A 34-year-old man is investigated following an unexplained collapse whilst at work. A resting ECG shows convex ST elevation in V1-V3 with a partial right bundle branch block pattern.
What is the most likely diagnosis?
Correct Answer D:
Brugada syndrome:
Brugada syndrome is a form of inherited cardiovascular disease with may present with sudden cardiac death. It is inherited in an autosomal dominant fashion and has an estimated prevalence of 1:5,000-10,000. Brugada syndrome is more common in Asians.
Pathophysiology:
ECG changes:
Management:
A 74-year-old man is admitted with chest pain associated with ECG changes. A troponin T taken 12 hours after admission indicates an acute myocardial infarction.
Which one of the following is most likely to predict a poor prognosis?
Correct Answer C:
Acute coronary syndrome: prognostic factors:
The 2006 Global Registry of Acute Coronary Events (GRACE) study has been used to derive regression models to predict death in hospital and death after discharge in patients with acute coronary syndrome.
Poor prognostic factors:
*Killip class - system used to stratify risk post myocardial infarction:
A 62-year-old patient presents to the Emergency Department with a 25 minute history of crushing central chest pain. ECG shows ST elevation in leads I and aVL.
Which coronary territory is likely to be affected?
Correct Answer A:
These ECG changes are most consistent with a lateral myocardial infarction. An anterolateral infarction is more likely to have changes in the chest leads.
ECG: coronary territories:
The table below shows the correlation between ECG changes and coronary territories:
A 64-year-old man with a history of ischaemic heart disease and poor left ventricular function presents with a broad complex tachycardia of 140 bpm. On examination blood pressure is 110/74 mmHg. Fusion and capture beats are seen on the 12 lead ECG.
What is the first line drug management?
Correct Answer B:
The history of ischaemic heart disease combined with the presence of fusion and capture beats strongly suggests a diagnosis of ventricular tachycardia (VT). Whilst lidocaine can also be used in VT, amiodarone would be preferred given his history of poor left ventricular function. In the 2010 joint European Resuscitation Council and Resuscitation Council (UK) guidelines amiodarone is also considered first-line in a peri-arrest situation.
Ventricular tachycardia: management:
Whilst a broad complex tachycardia may result from a supraventricular rhythm with aberrant conduction, the European Resuscitation Council advise that in a peri-arrest situation it is assumed to be ventricular in origin.
If the patient has adverse signs (systolic BP < 90 mmHg, chest pain, heart failure or rate > 150 beats/min) then immediate cardioversion is indicated. In the absence of such signs antiarrhythmics may be used. If these fail, then electrical cardioversion may be needed with synchronized DC shocks.
Drug therapy:
Verapamil should NOT be used in VT
If drug therapy fails:
You have ordered a B-type natriuretic peptide (BNP) test on a patient with suspected heart failure. It has come back as being slightly elevated.
Which one of the following factors may account for a falsely elevated BNP?
Correct Answer E:
Heart failure diagnosis:
NICE issued updated guidelines on diagnosis and management in 2010. The choice of investigation is determined by whether the patient has previously had a myocardial infarction or not.
Previous myocardial infarction:
No previous myocardial infarction:
Serum natriuretic peptides:
B-type natriuretic peptide (BNP) is a hormone produced mainly by the left ventricular myocardium in response to strain. Very high levels are associated with a poor prognosis.
Factors which alter the BNP level:
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