Which one of the following cardiac conditions is most associated with a louder murmur following the Valsalva maneuver?
Correct Answer D:
HOCM: features:
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.
Features:
Associations:
Echo - mnemonic - MR SAM ASH:
ECG:
You are called to review a 78-year-old man on the surgical wards. He is three days post-op following a colectomy. He was recently diagnosed with colon cancer (Duke's C) and has a history of polymyalgia rheumatica. Current medications include co-codamol 30/500, prednisolone and prophylactic dose low-molecular weight heparin. Five minutes ago he started to complain of severe central chest pain. An ECG performed by the nurses shows ST elevation in the anterior leads. Aspirin and oxygen have been given by the Foundation 1 doctor.
What is the most appropriate treatment?
Primary percutaneous coronary intervention is the most appropriate treatment given his recent operation and associated risk of bleeding.
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:
You are considering prescribing an antibiotic to a 28-year-old man who tells you he has Long QT syndrome.
Which antibiotic is it most important to avoid?
Correct Answer C:
Long QT syndrome:
Long QT syndrome (LQTS) is an inherited condition associated with delayed repolarization of the ventricles. It is important to recognize as it may lead to ventricular tachycardia and can therefore cause collapse/sudden death. The most common variants of LQTS (LQT1 & LQT2) are caused by defects in the alpha subunit of the slow delayed rectifier potassium channel. A normal corrected QT interval is less than 430 ms in males and 450 ms in females.
Causes of a prolonged QT interval:
Management:
Avoid drugs which prolong the QT interval and other precipitants if appropriate (e.g. Strenuous exercise)
Beta-blockers***
Implantable cardioverter defibrillators in high risk cases
*The usual mechanism by which drugs prolong the QT interval is blockage of potassium channels. See the link for more details
**A non-sedating antihistamine and classic cause of prolonged QT in a patient, especially if also taking P450 enzyme inhibitor, e.g. Patient with a cold takes terfenadine and erythromycin at the same time
***Note sotalol may exacerbate long QT syndrome
Which part of the ECG complex corresponds with the closure of the mitral valve?
Heart sounds:
The first heart sound (S1) is caused by closure of the mitral and tricuspid valves whilst the second heart sound (S2) is due to aortic and pulmonary valve closure.
S1:
S2:
S3:
S4:
Where is the most common site for primary cardiac tumours to occur in adults?
Correct Answer A:
Atrial myxoma - commonest site = left atrium
The most common site of atrial myxomas is at the fossa ovalis border in the left atrium.
Atrial myxoma:
Overview:
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