A 64-year-old female presents with central chest pain radiating down her left arm of 20 minutes duration. On examination the pulse is 90 bpm and regular and the BP is 205/110 mmHg. ECG shows 2 mm ST elevation in leads V2-6. Morphine and aspirin have already been given.
What is the most appropriate next step?
Correct Answer D:
The elevated blood pressure would be a contraindication to giving thrombolysis is this patient.
Thrombolysis:
Thrombolytic drugs activate plasminogen to form plasmin. This in turn degrades fibrin and help breaks up thrombi. They in primarily used in patients who present with a ST elevation myocardial infarction. Other indications include acute ischaemic stroke and pulmonary embolism, although strict inclusion criteria apply.
Examples:
Contraindications to thrombolysis:
Side-effects:
A 65-year-old man is admitted to the Emergency Department with chest pain, nausea and feeling lethargic. He has a history of type 1 diabetes mellitus and is known to have chronic kidney disease stage 4 secondary to diabetic nephropathy. An ECG taken on admission shows widespread ST elevation. Bloods tests show the following:
His renal function one month ago was as follows:
An echocardiogram shows a small effusion.
What is the most appropriate next step in management?
Correct Answer E:
This patient has uraemic pericarditis. Haemodialysis is urgently required to correct the uraemia which in turn will improve the symptoms of pericarditis.
Pericarditis:
Pericarditis is one of the differentials of any patient presenting with chest pain.
Features:
Causes:
ECG changes:
A 62-year-old man is reviewed two hours after a successful elective DC cardioversion for atrial fibrillation. Six weeks ago he presented in fast atrial fibrillation. A decision was made at the time to warfarinise him for six weeks after which he was to be cardioverted. During this time he had a normal transthoracic echocardiogram. He has no past medical history of note other than treatment for a basal cell carcinoma.
What is the most appropriate plan regarding anticoagulation?
Atrial fibrillation: cardioversion:
Onset < 48 hours:
If the atrial fibrillation (AF) is definitely of less than 48 hours onset patients should be heparinised. Patients who have risk factors for ischaemic stroke should be put on lifelong oral anticoagulation. Otherwise, patients may be cardioverted using either:
Following electrical cardioversion if AF is confirmed as being less than 48 hours duration then further anticoagulation is unnecessary.
Onset > 48 hours:
If the patient has been in AF for more than 48 hours then anticoagulation should be given for at least 3 weeks prior to cardioversion. An alternative strategy is to perform a transoesophageal echo (TOE) to exclude a left atrial appendage (LAA) thrombus. If excluded patients may be heparinised and cardioverted immediately. If there is a high risk of cardioversion failure (e.g. Previous failure or AF recurrence) then it is recommend to have at least 4 weeks amiodarone or sotalol prior to electrical cardioversion.
Following electrical cardioversion patients should be anticoagulated for at least 4 weeks. After this time decisions about anticoagulation should be taken on an individual basis depending on the risk of recurrence.
Which one of the following is an example of a centrally acting antihypertensive?
Centrally acting antihypertensives:
Examples of centrally acting antihypertensives include :
A 28-year-old female with a history of primary amenorrhoea and short stature is reviewed in clinic. On examination blood pressure in her right arm is 175/84 mmHg and 170/82 mmHg in her left.
What is the most likely cause for her elevated blood pressure?
Correct Answer A:
This patient has Turner's syndrome which is associated with coarctation of the aorta. The site of the coarctation, for example if it involves the origin of the left subclavian artery, determines whether there is a difference between the right and left arm blood pressure readings. There is no significant difference in this case.
Another cause worth considering in a young hypertensive patient with primary amenorrhoea would be congenital adrenal hyperplasia.
Essential hypertension would be unusual in a 28-year-old.
Turner's syndrome:
Turner's syndrome is a chromosomal disorder affecting around 1 in 2,500 females. It is caused by either the presence of only one sex chromosome (X) or a deletion of the short arm of one of the X chromosomes. Turner's syndrome is denoted as 45,XO or 45,X.
Click to expand