Questions

Question 1

Stable Angina VS Atypical Angina>?

Answer 1

Chest pain typical of angina is defined by the following three features:
constriction/tight-like pain in chest/neck/arm/jaw
brought on by physical activity
alleviated by rest or glyceryl trinitrate within minutes.

Two out of three features indicate atypical angina pain

Mx
Lifestyle interventions
- Diet and exercise advice
- Smoking cessation
- ↓ alcohol intake
- BMI of 25 or less

Medical management

Immediate symptomatic relief
- GTN spray

Long term symptomatic relief
- β-blocker or CCB if not tolerated, can be used in combination if insufficient control on β-blocker alone
- Other options (not first line):
1. Long acting nitrates (e.g. isosorbide mononitrate)
2. Nicorandil
3. Ivabradine
4. Ranolazine

Secondary prevention
- Aspirin
- Atorvastatin
- ACE inhibitor

Question 2

Unstable Angina?

Answer 2

Unstable angina is defined as myocardial ischaemia at restor on minimal exertion in the absence of acute cardiomyocyte injury/necrosis.
prolonged (>20 minutes) angina at rest;
new onset of ‘severe’ angina;
angina that is increasing in frequency, longer in duration, or lower in threshold;
angina that occurs after a recent episode of myocardial infarction.
None of these apply to this case of stable angina.

Question 3

Acute Myocarditis?

Answer 3

most common presenting features are
chest pain (in 85–95% of cases),
fever (in approximately 65%)
dyspnoea (19–49% of cases).
Other features include palpitations, syncope and fatigue.

Patients may have a history of a preceding flu-like, respiratory and/or gastrointestinal illness, making this a less likely diagnosis.

Mx
Supportive

Question 4

Acute Pericarditis?

Answer 4

Acute Pericarditis is inflammation of the pericardial sac.
acute retrosternal,
sharp,
pleuritic chest pain that varies in severity.
It is frequently exacerbated in the supine position, by coughing, and with inspiration.

Classic ECG changes occur in around 90% of patients and include widespread concave upward ST-segment elevation and PR-segment depression without T-wave inversions

Question 5

Heart Murmurs?

Answer 5

Mitral regurgitation
there is a holosystolic (pansystolic) murmur
heard best at the apex with the diaphragm of the stethoscope when the patient is in the left lateral decubitus position.
dyspnoea (usually on exertion),
lower limb oedema, palpitations, and/or decreased exercise tolerance.

First-line investigations would be an ECG and transthoracic echocardiogram.

Aortic regurgitation
is the diastolic leakage of blood from the aorta into the left ventricle.
decrescendo early diastolic murmur,
heard loudest at the left sternal edge. O
ther examination features include a collapsing pulse or displaced hyperdynamic apex beat

Aortic Stenosis
Often caused by calcification of the aortic valve,
aortic stenosis is characterised by an ejection systolic murmur heard loudest over the aortic area.
The murmur may radiate to the carotid arteries and is typically loudest on expiration and when the patient is sitting forwards

Mitral stenosis
caused by rheumatic valvulitis. T
history of rheumatic fever,
but other symptoms do include dyspnoea and orthopnoea.
On examination, a loud S1 is heard with a low-pitched, rumbling, mid-diastolic murmur, loudest over the apex.

Pulmonary regurgitation
caused by pulmonary hypertension or infective endocarditis.
It is usually asymptomatic.
The murmur of pulmonary regurgitation is an early decrescendo murmur heard loudest over the left sternal edge during inspiration.

Question 6

Infective endocarditis can causes by Intravenous drug (heroin).
Splinter haemorrhages and janeway lesions are cardinal signs.
First-line imaging investigation in endocarditis is transthoracic echocardiogram (TTE) and it should be performed as soon the diagnosis of endocarditis is suspected.