CARE OF PATIENT WITH CORONARY ARTERY DISEASE AND CARDIAC SURGERY EXAM

CARE OF PATIENT WITH CORONARY ARTERY DISEASE AND CARDIAC SURGERY EXAMCARE OF PATIENT WITH CORONARY ARTERY DISEASE AND CARDIAC SURGERY EXAM Q1. A 55-year-old man presented to the emergency department with a 4-week history of exertional chest pain, radiating to the left arm and associated with breathlessness, sweating and clamminess. His symptoms were initially infrequent, but over the preceding week he reported them almost every day on mild exertion. He denied any episodes of chest pain at rest. His risk factors included hypertension, hypercholesterolaemia and the fact he was a lifelong smoker. His father had suffered a myocardial infarction in his 50s. His medications included ramipril 5 mg od and simvastatin 40 mg od. Examination was unremarkable: his temperature was 36.8oC, his pulse was 70 beats per minute, his blood pressure was 130/80 mmHg and his SaO2 was 97% on air (normal range 94–98). His ECG (recorded when he was not in pain) showed sinus rhythm with no significant ST/T wave abnormalities. A chest X-ray was clear. Two measures of serum troponin were negative. What is the most appropriate management plan? D-dimer discharge and routine outpatient cardiology review discharge and urgent outpatient cardiology review inpatient coronary angiogram outpatient coronary angiogram D This patient has a very good history for crescendo angina. He has multiple risk factors for ischaemic heart disease. Despite his normal ECG and negative troponin it is important to investigate him as an inpatient to exclude significant coronary artery disease. Troponins are very sensitive biomarkers and most patients with normal ECGs and negative troponins could be safely discharged home from a cardiovascular point of view, but negative troponins do not exclude coronary artery disease and if the story is convincing for crescendo angina, the patient should be investigated as an inpatient. Q2. A 64-year-old man was referred to the medical out-patient department after he was found to be suffering from paroxysmal atrial fibrillation. He had no past medical history of note and was a non-smoker. A trans-thoracic echocardiogram showed that the left atrium was not dilated. What would you advise with regard to anti-thrombotic therapy against stroke? Aspirin Clopidogrel No anti-thrombotic therapy indicated Rivaroxaban Warfarin C Paroxysmal AF is known to be associated with increased risk of stroke as are persistent and permanent AF. CHA2DS2-VASc scale is used for risk stratification. CHA2DS2-VASc stands for, Congestive heart failure – 1 Hypertension – 1 Age (65-74) – 1 Age (≥75) – 2 Diabetes – 1 Stroke or TIA history – 2 Female – 1 Vascular disease – 1 A score of 0 indicates either no treatment or aspirin with the former preferred. A score of 1 indicates either aspirin or oral anti- coagulation agent with the latter preferred. A score of ≥2 indicates oral anti-coagulation agent. For more see guidelines by European Society of Cardiology 2010. Q3. A 52-year-old woman was about to undergo exploratory hysteroscopy under general anaesthesia. She reportedly had a normal ECG at the pre-assessment clinic, but preoperatively her pulse was found to be 50 beats per minute and a medical opinion was sought. She had no prior medical history and was otherwise well, with no cardiac symptoms. Clinical examination was normal. A 12-lead ECG was performed and is as shown in this figure. A From the history, it appears that this is an incidental finding in an otherwise asymptomatic and well patient. The 12-lead ECG shows ventricular bigeminy, with alternating sinus beats and monomorphic ventricular ectopics. This is generally a benign condition and provided appropriate monitoring is in place during general anaesthesia, then this shouldn’t delay the procedure. Q4. A 36 year-old man presented to the Emergency Department with sharp chest pain that was worse on lying down. There were no abnormal findings on physical examination. His ECG showed widespread concave ST elevation. He was given a week’s course of non-steroidal anti-inflammatory drugs, but returned with ongoing pain, an unchanged ECG and a pericardial rub. What is the most appropriate treatment? Azathioprine Colchicine Diclofenac Methylprednisolone Prednisolone B Most cases of pericarditis respond to NSAIDs alone, but colchicine has been shown to be beneficial when added to NSAIDs in those who respond poorly. Steroids are of limited use but can be considered in those refractory to both NSAIDs and colchicine. Q5. An 82-year-old woman presented with a 5-day history of feeling unwell. She had no significant past medical history and was generally fit and well, but she did admit to some recent mild dysuria. On examination she was febrile (temperature 38.4oC) and she was noted to have an ejection systolic murmur, loudest in the aortic area. Urinary sepsis was suspected and she was admitted for treatment with intravenous antibiotics. Two days later the laboratory reported that Escherichia coli had been grown from urine and blood cultures. She was now feeling better and was afebrile. A transthoracic echocardiogram, requested by the admitting team because of the murmur, was reported as follows: Left ventricle: normal size, thickness and function. Right ventricle: normal size and function. Atria: left atrium mildly dilated, right atrium normal sized. Aortic valve: mild aortic stenosis, peak gradient 30 mmHg, mean gradient 13 mmHg. Mitral valve: mild central mitral regurgitation, no stenosis. Pulmonary valve: normal function. Tricuspid valve: mild regurgitation, RVSP estimated at 20 mmHg. What is the most appropriate management? change antibiotic therapy continue current treatment further blood cultures refer for aortic valve surgery transoesophageal echocardiography B The clinical suspicion of endocarditis is low. This is likely to be urinary sepsis with consistent organisms grown in both urine and blood. The echocardiographic changes are not suggestive of infective endocarditis and are consistent with the age of the patient. Q6. A 60-year old man was referred to the cardiology clinic after being noted to have an ejection systolic murmur during a routine health check. The patient denied any symptoms, and in particular he had not noticed breathlessness, chest pain or dizziness. A transthoracic echocardiogram revealed a heavily calcified aortic valve with a peak gradient of 100mmHg. What should be organised? Cardiac catherisation, with coronary angiography CT coronary angiography Routine outpatient follow-up Transcatheter aortic valve implantation Transoesophageal echocardiography C This patient is currently asymptomatic and therefore routine follow-up and monitoring for symptoms is appropriate. In asymptomatic patients with severe AS, surgical mortality and the yearly risks of prosthetic valve complications are greater than the yearly risks of watchful waiting. However, such patients must be closely monitored by regular clinical and echocardiographic follow-up and should be educated regarding symptom recognition and prompt self-reporting. Q7. An 80 yr old man was brought to the Emergency Department after having a 'funny turn'. He could not give a clear account of himself, but on examination had an implanted device below his left clavicle. What does his ECG show? See image Anterior ST-elevation MI Anti-tachycardia pacing DDD pacing Posterior MI VVI pacing C Temporary dual chamber systems are becoming increasingly used in patients with reduced left ventricular function. VVI pacing is single chamber ventricular pacing with no sensing in the atrium. Antitachycardia pacing is seen in Implantable Cardioverter Defibrillators (ICDs) for the treatment of ventricular tachycardia. This is clearly not the case here. This patient has a dual chamber pacemaker in DDD mode. No P waves are sensed so there is a pacing spike before each P wave. However, each QRS is sensed and hence no paced QRS complexes are seen. A patient with a single chamber (AAI) pacemaker for sick sinus syndrome may have a similar ECG. Q8. A 26 yr old woman presented with 24 hours of pleuritic chest pain. There was no obvious precipitant, and she had no other respiratory features. Examination of her cardiovascular and respiratory systems, and of her legs, was normal. The serum D- dimer was marginally elevated. A chest radiograph was normal. She was given an injection of a treatment dose of low molecular weight heparin and admitted overnight. The next morning a lung V/Q scan was reported as normal. Further history was taken from the patient who said she felt generally a bit under the weather, also that she had had a rash on her cheeks during the last summer, but this had now gone. What would be the most appropriate investigation to do next? CT pulmonary angiogram Serum antinuclear antibodies Serum anti-neutrophil cytoplasmic antibodies Thrombophilia screen Ultrasound / Doppler of leg veins (left and right) B The likely diagnosis is systemic lupus erythematosus, manifesting with a photosensitive skin rash and pleurisy. Testing for serum antinuclear antibodies would be the appropriate screening test. If this was positive, the diagnosis would be confirmed (in the overwhelming majority of cases) by the finding of antibodies against double-stranded DNA (anti-dsDNA). Q9. A 72 year-old woman underwent left heart catheterisation after complaining of breathlessness. Her cardiologist suspected constrictive pericarditis. What would you expect to observe in the cardiac catheter laboratory? Apical ballooning on left ventriculogram Bradycardia Elevation and equalisation of all cardiac chamber pressures in diastole Giant V waves in the pulmonary capillary wedge pressure trace Low right atrial pressure C Constrictive pericarditis causes hypotension, tachycardia, elevation and equalisation of pressures in all cardiac chambers in diastole, inspiratory rise in RA pressure on inspiration (Kussmaul’s sign) and matching of LV and RV pressures during respiration. Q10. A 31-year-old man was admitted with fevers and a new murmur. Three sequential blood cultures were positive for staphylococcus aureus. Clinical examination revealed peripheries that were cool to touch, pulse 110/min, blood pressure 75/45 mmHg (arterial oxygen saturation 89% on room air), bi-basal crackles and pedal oedema to mid-shins. Laboratory tests included haemoglobin 8.2 g/dL and serum albumin 28 g/L. A transthoracic echocardiogram showed a normal sized left ventricle with severe aortic regurgitation and a 0.5cm vegetation on the aortic valve. The most important step in management is to: Give intravenous furosemide Refer for emergency valve replacement surgery Start appropriate intravenous antibiotics Start continuous positive airways pressure respiratory support Transfer to ICU for haemodynamic support B This patient has acute bacterial endocarditis. He has severe aortic regurgitation and septic shock. He needs emergency surgery. Other indications for urgent surgery would include: large vegetations (>10mm), embolic events, recurrent pulmonary oedema, abscess formation, conduction defects. Q11. A 33-year-old African-Caribbean woman presented to the emergency department complaining of progressive shortness of breath, fatigue and ankle swelling for a week. She had given birth to her third child 2 weeks previously via a normal vaginal delivery. She had not had any trouble in her previous pregnancies, had no relevant past medical history, and was on no regular medications. Clinical examination revealed that her pulse was 110 beats per minute, her blood pressure was 110/60 mmHg, her oxygen saturation on air was 95% (normal range 94–98), she had a soft pansystolic murmur, fine bibasal lung crepitations, and pitting peripheral oedema to the shins. Her blood tests showed haemoglobin 108 g/L (normal range 115–150) and normal renal function. Her chest radiograph is as shown in the figure. What is the most likely cause of the presentation? A anaemia B atypical pneumonia C peripartum cardiomyopathy D pulmonary embolus E rheumatic valve disease C The clinical presentation of heart failure with an enlarged cardiac silhouette on the chest radiograph. She is in the peripartum period and has risk factors for peripartum cardiomyopathy in that she is above the age of 30, has had previous pregnancies, and is of African-Caribbean ethnicity. The level of anaemia is unlikely to have caused such a presentation and there is no evidence of an atypical pneumonia. A pulmonary embolus should be considered but the time course of symptom development goes against this. Rheumatic valve disease is a possibility and an echocardiogram would of course be performed, but she has had two previous pregnancies without trouble so this diagnosis is less likely. Q12. A 30-year old man presented with palpitations, recurrent syncope and atypical chest pain. His family history included two brothers with sudden death. Examination was unremarkable. ECG revealed premature ventricular complexes and non-sustained ventricular tachycardia of left bundle branch morphology. Which investigation would most securely establish the diagnosis? Cardiac MRI scan Coronary angiography Echocardiography Radionucleide ventriculography 24h ECG monitoring A MRI of the heart is used to detect the myocardial fibrofatty infiltration of arrhythmogenic right ventricular dysplasia, which is the hallmark of the disease. It may also show dilatation and ectasia of the right ventricular outflow tract. In spite of the prominent right ventricular pathology, features of right-sided heart failure are rare. Q13. A 51-year old man presented to the Emergency Department with a recurrence of left-sided chest pain. This had lasted for three hours, and was less intense when he sat forward. He had suffered three or four similar attacks in the previous couple of years. Clinical examination was normal. A chest radiograph was unremarkable. An ECG was performed (see image). What treatment would you recommend to prevent his recurrent chest pain? See image Aspirin Colchicine Ibuprofen Prednisolone Warfarin B The ECG demonstrates widespread ST segment elevation and PR segment depression that is most consistent with acute pericarditis. Anti-platelets agents and anticoagulants should be avoided. Non-steroidal anti-inflammatory drugs are the treatment of choice for acute episodes, and in patients with recurrent episodes colchicine has been shown to be beneficial in preventing attacks. Q14. A 19-year-old athlete was referred to the cardiology outpatient clinic for further evaluation of recurrent syncope. Examination was unremarkable apart from bradycardia. His ECG confirmed sinus bradycardia and also showed type I second degree AV block. Echocardiography and cardiac MRI were normal-looking. There was no family history of note. What is the most likely cause of his syncope? Aortic stenosis Arrhythmogenic right ventricular dysplasia Hypertrophic cardiomyopathy Neuro-cardiogenic syncope Psychogenic syncope D The commonest cause of recurrent syncope in athletes is the neuro-cardiogenic (vaso-vagal) syncope, the cause of which is uncertain. All patients should be evaluated carefully for hypertrophic cardiomyopathy, aortic stenosis and arrhythmogenic right ventricular dysplasia. This patient’s work-up is benign. Psychogenic syncope is very rare in athletes. Q15. A 59-year-old man presented to the emergency department feeling intermittently dizzy. He had been discharged from hospital 10 days previously following an aortic valve replacement for severe aortic stenosis due to a bicuspid valve. He looked well, with a blood pressure of 150/65 mmHg. He was on warfarin for his mechanical valve with an INR of 2.6 and had a normal full blood count, electrolyte and renal function tests. A high-sensitivity troponin-I was elevated at 85 ng/L (normal threshold <34.3 ng/L). His ECG is as shown in the figure. What is the next best management step? A anti-platelet therapy B beta-blockers C echocardiography D intravenous amiodarone E pacemaker implantation E The ECG shows complete (or 3rd degree) AV block with dissociation between atrial (P-wave) activity and ventricular (QRS) activity. There is a narrow complex, regular escape rhythm. AV block is common following aortic valve surgery. Q16. A 66-year-old man with a history of hypertension underwent coronary artery bypass grafting for triple vessel disease. Twelve hours later, shortly after extubation on the ICU, his blood pressure fell to 70/50 mmHg. He was cool peripherally, he became anuric, and increasing inotropic support did not lead to significant improvement. His ECG did not show any features to suggest acute myocardial infarction. What is the most appropriate investigation / intervention to organise immediately? Cardiac catheterization CT scan chest Lung perfusion scan Surgical re-exploration Transoesophageal echocardiography E The most likely explanation of this gentleman’s deterioration is cardiac tamponade. Although trans-thoracic echocardiogram would be of help it does not exclude the diagnosis. Pericardial effusions, particularly in the early post-operative period, can be localized and difficult to identify by trans-thoracic echocardiography. An effusion may only occur posteriorly and therefore the best way to visualize these would be through transoesophageal echo. Q17. A 50-year-old man attended the cardiology clinic for routine review. His past medical history included ischaemic heart disease with myocardial infarction, diabetes, hypertension and cardiac failure. He complained of continuing shortness of breath on exertion, with an exercise tolerance of 50 metres. He denied any chest pain, palpitations, dizziness or collapses. His medications included aspirin 75 mg once daily, bisoprolol 5 mg once daily, ramipril 5 mg once daily, spironolactone 50 mg once daily, furosemide 40 mg once daily, atorvastatin 40 mg once daily, and metformin 500 mg three times per day. On examination his pulse was 65 beats per minute (regular), his blood pressure was 105/65 mmHg and his heart sounds were normal, his chest was clear, and there was minimal ankle oedema only. His ECG showed sinus rhythm with LBBB and QRS duration of 140 ms. His most recent echocardiogram showed an ejection fraction (EF) of 30% with regional wall motion abnormalities, and a recent myocardial perfusion scan showed an inferior infarct but no reversible ischaemia. A recent 48-hour tape did not show any ventricular arrhythmias. What is the best management plan? angiogram for possible revascularisation CRT-D CRT-P ICD medical management B This patient suffers from cardiac failure NYHA II/III. He is on appropriate secondary medications and increasing these further will be limited by his blood pressure and heart rate. There is no evidence of significant ischaemia on a recent functional test, hence angiography will probably not show any target for revascularisation of prognostic significance. His ejection fraction is 30% and he has LBBB with QRS=140 ms. He therefore meets the criteria for device therapy. According to NICE guidelines published in 2014, CRT-D is recommended. Q18. A 34-year-old chartered accountant was referred to cardiology clinic following the sudden death of his brother at the age of 28 years. He was otherwise fit and well. The ECG recorded in the clinic was as shown. Which is the correct interpretation of the ECG? See image arrhythmogenic cardiomyopathy Brugada syndrome hypertrophic cardiomyopathy long QT syndrome normal B The coved ST elevation in leads V1 and V2 are classical changes seen with Brugada syndrome. Q19. A 38 year old man with Down’s syndrome was admitted with shortness of breath. Examination revealed clubbing and central cyanosis. On cardiac auscultation there was a loud P2, but no murmurs. The chest was clear. What is the likely diagnosis? Eisenmenger’s syndrome Idiopathic pulmonary hypertension Obstructive sleep apnoea Pulmonary fibrosis Transposition of the great arteries A The most common cardiac defects in Down’s syndrome relate to abnormal development of the endocardial cushions, which form portions of the atrial septum and ventricular septum. This man has developed Eisenmenger’s syndrome, and the murmur across the defect has become inaudible. Q20. A 68-year-old woman presented with 6 weeks of fatigue. She was in atrial fibrillation at rate of 120/min but had no signs of cardiac failure, and no cardiac murmurs. She gave no history of previous arrhythmia or to suggest ischaemic heart disease, but had been diagnosed with mild hypertension 5 years previously. There were no ischaemic changes on the ECG. The chest radioagraph showed a normal sized heart and clear lung fields. What is the best immediate management? Adenosine Amiodarone DC cardioversion Digoxin Sotalol D In a patient with a probable first episode of AF an attempt should be made to restore sinus rhythm. However, if AF has been present for >48 hrs – as seems very likely in this case – it is necessary to anticoagulate before cardioversion, unless it can be documented by trans-oesophageal echocardiography (TOE) that the left atrium is free of thrombus. Digoxin will provide rate control whilst anticoagulation is 6 weeks before cardioversion. Q21. A 60 year old man presented to the Emergency Department with a 10-hour history of central chest pain and shortness of breath. His past medical history was unremarkable and he was on no regular medications. His ECG showed sinus rhythm with inferolateral ischaemia and his troponin was elevated. He was diagnosed with NSTEMI, started on aspirin, clopidogrel and fondaparinaux, and transferred to Coronary Care Unit. Whilst on the CCU he had a 20-second episode of regular broad complex tachycardia at a rate of 170/min. He had felt some palpitations at this time, but had remained hemodynamically stable. On examination his vital signs included temperature 37oC, pulse 80/min, BP 120/70mmHg and SaO2 98% on air. Cardiovascular and respiratory examination was unremarkable, and his ECG showed sinus rhythm with no new changes. What is the best next management? Amiodarone Bisoprolol Flecainide Magnesium Refer for consideration of ICD B In the context of acute myocardial infarction the most likely diagnosis is non-sustained ventricular tachycardia. Since the arrhythmia happened <48hours post-MI, it is probably due to abnormal automaticity and there is no indication for consideration of ICD at this point. Beta-blockers are the only medication that has been shown to increase survival in this context. Amiodarone is useful to suppress the arrhythmia but has not been shown to improve long-term survival. It should be considered if there are frequent episodes of non-sustained VT despite beta-blocker. Magnesium should be replaced if found to be low, but is not the best next management. Flecainide is contraindicated in patients with ischaemic heart disease. Q22. A 50-year old man presented 3 months after (metallic) mitral valve replacement (MVR) with increasing shortness of breath, fever and weight loss. Clinically he was in pulmonary oedema. Transoesophageal echocardiography (TOE) confirmed severe paravalvular mitral regurgitation. The first blood culture was positive for Staph epidermidis. After initial management of pulmonary oedema, which is the best therapeutic approach? Intravenous antibiotics for 4 weeks and then repeat TOE. Intravenous antibiotics for 4 weeks and then re-do MVR (bioprosthetic). Intravenous antibiotics for 4 weeks and then re-do MVR (metallic). Re-do MVR (bioprosthetic) and then complete 4 weeks of intravenous antibiotics. Re-do MVR (metallic) and then complete 4 weeks of intravenous antibiotics. E Clinically this man has an infected MVR, with severe paravalvular leak. Following surgery, the commonest infecting organisms (up to around 9 months) are coagulase negative staphylococci. Antibiotics alone will not cure the infection; the valve must be replaced again. In this case this should be with a metallic valve since a bioprosthetic valve would be likely to need replacing after 10-15 years due to degeneration thereby subjecting him to a high-risk third operation. Bioprosthetic and metallic valves have similar risk for subsequent endocarditis. Q23. A 75 year old man presented with 3 day history of on/off palpitations and breathlessness. He denied any chest pain, cough or fever. His past medical history included hypertension, ischaemic heart disease and diabetes. He was a lifelong smoker. On examination his vital signs were temperature 37.1oC, pulse 140/min (irregularly irregular), BP 115/65 mmHg, and respiratory rate 20/min, with SaO2 96% on room air. His heart sounds were normal and his chest was clear. There was no ankle oedema. His ECG confirmed atrial fibrillation with fast ventricular response and his CXR was normal. Aside from starting therapeutic dose low molecular weight heparin, what is the most appropriate immediate management option? Amiodarone Bisoprolol DC cardioversion Digoxin Flecainide B This is an acute presentation of atrial fibrillation with fast ventricular response for >48hours but without hemodynamic compromise. Therapeutic low molecular weight heparin is necessary, with rate-control as a first step. The patient will probably need to be started on warfarin and DC cardioverted on an elective basis once INR has been in the therapeutic range for 4 weeks. Q24. A 67 year old diabetic man was taking three agents to treat his hypertension. Three months previously, at routine medication review, his GP incidentally found that he was in atrial fibrillation. In the diabetic outpatient clinic you determine that he has never had symptoms that could be attributed to AF, and is not keen on cardioversion as his brother required a prolonged ITU admission for malignant hyperpyrexia following a routine anaesthetic for a hernia repair. Which management is most appropriate? Chemical cardioversion Oral anticoagulation prior to chemical cardioversion Oral anticoagulation prior to DC cardioversion Rate control only Rate control plus oral anticoagulation E Atrial fibrillation is common (1:4 lifetime risk, 1% prevalence). All patients are at risk of the increased risk of intracardiac thrombus formation, but many are unaware of symptoms attributable to arrhythmia (palpitations, breathlessness). Cardioversion aims to reduce the latter, and therefore is of little benefit in asymptomatic patients, and rate control is thus acceptable. His CHADSVASc score is 3, and therefore oral anticoagulation should be recommended. Q25. An 84-year-old man presented with a 4-week history of general deterioration, malaise, mild shortness of breath and fevers. He denied any cough, urinary symptoms or rashes. His past medical history included hypertension, diabetes, mild renal dysfunction, chronic obstructive pulmonary disease and a dual- chamber pacemaker first implanted 12 years previously (for sick sinus syndrome), with a first box change 1 year ago. His medications included ramipril 5 mg od, metformin 1 g bd, simvastatin 40 mg od and inhalers. On examination, his vital signs were: temperature 37.7oC, pulse 80 beats per minute, blood pressure 140/85 mmHg and SaO2 96% on air (normal range 94–98). His heart sounds were normal with no murmurs. The chest was clear, abdomen was soft and non-tender, and there were no rashes or splinter haemorrhages. The pacemaker site was clean. His ECG showed sinus rhythm, his chest X-ray was clear, and urine dip was negative. He had raised inflammatory markers and was started on broad spectrum antibiotics. Twenty-four hours later his blood cultures grew coagulase-negative staphylococcus from both bottles. A transthoracic echocardiogram did not show any obvious lead- or valvular vegetations. What is the most appropriate thing to do next? CT chest repeat blood cultures screen for cancer stop antibiotics transoesophageal echocardiogram E Coagulase-negative staphylococci are often considered contaminants or non-pathogenic microorganisms. However, they are one of the commonest causes of permanent pacemaker-related infections and they should not be dismissed in patients with indwelling devices who are suspected of having such infection. This patient presented with non-specific symptoms, he has risk factors for infection (diabetes, renal dysfunction and generator change) and has coagulase-negative staphylococci in both bottles. He should proceed to transoesophageal echocardiography. Excluding alternative sources of sepsis and repeating the blood cultures to check progress are also worth doing. Q26. A 70-year-old man with a background of stroke, hypercholesterolaemia, coronary artery bypass grafting, femoral artery angioplasty, type II diabetes and smoking presented to clinic with an irregular pulse. An ECG confirmed atrial fibrillation. What is his CHA2DS2-VASc score? 2 3 4 5 6 D Congestive cardiac failure Hypertension Age2 ≥75 (2 points) Diabetes Stroke2 – stroke/TIA in the past (2 points) Vascular disease Age 65–74 (1 point) Sex (female = 1 point) Q27. A 70 year old woman presented with 8 hours of chest pain. Her pulse rate was 40/minute and blood pressure 105/85 mmHg. The ECG showed complete heart block, also ST segment elevation and Q waves in leads II, III and AVF. What should be the immediate treatment? Adenosine (IV bolus) Atropine (IV bolus) Isoprenaline (IV infusion) Thrombolysis Transvenous pacing D The top priority is to achieve myocardial reperfusion. The bradycardia is not causing very significant hypotension: it does not require immediate symptomatic treatment, and it may resolve with reperfusion. Q28. A 48-year-old woman was referred for a cardiological opinion because of palpitations. There were no other associated symptoms, but she did have a family history of sudden death in a cousin, who died when she was in her 40's. Physical examination was normal, as was her ECG and echocardiogram. A 24 hour ECG demonstrated frequent ventricular ectopic activity. What is the likely diagnosis? Arrhythmogenic right ventricular dysplasia Brugada syndrome Hypertrophic obstructive cardiomyopathy Long QT syndrome No significant cardiac disease E Palpitations are a very common presenting feature and reassurance is generally all that is needed in the context of a normal ECG and echo. The distant family history of sudden death requires more information but is likely not to be relevant. However, all conditions listed - aside from 'no significant cardiac disease' - will generally have abnormal ECGs, and in the absence of a specific family history of them it is likely that she will need no further investigation. Q29. A 28-year-old woman presented with breathlessness and pleuritic chest pain. Which of the following test results is more than 90% specific for excluding pulmonary embolism (PE) in a patient presenting with a high clinical probability of the diagnosis? Negative D-Dimer Normal chest radiograph and arterial blood gases Normal lung perfusion on V/Q scan No evidence of deep vein thrombosis (DVT) on lower limb venography No evidence of PE on spiral CT C A normal lung perfusion scan has a specificity of around 98% for PE, whilst specificity for CT is usually quoted at around 85%. CT scanning does, however, have other clinical advantages over V/Q scanning, most notably because it may reveal an alternative explanation for a patient’s symptoms. Although negative D-dimer is helpful in the context of a low clinical suspicion, some studies have indicated a false negative rate as high as 20% for patients with high clinical probability. Neither normal chest radiograph, normal arterial blood gases nor the absence of DVT can be used in isolation to rule out pulmonary embolism, although they may all be helpful as part of an algorithm for the management of patients with breathlessness or pleuritic chest pain of uncertain cause. Q30. A 75-year-old man was admitted for an elective inguinal hernia repair. He gave no history of angina, falls or syncope, but his pre- operative resting ECG showed sinus rhythm (PR interval 160ms) and left bundle branch block (QRS124ms). During surgery, the anaesthetist noticed alternating left and right bundle branch block pattern. He made an uneventful recovery from surgery, but the anaesthetist requested a cardiological opinion. What should the cardiological opinion be? Arrange coronary angiography Arrange exercise stress test Arrange outpatient ambulatory rhythm (Holter) monitor Arrange permanent pacemaker Reassure that no investigations or treatment are required D Alternating left and right bundle branch block indicates advanced conduction system disease and is a class I indication for pacing, regardless of symptomatic status. Q31. A 65 year-old man attended for a routine outpatient echocardiogram. A large (1.5cm) vegetation was noted on his mitral valve, causing moderate mitral regurgitation. He was asymptomatic and had no past medical history. Strep. viridans was subsequently grown in three blood cultures. What is the best course of action? Commence high dose IV antibiotics and refer for urgent surgery Commence two weeks high dose IV antibiotics and then arrange surgical repair Give six weeks of high dose IV antibiotics and reassess Refer for percutaneous mitral valve repair Take more blood cultures A Early surgery for large vegetations (>1cm) has been shown to give a mortality benefit, even if asymptomatic. The timing of surgical intervention for infective endocarditis is complicated as the advantages of operating early have to be weighed against the benefits of high dose IV antibiotics for a period beforehand. Smaller vegetations which do not cause valve incompetence should be treated with antibiotics for at least two weeks prior to surgery. Q32. A 49 year old man known to have aortic stenosis secondary to a bicuspid aortic valve presented with a week of malaise and feeling sweaty and feverish over the last 24-48 hours. Examination revealed temperature 38.0oC, pulse 106/min, blood pressure 118/70 mmHg. There was a loud ejection systolic murmur and a soft early diastolic murmur at the left sternal edge. Non-visible haematuria was found on dipstick urinalysis. Several blood cultures were taken. What would be the most appropriate further management? Start benzylpenicillin Start ciprofloxacin Start flucloxacillin and gentamicin Start vancomycin, gentamicin and rifampicin Wait for blood culture results C Antibiotic treatment should be started immediately after multiple blood cultures have been taken where there is a strong clinical suspicion of infective endocarditis, as in this case. Waiting for culture results is the correct thing to do if the diagnosis is possible but unlikely. Streptococci (especially Streptococcus viridans) are the commonest organisms isolated in infective endocarditis, but staphylococci make up 25% of isolates, hence the need in this context to give antibiotics with action against these organisms. Q33. A 55-year-old man presented with sudden onset pleuritic chest pain, breathlessness and a single episode of haemoptysis. He denied any cough or fevers. His past medical history included hypertension, diabetes and bladder cancer, for which he had finished chemotherapy 3 weeks previously. His vital signs included: pulse 95 beats per minute, blood pressure 130/80 mmHg, temperature 37°C and SaO2 94% on air (normal range 94–98). His heart sounds were normal and his chest was clear. There was no sign of deep vein thrombosis (DVT). A serum D-dimer was negative, and a 12-lead ECG showed sinus rhythm with no ST/T abnormalities. His chest X-ray was clear. What is the best next investigation? coronary angiography CT coronary angiography CTPA echocardiogram myocardial perfusion scan C The history suggests PE rather than MI. He requires oxygen to maintain saturation, he has no crackles and his chest X-ray is clear. There are no new electrocardiogram (ECG) changes. His mild troponin elevation could be due to an underlying PE. Echocardiogram will be useful but unlikely to provide a diagnosis. Given the history, PE should be excluded before further cardiac investigations are considered. Q34. A 63-year old woman was referred to the cardiology clinic due to a 6-month history of palpitations, fatigue, weight loss and swelling of her ankles. She also complained of a sensation of fullness in her neck and had been having episodes of flushing and diarrhoea. On clinical examination there was an irregular pulse, prominent jugular veins with giant V-waves, a pansystolic murmur at the left sternal edge which increased in intensity on inspiration, a clear chest, hepatomegaly and marked peripheral oedema. What is the most likely diagnosis? Bacterial endocarditis Carcinoid syndrome Constrictive pericarditis Ebstein anomaly Marfan Sydrome B The clinical signs described are classical of severe tricuspid regurgitation (TR). The systemic symptoms of weight loss, episodic flushing and diarrhoea are suggestive of carcinoid syndrome. Carcinoid usually affects the right side of the heart because vasoactive substances released from hepatic metastases drain through the inferior vena cava to the right atrium. This results in endocardial fibrosis and causes the cusps of the tricuspid valve to adhere to the underlying right ventricle producing TR. Q35. A 32-year-old-woman presented to the Emergency Department with severe chest pain. She had a three day history of diarrhea and vomiting, and the pain started immediately after a profuse episode of vomiting. Cardiovascular examination was normal and her ECG as shown (see image). What is the most likely diagnosis? See image Acute anterior STEMI Acute inferior NSTEMI Coronary artery dissection Pericarditis Pulmonary embolus C In a young person, chest pain starting immediately after vomiting should raise the suspicion of coronary artery dissection. The ECG demonstrates anterior and anterolateral ST elevation and inferior reciprocal changes. In this context and clinical scenario, in a young person coronary dissection is a more common explanation that myocardial infarction. Q36. A 65 year old man was reviewed in the outpatient clinic with gradually worsening shortness of breath, which now caused him to stop halfway when walking up the stairs. He had an acute coronary syndrome six years ago. He had been taking bisoprolol, ramipril, furosemide and spironolactone for a diagnosis of heart failure for the last year. Attempts to increase the doses of these drugs had been prevented by hypotension. An echocardiogram confirmed severe left ventricular impairment. An ECG showed sinus rhythm at 60 bpm, a long PR interval (240 ms), and left bundle branch block. What is the most appropriate treatment to consider next? Cardiac resynchronization therapy Cardiac transplantation Coronary artery bypass grafting Dual chamber pacemaker Ivabradine A Cardiac resynchronization therapy (CRT), also known as biventricular pacing, reduces symptoms and improves prognosis in patients with heart failure. It is currently indicated in patients on optimal medical therapy, and with a broad QRS on ECG. Implantation is similar to a dual chamber pacemaker, but with the insertion of an extra lead to pace the left ventricle via the coronary sinus. Q37. A 63-year-old man has been seen in the implantable cardioverter defibrillator clinic having had a collapse. The cardiac physiologist has interrogated his device and found that he had an appropriate shock for ventricular fibrillation. He is on appropriate medication and so no changes to this are recommended. Can the patient continue to drive? he can continue to drive he can drive after 1 month he can drive after 6 months he can drive after 2 years he is permanently barred from driving D As the shock was accompanied by incapacity, ie collapse, he cannot drive for 2 years. If there had been programming changes or medication that would reduce the chance of further VF, then it would have been 6 months. Q38. Whilst attending a routine insurance medical it was noted that a 52 yr old man had a pulse rate of about 45/min. He was sent directly to the Emergency Department, where he declared himself to be fit and well, with no symptoms. His BP was 135/65 mmHg, and there were no abnormalities except for bradycardia on cardiovascular examination. A 12-lead ECG demonstrated complete heart block with a rate of 46/min and narrow QRS complexes. His notes contained an ECG performed 5 years previously that showed a prolonged PR interval. What is the most appropriate management? Discharge with arrangements for elective insertion of a permanent pacemaker Give Atropine 0.5mg IV Reassure and discharge with instruction to report to GP if develops any symptoms Transfer to Coronary Care Unit for external pacing Transfer to Coronary Care Unit for insertion of a temporary pacemaker A The patient is not in any immediate danger and without cardiovascular compromise; atropine and temporary pacing measures are not justified. All patients with acquired complete heart block should be paced as without this mortality approaches 15% per year. Those with a narrow complex escape rhythm are at lower risk, but disease progression can occur unpredictably, putting even those patients at risk of sudden death. Active management of bradycardia is required if the patient displays adverse signs (systolic BP<90mmHg; heart rate <40 beats/min; heart failure) or runs the risk of asystole (recent asystole; Mobitz II AV block; complete heart block with broad QRS; ventricular pause >3s). Q39. A 68-year-old man presented with breathlessness. On examination he had an early diastolic murmur at the left sternal edge. Which of the following features would suggest that his aortic incompetence is clinically significant? Austin-Flint murmur Displaced apex beat Graham-Steele murmur Long diastolic murmur Narrow pulse pressure B Severe aortic incompetence is suggested by the presence of one or more of the following clinical features: 1. Short early diastolic murmur (diastolic pressure in the left ventricle rapidly approaches that in the aorta) 2. Wide pulse-pressure 3. Displaced, hyperdynamic apex beat - implying significant volume overload. An Austin-Flint murmur may be heard in aortic incompetence (fluttering of the anterior mitral valve leaflet due to turbulance from the regurgitant jet), but it is not an indication of severity. Q40. A 50-year-old woman presented to the emergency department 90 minutes after she suffered sudden onset of left arm weakness, left facial droop and slurred speech. While in the emergency department she complained of chest pain. Her risk factors for vascular disease included being a heavy smoker and having hyperlipidaemia. Physical examination was normal, with the exception of left arm weakness. Her ECG was as shown (see Fig 123). An urgent CT head and CT aorta excluded aortic dissection and did not show any intracranial bleeding or large vessel ischaemia. What is the best next management? See image aspirin and clopidogrel aspirin, clopidogrel and fondaparinux observe primary PCI thrombolysis E This is a difficult clinical scenario. The patient has presented with both acute stroke and acute inferoanterolateral MI. Primary percutaneous coronary intervention (PPCI) in the context of acute stroke is high risk in view of further stroke or haemorrhagic transformation. The patient is within the window for thrombolysis, and aortic dissection and intracranial bleed has been excluded, hence thrombolysis for both STEMI and stroke is the best option. Q41. A 25-year-old man was referred to the cardiology outpatient clinic with a 3-month history of intermittent palpitations associated with pre-syncope, and – on one occasion - syncope. There was no family history of (premature) sudden death. Physical examination was unremarkable. A 12-lead ECG was performed (see image). A transthoracic echocardiogram showed normal left ventricular size and systolic function, but the right ventricle was mildly dilated with mild systolic impairment. There were no significant valvular lesions seen. The next most appropriate step is: See image Ambulatory (Holter) rhythm monitoring Cardiac MRI Coronary angiogram Electrophysiology study Implantable Cardioverter Defibrillator B The history is highly suggestive of a malignant (i.e. ventricular) arrhythmia. The 12-lead ECG shows an epsilon wave. This in conjunction with a suggestive history and impaired right ventricular function raises the possibility of arrhythmogenic right ventricular cardiomyopathy (ARVC). A cardiac MRI should be undertaken to assess for characteristic structural findings. In select cases an electrophysiological study may be helpful. Once the diagnosis is confirmed, an implantable cardioverter defibrillator would be recommended. Q42. 35 year old man presented with palpitations and an episode of syncope. His past medical history was unremarkable and he was an ex-smoker. His brother had died suddenly at 36 years of age. Vital signs were pulse 70/min, BP 135/60mmHg, SaO2=98% on air and temperature 37oC. Examination was unremarkable. His resting ECG revealed sinus rhythm with incomplete RBBB, epsilon wave in V1-2 and T wave inversion in V1-3. Telemetry showed two episodes of non-sustained ventricular tachycardia with LBBB pattern and inferior axis. What is the most likely diagnosis? Arrhythmogenic right ventricular cardiomyopathy Brugada syndrome Idiopathic ventricular tachycardia Pulmonary embolism Wellen’s syndrome A Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a rare disease but an important cause of sudden cardiac death in young adults. It should be suspected in patients who present with VT with LBBB pattern, especially if there is no apparent heart disease. It can be difficult to differentiate it from idiopathic ventricular tachycardia originating from the right ventricular outflow tract but the patient’s resting ECG shows most of the typical features of ARVC. Q43. A 45 yr old man who had recently suffered from a viral illness complained of ‘raw’ central chest pain that was relieved by sitting forward. On clinical examination he was comfortable, with a normal character pulse of 65/min and BP 135/70 mmHg that did not vary with respiration. His ECG showed ‘saddle’ shaped ST elevation in most leads, and an echocardiogram revealed a rim of fluid in the pericardial space with an echo-bright pericardium. Which treatment is most appropriate? Needle pericardiocentesis Pericardial drain insertion Pericardioscopy and biopsy Pericardiostomy Symptomatic management E The patient has a small pericardial effusion which is almost certain to be secondary to pericarditis from a viral illness. It is not causing any haemodynamic compromise, hence conservative / symptomatic management with analgaesia and anti- inflammatories is most appropriate. Only very large or very rapidly accumulating effusions require drainage. If an effusion is causing cardiovascular compromise (tamponade), immediate removal of 50-150mls of fluid by needle pericardiocentesis can be life saving. Q44. A 21-year old man with no known prior medical history suddenly collapsed whilst playing football. His friends started CPR and paramedics arrived within 5-minutes of the collapse. The initial rhythm was ventricular fibrillation which was successfully cardioverted with a 150 Joule DC shock. On arrival in the Emergency Department a12-lead ECG is performed (see image). What is the most likely diagnosis? See image Anterior ST Elevation Myocardial Infarction Brugada syndrome Long QT syndrome Pulmonary embolism Short QT syndrome B Brugada syndrome is characterized by ECG findings of down-sloping ST segment elevation in leads V1-V3 with RBBB pattern. This channelopathy, due a loss of function mutation of the SCN5A gene, is associated with ventricular fibrillation and sudden death. Q45. A 70-year-old man presented with severe anterior chest pain which radiated to his back. Chest radiography revealed a widened mediastinum, and an acute type B thoracic aortic dissection was confirmed on angiography. Which is the most appropriate treatment? Bendroflumethiazide (oral) Labetalol (intravenous) Lisinopril (oral) Nifedipine (oral) Sodium nitroprusside (intravenous) B Type A aortic dissections require surgical treatment. Type B dissections are usually managed medically with careful blood pressure control. In the acute phase, control of blood pressure with an intravenous infusion of Labetalol would be the ideal option. Labetalol has combined alpha and beta-adrenoceptor blocking activity and causes peripheral arteriolar vasodilatation without reflex tachycardia. Intravenous Nitroprusside causes tachycardia and would normally be combined with a beta-blocking agent. The other agents should not be used in the acute setting, when very careful titration of blood pressure is needed. They could be used later for more chronic control of blood pressure after the emergency has been managed. Q46. A man with permanent atrial fibrillation had resting heart rate 100 /min. Blood pressure was 120-86 mmHg, and there was no evidence of fluid retention. His serum creatinine was normal and echocardiography showed evidence of systolic dysfunction. He was receiving appropriate doses of furosemide and an angiotensin-converting-enzyme inhibitor. Which drug would you introduce next? Amiodarone Carvedilol Digoxin Losartan Metolazone B Beta-blockers have prognostic and symptomatic benefit in heart failure. In the UK only carvedilol and bisoprolol are licensed for this use. Digoxin can improve symptoms in severe heart failure. Whilst it may well slow resting heart rate in atrial fibrillation it has less benefit on exercise related increases in rate Q47. A 21-year old woman was referred to the cardiology clinic because of recent onset shortness of breath on exertion. Clinical examination was notable for fixed splitting of the second heart sound, with a soft systolic murmur over the left sternal edge. A 12-lead ECG demonstrated a right bundle branch block pattern with right axis deviation. What is the most likely cardiac defect? Patent foramen ovale Primum atrial septal defect Pulmonary stenosis Secundum atrial septal defect Ventricular septal defect D Fixed splitting of the second heart sound is often due to the presence of an ASD. The defect creates a left to right shunt that increases the blood flow to the right side of the heart, thereby causing the pulmonary valve to close later than the aortic valve independent of inspiration/expiration. On the 12-lead ECG, Secundum ASD is associated with RBBB+ right axis deviation whilst Primum ASD is associated with a RBBB+ left axis deviation. Q48. 75yr old man was seen in the cardiology clinic with severe symptomatic aortic stenosis. An echocardiogram was consistent with this diagnosis. His perioperative morality with open surgical valve replacement was calculated to be more than 50% because of his other co morbidities. What is the most appropriate treatment? Balloon valvotomy Medical management Pulmonary autograft Surgical valve replacement Transcatheter Aortic valve implantation E Prognosis of symptomatic severe aortic stenosis is poor. For patients unsuitable to undergo surgical valve replacement, transcatheter aortic-valve implantation (TAVI) can be beneficial. Indications for TAVI are: inoperable patients with severe aortic stenosis (mean gradient >40 mmHg or jet velocity >4 m/s) or AVA<1 cm², NYHA ≥ II and predicted surgical mortality risk of >50%. Studies have shown a mortality benefit for patients undergoing TAVI when compared to medical therapy including balloon valvotomy. Q49. A 56 year-old man, previously fit and well, was admitted with an anterior myocardial infarction. He was treated with primary coronary intervention and had a stent deployed in his left anterior descending artery. He was discharged from hospital 3 days later on the following medications: aspirin, clopidogrel, ramipril, bisoprolol, simvastatin and furosemide. He returned for review in the clinic at 6 weeks, when he reported no chest pain but some breathlessness on exertion. His ECG showed sinus rhythm with LBBB and a QRS duration of 120msec. His echocardiogram demonstrated an akinetic anterior wall and an ejection fraction of 29% with no dysschrony. Which should be considered for this patient? Cardiac resynchronisation defibrillator (CRT-D) Cardiac resynchronisation pacemaker (CRT-P) Implantable cardioverter defibrillator (ICD) Implantable loop recorder (ILR) Pacemaker C He has severe impairment to left ventricular function as a consequence of a myocardial infarction in spite of medical management and so is at risk of sudden death from cardiac arrhythmias. Cardiac resynchonisation would only be appropriate if the echo showed dyssynchrony. An implantable loop recorder is a diagnostic tool for the investigation of palpitations and/or syncope. Therefore, the most appropriate option would be an ICD. Q50. A 22 year-old woman presented with recurrent episodes of fainting in the gym. She had no other medical history, but a sibling had died suddenly as a teenager. Examination was unremarkable and her ECG showed inverted T waves in V1-V3 and a normal QTc. Her echocardiogram was entirely normal. A 24 hour Holter monitor showed multiple episodes of monomorphic ventricular tachycardia (VT). What investigation is likely to be most useful in making a diagnosis? Cardiac MRI scan Contrast-enhanced cardiac CT scan Coronary angiogram Right heart catheterisation and biopsy Transoesophageal echocardiogram A The ECG and history are suggestive of arrhythmogenic right ventricular cardiomyopathy. Fatty infiltration of the right ventricular wall can be visualised on T1 imaging. Q51. A 22 year old student presented to Emergency Department following an episode of palpitations lasting approximately 2 hours. He suffered from palpitations weekly, and occasionally became pre-syncopal with these. He had previously tried flecainide to terminate the symptoms, but this had little effect. By the time a 12 lead ECG was recorded his palpitations had terminated (see image). What is the best treatment for the likely cause of his palpitations? See image Digoxin Electrophysiology study and ablation Implantable Cardioverter Defibrillator (ICD) Metoprolol Verapamil B The ECG shows delta waves consistent with Wolf-Parkinson White (WPW) syndrome, and AV re-entry tachycardia is the likely cause for the palpitations. The frequency of symptoms and young age suggest curative ablation is the best treatment, rather than lifelong medication. Another reason is the association of symptomatic WPW with the small risk of ventricular fibrillation secondary to conduction of atrial fibrillation down the accessory pathway. Q52. A 58-year-old woman was admitted acutely with pulmonary oedema and hypotension. She had a mitral valve replacement four years previously for mitral regurgitation. Clinical examination revealed a mitral diastolic murmur and pulmonary oedema. Her biochemistry and full blood count weres normal. Her INR was 1.8. Echocardiography demonstrated thrombus around the valve. What is the best treatment? Low molecular weight heparin - treatment dose, SC Surgery Thrombolysis Unfractionatred heparin - treatment dose, IV Warfarin - increased dose to achieve INR 3-4 B Mechanical mitral valves are more prone to thrombosis than aortic valves if the INR drops below the therapeutic level. This is a medical/surgical emergency that can be rapidly fatal without immediate surgical intervention. Thrombus in this context cannot be treated with anticoagulants/fibrinolytics. Anticoagulation is clearly an important consideration when considering what type of valve prosthesis should be considered for an individual. Q53. A 66 yr old man with a history of peripheral vascular disease and chronic obstructive pulmonary disease presented to the Emergency Department following 2 hours of chest and back pain, which he was too unwell to describe in detail. On examination he was breathless (respiratory rate 22/min), tachycardic (110/min, regular), hypotensive (85/60 mmHg), and had a slow capillary refill time (5 seconds). Other findings on cardiovascular examination were that his pulse was difficult to feel on inspiration, and his JVP was grossly elevated. There was no palpable right ventricular heave. His chest sounds were clear. The ECG showed significant inferior ST segment depression. What is the most likely diagnosis? Acute inferior myocardial infarction Acute pulmonary embolism Acute tricuspid regurgitation Cardiac tamponade Severe / ‘life threatening’ exacerbation of chronic obstructive pulmonary disease D The feature of pulsus paradoxus (an exaggerated fall in systolic blood pressure on inspiration) along with the grossly elevated JVP makes cardiac tamponade the most likely cause of this man’s circulatory collapse and apparent right heart failure. The history of arterial disease, chest and back pain, and inferior ischaemia on ECG would suggest that the cause of pericardial effusion and tamponade is aortic dissection in this case. Q54. A 64-year-old woman presented to a primary angioplasty service via ambulance. She complained of sudden onset, sustained central chest discomfort associated with sweating and breathlessness that had come on two hours previously, shortly after an argument with a passing motorist. She had no significant past medical history. 12 lead electrocardiography showed 3mm of ST segment elevation in leads V1-6, I and AVL. She was treated with 300mg of Aspirin and 180mg Ticagrelor. Emergency coronary angiography revealed smooth, normal coronary arteries, with normal flow. Left ventricular angiography showed a ballooned, akinetic left ventricular apex extending to and involving the mid-anterior and mid-inferior wall. The basal segments contracted well. An ECG performed shortly after transfer to coronary care showed persistent ST segment elevation. What is the most likely diagnosis? Acute anterior ST-segment elevation myocardial infarction (STEMI) Coronary embolus Non ST-segment elevation myocardial infarction (NSTEMI) Pulmonary embolus Tako-Tsubo Cardiomyopathy E This is a typical presentation of Tako-Tsubo cardiomyopathy/apical ballooning syndrome, which can mimic STEMI closely. The key differences are that the coronary arteries are normal, the pattern of left ventricular akinesis does not correspond to a single coronary artery territory, and the ST-segment elevation has persisted in spite of coronary flow being normal. It is frequently reported to have been preceded by emotional stress. Q55. A 69-year-old woman with a previous history of a mechanical aortic valve replacement three years ago (for severe aortic stenosis) presented acutely following a syncopal episode whilst out shopping. She had suddenly lost consciousness whilst bending down and awoke on the floor. She felt that the loss of consciousness was sudden, but she recovered rapidly and denied any head injury. She reported a few dizzy spells in the previous weeks but said that she was now completely back to normal. Examination revealed blood pressure 115/86 mmHg and a prosthetic second heart sound, but was otherwise normal. Her blood tests were within normal limits with an INR of 2.2. Her chest radiograph did not show any abnormalities and her ECG was as shown (see image). What is the most appropriate investigation? See image Cardiac telemetry CT pulmonary angiogram CT brain scan Echocardiogram Ultrasound scan of carotid arteries A The history is suggestive of cardiac syncope. The ECG shows trifascicular block (RBBB, left-axis deviation and prolonged PR interval) and given the history of syncope and previous pre-syncopal episodes, one ought to be concerned about complete heart block. In this case, rhythm monitoring and pacemaker implantation would be indicated. Given the absence of neurology, the low risk nature of the fall and patient's complete and rapid recovery, a CT brain scan would not be indicated despite the patient being on warfarin. Q56. A 56 year old Caucasian man presented with 1 year of shortness of breath and fatigue on minimal exertion. He had previously undergone coronary artery bypass grafting 8 years ago following a myocardial infarction. He was currently taking aspirin, bisoprolol, ramipril, furosemide and simvastatin. On examination his pulse was 80/min (regular), BP 110/76 mmHg, JVP elevated 4cm, and there was a soft mitral regurgitant murmur, a few basal crackles, and a trace of ankle oedema. His ECG showed sinus rhythm, with left bundle branch block. An echocardiogram revealed severe left ventricular dysfunction and moderate secondary mitral regurgitation. What is the most appropriate treatment? Biventricular pacemaker implantation Digoxin Hydralazine and Isosorbide Dinitrate Mitral valve surgery Spironolactone E Spironolactone is recommended by NICE as second line treatment for heart failure. Hydralazine/Nitrate is also supported, but would only be preferred in Afro-Caribbean patients. Digoxin is only recommended as third line therapy, and biventricular pacing should only be considered after optimization of medical therapy. Q57. A 70 year old man was referred to cardiology outpatients with exertional breathlessness and ankle swelling. His symptoms had developed over the preceding 12 months. He did not describe angina. He had been prescribed furosemide 40mg once daily, which had slightly reduced the ankle swelling. On examination, blood pressure was 95/65 mmHg, his JVP was elevated at 6cm above the sternal angle, a faint ejection systolic murmur could be heard throughout the praecordium, and he had pitting oedema to the mid-shin. A 12 lead ECG showed sinus rhythm and that the ST segments in leads V4-6 were down-sloping, with associated T-wave inversion. An echocardiogram showed a dilated left ventricle with severe impairment of systolic function. Aortic valve morphology was not well seen, but the valve did not appear to open well. Peak velocity across the valve was 2.5 m/s, equating to a peak trans- valvular gradient of 25mmHg. What is the most appropriate next course of action? Arrange coronary angiography Arrange low-dose dobutamine stress-echocardiography Commence ACE-inhibitor Refer for aortic valve replacement Refer for consideration of heart transplantation