A 41-year-old man is admitted with left-sided pleuritic chest pain. He has a dry cough and reports that the pain is relieved by sitting forward. For the past three days he has been experiencing flu-like symptoms.
Given the likely diagnosis, what is the most likely finding on ECG?
Correct Answer C: Pericarditis is one of the differentials of any patient presenting with chest pain.
Pericarditis:
Features:
Causes:
ECG changes:
A 72-year-old man is investigated for exertional chest pain and has a positive exercise tolerance test. He declines an angiogram and is discharged on a combination of aspirin 75mg od, simvastatin 40mg on, atenolol 50mg od and a GTN spray prn. Examination reveals a pulse of 72 bpm and a blood pressure of 130/80 mmHg. On review he is still regularly using his GTN spray.
What is the most appropriate next step in management?
Correct Answer C: The BNF recommends an atenolol dose of 100mg daily in 1 or 2 doses for angina. 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:
Which one of the following conditions is most associated with a bisferiens pulse?
Correct Answer E:
Pulses:
Pulsus paradoxus:
Slow-rising/plateau:
Collapsing:
Pulsus alternans:
Bisferiens pulse:
'Jerky' pulse:
*HOCM may occasionally be associated with a bisferiens pulse
What is the most common cardiac defect seen in patients with Down's syndrome?
Correct Answer B: Endocardial cushion defects account for about 40% of congenital heart disease seen in patients with Down's syndrome.
Down syndrome:
Clinical features:
Cardiac complications:
Later complications:
A 17-year-old male is taken to the Emergency Department due to alcohol intoxication. On examination he is noted to be tachycardic with a rate of 140bpm. An ECG shows atrial fibrillation. The following morning he is noted to be in sinus rhythm.
What is the most appropriate management?
Correct Answer E: Supraventricular arrhythmias secondary to acute alcohol intake are well characterized and have been termed 'holiday heart syndrome'. No specific treatment is required.
Atrial fibrillation classification:
An attempt was made in the joint American Heart Association (AHA), American College of Cardiology (ACC) and European Society of Cardiology (ESC) 2012 guidelines to simplify and clarify the classification of atrial fibrillation (AF).
It is recommended that AF be classified into 3 patterns:
First detected episode (irrespective of whether it is symptomatic or self-terminating)
Recurrent episodes, when a patient has 2 or more episodes of AF. If episodes of AF terminate spontaneously then the term paroxysmal AF is used. Such episodes last less than 7 days (typically < 24 hours). If the arrhythmia is not self-terminating then the term persistent AF is used. Such episodes usually last greater than 7 days
In permanent AF there is continuous atrial fibrillation which cannot be cardioverted or if attempts to do so are deemed inappropriate. Treatment goals are therefore rate control and anti-coagulation if appropriate
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