A 62-year-old man comes for review. In the past month he has had two episodes of 'passing out'. The first occurred whilst going upstairs. The second occurred last week whilst he was getting out of a swimming pool. There were no warning signs prior to these episodes. He was told by people who witnessed the episode last week that he was only 'out' for around 15 seconds. He reports feeling 'groggy' for only a few seconds after the episode. On examination pulse is 90 / minute, blood pressure 110/86 mmHg, his lungs are clear and there is a systolic murmur which radiates to the carotid area.
Which one of the following investigations should be arranged first?
Correct Answer B: The systolic murmur may be a pointer to aortic stenosis (AS). Syncope is a late sign and typically occurs on exertion in patients with AS. It is therefore important to exclude this condition as a priority. An exercise tolerance test would be contraindicated in a patient with suspected aortic stenosis.
Aortic stenosis: Features of severe aortic stenosis:
Causes of aortic stenosis:
Management:
A 44-year-old female is investigated for suspected idiopathic pulmonary hypertension.
Which one of the following is the best method for deciding upon management strategy?
Correct Answer B: Pulmonary arterial hypertension: features and management
Pulmonary arterial hypertension (PAH) may be defined as a sustained elevation in mean pulmonary arterial pressure of greater than 25 mmHg at rest or 30 mmHg after exercise.
Features:
Management should first involve treating any underlying conditions, for example with anticoagulants or oxygen. Following this, it has now been shown that acute vasodilator testing is central to deciding on the appropriate management strategy. Acute vasodilator testing aims to decide which patients show a significant fall in pulmonary arterial pressure following the administration of Vasodilators such as intravenous epoprostenol or inhaled nitric oxide.
If there is a positive response to acute vasodilator testing:
If there is a negative response to acute vasodilator testing:
Which one of the following is least associated with myocarditis?
Correct Answer C:
Myocarditis
Causes:
Presentation:
Which one of the following ECG findings is least associated with digoxin use?
Correct Answer D:
Digoxin ECG features:
Which one of the following features would indicate cardiac tamponade rather than constrictive pericarditis?
Correct Answer A:
Cardiac tamponade:
The key differences between constrictive pericarditis and cardiac tamponade are summarized in the table below:
A commonly used mnemonic to remember the absent Y descent in cardiac tamponade is TAMponade = TAMpaX
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