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 94/60 mmHg and the pulse is 140-150 and irregular. ECG confirms atrial fibrillation.
What is the most appropriate management?
Correct Answer C: Heart failure is one of the adverse signs indicating the need for urgent synchronized DC cardioversion.
Peri-arrest rhythms: tachycardia:
The 2010 Resuscitation Council (UK) guidelines have simplified the advice given for the management of peri-arrest tachycardias. Separate algorithms for the management of broad-complex tachycardia, narrow complex tachycardia and atrial fibrillation have been replaced by one unified treatment algorithm.
Following basic ABC assessment, patients are classified as being stable or unstable according to the presence of any adverse signs:
If any of the above adverse signs are present then synchronized DC shocks should be given.
Treatment following this is given according to whether the QRS complex is narrow or broad and whether the rhythm is regular or irregular. The full treatment algorithm can be found at the Resuscitation Council website, below is a very limited summary:
Broad-complex tachycardia:
Regular:
Irregular:
Narrow-complex tachycardia:
Pulmonary arterial hypertension may be seen in each one of the following conditions, except:
Correct Answer A: Hepatitis B is not a recognized cause of pulmonary arterial hypertension.
Pulmonary arterial hypertension: causes and classification: 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. PAH has recently been reclassified by the WHO:
Group 1: Pulmonary arterial hypertension (PAH):
Group 2: Pulmonary hypertension with left heart disease:
Group 3: Pulmonary hypertension secondary to lung disease/hypoxia:
Group 4: Pulmonary hypertension due to thromboembolic disease
Group 5: Miscellaneous conditions:
*previously termed primary pulmonary hypertension
**the mechanism by which HIV infection produces pulmonary hypertension remains unknown
A 43-year-old man who is known to have Wolff-Parkinson White syndrome presents to the Emergency Department with palpitations. He has no other significant history of note. The palpitations started around 4 hours ago and are not associated with chest pain or shortness of breath. On examination blood pressure is 124/80 mmHg and the chest is clear on auscultation. An ECG show atrial fibrillation at a rate of 154 bpm.
Of the following options, what is the most appropriate management?
Correct Answer B: Adenosine should be avoided as blocking the AV node can paradoxically increase ventricular rate resulting in fall in cardiac output. Verapamil and digoxin should also be avoided in patients with Wolff-Parkinson White as they may precipitate VT or VF.
Another option to consider in this situation would be DC cardioversion.
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 62-year-old man is admitted to hospital following a myocardial infarction. Four days after admission he develops a further episode of central crushing chest pain.
Which is the best cardiac marker to investigate his chest pain?
Correct Answer D: By day four the CK-MB levels should have returned to normal from the initial myocardial infarction. If the CK-MB levels are elevated it would indicate a further coronary event.
Cardiac enzymes and protein markers: Interpretation of the various cardiac enzymes has now largely been superceded by the introduction of troponin T and I. Questions still however commonly appear in the MRCP
Key points for the exam:
Which one of the following is a cause of a soft second heart sound?
Correct Answer A:
Second heart sound (S2):
S2 is soft in severe aortic stenosis
Heart sounds: S2 is caused by the closure of the aortic valve (A2) closely followed by that of the pulmonary valve (P2)
Causes of a loud S2:
Causes of a soft S2:
Causes of fixed split S2:
Causes of a widely split S2:
Causes of a reversed (paradoxical) split S2 (P2 occurs before A2):
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