Which one of the following treatments have not been shown to improve mortality in patients with chronic heart failure?
Correct Answer C: Whilst useful in managing the symptoms of acute and chronic heart failure frusemide offers no prognostic benefits.
Heart failure: drug management:
A number of drugs have been shown to improve mortality in patients with chronic heart failure:
No long-term reduction in mortality has been demonstrated for loop diuretics such as furosemide.
NICE issued updated guidelines on management in 2010, key points include:
*Digoxin has also not been proven to reduce mortality in patients with heart failure. It may however improve symptoms due to its inotropic properties. Digoxin is strongly indicated if there is coexistent atrial fibrillation.
**Adults usually require just one dose but those with asplenia, splenic dysfunction or chronic kidney disease need a booster every 5 years.
A 70-year-old woman is brought to the Emergency Department by her relatives. For the past two hours she has experienced palpitations and 'tightness' in her chest. An ECG taken on arrival shows baseline atrial activity of around 300/min with a ventricular rate of 150/min.
What is the most likely diagnosis?
Correct Answer B: Tachycardia with a rate of 150/min ?atrial flutter.
Atrial flutter is a form of supraventricular tachycardia characterized by a succession of rapid atrial depolarization waves.
ECG findings:
Management:
You review a patient who has been admitted with a non-ST elevation myocardial infarction in the Emergency Department.
Following recent NICE guidance, which patients should receive clopidogrel?
Correct Answer A:
NICE NSTEMI/unstable angina guidelines are based on 6 month mortality risk:
The 6 month mortality may be calculated using a validated risk model such as GRACE.
Acute coronary syndrome: management: NICE produced guidelines in 2010 on the management of unstable angina and non-ST elevation myocardial infarction (NSTEMI). They advocate managing patients based on the early risk assessment using a recognized scoring system such as GRACE (Global Registry of Acute Cardiac Events) to calculate a predicted 6 month mortality.
All patients should receive:
Whilst it is common that non-hypoxic patients receive oxygen therapy there is little evidence to support this approach. The 2008 British Thoracic Society oxygen therapy guidelines advise not giving oxygen unless the patient is hypoxic.
Antithrombin treatment. Fondaparinux should be offered to patients who are not at a high risk of bleeding and who are not having angiography within the next 24 hours. If angiography is likely within 24 hours or a patients creatinine is > 265 μmol/l unfractionated heparin should be given.
Clopidogrel 300mg should be given to patients with a predicted 6 month mortality of more than 1.5% or patients who may undergo percutaneous coronary intervention within 24 hours of admission to hospital. Clopidogrel should be continued for 12 months.
Intravenous glycoprotein IIb/IIIa receptor antagonists (eptifibatide or tirofiban) should be given to patients who have an intermediate or higher risk of adverse cardiovascular events (predicted 6- month mortality above 3.0%), and who are scheduled to undergo angiography within 96 hours of hospital admission.
Coronary angiography should be considered within 96 hours of first admission to hospital to patients who have a predicted 6-month mortality above 3.0%. It should also be performed as soon as possible in patients who are clinically unstable.
The table below summaries the mechanism of action of drugs commonly used in the management of acute coronary syndrome:
Six weeks after having a prosthetic heart valve a patient develops infective endocarditis.
What is the most likely causative organism?
Correct Answer B:
Most common cause of endocarditis:
In the first two months following surgery for a prosthetic valve the most likely causative organism is Staphylococcus epidermidis.
Infective endocarditis: The strongest risk factor for developing infective endocarditis is a previous episode of endocarditis.
The following types of patients are affected:
Causes:
Culture negative causes:
Following prosthetic valve surgery Staphylococcus epidermidis is the most common organism in the first 2 months and is usually the result of perioperative contamination. After 2 months the spectrum of organisms which cause endocarditis return to normal, except with a slight increase in Staph. aureus infections.
A 60-year-old man presents with increasing shortness-of-breath on exertion. During the examination a third heart sound is heard. Examination of the respiratory system is unremarkable.
Which one of the following is most consistent with this finding?
Correct Answer A: A third heart sound is only considered a normal variant in patients < 40 years of age.
Heart sounds: The first heart sound (S1) is caused by closure of the mitral and tricuspid valves whilst the second heart sound (S2) is due to aortic and pulmonary valve closure.
S1:
S2:
S3:
S4:
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