (TAVR) is used for patients with a high operative risk

patient presents with acute chest pain

immediate management of suspected ACS: - GTN - aspirin 300mg. NICE do not recommend giving other antiplatelet agents (i.e. clopidogrel) outside of hospital - do not routinely give oxygen, only give if sats < 94% - perform an ecg as soon as possible but do not delay transfer to hospital. a normal ecg does not exclude acs. referral: current chest pain or chest pain in the last 12 hours with an abnormal ECG: emergency admission chest pain 12-72 hours ago: refer to hospital the same-day for assessment chest pain > 72 hours ago: perform full assessment with ECG and troponin measurement before deciding upon further action *NICE suggest the following in terms of oxygen therapy: do not routinely administer oxygen, but monitor oxygen saturation using pulse oximetry as soon as possible, ideally before hospital admission. Only offer supplemental oxygen to: people with oxygen saturation (SpO2) of less than 94% who are not at risk of hypercapnic respiratory failure, aiming for SpO2 of 94-98% people with chronic obstructive pulmonary disease who are at risk of hypercapnic respiratory failure, to achieve a target SpO2 of 88-92% until blood gas analysis is available.

Pulmonary A pressure = high CO = low SVR = high

in cardiogenic shock pulmonary pressures are often high. This is the basis for the use of venodilators in the treatment of pulmonary oedema.

A 58-year-old female on the respiratory ward was admitted with a pulmonary embolism one week ago and was started on warfarin at the time of diagnosis. She was covered with low molecular weight heparin until the INR was > 2 for 24 hours. For the past week she has been taking 4mg of warfarin and her INR four days ago was 2.2. Her INR has been checked today and is 1.3.What is the most appropriate action to take?

increase dose of warfarin to 6mg and start LMWH As her INR is < 2 she needs immediate anti-coagulation with rapid acting low molecular weight heparin. Her warfarin dose should also be increased to 6mg. Her INR should be carefully monitored and the LMWH discontinued when has adequate anti-coagulation.

what is takayasu's arteritis

it 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 younger females (e.g. 10-40 years) and Asian people. features: systemic features of a vasculitis e.g. malaise, headache unequal blood pressure in the upper limbs carotid bruit and tenderness absent or weak peripheral pulses upper and lower limb claudication on exertion aortic regurgitation (around 20%) associations: Renal artery stenosis Management: steroids

bendroflumethazide or indapamide in HTN mamagement

indapamide

A 50-year-old woman in the general medical ward complains of palpitations. She denies any chest pain or shortness of breath. Her ECG shows supraventricular tachycardia (AVNRT) was diagnosed. Her blood pressure is 135/86 mmHg. Initial Valsalva manoeuvre fails to restore sinus rhythm. Your consultant asks you to give her adenosine. The only access available is a 20G (small) cannula in the dorsum of her left hand. This is currently being used for infusion of 0.9% sodium chloride solution.What is the most appropriate way of administering adenosine in this patient?

insert a 16G cannula in her right antecubital vein = IV adenosine needs to be infused via a large-calibre vein or central route Adenosine cannot be given orally. Adenosine half-life is less than 10 seconds and therefore, a central route or large-calibre vein is required to administer adenosine effectively. In this case, the cannula in her left arm is unlikely to be large enough for adenosine. While a central route is an appropriate route, it is more practical to insert a peripheral cannula into the antecubital vein for rapid adenosine iv injection. A large bore cannula (preferably 16G) should be used.BNF: 'For rapid intravenous injection give over 2 seconds into central or large peripheral vein followed by rapid Sodium Chloride 0.9% flush; injection solution may be diluted with Sodium Chloride 0.9% if required'

dextrocardia on ecg

inverted p wave in lead I, axis deviation and loss of R wave progression.

A 63-year-old woman was diagnosed with stable angina 6 months ago, after which she was started on an anti-anginal medication to reduce her frequency and severity of symptoms.She currently takes her prescribed tablet twice a day at 8 am and 8 pm and is fully compliant with treatment but has noticed that her angina has worsened in the past few months. She has spoken to a cardiologist friend who suspects that this is related to how she is taking her drugs. what med is it

isosorbide mononitrate Continuous treatment with nitrates (such as isosorbide mononitrate) is associated with the development of tolerance, which results in reduced therapeutic effects. This explains why this patient is having worsening angina despite treatment.As a result, it is recommended that a nitrate-free interval each day (lasting at least 4 hours) should be ensured to maintain sensitivity - this involves either taking the second dose at an earlier time (e.g. 8 am and 3 pm) or switching to a once-daily modified-release preparation.

BP problems in diabetics

it can cause postural hypotension secondary to autonomic dysfunction

dabigatran: - use - side effects - reversal agent

it is an oral anticoagulant that works by being a direct thrombin inhibitor. it is one of the drugs developed over the past 20 years as an alternative to warfarin, with the advantage that it does require regular monitoring. use: has two main indications. firstly it is an option in the prophylaxis of VTE following hip or knee replacement surgery. secondly it is also licensed in the UK for prevention of stroke in patients with non-valvular atrial fibrillation who have one or more of the following risk factors present: - previous stroke, transient ischaemic attack or systemic embolism - left ventricular ejection fraction below 40% - symptomatic heart failure of New York Heart Association (NYHA) class 2 or above - age 75 years or older - age 65 years or older with one of the following: diabetes mellitus, coronary artery disease or hypertension side effects:Unsurprisingly haemorrhage is the major adverse effect.Doses should be reduced in chronic kidney disease and dabigatran should not be prescribed if the creatinine clearance is < 30 ml/min. reversing the effects = idarucizumab

what is regular, broad complex tachycardia and how is it managed

it is usually ventricular tachycardia (unless previously confirmed SVT with bundle branch block) and managed with a loading dose of IV amiodarone followed by a 24 hour infusion.

if someone has a rash which precedes after a sore throat that resolves without antibiotics, what will the rash not be

it wont be guttate psoriasis because if the infection was treated without abx it is probably viral, not strep - more likely to be pityriasis rosea

what does thiazides do to gglucose

it worsens glucose intolerance so avoid in people with inadequate glucose control

thiazides do what to glucose

it worsens glucose tolerance

in chronic blood loss what would happen to the reticulocyte count

it would icnrease as the bone marrow is producing more red blood cells

Abdominal pain, constipation, neuropsychiatric features, basophilic stippling

lead poisoning

when to take statins

last thing in the evening

inf MI leads to what axis deviation

left

MRI acoustic neuroma

left cerebellopontine angle tumour

doses for IV adenosine if vagal maneuvers dont treat SVT

rapid IV bolus of 6mg --> if unsuccessful give 12mg --> if unsuccessful give further 18mg dont use in asthmatics - verapamil is preferred

persistent ST elevation following a recent MI and having no chest pain is due to..

left ventricualr aneurysm

Four weeks after an anterior myocardial infarction a 69-year-old presents with pulmonary oedema. The ECG shows persistent ST elevation in the anterior leads.

left ventricular aneurysm

persistent ST elevation following recent MI, no chest pain...

left ventricular aneurysm

A 62-year-old man attends his general practitioner 4 weeks after his myocardial infarction, worried that he is losing his exercise tolerance. He feels he has been steadily declining since he was discharged and is now becoming short of breath even when climbing his stairs - he was previously fit and well before this. His initial treatment was with percutaneous coronary intervention.On examination, he has bibasal crackles, and a prominent S3 and S4 heart sound. There are no added sounds.An ECG shows ST elevation in V1-6.What is the most likely diagnosis?

left ventricular aneurysm This man is presenting with a likely complication of his myocardial infarction. His reduced exercise tolerance appears to be due to pulmonary oedema, suggested by his bibasal crackles. This suggests some form of failure of the left ventricle to pump properly, leading to a back-up of blood in the lungs. The presence of an S3 heart sound suggests the left ventricle is larger than normal (as S3 represents the sloshing of blood into a large ventricle during diastole). The presents of an S4 heart sound suggest that the left ventricle is stiffer than normal (as S4 represents the forceful atrial push of blood against a hard ventricular wall). These combined, suggests the left ventricle is larger than usual, with stiff walls and causing pulmonary congestion. This is highly suggestive of a left ventricular aneurysm. A left ventricular aneurysm will cause persistent ST elevation in V1-6 on an ECG. This is because the fibrosis and dead tissue is not able to properly move as expected.

left ventricular aneurysm vs left ventricular free wall rupture as complications post PCI

left ventricular aneurysm: - ischemic damage sustained may weaken the myocardium resulting in aneurysm formation. - this is typically associated with persistent ST elevation and left ventricular failure. - thrombus may form within the aneurysm increasing the risk of stroke. - patients are therefore anticoagulated. left ventricular free wall rupture: - this is seen in around 3% of MIs and occurs around 1-2 weeks afterwards. - Patients present with acute HF secondary to cardiac tamponade (raised JVP, pulsus paradoxus, diminished heart sounds). urgent pericardiocentesis and thoracotomy are required.

ecg findings for HOCM

left ventricular hypertrophy non-specific ST segment and T-wave abnormalities, progressive T wave inversion may be seen deep Q waves atrial fibrillation may occasionally be seen

A 56-year-old man has a total anterior circulation ischaemic stroke. He is also found to be in permanent atrial fibrillation. He has been prescribed aspirin 300 mg daily for the first two weeks, after which he will be switched to clopidogrel 75 mg daily.What additional therapy will he require for secondary prevention of stroke?

long term apixaban starting after 2 weeks A patient with AF + an acute stroke (not haemorrhagic) should have anticoagulation therapy started two weeks after the event

which diuretic is ototoxic

loop diuretics including furosemide and bumetanide

what is corrigans sign

rapid upstroke and collapse of the carotid artery pulse, also seen in aortic regurgitation.

A 60-year-old man presents to the emergency department with central chest pain. His ECG shows ST depression in leads II,III and aVF. Which of the following may indicate a worse outcome in this patient?

lung crackles on auscultation because it indicates cardiogenic shock which is a poor prognostic indicator in ACS

which antibiotics cause torsades de pointes

macrolides

Warfarin management of high INR

major bleeding = Stop warfarin, Give intravenous vitamin K 5mgProthrombin complex concentrate - if not available then FFP* *as FFP can take time to defrost prothrombin complex concentrate should be considered in cases of intracranial haemorrhage INR > 8 minor bleeding = Stop warfarin, Give intravenous vitamin K 1-3mgRepeat dose of vitamin K if INR still too high after 24 hoursRestart warfarin when INR < 5.0 INR > 8 no bleeding = Stop warfarinGive vitamin K 1-5mg by mouth, using the intravenous preparation orallyRepeat dose of vitamin K if INR still too high after 24 hoursRestart when INR < 5.0 INR 5-8 minor bleeding = Stop warfarinGive intravenous vitamin K 1-3mgRestart when INR < 5.0 INR 5-8 with no bleeding = Withhold 1 or 2 doses of warfarinReduce subsequent maintenance dose

You are reviewing a 65-year-old lady who takes 10 mg of amlodipine and 2.5 mg of ramipril for hypertension. Her clinic blood pressure (BP) today is 139/87 mmHg.What should you suggest regarding her medications?

make no changes to her meds, aim for a clinic BP <140/90

why may a 4th heart sound be present

may be heard in aortic stenosis, HOCM, hypertension caused by atrial contraction against a stiff ventricle (therefore coincides with the P wave on ECG) in HOCM a double apical impulse may be felt as a result of a palpable S4

indications of warfarin

mechanical heart valvestarget INR depends on the valve type and locationmitral valves generally require a higher INR than aortic valves. second-line after DOACs:venous thromboembolism: target INR = 2.5, if recurrent 3.5atrial fibrillation, target INR = 2.5

management of AR

medical management of any associated heart failure surgery: aortic valve indications includesymptomatic patients with severe ARasymptomatic patients with severe AR who have LV systolic dysfunction

prolonged dirrhoea causes what on abg

metabolic acidosis with hypokalaemia

upper GI hemorrhage, n warfarin and INR of 8.5 management

stop warfarin, give IV vit K 5mg, prothrombin complex concentrate

diastolic murmur + AFib

mitral stenosis

tapping apex beat

mitral stenosis

mid diastolic murmur + AF

mitral stenosis Both symptoms of dyspnoea and orthopnoea are very common in these patients, while women are also more likely to suffer from mitral stenosis. On auscultation, a mid-diastolic murmur is often heard, together with an opening snap. Pressure overload due to the stenosed valve can result in structural and electrical remodelling of the left atrium, thus potentially leading to atrial fibrillation, which is quite frequent in this group of patients. All the information points towards a diagnosis of mitral stenosis.

which valve is most commonly affected in infective endocarditis

mitral valve

A 33-year-old female presents to the emergency department with abdominal pain. She has a past medical history of hypertension.On examination, she has a palpable mass on the left side of her abdomen, and on auscultation of her heart, a murmur is heard. Ultrasound examination shows multiple cysts in her left kidney.Which one of the following valvular abnormalities is commonly associated with her condition?

mitral valve prolapse is assocated with PCKD

A 35-year-old mountain climber presents to the emergency department after concerns were raised during private performance testing. His ECG shows a progressively prolonged PR interval, the longest before a non-conducted p-wave. He is asymptomatic and has no notable past medical history.What is the appropriate management?

mobitz 1 (wenckebach phenomenon) is a normal variant in an athlete - therefore monitor

A 54-year-old man presents to the GP with 3 episodes of dizziness and fainting. An ECG is performed that shows a bradycardia with intermittently non-conducted P waves, there is no sign of PR elongation or shortening of the waves that are conducted.Given the most likely diagnosis, what is the best long-term management options?

mobitz II is an indication for a pacemaker

when is a calcium channel blocker given as first line in someone with HTN

more than or equal to 55 years and no type 2 diabetes or black african Caribbean origin

ST elevation, acute pulmonary oedema in a young patient with a recent flu-like illness. Typically, inflammatory markers and troponin will be raised, and ECG will show non-specific ST segment and T wave changes. Focal ST elevation is a possible finding, as in this patient.

myocarditis

all patients with INR above 8 with warfarin should what

stop warfarin, give oral vit K, and recheck INR in 24 hours

benzylpenicillin is useful for which bacteria

streptococci

myocarditis - causes - presentation - ix - mx - complications

myocarditis describes inflammation of the myocardium. There are a wide range of underlying causes. it should be particularly considered in younger patients who present with chest pain. causes: viral: coxsackie B, HIV bacteria: diphtheria, clostridia spirochaetes: Lyme disease protozoa: Chagas' disease, toxoplasmosis autoimmune drugs: doxorubicin presentation: - usually young patient with an acute history - chest pain - dyspnoea - arryhthmias Investigations: bloods - ↑ inflammatory markers in 99% - ↑ cardiac enzymes - ↑ BNP ECG - tachycardia - arrhythmias - ST/T wave changes including ST-segment elevation and T wave inversion Management - tx of underlying cause e.g. antibiotics if bacterial cause - supportive treatment e.g. of heart failure or arrhythmias complications - HF - arrhythmia, possibly leading to sudden death - dilated cardiomyopathy: usually a late complication

The typical murmur of aortic stenosis is a crescendo-decrescendo, low-pitched ejection systolic murmur, heard loudest in second right intercostal space, which radiates to the carotids. If severe stenosis is present other examination findings may include:

narrow pulse pressure slow rising pulse a thrill palpable over the cardiac apex a fourth heart sound (S4) indicative of left ventricular hypertrophy a soft/absent S2

A 75-year-old lady presented to the emergency department after suffering a fall 2 hours ago. Before the fall, she was nauseous and experienced sweating, pallor and discomfort in the stomach. She believed that she briefly lost her consciousness but then recovered quickly. She did not have any confusion or weakness after the fall. There were no tongue bites. Neurological examination was normal. Her hearing has always been bad since she was young.What is the diagnosis?

neurally-mediated syncope - due to prodrome symptoms of sweating, pallor and nausea/vomiting before a trasient loss of consciousness.

A 60-year-old woman presents to the GP clinic for a routine check-up. Her 7-day home blood pressure monitoring (HBPM) record shows a mean blood pressure of 155/100 mmHg. Her blood pressure checked by the nurse in the clinic is 160/100 mmHg. She only complains of mild headaches. Past medical history is insignificant for hypertension or diabetes.What antihypertensive drug therapy is most appropriate for this patient?

newly diagnosed patients with HTN >55 - add a Ca channel blocker

A 68-year-old man who has a history of diverticular disease was recently started on a new medication for his angina pectoris.He has presented to the emergency department with severe lower abdominal pain and fever. A computed tomography scan reveals a perforated sigmoid diverticulum. which drug caused this?

nicorandil is associated with ulcers that can occur anywhere along the GIT. They are refractory to treatment and only respond to withdrawal of treatment. patients with diverticular disease are at particular risk of bowel perforation during nicorandil treatment, hence the BNF advises caution in its use in this population.

is a new murmur suggestive of surgical mx in infective endocarditis

no

does anion gap include Ca

no Anion gap = (sodium + potassium) - (bicarbonate + chloride)

A 50 year old man visits his local general practice for health screening as he is starting a new job. He is well and has no relevant past medical history or family history of note. On examination he is comfortable at rest. His pulse rate is 75 beats per minute and irregular and his blood pressure is 128/84 mmHg. An ECG is conducted and shows atrial fibrillation. What is the most appropriate treatment of this patient?

no anticoag as he scores 0 on chadsvasc

do we give atropine in asystole or pulseless electrical activity

no not anymore

CXR in pulmonary embolism

normal

lateral t wave inversion =

nstemi

are women urine sent for msu

only if >65 + pregnant + if haematuria present

when is amiodarone given during ALS

only in VFib or pulseless VT patients in which they have received 3 shocks.

what is J wave on ecg

osborne waves - small hump at the end of QRS complex

A 53-year-old man presents as he is worried about palpitations. These are described as fast and irregular and typically occur twice a day. They seem to be more common after drinking alcohol. There is no history of chest pain or syncope. Examination of his cardiovascular symptoms is normal with a pulse of 72/min and a blood pressure of 116/78 mmHg. Blood tests and a 12-lead ECG are unremarkable. What is the most appropriate next step in management?

palpitations should first be investigated with a holter monitor after initial bloods/ECG. this is because we need to exclude arrhythmias. Holter monitoring should be arranged to try and capture such an episode. Given the episodes occur daily it is reasonable to do this over a 24 hour period initially.

One day following a thrombolysed inferior myocardial infarction a 72-year-old man develops signs of left ventricular failure. His blood pressure drops to 100/70mmHg. On examination he has a new early-to-mid systolic murmur.

papillary muscle rupture - acute MR secondary to papillary muscle rupture

monitoring warafrin

patients are monitored using the INR (international normalised ratio), the ratio of the prothrombin time for the patient over the normal prothrombin time. warfarin has a long half-life and achieving a stable INR may take several days there are a variety of loading regimes and computer software is now often used to alter the dose

who is not given dexamethasone for meningitis

people with suspected meningococcal septicaemia

management of cardiac tamponade

percutaneous balloon pericardiotomy

PR depressions and widespread ST elevations

pericarditis

what heart condition can behcets cause

pericarditis presents with oral and genital ulcers and erythema nodosum

3rd degree heart block mx

permanent pacemaker

A 57-year-old man is brought to the emergency department via ambulance after collapsing at work. On admission, his GCS is 13 out of 15. He is sent for an urgent head CT which shows a collection of blood in the subarachnoid space, midline shift, and hydrocephalus. Whilst the patient is being scheduled and prepared for surgery, he becomes haemodynamically unstable and drops his GCS further to 8 out of 15.What is most likely to been seen on an ECG?

polymorphic VT (torsades de pointes). SAH causes this

diagnostic test for OSA

polysomnography

A 54-year-old man is admitted following a myocardial infarction associated with ST elevation. He is treated with thrombolysis and does not undergo angioplasty. What advice should he be given regarding driving?

post MI cant drive for 4 weeks

A 65-year-old male who has been brought in by ambulance after calling the emergency services complaining of severe crushing chest pain. The ambulance carried out observations which showed tachycardia, hypertension, tachypnoea and normal oxygen saturations. They also did an electrocardiogram (ECG) which showed tall R waves in leads V1 and V2. On arrival the patient is sweaty and in obvious pain. A serial ECG shows tall R waves now in V3 also. Blood results show elevated cardiac enzymes. The patient's past medical history includes hyperthyroidism, polymyalgia rheumatica and hypercholesterolaemia.What is the most likely diagnosis?

posterior MI

what artery is affected in contralateral homonymous hemianopia with macular sparing

posterior cerebral

bp effect of bisoprolol

postural hypotension

mobitz type 2 - what is it and mx

pr interval stays the same manage with a permenant pacemaker

how to mx subacute hypothyroidism if the TSH level is > 10 mU/L on 2 separate occasions 3 months apart

prescribe long term low dose levothyroxinne (even if asx)

A 37-year-old female presents to the emergency department with severe shortness of breath and chest pain. She describes the pain as 7/10, being worse on inspiration.Her heart rate is 120, her respiratory rate is 20/min, her blood pressure is 130/76 mmHg and her temperature is 36.2 ºC. A chest examination highlights no abnormalities. Her left calf is swollen, tender, and erythematous.The doctor would like to complete an investigation but there is a prolonged wait for a computed tomography pulmonary angiogram (CTPA).What is the next best step in management for this patient?

prescribe rivaroxaban whilst awaiting further investigation

causes of orthostatic hypotension

primary autonomic failure: Parkinson's disease, Lewy body dementia secondary autonomic failure: e.g. Diabetic neuropathy, amyloidosis, uraemia drug-induced: diuretics, alcohol, vasodilators volume depletion: haemorrhage, diarrhoea

what may an irregular narrow complex tachycardia be and how is it managed?

probable atrial fibrillation if onset < 48 hr consider electrical or chemical cardioversion rate control: beta-blockers are usually first-line unless there is a contraindication

what does warfarin do to PT and APTT

prolonged PT Normal APTT

loss of function of K channels is known as what syndrome

prolonged QTc syndrome

Hypokalaemia ECG

prominent U-waves, best seen in precordial leads T waves have a 'sine wave' appearance prolonged QTc > 600ms borderline PR interval

A 76-year-old woman is brought into the emergency department by ambulance after collapsing suddenly at home. Initial assessment revealed a heart rate of 42 beats per minute and she is treated according to bradycardia resuscitation guidelines whereupon she stabilises.Her past medical history includes stable angina for which she is prescribed verapamil, however, she has recently been suffering from bouts of anxiety following a car accident, leading her sister to lend her some of the tablets she takes to 'calm her nerves'.Which of the following medications may this patient have taken thus leading to her presentation?

propranolol = Verapamil and beta-blockers should never be taken concurrently - possibility of heart block and fatal arrest

A 54-year-old man is admitted to the hospital. He experienced an episode of chest pain that lasted 20-minutes the day before but had since fully resolved. He has had no further episodes of pain. Serum troponins were in the normal range. A 12-lead ECG is performed, which shows deeply inverted T waves in leads V2 and V3. There are no elevated ST segments.What vessel is most likely to be affected?

proximal left anterior descending artery. Resolved chest pain in a patient with deeply inverted T waves in V2-3 → ?Wellen's pattern, suggestive of critical stenosis of the left anterior descending artery (LAD) Proximal left anterior descending artery is correct. The ECG pattern of T-wave inversion in V2 and V3 on a background of resolved and recent chest pain is highly suggestive of Wellen's syndrome. Patients often have normal or mildly elevated cardiac enzymes. It is due to critical stenosis of the left anterior descending artery. This patient is at an extremely high risk for extensive wall myocardial infarction within the coming days.

name for large drop in BP on inspiration

pulsus paradoxus = cardiac tamponade

signs of right sided heart failure

raised JVP, ankle oedema and hepatomegaly

salicylate poisoning on abg

raised anion gap metabolic acidosis

derranged LFTs after statin treatment

reatment with statins should be discontinued if serum transaminase concentrations rise to and persist at 3 times the upper limit of the reference range.

non resolution of c diff is treated how..

recurrent infection occurs in around 20% of patients, increasing to 50% after their second episode within 12 weeks of symptom resolution: oral fidaxomicin after 12 weeks of symptom resolution: oral vancomycin OR fidaxomicin

rr interval in complete heart block

regular

pulsus alternans means...

regular alternation of the force of the arterial pulse severe LVF

Pulsus alternans

regular alternation of the force of the arterial pulse severe LVF

difference between relative and absolute polycythaemia

relative polycythaemia = the red cell count (surrogate for mass, which is preferred in oxford handbook) would be normal, and haematocrit increases due to reduced plasma volume. - dehydration - stress (gaisbocks syndrome) absolute polycythaemia = the red cell mass is raised here, suggesting absolute polycythemia, where the increased haematocrit is because of an overproduction of these RBCs - primary/secondary

A 75-year-old woman who has been in hospital for the treatment of community acquired pneumonia develops new shortness of breath. CT pulmonary angiogram reveals a right sided pulmonary embolus.What will the arterial blood gas most likely show?

respiratory alkalosis because PE causes hyperventilation

95% of mitral stenosis cases are caused by what

rheumatic fever

A 12-year-old female from Bulgaria presents to the surgery. She reports being unwell for the past 2 weeks. Initially she had a sore throat but she is now experiencing joint pains intermittently in her knees, hips and ankles. On examination there are some pink, ring shaped lesions on the trunk and occasional jerking movements of the face and hands. What is the most likely diagnosis?

rheumatic fever

A 43-year-old man presents to his general practitioner for increasing fatigue and shortness of breath on exertion. He describes increasing breathlessness walking up flights of stairs that has now begun to limit his abilities to complete activities of daily living, alongside increasing fatigue present throughout the day.He has been managing hypertension and dyslipidaemia for several years but his past medical history is otherwise unremarkable. His social history is significant for past intravenous drug use in his early 20s, although he has been sober for 15 years. Prior to immigrating to the UK 10 years ago, he lived in a remote community in central Australia for all of his childhood and adolescent years.On examination, he appears well and you do not note any breathlessness as he enters the room or at rest. His vital signs are unremarkable. Cardiovascular examination is significant for a 2/6 diastolic murmur; an opening snap followed by a low-pitched rumble. The GP suspects this murmur maybe contributing to this patient's symptoms.What is the most likely underlying factor contributing to development of this patient's murmur?

rheumatic fever is the most common cause of mitral stenosis. This patient is likely suffering from rheumatic heart disease, and has developed mitral stenosis - the most common valvular defect of rheumatic heart disease. Additionally, rheumatic fever is the most common cause of mitral stenosis.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.Mitral stenosis is a diastolic murmur, characterised by opening snap and a low-pitched rumble. It is most commonly caused by rheumatic fever, but can also be due to calcium deposition and more rarely congenital malformation or as a sequelae of infective endocarditis from intravenous drug use.

complete heart block following an MI indicates a lesion in which artery

right coronary artery

A 57-year-old man with a background of hypertension presents to the emergency department with severe chest pain. An ECG shows ST elevation in leads II, III and aVF and the patient is diagnosed with ST-elevation myocardial infarction.Given the likely location of the coronary occlusion, from which complication is this patient most likely to suffer?

right coronary infarct supplies the AVN so can cause arrythmias after infarction

right inferior or superior lobe for inhaled foreign body obstruction

right inferior lobe bronchus

where are inhaled foreign objects likely to be found

right main bronchus

heart sound with HOCM

s4

A 55-year-old HIV positive man presents to the Emergency Department with sudden onset of chest pain. A more detailed history is taken which reveals that his pain is sharp and improves when he sits forward. Examination shows that he has a temperature of 38.1ºC and his heart rate is 115 beats/min. An ECG is carried out soon after and based on this man's symptoms, what would be the most likely initial finding?

saddle shaped/concave ST elevations This is a typical clinical picture of acute pericarditis. The combination of the pleuritic chest pain which improves upon sitting forward makes this the most likely diagnosis. Typically, widespread 'saddle-shaped' or concave ST elevation is seen in the ECG of patients with pericarditis.

dry cough, dyspnoea and weight loss. A violet-coloured rash on the cheeks and nose. Hypercalcaemia bilateral hilar lymphadenopathy what is the diagnosis?

sarcoidosis

what may an irregular broad complex tachycardia be?

seek expert help. Possibilities include: atrial fibrillation with bundle branch block - the most likely cause in a stable patient atrial fibrillation with ventricular pre-excitation torsade de pointes

A 52-year-old male attends the stroke unit with dizziness and vertigo while playing tennis. He is known to have hypertension and a previous myocardial infarct. He now complains of right arm pain. What is the most likely diagnosis?

subclavian steal syndrome = Subclavian steal syndrome characteristically presents with posterior circulation symptoms, such as dizziness and vertigo, during exertion of an arm. There is subclavian artery steno-occlusive disease proximal to the origin of the vertebral artery and is associated with flow reversal in the vertebral artery. Management involves percutaneous transluminal angioplasty or a stent.

Heart failure after a few weeks or asymptomatic, pansystolic murmur at lower left sternal edge and louder P2

vsd

hypocalcaemia management

severe hypocalcaemia (e.g. carpopedal spasm, tetany, seizures or prolonged QT interval) requires IV calcium replacement: = the preferred method is with intravenous calcium gluconate, 10ml of 10% solution over 10 minutes = intravenous calcium chloride is more likely to cause local irritation = ECG monitoring is recommended further management depends on the underlying cause

other indications for surgery in infective endocarditis

severe valvular incompetence aortic abscess (often indicated by a lengthening PR interval) infections resistant to antibiotics/fungal infections cardiac failure refractory to standard medical treatment recurrent emboli after antibiotic therapy

digoxin and QT interval

short

A 65-year-old male comes in with a 12-hour history of worsening nausea and vomiting. He has also experienced increasing thirst and urination and has been feeling more fatigued. He denies fever, diarrhoea, constipation, or pain in his chest.His medical history includes ischaemic heart disease - two years ago he had a STEMI with a stent placed in his left anterior descending artery, and a recent diagnosis of stage 3 non-small cell cancer of the lung.On examination, he has dry mucous membranes and is noted to have tender muscles and joints.Which of the following is expected to be found on ECG?

short QT interval

ECG abnormality for hypercalcaemia

shortening of QT interval

the most common ecg change for pulmonary embolism

sinus tachycardia

A 61-year-old man with angina and breathlessness at rest is diagnosed with severe aortic stenosis. As he has no past medical history, he undergoes an open aortic valve replacement and a mechanical valve is implanted.Which of the following drugs is most appropriate for long-term anticoagulation after the surgery?

warfarin used in preference to DOACs for patients with mechanical heart valves

Hypokalemia ecg

small or absent T waves (occasionally inversion) prolong PR interval ST depression long QT u waves

cardiacc tamponade ecg

small qrs complexes electrical alternans

VSD murmur

split S2 and pansystolic

GTN infusion or GTN spray for MI

spray

Which one of the following types of anti-anginal medication do patients commonly develop tolerance to?

standard release isosorbide mononitrate

common cause of IE in IVDU and worldwide

staph aureus

flucoloxacillin is good for which bacteria

staphylococci

An emergency buzzer goes off on the coronary care unit and you are the first doctor on the scene. A healthcare assistant whilst on an observation round found a 74-year-old man unresponsive. You tilt the head and chin lift and feel for a carotid pulse for 10 seconds whilst listening for breath, you feel neither a pulse nor hear breath sounds.Telemetry attached to the patient is showing sinus rhythm at a rate of 120bpm. The crash team is being called and the crash trolley is brought bedside. You are not aware of a DNACPR.What is the most appropriate initial action?

start chest compressions at a rate of 30:2. This patient is in cardiac arrest with a "non-shockable" rhythm (pulseless-electrical activity). Chest compression should immediately be started at a rate of 30:2 rescue breaths.

statin is contraindicated in wat

statins

if a macrolide is being started what drugs should be stopped

statins - increased risk of rhabdomyolysis

difference in pathophys between stemi and nstemi

stemi - complete blockage of an artery whereas nstemi - incomplete blockage

major bleeding and on warfarin management

stop warfarin, give IV vit K 5mg, prothrombin complex concentrate

A 76-year-old man with a history of ischaemic heart disease and hypertension presents for review. He had a myocardial infarction 20 years ago but has had no problems since. His current medication is clopidogrel, atorvastatin, ramipril and bisoprolol. He has recently been feeling light-headed an ECG shows atrial fibrillation.What antithrombotic medication should he now be taking?

switch to oral anticoagulant patients with stable cvd who have AF are generally managed on an anticoagulant and the antiplatelet stopped

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?

sydenham's chorea - late complication of rheumatic fever

indications for a temporary pacemakers

symptomatic/haemodynamically unstable bradycardia, not responding to atropine post-ANTERIOR MI: type 2 or complete heart block* trifascicular block prior to surgery *post-INFERIOR MI complete heart block is common and can be managed conservatively if asymptomatic and haemodynamically stable

You are a junior doctor who has been bleeped to a crash call. The patient is a 36-year-old male on the endocrine ward.You start assessing him using the ABCDE method.The patient looks pale and clammy, but is still responsive.Airway - clear and patent, the patient is talking.Breathing - respiratory rate is 24 breaths per minute and oxygen saturation is at 98% on room air. Chest expansion is equal and bilateral and the trachea is central. Air entry is good and equal bilaterally.Circulation - heart rate is 175 beats per minute, and blood pressure is 88/56 mmHg. IV access is already in place. His ECG shows a regular broad complex tachycardia.Which of the following is the most appropriate next action?

synchronised DC cardioversion under anaesthesia = In the context of a tachyarrhythmia, a systolic BP < 90 mmHg → DC cardioversion other things that would deem a pt unstable: shock: hypotension (systolic blood pressure < 90 mmHg), pallor, sweating, cold, clammy extremities, confusion or impaired consciousness syncope myocardial ischaemia heart failure

synchronised or unsyncrhonised dc shock in people wiyh AFib

synchronised beacuse they still have coordinated electrical actviity between the atria and the ventricles

mx of svt if pt is haemodynamically unstable

synchronised dc cardioversion

A 24-year-old female presents to her GP with lethargy and dizzy spells. On examination she is noted to have an absent left radial pulse and a high ESR. what si the most likely diagnosis

takayasu's arteritis

A 35-year-old woman presents to her GP complaining of right leg pain over the last 3 weeks. She reports that the pain comes on when walking or running. On further questioning, she reveals some weight loss over the last month but put this down to a new diet. Her only medication is the oral contraceptive pill and she smokes 10 cigarettes per day.Examination reveals weak pedal pulses in the right leg but no other abnormalities. Bilateral blood pressure readings show 106/92mmHg in her left arm and 138/104mmHg in her right.What is the most likely diagnosis?

takayasu's arteritis = Takayasu's is a vasculitis that affects the large and medium vessels such as the aorta and its branches. This commonly presents with limb claudication as well as other features such as differential limb blood pressures. The speed of onset and the presence of systemic features such as weight loss point towards an inflammatory cause. Takayasu's arteritis also commonly affects young women. it is not buergers disease as this is an important differential in a young smoker and most commonly presents with discolouration of the digits (to blue or red) and tingling, cold extremities, and, in extreme cases, necrosis, due to thrombosis in the small vessels. furthermore, Buergers disease is more common in men in the 20-40 years demographic. it is not coarctation of the aorta because this would present with differential limb blood pressures, this is generally picked up earlier in life as it can lead to complications in neonates. further, coarctation would not explain the weight loss. Coarctation of the aorta can present with hypertension and berry aneurysm rupture later on in life. DVT = It is important to consider DVT as a differential for leg pain, especially in a patient currently taking the oral contraceptive pill. However, the onset of symptoms and the diminished pedal pulses point more towards an arterial cause of the pain. PAD = The cause of this patient's leg pain is due to some form of arterial insufficiency. However, it would be unusual for a patient of this age to develop peripheral arterial disease. In peripheral arterial disease, you would expect bilateral symptoms, as well as more examination signs such as pallor and arterial ulceration.

post MI ecg

tall R waves ST depression in v1-v3

if anticoagulating for 3 weeks prior to cardioversion for AF what should INR be

target inr = 2.5

A 55-year-old woman presents to the cardiology clinic for a check-up following a recent episode of infective endocarditis. She is recovering well but is still experiencing some general fatigue and breathlessness on exertion and lying flat.On examination, there is a murmur which increases in intensity when the patient is making a fist. Her heart rate is 76 beats per minute with a blood pressure of 135/55mmHg. She has a collapsing pulse.Given the likely diagnosis, what murmur would be heard?

the most common valvular defect after infective endocarditis is aortic regurgitation. the answer is therefore early diastolic murmur. Features of the presentation pointing towards this diagnosis are: Intensity of the murmur is increased by the handgrip manoeuvre Collapsing pulse Wide pulse pressure (this is where there is a great difference between the systolic and diastolic figure of the blood pressure; it can be said to be wide if the difference is greater than 60mmHg, or if the systolic pressure is greater than 2x the diastolic pressure)

A 54-year-old woman is admitted to the hospital with worsening shortness of breath. She has recently been diagnosed with acute myeloid leukaemia and is significantly pancytopenic, with a haemoglobin of 68 g/L. Over the last few weeks, she has become breathless at rest, is fatigued, and complains her legs are swollen.On clinical assessment, she looks unwell. Her blood pressure is 130/88 mmHg, heart rate is 104 bpm, oxygen saturation 98% on room air, and respiratory rate is 20/minute. She has a few basal crepitations. A bedside echo reveals good left ventricular function.What is the most appropriate treatment?

the pt requires a red cell transfusion severe anaemia is a cause of high output HF

alcoholic liver disease ALT AST ratio

the ratio of AST:ALT is normally > 2, a ratio of > 3 is strongly suggestive of acute alcoholic hepatitis

A 72-year-old man presents to his general practitioner with new-onset constipation. This started about a week ago and coincided with the onset of regular stomach cramps. His wife reports that he has also been increasingly confused in the past few days, and has been very drowsy and lethargic, with weak muscles.His past medical history is only significant for hypertension, for which he takes regular amlodipine, atenolol, bendroflumethiazide, and ramipril. He has taken over-the-counter macrogol in the past 7 days to try and help with his constipation.Given the likely cause of his presentation, which medication could have this side effect?

thiazide diuretics - This man's constellation of symptoms may seem puzzling at first, but it should be recognised as the complications of hypercalcaemia. The common mnemonic for hypercalcaemia, and the resulting symptoms, are shown in the table below. the hypercalcaemia causes stones (kidney or biliary stones), bones (bney pain), groans (abdo pain), thrones (muscle weakess and hyporeflexia) and psychiatric moans (depression, anxiety and confusion)

what is eisenmngers syndrome

this 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 HTN. Associated with ventricular septal defect atrial septal defect patent ductus arteriosus Features original murmur may disappear cyanosis clubbing right ventricular failure haemoptysis, embolism Management heart-lung transplantation is required

massive PE and hypotension

thrombolyse - with alteplase

when to use ticagrelor and whne to use clopidogrel for NSTEMI

ticagrelor, if not high bleeding risk clopidogrel, if high bleeding risk

gold standard for diagnosis of aortic stenosis

toe

after fibrinolysis patient still has ST elevations on ecg

transfer patient for PCI

which valve is most affected in people suspected to have infective endocarditis because they are IV drug users?

tricuspid valve

A 62-year-old man is admitted with palpitations. He has no chest pain, physical examination is normal apart from tachycardia and he is haemodynamically stable. Cardiac monitoring shows a regular, monomorphic, broad complex tachycardia. A 12-lead electrocardiogram does not show any features of myocardial ischaemia.His past medical history includes type 2 diabetes mellitus and previous percutaneous coronary intervention to his left anterior descending, right coronary and circumflex arteries.Which of the following management options is contraindicated in this scenario?

verapamil is contraindicated for ventricular tachycardias

A newborn child is assessed. They are found to be in the 25th centile for their weight along with a systolic murmur heard best over the back. When feeling the femoral pulses the doctor notices that there is a radio-femoral delay. Which of the following may be causing these examination findings?

turner syndrome - CoA

Pseudopolyps

uc

In ALS, if IV access cannot be achieved then drugs should be given how are drugs administered

via the interosseous route

deterioration in renal function after starting an ACEi points towards

undiagnosed bilateral renal artery stenosis

A 65-year-old man has acute breathlessness. He had fevers and malaise over the last 3 weeks. There is decreased air entry and inspiratory crackles bilaterally. A pansystolic murmur is heard in the 5th intercostal space in the midclavicular line.His heart rate is 120 bpm, blood pressure is 93/60 mmHg, and respiratory rate is 26 /min. Oxygen saturations are 92% on room air and his temperature is 39ºC.Blood cultures show S. aureus twice and a chest x-ray shows bilateral oedema. Echocardiography shows an ejection fraction of 33% and valvular regurgitation.What is the definitive step in this patient's management?

urgent valvular surgery Infective endocarditis - indications for surgery: severe valvular incompetence aortic abscess (often indicated by a lengthening PR interval) infections resistant to antibiotics/fungal infections cardiac failure refractory to standard medical treatment recurrent emboli after antibiotic therapy

A 58-year-old man, Wayne, presents to the emergency department complaining of a cough, high fever, fatigue and palpitations. Wayne informs you that his palpitations started 12 hours ago. His temperature is 38ºC, his heart rate is 110bpm and his ECG shows an irregularly irregular rhythm with the absence of P waves. His blood pressure is 120/70 mmHg and his respiratory rate is 17/minute. His X-ray shows right lower-lobe consolidation. He is otherwise well, with no comorbidities. He is started on treatment for his underlying pneumonia. Which of the following management options should be considered for this patient's AF

use rhythm control to treat AFib if there is coexisting HF, first onset AF or an obvious reversible cause

investigation of PE in someone with renal impairment

v/q scan

what may a regular narrow complex tachycardia be and how is it managed?

vagal manoeuvres followed by IV adenosine if above unsuccessful consider diagnosis of atrial flutter and control rate (e.g. beta-blockers)

causes of pericarditis

viral infections (Coxsackie) tuberculosis uraemia (causes 'fibrinous' pericarditis) trauma post-myocardial infarction, Dressler's syndrome connective tissue disease hypothyroidism malignancy

A 65-year-old man with no significant past medical history is admitted to the Emergency Department. His ECG is consistent with an anterior myocardial infarction. Unfortunately he develops cardiac arrest shortly after arriving in the department. What is the most common cause of death in patients following a myocardial infarction?

ventricular fib

A 65-year-old man is on the ward recovering from an ST-elevated myocardial infarction (STEMI).Five days into his recovery, he reports sudden onset shortness of breath, particularly when lying flat. He also reports developing a wheezing cough.Examination reveals distended neck veins and an audible pan-systolic murmur.Based on the information provided, which of the following pathologies is the most likely explanation for this patient's current presentation?

ventricular septal defect A patient develops acute heart failure 5 days after a myocardial infarction. A new pan-systolic murmur is noted on examination - ventricular septal defect Ventricular septal defects usually occur within the first week of myocardial infarction (MI) and are caused by ischaemic damage to the inter-ventricular septum. It presents with acute heart failure and a pan-systolic murmur. An echocardiogram (ECHO) should be performed to confirm the diagnosis, especially as it can present similarly to acute mitral regurgitation caused by papillary muscle rupture or ischaemia following an MI.

A 70-year-old man with a past medical history of osteoarthritis and asthma attends his annual health check-up. He does not complain of any ongoing symptoms, and examination is unremarkable apart from an irregularly irregular pulse. An ECG confirms your suspicion of atrial fibrillation (AF). After ruling out any underlying causes of his AF, you decide to commence this man on treatment.Which of the following drugs should be prescribed to achieve rate-control of this man's AF?

verapamil

Are ACEi CI in pregnancy

yes

can warfarin be used during breastfeeding

yes

is RBBB often non pathological

yes

is d dimer often raised in aortic dissection

yes

verapamil is CI in hf

yes

can you use nifedipine with sildenafil

yes - not nicorandil

most common cause of aortic stenosis in young patients and older patients

younger patients < 65 years: bicuspid aortic valve older patients > 65 years: calcification

Resolved chest pain in a patient with deeply inverted T waves in V2-3

→ ?Wellen's pattern, suggestive of critical stenosis of the left anterior descending artery (LAD)