A 62-year-old female with a history of mitral regurgitation attends her dentist, who intends to perform dental polishing. She is known to be penicillin allergic.
What prophylaxis against infective endocarditis should be given?
Correct Answer C:
The 2008 NICE guidelines have fundamentally changed the approach to infective endocarditis prophylaxis. What is not yet clear is if there are any circumstances in which NICE would recommend using antibiotic prophylaxis.
Infective endocarditis: prophylaxis:
The 2008 guidelines from NICE have radically changed the list of procedures for which antibiotic prophylaxis is recommended.
NICE recommends the following procedures do not require prophylaxis:
The guidelines do however suggest:
What is the most common cardiac defect seen in Marfan's syndrome?
Correct Answer D:
Whilst mitral valve prolapse is seen in Marfan's syndrome, dilation of the aortic sinuses is more common.
Marfan's syndrome:
Marfan's syndrome is an autosomal dominant connective tissue disorder. It is caused by a defect in the fibrillin-1 gene on chromosome 15 and affects around 1 in 3,000 people.
Features:
The life expectancy of patients used to be around 40-50 years. With the advent of regular echocardiography monitoring and beta-blocker/ACE-inhibitor therapy this has improved significantly over recent years. Aortic dissection and other cardiovascular problems remain the leading cause of death however.
A 72-year-old man who has a history of ischaemic heart disease and left ventricular dysfunction is admitted with dyspnoea. He has not taken his diuretics for three days as he ran out. On examination you note bilateral crackles to the mid zones and a respiratory rate of 30/min.
Which other clinical finding is most specific with this presentation?
Pulsus alternans - seen in left ventricular failure.
Pulses:
Pulsus parodoxus:
Slow-rising/plateau:
Collapsing:
Pulsus alternans:
Bisferiens pulse:
'Jerky' pulse:
*HOCM may occasionally be associated with a bisferiens pulse
A 64-year-old man is admitted to the Emergency Department with chest pain radiating through to his back. On examination pulse 90 regular, BP 140/90. A CXR shows mediastinal widening. A CT shows dissection of the descending aorta.
What is the most suitable initial management?
Correct Answer B:
Aortic dissection:
Dissection of the descending aorta indicates a type B dissection, which should be managed medically with IV labetalol.
Stanford classification:
DeBakey classification:
Type A:
Type B*:
*Endovascular repair of type B aortic dissection may have a role in the future.
A 52-year-old man is admitted to the Emergency Department. He was found collapsed by neighbours. An ECG on arrival shows torsades de pointes.
Which one of his medications is most likely to have contributed to this presentation?
Torsades de pointes:
Torsades de pointes ('twisting of the points') is a rare arrhythmia associated with a long QT interval. It may deteriorate into ventricular fibrillation and hence lead to sudden death.
Causes of long QT interval:
Management:
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