A 52-year-old female is referred from the Emergency Department with a pulse of 36 beats/min. The ECG shows complete heart block with a narrow QRS complex. Blood pressure is 88/50 mmHg and there is no evidence of heart failure.
What is the most appropriate management?
Correct Answer E:
Peri-arrest rhythms: Bradycardia:
The 2010 Resuscitation Council (UK) guidelines emphasise that the management of bradycardia depends on:
Adverse signs:
The following factors indicate haemodynamic compromise and hence the need for treatment:
Atropine is the first line treatment in this situation. If this fails to work, or there is the potential risk of asystole then transvenous pacing is indicated.
Potential risk of asystole:
The following indicate a potential risk of asystole and hence the need for treatment with transvenous pacing:
If there is a delay in the provision of transvenous pacing the following interventions may be used:
A 60-year-old man is admitted with severe central chest pain to the resus department. The admission ECG shows ST elevation in leads V1-V4 with reciprocal changes in the inferior leads.
Which one of the following is most likely to account for these findings?
Widespread ST elevation in this territory implies a complete occlusion of the left anterior descending artery.
Causes of ST elevation:
A 70-year-old man is admitted to the Acute Medicine Unit as he is pyrexial and feeling generally unwell. He has a history of ischaemic heart disease and had a myocardial infarction 5 years ago. An echocardiogram is arranged which shows a small vegetation around the mitral valve.
Blood cultures are taken which are reported as follows:
What is the most appropriate antibiotic therapy?
Correct Answer A:
Infective endocarditis: prognosis and management: Poor prognostic factors:
Mortality according to organism:
Indications for surgery:
A 54-year-old man with atypical chest pain is referred to cardiology. An exercise ECG shows non specific ST and T wave changes. Following this an coronary angiogram is performed which demonstrates no evidence of atherosclerosis. A diagnosis of Prinzmetal's angina is suspected.
What is the most appropriate first-line treatment?
Correct Answer C:
Prinzmetal angina - treatment = dihydropyridine calcium channel blocker.
Angina pectoris: drug management:
The management of stable angina comprises lifestyle changes, medication, percutaneous coronary intervention and surgery. NICE produced guidelines in 2011 covering the management of stable angina.
Medication:
Nitrate tolerance:
Ivabradine:
A 76-year-old man is reviewed. He was recently admitted after being found to be in atrial fibrillation. This was his second episode of atrial fibrillation. He also takes ramipril for hypertension but has no other history of note.During admission he was warfarinised and discharged with planned follow-up in the cardiology clinic. However, on review today he is found to be in sinus rhythm.
What should happen regarding anticoagulation?
Correct Answer D: Warfarin should be continued indefinitely as this is his second episode of atrial fibrillation and he has risk factors for stroke (age, hypertension).
Atrial fibrillation: anticoagulation:
The European Society of Cardiology published updated guidelines on the management of atrial fibrillation in 2012. They suggest using the CHA2DS2-VASc score to determine the most appropriate anticoagulation strategy.
This scoring system superceded the CHADS2score.
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