A 40 year old man brought into the emergency room in a collapsed state. Carotid pulse was palpable (1+) and blood pressure was 80/45 mmHG.
Thought 1: How to approach wide complex tachycardia?
Thought 2: What is the first line drug in this case?
This ECG has wide-complex tachycardia(QRS duration=120msec) at a rate of 180 bpm with a RBBB pattern, left superior axis deviation and R-S interval is hardly 80msec suggesting Idiopathic Fasicular Left Ventricular Tachycardia (ILVT) and due to left superior axis deviation its Posterior Fasicular VT. Right ventricular outflow tract tachycardia is also differential here but it is usually with LBBB morphology. During wide complex tachycardia the differentiation between supraventricular and ventricular origin of the arrhythmia is important to guide therapy. Several algorithms have been developed to aid in this differentiation which we will discuss in next sections.
The patient was initially treated with successive rounds of synchronized DC Cardioversion, which were ineffective. Intravenous amiodarone, lidocaine and adenosine were also tried but did not terminate it. Finally, the patient received intravenous Verapamil, which terminated the tachycardia with resultant normal sinus rhythm. The patient was admitted and coronary angiography was done which showed clean coronaries. His hospitalization was uneventful and he was subsequently discharged home with the plan to return for a radiofrequency ablation.
Idiopathic Fasicular Left Ventricular Ventricular Tachycardia (ILVT):
Posterior fascicular VT by far accounts for the majority of ILVT, representing over 90% of cases. Often, ILVT is mistaken for supraventricular tachycardia with aberrancy. The surface electrocardiogram demonstrates tachycardia with a RBBB pattern and a left superior axis deviation. Other forms of ILVT include anterior fascicular VT presenting with a RBBB and right axis deviation as well as the more rare upper septal fascicular VT which can present with either a RBBB, left bundle branch block (LBBB), or a normal QRS.
Anatomically, it is believed that the re-entrant loop for posterior fascicular VT involves a verapamil-sensitive septal myocardium that exhibits decremental properties from the base to the apex of the LV. It was demonstrated that there is a mid-diastolic pre-Purkinje potential (P1) and a pre-systolic potential (P2). P1 is described as a low frequency mid-diastolic potential during VT whereas P2 is described as a sharp, short-duration, high-frequency presystolic potential. The septal myocardium serves as the antegrade limb for the VT and is responsible for the creation of P1 during VT. The retrograde limb consists of either the posterior fascicle or its nearby tissue creating P2 during VT. It has traditionally been thought that P2 was created by a retrograde limb formed by the posterior fascicle. However, other studies have challenged this idea. Morishima have suggested that P2 may actually represent activation of the myocardial tissue in proximity to the fascicle. Kuo et demonstrated that ablation of ILVT did not result in fascicular block, leading the authors to conclude that the fascicle may not be involved in the re-entry circuit, simply the tissue adjacent to it. It has still not been completely elucidated whether the circuit is completely defined by fascicular tissue alone or whether there is a component of ventricular myocardium involved.
ECG Features of ILVT:
How to approach broad complex tachycardia:
Several ECG algorithms have been developed to differentiate wide QRS-complex tachycardias. Most of them performed very well in the population they were based upon. Brugada algorithm (below). This is the most commonly used algorithm. SN 89%, SP 59.2%.
If the above criteria is inconclusive then following criteria is used depending on the morphology of bundle branch block:
More advanced tips:
Ultra -Simple Brugada Criteria:
In 2010 Joseph Brugada et al. published a new criterion to differentiate VT from SVT in wide complex tachycardias: the R wave peak time in Lead II . They suggest measuring the duration of onset of the QRS to the first change in polarity (either nadir Q or peak R) in lead II. If the RWPT is ≥ 50ms the likelihood of a VT very high (positive likelihood ratio 34.8)
HAPPY LEARNING :-)
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ECG of the Week ~ 25y male with palpitations, There was no syncope or history of cardiac disease, no history of drug use.
There is sinus rhythm, but with two pauses of about 1.7 seconds, which are almost exactly double the shorter P-P intervals. The P-wave of the second complex is different. Is this sinus arrest? Sinus pause? Sinoatrial exit block? Or just simple sinus "arrhythmia" (benign, vagally induced)?
Sinus arrhythmia is unlikely because, in sinus arrhythmia, the rate usually gradually slows and then gradually speeds up. Here, the long R-R intervals are nearly exactly the same as each other, and nearly exactly double the short R-R intervals, which are, in turn, nearly exactly identical to each other. It can't be sinus pause or arrest because the pause is less than 2 seconds. Also, sinus pause would not start up again at a multiple of the other P-P intervals.
Thus, it is almost certainly Sinoatrial exit block. This means that the underlying sinus node depolarizes at a constant rate, but occasionally does not "exit" the sinus node and depolarize the atrium; hence, no P-wave.
The fact that the long intervals are not EXACTLY double the short ones argues only weakly against this because the sinus rate is not always exactly the same.
Next Step : Why is the P-wave after the first long interval different from the others?
"The sinus node is a very long structure, extending from SVC/RA junction coming down on the RA wall.
Of course, without the actual SA recordings, no one can say for sure, but we essentially rely on the P-wave morphology and axis to make a determination about the origin of those p-waves.
"The exit site of the Sinus node activity is usually high up and therefore P-waves are usually positive. Sometimes, the exit site from sinus node can vary in the same person and can potentially result in slightly different morphology.
"The P-wave in question is different, but still appears like sinus to me, with a slightly lower exit and therefore the positivity is not as pronounced. The pause that occurs afterwards shows the p-wave that’s similar to other sinus p-waves."
Furthermore, the fact that the sinus node impulse is exiting at different parts of the long sinus node suggests that it is being blocked from its normal exit, and supports SinoAtrial exit block.
Final explanation of this case, Which is SinoAtrial exit block second degree type II:
SA block in this case: Suppose the impulse cannot exit using the normal transitional (T) cells (SA block), but does succeed in travelling down the SA node and exiting elsewhere. Then you get a different P-wave morphology, as we have in this case. In this case: the first PQRS is normal. The second sinus impulse is completely blocked and there is no p-wave or QRS. The third is partly blocked, but exits the SA node in a different area and you get a PQRS but with a different P-wave morphology. Then there are 7 normal beats, but the 11th sinus impulse is completely blocked but the 12th exits normally and the P-wave morphology is normal.
Management: The patient was admitted, had an uneventful overnight stay except was diagnosed with hyperthyroidism, and discharged. He will get follow up for the sinus abnormality. Patients with asymptomatic SA block do not need treatment (palpitations would not be a significant symptom). Patients with syncope or near syncope must be evaluated further.
Sinus Node Dysfunction (SND):
Partly adapted from the AHA/ACC guidelines for pacemaker insertion (JACC 2008; 51(21):e1-e62) and from online textbook UpToDate:
"SND refers to a broad array of abnormalities in sinus node and atrial impulse formation and propagation. These include persistent sinus bradycardia and chronotropic incompetence without identifiable causes, paroxysmal or persistent sinus arrest with replacement by subsidiary escape rhythms in the atrium, AV junction, or ventricular myocardium." (ACC/AHA)
Anatomy and Pathology of SND:
The sinoatrial (SA) node has pacemaker, or "P" cells and transitional, or "T" cells which transmit the impulse from the P cells to the atrium. It may be diseased due to ischemic, infiltrative, inflammatory, or fibrotic changes, or to excessive vagal tone, beta blockers, calcium channel blockers, or hyperkalemia.
1. Sinus pause: At least 2 seconds of pause
2. Sinus arrest: There is a complete absence of P-waves. If an escape beat comes within 3 seconds, is that sinus arrest or sinus pause? Lower pacemakers (AV node, bundle of HIS, right or left bundle, ventricle) which produce "escape" rhythms do not always function, so Asystole is a possible outcome of sinus arrest.
Etiology of sinus pauses and arrest: alteration in the impulse rate of the P cells. Therefore, the pause length is variable and not necessarily a multiple of the basic sinus rate. Pauses up to 3 seconds during carotic sinus massage (vagal stimulation) are within normal limits. But symptomatic carotid sinus hypersensitivity may be an indication for a pacer.
3. Sinoatrial nodal exit block (SA exit block): SA pacemaker, or P cells, are working but the impulse is not transmitted by the T cells to the surrounding atrial tissue. So there is no P-wave. The sinus impulse is invisible on the surface ECG if there is no P-wave (the P-wave comes from atrial activity).
3a. First Degree SA Block: slowing of impulse exit only. This cannot be seen on the surface ECG
3b. Second Degree SA Block:
Type I: (Wenckenbach): progressivley decreasing P-P intervals prior to a pause; the pause has a dduration less than 2 P-P cycles.
Type II: P-P interval is a multiple of the normal P-P intervals
3c. Third Degree SA Block: the impulse does not reach the atrium at all and thus cannot be differentiated from sinus arrest on the surface ECG.
Sick Sinus Syndrome findings include:
1. chronic, inappropriate, sinus bradycardia, which may be symptomatic if there is failure of "escape" rhythms
2. Sinus pauses, sinus arrest, and sinoatrial exit block
3. Alternating bradycardia and atrial tachyarrhythmias, including atrial fib (tachy-brady syndrome)
Not all patients with sick sinus syndrome need a pacemaker immediately, but if you encounter a patient who has symptomatic sinus pauses in the ED (syncope or near syncope) and you are not sure that it is sinus arrhythmia, you cannot safely send the patient home without further evaluation, usually by a cardiologist. Although the serious outcomes may take some time to manifest, we don't know of any way to predict that they won't happen immediately in your symptomatic ER patient, unless you can find and reverse an identifiable cause such as hyperkalemia or drug effect.
Natural History of Sick Sinus Syndrome:
Study Reference: In this study of 35 patients with sick sinus syndrome, as diagnosed by (1) age at least 45 years; (2) mean sinus rate at rest less than 45 beats/min, and/or intermittent sinoatrial block in at least 1 standard electrocardiogram recorded during diurnal hours on different days; (3) symptoms attributable to sinus node dysfunction, such as syncope or dizziness, and/or easy fatigue or effort dyspnea, the patients were followed up for up to 4 years (mean 17 ± 15 months). During follow-up, 20 patients (57%) had cardiovascular events that required treatment: 8 had syncope (23%); 6 had overt heart failure (17%); 4 patients had chronic atrial fibrillation (11%); and 2 patients had poorly tolerated episodes of paroxysmal tachyarrhythmias (6%). Actuarial rates of occurrence of all events were 35%, 49%, and 63%, respectively, after 1, 2, and 4 years. At univariate analysis, age at least 65 years, end-systolic left ventricular diameter at least 30 mm, end-diastolic left ventricular diameter at least 52 mm, and ejection fraction less than 55.
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Venepuncture ~ Basics and Troubleshooting, Vacutainer Colour codes in Blood sampling and tube types used
Venepuncture is the puncture of a vein as part of a medical procedure, typically to withdraw a blood sample or for an intravenous injection.
Veins to be used are:
• METACARPAL VEINS
• CEPHALIC VEIN
• BASILIC VEIN
• MEDIAN CUBITAL VEIN
Attributes of an ideal vein are:
Veins to be avoided:
Methods for improving venous access:
• Apply a tourniquet
• Lower the level of the arm below the heart
• Ask the patient to open and close their fist
• Light tapping / rubbing of the veins
• Relax the patient / consider the environment
• Warm up the patient’s hands
• DO NOT re-touch or palpate the vein once cleaned!!!
• The needle should form a 15 to 30 degree angle with the surface of the arm.
3. PROBLEMS OTHER THAN AN INCOMPLETE COLLECTION:
Haematoma/Bruising can be caused by:
• Tourniquet too tight / left on too long or use of RUBBER GLOVE!
• Arterial puncture
• Repeated insertion sites
If you stick yourself with a contaminated needle:
• Remove your gloves and dispose of them properly.
• Squeeze puncture site to promote bleeding.
• Wash the area well with soap and water.
• Record the patient's name and ID number.
• Follow your hospital protocol regarding treatment and follow-up.
Order Of Draw:
NOTE: NEVER FORCEFULLY EJECT THE COLLECTED BLOOD FROM THE SYRINGE INTO THE VACUUM TUBE.
Causes Of Hemolysis:
Vacutainer Colour codes in Blood sampling:
Intensity refers to the loudness of the murmur, and is graded according to the Levine scale, from 1 to 6:
ACC/AHA Stages Of Heart Failure:
Stage A identifies the patient who is at high risk for developing HF but has no structural disorder of the heart.
Stage B refers to a patient with a structural disorder of the heart but who has never developed symptoms of HF.
Stage C denotes the patient with past or current symptoms of HF associated with underlying structural heart disease.
Stage D designates the patient with end-stage disease who requires specialized treatment strategies such as mechanical circulatory support, continuous inotropic infusions, cardiac transplantation, or hospice care.
This classification system is intended to complement but not to replace the New York Heart Association (NYHA) functional classification, which primarily gauges the severity of symptoms in patients who are in stage C or D. It has been recognized for many years, however, that the NYHA functional classification reflects a subjective assessment by a physician and changes frequently over short periods of time and that the treatments used do not differ significantly across the classes. Therefore, the committee believed that a staging system was needed that would reliably and objectively identify patients in the course of their disease and would be linked to treatments that were uniquely appropriate at each stage of their illness. According to this new approach, patients would be expected to advance from one stage to the next unless progression of the disease was slowed or stopped by treatment. This new classification scheme adds a useful dimension to our thinking about HF similar to that achieved by staging systems for other disorders (e.g., those used in the classification of cancer).
B type natriuretic peptide is likely to be normal in which of the following?
Acute mitral regurgitation correct answer
A 68 year old asthmatic presents with shortness of breath. She also has a PMH of hypertension for which she is prescribed ramipril. On examination she is found to have a BP of 130/80mmHg, pulse of 90 irregularly, irregular and bilateral wheeze and normal heart sounds. A CXR reveals cardiomegaly. What is the most appropriate treatment of her AF?
Digoxin correct answer
Rate control is the most appropriate in this case. Digoxin should be utilised due to the cardiomegaly and history of asthma which means verapamil and atenolol should be avoided due to potential of precipitating heart failure and worsening asthma respectively.
Which of the following suggests the presence of mitral regurgitation as well as mitral stenosis?
Your answer was Displaced apex beat which is correct
Displaced apex beat correct answer
Localised tapping apex beat
A 81 year old male with a history of hypertension and inferior MI is seen in the cardiology clinic due to worsening angina and heart failure and 2 syncopal episodes. He is found to have an ejection systolic murmur loudest at the apex. Which investigation will confirm the most likely diagnosis?
Your answer was Echocardiography which is correct
Echocardiography correct answer
Exercise tolerance test
Aortic Stenosis explains all of the symptoms of worsening angina and heart failure and the 2 episodes of syncope. Although the murmur is loudest at the apex mitral regurgitation is less likely to explain the syncopal episodes.An Echocardiograph will confirm the diagnosis. Coronary angiography should be performed but is not used for the diagnosis.
Which of the following antibodies present in the maternal circulation may lead to congenital heart block?
Your answer was Anti Ro which is correct
Anti Ro correct answer
A 62 year old has had two syncopal episodes. She complains of intermittent palpitations. There is nil of note on examination and her bloods are normal. What is a useful first investigation?
Your answer was EEG which is incorrect
24 hour ECG correct answer
Exercise tolerance test
Which of the following suggests more severe mitral regurgitation?
Your answer was Length of murmur which is incorrect
Displacement of apex beat and systolic thrill correct answer
Length of murmur
Loudness of murmur
A 65 year old gentleman with type 2 diabetes mellitus is found incidentally to have left bundle branch block on his ECG. It had not been present on previous ECGs. An ECHO reveals no structural abnormality. You want to exclude a myocardial infarct. What investigation should be performed in the first instance?
Your answer was Thallium perfusion scan which is incorrect
Exercise tolerance test correct answer
Thallium perfusion scan
An echocardiogram is performed on a patient prior to surgery and reveals a very small pericardial effusion but no other abnormalities. He is asymptomatic. What should be done regarding this prior to surgery?
Your answer was Proceed with surgery, nil required which is correct
Proceed with surgery, nil required correct answer
Postpone surgery and perform further investigations
A 40 year old male presents with shortness of breath and a headache. He is found to have a blood pressure of 200/115mmHg and on fundoscopy has retinal haemorrhages and papilledema. An ECG shows LVH. Heart sounds normal and chest is clear. What is the most appropriate management?
Your answer was IV Labetalol which is incorrect
Atenolol correct answer
IV Sodium Nitroprusside
Atenolol is the most appropriate as blood pressure in malignant hypertension should be lowered gradually. Aims are lowering diastolic to 100 105mmHg over a few days. Blood pressure should be monitored 4 hourly and should not drop initially more than 25 per cent of presenting. First line therapy are beta blockers or calcium antagonist such as nifedipine (sublingual should be avoided as it can lead to dramatic falls).
A 45 year old male presents with palpitations. He had been drinking heavily the night before. His heart rate is about 140 bpm and is irregularly irregular. What is the most likely diagnosis?
Your answer was Atrial flutter which is incorrect
Paroxysmal atrial fibrillation correct answer
Torsades de pointes
A 50 year old female presents with shortness of breath, fatigue and peripheral oedema. On examination she has a raised JVP, pitting oedema, hepatomegaly and ascites. An echo is organised and reveals globally thickened walls oncluding the interatrial septa with atrial dilatation but the ventricles are not dilated. There is an increased scintillation pattern (granular speckling). There is a normal ejection fraction. An ECG shows low voltage complexes. Given the most likely diagnosis, how else might it present?
Your answer was Renal failure which is incorrect
Embolic symptoms correct answer
A 35 year old female with rheumatoid arthritis presents with pain and tightness behind of the left leg. On examination there is evidence of a swelling in the popliteal fossa of the left knee. What investigation should be organised?
Your answer was D dimers which is incorrect
Ultrasound of popliteal fossa correct answer
MRI of knee
The most likely diagnosis is a Baker's cyst and an ultrasound should be performed to confirm this. A d-dimer should only be measured if you suspect a DVT and according to the appropriate Well's score.
You are asked to review a 52 year old gentleman who has become suddenly unwell and hypotensive. He had an STEMI 2 days previously. On examination he has a pansystolic murmur lowest at the lower left sternal border and a raised JVP. Further investigation reveals a high right atrial pressure and low left atrial pressure. What is the most likely diagnosis?
Your answer was VSD which is incorrect
Tricuspid regurgitation correct answer
The history and findings of high right atrial pressure suggests tricuspid regurgitation which can occur post MI and is more commonly seen in those with chronic lung disease, endocarditis, rheumatic heart disease and congenital abnormalities. It leads to a pansystolic murmur at the LLSE, raised JVP and pulsatile liver and sometimes a RV impulse.
A 58 year old gentleman has severe central crushing chest pain for about half an hour which is finally relieved by GTN. There is evidence of ST depression in the anterolateral leads and his troponin is elevated. He is treated with aspirin, clopidogrel and LMWH. What is the next appropriate management?
Your answer was Coronary Angiography as an outpatient which is incorrect
Urgent coronary angiography as an inpatient correct answer
Discharged with Outpatient cardiac clinic follow up
Coronary Angiography as an outpatient
Exercise Tolerance Test
Which of the following is a risk factor for the development of Torsades de pointes?
Your answer was Hypermagnesaemia which is incorrect
Hypothermia correct answer
A temporary single chamber pacing wire is being inserted for a patient with complete heart block. Where should the lead be positioned?
Your answer was Right Ventricle Apex which is correct
Right Ventricle Apex correct answer
Left Ventricular Apex
Bundle of HIS
A 72 year old man has had several episodes of collapse and TIAs. He had suffered from an extensive Myocardial Infarction previously. The only finding on clinical examination is a displaced apex beat. An ECG revealed anterior ST elevation although he is currently pain free. What further investigation is the most appropriate for diagnosis of the underlying diagnosis?
Your answer was Transoesophageal echocragiogram which is incorrect
Cardiac MRI correct answer
A left ventricular aneurysm is a likely possibility due to the persistence of the ST elevation with no chest pain and history of previous MI. The aneurysm would provide an environment for a thrombus to form and lead to an embolic source causing TIAs. The preferred initial imaging is a cardiac MRI.
A 40 year gentleman is concerned as his brother died whilst playing football following a sudden cardiac arrest. It was discovered that he had Hypertrophic Obstructive Cardiomyopathy on post mortem. How would you screen this gentleman?
Your answer was Trans oesophageal ECHO which is correct
Trans oesophageal ECHO correct answer
ECG at rest
Exercise Tolerance test
Dobutamine Stress Echo
A 60 year old woman has a history of PAF for which she is on warfarin and amiodarone, hypercholesterolaemia for which she takes simvastatin and hypertension on bendroflumethiazide and ramipril. She is suffering from recurrent UTIs and has been advised to drink cranberry juice. What is cranberry juice likely to interact with?
Your answer was Warfarin which is correct
Warfarin correct answer
Cranberry juice can cause inhibition of cytochrome P450 and thus should avoided with warfarin.
A 78 year old man has a PMH of MI, Angina and Hypertension. He attends for pre op assessment for a hip replacement. He remains relatively fit and an ETT 2 years earlier had been negative. What other investigation would you organise for preoperative assessment?
Your answer was Repeat ETT which is incorrect
Echocardiogram correct answer
Dobutamine Stress ECHO
Echocardiogram is the most suitable to exclude Left ventricular impairment and valvular disease. His recent ETT and no history of worsening angina would make a repeat ETT, angiography and dobutamine stress echo would not be appropriate.
A 40 year old man is referred to the cardiology clinic due to increased SOB and several TIAs with left sided weakness and slurred speech. He has no significant PMH, is a non smoker and drinks 10units of alcohol per week. On examination blood pressure is 145/98 and his pulse was 80 and regular. Although his chest clear there is evidence of a diastolic murmur with postural changes. Bloods are normal. What is the likely diagnosis?
Your answer was Left atrial myxoma which is correct
Left atrial myxoma correct answer
Mitral Valve Prolapse
In pregnany, which antiarrhythmic should be utilised as prophylaxsis for paroxysmal SVT?
Your answer was Metoprolol which is correct
Metoprolol correct answer
A 70 year old woman has had 34 syncopal episodes in the last 4 months. She has recently been prescribed enalapril for hypertension. On examination her blood pressure is 165/120 mmHg, she has aloud ejection systolic murmur and heaving apex beat and bibasal crackles. Which investigation will provide the diagnosis?
Your answer was Echocardiogram which is incorrect
Cardiac catheterisation correct answer
A 20 year old has been admitted with chest pain. He admitted to using cocaine and is found to have a STEMI. What do you do next?
Your answer was Aspirin and clopidogrel and LMWH which is incorrect
Percutaneous coronary intervention correct answer
Aspirin and clopidogrel and LMWH
Glycoprotein IIb/IIIa inhibitors
A 60 year old gentleman with angina is having increased shortness of breath on exertion. An ECHO shows normal LVF however an ETT is positive. What is the most appropriate management?
Your answer was Atenolol which is correct
Atenolol correct answer
What characteristic when described with chest pain is most indicative of myocardial ischaemia?
Your answer was Relief with GTN which is incorrect
Radiation to jaw correct answer
Shortness of Breath
Relief with GTN
What effect do class 1c agents have on the heart?
Your answer was Little effect on the action potential which is correct
Slow transmission at the AV node
Affect the SA node
Lengthen the action potential
Shorten the action potential
Little effect on the action potential
An 80 year old female collapsed whilst out shopping. A first aider was on the scene who stated he could not find a pulse for the first few seconds. On examination there was nil of note and an ECG is normal. A 24 hour tape is organised and is normal except for a few ectopics. What is the most likely diagnosis?
Your answer was Complete heart block which is incorrect
Complete heart block
Carotid Sinus Hypersensitivity correct answer
Sick sinus syndrome
A 50 year old gentleman is on warfarin for AF with an INR of 2.0. He is planning to undergo a tooth extraction, how would you manage his warfarin?
Your answer was Maintain warfarin at the therapeutic dose which is correct
Maintain warfarin at the therapeutic dose correct answer
Stop warfarin and convert to UFH until after procedure
Stop warfarin and convert to LMWH until after procedure
Convert to aspirin
Stop warfarin for 5 days before
As long as the INR is 2.0 or below then the British Haematological Society guidelines suggest the procedure can be performed.
A 60 year old woman is brought into A and E, she looks unwell. She had had been complaining of a sudden onset of palpitation and then collapsed. On examination she looks pale and sweaty, is drowsy and her blood pressure is 80/50mmHg. An ECG is performed and shows Torsades de Pointes. What following drug is not known to be associated with Torsades de Pointes?
Your answer was Digoxin which is incorrect
Verapamil correct answer
Verapamil is not associated with Torsades de Pointes due to its suppression of after depolarisations. Risperidone, erythromycin and sotalol can lead to prolonged QT interval.
A 55 year old gentleman presents to A and E following a collapse at work. He has a past medical history of hypertension managed with perindopril and is a smoker of 30 a day. On examination he has a left sided hemiplegia. Other examination findings and blood results are unremarkable. A CT head is organised and no intracerebral haemorrhage is seen. How long after presentation is thrombolysis appropriate to?
Your answer was 4 1/2 hours which is correct
4 1/2 hours correct answer
A 20 year old female is referred to the clinic due to palpitations which sometimes occur on exertion and are associated with nausea and light headedness. Her examination is unremarkable as are her blood results. What is the next most appropriate investigation for diagnosis?
Your answer was 24 hour ECG which is incorrect
12 lead ECG
Continuous loop recorder correct answer
24 hour ECG
Tilt Table Test
Due to the intermittent nature of her symptoms then continuous monitoring is the most appropriate for diagnosis as a 12 hour ECG is unlikely to rule out arrhythmias although may show features of some conditions such as WPW.
A 73 year old woman has a history of myocardial infarction and poor exercise tolerance due to SOB attends for preoperative assessment for a hip replacement. Her current medication is aspirin, ramipril and simvastatin. There is nil of note on examination and her HR and BP are within normal parameters. Blood results are normal. How would you assess her cardiovascular status further for suitability for surgery?
Your answer was Echocardiogram which is incorrect
Dobutamine stress echo correct answer
Exercise Tolerance Test
An exercise tolerance test would be the most appropriate but due to her requirement for a hip replacement and poor exercise tolerance test then a Dobutamine stress echo is the most appropriate as it does not require the patient to exercise but provides a similar stress via IV infusion of dobutamine. ECG monitoring and ECHO are undertaken during this test.
A 62 year old male is brought to A and E following a collapse. A first aider was on the scene and stated he was pulseless for a few seconds. He states he has been suffering from intermittent palpitations. What is the most likely diagnosis?
Your answer was Ventricular cardia which is incorrect
Sick sinus syndrome correct answer
Paroxysmal atrial fibrillation
Supra ventricular Tachycardia
The history reveals episodes of tachycardia, when the patient is aware of palpitations and bradycardia where he has collapsed and is pulseless. Thus it is indicative of Sick sinus syndrome where there is sinoatrial node dysfunction with periods of sinus bradycardia, sometimes asystole, conduction defects and SVT/atrial tachyarrhythmias. It can present with syncope, dizziness, palpitations, angina, CCF or stroke due to embolic events.(tachy-brady syn)
What investigation should be utilised to confirm an intraventricular thrombus following an Echo?
Your answer was Transthoracic echo which is correct
Transthoracic echo correct answer
Persistent ST elevation on ECG
Transthoracic echo is much more useful for assessing ventricles than transesophageal. Persistence of ST elevation on an ECG suggests development of a ventricular aneurysm post MI and although there may be a thrombus formed within this it is definitive.
A 67 year old male presents to his GP with a cold right hand. He has had a previous coronary artery bypass graft 3 years ago. Over the last few months he has noticed his hand being cold and painful. It occurs at rest and is not worsened by any particular movements. On examination his capillary refill time is slowed to about 3 seconds. The hand is cold and the radial pulse is impalpable. The rest of the examination is normal. He has not had an angina attack for some time. What is the most likely cause?
Your answer was Embolism which is incorrect
Radial artery trauma correct answer
Atherosclerosis of the radial artery
Ulnar artery trauma
This patient has had a CABG in the past. This means the radial artery may have been utilised for catheterisation. This can cause trauma to the radial artery and if this does not recanalise and there is significant athersclerosis to the ulnar artery this can lead to a compromised blood supply to the hand. In some patients the radial artery can be used for grafting. Subclavian stenosis can occur following CABG when the internal mammary artery is utilised however this does not typical present in this fashion as there is intermittent arm claudication worsened with arm raised above the head and there can be a steal syndrome leading to angina.
A 29 year old female who was on methadone dies suddenly whilst out running. Which of the following is the most likely cause?
Your answer was VF which is incorrect
Prolonged QT correct answer
Methadone can lead to a prolonged QT interval. Torsades de point is therefore a risk.
What is the most likely cause from the following to lead to cyanosis in the newborn within the first 24 hours?
Patent Ductus Arteriosus
Tetralogy of Fallot
Transposition of the great vessels correct answer
After cardioversion for AF, which of the following suggests there is a good chance of maintaining sinus rhythm?
Your answer was Duration of AF less than 6 months which is correct
Left ventricular dysfunction
Previous successful cardioversions
Left atrium enlarged
Duration of AF less than 6 months correct answer
After cardioversion for AF, which of the following suggests there is a good chance of maintaining sinus rhythm?
Your answer was Duration of AF less than 6 months which is correct
Left ventricular dysfunction
Previous successful cardioversions
Left atrium enlarged
Duration of AF less than 6 months correct answer
Which of the following cardiac abnormalities is most susceptible to the development of infective endocarditis?
Aortic regurgitation correct answer
Atrial septal defect
Mitral Valve Prolapse
Of the options here the highest risk is aortic regurgitation. Aortic stenosis is also at high risk as are prosthetic valves. ASD and mitral stenosis is at low risk as is MVP without regurgitation.
Which of the following is not useful in differentiating ventricular tachycardia from supraventricular tachycardia with aberrant conduction?
Your answer was Very irregular rhythm which is correct
Very irregular rhythm correct answer
Capture and fusion beats
QRS width >160 ms
RBBB with left axis deviation on ECG
Concordance of QRS in chest leads
A 68 year old male presents with severe central chest pain. He is found to have ST elevation in the anterolateral leads. A primary PCI is performed and a stent inserted. He is then found to be hypotensive at 70/40 with a few bibasal crepitations. Heart sounds are pure. A central line is inserted and his pulmonary artery wedge pressure is 12 mmHg. Which of the following is the most appropriate management?
Your answer was Inotropes which is incorrect
IV fluids correct answer
Hypotension can occur following an MI for numerous reasons. These include hypovolaemia, decreased left ventricular filling secondary to right ventricular failure, GTN therpay leading to vasodilatation and mechanical failure due to for example large infarcts. There is a low PCWP suggesting the patient may be underfilled and it is appropriate to give IV fluid challenges to optimise this before treating other potential causes and before inotropes can be commenced if appropriate.
A 50 year old gentleman presents with central chest pain with associated autonomic features. He looks grey and clammy and on auscultation his heart sounds are normal but there is bibasal crackles. His heart rate is 80 bpm and his blood pressure is 103/60 mm Hg. His ECG revealed ST elevation V1 to V4 and ST depression II, II and aVF. He is referred for Primary PCI. What is likely to be found at angiography?
Your answer was 70 per cent stenosis of left anterior descending artery which is incorrect
Complete occlusion of left anterior descending artery correct answer
70 per cent stenosis of left anterior descending artery
80 per cent stenosis of left circumflex artery
Complete occlusion of right coronary artery
A 68 year old female has recently had a mitral valve replacement. She presents feeling generally unwell, feverish with night sweats and weight loss. On examination she is pyrexial and there is a murmur in the aortic area and inflammatory markers are raised. Blood cultures are taken. What other investigation is most likely to confirm the diagnosis?
Transoesophageal Echocardiogram correct answer
The diagnosis you would be suspecting is infective endocarditis. The major criteria in Dukes criteria require two positive blood cultures and echocardiogram findings. TOE has been shown to be more sensitive and is more useful for visualising mitral valve lesions as in this case.
A 39 year old female who is being treated for hypertension and has recently commenced ramipril presents with sudden onset shortness of breath. His is has a regular pulse but is tachycardic and his heart sounds are pure. On auscultation of the chest there is bibasal crackles. What is the most likely underlying cause?
Your answer was Ischaemic heart disease which is incorrect
Renal artery stenosis correct answer
Ischaemic heart disease
This patient is likely to have renal artery stenosis and the ACE-I may have precipitated ARF and flash pulmonary oedema secondary to this. His pulse is regular thus this excludes AF. IHD and STEMI are much less likely considering the patients age and there is nothing indicative of this in the history.
An ETT shows J point ST depression of approximately 1 mm. What treatment should be initiated?
Your answer was Nil which is correct
Commence beta blockers
Nil correct answer
Referral for Angiography
A 30 year old woman presents with palpitations. She is found to have a regular tachycardia of 200 bpm. She is normally fit and healthy and has no past medical history however drinks 5 mugs of coffee per day and uses alcohol excessively. She is not compromised with a blood pressure of 130/80mmHg with no chest pain and no signs of heart failure. Her bloods are all within normal parameters however the ECG confirms a narrow complex tachycardia of 200 bpm. If after giving IV adenosine 3mg and then 6mg this fails what should be the next management step?
Your answer was IV 12mg adenosine which is correct
IV 12mg adenosine correct answer
IV amiodarone 900mg
A 72 year old female has a permanent pacemaker for complete heart block. She then presents with palpitations and shortness of breath and is found to be in fast atrial fibrillation. She is rate controlled and warfarin is commenced. It is decided that she should have DC cardioversion. In regards to this, which of the following is true?
During cardioversion pads placed 12-15cm away from permanent pacemaker, pacemaker and lead function check immediately following procedure and 4-6 weeks after correct answer
Cardioversion is contraindicated
During cardioversion pads placed 12-15cm away from permanent pacemaker, nil else required
No extra precautions required
Removal of pacemaker, then reinsertion following cardioversion
A permanent pacemaker or ICD is not a contraindication to DC cardioversion, however DC cardioversion can alter the settings of these devices. There is therefore certain precautions which must be taken including placing pads 12-15cm away from device and an immediate check of pacemaker and lead function and a further check at 4-6 weeks
A 42 year old female with rheumatoid arthritis presents with dyspnoea, fatigue and ankle swelling. An ECG reveals 2:1 heart block and an echo is performed and reveals ventricular wall thickening with granular sparkling of left ventricle and dilated atria. What is the most likely diagnosis?
Cardiac amyloid correct answer
A 25 year old female is referred due to palpitations. On examination her heart rate and blood pressure are normal, chest is clear however there is splitting of the first heart sound. On an ECG what is the first heart sound associated with?
R Wave correct answer
A patient is diagnosed with infective endocarditis. Which of the following requires urgent surgical intervention?
Your answer was Prolonged PR interval which is correct
Prolonged PR interval correct answer
Pyrexia and raised ESR despite antibiotic therapy
Shortened PR interval
A 60 year old who is on Lithium for bipolar disorder is found to be hypertensive by her GP is to be commenced on anti hypertensive therapy. What anti hypertensive would you prescribe to limit the risk of lithium toxicity?
Your answer was Bendroflumethiazide which is incorrect
Atenolol correct answer
A 50 year old man was admitted with central crushing chest pain. He is a smoker and is on ramipril fro hypertension which has not been well controlled. He is found to have ST depression in leads I, II, aVL, V4 V6 and his 12 hour troponin was 1.0. He underwent angiography and stent insertion. Three days later he is complaining of the same crushing central chest pain. A repeat ECG showed the same ST depression. Which enzyme should be measured to assess if there is further damage to the myocardium?
Your answer was LDH which is incorrect
CKMB correct answer
In this example CKMB would be useful if there has been a baseline value as it increase shortly after onset of chest pain and an increase again would indicate a new event as the levels decrease quickly. Troponin is not indicative as it does not reach its peak until 24-48 hours after onset of chest pain and remains elevated for up to 2 weeks following chest pain. LDH has a later peak at 3-6 days.
A 22 year old female has been suffering from intermittent palpitations. She states these occur about four times a year and she is finding them increasingly troublesome. A 24 hour ECG is organised and she is found to have paroxysmal atrial fibrillation. She is fit and well otherwise. She was commenced on a beta blocker however could not tolerate the side effects as she was having vivid dreams which were disturbing her sleep. Which of the following could be utilised as an alternative?
Your answer was Verapamil which is incorrect
Flecainide correct answer
This patient due to the infrequency of the episodes may be suitable for a "pill in the pocket" approach. Flecainide can be utilised PRN with the patient only taking it when they are suffering from an episode of AF. This is useful for infrequent episodes and can be used in patients with no past history of structural heart disease, LVF or unstable AF. Sotalol is another option. A regular betablocker can also be tried. If there is LV dysfunction or the others fail. Amiodarone can be considered. Surgery is also an option where pharmacological therapy has failed or there is evidence of WPW. Digoxin and verapamil are used in rate control.
A 55 year old man with poor dentition, has infective endocarditis. He presents with night sweats and lethargy to his e GP. Blood cultures are taken and grow Strep Viridans. Examination reveals splinter haemorrhages and a pyrexia of 37.8 C. On auscultation his chest is clear however there is evidence of a systolic murmur. Investigations revealed a Hb of 10.1 g/dL, WCC of 15.0 x109, an ESR of 101 and Acute Renal Failure. His ECG reveals a PR interval of 140 and an ECHO reveals vegetations on the mitral valve and mitral regurgitation. After 12 days of antibiotics intravenously, urgent surgical intervention is required for?
Your answer was Systolic Murmur which is incorrect
Prolonged PR Interval correct answer
Continually high ESR
Large mobile vegetation on mitral valve
The correct answer is the prolongation of PR interval as this implies that the myocardium has been affected and there may be formation of an abscess. If there is evidence of regurgitation with heart failure or obstruction of the valve this is another indication for surgery. If there is rupture into the pericardium immediate referral is required. Neither continued pyrexia or raised ESR are indications for surgical intervention.
What s the best indicator of the severity of aortic stenosis?
Your answer was Character of second heart sound which is correct
Character of second heart sound correct answer
Character of apex beat
Intensity of murmur
Co Existence of AR
In heart failure, what leads to a shift to the right of the pressure volume curve?
Reduced compliance secondary to volume overload
Increased contractibility of the chamber
Increased Compliance secondary to volume overload correct answer
A patient has taken an amitriptyline overdose. She is tachycardic and hypotensive and is having short runs of non sustained ventricular tachcardia. Her blood gases reveal a metabolic acidosis. In terms of the non sustained Ventricular tachycardia, what is the most appropriate management?
Your answer was IV Magnesium which is incorrect
IV Sodium bicarbonate correct answer
IV Amiodarone 900mg
IV Adenosine 6mg
In amitriptyline overdose Sodium bicarbonate is the treatment of choice. It has been shown to stabilise arrhythmias and increase blood pressure. Magnesium is useful in the management of VT not secondary to TCA overdose however is not the treatment of choice here. Adenosine is utilised for SVT.
A 30 year old male presents to his GP due to shortness of breath and chest discomfort whilst exercising. On examination there is a double apical impulse and a harsh mid systolic murmur loudest between the apex and the left sternal border. His ECG shows LVH and widespread Q waves. You suspect HOCM, which of the following is associated with increased risk of sudden death?
Your answer was Family history of sudden death which is incorrect
Degree of left ventricular hypertrophy correct answer
Asymmetrical septal hypertrophy
Loudness of murmur
Family history of sudden death
The most strongly correlated is the degree of LVH. Previously documented VT is also a risk factor.
The existence of atrial fibrillation with mitral stenosis results in which of the following?
Your answer was Disappearance of a wave and large V wave which is correct
Disappearance of a wave and large V wave correct answer
Large a wave
Large a wave and v wave
Deep x and y descents
A 42 year old male is found to be hypertensive with a blood pressure of 190/100 mmHg. He is otherwise fit and well and there is nil of note on examination. Bloods reveal normal renal function however there is evidence of hypokalaemia, elevated bicarbonate and both renin and aldosterone levels are increased. A 24 hour urinary cortisol fell within the normal range. What is the most likely diagnosis?
Your answer was Conn's syndrome which is incorrect
Renal artery fibromuscular dysplasia correct answer
This patient most likely is suffering from renal artery stenosis. The underlying pathology is fibromuscular dysplasia of the renal artery. It leads to hypoperfusion and thus leads to activation of the renin-angiotensin-aldosterone system leading to elevated renin and aldosterone levels and thus hypokalaemia. Conn's syndrome would lead to elevated aldosterone levels and suppressed renin levels. There is a normal cortisol and nil of note on examination thus Cushing's syndrome is unlikely. There is no symptoms to suggest phaeochromocytoma.
A patient presents bradycardic and she is haemodynamically unstable. It is thought to be related to a beta blocker overdose. She is given IV fluids and atropine with no response. Which of the following should be utilised?
Your answer was Temporary cardiac pacing which is incorrect
Glucagon correct answer
Temporary cardiac pacing
Glucagon can increase myocardial contraction, heart rate and AV conduction and many feel it is the drug of choice. Cardiac pacing is reserved for those who feel medical management. Haemodialysis may be useful for atenolol overdoses. High dose insulin has been shown to be useful in a few case reports but should always be discussed with a specialist. Adenosine is used in the management of SVTs and must be avoided.
How long should you advise a patient not to drive after pacemaker insertion?
One week correct answer
Can drive immediately
After permanent pacemaker insertion patient's should be advised not to drive for one week.
A 50 year old woman presents with left arm and leg weakness of 5 hours duration. She is known to have AF. She is hypertensive but her AF is rate controlled with a HR of 80. Neurological exam confirms 4/5 weakness but there is nil else remarkable, bloods are normal and CT head shows no evidence of haemorrhage. As there is no evidence of haemorrhage on CT, what anti platelet or anticoagulant are yo going to prescribe?
Your answer was Warfarin to be commenced covered by LMWH which is incorrect
Aspirin correct answer
Warfarin to be commenced covered by LMWH
As the symptoms have been present for 5 hours then thrombolysis is not appropriate as it it only recommended for up to 4 hours. Due to her AF she will need to be anticoagulated and it is recommended this should be delayed until 2 weeks later although this varies as there is early risk of haemorrhagic transformation. Aspirin should be commenced in the meantime.
Formula To Calculate Infusion Rate:
To find out drug concentration multiply the available milligrams by 1000 (1 mg =
1,000 mcg) and then divide the result by the amount of solution.
Now you can start Dopamine infusion at 10 ml/hr ( 10 microdrops per min)
Rule Of 6
The Rule of Six for drug infusion states that:
When (6 * body weight of patient) mg of a drug is diluted in 100 ml,
every ml/hr of the drug infused is equal to one mcg/kg/min
In other words,
(6 * BW) mg diluted in 100ml, 1 ml/hr = 1 mcg/kg/min, where BW - body weight
You can download this file for quick reference
HAPPY LEARNING :-)
The normal renal response when hypokalemia is due to non-renal causes is a TTKG <2, where a TTKG >5 is indicative of increased secretion of K+ in the cortical collecting ducts. Thus a transtubular potassium concentration gradient (TTKG) of greater than 3.0 indicates hypokalemia of renal origin, while a value below 2.0 indicates intracellular shift of K+, as found in ion channelopathy hypokalemic periodic paralysis.
The transtubular K+ concentration ([K+]) gradient (TTKG) is calculated using the following formula:
ECG Findings in RBBB:
QRS Morphology in the Lateral Leads
The R wave in the lateral leads may be either:
QRS Morphology in V1
The QRS complex in V1 may be either:
Incomplete LBBB is diagnosed when typical LBBB morphology is associated with a QRS duration < 120ms.
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