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Cardiology

151. You review a 61-year-old man with paroxysmal atrial fibrillation. You consider aclass 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 agentssuch 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 agentspredominantly 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 3days 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 Your answerAortic regurgitation

Tricuspid regurgitation may occur in post-myocardial infarction, in association with corpulmonale, 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 jugularvenous cardiovascular wave and a pulsatile liver that pulsates in systole. A right ventricular

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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 pulmonaryembolus, 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 hilarlymph 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?

HypernatraemiaHyperkalaemia

Hypercalcaemia Your answer

Hyperphosphataemia

Hypokalaemia

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.

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155. An elderly man is seen in the Accident and Emergencydepartment complaining of breathlessness. He has a history of asthma and usessalbutamol inhalers regularly. On examination, his JVP is raised with bilateralpedal oedema. Fine crepitations and occasional wheezing can be heard onauscultation. 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 hismanagement?

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 inan hour. Frusemide relieves breathlessness and reduces preload.

156. A 72-year-old man presents for an excision of three teeth under localanaesthesia. He has a past history of rheumatic heart disease. Mitral stenosis hasbeen identified but the rotten teeth are being removed before valvereplacement. 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

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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 hourbefore procedure and 0.5 g 6 hours later. For general anaesthesia, ivvancomycin, clindamycin or teicoplanin may be used. Oral vancomycin hasvirtually no systemic absorption and is not a suitable choice for this reason. Forpatients with prosthetic heart valves or those with previous endocarditis whohave 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 beused.

157. A 34-year-old professional footballer is evaluated for symptoms of dizziness duringexercise. 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 Your answer

Atrial septal defect

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 shouldbe 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 alsooccur 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 onsquatting and passive leg elevation and increases with the Valsalva manoeuvre. The most

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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 Your answerAspartate aminotransferase

Lactate dehydrogenase

Troponin T and troponin I are regulatory proteins with a very high specificity for cardiacinjury. 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 lactatedehydrogenase 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 inpatients 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

30 bpm when awake and asymptomatic

Your

answer

40-year-old man with Lyme disease having symptomatic complete AV

block

40-year-old man with chronic asymptomatic trifascicular block and first-

degree 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

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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 permanentpacing. 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 serumcholesterol of 6.5 mmol/l and HDL of 1.3 mmol/l is seen by his GP. He is notdiabetic and has never smoked. His family history is unknown as he was adopted.Apart from advice on lifestyle modification, which of the following combinationof 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 becalculated from the Framingham model. Other methods to estimate thecoronary risk include the Sheffield table, New Zealand Guidelines and thatrecently published by the SCORE study group. The National Service Frameworkfor Coronary Heart Disease states that people whose estimated risk ofcoronary heart disease based on a specified risk factor profile of > 30% over

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10 years should be offered appropriate advice and treatment.

Several treatments reduce the risk of coronary artery disease, the absolutebenefits being proportional to the pre-treatment risk: note that individualpatients may be eligible for more than one treatment. The most cost-effective preventive treatments are aspirin, initial antihypertensive

treatment (bendrofluazide, atenolol) and intensive antihypertensivetreatment (bendrofluazide, atenolol and enalapril). In contrast, simvastatinand clopidogrel were the least cost-effective. The cost per coronary eventprevented in a patient with a 10% coronary risk over 5 years is 3500 foraspirin, 12,500 for initial antihypertensive treatment, 18,300 for intensiveantihypertensive, 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. Threepossible 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 myocardialtoxicity. Documented cocaine use should not be considered to rule outunderlying significant coronary artery disease (CAD), since the drug mayprecipitate coronary vasospasm or acute myocardial infarction in the patientwith atherosclerotic CAD.Where elective angioplasty is available, this ispreferable to thrombolysis as outcome studies show it to be superior.

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162. Which is the best clinical marker of the severity of aortic stenosis?

Character of apex beat

Character of carotid pulseCharacter of S2 Your answer

Intensity of murmur

Pulse rate

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, thepoorly 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 isincreased). 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 ventricularfailure. 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 hisGP 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 bestwith 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 bysitting 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), sclerodermaor 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 severecases, 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

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first year.

164. A 52-year-old woman, with a prior history of rheumatic fever, presents withshortness 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 ata rate of around 150 bpm. Echo demonstrates preserved left ventricularfunction, a heavily calcified mitral valve with moderate mitral stenosis (mitralvalve 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 isnot currently indicated. Even if the mitral stenosis were to be severe thepresence of heavy calcification of the valve and concomitant mitral regurgitationwould preclude percutaneous valvotomy. She is in permanent atrial fibrillationand as such, by definition, sinus rhythm cannot be restored (as opposed topersistent 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 workingoutdoors because of its side-effect profile.

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165. A 63-year-old man with known chronic heart failure is admitted withsymptoms at rest. Examination reveals pitting oedema to his knees, elevatedjugular venous pressure and basal crepitations. He is in sinus rhythm at a rate of80 bpm and his blood pressure is 100/60 mmHg. Current medication includesbisoprolol 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, potassium4.9 mmol/l and creatinine of 169 mol/l. The admitting doctor commences himon 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 mostappropriate 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 HeartAssociation class IV). Examination has revealed significant fluid retention. Theinitial management plan of changing to iv frusemide is sensible since coexistentgut wall oedema is likely to impinge on oral absorption. Increasing thevasodilators in the form of ramipril is again a sensible approach. The addition ofa thiazide (inhibiting sodium reabsorption in distal tubule) may work in synergywith a loop diuretic; the same is true for metolazone. Spironolactone, analdosterone antagonist, has been shown to improve the mortality rate andsymptoms and reduce hospitalisation in patients with severe CHF already onconventional treatment. Benefits are in addition to its diuretic effect sincealdosterone itself has adverse effects on myocardial structure and function.Clearly, careful monitoring of renal function and biochemistry is important insuch patients.

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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 axisdeviation

Youranswer

QRS duration less than 140 ms

P wave preceding wide QRS complex

V-lead polarity is discordant

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 tachycardiawith 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 nodeand 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 witha 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 defectEbsteins anomaly

Hypertrophic cardiomyopathy

Mitral valve prolapse

Patent ductus arteriosus Your answer

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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. Hypertrophiccardiomyopathy 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-pressuresystem 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 immediatereperfusion therapy. Fast-track systems in hospitals have been developed to minimise the

delay of thrombolysis; these are facilitated by specifically trained medical and nursingstaff, 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 andcontinuous 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 Your answer

Carotid endarterectomy

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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, ageolder 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 aneed 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 issignificant mass effect.

170. A 12-year-old boy with known heart disease is being advised regarding antibioticprophylaxis.

Which cardiac lesion is most likely to be prone to infection?

Atrial septal defect

Aortic regurgitation Your answer

Mitral stenosisMitral valve prolapse without regurgitation

Mitral regurgitation

Infection of previously affected valves most commonly involves the aortic valves. Mitral

regurgitation and mitral valve prolapse with regurgitation present a moderate risk, whilemitral 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 Your answer

Ventricular fibrillation

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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 rapidoscillations 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 maybe 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 positive-pressure ventilation. Which of the following statements is true when comparedto 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 aresignificantly increased when compared to spontaneous ventilation. A large tidalvolume causes a rise in pulmonary vascular resistance, which may lead topulmonary hypertension and right ventricular compromise. The over-inflatedalveoli cause compression of the alveolar blood vessels. Moreover, the resultantincrease in RV volume may impede LV filling (ventricular interdependence).Hyperinflation also releases prostaglandins, which decrease blood pressure. Theintrathoracic pressure is increased at all points in the respiratory cycle.

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Inspiration during IPPV increases intrathoracic pressure and so increases rightatrial pressure relative to atmospheric pressure, therefore leading to decreasedvenous return. The increased intrathoracic pressure also decreases the gradientacross 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 andthen 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) Your answer

Cardiac catheterisation

Treadmill test

The key in assessing any episode of loss of consciousness is a detailed history includingeye-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 thediagnosis 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 ofpostural 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 initiallyuncertain, 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 toobtain 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

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174. A 78-year-old woman presents to A&E with three episodes of syncope in thelast 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 bloodpressure of 100/40 mmHg. Potassium is 5.3 mmol/l. Her ECG shows completeheart block with rate of 40 bpm. QRS duration is 150 ms with a right bundle-branch 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 syncopalepisodes. Her QRS duration is prolonged (normal up to 120 ms), and this isgenerally 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 toremember that cardiac output will be influenced by heart rate. In the elderly,cerebral vascular dysregulation may compound the effect thereby contributing tocerebral hypoperfusion. Ideally she should receive a transvenous temporarypacemaker. If further acute problems occur while waiting for a transvenoustemporary pacemaker (eg awaiting transfer to a room with fluoroscopy), thenexternal 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 atrest. The ECG shows ST depression in the lateral leads and his troponin T level is

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8.2 g/l. Which of the following is the most appropriate combination of drugs forinitial 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, anti-platelet therapy, anticoagulation and a -blocker. A systematic review foundthat aspirin alone (75325 mg/day) reduces the risk of death and myocardialinfarction in patients with UA. A large, randomised, control trial (RCT) has shownthat the combination of clopidogrel (75 mg/day) and aspirin is superior to aspirinalone. Many RCTs have found that treating those patients at risk of UA with lowmolecular weight heparin (LMWH) is more effective than aspirin alone. Theadvantages of LMWH over unfractionated heparin include its ease ofadministration 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. Thosewho undergo coronary angioplasty should also be considered for treatment withan intravenous glycoprotein IIb/IIIa inhibitor such as abciximab, tirofiban oreptifibatide.

176. The epsilon potential is seen on the ECG of patients with which of the following?

Hypertrophic cardiomyopathy

Restrictive cardiomyopathy

Right ventricular dysplasia Your answer

Romano Ward syndrome

Digoxin toxicity

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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 wavesepsilon since epsilon follows delta in the Greek alphabet.)

Right ventricular dysplasia is characterised by the displacement of myocytes by fat. Thisdelays 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. Apulmonary ventilationperfusion scan shows a perfusion defect. Whichinvestigation 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 thiswould 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 followingconditions?

Ischaemic heart disease

Your answer

Mitral stenosis

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Pericarditis

Pulmonary embolism

Tricuspid stenosis

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

179. A 35-year-old-woman of African origin presents with a 4-month history ofincreasing swelling over her feet and abdominal distension. She has no history ofcough, orthopnoea or breathlessness on exertion. Her heart rate is 98beats/minute: irregularly irregular. Her JVP is markedly raised and she haspitting lower limb oedema. The heart sounds are soft, and there are no audiblemurmurs. Abdominal examination reveals hepatomegaly along with ascites.Chest X-ray reveals a normal cardiac size and clear lung fields. A lateral X-rayshows 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

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a normal heart size. The possibilities are constrictive pericarditis andrestrictive cardiomyopathy. The presence of calcification around the heartfavours constrictive pericarditis.

Causes of restrictive cardiomyopathy include cardiac amyloidosis,haemachromatosis, endomyocardial fibrosis, systemic sclerosis, carcinoid

syndrome and malignancy. Cardiac amyloidosis is usually associated withmyeloma. 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 dailyand amlodipine 10 mg once daily. He is an ex-smoker with a past history ofuncomplicated myocardial infarction. Blood pressure is 170/100 mmHg in botharms. 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, 138mmol/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

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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 thecalcified aortic valve. What is the risk of sudden cardiac death per year in such patients?

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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 cyclo-

oxygenase-2 (Cox-2) specific inhibitor and has a reduced adverse effect on thegastrointestinal 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 patientswith 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. Onexamination 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 Your answerStaphylococcus aureus

Streptococcus bovis

Gram-negative bacilli

Staphylococcus epidermidis

Infective endocarditis on native valves prevalence of organisms:

Streptococci Viridans group 3040%

Enterococci 1015%

Other 2025%Staphylococci Staphylococcus aureus 927%

Coagulase-negative 13%

Gram-negative bacilli Haemophilus spp. 38%

Anaerobes Rickettsia/fungi 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 followingcardiac surgery.

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

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this occasion has a ventricular rate of 165/min and a blood pressure of 90/50mmHg, feeling faint and unwell.

Which of the following anti-arrhythmics would be the most appropriateprophylaxis for her?

Flecainide

Your answer

Amiodarone

Digoxin

Phenytoin

Propafenone

This patient has paroxysmal supraventricular tachycardia (SVT). While digoxinslows the ventricular rate in patients with chronic atrial fibrillation, it does notmaintain sinus rhythm in patients with paroxysmal tachycardia. Amiodarone isknown to be teratogenic and is contraindicated in pregnancy. While there is no

evidence that flecainide is teratogenic, no randomised controlled trials haveincluded pregnant women, for obvious reasons. Several case series describe useof flecainide in pregnant women and it appears to have a relatively good safetyprofile 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 ofhypertension, 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 rightmiddle cerebral artery territory.

CT angiogram of the carotid system shows a 60% stenosis of the right internal carotid

artery.

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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

HyperlipidaemiaPresence of moderate carotid stenosis Your answer

Presence of previous strokes on CT scan

This is a transient ischaemic attack (TIA). About 1520% of patients with stroke have apreceding 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. Therisk 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, speechimpairment); 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. Moreresearch 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 includingaspirin, 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 population-based 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 endarterectomyis 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) differsfrom 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 andipsilateral severe (70 to 99%) carotid artery stenosis, CEA is recommended by a

surgeon with a perioperative morbidity and mortality of

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factors such as age, gender, comorbidities, and severity of initial symptoms.

When degree of stenosis is

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188. Which of the following microanatomical structures within the heart interacts withconventional calcium-channel blockers?

L type Calcium-channels Your answer

Calcium-channel T type

T tubules

Titin

Tropomyosin

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 withconventional 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 explainsthe stressstrain elastic relation of striated muscle. It is the largest protein molecule yetdescribed. 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 formof perindopril 4 mg od for the past 3 years. However, on repeatedmeasurements, her readings have been > 160 mmHg systolic, with diastolicreadings being in the order of 8085 mmHg. Renal function is normal as is urinedipstick testing. There is no evidence of left ventricular hypertrophy on ECG. Sheis obese with a BMI of 33.

What would you consider adding as your next drug?

Atenolol

Bendrofluazide

Doxazosin

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Amlodipine

Your answer

Spironolactone

This woman has hypertension resistant to a single agent. It is increasinglyrecognised that more than one agent is required to adequately control bloodpressure. Whilst guidelines suggest either a thiazide or calcium channelantagonist could be added next, in view of the fact she is obese, a calciumchannel antagonist may be the better choice. Meta-analyses have shown thatboth thiazides and beta blockers are associated with an increased risk of thedevelopment of Type 2 diabetes in at risk patients. Indeed, the ASCOT study didsuggest that the combination of ACE inhibitor and calcium antagonist wasassociated 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. Thisoccurred unexpectedly while he was walking his dog. There have been no similarepisodes in the past. On examination there were no positive findings. An ECGperformed with carotid sinus massage revealed a 5-second pause. Which of thefollowing statements is true?

Carotid sinus hypersensitivity is due to atherosclerosis

Carotid sinus massage is contraindicated in patients with carotidvascular disease

Your

answer

A permanent pacemaker has no role in the management of thesepatients

Carotid sinus hypersensitivity is related to vertebrobasilarischaemia

Carotid sinus massage is contraindicated in patients taking -blockers

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Carotid sinus baroreceptors consist of sensory nerve endings located in theinternal 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 canoccur during the periods of hypersensitive carotid reflex, some form ofventricular pacing, with or without atrial pacing, is generally required. Themechanism responsible for carotid sinus hypersensitivity is unknown, butpossibilities include a high level of resting vagal tone, hyperresponsiveness toacetylcholine or an excessive release of acetylcholine.

191. A patient has tuboeruptive xanthomas, distributed subcutaneously andmainly 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. Eruptivexanthomas are associated with hyperchylomicronaemia (type I and type Vhyperlipoproteinaemia). Xanthoma tendinosum, which are nodular swellings oftendons, usually occur in type II hyperlipoproteinaemia.

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

Shock liver syndrome

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Anaesthetic-induced

Haemolysis on bypass

Your answer

Narcotic-induced

Right heart failure

Isolated elevation of direct and indirect bilirubin, indicates haemolysis on thecardiopulmonary bypass and can be confirmed by increased plasma free-

haemoglobin levels. There is no specific treatment. Markedly raised enzymelevels are seen in patients with the shock liver syndrome, and the treatment isaimed at maximising cardiac output and oxygenation. Right heart failure isanother cause of hyperbilirubinaemia in the immediate post-bypass period, and,in this case, the direct bilirubin and alkaline phosphatase are increased withoutenzyme 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 withstrain. 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 gradientgreater 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 usuallyshort-lived.

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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 showsminor mismatch at the lung bases. There is no evidence of RV dysfunction,

clinically and on echocardiography. In addition to oxygen, which of the followingis 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, probablyassociated with pulmonary infarction. The management in this case would beheparin and non-steroidal anti-inflammatory drugs (NSAIDs) to control her chestpain. If there were signs of a large/massive PE (hypotension, right ventricular

dysfunction), the ideal management would include thrombolytic therapy ormechanical 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

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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 leftatrium 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 ofpulmonary plethora is more suggestive of atrial septal defect. Polycythaemia may occur ifthe shunt is reversed (Eisenmengers syndrome).

196. In an asymptomatic patient, a permanent pacemaker is indicated in which ofthe following conditions?

First-degree block at the AV node

First-degree block in the distal conduction system with an HVinterval < 100 ms

Second-degree block at the AV node

Second-degree block at the distal conduction system

Your

answer

Third-degree block at the AV node

In an asymptomatic patient, a permanent pacemaker (PPM) is indicated insecond- and third-degree heart block at the distal conduction system. If thethird-degree block at the AV node had been associated with symptoms, it wouldhave been an indication for PPM. Also, a PPM is indicated for cases of first-degree AV block in the distal conduction system with an HV (Bundle of His toventricular depolarisation) interval of greater than 100 ms associated with

symptoms.

197. A 65-year-old woman with a history of heavy smoking presents for review. She haswoken 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

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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 embolusExacerbation 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 neckveins 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 andcardiomyopathy.

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 oxygentherapy, 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 thrombolysisis being considered.

Which one of the following would be an absolute contraindication for thrombolytictherapy?

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 mmHgYour

answer

A proven (ie computed tomography (CT) scan-proven) intracranial haemorrhage (ICH) isan 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

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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 beconsidered 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/orinternational 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 Prolongedcardiopulmonary 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 afterwalking 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 Your answer

Simvastatin

Isosorbide mononitrate

Angiotensin-converting enzyme (ACE) inhibitor

Nicardipine

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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 agentsand 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 andcontractility.

200. A patient with angina is admitted for cardiac catheterisation. There is a suspicion thatshe 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 Your answerTSH levels

T4 levels

Measurement of TPO (thyroid peroxidase) antibodies

Ultrasound scan

Cardiac catheterisation requires the use of an iodine-containing contrast. This may worsenthe 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 andthus 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 showthe presence of a solitary lesion or a multinodular goitre, but will not provide a definitivediagnosis. The most reliable diagnostic method is a radionuclide ( 99Tcm, 123I, or131I) 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 patientshould receive an antithyroid drug before undergoing catheterisation. The antithyroid

medication must be continued for at least 2 weeks after the procedure.