1. Chest Pain

Question 1

A 76-year-old woman is brought into A&E with central crushing chest pain that radiates to her jaw and left arm. An ECG is performed, which shows ST elevation in leads ll, lll and aVF. Her SaO2 is 89%. Before she is sent to the cathlab for percutaneous coronary intervention, she is started on a combination of drugs. Which of the following should not be given? 
A Morphine 
B Oxygen 
C Aspirin 
D Clopidogrel 
E Warfarin

Answer 1

E: Warfarin

Warfarin causes an initial pro-thrombotic phase because it blocks protein C and protein S. Therefore, heparin must be co-administered with warfarin to begin with, until the INR stabilises (between 2-3).

Question 2

Stable Angina Definition

Answer 2

Chest pain resulting from myocardial ischaemia that is precipitated by exertion and relieved by rest.
Most common cause = Atherosclerotic disease

Question 3

Name 3 rare types of Angina and explain what they are

Answer 3

Decubitus angina – symptoms occur when lying down
Prinzmetal angina – symptoms caused by coronary vasospasm
Coronary syndrome X – symptoms of angina but with normal exercise tolerance and normal coronary angiograms

Question 4

Management of Stable Angina

Answer 4

Conservative:

• Stop smoking
• Lose weight
• Exercise

Medical:

• Anti-anginals (BB/CCB)
• Symptomatic (GTN spray)
• RF reduction (aspirin, statins, ACEi)

Question 5

Define ACS

Answer 5

Acute Coronary Syndrome: a constellation of symptoms caused by sudden reduced blood flow to the heart muscle. (ECG and troponin normal)

• Unstable Angina Pectoris: chest pain at rest due to ischaemia without cardiac injury
• Non-ST elevation MI (troponin raised)
• ST-elevation MI

Question 6

Symptoms of ACS

Answer 6

Acute-onset central, crushing chest pain
Radiates to arms/neck/jaw
Pallor
Sweating 
NOTE: silent infarcts in elderly and diabetics

Question 7

Investigations for ACS

Answer 7

ECG
STEMI: Hyperacute T waves, ST elevation, new-onset LBBB
UAP/NSTEMI: ST depression, T wave inversion
Old Infarct: pathological Q waves
Troponins
Elevated troponins suggests myocardial injury (i.e. STEMI or NSTEMI)

Question 8

ECG leads and site of infarct

Answer 8

Inferior (right coronary artery): II, III, aVF
Anterior (left anterior descending): V1-V5
Lateral (left circumflex): I, aVL, V5/6
Posterior (posterior descending): tall R wave + ST depression in V1-3

Question 9

Management of ACS - General

Answer 9

Morphine
Oxygen 
Nitrates
Antiplatelets (aspirin + clopidogrel)
Beta-blockers
ACE inhibitors 
Statins 
Heparin

Question 10

STEMI treatment

Answer 10

AIM: Coronary reperfusion either by PCI or fibrinolysis

Patient presenting < 12 hours from onset of symptoms:
Send to cathlab for PCI if it can happen within 120 mins of the time that fibrinolysis could have been administered

Patient presenting > 12 hours from onset of symptoms
Coronary angiography followed by PCI if indicated

Question 11

NSTEMI/UAP Management

Answer 11

Immediate

• Aspirin + other antiplatelet (e.g. clopidogrel, ticagrelor)
• Fondaparinux – if low bleeding risk unless coronary angiography planned within 24 hrs of admission
• LMWH – if coronary angiography is planned

Risk Stratify using GRACE score
HIGH risk
GlpIIb/IIIa inhibitor (e.g. tirofiban)
Coronary angiography (within 72 hours)
LOW risk
Conservative management (control risk factors)

Question 12

Complications of ACS

Answer 12

DARTH VADER
Death 
Arrhythmia
Re-infarction
Tamponade
Heart Failure

Valve disease
Aneurysm
Dressler's Syndrome
Enbolism
Rupture

Question 13

Complications of ACS

Answer 13

DARTH VADER
Death 
Arrhythmia
Re-infarction
Tamponade
Heart Failure

Valve disease
Aneurysm
Dressler's Syndrome
Enbolism
Rupture

Question 14

Define pericarditis and state 5 causes

Answer 14

Inflammation of the pericardium

Causes:
Idiopathic
Infective (e.g. Coxsackie B)
Connective tissue disease (e.g. sarcoidosis)
Dressler Syndrome (2-10 weeks after MI)
Malignancy

Question 15

Symptoms and Signs of pericarditis

Answer 15

Sharp, central chest pain 
Pleuritic
Relieved by sitting forward 
Fever/flu-like symptoms (if viral)
Pericardial friction rub 
Tamponade (if pericardial effusion)

Question 16

Investigations for pericarditis

Answer 16

ECG - Widespread saddle-shaped ST elevation
Bloods (FBC, CRP)
CXR (pericardial effusion)

Question 17

A 54-year-old man is complaining of sharp, central chest pain that has arisen over the last 24 hours. On inspection, the patient is sitting forward on the examination couch. On auscultation, a scratching sound is heard – loudest over the lower left sternal edge, when the patient is leaning forward. He has a past medical history of a ST-elevation MI which was diagnosed, and treated with PCI, 6 weeks ago. What is the most likely diagnosis?
A Viral pericarditis
B Constrictive pericarditis
C Cardiac tamponade
D Dressler syndrome
E Tietze syndrome

Answer 17

D Dressler syndrome

Tietze syndrome = a rare inflammatory disorder characterised by chest pain and swelling of the cartilage of one or more of the upper ribs (costochondral junction), specifically where the ribs attach to the sternum.

Question 18

A 27-year-old man presents complaining of sharp chest pain. He mentions that he has taken a few days off work recently because of the flu. What would you expect to see on his ECG?
A ST elevation in leads II, III and aVF
B Widespread saddle-shaped ST elevation
C ST depression
D Tented T waves
E Absent P waves

Answer 18

B Widespread saddle-shaped ST elevation

Question 19

Non-cardiac causes of chest pain

Answer 19

Respiratory

• PE
• Pneumothorax
• Pleurisy

Gastrointestinal

• Oesophagitis (due to GORD)
• Oesophageal spasm
• Peptic ulcer disease/gastritis
• Boerhaave’s perforation

Other:

• Costochondritis
• Anxiety

Question 20

Define AF and state causes

Answer 20

Atrial Fibrillation: characterised by rapid, chaotic and ineffective atrial electrical conduction.

Causes (Loads)

• Pneumonia
• PE
• Hyperthyroidism
• Ischaemic heart disease
• Alcohol
• Pericarditis

Question 21

Symptoms and Signs of AF

Answer 21

• Palpitations
• Syncope
• Irregularly irregular pulse
• Underlying cause

Question 22

Investigations for AF

Answer 22

• ECG: irregularly irregular tachycardia with no p waves

Tests for underlying cause

Question 23

Atrial Fibrillation - Management

Answer 23

if the patient is haemodynamically UNSTABLE – DC CARDIOVERSION

Rhythm Control
< 48 hrs since onset of AF
DC cardioversion
OR chemical cardioversion (flecainide or amiodarone)
NOTE: flecainide is contraindicated if there is a history of IHD
> 48 hrs since onset of AF –> anticoagulate for 3-4 weeks before attempting cardioversion

Rate Control
Verapamil
Beta-blockers
Digoxin

Treat cause

Question 24

What is the stroke risk stratification score in AF and how does it affect Mx?

Answer 24

Stroke Risk Stratification
CHA2DS2-Vasc score
LOW risk –> aspirin or none
HIGH risk –> warfarin

Question 25

Supraventricular Tachycardia Definition and 2 types

Answer 25

A regular, narrow-complex tachycardia with no p waves and a supraventricular origin. AVNRT: A local circuit forms around the AV node AVRT: A re-entry circuit forms between the atria and ventricles due to the presence of an accessory pathway (Bundle of Kent)

Question 26

Supraventricular Tachycardia Signs and Symptoms

Answer 26

Palpitations Dyspnoea Syncope Chest discomfort

Question 27

Supraventricular Tachycardia Investigations

Answer 27

ECG during tachycardia Regular Narrow complex tachycardia Absent p waves ECG after termination of SVT AVNRT = normal AVRT = ’Delta wave’ (slurred upstroke on QRS complex)

Question 28

Wolff-Parkinson-White Syndrome Definition

Answer 28

Presence of an accessory pathway resulting early depolarisation of the ventricles (pre-excitation) --> delta wave (slurred upstroke) on ECG If a wave of depolarisation travels retrograde back into the atria, it can set up a re-entry circuit between the atria and ventricles --> AVRT

Question 29

Supraventricular Tachycardia Management - 4 steps

Answer 29

Step 1: Haemodynamically unstable: Synchronised DC cardvioversion Stable: --> Step 2 Vasovagal Manoeuvres --> ``` Step 3: (NB if adenosine contra-ind, e.g. ASTHMA, use VERAPAMIL) a) IV Adenosine 6mg --> b) IV Adenosine 12mg --> c) IV Adenosine 12mg again --> ``` ``` Step 4: Choose from: IV BB (e.g. metoprolol) IV Amiodarone IV Digoxin Synchronised DC Cardioversion ```

Question 30

``` A 46-year-old man has been admitted to A&E after experiencing palpitations, which began about 4 hours ago. An ECG is performed, which reveals atrial fibrillation. He has no previous history of ischaemic heart disease. He refuses DC cardioversion. What is the next most appropriate treatment option? A  Defibrillation B  Low molecular weight heparin C  Warfarin D  Flecainide E  Digoxin ```

Answer 30

D  Flecainide (Or Amiodarone) - for chemical cardioversion

Question 31

``` A 27-year-old man presents with palpitations and light-headedness. An ECG shows features consistent with a supraventricular tachycardia. Adenosine is administered and the SVT is terminated. A repeat ECG shows a short PR interval and a QRS complex with a slurred upstroke. What is the diagnosis? A  Brugada syndrome B  LBBB C  Romano-Ward syndrome D  Wolff-Parkinson-White syndrome E  Complete heart block ```

Answer 31

D  Wolff-Parkinson-White syndrome

Question 32

``` A 52-year-old man was watching TV yesterday when he suddenly become very aware of his heart beating rapidly. This lasted for around 45 mins and then subsided spontaneously. It has happened several times over the past 2 months. An ECG reveals no abnormalities. However, due to the strong suspicion of atrial fibrillation, the patient is placed on a 24-hr tape, which confirms the diagnosis. Which scoring system would be used to determine the benefit of long-term anticoagulation in this patient? A  QRISK2 score B  ABCD2 Score C GRACE score D  CHA2DS2-VASc score E  CURB-65 score ```

Answer 32

D  CHA2DS2-VASc score | AF can be PAROXYSMAL (coming and going)

Question 33

Define Syncope and list causes (4 categories)

Answer 33

Loss of consciousness due to hypoperfusion to the brain Vasovagal: - Increased vagal discharge --> drop in BP/HR - Precipitated by e.g. LT standing, sight of blood - May feel sweaty/pale before collapse Arrhythmia: low-output state, may have palpitations before collapse Outflow obstruction: HOCM, aortic stenosis Postural htn: - Inability to compensate for drop in BP caused by standing up - Dehydration and Medications (Anti-HTN) are common causes

Question 34

Clinical features of HOCM

Answer 34

Hypertrophic Obstructive Cardiomyopathy - Jerky carotid pulse - Ejection systolic (cresc-decr) murmur - Double Apex beat - FMHx of sudden death <65

Question 35

Other causes of collapse

Answer 35

Syncopal: - Vertebrobasillar insufficiency - Subclavian steal syndrome - Aortic dissection Non-Syncopal: - Intoxication - Head trauma - Metabolic (e.g. hypoglycaemia) - Epileptic seizure OSCE TIP (blackout): ask about missed meals/inappropriate insulin dosing if diabetic

Question 36

A 52-year-old patient is recovering on the cardiology ward after undergoing a valve replacement. A routine blood test reveals the following results: Na+ : 135 mmol/L (135 – 145)K+ : 8.7 mmol/L (3.5 – 6.0)Ca2+ : 0.3 mmol/L (2.2 – 2.6)An ECG is performed which shows no obvious abnormalities. He has a past medical history of hypertension which is treated with ramipril. Given the above information, what should be the next step in the management of this patient? A Urgently draw another blood sample B 10 mL 10% calcium gluconate C 20 mL 20% calcium gluconate D 50 mL 50% dextrose + 10 U insulin E IV salbutamol

Answer 36

Drawing blood too fast can lead to red cell lysis, releasing all the intracellular potassium into the sample. This is a common cause of erroneously high potassium levels. In this circumstance, another set of bloods should be taken urgently. Furthermore, a potassium > 6 mmol/L is very likely to cause ECG changes and a calcium of 0.3 mmol/L is incompatible with life! NB: True hyperkalaemia can be treated with 10 mL 10% calcium gluconate