Which of the following features is not associated with patent ductus arteriosus?
Correct Answer B:
Patent ductus arteriosus:
Overview:
Features:
Management:
A 78-year-old woman with no past medical history of note is admitted with palpitations and shortness of breath, having been unwell for the past three days. Examination reveals an irregularly irregular pulse of 130 bpm, a third heart sound, blood pressure of 108/70 mmHg, oxygen saturations of 96% on air and bi-basal lung crepitations.
What is the most appropriate therapy to control her heart rate?
Correct Answer D:
Digoxin is strongly indicated for coexistent atrial fibrillation and heart failure. Beta-blockers should not be introduced until any heart failure has been stabilised. Giving amiodarone or flecainide may result in cardioversion before the patient has been adequately anticoagulated If there was a more acute history and the patient was in significant heart failure then DC cardioversion would be appropriate, as per Advanced Life Support guidelines.
Atrial fibrillation: rate control and maintenance of sinus rhythm:
The Royal College of Physicians and NICE published guidelines on the management of atrial fibrillation (AF) in 2006. The following is also based on the joint American Heart Association (AHA), American College of Cardiology (ACC) and European Society of Cardiology (ESC) 2012 guidelines.
Agents used to control rate in patients with atrial fibrillation:
Agents used to maintain sinus rhythm in patients with a history of atrial fibrillation:
The table below indicates some of the factors which may be considered when considering either a rate control or rhythm control strategy:
A 57-year-old man with NYHA class III heart failure is currently treated with furosemide and ramipril.
What is the most suitable beta-blocker to add to improve his long-term prognosis?
Correct Answer C:
Both carvedilol and bisoprolol have been shown to reduce mortality in stable heart failure. The other beta blockers have no evidence base to support their use.
Heart failure: drug management:
A number of drugs have been shown to improve mortality in patients with chronic heart failure:
No long-term reduction in mortality has been demonstrated for loop diuretics such as furosemide.
NICE issued updated guidelines on management in 2010, key points include:
*Digoxin has also not been proven to reduce mortality in patients with heart failure. It may however improve symptoms due to its inotropic properties. Digoxin is strongly indicated if there is coexistent atrial fibrillation.
**Adults usually require just one dose but those with asplenia, splenic dysfunction or chronic kidney disease need a booster every 5 years.
Which one of the following is least associated with aortic regurgitation?
William's syndrome is associated with supravalvular aortic stenosis.
Aortic regurgitation:
Causes (due to valve disease):
Causes (due to aortic root disease):
A 71-year-old man who is known to have atrial fibrillation comes for review. He had a transient ischaemic attack two weeks ago and takes bendroflumethiazide for hypertension but is otherwise well. His latest blood pressure is 124/76 mmHg. You are discussing management options to try and reduce his future risk of having a stroke.
What is his CHA2DS2-VASc score?
One point for hypertension, one point for being over the age of 65 years (but under the age of 75 years) and two points ('S2') for the recent TIA.
Atrial fibrillation: anticoagulation:
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.
The table below shows a suggested anticoagulation strategy* based on the score:
Score………… Anticoagulation:
*The wording in the guidelines ('is preferred to') can be slightly confusing. It basically means that, say for a score of 0, whilst aspirin is an acceptable management option the weight of the clinical evidence would support no treatment instead.
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