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Cardiology Progress Test Secrets Dr James Moggridge Cardiology Trainee (UHW/GUH) James.Moggridge@wales.nhs.uk Sponsored by: Contents Wednesday Session: Thursday Session: Anatomy&Physiology ✓ ChestPain 01 04 ECGs ✓ Arrhythmias 02 05 Pharmacology ✓ HeartFailure 03 06Chest Pain: Common Progress Test Questions: • Acute Coronary Syndrome • Diagnosis • Management • Complications • Pericarditis • Takotsubo’s Cardiomyopathy • Pulmonary EmbolismChest Pain: Acute Coronary Syndrome:Chest Pain: Acute Coronary Syndrome: STEMI • Aspirin 300mg • Second Anti-Platelet Agent • Prasugrel 60mg • Ticagrelor 180mg • Clopidogrel 300/600mg • UFH (Fondaparinux 2.5mg) • Secondary Prevention post PCI: A = ACE Inhibitor/ARB B = Beta-Blocker C = Cholesterol – Statin D = Dual Anti-Platelet TherapyChest Pain: Acute Coronary Syndrome: NSTEACS • Aspirin 300mg • Second Anti-Platelet Agent • Prasugrel 60mg • Ticagrelor 180mg • Clopidogrel 300/600mg • UFH (Fondaparinux 2.5mg) • Secondary Prevention post PCI/Medical Management: A = ACE Inhibitor/ARB B = Beta-Blocker C = Cholesterol – Statin D = Dual Anti-Platelet TherapyChest Pain: Acute Coronary Syndrome: Complications DARTH VADER • Death • Arrythmia • Rupture • Tamponade • Heart Failure • Valve Disease • Aneurysm of ventricle • Dressler’s Syndrome • Embolism (mural thrombus) • RecurrenceChest Pain: Acute Coronary Syndrome: Complications DARTH VADER • Death • Arrythmia • Rupture • Tamponade • Heart Failure Echocardiogram • Valve Disease • Aneurysm of ventricle • Dressler’s Syndrome • Embolism (mural thrombus) • RecurrenceChest Pain: Pericarditis: • Central chest pain • Positional • Associated with viral illness • Can be post MI (Dressler’s Syndrome) • Thickened pericardium on echo • Could have small pericardial effusion • Clinically may hear pericardial rub • Widespread concave ST Elevation on ECG & PR depression • Treat with NSAIDs • Colchicine • Ibuprofen • Steroids may be used if not responding to NSAIDs/Chronic • No indication for drainage unless; • Tamponade • SepticChest Pain: Takotsubo’s Cardiomyopathy: • Often a diagnosis of exclusion • Stress related • Difficult to distinguish from ACS clinically • Chest pain • Troponin rise • ST changes anteriorly on ECG • Apical akinesia/hypokinesia on echo • Complications; • Acute LV Failure • LV Thrombus • Long QT Syndrome • Treatment focuses around LV failure medical therapy (Bisoprolol, ACEi/ARB) • Often improves/resolvesChest Pain: Pulmonary Embolism: • Pleuritic, lateral chest pain • Associated with haemoptysis & DVT • Varying spectrum of severity • Can cause right sided heart failure • Raised JVP • Peripheral Oedema • Hypoxia • Most common ECG finding – Sinus Tachycardia • Diagnostic test – CTPA/VQ Scan • Treatment; S1 • If haemodynamically unstable – thrombolysis Q3 • Initial high dose DOAC/Warfarin T3 • Length of treatment determined by causative factorsChest Pain: Common Questions: A 48-year-old man presents to the ED with sudden onset chest pain starting 45 minutes ago. An ECG is performed, and a diagnosis of Inferior STEMI is made. Which of the following is the most appropriate management? a. Urgent Thrombolysis b. Bisoprolol 2.5mg c. IV GTN infusion d. Bedside Echocardiogram e. Enoxaparin 40mgChest Pain: Common Questions: A 48-year-old man presents to the ED with sudden onset chest pain starting 45 minutes ago. An ECG is performed, and a diagnosis of Inferior STEMI is made. Which of the following is the most appropriate management? a. Urgent Thrombolysis b. Bisoprolol 2.5mg c. IV GTN infusion d. Bedside Echocardiogram e. Enoxaparin 40mgChest Pain: Common Questions: A 67-year-old man is treated for an anterior STEMI with primary PCI to the Left Anterior Descending Artery. He is admitted to the Coronary Care Unit for further treatment. 24 hours following admission, he acutely deteriorates. On assessment, he is hypoxic requiring 15 litres O2 therapy with widespread crackles throughout the chest. Which of the following would be the most appropriate to aid diagnosis? a. Coronary Angiogram b. High-Sensitivity Troponin T c. BNP d. Echocardiogram e. Peak FlowChest Pain: Common Questions: A 67-year-old man is treated for an anterior STEMI with primary PCI to the Left Anterior Descending Artery. He is admitted to the Coronary Care Unit for further treatment. 24 hours following admission, he acutely deteriorates. On assessment, he is hypoxic requiring 15 litres O2 therapy with widespread crackles throughout the chest. Which of the following would be the most appropriate to aid diagnosis? a. Coronary Angiogram b. High-Sensitivity Troponin T c. BNP d. Echocardiogram e. Peak FlowChest Pain: Common Questions: A 91-year-old lady presents to the Medical Assessment Unit with a 1 week history of haemoptysis, shortness of breath and right sided chest pain. She has a HR of 102bpm & BP of 130/70. Which of the following is the most appropriate initial investigation? a. Echocardiogram b. Chest X-Ray c. D-Dimer d. Troponin e. CT Pulmonary AngiogramChest Pain: Common Questions: A 91-year-old lady presents to the Medical Assessment Unit with a 1 week history of haemoptysis, shortness of breath and right sided chest pain. She has a HR of 102bpm & BP of 130/70. Which of the following is the most appropriate initial investigation? a. Echocardiogram b. Chest X-Ray c. D-Dimer d. Troponin e. CT Pulmonary AngiogramChest Pain: Common Questions: A 32-year-old lady presents to ED with a 1-day history of chest pain. Initial Troponin returned as 2453ng/L (0-35). Echo revealed apical akinesia with severe left ventricular systolic dysfunction. Which of the most appropriate initial treatment? a. Colchicine 500mcg b. Aspirin 300mg c. Primary PCI d. Furosemide 40mg e. Heart TransplantChest Pain: Common Questions: A 32-year-old lady presents to ED with a 1-day history of chest pain. Initial Troponin returned as 2453ng/L (0-35). Echo revealed apical akinesia with severe left ventricular systolic dysfunction. Which of the most appropriate initial treatment? a. Colchicine 500mcg b. Aspirin 300mg c. Primary PCI d. Furosemide 40mg e. Heart TransplantChest Pain: Common Questions: A 68-year-old lady with a background of metastatic breast cancer presents to ED with a 2-week history of progressive chest pain and shortness of breath. Examination reveals a raised JVP, hypoxia and tachypnoea. HR 136bpm, BP 67/44. An echocardiogram is performed, revealing a large pericardial effusion. What is the most appropriate immediate management? a. Colchicine 500mcg b. Urgent Thrombolysis c. DC Cardioversion d. Pericardiocentesis e. Dobutamine InfusionChest Pain: Common Questions: A 68-year-old lady with a background of metastatic breast cancer presents to ED with a 2-week history of progressive chest pain and shortness of breath. Examination reveals a raised JVP, hypoxia and tachypnoea. HR 136bpm, BP 67/44. An echocardiogram is performed, revealing a large pericardial effusion. What is the most appropriate immediate management? a. Colchicine 500mcg b. Urgent Thrombolysis c. DC Cardioversion d. Pericardiocentesis e. Dobutamine InfusionArrhythmias: Common Progress Test Questions: • Atrial Fibrillation • Supraventricular Tachycardia • Complete Heart Block • ALS Pathways • Shockable & Non-Shockable RhythmsArrhythmias: Atrial Fibrillation: • Extremely common condition • Associated with older age • Many patients can be completely asymptomatic • Varying rates based off AV Nodal sensitivity • Symptoms: • Palpitations • Shortness of breath • Chest pain • Pre-syncope • Rarely syncope • Can be related to systemic illness (Sepsis)Arrhythmias: Atrial Fibrillation:Arrhythmias: Atrial Fibrillation: Haemodynamic Instability: • DC Cardioversion • Systolic BP <90mmHg • 120-150J • Altered Mental Status Irrespective of • Max x3 Shocks • Cardiac Ischaemia Anticoagulation • If fails; • Decompensated Heart Failure • 300mg IV Amiodarone secondary to arrhythmia over 10-20mins • Then repeat DCCV Onset <48 hours and clinically stable: • DC Cardioversion • Opt for Pharmacological or Electrical treatment • 120-150J • Need to be sure this is a first- Irrespective of • Max x3 Shocks time presentation if not on Anticoagulation • If fails; anticoagulation • 300mg IV Amiodarone over 10-20mins • Can opt for Medical Management • Patients with Paroxysmal AF to • Amiodarone be treated as those with >48 • Flecainide (If no HF/IHD) hours onsetArrhythmias: Atrial Fibrillation: Onset >48 hours and clinically stable: • DC Cardioversion • Medical management Established (minimum 3 st weeks)Anticoagulation • 120-150J • Beta-blocker 1 line • Max x3 Shocks • CCB (Verapamil/Diltiazem) if unable to take Beta-blockers • If no response/underlying heart failure – add in Digoxin • Loading dose 0.75 – 1mg divided in doses over 24hrs • 125-250mcg maintenance dose daily • Aim HR <110bpm Long Term Management of Atrial Fibrillation: • Rate Control • If no response to maximum • B-Blocker/CCB/Digoxin dose B-Blocker/CCB & Digoxin – switch to PO • Rhthym Control Amiodarone • Amiodarone/Dronedarone/Flecainide • Anticoagulation (Based off Chads2Vasc Score)Arrhythmias: Atrial Fibrillation: • Offer anticoagulation to patients with AF and CHA2DS2VASC Score= 2 or more • Consider anticoagulation in men with CHA2DS2VASC Score = 1 • Do not offer anticoagulation in women with CHA2DS2VASC Score = 1 or men with CHA2DS2VASC Score = 0 • First line anticoagulant is DOAC • Apixaban/Rivaroxaban/Edoxaban • Warfarin indicated for those with contraindications to DOAC • Weight • Renal Function • Mechanical Valve • LV ThrombusArrhythmias: Supraventricular Tachycardia: • AVNRT • AVRT • Atrial Tachycardia • Atrial Flutter • Umbrella term for regular, narrow-complex tachycardia • Symptoms: • Palpitations • Chest pain • Shortness of breath • Pre-syncope • Can be associated with pain & systemic illness • Closely connected to sympathetic activationArrhythmias: Supraventricular Tachycardia: Haemodynamic Instability: • DC Cardioversion • Systolic BP <90mmHg • 120-150J • Altered Mental Status Irrespective of • Max x3 Shocks • Cardiac Ischaemia Anticoagulation • If fails; • Decompensated Heart Failure • 300mg IV Amiodarone secondary to arrhythmia over 10-20mins • Then repeat DCCV Haemodynamically Stable: • Vagal Manoeuvres • Carotid Sinus Massage • Valsalva • Give Adenosine • 6mg IV • If unsuccessful 12mg IV • If unsuccessful 18mg IV • If Adenosine unsuccessful • Verapamil or Beta Blocker • If no response to medical therapy • DC Cardioversion (starting at low energy and increasing) • Max x3 attemptsArrhythmias: Supraventricular Tachycardia: Anticoagulation: • Only indicated in Atrial Flutter/Atrial Fibrillation • Based off CHA2DS2VASC ScoreArrhythmias: Complete Heart Block: • Marked bradycardia • Can be life threatening • Symtoms • Syncope • Pre-syncope • Chest pain • Heart failure • Can be associated with MI • Often associated with older age Haemodynamically Stable: • Risk of asystole • CHB Arrhythmias: • Recent asystole • Mobitz II HB Complete Heart Block: • Ventricular Pause > 3 seconds Haemodynamic Instability: • Shock Interim Measures: • Syncope IV Atropine 500mcg Inadequate • IV Atropine 500mcg (up to max 3mg) • Myocardia Ischaemia response • Isoprenaline Infusion • Heart Failure • Adrenaline infusion • Transcutaneous Pacing Definitive Management: • Temporary Transvenous Pacing • Permanent Pacemaker ImplantArrhythmias: ALS Pathways: Shockable & Non-Shockable Rhythms • Shockable Rhythms: Ventricular Fibrillation Ventricular Tachycardia • Non-Shockable Rhythms: Pulseless Electrical Activity AsystoleArrhythmias: Common Questions: A 28-year-old lady presents to the ED with a 6-hour history of palpitations. She is alert, pain free with a BP of 126/84. Her ECG is attached. Which of the following is the most appropriate initial management?Arrhythmias: Common Questions: A 28-year-old lady presents to the ED with a 6-hour history of palpitations. She is alert, pain free with a BP of 126/84. Her ECG is attached. Which of the following is the most appropriate initial management? a. DC Cardioversion b. Digoxin 500mcg c. Amiodarone 300mg IV d. Adenosine 6mg IV e. Apixaban 5mgArrhythmias: Common Questions: A 28-year-old lady presents to the ED with a 6-hour history of palpitations. She is alert, pain free with a BP of 126/84. Her ECG is attached. Which of the following is the most appropriate initial management? a. DC Cardioversion b. Digoxin 500mcg c. Amiodarone 300mg IV d. Adenosine 6mg IV e. Apixaban 5mgArrhythmias: Common Questions: A 39-year-old man presents to the GP surgery with a 2-week history of intermittent palpitations. A 48hr holter monitor is arranged which reveals paroxysmal atrial fibrillation. He is normally fit and well with no other past medical history. Which of the following is the most appropriate initial management? a. Apixaban 5mg BD b. Bisoprolol 2.5mg OD c. Amiodarone 200mg OD d. Urgent DC Cardioversion e. Radiofrequency AblationArrhythmias: Common Questions: A 39-year-old man presents to the GP surgery with a 2-week history of intermittent palpitations. A 48hr holter monitor is arranged which reveals paroxysmal atrial fibrillation. He is normally fit and well with no other past medical history. Which of the following is the most appropriate initial management? a. Apixaban 5mg BD b. Bisoprolol 2.5mg OD c. Amiodarone 200mg OD d. Urgent DC Cardioversion e. Radiofrequency AblationArrhythmias: Common Questions: A 74-year-old female suffers an in-hospital cardiac arrest following a recent cholecystectomy. CPR is commenced and defibrillator pads are applied. At 2 minutes, a rhythm check is performed. There is no pulse. The defibrillator reads the following rhythm. What is the most appropriate next action? a. IV Adrenaline 1mg 1:10,000 b. IV Amiodarone 300mg c. IV Isoprenaline Infusion d. Urgent thrombolysis e. Urgent Shock at 150JArrhythmias: Common Questions: A 74-year-old female suffers an in-hospital cardiac arrest following a recent cholecystectomy. CPR is commenced and defibrillator pads are applied. At 2 minutes, a rhythm check is performed. There is no pulse. The defibrillator reads the following rhythm. What is the most appropriate next action? a. IV Adrenaline 1mg 1:10,000 b. IV Amiodarone 300mg c. IV Isoprenaline Infusion d. Urgent thrombolysis e. Urgent Shock at 150JArrhythmias: Common Questions: A 65-year-old female undergoes a mechanical aortic valve replacement. She has a past medical history of aortic stenosis, atrial fibrillation and Type 2 Diabetes Mellitus. Which of the following medications would be contraindicated in this patient? a. Apixaban b. Amiodarone c. Warfarin d. Furosemide e. DigoxinArrhythmias: Common Questions: A 65-year-old female undergoes a mechanical aortic valve replacement. She has a past medical history of aortic stenosis, atrial fibrillation and Type 2 Diabetes Mellitus. Which of the following medications would be contraindicated in this patient? a. Apixaban b. Amiodarone c. Warfarin d. Furosemide e. DigoxinArrhythmias: Common Questions: A 58-year-old female presents to ED with palpitations starting 24 hours earlier. She is haemodynamically stable. 12 lead ECG reveals atrial fibrillation with a rate of 148bpm. What is the most appropriate treatment? a. Carotid sinus massage b. Bisoprolol 5mg c. Flecainide 50mg d. Rivaroxaban 20mg e. Dronedarone 400mgArrhythmias: Common Questions: A 58-year-old female presents to ED with palpitations starting 24 hours earlier. She is haemodynamically stable. 12 lead ECG reveals atrial fibrillation with a rate of 148bpm. What is the most appropriate treatment? a. Carotid sinus massage b. Bisoprolol 5mg c. Flecainide 50mg d. Rivaroxaban 20mg e. Dronedarone 400mgHeart Failure: Common Progress Test Questions: • Diagnosis • Type of heart failure • Symptoms • Medical managementHeart Failure: Symptoms:Heart Failure: Diagnosis:Heart Failure: Medical Management:Heart Failure: Common Questions: An 82-year-old man is admitted to the Cardiology ward with dyspnoea on minimal exertion. An echocardiogram reveals severe left ventricular systolic dysfunction, and a diagnosis of heart failure is made. ECG reveals sinus rhythm at 85bpm. Which of the following medications is not indicated in this patient? a. Carvedilol 12.5mg OD b. Entresto 24/26mg BD c. Dapagliflozin 10mg OD d. Eplerenone 25mg OD e. Digoxin 125mcg ODHeart Failure: Common Questions: An 82-year-old man is admitted to the Cardiology ward with dyspnoea on minimal exertion. An echocardiogram reveals severe left ventricular systolic dysfunction, and a diagnosis of heart failure is made. ECG reveals sinus rhythm at 85bpm. Which of the following medications is not indicated in this patient? a. Carvedilol 12.5mg OD b. Entresto 24/26mg BD c. Dapagliflozin 10mg OD d. Eplerenone 25mg OD e. Digoxin 125mcg ODHeart Failure: Common Questions: A 73-year-old man presents to ED with acute breathlessness. He has a past medical history of severe LV failure and mitral regurgitation. He is requiring 15litres of O2 therapy. A Chest X-ray is performed. What is the most appropriate treatment? a. Tazocin 4.5g TDS b. Bisoprolol 2.5mg OD c. Urgent thrombolysis d. IV Furosemide 40mg STAT e. 250ml N.Saline 0.9% fluid bolusHeart Failure: Common Questions: A 73-year-old man presents to ED with acute breathlessness. He has a past medical history of severe LV failure and mitral regurgitation. He is requiring 15litres of O2 therapy. A Chest X-ray is performed. What is the most appropriate treatment? a. Tazocin 4.5g TDS b. Bisoprolol 2.5mg OD c. Urgent thrombolysis d. IV Furosemide 40mg STAT e. 250ml N.Saline 0.9% fluid bolusHeart Failure: Common Questions: A 70-year-old lady is admitted to the Cardiology ward with fatigue and worsening orthopnoea. She has a past medical history of rheumatic fever and previous breast cancer. Examination reveals bilateral crepitations to both lung bases and a subtle diastolic murmur. What is the most likely diagnosis? a. Pulmonary Stenosis b. Aortic Stenosis c. Mitral Stenosis d. Mitral Regurgitation e. Tricuspid RegurgitationHeart Failure: Common Questions: A 70-year-old lady is admitted to the Cardiology ward with fatigue and worsening orthopnoea. She has a past medical history of rheumatic fever and previous breast cancer. Examination reveals bilateral crepitations to both lung bases and a subtle diastolic murmur. What is the most likely diagnosis? a. Pulmonary Stenosis b. Aortic Stenosis c. Mitral Stenosis d. Mitral Regurgitation e. Tricuspid RegurgitationHeart Failure: Common Questions: A 68-year-old man presents to the GP with a 4-month history of exertional dyspnoea and fatigue. Which of the following would be the most appropriate initial investigation? a. NT-proBNP b. Troponin c. D-Dimer d. Coronary Angiogram e. CTPAHeart Failure: Common Questions: A 68-year-old man presents to the GP with a 4-month history of exertional dyspnoea and fatigue. Which of the following would be the most appropriate initial investigation? a. NT-proBNP b. Troponin c. D-Dimer d. Coronary Angiogram e. CTPAHeart Failure: Common Questions: A 25-year-old man presents is seen in clinic with a 10-month history of presyncope and breathlessness. On examination, an ejection systolic murmur is heard. He has a family history of heart failure and premature cardiac death. Which of the following would be the most appropriate investigation? a. VT Stimulation b. Cardiac MRI c. Coronary Angiogram d. Spirometry e. CT ThoraxHeart Failure: Common Questions: A 25-year-old man presents is seen in clinic with a 10-month history of presyncope and breathlessness. On examination, an ejection systolic murmur is heard. He has a family history of heart failure and premature cardiac death. Which of the following would be the most appropriate investigation? a. VT Stimulation b. Cardiac MRI c. Coronary Angiogram d. Spirometry e. CT Thorax Contents Wednesday Session: Thursday Session: Anatomy&Physiology ✓ ChestPain✓ 01 04 ECGs ✓ Arrhythmias✓ 02 05 Pharmacology ✓ HeartFailur✓ 03 06 Cardiology Progress Test Secrets Internal Medicine Trainee (UHW/GUH) James.Moggridge@wales.nhs.uk Any Questions? Sponsored by: