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  • Question 1 - You are summoned to a cardiac arrest in the resuscitation area of your...

    Incorrect

    • You are summoned to a cardiac arrest in the resuscitation area of your Emergency Department. The patient is experiencing asystole, and adrenaline is given as part of the cardiac arrest protocol.
      Which ONE statement is NOT TRUE regarding the utilization of adrenaline in cardiac arrest?

      Your Answer: It can be given by the IV or IO routes

      Correct Answer: In VF arrest it should be given before the 3rd shock

      Explanation:

      Adrenaline should be administered promptly once access to the circulatory system has been established in cases of non-shockable cardiac arrests such as PEA or asystole. The recommended dose is 1 mg, which can be given either as 10 mL of a 1:10,000 solution or as 1 mL of a 1:1000 solution through the intravenous (IV) or intraosseous (IO) routes.

      In cases of shockable cardiac arrests like ventricular fibrillation (Vf) or pulseless ventricular tachycardia (pVT), adrenaline should be administered after the third shock has been delivered and chest compressions have been resumed. The same dose of 1 mg can be given using the same concentration options as mentioned earlier.

      Subsequently, adrenaline should be administered every 3-5 minutes, alternating with chest compressions, without interrupting the compressions. The alpha-adrenergic effects of adrenaline cause constriction of blood vessels throughout the body, leading to increased pressures in the coronary and cerebral circulation.

      The beta-adrenergic effects of adrenaline have positive effects on the heart, increasing its contractility (inotropic) and heart rate (chronotropic), which may also enhance blood flow to the coronary and cerebral arteries. However, it is important to note that these benefits may be counteracted by increased oxygen consumption by the heart, the potential for abnormal heart rhythms, temporary decrease in oxygen levels due to abnormal blood flow in the lungs, impaired microcirculation, and increased dysfunction of the heart after the cardiac arrest.

      While there is no evidence supporting the long-term benefits of adrenaline use in cardiac arrest cases, some studies have shown improved short-term survival rates, which justifies its continued use.

    • This question is part of the following fields:

      • Cardiology
      24
      Seconds
  • Question 2 - A 45-year-old woman comes in with central chest pain that is spreading to...

    Incorrect

    • A 45-year-old woman comes in with central chest pain that is spreading to her left arm for the past 30 minutes. Her vital signs are as follows: heart rate of 80 beats per minute, blood pressure of 118/72, and oxygen saturation of 98% on room air. The ECG shows the following findings:
      ST depression in leads V1-V4 and aVR
      ST elevation in V5-V6, II, III, and aVF
      Positive R wave in V1 and V2
      What is the most likely diagnosis in this case?

      Your Answer: Acute inferior myocardial ischaemia

      Correct Answer: Acute inferoposterior myocardial infarction

      Explanation:

      The ECG shows the following findings:
      – There is ST depression in leads V1-V4 and aVR.
      – There is ST elevation in leads V5-V6, II, III, and aVF.
      – There is a positive R wave in leads V1 and V2, which indicates a reverse Q wave.
      These ECG changes indicate that there is an acute inferoposterior myocardial infarction.

    • This question is part of the following fields:

      • Cardiology
      64
      Seconds
  • Question 3 - A 42-year-old man presents with central chest pain that has been present for...

    Correct

    • A 42-year-old man presents with central chest pain that has been present for the past three days. The pain is worsened by deep inspiration and lying flat and relieved by sitting forwards. He recently returned from a vacation in Spain, which involved a short flight. He has no significant medical history but smokes 15 cigarettes per day. His father died from a heart attack at the age of 58. His vital signs are as follows: HR 102, BP 128/72, temperature 37.1oC, SaO2 96% on room air. His ECG shows widespread concave ST elevation and PR depression.
      What is the SINGLE most likely diagnosis?

      Your Answer: Pericarditis

      Explanation:

      Pericarditis refers to the inflammation of the pericardium, which can be caused by various factors such as infections (typically viral, like coxsackie virus), drug-induced reactions (e.g. isoniazid, cyclosporine), trauma, autoimmune conditions (e.g. SLE), paraneoplastic syndromes, uremia, post myocardial infarction (known as Dressler’s syndrome), post radiotherapy, and post cardiac surgery.

      The clinical presentation of pericarditis often includes retrosternal chest pain that worsens with lying flat and improves when sitting forwards, along with shortness of breath, rapid heartbeat, and the presence of a pericardial friction rub.

      Characteristic electrocardiogram (ECG) changes associated with pericarditis typically show widespread concave or ‘saddle-shaped’ ST elevation, widespread PR depression, reciprocal ST depression and PR elevation in aVR (and sometimes V1), and sinus tachycardia is commonly observed.

    • This question is part of the following fields:

      • Cardiology
      26.5
      Seconds
  • Question 4 - A 68 year old male is brought to the emergency department by a...

    Incorrect

    • A 68 year old male is brought to the emergency department by a concerned coworker who noticed that the patient seemed unsteady on his feet and very short of breath when walking to his car. The patient tells you they usually feel a bit short of breath when doing things like walking to their car or going up the stairs. On examination you note a regular pulse, rate 88 bpm, but an audible ejection systolic murmur loudest at the left sternal edge. Blood pressure is 148/94 mmHg. What is the likely diagnosis?

      Your Answer: Mitral stenosis

      Correct Answer: Aortic stenosis

      Explanation:

      Severe aortic stenosis (AS) is characterized by several distinct features. These include a slow rising pulse, an ejection systolic murmur that is heard loudest in the aortic area and may radiate to the carotids, and a soft or absent S2 heart sound. Additionally, patients with severe AS often have a narrow pulse pressure and may exhibit an S4 heart sound.

      AS is commonly caused by hypertension, although blood pressure findings can vary. In severe cases, patients may actually be hypotensive due to impaired cardiac output. Symptoms of severe AS typically include Presyncope or syncope, exertional chest pain, and shortness of breath. These symptoms can be remembered using the acronym SAD (Syncope, Angina, Dyspnoea).

      It is important to note that aortic stenosis primarily affects older individuals, as it is a result of scarring and calcium buildup in the valve. Age-related AS typically begins after the age of 60, but symptoms may not appear until patients are in their 70s or 80s.

      Diastolic murmurs, on the other hand, are associated with conditions such as aortic regurgitation, pulmonary regurgitation, and mitral stenosis.

      Further Reading:

      Valvular heart disease refers to conditions that affect the valves of the heart. In the case of aortic valve disease, there are two main conditions: aortic regurgitation and aortic stenosis.

      Aortic regurgitation is characterized by an early diastolic murmur, a collapsing pulse (also known as a water hammer pulse), and a wide pulse pressure. In severe cases, there may be a mid-diastolic Austin-Flint murmur due to partial closure of the anterior mitral valve cusps caused by the regurgitation streams. The first and second heart sounds (S1 and S2) may be soft, and S2 may even be absent. Additionally, there may be a hyperdynamic apical pulse. Causes of aortic regurgitation include rheumatic fever, infective endocarditis, connective tissue diseases like rheumatoid arthritis and systemic lupus erythematosus, and a bicuspid aortic valve. Aortic root diseases such as aortic dissection, spondyloarthropathies like ankylosing spondylitis, hypertension, syphilis, and genetic conditions like Marfan’s syndrome and Ehler-Danlos syndrome can also lead to aortic regurgitation.

      Aortic stenosis, on the other hand, is characterized by a narrow pulse pressure, a slow rising pulse, and a delayed ESM (ejection systolic murmur). The second heart sound (S2) may be soft or absent, and there may be an S4 (atrial gallop) that occurs just before S1. A thrill may also be felt. The duration of the murmur is an important factor in determining the severity of aortic stenosis. Causes of aortic stenosis include degenerative calcification (most common in older patients), a bicuspid aortic valve (most common in younger patients), William’s syndrome (supravalvular aortic stenosis), post-rheumatic disease, and subvalvular conditions like hypertrophic obstructive cardiomyopathy (HOCM).

      Management of aortic valve disease depends on the severity of symptoms. Asymptomatic patients are generally observed, while symptomatic patients may require valve replacement. Surgery may also be considered for asymptomatic patients with a valvular gradient greater than 40 mmHg and features such as left ventricular systolic dysfunction. Balloon valvuloplasty is limited to patients with critical aortic stenosis who are not fit for valve replacement.

    • This question is part of the following fields:

      • Cardiology
      89.7
      Seconds
  • Question 5 - A 42 year old male comes to the emergency department with a sudden...

    Correct

    • A 42 year old male comes to the emergency department with a sudden onset of 'tearing' pain in the middle of his chest that extends to the center of his back. The patient is tall and has a slender physique. Additionally, you observe that the patient has elongated arms and fingers. During the chest examination, you notice a prominent protrusion of the sternum (pectus carinatum). What is the probable underlying cause of this patient's chest pain?

      Your Answer: Aortic dissection

      Explanation:

      Marfan’s syndrome is a condition that greatly increases the risk of aortic dissection. This patient exhibits several characteristics commonly seen in individuals with Marfan syndrome, such as tall stature, low BMI, and pectoral abnormalities like pectus carinatum and excavatum. Additionally, their long limbs and fingers are also indicative of Marfan’s syndrome. It is important to note that aortic dissection tends to occur at a much younger age in individuals with Marfan syndrome compared to those without connective tissue diseases. The median age for type A dissection in Marfan’s patients is 36.7 years, while for type B dissection it is 40 years. In contrast, individuals without Marfan’s syndrome typically experience dissection at the ages of 63 and 62 years for type A and type B dissections, respectively.

      Further Reading:

      Aortic dissection is a life-threatening condition in which blood flows through a tear in the innermost layer of the aorta, creating a false lumen. Prompt treatment is necessary as the mortality rate increases by 1-2% per hour. There are different classifications of aortic dissection, with the majority of cases being proximal. Risk factors for aortic dissection include hypertension, atherosclerosis, connective tissue disorders, family history, and certain medical procedures.

      The presentation of aortic dissection typically includes sudden onset sharp chest pain, often described as tearing or ripping. Back pain and abdominal pain are also common, and the pain may radiate to the neck and arms. The clinical picture can vary depending on which aortic branches are affected, and complications such as organ ischemia, limb ischemia, stroke, myocardial infarction, and cardiac tamponade may occur. Common signs and symptoms include a blood pressure differential between limbs, pulse deficit, and a diastolic murmur.

      Various investigations can be done to diagnose aortic dissection, including ECG, CXR, and CT with arterial contrast enhancement (CTA). CT is the investigation of choice due to its accuracy in diagnosis and classification. Other imaging techniques such as transoesophageal echocardiography (TOE), magnetic resonance imaging/angiography (MRI/MRA), and digital subtraction angiography (DSA) are less commonly used.

      Management of aortic dissection involves pain relief, resuscitation measures, blood pressure control, and referral to a vascular or cardiothoracic team. Opioid analgesia should be given for pain relief, and resuscitation measures such as high flow oxygen and large bore IV access should be performed. Blood pressure control is crucial, and medications such as labetalol may be used to reduce systolic blood pressure. Hypotension carries a poor prognosis and may require careful fluid resuscitation. Treatment options depend on the type of dissection, with type A dissections typically requiring urgent surgery and type B dissections managed by thoracic endovascular aortic repair (TEVAR) and blood pressure control optimization.

    • This question is part of the following fields:

      • Cardiology
      37.7
      Seconds
  • Question 6 - You are asked to assess an older patient who has fainted. They have...

    Incorrect

    • You are asked to assess an older patient who has fainted. They have a bradyarrhythmia evident on their ECG, and you determine to administer a dose of atropine.
      Which ONE statement about the use of atropine is accurate?

      Your Answer: It acts as an agonist to the action of acetylcholine

      Correct Answer: It blocks the effects of the vagus nerve on both the SA and AV nodes

      Explanation:

      Atropine acts as an antagonist to the parasympathetic neurotransmitter acetylcholine at muscarinic receptors. This means that it blocks the effects of the vagus nerve on both the SA node and the AV node, resulting in increased sinus automaticity and improved AV node conduction.

      The side effects of atropine are dependent on the dosage and may include dry mouth, nausea and vomiting, blurred vision, urinary retention, and tachyarrhythmias. Elderly patients may also experience acute confusion and hallucinations.

      Atropine is recommended for use in cases of sinus, atrial, or nodal bradycardia or AV block when the patient’s hemodynamic condition is unstable due to the bradycardia. According to the ALS bradycardia algorithm, an initial dose of 500 mcg IV is suggested if any adverse features such as shock, syncope, myocardial ischemia, or heart failure are present. If this initial dose is unsuccessful, additional 500 mcg doses can be administered at 3-5 minute intervals, with a maximum dose of 3 mg. It is important to avoid doses exceeding 3 mg as they can paradoxically slow the heart rate.

      Asystole during cardiac arrest is typically caused by primary myocardial pathology rather than excessive vagal tone. Therefore, there is no evidence supporting the routine use of atropine in the treatment of asystole or PEA. Consequently, atropine is no longer included in the non-shockable part of the ALS algorithm.

      Aside from its use in cardiac conditions, atropine also has other applications. It can be used topically in the eyes as a cycloplegic and mydriatic, to reduce secretions during anesthesia, and in the treatment of organophosphate poisoning.

    • This question is part of the following fields:

      • Cardiology
      26.9
      Seconds
  • Question 7 - A 58-year-old woman presents with abrupt intense chest discomfort that extends to her...

    Incorrect

    • A 58-year-old woman presents with abrupt intense chest discomfort that extends to her back. She is perspiring and experiencing nausea. During the examination, her blood pressure measures 176/96 in her right arm and 143/78 in her left arm. An early diastolic murmur is audible upon auscultation.

      What is the SINGLE most probable diagnosis?

      Your Answer: Aortic aneurysm

      Correct Answer: Aortic dissection

      Explanation:

      Acute aortic dissection is characterized by the rapid formation of a false, blood-filled channel within the middle layer of the aorta. It is estimated to occur in 3 out of every 100,000 individuals per year.

      Patients with aortic dissection typically experience intense chest pain that spreads to the area between the shoulder blades. The pain is often described as tearing or ripping and may also extend to the neck. Sweating, paleness, and rapid heartbeat are commonly observed at the time of presentation. Other possible symptoms include focal neurological deficits, weak pulses, fainting, and reduced blood flow to organs.

      A significant difference in blood pressure between the arms, greater than 20 mmHg, is a highly sensitive indicator. If the dissection extends backward, it can involve the aortic valve, leading to the early diastolic murmur of aortic regurgitation.

      Risk factors for aortic dissection include hypertension, atherosclerosis, aortic coarctation, the use of sympathomimetic drugs like cocaine, Marfan syndrome, Ehlers-Danlos syndrome, Turner’s syndrome, tertiary syphilis, and pre-existing aortic aneurysm.

      Aortic dissection can be classified according to the Stanford classification system:
      – Type A affects the ascending aorta and the arch, accounting for 60% of cases. These cases are typically managed surgically and may result in the blockage of coronary arteries and aortic regurgitation.
      – Type B begins distal to the left subclavian artery and accounts for approximately 40% of cases. These cases are usually managed with medication to control blood pressure.

    • This question is part of the following fields:

      • Cardiology
      25.6
      Seconds
  • Question 8 - A 67 year old female attends the emergency department complaining of palpitations. The...

    Incorrect

    • A 67 year old female attends the emergency department complaining of palpitations. The patient reports experiencing brief episodes of palpitations over the past few weeks, but they usually resolve themselves after 5-10 minutes. However, today's episode has been ongoing for 30 minutes. The patient denies any chest pain or shortness of breath. She is currently taking aspirin 75mg once daily as her only medication. Blood tests are conducted, and the results are as follows:

      Hemoglobin (Hb): 115 g/l
      Platelets: 155 * 109/l
      White blood cells (WBC): 6.4 * 109/l
      Sodium: 138 mmol/l
      Potassium: 3.8 mmol/l
      Urea: 4.1 mmol/l
      Creatinine: 74 µmol/l
      Glomerular filtration rate (GFR): 68 mL/min/1.73m2

      An electrocardiogram (ECG) is performed, revealing atrial fibrillation. You decide to assess the patient's bleeding risk using the ORBIT tool. What is this patient's ORBIT score?

      Your Answer: 1

      Correct Answer: 3

      Explanation:

      Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting around 5% of patients over the age of 70-75 years and 10% of patients aged 80-85 years. While AF can cause palpitations and inefficient cardiac function, the most important aspect of managing patients with AF is reducing the increased risk of stroke.

      AF can be classified as first detected episode, paroxysmal, persistent, or permanent. First detected episode refers to the initial occurrence of AF, regardless of symptoms or duration. Paroxysmal AF occurs when a patient has 2 or more self-terminating episodes lasting less than 7 days. Persistent AF refers to episodes lasting more than 7 days that do not self-terminate. Permanent AF is continuous atrial fibrillation that cannot be cardioverted or if attempts to do so are deemed inappropriate. The treatment goals for permanent AF are rate control and anticoagulation if appropriate.

      Symptoms of AF include palpitations, dyspnea, and chest pain. The most common sign is an irregularly irregular pulse. An electrocardiogram (ECG) is essential for diagnosing AF, as other conditions can also cause an irregular pulse.

      Managing patients with AF involves two key parts: rate/rhythm control and reducing stroke risk. Rate control involves slowing down the irregular pulse to avoid negative effects on cardiac function. This is typically achieved using beta-blockers or rate-limiting calcium channel blockers. If one drug is not effective, combination therapy may be used. Rhythm control aims to restore and maintain normal sinus rhythm through pharmacological or electrical cardioversion. However, the majority of patients are managed with a rate control strategy.

      Reducing stroke risk in patients with AF is crucial. Risk stratifying tools, such as the CHA2DS2-VASc score, are used to determine the most appropriate anticoagulation strategy. Anticoagulation is recommended for patients with a score of 2 or more. Clinicians can choose between warfarin and novel oral anticoagulants (NOACs) for anticoagulation.

      Before starting anticoagulation, the patient’s bleeding risk should be assessed using tools like the HAS-BLED score or the ORBIT tool. These tools evaluate factors such as hypertension, abnormal renal or liver function, history of bleeding, age, and use of drugs that predispose to bleeding.

    • This question is part of the following fields:

      • Cardiology
      50.2
      Seconds
  • Question 9 - You conduct a cardiovascular examination on a 62-year-old man who complains of shortness...

    Incorrect

    • You conduct a cardiovascular examination on a 62-year-old man who complains of shortness of breath. He informs you that he has a known heart valve issue. During auscultation, you observe a significantly split second heart sound (S2).
      What is the most probable cause of this finding?

      Your Answer: Tricuspid stenosis

      Correct Answer: Mitral regurgitation

      Explanation:

      The second heart sound (S2) is created by vibrations produced when the aortic and pulmonary valves close. It marks the end of systole. It is normal to hear a split in the sound during inspiration.

      A loud S2 can be associated with certain conditions such as systemic hypertension (resulting in a loud A2), pulmonary hypertension (resulting in a loud P2), hyperdynamic states (like tachycardia, fever, or thyrotoxicosis), and atrial septal defect (which causes a loud P2).

      On the other hand, a soft S2 can be linked to decreased aortic diastolic pressure (as seen in aortic regurgitation), poorly mobile cusps (such as calcification of the aortic valve), aortic root dilatation, and pulmonary stenosis (which causes a soft P2).

      A widely split S2 can occur during deep inspiration, right bundle branch block, prolonged right ventricular systole (seen in conditions like pulmonary stenosis or pulmonary embolism), and severe mitral regurgitation. However, in the case of atrial septal defect, the splitting is fixed and does not vary with respiration.

      Reversed splitting of S2, where P2 occurs before A2 (paradoxical splitting), can occur during deep expiration, left bundle branch block, prolonged left ventricular systole (as seen in hypertrophic cardiomyopathy), severe aortic stenosis, and right ventricular pacing.

    • This question is part of the following fields:

      • Cardiology
      51.1
      Seconds
  • Question 10 - A 70-year-old diabetic smoker presents with central chest pain that radiates to his...

    Incorrect

    • A 70-year-old diabetic smoker presents with central chest pain that radiates to his left shoulder and jaw. He is given 300 mg aspirin and morphine, and his pain subsides. The pain lasted approximately 90 minutes in total. His ECG shows normal sinus rhythm. He is referred to the on-call medical team for admission, and a troponin test is scheduled at the appropriate time. His blood tests today reveal a creatinine level of 298 micromoles per litre.
      Which of the following medications should you also consider administering to this patient?

      Your Answer: Fondaparinux

      Correct Answer: Unfractionated heparin

      Explanation:

      This patient’s medical history suggests a diagnosis of acute coronary syndrome. It is important to provide pain relief as soon as possible. This can be achieved by administering GTN (sublingual or buccal), but if there is suspicion of an acute myocardial infarction (MI), intravenous opioids such as morphine should be offered.

      Aspirin should be given to all patients with unstable angina or NSTEMI as soon as possible and should be continued indefinitely, unless there are contraindications such as a high risk of bleeding or aspirin hypersensitivity. A single loading dose of 300 mg should be given immediately after presentation.

      For patients without a high risk of bleeding and no planned coronary angiography within 24 hours of admission, fondaparinux should be administered. However, if coronary angiography is planned within 24 hours, unfractionated heparin can be offered as an alternative to fondaparinux. For patients with significant renal impairment (creatinine above 265 micromoles per litre), unfractionated heparin should be considered, with dose adjustment based on clotting function monitoring.

      Routine administration of oxygen is no longer recommended, but oxygen saturation should be monitored using pulse oximetry as soon as possible, preferably before hospital admission. Supplemental oxygen should only be given to individuals with an oxygen saturation (SpO2) below 94% who are not at risk of hypercapnic respiratory failure, aiming for an SpO2 of 94-98%. For individuals with chronic obstructive pulmonary disease at risk of hypercapnic respiratory failure, a target SpO2 of 88-92% should be achieved until blood gas analysis is available.

      Bivalirudin, a specific and reversible direct thrombin inhibitor (DTI), is recommended by NICE as a potential treatment for adults with STEMI undergoing percutaneous coronary intervention.

      For more information, refer to the NICE guidelines on the assessment and diagnosis of chest pain of recent onset.

    • This question is part of the following fields:

      • Cardiology
      70.4
      Seconds
  • Question 11 - A 37 year old female presents to the emergency department complaining of shortness...

    Incorrect

    • A 37 year old female presents to the emergency department complaining of shortness of breath and chest pain in the center of her chest. Upon further questioning, the patient reveals that she experienced muscle pain, gastrointestinal issues, a mild fever, and fatigue for approximately three days about a week ago. She informs you that she is typically in good health and regularly runs 5-10km two to three times per week. The patient has no significant medical history, does not take any medications on a regular basis, has never smoked, and does not consume alcohol. Given the patient's symptoms, you suspect the possibility of myocarditis. Which of the following sets of blood test results would be expected in a patient with myocarditis?

      Your Answer: creatine kinase: normal, troponin I: elevated, BNP: elevated

      Correct Answer: creatine kinase: elevated, troponin I: elevated, BNP: elevated

      Explanation:

      In cases of myocarditis, levels of cardiac muscle enzymes (CK-MB, Troponin I, and Troponin T) and B-type natriuretic peptide (BNP) are usually elevated. It is important to note that CK-MB is a subtype of CK, so an increase in CK-MB will also result in an increase in total CK levels. This poses a challenge in differentiating myocarditis from coronary artery disease in the emergency department. Typically, a definitive diagnosis is not made until the patient undergoes additional tests such as angiography and possibly endomyocardial biopsy (EMB).

      Further Reading:

      Myocarditis is inflammation of the myocardium, the middle layer of the heart wall, that is not caused by a blockage in the coronary arteries. It can be caused by various factors, including infections (such as viruses, bacteria, parasites, and fungi), immune reactions, toxins, physical injury, and certain medications or vaccines. Coxsackie virus is the most common cause of myocarditis in Europe and the USA, while globally, Trypanosoma cruzi, which causes Chagas disease, is the most common cause.

      The symptoms of myocarditis can vary widely and often resemble those of heart failure or coronary heart disease. Common symptoms include chest pain, palpitations, breathlessness, fatigue, and swelling. The clinical presentation can also be influenced by the underlying cause of the inflammation. Diagnosis of myocarditis is challenging as there is no specific clinical presentation, and the gold standard test, endomyocardial biopsy, is not readily available in emergency departments.

      Various tests can be performed to aid in the diagnosis of myocarditis, including electrocardiogram (ECG), chest X-ray, cardiac enzymes (such as troponin or CK-MB), brain natriuretic peptide (BNP) levels, and echocardiogram. These tests may show non-specific abnormalities, such as ST-segment and T-wave abnormalities on ECG, bilateral pulmonary infiltrates on chest X-ray, elevated cardiac enzymes and BNP levels, and left ventricular motion abnormalities on echocardiogram.

      Management of myocarditis is primarily supportive, focusing on treating cardiac failure and addressing the underlying cause. Supportive care and conventional heart failure therapy, such as ACE inhibitors or angiotensin II receptor blockers, vasodilators, beta-blockers, and diuretics, may be used to improve cardiac function and reduce symptoms. Treatment of the underlying cause, such as antiparasitic agents for Chagas disease or antibiotics for bacterial infections, may also be necessary. In severe cases leading to cardiogenic shock, more aggressive treatment with invasive monitoring, inotropes, vasopressors, and potentially heart transplantation may be required.

      In summary, myocarditis is inflammation of the myocardium that can be caused by various factors. It presents with a wide range of symptoms and can be challenging to diagnose. Management involves supportive care, treatment of cardiac failure, and addressing the underlying cause. Severe cases may require more aggressive treatment and potentially heart transplantation.

    • This question is part of the following fields:

      • Cardiology
      69.5
      Seconds
  • Question 12 - A 55-year-old male with a past medical history of high blood pressure arrives...

    Correct

    • A 55-year-old male with a past medical history of high blood pressure arrives at the emergency department complaining of sudden chest and interscapular pain that feels like tearing. You suspect aortic dissection. Which of the following signs and symptoms aligns with the diagnosis of aortic dissection?

      Your Answer: Blood pressure differential of more than 10 mmHg between left and right arms

      Explanation:

      A significant proportion of the population experiences a difference of 10 mmHg or more in blood pressure between their upper limbs. Pericarditis can be identified by the presence of saddle-shaped ST elevation and pain in the trapezius ridge. Aortic dissection is characterized by a diastolic murmur with a decrescendo pattern, which indicates aortic incompetence.

      Further Reading:

      Aortic dissection is a life-threatening condition in which blood flows through a tear in the innermost layer of the aorta, creating a false lumen. Prompt treatment is necessary as the mortality rate increases by 1-2% per hour. There are different classifications of aortic dissection, with the majority of cases being proximal. Risk factors for aortic dissection include hypertension, atherosclerosis, connective tissue disorders, family history, and certain medical procedures.

      The presentation of aortic dissection typically includes sudden onset sharp chest pain, often described as tearing or ripping. Back pain and abdominal pain are also common, and the pain may radiate to the neck and arms. The clinical picture can vary depending on which aortic branches are affected, and complications such as organ ischemia, limb ischemia, stroke, myocardial infarction, and cardiac tamponade may occur. Common signs and symptoms include a blood pressure differential between limbs, pulse deficit, and a diastolic murmur.

      Various investigations can be done to diagnose aortic dissection, including ECG, CXR, and CT with arterial contrast enhancement (CTA). CT is the investigation of choice due to its accuracy in diagnosis and classification. Other imaging techniques such as transoesophageal echocardiography (TOE), magnetic resonance imaging/angiography (MRI/MRA), and digital subtraction angiography (DSA) are less commonly used.

      Management of aortic dissection involves pain relief, resuscitation measures, blood pressure control, and referral to a vascular or cardiothoracic team. Opioid analgesia should be given for pain relief, and resuscitation measures such as high flow oxygen and large bore IV access should be performed. Blood pressure control is crucial, and medications such as labetalol may be used to reduce systolic blood pressure. Hypotension carries a poor prognosis and may require careful fluid resuscitation. Treatment options depend on the type of dissection, with type A dissections typically requiring urgent surgery and type B dissections managed by thoracic endovascular aortic repair (TEVAR) and blood pressure control optimization.

    • This question is part of the following fields:

      • Cardiology
      38.5
      Seconds
  • Question 13 - A 45 year old female comes to the emergency department with abrupt onset...

    Correct

    • A 45 year old female comes to the emergency department with abrupt onset tearing chest pain that spreads to the throat and back. You contemplate the likelihood of aortic dissection. What is the predominant risk factor observed in individuals with aortic dissection?

      Your Answer: Hypertension

      Explanation:

      Aortic dissection is a condition that occurs when the middle layer of the aorta, known as the tunica media, becomes weakened. This weakening leads to the development of cases of aortic dissection.

      Further Reading:

      Aortic dissection is a life-threatening condition in which blood flows through a tear in the innermost layer of the aorta, creating a false lumen. Prompt treatment is necessary as the mortality rate increases by 1-2% per hour. There are different classifications of aortic dissection, with the majority of cases being proximal. Risk factors for aortic dissection include hypertension, atherosclerosis, connective tissue disorders, family history, and certain medical procedures.

      The presentation of aortic dissection typically includes sudden onset sharp chest pain, often described as tearing or ripping. Back pain and abdominal pain are also common, and the pain may radiate to the neck and arms. The clinical picture can vary depending on which aortic branches are affected, and complications such as organ ischemia, limb ischemia, stroke, myocardial infarction, and cardiac tamponade may occur. Common signs and symptoms include a blood pressure differential between limbs, pulse deficit, and a diastolic murmur.

      Various investigations can be done to diagnose aortic dissection, including ECG, CXR, and CT with arterial contrast enhancement (CTA). CT is the investigation of choice due to its accuracy in diagnosis and classification. Other imaging techniques such as transoesophageal echocardiography (TOE), magnetic resonance imaging/angiography (MRI/MRA), and digital subtraction angiography (DSA) are less commonly used.

      Management of aortic dissection involves pain relief, resuscitation measures, blood pressure control, and referral to a vascular or cardiothoracic team. Opioid analgesia should be given for pain relief, and resuscitation measures such as high flow oxygen and large bore IV access should be performed. Blood pressure control is crucial, and medications such as labetalol may be used to reduce systolic blood pressure. Hypotension carries a poor prognosis and may require careful fluid resuscitation. Treatment options depend on the type of dissection, with type A dissections typically requiring urgent surgery and type B dissections managed by thoracic endovascular aortic repair (TEVAR) and blood pressure control optimization.

    • This question is part of the following fields:

      • Cardiology
      59.6
      Seconds
  • Question 14 - You are summoned to a cardiac arrest in the resuscitation area of your...

    Incorrect

    • You are summoned to a cardiac arrest in the resuscitation area of your Emergency Department.
      Which ONE statement about the utilization of amiodarone in cardiac arrest is accurate?

      Your Answer: It is indicated in PEA arrests

      Correct Answer: It increases the duration of the action potential

      Explanation:

      Amiodarone is a medication that is recommended to be administered after the third shock in a shockable cardiac arrest (Vf/pVT) while chest compressions are being performed. The prescribed dose is 300 mg, given as an intravenous bolus that is diluted in 5% dextrose to a volume of 20 mL. It is important to note that amiodarone is not suitable for treating PEA or asystole.

      In cases where VF/pVT persists after five defibrillation attempts, an additional dose of 150 mg of amiodarone should be given. However, if amiodarone is not available, lidocaine can be used as an alternative. The recommended dose of lidocaine is 1 mg/kg. It is crucial to avoid administering lidocaine if amiodarone has already been given.

      Amiodarone is classified as a membrane-stabilizing antiarrhythmic drug. It works by prolonging the duration of the action potential and the refractory period in both the atrial and ventricular myocardium. This medication also slows down atrioventricular conduction and has a similar effect on accessory pathways.

      Additionally, amiodarone has a mild negative inotropic action, meaning it weakens the force of heart contractions. It also causes peripheral vasodilation through non-competitive alpha-blocking effects.

      It is important to note that while there is no evidence of long-term benefits from using amiodarone, it may improve short-term survival rates, which justifies its continued use.

    • This question is part of the following fields:

      • Cardiology
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  • Question 15 - You conduct a cardiovascular examination on a 72-year-old man who complains of difficulty...

    Incorrect

    • You conduct a cardiovascular examination on a 72-year-old man who complains of difficulty breathing. He informs you that he has a known heart valve issue. During the examination, you observe a pronounced first heart sound (S1).
      What is the most probable cause of this finding?

      Your Answer: Mitral regurgitation

      Correct Answer: Mitral stenosis

      Explanation:

      The first heart sound (S1) is created by vibrations produced when the mitral and tricuspid valves close. It occurs at the end of diastole and the start of ventricular systole, coming before the upstroke of the carotid pulsation.

      A sample of the normal heart sounds can be listened to here (courtesy of Littman stethoscopes).

      A loud S1 can be associated with the following conditions:
      – Increased transvalvular gradient (e.g. mitral stenosis, tricuspid stenosis)
      – Increased force of ventricular contraction (e.g. tachycardia, hyperdynamic states like fever and thyrotoxicosis)
      – Shortened PR interval (e.g. Wolff-Parkinson-White syndrome)
      – Mitral valve prolapse
      – Thin individuals

      A soft S1 can be associated with the following conditions:
      – Inappropriate apposition of the AV valves (e.g. mitral regurgitation, tricuspid regurgitation)
      – Prolonged PR interval (e.g. heart block, digoxin toxicity)
      – Decreased force of ventricular contraction (e.g. myocarditis, myocardial infarction)
      – Increased distance from the heart (e.g. obesity, emphysema, pericardial effusion)

      A split S1 can be associated with the following conditions:
      – Right bundle branch block
      – LV pacing
      – Ebstein anomaly

    • This question is part of the following fields:

      • Cardiology
      37.6
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  • Question 16 - A 48 year old woman comes to the emergency department complaining of episodes...

    Incorrect

    • A 48 year old woman comes to the emergency department complaining of episodes of lightheadedness. She mentions that she is an avid jogger and noticed on her fitness tracker that her heart rate had dropped to 48 beats per minute. Which of the following characteristics would warrant drug intervention or transcutaneous pacing in a patient with bradycardia?

      Your Answer: Prolonged PR interval

      Correct Answer: Myocardial ischaemia

      Explanation:

      Indications for drug treatment or pacing in patients with bradycardia include shock, syncope, myocardial ischemia, heart failure, and the presence of risk factors for asystole. If any of these adverse features are present, it is important to consider drug treatment or pacing. However, even if none of these adverse features are present, patients may still require drug treatment or pacing if they have risk factors for developing asystole, such as recent asystole, Mobitz II AV block, complete heart block with broad QRS, or a ventricular pause longer than 3 seconds.

      Further Reading:

      Causes of Bradycardia:
      – Physiological: Athletes, sleeping
      – Cardiac conduction dysfunction: Atrioventricular block, sinus node disease
      – Vasovagal & autonomic mediated: Vasovagal episodes, carotid sinus hypersensitivity
      – Hypothermia
      – Metabolic & electrolyte disturbances: Hypothyroidism, hyperkalaemia, hypermagnesemia
      – Drugs: Beta-blockers, calcium channel blockers, digoxin, amiodarone
      – Head injury: Cushing’s response
      – Infections: Endocarditis
      – Other: Sarcoidosis, amyloidosis

      Presenting symptoms of Bradycardia:
      – Presyncope (dizziness, lightheadedness)
      – Syncope
      – Breathlessness
      – Weakness
      – Chest pain
      – Nausea

      Management of Bradycardia:
      – Assess and monitor for adverse features (shock, syncope, myocardial ischaemia, heart failure)
      – Treat reversible causes of bradycardia
      – Pharmacological treatment: Atropine is first-line, adrenaline and isoprenaline are second-line
      – Transcutaneous pacing if atropine is ineffective
      – Other drugs that may be used: Aminophylline, dopamine, glucagon, glycopyrrolate

      Bradycardia Algorithm:
      – Follow the algorithm for management of bradycardia, which includes assessing and monitoring for adverse features, treating reversible causes, and using appropriate medications or pacing as needed.
      https://acls-algorithms.com/wp-content/uploads/2020/12/Website-Bradycardia-Algorithm-Diagram.pdf

    • This question is part of the following fields:

      • Cardiology
      46.8
      Seconds
  • Question 17 - A 72 year old male presents with central chest pain radiating to the...

    Incorrect

    • A 72 year old male presents with central chest pain radiating to the jaw and left arm. The patient is sweating profusely and appears pale. The pain began 4 hours ago. ECG reveals 2-3 mm ST elevation in leads II, III and aVF. 300 mg aspirin has been administered. Transporting the patient to the nearest coronary catheter lab for primary PCI will take 2 hours 45 minutes. What is the most suitable course of action for managing this patient?

      Your Answer: Administer clopidogrel and transfer for PCI

      Correct Answer: Administer fibrinolysis

      Explanation:

      Fibrinolysis is a treatment option for patients with ST-elevation myocardial infarction (STEMI) if they are unable to receive primary percutaneous coronary intervention (PCI) within 120 minutes, but fibrinolysis can be administered within that time frame. Primary PCI is the preferred treatment for STEMI patients who present within 12 hours of symptom onset. However, if primary PCI cannot be performed within 120 minutes of the time when fibrinolysis could have been given, fibrinolysis should be considered. Along with fibrinolysis, an antithrombin medication such as unfractionated heparin (UFH), low molecular weight heparin (LMWH), fondaparinux, or bivalirudin is typically administered.

      Further Reading:

      Acute Coronary Syndromes (ACS) is a term used to describe a group of conditions that involve the sudden reduction or blockage of blood flow to the heart. This can lead to a heart attack or unstable angina. ACS includes ST segment elevation myocardial infarction (STEMI), non-ST segment elevation myocardial infarction (NSTEMI), and unstable angina (UA).

      The development of ACS is usually seen in patients who already have underlying coronary heart disease. This disease is characterized by the buildup of fatty plaques in the walls of the coronary arteries, which can gradually narrow the arteries and reduce blood flow to the heart. This can cause chest pain, known as angina, during physical exertion. In some cases, the fatty plaques can rupture, leading to a complete blockage of the artery and a heart attack.

      There are both non modifiable and modifiable risk factors for ACS. non modifiable risk factors include increasing age, male gender, and family history. Modifiable risk factors include smoking, diabetes mellitus, hypertension, hypercholesterolemia, and obesity.

      The symptoms of ACS typically include chest pain, which is often described as a heavy or constricting sensation in the central or left side of the chest. The pain may also radiate to the jaw or left arm. Other symptoms can include shortness of breath, sweating, and nausea/vomiting. However, it’s important to note that some patients, especially diabetics or the elderly, may not experience chest pain.

      The diagnosis of ACS is typically made based on the patient’s history, electrocardiogram (ECG), and blood tests for cardiac enzymes, specifically troponin. The ECG can show changes consistent with a heart attack, such as ST segment elevation or depression, T wave inversion, or the presence of a new left bundle branch block. Elevated troponin levels confirm the diagnosis of a heart attack.

      The management of ACS depends on the specific condition and the patient’s risk factors. For STEMI, immediate coronary reperfusion therapy, either through primary percutaneous coronary intervention (PCI) or fibrinolysis, is recommended. In addition to aspirin, a second antiplatelet agent is usually given. For NSTEMI or unstable angina, the treatment approach may involve reperfusion therapy or medical management, depending on the patient’s risk of future cardiovascular events.

    • This question is part of the following fields:

      • Cardiology
      56.3
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  • Question 18 - A 35-year-old male presents to the emergency department complaining of gradual onset sharp...

    Correct

    • A 35-year-old male presents to the emergency department complaining of gradual onset sharp chest pain over the past 24 hours. The patient reports that the pain worsens with deep inspiration and feels more comfortable when sitting leaning forward. When asked about pain radiation, the patient confirms that the pain extends to the left side of the neck and points to the ridge of the trapezius. Physical examination reveals clear lung fields, regular rhythm with quiet heart sounds, and no murmurs. The patient's vital signs are as follows:

      Blood pressure: 108/66 mmHg
      Pulse rate: 94 bpm
      Respiratory rate: 18 rpm
      Temperature: 37.3ºC
      Oxygen saturations: 97% on room air

      What is the most likely diagnosis?

      Your Answer: Acute pericarditis

      Explanation:

      Radiation to the trapezius ridge is a distinct symptom of acute pericarditis. The patient in question exhibits characteristics that align with a diagnosis of pericarditis. Pericarditis is a common condition affecting the pericardium, and it is often considered as a potential cause for chest pain. It is worth noting that the specific radiation of pain to the trapezius ridge is highly indicative of pericarditis, as it occurs when the phrenic nerve, which also innervates the trapezius muscle, becomes irritated while passing through the pericardium.

      Further Reading:

      Pericarditis is an inflammation of the pericardium, which is the protective sac around the heart. It can be acute, lasting less than 6 weeks, and may present with chest pain, cough, dyspnea, flu-like symptoms, and a pericardial rub. The most common causes of pericarditis include viral infections, tuberculosis, bacterial infections, uremia, trauma, and autoimmune diseases. However, in many cases, the cause remains unknown. Diagnosis is based on clinical features, such as chest pain, pericardial friction rub, and electrocardiographic changes. Treatment involves symptom relief with nonsteroidal anti-inflammatory drugs (NSAIDs), and patients should avoid strenuous activity until symptoms improve. Complicated cases may require treatment for the underlying cause, and large pericardial effusions may need urgent drainage. In cases of purulent effusions, antibiotic therapy is necessary, and steroid therapy may be considered for pericarditis related to autoimmune disorders or if NSAIDs alone are ineffective.

    • This question is part of the following fields:

      • Cardiology
      33
      Seconds
  • Question 19 - You evaluate the ECG of a 62-year-old male who has come in with...

    Incorrect

    • You evaluate the ECG of a 62-year-old male who has come in with episodes of Presyncope. What is the most suitable threshold to utilize in differentiating between a normal and prolonged QTc?

      Your Answer: 550ms

      Correct Answer: 450 ms

      Explanation:

      An abnormal QTc, which is the measurement of the time it takes for the heart to recharge between beats, is generally considered to be greater than 450 ms in males. However, some sources may use a cutoff of greater than 440 ms as abnormal in males. To further categorize the QTc, a measurement of 430ms or less is considered normal, 431-450 ms is borderline, and 450 ms or more is considered abnormal in males. Females typically have a longer QTc, so the categories for them are often quoted as less than 450 ms being normal, 451-470 ms being borderline, and greater than 470ms being abnormal.

      Further Reading:

      Long QT syndrome (LQTS) is a condition characterized by a prolonged QT interval on an electrocardiogram (ECG), which represents abnormal repolarization of the heart. LQTS can be either acquired or congenital. Congenital LQTS is typically caused by gene abnormalities that affect ion channels responsible for potassium or sodium flow in the heart. There are 15 identified genes associated with congenital LQTS, with three genes accounting for the majority of cases. Acquired LQTS can be caused by various factors such as certain medications, electrolyte imbalances, hypothermia, hypothyroidism, and bradycardia from other causes.

      The normal QTc values, which represent the corrected QT interval for heart rate, are typically less than 450 ms for men and less than 460ms for women. Prolonged QTc intervals are considered to be greater than these values. It is important to be aware of drugs that can cause QT prolongation, as this can lead to potentially fatal arrhythmias. Some commonly used drugs that can cause QT prolongation include antimicrobials, antiarrhythmics, antipsychotics, antidepressants, antiemetics, and others.

      Management of long QT syndrome involves addressing any underlying causes and using beta blockers. In some cases, an implantable cardiac defibrillator (ICD) may be recommended for patients who have experienced recurrent arrhythmic syncope, documented torsades de pointes, previous ventricular tachyarrhythmias or torsades de pointes, previous cardiac arrest, or persistent syncope. Permanent pacing may be used in patients with bradycardia or atrioventricular nodal block and prolonged QT. Mexiletine is a treatment option for those with LQT3. Cervicothoracic sympathetic denervation may be considered in patients with recurrent syncope despite beta-blockade or in those who are not ideal candidates for an ICD. The specific treatment options for LQTS depend on the type and severity of the condition.

    • This question is part of the following fields:

      • Cardiology
      55.1
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  • Question 20 - A 72-year-old woman with a history of type II diabetes and hypertension presents...

    Incorrect

    • A 72-year-old woman with a history of type II diabetes and hypertension presents with a history of central chest pain that lasted approximately 45 minutes. Her ECG showed T wave inversion in the lateral leads, but her pain settled, and ECG normalized following the administration of GTN spray and IV morphine. She was also given 325 mg of aspirin on arrival. A troponin test has been organized and admission arranged.
      Which of the following medications should you also consider administering to this patient?

      Your Answer: Bivalirudin

      Correct Answer: Fondaparinux

      Explanation:

      This patient is likely experiencing an acute coronary syndrome, possibly a non-ST-elevation myocardial infarction (NSTEMI) or unstable angina. The troponin test will help confirm the diagnosis. The patient’s ECG showed ST depression in the inferior leads, but this normalized after treatment with GTN and morphine, ruling out a ST-elevation myocardial infarction (STEMI).

      Immediate pain relief should be provided. GTN (sublingual or buccal) can be used, but intravenous opioids like morphine should be considered, especially if a heart attack is suspected.

      Aspirin should be given to all patients with unstable angina or NSTEMI as soon as possible and continued indefinitely, unless there are contraindications like bleeding risk or aspirin hypersensitivity. A loading dose of 300 mg should be administered right after presentation.

      Fondaparinux should be given to patients without a high bleeding risk, unless coronary angiography is planned within 24 hours of admission. Unfractionated heparin can be an alternative to fondaparinux for patients who will undergo coronary angiography within 24 hours. For patients with significant renal impairment, unfractionated heparin can also be considered, with dose adjustment based on clotting function monitoring.

      Routine administration of oxygen is no longer recommended, but oxygen saturation should be monitored using pulse oximetry as soon as possible, preferably before hospital admission. Supplemental oxygen should only be offered to individuals with oxygen saturation (SpO2) below 94% who are not at risk of hypercapnic respiratory failure, aiming for a SpO2 of 94-98%. For individuals with chronic obstructive pulmonary disease at risk of hypercapnic respiratory failure, a target SpO2 of 88-92% should be achieved until blood gas analysis is available.

      Bivalirudin, a specific and reversible direct thrombin inhibitor (DTI), is recommended by NICE as a possible treatment for adults with STEMI undergoing percutaneous coronary intervention.

      For more information, refer to the NICE guidelines on the assessment and diagnosis of chest pain of recent onset.

    • This question is part of the following fields:

      • Cardiology
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  • Question 21 - A 72 year old male presents to the emergency department with central chest...

    Incorrect

    • A 72 year old male presents to the emergency department with central chest pain. After evaluating the patient and reviewing the tests, your consultant determines that the patient has unstable angina. Your consultant instructs you to contact the bed manager and arrange for the patient's admission. What crucial finding is necessary to establish the diagnosis of unstable angina?

      Your Answer: Chest pain that is heavy in nature

      Correct Answer: Normal troponin assay

      Explanation:

      Distinguishing between unstable angina and other acute coronary syndromes can be determined by normal troponin results. Unstable angina is characterized by new onset angina or a sudden worsening of previously stable angina, often occurring at rest. This condition typically requires hospital admission. On the other hand, stable angina is predictable and occurs during physical exertion or emotional stress, lasting for a short duration of no more than 10 minutes and relieved within minutes of rest or sublingual nitrates.

      To diagnose unstable angina, it is crucial to consider the nature of the chest pain and negative cardiac enzyme testing. The presence or absence of chest pain at rest and the response to rest and treatment with GTN are the most useful descriptors in distinguishing between stable and unstable angina. It is important to note that patients with unstable angina may not exhibit any changes on an electrocardiogram (ECG).

      If troponin results are abnormal, it indicates a myocardial infarction rather than unstable angina.

      Further Reading:

      Acute Coronary Syndromes (ACS) is a term used to describe a group of conditions that involve the sudden reduction or blockage of blood flow to the heart. This can lead to a heart attack or unstable angina. ACS includes ST segment elevation myocardial infarction (STEMI), non-ST segment elevation myocardial infarction (NSTEMI), and unstable angina (UA).

      The development of ACS is usually seen in patients who already have underlying coronary heart disease. This disease is characterized by the buildup of fatty plaques in the walls of the coronary arteries, which can gradually narrow the arteries and reduce blood flow to the heart. This can cause chest pain, known as angina, during physical exertion. In some cases, the fatty plaques can rupture, leading to a complete blockage of the artery and a heart attack.

      There are both non modifiable and modifiable risk factors for ACS. non modifiable risk factors include increasing age, male gender, and family history. Modifiable risk factors include smoking, diabetes mellitus, hypertension, hypercholesterolemia, and obesity.

      The symptoms of ACS typically include chest pain, which is often described as a heavy or constricting sensation in the central or left side of the chest. The pain may also radiate to the jaw or left arm. Other symptoms can include shortness of breath, sweating, and nausea/vomiting. However, it’s important to note that some patients, especially diabetics or the elderly, may not experience chest pain.

      The diagnosis of ACS is typically made based on the patient’s history, electrocardiogram (ECG), and blood tests for cardiac enzymes, specifically troponin. The ECG can show changes consistent with a heart attack, such as ST segment elevation or depression, T wave inversion, or the presence of a new left bundle branch block. Elevated troponin levels confirm the diagnosis of a heart attack.

      The management of ACS depends on the specific condition and the patient’s risk factors. For STEMI, immediate coronary reperfusion therapy, either through primary percutaneous coronary intervention (PCI) or fibrinolysis, is recommended. In addition to aspirin, a second antiplatelet agent is usually given. For NSTEMI or unstable angina, the treatment approach may involve reperfusion therapy or medical management, depending on the patient’s risk of future cardiovascular events.

    • This question is part of the following fields:

      • Cardiology
      70.7
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  • Question 22 - You are treating a 68 year old male who has been brought into...

    Correct

    • You are treating a 68 year old male who has been brought into the resuscitation bay by the ambulance crew. The patient was at home when he suddenly experienced dizziness and difficulty breathing. The ambulance crew presents the patient's ECG to you. You are considering administering atropine to address the patient's bradyarrhythmia. Which of the following statements is accurate regarding the use of atropine?

      Your Answer: Up to 6 doses of 500 mcg can be given every 3-5 minutes

      Explanation:

      When treating adults with bradycardia, it is recommended to administer a maximum of 6 doses of atropine 500 mcg. These doses can be repeated every 3-5 minutes. The total cumulative dose of atropine should not exceed 3 mg in adults.

      Further Reading:

      Causes of Bradycardia:
      – Physiological: Athletes, sleeping
      – Cardiac conduction dysfunction: Atrioventricular block, sinus node disease
      – Vasovagal & autonomic mediated: Vasovagal episodes, carotid sinus hypersensitivity
      – Hypothermia
      – Metabolic & electrolyte disturbances: Hypothyroidism, hyperkalaemia, hypermagnesemia
      – Drugs: Beta-blockers, calcium channel blockers, digoxin, amiodarone
      – Head injury: Cushing’s response
      – Infections: Endocarditis
      – Other: Sarcoidosis, amyloidosis

      Presenting symptoms of Bradycardia:
      – Presyncope (dizziness, lightheadedness)
      – Syncope
      – Breathlessness
      – Weakness
      – Chest pain
      – Nausea

      Management of Bradycardia:
      – Assess and monitor for adverse features (shock, syncope, myocardial ischaemia, heart failure)
      – Treat reversible causes of bradycardia
      – Pharmacological treatment: Atropine is first-line, adrenaline and isoprenaline are second-line
      – Transcutaneous pacing if atropine is ineffective
      – Other drugs that may be used: Aminophylline, dopamine, glucagon, glycopyrrolate

      Bradycardia Algorithm:
      – Follow the algorithm for management of bradycardia, which includes assessing and monitoring for adverse features, treating reversible causes, and using appropriate medications or pacing as needed.
      https://acls-algorithms.com/wp-content/uploads/2020/12/Website-Bradycardia-Algorithm-Diagram.pdf

    • This question is part of the following fields:

      • Cardiology
      151
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  • Question 23 - You evaluate a 62-year-old woman in the Emergency Room with intense central chest...

    Incorrect

    • You evaluate a 62-year-old woman in the Emergency Room with intense central chest discomfort. She is extremely worried as she experienced a heart attack (MI) 8 weeks ago. Today the pain is sharp and is alleviated by leaning forward. During the examination, her temperature is recorded as 37.9°C and she has pitting edema in both ankles. The ECG shows Q waves in the anterolateral leads.

      What is the MOST LIKELY diagnosis in this case?

      Your Answer: Cardiac tamponade

      Correct Answer: Dressler’s syndrome

      Explanation:

      Dressler’s syndrome is a form of pericarditis that occurs within 2 to 10 weeks following a heart attack or cardiac surgery. It is distinguished by intense chest pain that is usually alleviated by assuming an upright position. Additionally, individuals may experience a mild fever, a pericardial rub, pulsus paradoxus, and indications of right ventricular failure.

    • This question is part of the following fields:

      • Cardiology
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  • Question 24 - A 72 year old male comes to the emergency department complaining of sudden...

    Correct

    • A 72 year old male comes to the emergency department complaining of sudden difficulty breathing, heart palpitations, and a cough that produces pink frothy sputum. During the examination, you observe an irregular heart rhythm, crackling sounds in the lower parts of the lungs, a loud first heart sound, and a mid-late diastolic murmur. What is the probable diagnosis?

      Your Answer: Mitral stenosis

      Explanation:

      Mitral stenosis is a condition characterized by a narrowing of the mitral valve, which can lead to various symptoms. One common symptom is a mid-late diastolic murmur, which can be heard during a physical examination. This murmur may also be described as mid-diastolic, late-diastolic, or mid-late diastolic. Additionally, patients with chronic mitral stenosis may not experience any symptoms, and the murmur may only be detected incidentally.

      A significant risk associated with mitral stenosis is the development of atrial fibrillation (AF). When AF occurs in patients with mitral stenosis, it can trigger acute pulmonary edema. This happens because the left atrium, which is responsible for pumping blood across the narrowed mitral valve into the left ventricle, needs to generate higher pressure. However, when AF occurs, the atrial contraction becomes inefficient, leading to impaired emptying of the left atrium. This, in turn, causes increased back pressure in the pulmonary circulation.

      The elevated pressure in the left atrium and pulmonary circulation can result in the rupture of bronchial veins, leading to the production of pink frothy sputum. This symptom is often observed in patients with mitral stenosis who develop acute pulmonary edema.

      Further Reading:

      Mitral Stenosis:
      – Causes: Rheumatic fever, Mucopolysaccharidoses, Carcinoid, Endocardial fibroelastosis
      – Features: Mid-late diastolic murmur, loud S1, opening snap, low volume pulse, malar flush, atrial fibrillation, signs of pulmonary edema, tapping apex beat
      – Features of severe mitral stenosis: Length of murmur increases, opening snap becomes closer to S2
      – Investigation findings: CXR may show left atrial enlargement, echocardiography may show reduced cross-sectional area of the mitral valve

      Mitral Regurgitation:
      – Causes: Mitral valve prolapse, Myxomatous degeneration, Ischemic heart disease, Rheumatic fever, Connective tissue disorders, Endocarditis, Dilated cardiomyopathy
      – Features: pansystolic murmur radiating to left axilla, soft S1, S3, laterally displaced apex beat with heave
      – Signs of acute MR: Decompensated congestive heart failure symptoms
      – Signs of chronic MR: Leg edema, fatigue, arrhythmia (atrial fibrillation)
      – Investigation findings: Doppler echocardiography to detect regurgitant flow and pulmonary hypertension, ECG may show signs of LA enlargement and LV hypertrophy, CXR may show LA and LV enlargement in chronic MR and pulmonary edema in acute MR.

    • This question is part of the following fields:

      • Cardiology
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  • Question 25 - A 55 year old female presents to the emergency department 3 hours after...

    Incorrect

    • A 55 year old female presents to the emergency department 3 hours after experiencing severe central chest pain that radiates to the back while gardening. The patient describes the pain as tearing and states it is the worst pain she has ever felt. You note a past medical history of poorly controlled hypertension. The patient's vital signs are as follows:

      Blood pressure 182/98 mmHg
      Pulse rate 94 bpm
      Respiration rate 22 rpm
      Oxygen saturation 97% on room air
      Temperature 37.3ºC

      An ECG is performed which shows normal sinus rhythm. Chest X-ray reveals a widened mediastinum and an abnormal aortic contour.

      What is the most appropriate initial treatment for this patient?

      Your Answer: Intravenous verapamil

      Correct Answer: Intravenous labetalol

      Explanation:

      The most appropriate initial treatment for this patient would be intravenous labetalol. Labetalol is a non-selective beta blocker with alpha-blocking properties. It is the preferred initial treatment for aortic dissection because it helps to reduce blood pressure and heart rate, which can help to decrease the shear forces acting on the aortic wall and prevent further dissection. Intravenous administration of labetalol allows for rapid and effective control of blood pressure.

      Other treatment options, such as intravenous magnesium sulphate, intravenous verapamil, GTN sublingual spray, and oral nifedipine, are not appropriate for the management of aortic dissection. Magnesium sulphate is used for the treatment of certain arrhythmias and pre-eclampsia, but it does not address the underlying issue of aortic dissection. Verapamil and nifedipine are calcium channel blockers that can lower blood pressure, but they can also cause reflex tachycardia, which can worsen the condition. GTN sublingual spray is used for the treatment of angina, but it does not address the underlying issue of aortic dissection.

      Further Reading:

      Aortic dissection is a life-threatening condition in which blood flows through a tear in the innermost layer of the aorta, creating a false lumen. Prompt treatment is necessary as the mortality rate increases by 1-2% per hour. There are different classifications of aortic dissection, with the majority of cases being proximal. Risk factors for aortic dissection include hypertension, atherosclerosis, connective tissue disorders, family history, and certain medical procedures.

      The presentation of aortic dissection typically includes sudden onset sharp chest pain, often described as tearing or ripping. Back pain and abdominal pain are also common, and the pain may radiate to the neck and arms. The clinical picture can vary depending on which aortic branches are affected, and complications such as organ ischemia, limb ischemia, stroke, myocardial infarction, and cardiac tamponade may occur. Common signs and symptoms include a blood pressure differential between limbs, pulse deficit, and a diastolic murmur.

      Various investigations can be done to diagnose aortic dissection, including ECG, CXR, and CT with arterial contrast enhancement (CTA). CT is the investigation of choice due to its accuracy in diagnosis and classification. Other imaging techniques such as transoesophageal echocardiography (TOE), magnetic resonance imaging/angiography (MRI/MRA), and digital subtraction angiography (DSA) are less commonly used.

      Management of aortic dissection involves pain relief, resuscitation measures, blood pressure control, and referral to a vascular or cardiothoracic team. Opioid analgesia should be given for pain relief, and resuscitation measures such as high flow oxygen and large bore IV access should be performed. Blood pressure control is crucial, and medications such as labetalol may be used to reduce systolic blood pressure. Hypotension carries a poor prognosis and may require careful fluid resuscitation. Treatment options depend on the type of dissection, with type A dissections typically requiring urgent surgery and type B dissections managed by thoracic endovascular aortic repair (TEVAR) and blood pressure control optimization.

    • This question is part of the following fields:

      • Cardiology
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  • Question 26 - A 25-year-old is brought into the emergency department after being discovered unresponsive in...

    Incorrect

    • A 25-year-old is brought into the emergency department after being discovered unresponsive in a neighbor's backyard. It is suspected that the patient had consumed alcohol at a nearby bar and opted to walk home in the snowy conditions. The patient's temperature is documented as 27.8ºC. The nurse connects leads to conduct a 12-lead ECG. Which of the subsequent ECG alterations is most closely linked to hypothermia?

      Your Answer: Short QT interval

      Correct Answer: Osborne Waves (J waves)

      Explanation:

      Hypothermia can cause various changes in an electrocardiogram (ECG). These changes include a slower heart rate (bradycardia), the presence of Osborn waves (also known as J waves), a prolonged PR interval, a widened QRS complex, and a prolonged QT interval. Additionally, shivering artifact, ventricular ectopics (abnormal heartbeats originating from the ventricles), and even cardiac arrest (ventricular tachycardia, ventricular fibrillation, or asystole) may occur.

      Further Reading:

      Hypothermic cardiac arrest is a rare situation that requires a tailored approach. Resuscitation is typically prolonged, but the prognosis for young, previously healthy individuals can be good. Hypothermic cardiac arrest may be associated with drowning. Hypothermia is defined as a core temperature below 35ºC and can be graded as mild, moderate, severe, or profound based on the core temperature. When the core temperature drops, basal metabolic rate falls and cell signaling between neurons decreases, leading to reduced tissue perfusion. Signs and symptoms of hypothermia progress as the core temperature drops, initially presenting as compensatory increases in heart rate and shivering, but eventually ceasing as the temperature drops into moderate hypothermia territory.

      ECG changes associated with hypothermia include bradyarrhythmias, Osborn waves, prolonged PR, QRS, and QT intervals, shivering artifact, ventricular ectopics, and cardiac arrest. When managing hypothermic cardiac arrest, ALS should be initiated as per the standard ALS algorithm, but with modifications. It is important to check for signs of life, re-warm the patient, consider mechanical ventilation due to chest wall stiffness, adjust dosing or withhold drugs due to slowed drug metabolism, and correct electrolyte disturbances. The resuscitation of hypothermic patients is often prolonged and may continue for a number of hours.

      Pulse checks during CPR may be difficult due to low blood pressure, and the pulse check is prolonged to 1 minute for this reason. Drug metabolism is slowed in hypothermic patients, leading to a build-up of potentially toxic plasma concentrations of administered drugs. Current guidance advises withholding drugs if the core temperature is below 30ºC and doubling the drug interval at core temperatures between 30 and 35ºC. Electrolyte disturbances are common in hypothermic patients, and it is important to interpret results keeping the setting in mind. Hypoglycemia should be treated, hypokalemia will often correct as the patient re-warms, ABG analyzers may not reflect the reality of the hypothermic patient, and severe hyperkalemia is a poor prognostic indicator.

      Different warming measures can be used to increase the core body temperature, including external passive measures such as removal of wet clothes and insulation with blankets, external active measures such as forced heated air or hot-water immersion, and internal active measures such as inhalation of warm air, warmed intravenous fluids, gastric, bladder, peritoneal and/or pleural lavage and high volume renal haemofilter.

    • This question is part of the following fields:

      • Cardiology
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  • Question 27 - You are summoned to a cardiac arrest in the resuscitation area of your...

    Incorrect

    • You are summoned to a cardiac arrest in the resuscitation area of your Emergency Department.
      Which ONE statement about the utilization of amiodarone in cardiac arrest is NOT true?

      Your Answer: A dose of 150 mg can be given following the 5th shock in pulseless VT arrest

      Correct Answer: It should be administered as an infusion of 300 mg over 20-60 minutes

      Explanation:

      Amiodarone is a medication that is recommended to be administered after the third shock in a shockable cardiac arrest (Vf/pVT) while chest compressions are being performed. The prescribed dose is 300 mg, given as an intravenous bolus that is diluted in 5% dextrose to a volume of 20 mL. It is important to note that amiodarone is not suitable for treating PEA or asystole.

      In cases where VF/pVT persists after five defibrillation attempts, an additional dose of 150 mg of amiodarone should be given. However, if amiodarone is not available, lidocaine can be used as an alternative. The recommended dose of lidocaine is 1 mg/kg. It is crucial to avoid administering lidocaine if amiodarone has already been given.

      Amiodarone is classified as a membrane-stabilizing antiarrhythmic drug. It works by prolonging the duration of the action potential and the refractory period in both the atrial and ventricular myocardium. This medication also slows down atrioventricular conduction and has a similar effect on accessory pathways.

      Additionally, amiodarone has a mild negative inotropic action, meaning it weakens the force of heart contractions. It also causes peripheral vasodilation through non-competitive alpha-blocking effects.

      It is important to note that while there is no evidence of long-term benefits from using amiodarone, it may improve short-term survival rates, which justifies its continued use.

    • This question is part of the following fields:

      • Cardiology
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  • Question 28 - A 32-year-old woman comes to the Emergency Department complaining of dizziness and palpitations....

    Incorrect

    • A 32-year-old woman comes to the Emergency Department complaining of dizziness and palpitations. She informs you that she was recently diagnosed with type B Wolff-Parkinson-White syndrome. You conduct an ECG.
      Which of the following ECG characteristics is NOT observed in type B Wolff-Parkinson-White (WPW) syndrome?

      Your Answer: QRS duration longer than 110 ms

      Correct Answer: Dominant R wave in V1

      Explanation:

      Wolff-Parkinson-White (WPW) syndrome is a condition that affects the electrical system of the heart. It occurs when there is an abnormal pathway, known as the bundle of Kent, between the atria and the ventricles. This pathway can cause premature contractions of the ventricles, leading to a type of rapid heartbeat called atrioventricular re-entrant tachycardia (AVRT).

      In a normal heart rhythm, the electrical signals travel through the bundle of Kent and stimulate the ventricles. However, in WPW syndrome, these signals can cause the ventricles to contract prematurely. This can be seen on an electrocardiogram (ECG) as a shortened PR interval, a slurring of the initial rise in the QRS complex (known as a delta wave), and a widening of the QRS complex.

      There are two distinct types of WPW syndrome that can be identified on an ECG. Type A is characterized by predominantly positive delta waves and QRS complexes in the praecordial leads, with a dominant R wave in V1. This can sometimes be mistaken for right bundle branch block (RBBB). Type B, on the other hand, shows predominantly negative delta waves and QRS complexes in leads V1 and V2, and positive in the other praecordial leads, resembling left bundle branch block (LBBB).

      Overall, WPW syndrome is a condition that affects the electrical conduction system of the heart, leading to abnormal heart rhythms. It can be identified on an ECG by specific features such as shortened PR interval, delta waves, and widened QRS complex.

    • This question is part of the following fields:

      • Cardiology
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  • Question 29 - A 48 year old female presents to the emergency department complaining of palpitations....

    Correct

    • A 48 year old female presents to the emergency department complaining of palpitations. She reports experiencing brief episodes of palpitations over the past week, which typically resolve on their own after 5-10 minutes. However, today's episode has been ongoing for 30 minutes. The patient denies any chest pain or shortness of breath. The patient's vital signs are as follows:

      Blood pressure: 110/70 mmHg
      Pulse: 120 bpm
      Respiration rate: 17 bpm
      Temperature: 36.5ºC
      Oxygen saturations: 97% on room air

      An electrocardiogram (ECG) is performed and reveals atrial fibrillation. What is the most appropriate initial management for this patient?

      Your Answer: Administer 50 mg atenolol

      Explanation:

      When managing newly diagnosed atrial fibrillation, a rate control strategy is often used. In this approach, beta blockers are typically the first line of treatment. However, sotalol is not recommended, and instead, other beta blockers like atenolol, acebutolol, metoprolol, nadolol, oxprenolol, and propranolol are preferred. Among these options, atenolol is commonly chosen in NHS trusts due to its cost-effectiveness.

      For patients with signs of hemodynamic instability or adverse features, rhythm control (cardioversion) may be considered if they present within 48 hours of likely onset. However, in the case of this patient, their symptoms started a week ago, and there are no indications of hemodynamic instability or adverse features.

      Digoxin monotherapy is typically reserved for individuals who have limited physical activity or are unable to take other first-line rate control medications due to other health conditions or contraindications.

      Further Reading:

      Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting around 5% of patients over the age of 70-75 years and 10% of patients aged 80-85 years. While AF can cause palpitations and inefficient cardiac function, the most important aspect of managing patients with AF is reducing the increased risk of stroke.

      AF can be classified as first detected episode, paroxysmal, persistent, or permanent. First detected episode refers to the initial occurrence of AF, regardless of symptoms or duration. Paroxysmal AF occurs when a patient has 2 or more self-terminating episodes lasting less than 7 days. Persistent AF refers to episodes lasting more than 7 days that do not self-terminate. Permanent AF is continuous atrial fibrillation that cannot be cardioverted or if attempts to do so are deemed inappropriate. The treatment goals for permanent AF are rate control and anticoagulation if appropriate.

      Symptoms of AF include palpitations, dyspnea, and chest pain. The most common sign is an irregularly irregular pulse. An electrocardiogram (ECG) is essential for diagnosing AF, as other conditions can also cause an irregular pulse.

      Managing patients with AF involves two key parts: rate/rhythm control and reducing stroke risk. Rate control involves slowing down the irregular pulse to avoid negative effects on cardiac function. This is typically achieved using beta-blockers or rate-limiting calcium channel blockers. If one drug is not effective, combination therapy may be used. Rhythm control aims to restore and maintain normal sinus rhythm through pharmacological or electrical cardioversion. However, the majority of patients are managed with a rate control strategy.

      Reducing stroke risk in patients with AF is crucial. Risk stratifying tools, such as the CHA2DS2-VASc score, are used to determine the most appropriate anticoagulation strategy. Anticoagulation is recommended for patients with a score of 2 or more. Clinicians can choose between warfarin and novel oral anticoagulants (NOACs) for anticoagulation.

      Before starting anticoagulation, the patient’s bleeding risk should be assessed using tools like the HAS-BLED score or the ORBIT tool. These tools evaluate factors such as hypertension, abnormal renal or liver function, history of bleeding, age, and use of drugs that predispose to bleeding.

    • This question is part of the following fields:

      • Cardiology
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  • Question 30 - A 75 year old female is brought to the hospital by paramedics after...

    Correct

    • A 75 year old female is brought to the hospital by paramedics after experiencing a cardiac arrest at home during a family gathering. The patient is pronounced deceased shortly after being admitted to the hospital. The family informs you that the patient had been feeling unwell for the past few days but chose not to seek medical attention due to concerns about the Coronavirus. The family inquires about the likelihood of the patient surviving if the cardiac arrest had occurred within the hospital?

      Your Answer: 20%

      Explanation:

      For the exam, it is important to be familiar with the statistics regarding the outcomes of outpatient and inpatient cardiac arrest in the UK.

      Further Reading:

      Cardiopulmonary arrest is a serious event with low survival rates. In non-traumatic cardiac arrest, only about 20% of patients who arrest as an in-patient survive to hospital discharge, while the survival rate for out-of-hospital cardiac arrest is approximately 8%. The Resus Council BLS/AED Algorithm for 2015 recommends chest compressions at a rate of 100-120 per minute with a compression depth of 5-6 cm. The ratio of chest compressions to rescue breaths is 30:2.

      After a cardiac arrest, the goal of patient care is to minimize the impact of post cardiac arrest syndrome, which includes brain injury, myocardial dysfunction, the ischaemic/reperfusion response, and the underlying pathology that caused the arrest. The ABCDE approach is used for clinical assessment and general management. Intubation may be necessary if the airway cannot be maintained by simple measures or if it is immediately threatened. Controlled ventilation is aimed at maintaining oxygen saturation levels between 94-98% and normocarbia. Fluid status may be difficult to judge, but a target mean arterial pressure (MAP) between 65 and 100 mmHg is recommended. Inotropes may be administered to maintain blood pressure. Sedation should be adequate to gain control of ventilation, and short-acting sedating agents like propofol are preferred. Blood glucose levels should be maintained below 8 mmol/l. Pyrexia should be avoided, and there is some evidence for controlled mild hypothermia but no consensus on this.

      Post ROSC investigations may include a chest X-ray, ECG monitoring, serial potassium and lactate measurements, and other imaging modalities like ultrasonography, echocardiography, CTPA, and CT head, depending on availability and skills in the local department. Treatment should be directed towards the underlying cause, and PCI or thrombolysis may be considered for acute coronary syndrome or suspected pulmonary embolism, respectively.

      Patients who are comatose after ROSC without significant pre-arrest comorbidities should be transferred to the ICU for supportive care. Neurological outcome at 72 hours is the best prognostic indicator of outcome.

    • This question is part of the following fields:

      • Cardiology
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SESSION STATS - PERFORMANCE PER SPECIALTY

Cardiology (9/30) 30%
Passmed