Which part of the jugular venous waveform is associated with the closure of the tricuspid valve?
Correct Answer B: JVP: C wave - closure of the tricuspid valve. The c wave of the jugular venous waveform is associated with the closure of the tricuspid valve.
Jugular venous pulse:
As well as providing information on right atrial pressure, the jugular vein waveform may provide clues to underlying valvular disease. A non-pulsatile JVP is seen in superior vena caval obstruction. Kussmaul's sign describes a paradoxical rise in JVP during inspiration seen in constrictive pericarditis.
'a' wave = atrial contraction:
Cannon 'a' waves:
'c' wave:
'v' wave:
'x' descent = fall in atrial pressure during ventricular systole
'y' descent = opening of tricuspid valve
A 71-year-old woman presents with palpitations and 'light headedness'. An ECG shows that she is in atrial fibrillation with a rate of 130 / min. Her blood pressure is normal and examination of her cardiorespiratory system is otherwise unremarkable. Her past medical history includes well controlled asthma (salbutamol & beclomethasone) and depression (citalopram). Her symptoms have been present for around three days.
What is the most appropriate medication to use for rate control?
Correct Answer A: Her history of asthma is a contraindication to the prescription of a beta-blocker. NICE therefore recommend a rate-limiting calcium channel blocker. Consideration should also be given to antithrombotic therapy.
Atrial fibrillation: rate control and maintenance of sinus rhythm:
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 used to control rate in patients with atrial fibrillation:
Agents used to maintain sinus rhythm in patients with a history of atrial fibrillation:
A 62-year-old man is referred from the Emergency Department with a pulse of 40 beats/min.
Which one of the following factors carries the least risk of asystole when risk stratifying the patient?
Correct Answer C: Complete heart block with a narrow complex QRS complex carries the least risk of asystole as the atrioventricular junctional pacemaker may provide an haemodynamically acceptable and stable heart rate. The other four factors are indications for transvenous pacing.
Peri-arrest rhythms: bradycardia:
The 2010 Resuscitation Council (UK) guidelines emphasize that the management of bradycardia depends on:
Adverse signs: The following factors indicate haemodynamic compromise and hence the need for treatment:
Atropine is the first line treatment in this situation. If this fails to work, or there is the potential risk of asystole then transvenous pacing is indicated.
Potential risk of asystole: The following indicate a potential risk of asystole and hence the need for treatment with transvenous pacing:
If there is a delay in the provision of transvenous pacing the following interventions may be used:
A 34-year-old man is seen in the cardiology clinic. He has been referred by his GP with a history of increasing dyspnoea and exercise-related syncope. His father died suddenly when at the age of 42- years-old. An ECG attached to the admission letter shows left ventricular hypertrophy with widespread T wave inversion.
Given the likely diagnosis, what is the most appropriate next investigation?
Correct Answer B: The likely diagnosis is hypertrophic obstructive cardiomyopathy which should be investigated with a transthoracic echocardiogram.
HOCM: features Hypertrophic obstructive cardiomyopathy (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.
Features:
Associations:
Echo - mnemonic - MR SAM ASH:
ECG:
Which one of the following features is not part of the modified Duke criteria used in the diagnosis of infective endocarditis?
Correct Answer C: The modified Duke criteria have now been adopted in the latest guidelines from the European Society of Cardiology.
Infective endocarditis: Modified Duke criteria:
Infective endocarditis diagnosed if:
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:
Evidence of endocardial involvement:
Minor criteria:
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