A 56-year-old man with a past history of ischaemic heart disease is admitted with central chest pain radiating to his left arm associated with nausea. On arrival in the Coronary Care Unit he is noted to be in complete heart block.
Which coronary artery is likely to be affected?
Correct Answer B:
The right coronary artery supplies the atrioventricular node in 90% of patients.
Coronary circulation:
Arterial supply of the heart:
A 70-year-old man with a background of ischaemic heart disease and peripheral arterial disease presents to the Emergency Department. He has been feeling generally unwell for the past two days with fever and myalgia but this morning developed a purple, cold left middle toe. On examination there are signs of early ischaemia to the toe and a faint livedo reticularis rash is seen on the foot. A diagnosis of cholesterol embolization is suspected.
Which of the following features would be most supportive of this diagnosis?
Correct Answer E: Eosinophilia is seen in around 70% of cases of cholesterol embolization.
Cholesterol embolization:
Overview:
Features:
A 58-year-old man who is taking lithium for bipolar disorder presents for review. During routine examination he found to be hypertensive with a blood pressure of 166/82 mmHg. This is confirmed with two separate readings. Urine dipstick is negative and renal function is normal.
What is the most appropriate medication to start?
Correct Answer A:
Diuretics, ACE-inhibitors and angiotensin II receptor antagonists may cause lithium toxicity. The BNF advises that neurotoxicity may be increased when lithium is given with diltiazem or verapamil but there is no significant interaction with amlodipine. Alpha-blockers are not listed as interacting with lithium but they would not be first-line treatment for hypertension.
The NICE hypertension guidelines suggest amlodipine wouldn't be a bad first choice, even if we ignore his lithium treatment.
Lithium Toxicity:
Lithium is mood stabilizing drug used most commonly prophylactically in bipolar disorder but also as an adjunct in refractory depression. It has a very narrow therapeutic range (0.4-1.0 mmol/L) and a long plasma half-life being excreted primarily by the kidneys. Lithium toxicity generally occurs following concentrations > 1.5 mmol/L.
Toxicity may be precipitated by dehydration, renal failure, diuretics (especially bendroflumethiazide) or ACE inhibitors
Features of toxicity:
Management:
Which one of the following features is not part of the modified Duke criteria used in the diagnosis of infective endocarditis?
A prolonged PR interval is part of the diagnostic criteria of rheumatic fever. The modified Duke criteria have now been adopted in the latest guidelines from the European Society of Cardiology.
Infective endocarditis: Modified Duke criteria:
Infective endocarditis diagnosed if:
Pathological criteria:
Positive histology or microbiology of pathological material obtained at autopsy or cardiac surgery (valve tissue, vegetations, embolic fragments or intracardiac abscess content).
Major criteria:
1- Positive blood cultures:
2- Evidence of endocardial involvement:
Minor criteria:
A 71-year-old man who had rheumatic fever as a child is admitted to the cardiology ward with suspected infective endocarditis. This is confirmed by blood cultures and echocardiography.
Which one of the following is most likely to be represent a need for surgical intervention?
Correct Answer C: Infective endocarditis - indications for surgery:
Lengthening of the PR interval is likely to represent an aortic root abscess which will require surgical intervention.
Infective endocarditis: prognosis and management:
Poor prognostic factors:
Mortality according to organism:
Current antibiotic guidelines (source: British National Formulary):
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