A 74-year-old man with symptomatic aortic stenosis is reviewed in the cardiology clinic. He is otherwise fit and well and keen for intervention if possible.
What type of intervention is he most likely to be offered?
Correct Answer C: Prosthetic heart valves - mechanical valves last longer and tend to be given to younger patients.
Prosthetic heart valves The most common valves which need replacing are the aortic and mitral valve. There are two main options for replacement: biological (bioprosthetic) or mechanical.
Following the 2008 NICE guidelines for prophylaxis of endocarditis antibiotics are no longer recommended for common procedures such as dental work.
A 36-year-old woman presents for a routine antenatal review. She is now 15 weeks pregnant. Her blood pressure in clinic is 154/94 mmHg. This is confirmed with ambulatory blood pressure monitoring. On reviewing the notes it appears her blood pressure four weeks ago was 146/88 mmHg. A urine dipstick shows protein + and nothing else.There is no significant past medical history of note.
What is the most likely diagnosis?
Correct Answer E: This lady has pre-existing hypertension. Pregnancy related blood pressure problems (such as pregnancy induced hypertension or pre-eclampsia) do not occur before 20 weeks. The raised ambulatory blood pressure readings exclude a diagnosis of white-coat hypertension.
Note the use of the term 'pre-existing hypertension' rather than essential hypertension. Raised blood pressure in a 36-year-old females not that common and raises the possibility of secondary hypertension.
Hypertension in pregnancy
The classification of hypertension in pregnancy is complicated and varies. Remember, in normal pregnancy:
Hypertension in pregnancy in usually defined as:
After establishing that the patient is hypertensive they should be categorized into one of the following groups:
A 52-year-old female with a known history of systemic sclerosis presents for annual review to the rheumatology clinic. Which one of the following symptoms is most characteristic in patients who have developed pulmonary arterial hypertension?
Correct Answer A: 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.
Pulmonary arterial hypertension:
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 features would indicate cardiac tamponade rather than constrictive pericarditis?
Correct Answer C: In cardiac tamponade there is characteristically no Y descent on the JVP. The other four features are seen in both cardiac tamponade and constrictive pericarditis.
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
A 24-year-old male is diagnosed as having hypertrophic obstructive cardiomyopathy.
Which one of the following markers is most useful in assessing risk of sudden death?
Correct Answer A: Hypertrophic obstructive cardiomyopathy (HOCM) is an autosomal dominant disorder of muscle tissue caused by defects in the genes encoding contractile proteins. Mutations to various proteins including beta-myosin, alpha-tropomyosin and troponin T have been identified. Septal hypertrophy causes left ventricular outflow obstruction. It is an important cause of sudden death in apparently healthy individuals.
HOCM:
Poor prognostic factors:
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