The most common cause of restrictive cardiomyopathy in the UK is:
Correct Answer E:
Restrictive cardiomyopathy: amyloid (most common), haemochromatosis, Loffler's syndrome, sarcoidosis, scleroderma.
Restrictive cardiomyopathy:
Features:
Features suggesting restrictive cardiomyopathy rather than constrictive pericarditis:
Causes:
Which of the following is a cause of a loud second heart sound?
Correct Answer C:
Second heart sound (S2):
Heart sounds: S2: 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):
A 53-year-old man is reviewed in the cardiology clinic with a history of chest pain and syncope. On examination he has an ejection systolic murmur radiating to the carotid area.
What is the most likely cause of his symptoms?
Correct Answer A: Aortic stenosis - most common cause:
Aortic stenosis:
Causes of aortic stenosis:
Management:
An 82-year-old man is reviewed. He is known to have ischaemic heart disease and is still getting regular attacks of angina despite taking atenolol 100mg od. Examination of his cardiovascular system is unremarkable with a pulse of 72 bpm and a blood pressure of 148/92 mmHg.
What is the most appropriate next step in management?
Correct Answer D:
NICE guidelines recommend adding a calcium channel blocker for angina which is not adequately controlled with beta-blocker monotherapy. Verapamil is contraindicated whilst taking a beta-blocker and diltiazem should be used with caution due to the risk of bradycardia. The starting dose of isosorbide mononitrate is 10mg bd.
Angina pectoris: drug management:
The management of stable angina comprises lifestyle changes, medication, percutaneous coronary intervention and surgery. NICE produced guidelines in 2011 covering the management of stable angina.
Medication:
Nitrate tolerance:
Ivabradine:
A 58-year-old man presents to the Emergency Department following an episode of transient right sided weakness which lasted approximately 20 minutes. He has had two previous episodes of a similar nature. On examination he is found to be in atrial fibrillation at a rate of 80 bpm. CT head normal . He is started on aspirin 300mg od. Two days later he has a carotid doppler which is normal.
What is the most appropriate management?
This patient has atrial fibrillation. As a consequence he has had a number of transient ischaemic attacks (TIAs) and hence needs to be anticoagulated with warfarin.
In patients who've had an ischaemic stroke the guidelines recommend waiting two weeks before anticoagulation is commenced to reduce the risk of haemorrhagic transformation. However, NICE recommend for TIA patients: 'in the absence of cerebral infarction or haemorrhage, anticoagulation therapy should begin as soon as possible.'
Atrial fibrillation: anticoagulation:
The European Society of Cardiology published updated guidelines on the management of atrial fibrillation in 2012. They suggest using the CHA2DS2-VASc score to determine the most appropriate anticoagulation strategy.
This scoring system superceded the CHADS2score.
Below shows a suggested anticoagulation strategy* based on the score: Score………… Anticoagulation
*The wording in the guidelines ('is preferred to') can be slightly confusing. It basically means that, say for a score of 0, whilst aspirin is an acceptable management option the weight of the clinical evidence would support no treatment instead.
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