A 62-year-old man is admitted with to the cardiology ward with infective endocarditis. Blood cultures grow Streptococcus bovis.
What is the most appropriate investigation given the blood culture findings?
Correct Answer E: Streptococcus bovis endocarditis is associated with colorectal cancer.
Infective endocarditis: The strongest risk factor for developing infective endocarditis is a previous episode of endocarditis.
The following types of patients are affected:
Causes:
Culture negative causes:
Following prosthetic valve surgery Staphylococcus epidermidis is the most common organism in the first 2 months and is usually the result of perioperative contamination. After 2 months the spectrum of organisms which cause endocarditis return to normal, except with a slight increase in Staph. aureus infections.
A 65-year-old man with a history of paroxysmal atrial fibrillation presents with palpitations. He has no other history of note and a recent echocardiogram was normal. An ECG confirms fast atrial fibrillation.
Which one of the following agents is most likely to cardiovert him into sinus rhythm?
Correct Answer C: Atrial fibrillation - cardioversion: amiodarone + flecainide.
Atrial fibrillation: pharmacological cardioversion:
The Royal College of Physicians and NICE published guidelines on the management of atrial fibrillation (AF) in 2006. 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.
Agents with proven efficacy in the pharmacological cardioversion of atrial fibrillation:
Less effective agents:
A 2-day-old baby girl is noted to become cyanotic whilst feeding and crying. A diagnosis of congenital heart disease is suspected.
What is the most likely cause?
Correct Answer A:
Congenital heart disease:
The key point to this question is that whilst tetralogy of Fallot is more common than transposition of the great arteries (TGA), Fallot's doesn't usually present until 1-2 months following the identification of a murmur or cyanosis. In the neonate, TGA is the most common presenting cause of cyanotic congenital heart disease. The other 3 options are causes of acyanotic congenital heart disease.
Congenital heart disease: types:
1- Acyanotic - most common causes:
VSDs are more common than ASDs. However, in adult patients ASDs are the more common new diagnosis as they generally presents later.
2- Cyanotic - most common causes:
Fallot's is more common than TGA. However, at birth TGA is the more common lesion as patients with Fallot's generally presenting at around 1-2 months.
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?
Correct Answer A: This patient has Wolff-Parkinson White syndrome, with accessory pathway ablation being the definitive treatment.
Wolff-Parkinson White:
Wolff-Parkinson White (WPW) syndrome is caused by a congenital accessory conducting pathway between the atria and ventricles leading to a atrioventricular re-entry tachycardia (AVRT). As the accessory pathway does not slow conduction AF can degenerate rapidly to VF Possible ECG features include:
Differentiating between type A and type B:
Associations of WPW:
Management:
*In the majority of cases, or in a question without qualification, Wolff-Parkinson-White syndrome is associated with left axis deviation.
**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.
A 71-year-old woman is reviewed in the falls clinic. Her blood pressure is 146/ 94 mmHg. This is confirmed on a second reading.
In line with recent NICE guidance, what is the most appropriate next-step?
Correct Answer C: Hypertension - NICE now recommend ambulatory blood pressure monitoring to aid diagnosis The 2011 NICE guidelines recognize that in the past there was over treatment of 'white coat' hypertension. The use of ambulatory blood pressure monitoring (ABPM) aims to reduce this. There is also good evidence that ABPM is a better predictor of cardiovascular risk than clinic blood pressure readings. See the following study for more details: Verdecchia P. Prognostic value of ambulatory blood pressure: current evidence and clinical implications. Hypertension 2000; 35: 844-851.
Hypertension: diagnosis and management:
NICE published updated guidelines for the management of hypertension in 2011. Some of the key changes include:
Blood pressure classification: This becomes relevant later in some of the management decisions that NICE advocate.
Diagnosing hypertension If a BP reading is >= 140 / 90 mmHg patients should be offered ABPM to confirm the diagnosis. Patients with a BP reading of >= 180/110 mmHg should be considered for immediate treatment. Ambulatory blood pressure monitoring (ABPM):
Managing hypertension: ABPM/HBPM >= 135/85 mmHg (i.e. stage 1 hypertension):
For patients < 40 years consider specialist referral to exclude secondary causes.
Step 1 treatment:
Step 2 treatment:
Step 3 treatment:
NICE define a clinic BP >= 140/90 mmHg after step 3 treatment with optimal or best tolerated doses as resistant hypertension. They suggest step 4 treatment or seeking expert advice.
Step 4 treatment:
If BP still not controlled seek specialist advice.
New drugs
Direct renin inhibitors:
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