Which one of the following conditions is most associated with angiodysplasia?
Correct Answer C:
Angiodysplasia is associated with aortic stenosis.
The association between angiodysplasia and aortic stenosis is thought to be caused by von Willebrand factor (vWF) being proteolyzed in the turbulent blood flow around the aortic valve.
vWF is most active in vascular beds with high shear stress, such as angiodysplasia, and deficiency of vWF increases the bleeding risk from such lesions.
Angiodysplasia:
Angiodysplasia is a vascular deformity of the gastrointestinal tract which predisposes to bleeding and iron deficiency anaemia. There is thought to be an association with aortic stenosis, although this is debated.
Angiodysplasia is generally seen in elderly patients.
Diagnosis:
Management:
A 65-year-old man admitted to the Acute Medical Unit is noted to have cannon 'a' waves of his jugular venous pressure during cardiovascular examination.
Which one of the following would not cause this finding?
Correct Answer A:
Whilst tricuspid stenosis may cause large 'a' waves it does not cause cannon 'a' waves.
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.
Which of the following is responsible for the early repolarization phase of the myocardial action potential?
Correct Answer E:
Electrical activity of the heart:
NB cardiac muscle remains contracted 10-15 times longer than skeletal muscle.
Conduction velocity:
A 45-year-old man presents with pleuritic central chest pain.
Which one of the following ECG findings is most specific for pericarditis?
ST elevation is seen but is not specific as it may also indicate ischaemia.
Pericarditis:
Pericarditis is one of the differentials of any patient presenting with chest pain.
Features:
Causes:
ECG changes:
A 78-year-old man with a four month history of exertional chest pain is reviewed. The pain typically comes on when he is walking up a hill, is centrally located and radiates to the left arm. It then settles with rest after about 2- 3 minutes. Clinical examination and a resting 12 lead ECG are normal.
Following NICE guidelines, what is the most appropriate diagnostic strategy?
Correct Answer B:
NICE do not recommend any further investigation for patients with an estimated coronary artery disease risk of greater than 90%. This includes all men over the age of 70 years who have typical symptoms.
Chest pain: assessment of patients with suspected cardiac chest pain:
NICE issued guidelines in 2010 on the 'Assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin'.
Patients presenting with acute chest pain:
Immediate management of suspected acute coronary syndrome (ACS):
Referral:
*NICE suggest the following in terms of oxygen therapy:
Patients presenting with stable chest pain:
With all due respect to NICE the guidelines for assessment of patients with stable chest pain are rather complicated. They suggest an approach where the risk of a patient having coronary artery disease (CAD) is calculated based on their symptoms (whether they have typical angina, atypical angina or non-anginal chest pain), age, gender and risk factors.
NICE define anginal pain as the following:
If patients have typical anginal symptoms and a risk of CAD is greater than 90% then no further diagnostic testing is required. It should be noted that all men over the age of 70 years who have typical anginal symptoms fall into this category.
For patients with an estimated risk of 10-90% the following investigations are recommended. Note the absence of the exercise tolerance test:
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