A 61-year-old man is admitted with central crushing chest pain to the Emergency Department. An ECG taken immediately on arrival shows ST-elevation in leads II, III and aVF. His only past medical history of note is hypertension for which he takes ramipril, aspirin and simvastatin.
What is the optimum management of this patient? (LMWH = low-molecular weight heparin)
Correct Answer E:
Primary percutaneous coronary intervention is the gold-standard treatment for ST-elevation myocardial infarction.
Myocardial infarction: management:
A number of studies over the past 10 years have provided an evidence for the management of ST elevation myocardial infarction (STEMI).
In the absence of contraindications, all patients should be given:
NICE suggest the following in terms of oxygen therapy:
Primary percutaneous coronary intervention (PCI) has emerged as the gold-standard treatment for STEMI but is not available in all centres. Thrombolysis should be performed in patients without access to primary PCI.
With regards to thrombolysis:
An ECG should be performed 90 minutes following thrombolysis to assess whether there has been a greater than 50% resolution in the ST elevation:
Which one of the following drugs is best avoided in patients with hypertrophic obstructive cardiomyopathy?
Correct Answer C:
HOCM - drugs to avoid: nitrates, ACE-inhibitors, inotropes.
Verapamil should however be avoided in patients with coexistent Wolff-Parkinson White as it may precipitate VT or VF.
HOCM: management:
Hypertrophic obstructive cardiomyopathy (HOCM) is an autosomal dominant disorder of muscle tissue caused by defects in the genes encoding contractile proteins. The estimated prevalence is 1 in 500.
Management:
Drugs to avoid:
*Although see the 2008 NICE guidelines on infective endocarditis prophylaxis.
Each one of the following is associated with aortic dissection, except:
Correct Answer A:
Aortic dissection:
Stanford classification:
DeBakey classification:
Associations:
Complications of backward tear:
Complications of forward tear:
Which part of the jugular venous waveform is associated with the opening of the tricuspid valve?
JVP: y descent = opening of tricuspid valve.
Jugular venous pulse: As well as providing information on right atrial pressure, the jugular vein waveform may provide clues to underlying valvular disease. A non-pulsatile JVP is seen in superior vena caval obstruction. Kussmaul's sign describes a paradoxical rise in JVP during inspiration seen in constrictive pericarditis.
'a' wave = atrial contraction:
Cannon 'a' waves:
'c' wave:
'v' wave:
'x' descent = fall in atrial pressure during ventricular systole.
'y' descent = opening of tricuspid valve.
A 60-year-old man is investigated for progressive shortness of breath. On examination a loud P2 is noted associated with a left parasternal heave. An ECG shows evidence of right ventricular strain and a diagnosis of pulmonary hypertension is suspected.
Which one of the following is the single most important test to confirm the diagnosis?
Whilst echocardiography may strongly point towards a diagnosis of pulmonary hypertension all patients need to have right heart pressures measured. Cardiac catheterization is therefore the single most important investigation.
Pulmonary arterial hypertension: features and management:
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.
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:
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