Cardio SAQ

Question 1

76-year-old with syncope and back pain. Left arm BP 190/110, pulse 75 bpm, LSB 2/6 early diastolic murmur. Right arm weak pulse. Femoral pulse 2+.
1. ECG abnormality
2. What causes syncope in this gentleman
3. Three investigations to confirm the diagnosis
4. Describe your management

Answer 1

1. ST elevation over lead II, III, aVF. Reciprocal ST depression over leads I, aVL, V1-3. Q waves over leads II, III
2. Aortic regurgitation due to Type A aortic dissection
3. CXR, CT thorax with contrast (aortogram), echo (TEE), cTnT, CKMB
4. Bed rest, NPO, IV line
   IV labetolol and nitroprusside to manage HT
   IV analgesic
   Monitor vitals, maintain saO2 >90%
   Consult CTS for surgical repair of type A aortic dissection

Question 3

Man with pulse 58/min, ankle edema (features of heart failure) with following ECG
What is 1st line Mx?

Answer 3

Transvenous pacing as this complete heart block ( AV dissociation: no P to QRS complex matching –> decompensating into acute heart failure –> acute APO)

ACLS unstable bradycardia features: hypotension, altered mental state, ischemic chest discomfort, and acute heart failure

Question 4

Answer 4

a) ST elevation in leads II, III, aVF. ST depression in lead I, aVL (reciprocal leads) –> inferior STEMI
b) cTnT+ CKMB, CXR, R/LFT, lipid profile, HbA1c, aPTT+INR (baseline for thrombolytics treatment)
c) DAPT (aspirin and ticagrelor) + anticoagulant (enoxaparin), ACEI, B blocker, nitrates, statins
d) Arrhythmia: symptomatic sinus bradycardia, AV block, tachycarrhythmia, stable sustained monomorphic VT, sustained polymorphic VT
Pump failure: LV dysfunction, RV dysfunction
Mechanical complications: VSD, MR
Pericarditis

Question 5

Answer 5

Cause of palpitation: AF

Fast AF (ventricular rate >100bpm) : requires rate control diltiazem/verapamil
For persistent AF, anticoagulated for 3 weeks before conversion and continue for 4 weeks after (delayed cardioversion approach)
Amiodarone 150mg over 10 min then 1mg/min for 6 hours.
If failed cardioversion than do maintenance rhythm control: flecainide, procainamide

Non valvular AF: can be discharged with DOAC (dabigatran (thrombin inhibitor) or apixiban/rivaroxaban)

Question 6

Answer 6

a) Aspirin: secondary prevention of MI and CVD
Lisinopril: decreases the preload and reduces blood pressure. (improves peri MI cardiac remodelling)
Metoprolol: decreases myocardial workload and thus oxygen demand by reducing HR and BP
Atorvastatin: used to reduce cholesterol levels and atherosclerosis worsening
b)
aspirin AE: nausea, dyspepsia, peptic ulcer bleeding
lisinopril AE: dry cough, hyperK, angioedema, hypotension
metoprolol AE: bradycardia, bronchospasm, dizziness
Atorvastatin AE: myositis, arthralgia, hepatitis, hyperglycemia, rhabdomyolysis
c)
Multi compartment dose administration aids (pill boxes)
Polypill: multiple drugs in one pill (dont need to take so many pills)

Question 7

Answer 7

a) aortic stenosis
b) degenerative cause (elderly), bicuspid aortic valve
c) transesophageal echocardiogram
d) TAVR: balloon expanding stent or self expandible stent (improved outcome as less thrombus/calcification cracking)

Question 8

Answer 8

Correct underlying caues: hypoxia, electrolyte disorders, sepsis, thyrotoxicosis
If fast ventricular rate >100bpm –> do ventricular rate control. Diltiazem/verapamil.

Cardioversion with 3 weeks anticoagulant before cardioversion than continue 4 weeks post cardioversion. Or do immediate cardioversion but do TEE to rule out LA thrombus in LAA.
Cardioversion with IV/oral amiodarone.

Anticoagulant: secondary prevention of cardioembolic stroke –> DOAC: dabigatran

Question 9

Lady suddenly collapses. BP of 90/50mmHg and HR of 76bpm. spO2 91% on nasal cannula.
a. 3 findings on ECG
b. most likely cause of syncope?
c. 3 Ix to confirm dx?
d. 3 treatment options for her condition?

Answer 9

a) sinus tachycardia, right axis deviation, RBBB, R wave in lead V1, S1Q3T3, T wave inversion over leads V1-4
b) PE
c) 1st line is CTPA, D-dimer (rule out PE), VQ scan (only if renal dysfunction so cannot do CTPA)
d) LMWH, tPA, embolectomy

Question 10

Cardiologist for management of heart: clopidogrel, esomeprazole, simvastatin, losartan
HA for management of hypertension: lisinopril, amlodopine

a) Name 3 pairs of drugs that show drug drug interaction
b) specific AE for each pair of drug drug interaction
c) 4 ways to minimize AE

Answer 10

a)
* Losartan: lisinopril. AE: hyperK, postural hypotension. Swap one to K+ sparing diuretic (e.g. spironolactone, eplerenone)
* Simvastatin (CYP3A4 substrate): esomeprazole or amlodopine –> increased risk of myopathy/rhabdomyolysis. Avoid concomitant use and switch to a different statin with less interaction risk or limit simvastatin dose to 20mg/d
* Clopidorel: esomeprazole. AE: decreased effectiveness of clopidogrel (coverage of thrombus and stroke formation). Increase dosage of clopidogrel for adequate anticoagulant coverage