Stress ECG
Magnetic resonance angiography
A 75-year-old man is referred for total hip replacement. He has a history of hypertension and angina and has suffered a myocardial infarction some 8 years earlier. Current medication includes atenolol 50 mg daily, ramipril 10 mg daily, aspirin 75 mg daily and isosorbide dinitrate 60 mg. Blood pressure at the preoperative assessment was 160/80 mmHg but he maintains that his readings with the general practitioner have been normal. He last had an exercise test some 3 years earlier and managed 8 min with no significant electrocardiogram (ECG) changes.
Which one of the following investigations in addition to standard assessment would be most appropriate for the preoperative assessment of this patient?
Repeat exercise ECG test
Routine echocardiogram Correct answer
99Tcm MIBI SPECT scan Your answer
Stress ECG
Magnetic resonance angiography
From the history given it appears that this man has relatively stable angina and there seems little value to be gained from further imaging of his coronary arteries. Routine echocardiogram would add information about left ventricular function and point out any valvular disease. Given possible haemodynamic changes during total hip replacement, significant left venticule (LV) impairment or valvular disease may impact significantly on operative prognosis. His blood pressure does appear labile and it would be worthwhile to document that his normal blood pressure is within acceptable limits. If he has significant white coat hypertension, when he attends for surgery he may well be cancelled if his blood pressure is too high. For this reason, 24-h outpatient blood pressure recording would seem sensible.
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A 64-year-old woman suffers from frequent and painful urinary tract infections. After her third course of antibiotics in the past 6 months she is advised by the GP to take cranberry juice supplements. Significant past medical history of note
includes hypertension for which she takes ramipril and bendroflumethiazide and hypercholesterolaemia for which she takes simvastatin. There is also a history of paroxysmal atrial fibrillation for which she takes warfarin and amiodarone.
Which of her medications is most likely to interact with the cranberry juice?
Simvastatin
Amiodarone
Bendroflumethiazide
Warfarin
Ramipril
A 64-year-old woman suffers from frequent and painful urinary tract infections. After her third course of antibiotics in the past 6 months she is advised by the GP to take cranberry juice supplements. Significant past medical history of note includes hypertension for which she takes ramipril and bendroflumethiazide and hypercholesterolaemia for which she takes simvastatin. There is also a history of paroxysmal atrial fibrillation for which she takes warfarin and amiodarone.
Which of her medications is most likely to interact with the cranberry juice?
Simvastatin
Amiodarone
Bendroflumethiazide
Warfarin Your answer
Ramipril
Cranberry juice contains a number of bioflavinoids, some of which are thought to cause inhibition of the cytochrome p450 2C9 isoenzyme which is responsible for warfarin metabolism. Metabolism of simvastatin is inhibited by grapefruit juice. The warfarin interaction was given as a Committee for Safety of Medicines (CSM) warning in 2003 and features prominently in the MRCP examination.
A 63-year-old smoker is admitted with nausea, sweating and central crushing chest pain. A 12 lead ECG reveals ST elevation in leads II , III and aVF.
Which coronary artery is most likely to have been affected in this case? Circumflex artery
Left anterior descending artery
Right coronary artery Obtuse marginal artery Posterolateral artery
A 63-year-old smoker is admitted with nausea, sweating and central crushing chest pain. A 12 lead ECG reveals ST elevation in leads II , III and aVF.
Which coronary artery is most likely to have been affected in this case?
Circumflex artery Your answer
Left anterior descending artery
Right coronary artery Correct answer
Obtuse marginal artery
Posterolateral artery
The right coronary artery generally supplies the right ventricle, the posterior third of the interventricular septum, the inferior wall of the left ventricle and a portion of the posterior wall of the left ventricle. Occasionally the posterior
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interventricular septum may be supplied by a branch of the of the left circumflex artery, a so called left dominant circulation. The left anterior descending and left circumflex coronary arteries arise at the left main coronary artery bifurcation and supply the anterior left ventricle, the bulk of the interventricular septum (anterior two thirds), the apex,
and the lateral and posterior left ventricular walls.
A 20-year-old-man attends A&E with palpitations described as ‘regular rapid beating of the heart’. An ECG shows a regular rhythm with a rate of 200 beats/minute and a QRS duration of 80 ms. The tachycardia spontaneously resolves. An ECG in sinus rhythm reveals a PR interval of 60 ms and a QRS duration of 120 ms with a positive delta in V1. Which of the
following statements is true regarding this man’s tachycardia?
Carotid sinus massage will be ineffective
Intravenous adenosine is of no use
Digoxin should be used as a prophylactic agent
Verapamil is contraindicated
Atrial fibrillation is well tolerated in such patients
A 20-year-old-man attends A&E with palpitations described as ‘regular rapid beating of the heart’. An ECG shows a regular rhythm with a rate of 200 beats/minute and a QRS duration of 80 ms. The tachycardia spontaneously resolves. An ECG in sinus rhythm reveals a PR interval of 60 ms and a QRS duration of 120 ms with a positive delta in V1. Which of the
following statements is true regarding this man’s tachycardia?
Carotid sinus massage will be ineffective
Intravenous adenosine is of no use
Digoxin should be used as a prophylactic agent
Verapamil is contraindicated Your answer
Atrial fibrillation is well tolerated in such patients
This man has type A Wolff–Parkinson–White (WPW) syndrome, in which an abnormal band of atrial tissue connects the atria to the ventricle to bypass the atrioventricular (AV) node. As the AV node and bypass tract have different
conduction speeds and refractory periods, a re-entry circuit can be formed that results in tachycardia. Carotid sinus massage or intravenous adenosine will often terminate an episode of tachycardia.
Prophylactic drug therapy is indicated for symptomatic patients. Agents such as flecainide, disopyramide or amiodarone are used in an attempt to slow the conduction rate and prolong the refractory period of the bypass tract. Digoxin and verapamil are contraindicated as they increase conduction in the bypass tract.
Atrial fibrillation is poorly tolerated and is a life-threatening arrhythmia in such patients: the bypass tract lacks the rate-limiting properties of the normal AV node and ventricular fibrillation ensues. This is treated as a medical emergency with DC cardioversion.
A 25-year-old man was found by his family at home having suffered a cardiac arrest. He was previously well, apart from well controlled Type 1 diabetes controlled with a basal bolus insulin regime. His family followed the ambulance and ask if they can be in the resuscitation room. After 20 mins of repeated resuscitation cycles he has remained in asystole. Blood gases;
pH 7.01
PO2 8.4 kPa PCO2 3.9 kPa Bicarb 10 mmol/l
Which person is the most appropriate person to make the decision to discontinue resuscitation?
A&E consultant
On call medical consultant
Parents of the patient
Patient’s fianceé
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well controlled Type 1 diabetes controlled with a basal bolus insulin regime. His family followed the ambulance and ask if they can be in the resuscitation room. After 20 mins of repeated resuscitation cycles he has remained in asystole. Blood gases;
pH 7.01
PO2 8.4 kPa PCO2 3.9 kPa Bicarb 10 mmol/l
Which person is the most appropriate person to make the decision to discontinue resuscitation?
A&E consultant
On call medical consultant
Parents of the patient Your answer
Patient’s fianceé
Resuscitation team leader Correct answer
Clear, appropriate communication is a key component of resuscitation. Whilst it may of course be appropriate to allow the presence of relatives within the resuscitation room, they do not have the authority to continue or discontinue resuscitation; of course relatives do however need to be informed of progress. Whilst the experience of the A&E or on-call medical consultants may be useful in gaining advice, the resuscitation team leader is usually a senior
anaesthetist or physician in their own right, and qualified to decide on discontinuing resuscitation, if there is any doubt they can consider discussing with the consultant on call.
A 70-year-old lady with a history of asthma presents with shortness of breath for some days. She is also treated with ramipril 10mg daily. On examination her blood pressure is 135/85 mmHg, pulse is 100/min (atrial fibrillation). She is not in cardiac failure. Examination of the respiratory system reveals wheeze consistent with asthma.
Results; Hb 13.2 g/dl WCC 6.1 x109 /l PLT 240 x109 /l + Na 138 mmol/l + K 4.7 mmol/l Creatinine 125 µmol/l
CXR Cardiomegaly consistent with longstanding hypertensive heart disease
Which of the following is the most appropriate treatment for her atrial fibrillation?
Diltiazem
Digoxin
Amiodarone
Atenolol
Dysopyramide
A 70-year-old lady with a history of asthma presents with shortness of breath for some days. She is also treated with ramipril 10mg daily. On examination her blood pressure is 135/85 mmHg, pulse is 100/min (atrial fibrillation). She is not in cardiac failure. Examination of the respiratory system reveals wheeze consistent with asthma.
Results;
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WCC 6.1 x10 /l9 PLT 240 x10 /l9 + Na 138 mmol/l K+ 4.7 mmol/l Creatinine 125 µmol/lCXR Cardiomegaly consistent with longstanding hypertensive heart disease
Which of the following is the most appropriate treatment for her atrial fibrillation?
Diltiazem
Digoxin Your answer
Amiodarone
Atenolol
Dysopyramide
This lady has been in atrial fibrillation for an unknown period of time and her pressing need at this point is rate control. Options for rate control include diltiazem, atenolol and digoxin. Atenolol may lead to worsening of her asthma and should not be used. Diltiazem is negatively inotropic and may precipitate cardiac failure (presence of cardiomegaly on CXR); as such digoxin is an effective option for rate control here.
A 71-year-old lady with a history of one previous myocardial infarction presents to the Emergency department. She has sudden onset shortness of breath and palpitations which happened after her dinner a couple of hours earlier. A previous ECG from clinic a month earlier shows sinus rhythm. Medication includes ramipril 10mg daily, amlodipine 10mg daily and aspirin 75mg. On examination her blood pressure is 100/60 mmHg, pulse is 140/min irregular and she has evidence of LVF. Bloods Hb 14.0 g/dl WCC 6.7 x109 /l PLT 190 x109 /l + Na 140 mmol/l K+ 5.0 mmol/l Creatinine 130 µmol/l
ECG Fast atrial fibrillation, lateral ST depression
Which of the following is the most appropriate medication to control her AF?
Digoxin
Amiodarone Flecainide Sotalol
Verapamil
A 71-year-old lady with a history of one previous myocardial infarction presents to the Emergency department. She has sudden onset shortness of breath and palpitations which happened after her dinner a couple of hours earlier. A previous ECG from clinic a month earlier shows sinus rhythm. Medication includes ramipril 10mg daily, amlodipine 10mg daily and aspirin 75mg. On examination her blood pressure is 100/60 mmHg, pulse is 140/min irregular and she has evidence of LVF. Bloods
WCC 6.7 x10 /l9 PLT 190 x10 /l9 + Na 140 mmol/l K+ 5.0 mmol/l Creatinine 130 µmol/l
ECG Fast atrial fibrillation, lateral ST depression
Which of the following is the most appropriate medication to control her AF?
Digoxin
Amiodarone Correct answer
Flecainide Your answer
Sotalol
Verapamil
Flecainide, whilst effective at cardioverting atrial fibrillation is contra-indicated in patients with a history of ischaemic heart disease since the CAST post infarct trial demonstrated increased mortality in patients treated with flecainide. Sotalol and verapamil are negatively inotropic and likely to worsen LVF. Digoxin would be effective at slowing the ventricular rate, but given that she was in sinus rhythm 1 month earlier, it would be a reasonable objective to attain sinus rhythm again. As such IV loading with amiodarone would appear to be the most appropriate option in this patient.
A 78-year-old lady is admitted from home by ambulance. She was found lying on the floor by her home help after suffering a fall. She has a history of hypertension managed with ramipril 10mg PO daily. On examination her temperature is 30.0oC, her BP is 100/50 mmHg, with a pulse of 52/min. She has a fractured left neck of femur.
Bloods; Hb 14.5 g/dl WCC 4.5 x10 /l9 PLT 192 x10 /l9 + Na 143 mmol/l + K 5.3 mmol/l Creatinine 195 µmol/l
Which of the following ECG features is most characteristic of moderate to severe hypothermia?
Long QT interval
Short PR interval
2nd degree heart block Complete heart block J waves
A 78-year-old lady is admitted from home by ambulance. She was found lying on the floor by her home help after suffering a fall. She has a history of hypertension managed with ramipril 10mg PO daily. On examination her temperature is 30.0oC, her BP is 100/50 mmHg, with a pulse of 52/min. She has a fractured left neck of femur.
Bloods;
Hb 14.5 g/dl
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+ Na 143 mmol/l + K 5.3 mmol/l Creatinine 195 µmol/l
Which of the following ECG features is most characteristic of moderate to severe hypothermia?
Long QT interval Your answer
Short PR interval
2nd degree heart block
Complete heart block
J waves Correct answer
Whilst varying degrees of heart block may be seen in association with hypothermia, J waves are said to be most characteristic of moderate to severe hypothermia. J waves are best seen in the left chest leads and are described as a dome or hump in the terminal portion of the QRS complex. The size of the J wave is correlated with the degree of hypothermia. Slow atrial fibrillation may also be seen as core temperature falls. Death from ventricular arrhythmias is common in moderate to severe hypothermia.
A 70-year-old woman presents to the pre-operative orthopaedic clinic prior to hip replacement. She has suffered a myocardial infarction 4 years earlier and is managed with aspirin 75mg daily, ramipril 10mg daily and atorvastatin 40mg daily. There is no history of angina but she is only able to walk around 50 yards. On examination she looks well, her BP is 145/80 mmHg with a pulse of 75/minute.
Bloods; Hb 14.0 g/dl WCC 5.9 x109 /l PLT 180 x109 /l + Na 140 mmol/l + K 5.0 mmol/l Creatinine 130 µmol/l
Which of the following is the most appropriate investigation to assess her suitability for surgery from the point of view of her cardiovascular status?
12-lead ECG
Treadmill stress test
Echocardiogram
Dobutamine stress echo
Cardiac angiography
A 70-year-old woman presents to the pre-operative orthopaedic clinic prior to hip replacement. She has suffered a myocardial infarction 4 years earlier and is managed with aspirin 75mg daily, ramipril 10mg daily and atorvastatin 40mg daily. There is no history of angina but she is only able to walk around 50 yards. On examination she looks well, her BP is 145/80 mmHg with a pulse of 75/minute.
Bloods; Hb 14.0 g/dl WCC 5.9 x109 /l PLT 180 x109 /l + Na 140 mmol/l