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Cardiology Finals Revision Session Helena Martin (IMT1) – Helena.martin@gstt.nhs.ukWhat you need to know • ACS • Stable Angina • Pericarditis • Heart Failure • Valvular heart disease • Infective Endocarditis • Atrial fibrillation • SVTs • PacemakersQuestion 1 radiates to the jaw or shoulder for the past 30 minutes. He also feels short of breath and nauseous. O2 is 96% and you carry out an ECG and note that there is ST elevation in leads V3, V4. What part of the heart is likely to be affected by this MI? a) Superior b) Anterior c) Inferior d) Left lateral e) Right lateral• B - AnteriorQuestion 2 palpitations in his chest. He described this as his heart was skipping a beat. On examination it was found that the patient had a SVT. Which of the following would be the most appropriate in the acute management of this patient to return to normal sinus rhythm? a) Valsalvar manoeuvre b) Amiodarone c) Atropine d) DC cardioversion e) AdrenalineA - Valsalva manoeuvre The patient in the question has a supra-ventricular tachycardia. SVT are a form of narrow complex tachycardia and therefore the as the patient is young, the first line in this case would be valsalva manoeuvre which is where the nose and mouth is held during forceful expiration to stimulate the vagus nerve to return the heart into sinus rhythm. Amiodarone would be used in a broad-complex tachycardia. Atropine and adrenaline would be used during an episode of bradycardia to speed the heart up. DC cardioversion would not be first line in this management Question 3 unwell, reporting myalgia,nausea and weakness.tory of feeling generally His observations are: Respiratory rate: 24/min Blood oxygen saturation:97% on room air Heart rate: 109bpm Blood pressure: 91/56mmHg Temperature: 37.7 C GCS 15/15 Whilst the fluid is running,the patient begins to complain of palpitations, chest pain and shortnessof breath. An ECG is performed and is shownbelow. What electrolyte abnormality is most likely to have precipitated this rhythm? A) hypercalcaemia B) Hyperkalaemia C) hypermagnesaemia D) hypokalaemia E) hyponatraemiaAnswer D Hypokalaemia – resulting in Torsades de Pontes Polymorphic ventricular tachycardia (PVT) is a form of ventricular tachycardia in which there are multiple ventricular foci with the most common cause of PVT is myocardial ischaemia/infarction.on. TheQuestion 4 A 45-year-old male recently had a coronary artery bypass graft (CABG) after suffering an myocardial infarction 2 weeks ago. He now has a sharp pain in his chest which is radiating to his left shoulder and is worse when he takes a deep breath in. flat. On examination, his vital signs are normal and there are no murmurs onying auscultation.His troponin blood test comes back normal. What is the most likely diagnosis? a) Pericarditis b) Interstitial lung disease c) Endocarditis d) Myocardial infarction e) Aortic dissectionA - Pericarditis Pericarditis – this is inflammation of the membrane that surrounds the heart, movement of the heart causes pain. It causes pleuritic pain which is classically sharp and worse on inspiration. Pericarditis pain is relieved when leaning forward. It can occur after a CABG as the tissue has been damaged, another cause is Dressler Syndrome whereby pericarditis occurs as a complication of an MI 2-3 weeks afterwards. They may have a fever, this is not present in this description.Question 5 A 83 year old lady presents to heart failure follow up clinic. She has a history of NSTEMI and gallstones. Her symptoms are reasonably poorly controlled. She is able to walk around her bungalow, but struggles to walk to her local shops 100m away due to breathlessness. She had recently seen her GP who added spironolactone to her regular medications due to persistent hypokalaemia. Her potassium has since normalised. Her latest echo reveals an ejection fraction of 25%. Her ECG is sinus rhythm Her last BNP was 1000 pg/ml. She is currently taking senna, ramipril 10mg, aspirin 75m, frusemide 40mg bd, simvastatin 40mg, and spironolactone 50mg. Her observations at clinic are: oxygen saturations: 94% on room air blood pressure: 126/66 mmHg heart rate: 84/min Which additional medication would be beneficial? A) Ivabradine B) Bisoprolol C) Digoxin D) Diltiazem E) AtenololB - Bisoprolol This patient is already taking some prognosticallybeneficial medications; ACE inhibitor and aldosteroneantagonist.The additional of a beta blocker would be a beneficial medication; both from a preventative of re-modelling and a reduction in heart rate. Heart rate is a well established modifiable risk factor,which when appropriately controlled can improve morbidity and mortality in heart failure. This patient's heart rate is not well controlled. Bisoprolol, carvedilol, nebivolol and metoprolol are the only evidence-based cardioselective beta blockers for heart failure patients. Ivabradineis an If (funny)channel blocker,which reduces heart rate by blocking the If current in the sinoatrial node. NICE guidelines Ejection fraction <35%abradine for heart failure in a select groupof patients: Heart rate >75/min Sinus rhythm NYHAclass 2-4 Maximally titrated beta blocker therapy. Since this patient is not on maximal beta blocker therapy,it would not be appropriate to commence ivabradine. Diltiazem may be used as an anti-anginal medication, but this patient does not have angina.Digoxin may be of benefit in heart rate, especially if the patient has atrial fibrillation, but should only be considered following failure of first and second line therapies.Question 6 You are reviewing in clinic a 67-year-old man who has type 2 diabetes. His glycaemic control is reasonable with metformin therapy; the latest HbA1c is pressure reading of 152/90 mmHg. A 24 hour blood pressure monitor wasod requested. The report shows his average blood pressure was 142/88 mmHg. What is the most appropriate course of action? A) Start an ACE inhibitor B) Start a calcium channel blocker C) Repeat 24h blood pressure monitoring in 4-8 weeks time D) Request an US of his kidneys E) Do nothing, monitor BP regularlyA – start ACEi • This patient has stage 1 hypertension as defined by NICE. He should however be treated because he has underlying diabetes. The first-line treatment for a patient aged > 55 years is a calcium channel blocker. However, in patients with diabetes ACE inhibitors are used first-line due to their renoprotective effect.Question 7 A 64-year-oldwoman presents to the emergency department with breathlessness.She has exercisetolerance.She now finds that even a few steps make her short of breath whilst her normallyshe would be able to walk to her local shops and back. She finds that she cannot lie down as it makes her feel worse. She has a past medical history of hypertension, previousmyocardialinfarction and asthma. On examination,she has a raised JVP, bilateral crepitationson auscultation,reduced air entry in both bases and dull percussion.On her chest X-ray, there is evidenceof pulmonary oedema and bilateral pleural effusions. What is the most appropriatemanagement plan? A) Give IV furosemide B) Pleural aspirate and if exudate, insert chest drain C) Insert chest drain on one side D) Insert chest drain on both sides E) NIVA – Give IV furosemide Heart failure: acute management • IV loop diuretics e.g. furosemide Possible additional treatments • Oxygen (Aim Sats 94-98%) • Vasodilators (nitrates should not be routinely given to all patients.They may, however, have a role if concomitant myocardial ischaemia, severe hypertension or regurgitant aortic or mitral valve disease. the major side-effect/contraindication is hypotension) Patients with respiratory failure - CPAP Patients with hypotension (e.g. < 85 mmHg)/cardiogenic shock, this can be a difficult scenario to nitrates) may exacerbate the hypotension. May need inotropic agents (dobutamine), vasopressors,d mechanically circulatory assistance (intraaortic balloon) Question 8 A 51-year-old man is referred to the cardiology clinic by his GP. He complains of a 1-year history of exertional breathlessness. He also feels breathless when lying flat. He has a past medical history of hypertension, chronic kidney disease, and atrial fibrillation and is prescribed ramipril, bisoprolol, and apixaban. On examination, his pulse is 70bpm and his blood pressure is 134/92mmHg. He has coarse crackles at both lung bases. His blood tests are shown below: The echocardiogram shows: Regular furosemide is started. What additional medication should be prescribed? Summary: Left ventricular systolic function is moderately impaired. The ejection fraction is visually estimated at ~51%. A) Amlodipine Male: (135-180) Hb 141 g/L Female: (115 - 160) B) Dapagliflozin C) Ivabradine Platelets 177* 10 /L (150 - 400) D) Sacubitril and valsartan E) Spironolactone WBC 6.7 * 10 /L (4.0 - 11.0) Na + 138 mmol/L (135 - 145) K + 5.5 mmol/L (3.5 - 5.0) Urea 12.9 mmol/L (2.0 - 7.0) Creatinine 188 µmol/L (55 - 120)B - Dapagliflozin Management of HFpEFQuestion 9 A 53-year-old gentleman is reviewed in clinic due to abnormal blood tests. He has a past medical history of hypertension, type two diabetes, obesity, and depression. He started taking atorvastatin two months ago due to a routine assessment of QRISK and elevated cholesterol levels. He had a blood test as requested at three months following the start of treatment. These shows that his alanine aminotransferase have increased from 28iU/L to 94iU/L. Other blood tests have remained within normal ranges apart from cholesterol which as improved from 5.4mmol/L to 4.9mmol/L. How should his atorvastatin treatment be managed? A) Stop atorvastatin and repeat LFT within 4-6 weeks B) Continue atorvastatin and repeat LFT within 4-6 weeks C) Change atorvastatin to simvastatin D) Investigate for elevated creatine kinase E) Stop atorvastatin and arrange for an urgent abdominal USB – Continue Atorvastatin and repeat LFT within 4-6 weeks • This patient has developed elevated transaminases following starting aeeks. statin, but these are within three times the upper range of normal. Please note that this is three times the maximum normal range, not three times above the patient's baseline result. Therefore it is acceptable to continue atorvastatin but monitor liver function with a repeat test in 4-6 weeks. If stopping the atorvastatin and repeating LFT would have been appropriate. There is no need to arrange for an ultrasound at the moment as there is a clear explanation, and there is no evidence of new muscle pain to justify testing for creatinine kinase. Changing statin can play a role if the statin is not tolerated, but that is not the case so far.Question 10 A 58-year-old woman was admitted with a stroke following a month's history of recurrent fevers, anorexia and weight loss. On examination, she had a left-sided hemiparesis and facial droop. Cardiovascularexamination revealed splinter haemorrhagesin 5 of her fingers acrossboth hands, and a soft diastolic murmur heard loudest in expiration over the aortic area. A trans-thoracicechocardiogramshowed an oscillating vegetation on an aortic leaflet, in the path of regurgitant jets. Two blood cultures were positive for Streptococcispp. She was diagnosedwith infective endocarditis and started on intravenous benzylpenicillin 1.2gevery 4 hours and gentamicin 1mg/kgtwice daily therapy. She was reviewed after 5 dayson antibiotic therapywith the following results. What is the most important next step in management? A) Increase Abx to IV BenPen 2.4gevery 4 hours and gentamicin 1mg/kgtwice daily B) Organiseurgent colonoscopy C) Switch Abx to Cef 2g once daily D) Refer to cardiothoracic surgeons E) Organiseurgent trans-oesophagealechoAnswer D – Refer to Cardio-thoracics This patient has infective endocarditis, as diagnosed by two positive major criteria from the Duke'scriteria for infective endocarditis. In addition, she has a number of minor criteria, including fever, vascular events (stroke), immunological events (splinter haemorrhages,renal impairment secondary to glomerulonephritis). Despite starting on appropriate empirical treatment she appears enlarging aortic abscessdisrupting the atrioventricular node, which is an indication for referral for cardiothoracic surgery in infective endocarditis. Heart failure: valve obstructionresulting in pulmonary oedema or shock,severe acute regurgitation appropriate antibiotics, multiresistant microorganismsting fever and positive blood cultures for greater than 10 days despite predictors of complications eg. heart failure.lting in one or more embolic episodes despite appropriate antibiotic therapy,or other treated with vancomycinand gentamicin, so options (a) and (c) are incorrect. Streptococcus Bovis bacteraemia is associated with bowel malignancy,and a colonoscopyshould be arranged to rule out malignancy,however, the worsening PR prolongation takes priority and should be managed first. An urgent trans-oesophagealechocardiogrammay be useful to evaluate the sizeof the aortic abscess,however, it would not change management as this patient needs to be referred to the cardiothoracicsurgeons as there is already evidence of enlarging vegetation.Question 11 A 77-year-old man with known atrial fibrillation is admitted followingan upper gastrointestinalhaemorrhage. His atrial fibrillationis managed using bisoprolol and warfarin. Since his admission, he has had four large episodes of haematemesis. one of a series of investigations.The haematologylaboratory phone through and as inform you his INR is 8.5. He is currently hypotensive (90/45 mmHg) and tachycardic (120 beats per minute). You begin resuscitation using 0.9% saline, and send a cross match, group and save. What is the most appropriate treatmentof this patientsINR? A) FFP + stop warfarin B) Vitamin K + Stop warfarin C) Prothrombin complex concentrates D) Prothrombin complex concentrates + Vitamin K + stop warfarin E) Stop warfarinAnswer – D. Give FFP + Vit K + stop warfarin The nub of this question is the emergency management of haemorrhage in patients on warfarin. This patient has an INR greater than 8 and is actively bleeding. Therefore the answer is 4. Patients on warfarin have reduced levels of Factor X, IX, VII and II. Rapid correction is most effectively achieved through administration of prothrombin complex concentrates. The British Journal of Haematology states that: 'Emergency anticoagulation reversal in patients with major bleeding should be with 2550 u/kg four-factor intravenous vitamin K'ncentrate and 5 mg Follow this link for more information n4thed.pdf.bcshguidelines.com/documents/warfariQuestion 12 • Which cardiac biomarker elevates first? A) Troponin B) Creatine Kinase (CK) C) Myoglobin D) BNP E) CreatinineAnswer - CQuestion 13 • Which of the following group of drugs are the 1st line treatment in both hypertension and heart failure? • A. ACE inhibitors • B. Diuretics. • C. Ivabradine • D. AmlodipineAnswer – A (ACEi)Question 14 • a one-week history of palpitations.She was diagnosed with AF at the time andslywith commencedon aspirin and a beta-blocker.Her echocardiogramshowed no significant abnormalitiesand her ECG in clinic today confirms atrial fibrillation with a ventricular considered for cardioversion.What do you advise?alpitationsand wouldlike to be • A. She needs to be warfarinized for at least 48 hours pre-cardioversion • B. Anticoagulationshould be continued after successful cardioversionfor at least 4 weeks • C. If a TOE rules out atrial thrombus,no anticoagulationis required post-procedure • D. Anticoagulationis not required prior to chemicalcardioversion • E. Anticoagulationis not required prior to cardioversionas her CHADS2 score is zeroAnswer - B • Anticoagulation should be continued for at least 4 weeks post- cardioversion as ‘atrial stunning’ may occur. Anticoagulation is required prior to both chemical and electrical cardioverison. If a patient has not had oral anticoagulation for at least 3 weeks, it is reasonable to perform DCthrombus. However, LMWH should be commenced prior to a TOE-guided cardioversion and continued post- cardioversion until target INR is reached.Question 15 • A 25-year-old male developed sharp central chest pain and palpitationsafter drinking three cans of energy drink whilst revising for exams. The symptoms were ongoing when he initially attendedthe ED, and an ECG showed a sinus normally fit and well. His father recently had a myocardial infarction at the age of 62. All observationsand examination are normal. Troponin and D-dimer tests were negative. • What would you recommend? • A. Admit for observations • B. Exercise treadmill test • C. Stress echocardiogram • D. CT coronary angiogram • E. No further investigationQuestion 16 • A patient with on maximum dose bisoprolol for his stable angina. What agent would you recommend adding in next? A) Verapamil B) Diltiazem C) Amlodipine D) ISMN E) IvabradineAnswer – C (Amlodipine)Thank you - Questions