A 49-year-old hypertensive, male smoker complains of central crushing chest pain and nausea. Upon examination, his ECG reveals newly inverted T waves in V2 and V3. Which coronary artery is likely affected by critical stenosis based on these ECG findings?
A 54-year-old man with a history of hypertension and elevated BMI presents to the Emergency Department with chest pain. An ECG shows ST depression in V1 to V4 and subsequent blood tests reveal a troponin of 10,000, indicating a non-ST-elevation myocardial infarction (NSTEMI). He is started on appropriate secondary prevention medications and transferred to the cardiology unit for in-patient angiography.
You are urgently called to review the patient as he reports sudden onset of shortness of breath. He denies any chest pain. His vital signs are heart rate 130 beats per minute, blood pressure 95/62 mmHg, temperature 36.1ºC, respiratory rate 28/min, and saturations 94% on 10 litres of oxygen. On examination, heart sounds are normal with no added sounds. JVP is mildly elevated. There is no evidence of ascites or peripheral edema. A repeat ECG shows sinus tachycardia but no dynamic changes. A portable chest x-ray reveals cardiomegaly with upper lobe diversion and peri-hilar shadowing. An urgent bedside echocardiogram shows significant LV systolic dysfunction with a 2cm pericardial effusion but no signs of tamponade.
What is the best next step in managing this patient?
An 85-year-old male was admitted to the coronary care unit (CCU) after being admitted as a primary percutaneous coronary intervention (PPCI) call for sudden onset chest pain and ST elevation on anterior leads of his ECG. Angiography demonstrated a mid-left anterior descending artery acute occlusion likely secondary to plaque rupture that was stented with a drug-eluting stent. Two hours after being admitted to CCU, he complained of nausea and vomited twice, which settled after being prescribed cyclizine by a passing medical senior house officer. Thirty minutes afterwards, you are asked to see the patient as the patient has become increasingly short of breath. He complains of no new chest pain, nausea, vomiting, sweating or palpitations. Interrogation of his cardiac telemetry reveals a new sinus tachycardia only without other arrhythmias. On examination, the patient is in respiratory distress, with bibasal inspiratory crackles and raised jugular venous pulse.
His observations are as follows: blood pressure is 186/80 mmHg, heart rate 120 beats per minute and regular, Sats 92% on 3 litres, respiratory rate 33/min.
A repeat 12-lead ECG reveals no new ST elevation changes or other ischaemic changes. A portable chest radiograph demonstrates bibasal alveolar oedema and bilateral small pleural effusions. What is the cause of the patient’s deterioration?
A 57-year-old man presents to the Emergency Department with sudden onset severe chest pain that has persisted for three hours. He reports feeling short of breath and clammy. His medical history includes hypertension, hypercholesterolemia, and gout, and he is currently taking amlodipine, ramipril, atorvastatin, allopurinol, and orlistat. He smokes 20 cigarettes per day and drinks 30 units of alcohol per week. On examination, he appears pale and clammy, with a prominent early diastolic murmur in the aortic area. His blood pressure is 196/78 mmHg in his right arm and 152/65 mmHg in his left arm, and his heart rate is 92 bpm. His oxygen saturations are 96% on air. An ECG shows normal sinus rhythm with ST elevation in leads II, III, and aVF, and a chest x-ray is normal.
What is the most appropriate immediate management step?
A 50-year-old CEO presents with sudden onset retrosternal chest pain accompanied by light-headedness. She has no past medical history except for menopause six years ago and a brief course of hormone replacement therapy. Upon examination, her peripheries are cool, and her heart sounds are normal. There is no peripheral oedema, and her calves are soft and non-tender. Her ECG shows ST elevation in V2-V4, and her troponin level is 0.8 (normal range <0.03). Overnight, percutaneous coronary intervention was performed, revealing no occlusions in her coronary arteries. However, ballooning of her left ventricular mid-cavity and apex was observed, along with left ventricular hypokinesia. What is the most probable diagnosis?
A 36-year-old woman arrives at the Emergency Department complaining of sudden chest pain and difficulty breathing that started while she was watching TV four hours ago. She describes the pain as severe, located in the center of her chest, and not radiating. She denies coughing or coughing up blood. She has no significant medical history except for taking oral contraceptives.
Upon examination, the patient is overweight, has a heart rate of 114 beats per minute, and a blood pressure of 101/63 mmHg. Her respiratory rate is 22, and her oxygen saturation is 94% on room air. Her jugular venous pressure is 5 cm, but there is no swelling in her extremities. Scattered crepitations are heard upon chest auscultation. Her heart sounds are dual, with no audible murmurs. A portable chest x-ray shows clear lung fields.
Shortly after, the patient’s blood pressure drops to 90/59 mmHg. A bedside echocardiogram reveals elevated right ventricular filling pressures with evidence of strain. What is the most appropriate course of action?
You review a 70-year-old patient in cardiology outpatient clinic. He has a left ventricular ejection fraction of 15% on maximal medical therapy. On reviewing his ECG you note a QRS duration of 135ms without evidence of left bundle branch block. Upon taking a history you note the patient is breathless at rest and struggles to walk around his bungalow.
Which implantable device would be appropriate to consider?
A 56 year-old man with a history of ischaemic heart disease and Crohn’s disease presents with colonic enterocutaneous fistulae. He undergoes surgery and a temporary ileostomy is created for bowel dysfunction and healing promotion. However, two days after the operation, he experiences palpitations and the surgical team seeks your assistance.
Upon examination, his pulse rate is 220 bpm and blood pressure is 135/90 mmHg. Oxygen saturation is 96% on 2L nasal oxygen. A clear chest is observed during auscultation. A 12-lead ECG shows a wide-complex tachycardia with a polymorphic waveform.
The morning blood tests reveal the following results: Hb 129 g/l, platelets 643 * 109/l, WBC 13.8 * 109/l, Na+ 129 mmol/l, K+ 3.3 mmol/l, phosphate 0.63 mmol/l, Mg++ 0.59 mmol/l, urea 8.1 mmol/l, creatinine 97 µmol/l, bilirubin 15 µmol/l, ALP 143 u/l, ALT 53 u/l, and albumin 31 g/l.
What is the most appropriate initial management for this patient?
A 58-year-old, previously healthy man experiences an infero-posterior myocardial infarction (MI) and undergoes primary angioplasty. He initially stabilizes, but the nursing staff expresses concerns about his condition the following day. On examination, his blood pressure is 85/60 mmHg, his pulse is 50 bpm and regular, and his JVP is elevated at 6 cm. A creatinine level taken that morning is elevated at 140 µmol/l. Despite administering 2 mg of atropine, there is no significant improvement in his pulse or BP. A CVP line is inserted, which measures a CVP of 10. What is the most appropriate next intervention?
A 19-year-old male complains of gradually worsening shortness of breath over the past year. He denies cough, wheeze or chest pain and has no significant medical history. During examination, a loud second heart sound is noted and an ECG reveals right bundle branch block (RBBB) with left axis deviation (LAD).
What is the probable diagnosis?