Cardiology

151. You review a 61-year-old man with paroxysmal atrial fibrillation. You consider a class Ic antiarrhythmic agent as the most appropriate choice to maintain him in sinus rhythm. What statement best describes the effect that class Ic agents have on electrical activity in the heart? Lengthen the cardiac action potential Shorten the cardiac action potential Widen the duration of the action potential Have no effect on the duration of the action potential Your answer Predominantly affect the AV node Class Ic antiarrhythmic agents such as flecainide or propafenone have no significant effect on the cardiac action potential. They are commonly used for the treatment and prophylaxis of atrial arrhythmias such as paroxysmal atrial fibrillation and atrial tachycardia. Class Ia agents such as quinidine lengthen the action potential, Ib agents such as lidocaine shorten the action potential, and class III agents widen the duration of the action potential. Beta-blocking agents predominantly affect the sinus node, whereas calcium-channel blocking agents predominantly affect the atrioventricular (AV) node. It is important to note that class I agents should be avoided in patients with significant coronary artery disease; flecainide, in particular, was shown to be associated with increased mortality in a postmyocardial infarction study.

152. A 58-year-old male patient has suffered from a recent acute myocardial infarction 3 days ago. He becomes acutely unwell with a hypotensive episode. A Swan-Ganz catheter was inserted and the following was noted: right atrial pressure was 12 (very high); calculated left atrial pressure was 2 (low normal). What is the likely cause? Right heart failure Left heart failure Mitral regurgitation Tricuspid regurgitation Aortic regurgitation

Your answer

Tricuspid regurgitation may occur in post-myocardial infarction, in association with cor pulmonale, rheumatic heart disease, infective endocarditis, carcinoid syndrome, Ebsteins anomaly, and other congenital abnormalities of the atrioventricular valves. Regurgitation gives rise to high right atrial pressures (as seen here). Physical signs include a large jugular venous cardiovascular wave and a pulsatile liver that pulsates in systole. A right ventricular

impulse may be felt at the left sternal edge and there is a blowing pansystolic murmur. Severe tricuspid regurgitation may require valve repair, or rarely replacement. Another consideration with this type of presentation post-myocardial infarction is pulmonary embolus, a high proportion of those patients who die post-myocardial infarction, do so because of thrombo-embolic disease.

153. A 55-year-old, chronic heavy smoker is brought to A&E with a 2-day history of polyuria, polydipsia, nausea and altered sensorium. On examination, he is lethargic and confused. A chest X-ray shows a round shadow in the right mid-zone with enlarged hilar lymph nodes on the right side. An ECG is normal except for a narrowed QT interval. What is the most likely metabolic abnormality in this case? Hypernatraemia Hyperkalaemia Hypercalcaemia Hyperphosphataemia Hypokalaemia

Your answer

This man most probably has bronchial carcinoma with bony metastases resulting in hypercalcaemia

154. What is the most likely lipid abnormality in a 48-year-old Asian man with good glycaemic control? Elevated high-density lipoprotein (HDL) Elevated low-density lipoprotein (LDL) Elevated LDL/elevated triglycerides Low HDL/elevated LDL Low HDL/elevated triglycerides

Your answer

Asians do not have classical LDLrelated risk for ischaemic heart disease. Their profile includes low HDL and elevated triglycerides, meaning that measurement of LDL alone may underestimate their risk.

155. An elderly man is seen in the Accident and Emergency department complaining of breathlessness. He has a history of asthma and uses salbutamol inhalers regularly. On examination, his JVP is raised with bilateral pedal oedema. Fine crepitations and occasional wheezing can be heard on auscultation. BP is 130/80 and his heart rate is 98/min. His oxygen saturation on air is 99%. Given the likeliest clinical diagnosis,what would be the next step in his management? Intravenous frusemide Your answer Nebulised salbutamol Intravenous hydrocortisone Nebulised corticosteroid and salbutamol Oral frusemide and salbutamol

The clinical signs and symptoms suggest heart failure. The immediate management consists of giving intravenous frusemide and oxygen therapy. Intravenous frusemide acts in less than 30 minutes, while oral frusemide acts in an hour. Frusemide relieves breathlessness and reduces preload.

156. A 72-year-old man presents for an excision of three teeth under local anaesthesia. He has a past history of rheumatic heart disease. Mitral stenosis has been identified but the rotten teeth are being removed before valve replacement. He is allergic to penicillin. Which of the following would be the most appropriate antibiotic regime for him? Amoxicillin 3 g po 1 hour before procedure Clindamycin 600 mg po 1 hour before procedure Your answer

Vancomycin 1 g po 1 hour before procedure Ciprofloxacin 1 g po 1 hour before procedure Augmentin 1 g po before procedure This patient is allergic to penicillin, which immediately rules out options A and E. Alternatives include clindamycin as a single dose or 1.5 g erythromycin 1 hour before procedure and 0.5 g 6 hours later. For general anaesthesia, iv vancomycin, clindamycin or teicoplanin may be used. Oral vancomycin has virtually no systemic absorption and is not a suitable choice for this reason. For patients with prosthetic heart valves or those with previous endocarditis who have no history of penicillin allergy, ampicillin and gentamicin are the treatments of choice; for those who are penicillin allergic, any of vancomycin, clindamycin or teicoplanin IV may be used.

157. A 34-year-old professional footballer is evaluated for symptoms of dizziness during exercise. Physical examination reveals a laterally displaced apical impulse. On auscultation, there is a 2/6 mid-systolic murmur in the aortic area that increases on sudden standing. The ECG shows LVH and Q waves in the V2V5 leads. What is the most likely diagnosis? Young-onset hypertension Acute MI Aortic stenosis Hypertrophic cardiomyopathy Atrial septal defect

Your answer

Hypertrophic cardiomyopathy is the single, most common cause of sudden death in young athletes. The majority of patients are asymptomatic or only mildly symptomatic. Syncope and sudden death are associated with severe exertion and competitive sports, which should be avoided in patients with hypertrophic cardiomyopathy. The most common symptom is dyspnoea. Typical examination findings include left ventricular hypertrophy and a loud S4. Forceful atrial systole causes a double apical impulse. A triple apical impulse can also occur due to a late systolic bulge. The carotid pulse also demonstrates a late systolic pulse causing the characteristic jerky feature. In contrast to aortic stenosis, the systolic murmur of hypertrophic cardiomyopathy does not radiate to the carotids. Moreover, it decreases on squatting and passive leg elevation and increases with the Valsalva manoeuvre. The most

common changes seen on the ECG are STT wave abnormalities followed by LVH. Q waves may also occur in leads II, III, aVF or V2V6. The exact cause of the Q waves remains unclear.

158. A 70-year-old obese man is admitted with a 6-hour history of chest pain. An ECG reveals an inferior wall myocardial infarction. Measurement of which of the following would best confirm the diagnosis? Creatine kinase Creatine kinase MB Cardiac-specific troponin T Aspartate aminotransferase Lactate dehydrogenase

Your answer

Troponin T and troponin I are regulatory proteins with a very high specificity for cardiac injury. They are released early (24 h) and can persist for up to 7 days. Most hospitals check levels at 6 and 12hrs after admission. They are more sensitive and cardiospecific than CKMB. The latter is a cardiac-specific isoform of creatine kinase and allows greater diagnostic accuracy than creatine kinase. Both aspartate aminotransferase and lactate dehydrogenase are non-specific enzymes that are rarely used nowadays for the diagnosis of myocardial infarction. LDH peaks at 34 days and remains elevated for up to 10 days following a cardiac event, and can thus be useful in confirming myocardial infarction in patients presenting several days after an episode of chest pain.

159. Which of the following patients would be best served by a permanent pacemaker? 40-year-old man with third-degree AV block and a maximum documented period of asystole of 1.5 s 40-year-old man with type II second-degree AV block and an escape rate of Your 30 bpm when awake and asymptomatic answer 40-year-old man with Lyme disease having symptomatic complete AV block 40-year-old man with chronic asymptomatic trifascicular block and firstdegree AV block 40-year-old man 3 days after suffering an acute anterior MI and having a persistent first-degree AV block and old right bundle-branch block

Third-degree and advanced second-degree atrioventricular block associated with any of the following conditions definitely needs a permanent pacemaker: symptomatic bradycardia documented periods of asystole of 3 s or more any escape rate less than 40 bpm in awake, asymptomatic patients In Lyme disease, the AV block is usually temporary and so does not need permanent pacing. Chronic asymptomatic bi- and trifascicular block needs pacing if associated with type II second-degree or third-degree AV block, but not otherwise. Following an acute myocardial infarct, pacing is generally indicated for a second- and third-degree block only at or below the AV node level.

160. A 62-year-old-man with a blood pressure of 160/98 mmHg, total serum cholesterol of 6.5 mmol/l and HDL of 1.3 mmol/l is seen by his GP. He is not diabetic and has never smoked. His family history is unknown as he was adopted. Apart from advice on lifestyle modification, which of the following combination of drugs should he receive under current guidelines? Aspirin, antihypertensive treatment Statin, aspirin Clopidogrel, aspirin, statin Antihypertensive treatment, aspirin, statin Your answer Antihypertensive treatment, clopidogrel, statin This man has a five-year coronary risk of about 10%. The coronary risk can be calculated from the Framingham model. Other methods to estimate the coronary risk include the Sheffield table, New Zealand Guidelines and that recently published by the SCORE study group. The National Service Framework for Coronary Heart Disease states that people whose estimated risk of coronary heart disease based on a specified risk factor profile of > 30% over

10 years should be offered appropriate advice and treatment. Several treatments reduce the risk of coronary artery disease, the absolute benefits being proportional to the pre-treatment risk: note that individual patients may be eligible for more than one treatment. The most costeffective preventive treatments are aspirin, initial antihypertensive treatment (bendrofluazide, atenolol) and intensive antihypertensive treatment (bendrofluazide, atenolol and enalapril). In contrast, simvastatin and clopidogrel were the least cost-effective. The cost per coronary event prevented in a patient with a 10% coronary risk over 5 years is 3500 for aspirin, 12,500 for initial antihypertensive treatment, 18,300 for intensive antihypertensive, 60,000 for clopidogrel and 61,400 for simvastatin.

161. A 22-year-old cocaine addict presents with an acute myocardial infarction. His blood pressure is 180/110 mmHg. Which is the most appropriate treatment? Thrombolysis Heparin Percutaneous coronary intervention Your answer Naloxone Glycoprotein 2b/3a inhibitors

Cocaine use has recently been implicated as a cause of unstable angina. Three possible mechanisms by which cocaine induces myocardial ischemia are: (1) increased myocardial oxygen demand, (2) decreased myocardial oxygen supply secondary to vasospasm or coronary thrombosis, and (3) direct myocardial toxicity. Documented cocaine use should not be considered to rule out underlying significant coronary artery disease (CAD), since the drug may precipitate coronary vasospasm or acute myocardial infarction in the patient with atherosclerotic CAD.Where elective angioplasty is available, this is preferable to thrombolysis as outcome studies show it to be superior.

162. Which is the best clinical marker of the severity of aortic stenosis? Character of apex beat Character of carotid pulse Character of S2 Intensity of murmur Pulse rate

Your answer

Physical findings of aortic stenosis may include a narrow pulse pressure, especially when stroke volume decreases, and a slow-rising, small-volume carotid pulse. However, the poorly compliant arterial wall may mask these abnormalities, so that the carotid pulse appears relatively normal. The cardiac apex impulse is forceful and sustained, but this finding may be masked by kyphosis (in which the anteroposterior diameter of the chest is increased). The first heart sound is soft. The aortic component of the second heart sound is also soft; it may be inaudible when stenosis is severe and the valve is heavily calcified. Reverse splitting of the second heart sound may occur in patients with left ventricular failure. A fourth heart sound is common but disappears in one-quarter of elderly patients who develop atrial fibrillation. Ejection sounds are rare because the valve cusps are immobile. 163. An 18-year-old student who has never been vaccinated against measles presents to his GP with symptoms suggestive of the disease. He is sent home and advised to rest, but later presents to A&E with anterior chest pain that is worse on inspiration and relieved by sitting forward. On examination there appears to be a rub on auscultation. What diagnosis fits best with this clinical picture? Viral pleurisy Pericarditis Your answer Myocardial ischaemia Pneumothorax Secondary bacterial pneumonia Pericarditis presents with anterior pleuritic chest pain, worse on inspiration and relieved by sitting forward. It is associated with a pericardial friction rub, which is best heard when the patient is upright and leaning forward. There may be associated cardiac tamponade ( Complications), evidenced by tachycardia, low blood and pulse pressure and distended neck veins. Associations Pericarditis may be infectious in origin (viral, bacterial or fungal), inflammatory (eg rheumatoid, related to systemic lupus erythematosus (SLE), scleroderma or vasculitis), drug-induced, myocardial infarction-related, postradiotherapy, uraemic, neoplastic, related to sarcoid, or to a host of other causes. For viral pericarditis, as in this case, limitation of activity is advised with additional pain relief using non-steroidals and opiate-based agents such as codeine phosphate. In severe cases, oral prednisolone may be considered. Prognosis varies according to the underlying cause, but recurrence of pericarditis occurs in 1015% of patients with pericarditis within the

first year.

164. A 52-year-old woman, with a prior history of rheumatic fever, presents with shortness of breath on strenuous exertion while working as a landscape gardener. She is in permanent atrial fibrillation and is on long-term warfarin and digoxin (125 g once daily). Clinical examination reveals her to be in atrial fibrillation at a rate of around 150 bpm. Echo demonstrates preserved left ventricular function, a heavily calcified mitral valve with moderate mitral stenosis (mitral valve area 1.5 cm2) and moderate mitral regurgitation. Her left atrium is dilated. What is the most appropriate initial treatment option? Amiodarone Atenolol Your answer DC shock Mitral valve replacement Percutaneous mitral valvotomy

This woman has moderate, mixed mitral valve disease and therefore surgery is not currently indicated. Even if the mitral stenosis were to be severe the presence of heavy calcification of the valve and concomitant mitral regurgitation would preclude percutaneous valvotomy. She is in permanent atrial fibrillation and as such, by definition, sinus rhythm cannot be restored (as opposed to persistent or paroxysmal). Better rate control is required. Digoxin on its own may not control catecholamine-driven tachycardia (eg during exertion). Amiodarone, while effective, would not be the first choice for this young patient working outdoors because of its side-effect profile.

165. A 63-year-old man with known chronic heart failure is admitted with symptoms at rest. Examination reveals pitting oedema to his knees, elevated jugular venous pressure and basal crepitations. He is in sinus rhythm at a rate of 80 bpm and his blood pressure is 100/60 mmHg. Current medication includes bisoprolol 10 mg once daily, frusemide 80 mg once daily and ramipril 2.5 mg twice daily. Blood tests reveal a sodium concentration of 133 mmol/l, potassium 4.9 mmol/l and creatinine of 169 mol/l. The admitting doctor commences him on iv frusemide 80 mg twice daily and increases his ramipril to 5 mg twice daily. When you review him the following day what other drug would be most appropriate to add in? Amiloride 5 mg od Bendrofluazide 2.5 mg od Bumetanide 2 mg bd Metolazone 5 mg od Spironolactone 25 mg od Your answer This man has decompensated CHF with symptoms at rest (New York Heart Association class IV). Examination has revealed significant fluid retention. The initial management plan of changing to iv frusemide is sensible since coexistent gut wall oedema is likely to impinge on oral absorption. Increasing the vasodilators in the form of ramipril is again a sensible approach. The addition of a thiazide (inhibiting sodium reabsorption in distal tubule) may work in synergy with a loop diuretic; the same is true for metolazone. Spironolactone, an aldosterone antagonist, has been shown to improve the mortality rate and symptoms and reduce hospitalisation in patients with severe CHF already on conventional treatment. Benefits are in addition to its diuretic effect since aldosterone itself has adverse effects on myocardial structure and function. Clearly, careful monitoring of renal function and biochemistry is important in such patients.

166. A patient has broad-complex tachycardia features resembling ventricular tachycardia rather than supraventricular tachycardia with a bundle-branch conduction defect. Which of the following makes Wolff-Parkinson-White the most likely underlying diagnosis? Absence of capture or fusion beat ECG in sinus rhythm reveals right bundle-branch block with left axis deviation QRS duration less than 140 ms P wave preceding wide QRS complex V-lead polarity is discordant

Your answer

ECG in sinus rhythm showing right bundle branch block and left axis deviation increases the index of suspicion that WPW is the underlying diagnosis.Supraventricular tachycardia with bundle branch block may resemble ventricular tachycardia on the ECG. Eighty percent of all broad complex tachycardias are due to ventricular tachycardia and the proportion is even higher in patients with structural heart disease. Therefore in all cases of doubt, ventricular tachycardia should be diagnosed. The ECG shows a rapid ventricular rhythm with broad (often 0.14 seconds or more) abnormal QRS complexes. AV dissociation may result in visible P waves. Capture beats (intermittent narrow QRS complex owing to normal ventricular activation via the AV node and conducting system) and fusion beats (intermediate between ventricular tachycardia beat and capture beat) are seen. Ventricular tachycardia is more likely than supraventricular tachycardia with bundle branch block when there is: A very broad QRS (> 0.14 seconds) Atrioventricular dissociation A bifid upright QRS with a taller first peak in V1 A deep S wave in V6 A concordant (same polarity) QRS direction in all chest leads (V1 V6)

167. A patient attending the cardiology clinic requires dental treatment. Which of the following conditions would carry the greatest need for antibiotic prophylaxis? Atrial septal defect Ebsteins anomaly Hypertrophic cardiomyopathy Mitral valve prolapse Patent ductus arteriosus

Your answer

Patent ductus arteriosus carries a high risk of endocarditis. The other high-risk lesions are small ventricular septal defects and aortic regurgitation. The risk of endocarditis is highest where there are high-velocity jets of blood that damage the endothelium. Hypertrophic cardiomyopathy may be associated with highvelocity flow in the left ventricular outflow tract (LVOT) when there is marked LVOT obstruction, although, in practice, the risk of endocarditis is small. Atrial septal defects (ASDs) are large holes in a low-pressure system and therefore carry a low risk of endocarditis and do not normally require prophylaxis. Mitral valve prolapse only requires prophylaxis where there is associated mitral regurgitation.

168. A patient presents to the emergency department with severe chest pain, what are the indications for thrombolysis? Q waves in any two leads 1 mm ST depression in 1 chest lead 1 mm ST depression in 2 limb leads Ebsteins anomaly 1 mm ST elevation in 2 limb leads

Your answer

Acute injury ST elevation of 1 mm in two or more limb leads, or 2 mm or more in two precordial leads, not suggestive of early repolarisation, pericarditis or repolarisation abnormality from left ventricular hypertrophy or bundle branch block, require immediate reperfusion therapy. Fast-track systems in hospitals have been developed to minimise the delay of thrombolysis; these are facilitated by specifically trained medical and nursing staff, with the aim of ensuring clinical assessment and electrocardiography within 15 min of arrival and the institution of thrombolytic therapy within 30 min. Audit programmes and continuous training are necessary for centres to achieve this 30 min median door-to-needle time. Prior to the advent of fast-track systems, door-to-needle times of between 60 and 90 min were frequently recorded in clinical trials and in observational studies.

169. A 70-year-old woman had a history of dyspnoea and palpitations for six months. An electrocardiogram (ECG) at that time showed atrial fibrillation. She was given digoxin, diuretics, and aspirin. She now presents with two short-lived episodes of altered sensation in the left face, left arm, and leg. There is poor coordination of the left hand. The echocardiogram (ECHO) was normal, as was a computed tomography (CT) head scan. What is the most appropriate next step in management? Anticoagulation Carotid endarterectomy Your answer

Clopidogrel Corticosteroid treatment No action Anticoagulation is indicated in patients with any one of prosthetic heart valve, prior history of rheumatic heart valve disease, prior history of stroke or transient ischaemic attack, age older than 75 years, hypertension or coronary artery disease with poor left ventricle (LV) function. Other risk factors that occur concurrently with atrial fibrillation and suggest a need for possible anticoagulation include diabetes mellitus, age 6575 years, and coronary artery disease with normal LV function (clinicians look for two of these moderate risk factors). In the case of this woman she has suffered at least two transient ischaemic attacks (TIAs), with some residual poor damage to coordination in the left arm, so that she now fits the criteria for anticoagulation. Carotid endarterectomy is indicated where there is symptomatic carotid stenosis. Clopidogrel would be indicated in TIA without atrial fibrillation. Corticosteroids may be considered in cases of cerebral oedema where there is significant mass effect.

170. A 12-year-old boy with known heart disease is being advised regarding antibiotic prophylaxis. Which cardiac lesion is most likely to be prone to infection? Atrial septal defect Aortic regurgitation Mitral stenosis Mitral valve prolapse without regurgitation Mitral regurgitation

Your answer

Infection of previously affected valves most commonly involves the aortic valves. Mitral regurgitation and mitral valve prolapse with regurgitation present a moderate risk, while mitral valve prolapse without regurgitation is a low risk. Infective endocarditis in pure mitral stenosis and atrial septal defect is uncommon.

171. A 60-year-old man complains of dizziness and palpitations. An ECG shows tachycardia, broad QRS complexes, AV dissociation and the presence of capture beats. What is the most probable diagnosis? Sustained ventricular tachycardia Ventricular fibrillation Your answer

Torsades de pointes Ventricular premature beats Atrial tachycardia The features are highly suggestive of sustained ventricular tachycardia. In ventricular fibrillation, there is very rapid and irregular ventricular activation with no mechanical effect. The patient is pulseless and rapidly becomes unconscious. The ECG shows shapeless rapid oscillations with no hint of organised complexes. In torsades de pointes, ventricular repolarisation is greatly prolonged (long QT syndrome). It is characterised on ECG by rapid, irregular, sharp complexes that continuously change from an upright to an inverted position. Prolonged QT intervals are also seen between spells of tachycardia or immediately preceding the onset of tachycardia. Broad QRS complexes may be seen in ventricular premature beats, but, following a premature beat, there is usually a compensatory pause. This condition is usually asymptomatic. In atrial tachycardia, the P waves are abnormally shaped and occur in front of the QRS complexes.

172. An elderly man is admitted to the ICU and put on intermittent positivepressure ventilation. Which of the following statements is true when compared to spontaneous ventilation? Lung volumes are decreased Pulmonary vascular resistance is decreased Systemic blood pressure rises Venous return and cardiac output fall Your answer Intrathoracic pressure is decreased

During intermittent positive-pressure ventilation (IPPV), lung volumes are significantly increased when compared to spontaneous ventilation. A large tidal volume causes a rise in pulmonary vascular resistance, which may lead to pulmonary hypertension and right ventricular compromise. The over-inflated alveoli cause compression of the alveolar blood vessels. Moreover, the resultant increase in RV volume may impede LV filling (ventricular interdependence). Hyperinflation also releases prostaglandins, which decrease blood pressure. The intrathoracic pressure is increased at all points in the respiratory cycle.

Inspiration during IPPV increases intrathoracic pressure and so increases right atrial pressure relative to atmospheric pressure, therefore leading to decreased venous return. The increased intrathoracic pressure also decreases the gradient across the LV that it has to work against, which results in a decreased afterload. Both these effects reduce intrathoracic blood volume.

173. A patient with underlying ischaemic heart disease had two transient episodes of loss of consciousness but feels fine at present. Both episodes were preceded by a feeling of dizziness, "vision going black" and witnesses report that the subject went very pale and then collapsed, lying motionless for a few seconds before making a rapid recovery. No abnormal movements were seen during the period of unconsciousness. What investigation will you order next? Echocardiography Computed tomography (CT) of the head 24-hour electrocardiogram (ECG) Cardiac catheterisation Treadmill test

Your answer

The key in assessing any episode of loss of consciousness is a detailed history including eye-witness descriptions. This is necessary to try to clinically distinguish between the many different possible aetiologies of such an occurrence. In this case the pre-syncopal symptoms, as well as the brief nature of the attack, pallor, lack of convulsions and prior cardiac history are all in favour of a cardiac cause. Loss of consciousness of cardiac origin may result from abnormalities of heart rhythm, due to extremes of rate, either fast or slow, or from some major disturbance of cardiovascular function, with resultant reduced cerebral perfusion. The importance in establishing the diagnosis of cardiac syncope is the associated adverse prognosis, which may be improved with appropriate treatment. The probability of cardiac syncope is increased in the presence of structural cardiovascular disease identified from the history, clinical examination, or investigation. Syncope is defined as a transient loss of consciousness with the loss of postural tone, and is most commonly due to cardiovascular mechanisms resulting in reduced cerebral perfusion. It is a common presentation, resulting in 12% of emergency department visits and up to 6% of hospital admissions. The cause is often initially uncertain, and assessment must first differentiate syncope from other causes of loss of consciousness, in particular epileptic seizures. The next priority is to identify high-risk patients. Documentation of cardiac rhythm during syncope is desirable, but is difficult to obtain because of the intermittent and usually infrequent nature of the symptom. Holter monitoring is unlikely to record the rhythm during an episode, but may provide evidence of lesser degrees of abnormality, which may support a diagnosis such as sinoatrial dysfunction

174. A 78-year-old woman presents to A&E with three episodes of syncope in the last 24 hours. There is no history of chest pain. She is taking frusemide 80 mg od and ramipril 10 mg od for known hypertension. She is conscious with a blood pressure of 100/40 mmHg. Potassium is 5.3 mmol/l. Her ECG shows complete heart block with rate of 40 bpm. QRS duration is 150 ms with a right bundlebranch block configuration. What is the optimum initial management? Dobutamine External pacing Intravenous calcium chloride Temporary transvenous pacing Your answer Withhold medication and observe

This woman has complete heart block with an unstable escape rhythm. The latter is exemplified by the fact that she has already had three syncopal episodes. Her QRS duration is prolonged (normal up to 120 ms), and this is generally more unstable than an escape rhythm of normal duration (ie < 120 ms) since this originates from around the His bundle. Her blood pressure is low, particularly with a background of hypertension. In addition, it is important to remember that cardiac output will be influenced by heart rate. In the elderly, cerebral vascular dysregulation may compound the effect thereby contributing to cerebral hypoperfusion. Ideally she should receive a transvenous temporary pacemaker. If further acute problems occur while waiting for a transvenous temporary pacemaker (eg awaiting transfer to a room with fluoroscopy), then external pacing can be instituted in the short term with appropriate sedation.

175. A 48-year-old man is admitted with a prolonged episode of chest pain at rest. The ECG shows ST depression in the lateral leads and his troponin T level is

8.2 g/l. Which of the following is the most appropriate combination of drugs for initial treatment? Aspirin, ramipril, unfractionated heparin, diltiazem Aspirin, warfarin, low molecular weight heparin, atenolol Aspirin, clopidogrel, low molecular weight heparin, atenolol Your answer Aspirin, losartan, unfractionated heparin, atenolol Aspirin, ramipril, low molecular weight heparin, nicorandil

The initial treatment of unstable angina (UA) should include bed rest, antiplatelet therapy, anticoagulation and a -blocker. A systematic review found that aspirin alone (75325 mg/day) reduces the risk of death and myocardial infarction in patients with UA. A large, randomised, control trial (RCT) has shown that the combination of clopidogrel (75 mg/day) and aspirin is superior to aspirin alone. Many RCTs have found that treating those patients at risk of UA with low molecular weight heparin (LMWH) is more effective than aspirin alone. The advantages of LMWH over unfractionated heparin include its ease of administration and no need for monitoring. Diltiazem or verapamil can be used if -blockers are contraindicated. Patients with a high risk of UA should be considered for revascularisation. Those who undergo coronary angioplasty should also be considered for treatment with an intravenous glycoprotein IIb/IIIa inhibitor such as abciximab, tirofiban or eptifibatide.

176. The epsilon potential is seen on the ECG of patients with which of the following? Hypertrophic cardiomyopathy Restrictive cardiomyopathy Right ventricular dysplasia Romano Ward syndrome Digoxin toxicity

Your answer

The epsilon potential is a right ventricular conduction delay, and appears as a sharp deflection after termination of the QRS complex during the ST segment or upstroke of the T wave. It is seen in the right ventricular leads V1 and V2. (Fontaine named the waves epsilon since epsilon follows delta in the Greek alphabet.) Right ventricular dysplasia is characterised by the displacement of myocytes by fat. This delays the excitation and depolarisation of those viable myocytes enveloped by the fatty tissue, and so leads to epsilon potentials.

177. An 80-year-old woman suddenly complains of dyspnoea and palpitations. A pulmonary ventilationperfusion scan shows a perfusion defect. Which investigation report would provide a clue to the diagnosis? Increased platelet count Your answer Abnormal liver function tests Increased neutrophil count Abnormal lipid profile Decreased serum albumin levels

A raised platelet count would increase the risk of pulmonary embolism. Liver dysfunction and low serum protein levels would lead to a decreased production of coagulation factors and thus prolong the INR. Neutrophilia may occur due to respiratory infection, but this would cause a ventilation defect and not a perfusion defect. Abnormal lipid profiles predispose to atherosclerosis and lead to arterial thromboemboli. 178. Left bundle branch block is associated with which one of the following conditions? Ischaemic heart disease Your answer Mitral stenosis

Pericarditis Pulmonary embolism Tricuspid stenosis

Mitral stenosis, tricuspid stenosis and secondary pulmonary hypertension due to pulmonary embolism are associated with right ventricular strain and hypertrophy with partial or complete right bundle branch block. Pericarditis is not associated with bundle branch block.

179. A 35-year-old-woman of African origin presents with a 4-month history of increasing swelling over her feet and abdominal distension. She has no history of cough, orthopnoea or breathlessness on exertion. Her heart rate is 98 beats/minute: irregularly irregular. Her JVP is markedly raised and she has pitting lower limb oedema. The heart sounds are soft, and there are no audible murmurs. Abdominal examination reveals hepatomegaly along with ascites. Chest X-ray reveals a normal cardiac size and clear lung fields. A lateral X-ray shows calcification around the heart border. Urinalysis is normal. Her ECG shows a low QRS voltage and lateral T-wave changes. What is the likely diagnosis? Dilated cardiomyopathy Cirrhosis of the liver Constrictive pericarditis Your answer Restrictive cardiomyopathy Hypertrophic cardiomyopathy This patient has signs of severe right heart failure but the chest X-ray reveals

a normal heart size. The possibilities are constrictive pericarditis and restrictive cardiomyopathy. The presence of calcification around the heart favours constrictive pericarditis. Causes of restrictive cardiomyopathy include cardiac amyloidosis, haemachromatosis, endomyocardial fibrosis, systemic sclerosis, carcinoid syndrome and malignancy. Cardiac amyloidosis is usually associated with myeloma. It is more common in males in their sixth or seventh decades.

180. A 65-year-old man is referred to out-patients with resistant hypertension. He is already taking bendrofluazide 2.5 mg once daily, lisinopril 20 mg once daily and amlodipine 10 mg once daily. He is an ex-smoker with a past history of uncomplicated myocardial infarction. Blood pressure is 170/100 mmHg in both arms. The only other abnormality on examination is a left femoral bruit. Results of investigations are as follows: LVH on ECG; creatinine, 140 mol/l; sodium, 138 mmol/l; potassium, 5.2 mmol/l; chest X-ray, normal; 24-hour blood pressure, sustained systolic and diastolic hypertension with no evidence of nocturnal dip. What is the most likely underlying aetiology for his hypertension? Coarctation Conns syndrome Cushings syndrome Polycystic kidney disease Renal artery stenosis Your answer A secondary cause for hypertension is more likely in patients with resistant hypertension and in those who fail to show a nocturnal dip (usually an approximately 20% drop). Other clinical and investigative findings may raise the index of suspicion. In this case, renovascular disease should be suspected since he has documented evidence of co-morbid vascular disease and arterial bruit. A discrepancy in renal size on ultrasound would add further weight to the

diagnosis. Further imaging, such as angiography or magnetic resonance angiography, should be considered in patients with a high index of suspicion for renovascular disease.

181. A 68-year-old man, although asymptomatic from the cardiac viewpoint, has an ejection systolic murmur best heard in the aortic area. The murmur radiates to the carotids. Echocardiography confirms severe aortic stenosis with a gradient of 85 mmHg across the calcified aortic valve. What is the risk of sudden cardiac death per year in such patients? <5% 69% 1025% 2550% More than 75% Your answer

The natural history of aortic stenosis (AS) in adults is characterised by a long latent period, during which there is a gradually increasing obstruction and an increase in the pressure load on the myocardium while the patient remains asymptomatic. Once symptoms appear in patients with an unrelieved obstruction, the prognosis is poor. Survival curves have shown that the interval from the onset of symptoms to the time of death is approximately two years in patients with heart failure, three years in those with syncope and five years in those with angina. Before the advent of surgery, sudden cardiac death was quite common in cases of aortic stenosis (in 1968, Campbell reported that of 70 patients with aortic stenosis who died, 44 (73%) of the deaths were sudden. Although AS may be responsible for sudden death, this usually occurs in patients who have previously been symptomatic. There is a 69% incidence of sudden cardiac death in asymptomatic children with aortic stenosis. 182. An elderly woman is taking frusemide and ramipril for heart failure. She visited her GP complaining of pain in her left knee and was prescribed rofecoxib. Two weeks later she is admitted in A&E with breathlessness and pedal oedema. What is the most likely cause of her symptoms? Drug interaction with frusemide Drug interaction with ramipril Fluid retention due to rofecoxib Impairment of renal function Anaemia due to gastrointestinal bleeding

Your answer

Rofecoxib does not interact with or affect the actions of frusemide. It may act in conjunction with ramipril to cause deterioration of renal function. Rofecoxib is a cyclooxygenase-2 (Cox-2) specific inhibitor and has a reduced adverse effect on the gastrointestinal tract; thus gastric irritation and bleeding is much less common than with other NSAIDs such as ibuprofen or mefenamic acid. However, rofecoxib can cause fluid retention and worsen a pre-existing heart failure. It is therefore contraindicated in patients with severe congestive heart failure. Rofecoxib has now been withdrawn from the market, as it has been found to be associated with severe cardiac side effects.

183. A 40-year-old woman is admitted with a stroke after a prolonged pyrexial illness. On examination she is in sinus rhythm, has splenomegaly and a pansystolic murmur at the apex. Blood cultures confirm an infective endocarditis. Which of the following is the most common causative organism? Streptococcus viridans Staphylococcus aureus Streptococcus bovis Gram-negative bacilli Staphylococcus epidermidis Your answer

Infective endocarditis on native valves prevalence of organisms: Streptococci Viridans group Enterococci Other Staphylococci Staphylococcus aureus Coagulase-negative Gram-negative bacilli Haemophilus spp. Anaerobes Rickettsia/fungi 3040% 1015% 2025% 927% 13% 38% less than 2%

Members of the viridans group of streptococci are the commonest cause of subacute endocarditis on native valves. These commensals of the upper respiratory tract may enter the bloodstream on chewing, tooth brushing or at the time of dental treatment. Staphylococcus aureus is a common cause of acute endocarditis originating from skin infections, abscesses, vascular access sites or intravenous drug misuse. Staphylococcus epidermidis is the most common organism causing postoperative endocarditis following cardiac surgery.

184. A 32-year-old woman who is known to be 17 weeks pregnant presents for review. She has periods of paroxysmal supraventricular tachycardia (SVT) and on

this occasion has a ventricular rate of 165/min and a blood pressure of 90/50 mmHg, feeling faint and unwell. Which of the following anti-arrhythmics would be the most appropriate prophylaxis for her?

Flecainide Your answer Amiodarone Digoxin Phenytoin Propafenone This patient has paroxysmal supraventricular tachycardia (SVT). While digoxin slows the ventricular rate in patients with chronic atrial fibrillation, it does not maintain sinus rhythm in patients with paroxysmal tachycardia. Amiodarone is known to be teratogenic and is contraindicated in pregnancy. While there is no evidence that flecainide is teratogenic, no randomised controlled trials have included pregnant women, for obvious reasons. Several case series describe use of flecainide in pregnant women and it appears to have a relatively good safety profile compared with other anti-arrhythmics.

185. A 54-year-old man suddenly develops weakness of the left side of his face and arm and difficulty in speech. This episode lasts for 15 minutes. He has a history of hypertension, which is well controlled on a calcium channel blocking agent. His brother had had a severe disabling stroke at the age of 50. Cholesterol level is 5.8mmol/l. CT scan performed the same day shows the presence of 2 old lacunar strokes in the right middle cerebral artery territory. CT angiogram of the carotid system shows a 60% stenosis of the right internal carotid artery.

Which of the following factors is the strongest predictor of his being at a high risk of early recurrent stroke? Positive family history History of hypertension Hyperlipidaemia Presence of moderate carotid stenosis Presence of previous strokes on CT scan

Your answer

This is a transient ischaemic attack (TIA). About 1520% of patients with stroke have a preceding transient ischaemic attack. The issue of subsequent stroke prevention is therefore paramount when managing such a warning event. The urgency of treatment of minor stroke or transient ischaemic attack should depend on the early risk of major stroke. The risk of recurrent stroke during the first few days after a transient ischaemic attack or minor stroke is much higher than previously estimated. Recent studies have identified potential risk factors for those at highest risk of subsequent stroke: age>60 years; hypertension; duration of symptoms >60 minutes; certain clinical features (unilateral weakness, speech impairment); presence of diabetes mellitus. Brain imaging also seems to be of prognostic value: the presence of infarction on CT brain scans in patients with transient ischaemic attack or minor stroke is associated with an increased risk of stroke recurrence. More research is needed to determine the optimal medical management according to individual risk factors. There are several treatments that are likely to be effective in preventing stroke in the acute phase after a transient ischaemic attack or minor ischaemic stroke including aspirin, possibly in combination with clopidogrel and anticoagulation in patients with atrial fibrillation, and possibly statins. The subgroup of patients with large-artery atherosclerosis (usually carotid bifurcation stenosis) accounts for the largest proportion of early recurrent strokes. A recent populationbased study of prognosis of patients with transient ischaemic attack and =50% symptomatic carotid-artery stenosis reported risks of stroke of about 20% during the 2 weeks before endarterectomy and other studies have highlighted the high risk of stroke if endarterectomy is delayed, and hence the rapid decrease in benefit from surgery with increasing time since event. For neurologically stable patients with transient ischaemic attack and minor stroke, benefit from endarterectomy is greatest if done within 2 weeks of the event. NB. The risk benefit ratio of treating symptomatic carotid stenosis (secondary stroke prevention) differs from that of treating asymptomatic stenosis as part of primary prevention, where stenosis must be severe in order to justify the risk of surgery. From the American Heart Association guidelines (2006): For patients with recent TIA or ischemic stroke within the last 6 months and ipsilateral severe (70 to 99%) carotid artery stenosis, CEA is recommended by a surgeon with a perioperative morbidity and mortality of <6% For patients with recent TIA or ischemic stroke and ipsilateral moderate (50 to 69%) carotid stenosis, CEA is recommended, depending on patient-specific Class I, Level A Class I, Level A

factors such as age, gender, comorbidities, and severity of initial symptoms. When degree of stenosis is <50%, there is no indication for CEA Class III, Level A

186. A 32-year-old man is brought to A&E in a collapsed state having sustained a precordial stab wound. Which of the following cardiac valves is most likely to have been injured? Aortic valve Tricuspid valve Pulmonary valve Mitral valve Thebasian valve

Your answer

The tricuspid valve is the most anterior valve of the human heart and is the commonest to be injured during a stabbing attack. Penetrating injuries may cause lacerations to any of the heart chambers or great vessels, and death may result from haemorrhage or cardiac tamponade. Late complications include infective pericarditis, valve damage or intracardiac shunts. Echocardiography is useful in diagnosing the underlying problem.

187. A 65-year-old man with chronic renal failure has a serum potassium level of 7.1 mmol/l (normal 3.5-5.5 mmol/l). What would be the most characteristic finding on ECG? Reduced P waves Prolonged QT intervals Prominent U waves Narrow QRS complexes T-wave inversion Your answer

Hyperkalaemia causes hyperpolarisation of cell membranes, leading to decreased cardiac excitability, hypotension, bradycardia and eventual asystole. The ECG shows characteristic tall, peaked T waves with widened QRS complexes. There is a progressive diminution in the amplitude of the P wave, which eventually disappears. Prominent U waves are seen in hypokalaemia while T-wave inversion occurs in ischaemic heart disease. Prolonged QT intervals are seen in acute myocardial infarction, hypocalcaemia, hypothermia and procainamide administration.

188. Which of the following microanatomical structures within the heart interacts with conventional calcium-channel blockers? L type Calcium-channels Calcium-channel T type T tubules Titin Tropomyosin Your answer

The T tubules are a tubular network formed by the invagination of the sarcolemma of the myocyte. Sarcolemmal calcium channels are located on the T tubules; there are two main types of channels T and L types. The T (transient) channels do not interact with conventional calcium-channel blockers. Calcium-channel blockers interact with the L-type calcium channels. Titin tethers the myosin molecule to the Z line, and its elasticity explains the stressstrain elastic relation of striated muscle. It is the largest protein molecule yet described. The thin actin filaments intertwine and are carried on a heavier tropomyosin molecule that functions as a backbone. At regular intervals along this structure is a group of three regulatory proteins called the troponin complex, which is composed of troponin C, troponin I and troponin M.

189. A 72-year-old Caucasian woman is referred to out-patients for advice regarding her hypertension management. She has been on treatment in the form of perindopril 4 mg od for the past 3 years. However, on repeated measurements, her readings have been > 160 mmHg systolic, with diastolic readings being in the order of 8085 mmHg. Renal function is normal as is urine dipstick testing. There is no evidence of left ventricular hypertrophy on ECG. She is obese with a BMI of 33. What would you consider adding as your next drug? Atenolol Bendrofluazide Doxazosin

Amlodipine Your answer Spironolactone

This woman has hypertension resistant to a single agent. It is increasingly recognised that more than one agent is required to adequately control blood pressure. Whilst guidelines suggest either a thiazide or calcium channel antagonist could be added next, in view of the fact she is obese, a calcium channel antagonist may be the better choice. Meta-analyses have shown that both thiazides and beta blockers are associated with an increased risk of the development of Type 2 diabetes in at risk patients. Indeed, the ASCOT study did suggest that the combination of ACE inhibitor and calcium antagonist was associated with the development of less type 2 diabetes than a beta blocker/thiazide alternative.

190. A 75-year-old-man presents to A&E with a history of sudden collapse. This occurred unexpectedly while he was walking his dog. There have been no similar episodes in the past. On examination there were no positive findings. An ECG performed with carotid sinus massage revealed a 5-second pause. Which of the following statements is true? Carotid sinus hypersensitivity is due to atherosclerosis Carotid sinus massage is contraindicated in patients with carotid vascular disease A permanent pacemaker has no role in the management of these patients Carotid sinus hypersensitivity is related to vertebrobasilar ischaemia Carotid sinus massage is contraindicated in patients taking blockers

Your answer

Carotid sinus baroreceptors consist of sensory nerve endings located in the internal carotid artery just above the bifurcation of the common carotid artery. Cardioinhibitory carotid sinus hypersensitivity is defined as cardiac asystole of > 3 s. The pure vasodepressor type is defined as a systolic blood pressure drop of > 50 mmHg (in the absence of significant bradycardia). A mixed type consists of a combination of cardioinhibitory and vasodepressor responses. As AV block can occur during the periods of hypersensitive carotid reflex, some form of ventricular pacing, with or without atrial pacing, is generally required. The mechanism responsible for carotid sinus hypersensitivity is unknown, but possibilities include a high level of resting vagal tone, hyperresponsiveness to acetylcholine or an excessive release of acetylcholine. 191. A patient has tuboeruptive xanthomas, distributed subcutaneously and mainly on the extensor surface of extremities. What is the probable diagnosis? Type I hyperlipoproteinaemia Type II hyperlipoproteinaemia Type III hyperlipoproteinaemia Your answer Type IV hyperlipoproteinaemia Type V hyperlipoproteinaemia Tuboeruptive xanthomas occur in type III hyperlipoproteinaemia. Eruptive xanthomas are associated with hyperchylomicronaemia (type I and type V hyperlipoproteinaemia). Xanthoma tendinosum, which are nodular swellings of tendons, usually occur in type II hyperlipoproteinaemia.

192. A 50-year-old man underwent coronary artery bypass grafting 2 days ago. A routine liver function test result now shows that both the direct and indirect bilirubin are elevated. All the other liver function tests are normal. Which of the following is the most likely cause? Shock liver syndrome

Anaesthetic-induced Haemolysis on bypass Your answer Narcotic-induced Right heart failure Isolated elevation of direct and indirect bilirubin, indicates haemolysis on the cardiopulmonary bypass and can be confirmed by increased plasma freehaemoglobin levels. There is no specific treatment. Markedly raised enzyme levels are seen in patients with the shock liver syndrome, and the treatment is aimed at maximising cardiac output and oxygenation. Right heart failure is another cause of hyperbilirubinaemia in the immediate post-bypass period, and, in this case, the direct bilirubin and alkaline phosphatase are increased without enzyme elevation. Treatment is as for right heart failure.

193. A 60-year-old woman is found to have a systolic murmur at a routine medical. She is asymptomatic. Electrocardiography (ECG) shows marked left ventricular hypertrophy with strain. Echocardiography shows a peak aortic valve gradient of 90 mmHg. What is the correct management? Aortic valvuloplasty Anticoagulation Regular out-patient review Routine aortic valve replacement Urgent aortic valve replacement

Your answer

Surgery for aortic valve replacement is indicated in symptomatic patients (angina, exertional breathlessness, syncope) as the risk of sudden death increases dramatically with the onset of symptoms or those with severe asymptomatic disease (peak outflow gradient greater than around 50 mmHg. Patients with a gradient of less than 25 mmHg have a 20% chance of needing surgical intervention within 15 years. Valvuloplasty is used only in patients with critical aortic stenosis who are unfit for surgery as the benefits are usually short-lived.

194. A 30-year-old woman presents with pleuritic chest pain and haemoptysis. Her blood pressure is stable at 130/80 mmHg. A ventilation/perfusion scan shows minor mismatch at the lung bases. There is no evidence of RV dysfunction, clinically and on echocardiography. In addition to oxygen, which of the following is the appropriate management for this patient? Heparin and consideration for surgery Heparin and NSAIDs Your answer Heparin plus mechanical intervention Heparin plus thrombolytic therapy Supportive This patient has had a small to moderate pulmonary embolism, probably associated with pulmonary infarction. The management in this case would be heparin and non-steroidal anti-inflammatory drugs (NSAIDs) to control her chest pain. If there were signs of a large/massive PE (hypotension, right ventricular dysfunction), the ideal management would include thrombolytic therapy or mechanical intervention.

195. During a routine medical check-up, a 2-year-old boy has been found to have a continuous machinery murmur on auscultation just below the left clavicle. Given the likely diagnosis, what would be the most characteristic investigative finding in this patient? Dilated left ventricle on echocardiogram Your answer Right ventricular hypertrophy on ECG Hilar haziness on chest X-ray Prominent pulmonary artery and pulmonary plethora on chest X-ray Polycythaemia This boy has a persistent ductus arteriosus. Because the aortic pressure exceeds the

pulmonary artery pressure throughout a cardiac cycle, a persistent ductus produces a continuous left to right shunting. This leads to increased pulmonary venous return to the left heart and an increased left ventricular volume load. The echocardiogram shows a dilated left atrium and left ventricle. Right heart changes are apparent in late disease. Hilar haziness occurs in pulmonary oedema due to congestive cardiac failure. A prominent pulmonary artery may be seen on chest X-ray in persistent ductus, but the presence of pulmonary plethora is more suggestive of atrial septal defect. Polycythaemia may occur if the shunt is reversed (Eisenmengers syndrome).

196. In an asymptomatic patient, a permanent pacemaker is indicated in which of the following conditions? First-degree block at the AV node First-degree block in the distal conduction system with an HV interval < 100 ms Second-degree block at the AV node Second-degree block at the distal conduction system Third-degree block at the AV node In an asymptomatic patient, a permanent pacemaker (PPM) is indicated in second- and third-degree heart block at the distal conduction system. If the third-degree block at the AV node had been associated with symptoms, it would have been an indication for PPM. Also, a PPM is indicated for cases of firstdegree AV block in the distal conduction system with an HV (Bundle of His to ventricular depolarisation) interval of greater than 100 ms associated with symptoms.

Your answer

197. A 65-year-old woman with a history of heavy smoking presents for review. She has woken during the early hours of the morning for the second time with shortness of breath so bad that she had to fling open the windows. On examination there are crackles in the

lung bases, her chest X-ray shows bilateral fluffy perihilar shadowing. ECG reveals small anterior Q waves and a sinus tachycardia of 105 bpm. What diagnosis fits best with this clinical picture? Cryptogenic fibrosing alveolitis Pulmonary embolus Exacerbation of COPD Sarcoidosis Pulmonary oedema Your answer The history of paroxysmal nocturnal dyspnoea, chest X-ray suggestive of pulmonary oedema and ECG with changes of a previous anterior myocardial infarction suggests that this woman is suffering from left ventricular failure. A history of pink frothy sputum and distended neck veins on examination would also contribute to the diagnosis. Causes of pulmonary oedema include acute myocardial infarction, hypertensive heart failure, valvular disease, ventricular septal defect, cardiac tamponade, cardiac arrhythmias, endocarditis, myocarditis and cardiomyopathy. Echocardiography is useful to determine the differential diagnoses, and provides information about valvular disease, diastolic vs systolic dysfunction, ejection fraction and estimates of right-sided pressures. The acute management of pulmonary oedema includes oxygen therapy, intravenous furosemide and vasodilator therapy with iv nitrates. Many acute wards also have intermittent positive-pressure ventilation available, a useful adjunct to medical therapy for left ventricular failure.

198. A 50-year-old woman presents with an acute myocardial infarction, and thrombolysis is being considered. Which one of the following would be an absolute contraindication for thrombolytic therapy? Background diabetic retinopathy Past history of a minor stroke 5 years ago with full recovery and no evidence of underlying cerebrovascular lesion Menstruation Dyspeptic symptoms Resting blood pressure 220/130 mmHg Your answer

A proven (ie computed tomography (CT) scan-proven) intracranial haemorrhage (ICH) is an absolute contraindication to thrombolysis. A fully recovered previous TIA would not prove and absolute contraindication. There remains however some debate over the risk of ICH in the context of a previous stroke. In the American College of Cardiology guidelines (2004), a history of ischaemic stroke within 3 months is given as an absolute

contraindication, as is any history of intracranial haemorrhage. The NICE guidelines however (below) list any history of cerebrovascular disease as a contraindication. Diabetes is not a contraindication but active, untreated haemorrhagic retinopathy would be considered a contraindication due to the risk of visual loss. In this case a clear assessment of risk of thrombolysis versus reward must be explained to the patient. Dyspepsia is not a contraindication but an active bleeding peptic ulcer is. Pregnancy, warfarin therapy and/or international normalised ratio (INR) >1.8 are relative contraindications. The NICE guideline (2002) contraindications are included below. Current Contraindications to Thrombolysis Current contraindications* to treatment are related to risk of bleeding and are divided into absolute and relative: Absolute Contraindications Gastrointestinal (GI) bleeding in the previous month History of cerebrovascular disease especially recent events or with any residual disability Bleeding disorder or on anticoagulant therapy Major surgery, trauma or head injury in previous 3 weeks Prolonged cardiopulmonary resuscitation (CPR) (>30 minutes) Hypertension (>180 mmHg systolic) Aortic dissection Acute pancreatitis Lung cavitations Relative Contraindications Major hepatic or renal disease Non-compressible puncture site Known terminal illness Recent retinal laser treatment *As listed in recommendations from the European Society of Cardiology. Also, in the case of streptokinase, previous allergic reactions to either streptokinase or anistreplase or administration of either drug in the previous 2 years.

199. A 65-year-old male patient with stable angina complains of shortness of breath after walking two flights of stairs. He has normal left ventricular function on the echocardiogram and a positive exercise tolerance test (3 mm ST depression at stage III). What is the most appropriate therapy? Atenolol Simvastatin Isosorbide mononitrate Angiotensin-converting enzyme (ACE) inhibitor Nicardipine Your answer

Beta-blocking agents are the cornerstone of the pharmacological management of chronic angina pectoris. They are well tolerated and reduce the frequency and duration of anginal episodes and improve exercise tolerance. They are also effective antihypertensive agents and prevent some arrhythmias. They act by competitively inhibiting catecholamine effects on the -adrenergic receptor. This reduces heart rate and improves coronary perfusion (by prolonging diastole), thereby reducing an exercise-induced rise in blood pressure and contractility.

200. A patient with angina is admitted for cardiac catheterisation. There is a suspicion that she may be suffering from hyperthyroidism. Which investigation would be useful to differentiate as to whether the use of contrast media may worsen any underlying thyroid condition? Thyroid scan TSH levels T4 levels Measurement of TPO (thyroid peroxidase) antibodies Ultrasound scan Your answer

Cardiac catheterisation requires the use of an iodine-containing contrast. This may worsen the hyperthyroidism caused by toxic multinodular goitre, whereas it may improve the symptoms in patients with Graves disease. TSH and T4 levels do not differentiate the two conditions. TPO antibodies occur in autoimmune hypothyroidism and Graves disease and thus do not indicate the presence of hyperthyroidism. About 515% of euthyroid women and up to 2% of euthyroid men have thyroid antibodies. Ultrasound can be used to show the presence of a solitary lesion or a multinodular goitre, but will not provide a definitive diagnosis. The most reliable diagnostic method is a radionuclide (99Tcm, 123I, or 131I) scan of the thyroid, which will distinguish the diffuse, high uptake of Graves disease from nodular thyroid disease. If a toxic multinodular goitre or toxic adenoma is detected, the patient should receive an antithyroid drug before undergoing catheterisation. The antithyroid medication must be continued for at least 2 weeks after the procedure.