A 59-year-old female is admitted to the Emergency Department with a 30 minute history of central chest pain radiating to her left arm. An ECG shows ST elevation in leads II, III, aVF.
Which coronary artery is most likely to be affected?
Correct Answer A: Inferior MI - right coronary artery lesion.
ECG: coronary territories: The table below shows the correlation between ECG changes and coronary territories:
A 55-year-old smoker with a past history of hypertension presents to the Emergency Department with shortness of-breath since the morning. Examination reveals bibasal crackles whilst the CXR shows upper lobe diversion and perihilar shadowing. The ECG and cardiac enzymes are normal.
What is the likely cause of his breathlessness?
Correct Answer D: Flash pulmonary oedema, U&Es worse on ACE inhibitor, asymmetrical kidneys --> renal artery stenosis - do MR angiography.
Renal artery stenosis may cause sudden onset or 'flash' pulmonary oedema. A myocardial infarction is unlikely given the normal ECG and cardiac enzymes. Chest pain would also be expected in a 55- year-old patient with no history of diabetes. Fibromuscular dysplasia is generally seen in young woman.
Renal vascular disease:
Renal vascular disease is most commonly due to atherosclerosis (> 95% of patients). It is associated with risk factors such as smoking and hypertension that cause atheroma elsewhere in the body. It may present as hypertension, chronic renal failure or 'flash' pulmonary oedema. In younger patients however fibro-muscular-dysplasia (FMD) needs to be considered. FMD is more common in young women and characteristically has a 'string of beads' appearance on angiography. Patients respond well to balloon angioplasty.
Investigation:
An 18-year-old female who is known to have Turner's syndrome is referred to cardiology as she has a murmur. On examination a soft ejection systolic murmur is heard.
What is the most likely cause of this finding?
Correct Answer E: Turner's syndrome - most common cardiac defect is bicuspid aortic valve.
Turner's syndrome:
Turner's syndrome is a chromosomal disorder affecting around 1 in 2,500 females. It is caused by either the presence of only one sex chromosome (X) or a deletion of the short arm of one of the X chromosomes. Turner's syndrome is denoted as 45,XO or 45,X.
Features:
There is also an increased incidence of autoimmune disease (especially autoimmune thyroiditis) and Crohn's disease.
A 74-year-old man presents for a medication review. Blood pressure is recorded as 184/72 mmHg. This is confirmed on two further occasions.
What is the most appropriate first line therapy?
Correct Answer D: The 2011 NICE guidelines recommended treating isolated systolic hypertension the same way as standard hypertension. In this age group calcium channel blockers would be first-line.
Isolated systolic hypertension:
Isolated systolic hypertension (ISH) is common in the elderly, affecting around 50% of people older than 70 years old. The Systolic Hypertension in the Elderly Program (SHEP) back in 1991 established that treating ISH reduced both strokes and ischaemic heart disease. Drugs such as thiazides were recommended as first line agents.
This approach is contradicated by the 2011 NICE guidelines which recommends treating ISH in the same stepwise fashion as standard hypertension.
Which one of the following is not an indication for insertion of a temporary pacemaker?
Correct Answer A: Complete heart block following an inferior MI is NOT an indication for pacing, unlike with an anterior MI.
Post-inferior MI complete heart block is common and can be managed conservatively if the patient is asymptomatic and haemodynamically stable.
Pacemakers: temporary:
Indications for a temporary pacemaker:
*Post-INFERIOR MI complete heart block is common and can be managed conservatively if asymptomatic and haemodynamically stable
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