Which one of the following clinical signs would best indicate severe calcified aortic stenosis?
Correct Answer E:
The apex beat is not normally displaced in aortic stenosis. Displacement would indicate left ventricular dilatation and hence severe disease.
Aortic stenosis:
Causes of aortic stenosis:
Management:
A 51-year-old man presents four weeks after being discharged from hospital. He had been admitted with chest pain and thrombolysed for a myocardial infarction. This morning he developed marked tongue and facial swelling.
Which one of the following drugs is most likely to be responsible?
ACE inhibitors are the most common cause of drug-induced angioedema.
Angiotensin-converting enzyme inhibitors:
Angiotensin-converting enzyme (ACE) inhibitors are now the established first-line treatment in younger patients with hypertension and are also extensively used to treat heart failure. They are known to be less effective in treating hypertensive Afro-Caribbean patients. ACE inhibitors are also used to treat diabetic nephropathy and have a role in secondary prevention of ischaemic heart disease.
Mechanism of action :
Side-effects:
Cautions and contraindications:
Monitoring:
*Renal Association UK, Clinical Knowledge Summaries quote 50% which seems rather high. SIGN advise that the fall in eGFR should be less than 20%. The NICE CKD guidelines suggest that a decrease in eGFR of up to 25% or a rise in creatinine of up to 30% is acceptable.
A 24-year-old female develops transient slurred speech following a flight from Australia to the United Kingdom. Both a CT head and ECG are normal.
Which one of the following tests is most likely to reveal the underlying cause?
Correct Answer A:
Paradoxical embolus - PFO most common cause - do TOE.
Transesophageal echocardiography provides superior views of the atrial septum and therefore is preferred to transthoracic echocardiography for detecting patent foramen ovale.
Paradoxical embolization:
For a right-sided thrombus (e.g. DVT) to cause a left-sided embolism (e.g. stroke) it must obviously pass from the right-to-left side of the heart.
The following cardiac lesions may cause such events:
A 42-year-old man of Afro-Caribbean origin is diagnosed as having hypertension. Secondary causes of hypertension have been excluded.
What is the most appropriate initial drug therapy?
ACE inhibitors have reduced efficacy in black patients and are therefore not used first-line.
Hypertension: diagnosis and management:
NICE published updated guidelines for the management of hypertension in 2011. Some of the key changes include:
Blood pressure classification:
This becomes relevant later in some of the management decisions that NICE advocate.
Diagnosing hypertension:
If a BP reading is >= 140 / 90 mmHg patients should be offered ABPM to confirm the diagnosis.
Patients with a BP reading of >= 180/110 mmHg should be considered for immediate treatment. Ambulatory blood pressure monitoring (ABPM):
If ABPM is not tolerated or declined HBPM should be offered.
Home blood pressure monitoring (HBPM):
Managing hypertension:
ABPM/HBPM >= 135/85 mmHg (i.e. stage 1 hypertension):
ABPM/HBPM >= 150/95 mmHg (i.e. stage 2 hypertension):
For patients < 40 years consider specialist referral to exclude secondary causes.
Step 1 treatment:
Step 2 treatment:
Step 3 treatment:
NICE define a clinic BP >= 140/90 mmHg after step 3 treatment with optimal or best tolerated doses as resistant hypertension. They suggest step 4 treatment or seeking expert advice.
Step 4 treatment:
If BP still not controlled seek specialist advice.
Blood pressure targets:
New drugs:
Direct renin inhibitors:
A 17-year-old girl with Turner's syndrome is reviewed in the cardiology clinic. Other than coarctation of the aorta, what is the most common cardiac abnormality found in patients with Turner's syndrome?
Correct Answer B:
Up to 15% of adults with Turner's syndrome have bicuspid aortic valves.
Turner's syndrome:
Turner's syndrome is a chromosomal disorder affecting around 1 in 2,500 females. It is caused by either the presence of only one sex chromosome (X) or a deletion of the short arm of one of the X chromosomes.
Turner's syndrome is denoted as 45,XO or 45,X.
Features:
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