Cardiology Past Paper PDF

Cardiology ‫دعواتكم بالتوفيق ولكم بالمثل‬ PassM Q Bank M Y Elamin May 14, 2023 ‫ ص‬10:49 2022/‫‏‬10/‫‏‬25 PassMedicine PassMedicine Question 1 of 101 A 51-year-old man presen...

Cardiology ‫دعواتكم بالتوفيق ولكم بالمثل‬ PassM Q Bank M Y Elamin May 14, 2023 ‫ ص‬10:49 2022/‫‏‬10/‫‏‬25 PassMedicine PassMedicine Question 1 of 101 A 51-year-old man presents four weeks after being discharged from hospital. He had been admitted with chest pain and thrombolysed for a myocardial infarction. This morning he developed marked tongue and facial swelling. Which one of the following drugs is most likely to be responsible? Atorvastatin 3% Isosorbide mononitrate 13% Atenolol 3% Aspirin 13% Ramipril 67% ACE inhibitors are the most common cause of drug-induced angioedema. Discuss (5) Improve Next question ACE inhibitors Angiotensin-converting enzyme (ACE) inhibitors are now the established first-line treatment in younger patients with hypertension and are also extensively used to treat heart failure. They are known to be less effective in treating hypertensive Afro-Caribbean patients. ACE inhibitors are also used to treat diabetic nephropathy and have a role in the secondary prevention of ischaemic heart disease. Mechanism of action: inhibit the conversion angiotensin I to angiotensin II ACE inhibitors are activated by phase 1 metabolism in the liver Side-effects: https://www.passmedicine.com/v7/question/questions.php?q=0 1/7 ‫ ص‬10:49 2022/‫‏‬10/‫‏‬25 PassMedicine cough occurs in around 15% of patients and may occur up to a year after starting treatment thought to be due to increased bradykinin levels angioedema: may occur up to a year after starting treatment hyperkalaemia first-dose hypotension: more common in patients taking diuretics Cautions and contraindications pregnancy and breastfeeding - avoid renovascular disease - may result in renal impairment aortic stenosis - may result in hypotension hereditary of idiopathic angioedema specialist advice should be sought before starting ACE inhibitors in patients with a potassium >= 5.0 mmol/L Interactions patients receiving high-dose diuretic therapy (more than 80 mg of furosemide a day) significantly increases the risk of hypotension Monitoring urea and electrolytes should be checked before treatment is initiated and after increasing the dose a rise in the creatinine and potassium may be expected after starting ACE inhibitors acceptable changes are an increase in serum creatinine, up to 30% from baseline and an increase in potassium up to 5.5 mmol/l. significant renal impairment may occur in patients who have undiagnosed bilateral renal artery stenosis https://www.passmedicine.com/v7/question/questions.php?q=0 2/7 ‫ ص‬10:49 2022/‫‏‬10/‫‏‬25 PassMedicine Flow chart showing the management of hypertension as per current NICE guideliness Next question                Search Search textbook... Go Google search on "ACE inhibitors" Links NICE 17 8 2014 Chronic kidney disease guidelines https://www.passmedicine.com/v7/question/questions.php?q=0 3/7 ‫ ص‬10:49 2022/‫‏‬10/‫‏‬25 PassMedicine PassMedicine Question 2 of 101 A 51-year-old man is started on lisinopril after being found to have an average blood pressure of 154/93 on ambulatory blood pressure monitoring. Around two weeks after starting treatment he represents with a persistent dry cough. Accumulation of which one of the following proteins is responsible for this? Adenosine 3% Histamine 4% Bradykinin 88% Acetylcholine 3% Neurokinin A 2% ACE inhibitors prevent the breakdown of inflammatory peptides such as bradykinin and cough is a frequent side effect. Important for me Less important Discuss (2) Improve Next question ACE inhibitors Angiotensin-converting enzyme (ACE) inhibitors are now the established first-line treatment in younger patients with hypertension and are also extensively used to treat heart failure. They are known to be less effective in treating hypertensive Afro-Caribbean patients. ACE inhibitors are also used to treat diabetic nephropathy and have a role in the secondary prevention of ischaemic heart disease. Mechanism of action: https://www.passmedicine.com/v7/question/questions.php?q=0 1/7 ‫ ص‬10:49 2022/‫‏‬10/‫‏‬25 PassMedicine inhibit the conversion angiotensin I to angiotensin II ACE inhibitors are activated by phase 1 metabolism in the liver Side-effects: cough occurs in around 15% of patients and may occur up to a year after starting treatment thought to be due to increased bradykinin levels angioedema: may occur up to a year after starting treatment hyperkalaemia first-dose hypotension: more common in patients taking diuretics Cautions and contraindications pregnancy and breastfeeding - avoid renovascular disease - may result in renal impairment aortic stenosis - may result in hypotension hereditary of idiopathic angioedema specialist advice should be sought before starting ACE inhibitors in patients with a potassium >= 5.0 mmol/L Interactions patients receiving high-dose diuretic therapy (more than 80 mg of furosemide a day) significantly increases the risk of hypotension Monitoring urea and electrolytes should be checked before treatment is initiated and after increasing the dose a rise in the creatinine and potassium may be expected after starting ACE inhibitors acceptable changes are an increase in serum creatinine, up to 30% from baseline and an increase in potassium up to 5.5 mmol/l. significant renal impairment may occur in patients who have undiagnosed bilateral renal artery stenosis https://www.passmedicine.com/v7/question/questions.php?q=0 2/7 ‫ ص‬10:49 2022/‫‏‬10/‫‏‬25 PassMedicine Flow chart showing the management of hypertension as per current NICE guideliness Next question                Search Search textbook... Go Google search on "ACE inhibitors" Links NICE 17 8 2014 Chronic kidney disease guidelines https://www.passmedicine.com/v7/question/questions.php?q=0 3/7 ‫ ص‬10:50 2022/‫‏‬10/‫‏‬25 PassMedicine PassMedicine Question 3 of 101 A 64-year-old man attends his GP for an annual health check. He was found to be hypertensive and his GP started ramipril 2.5mg OD. His other medications include lansoprazole 30mg OD, furosemide 20mg OD and atorvastatin 40mg ON. His U+E have generally been stable and a blood test showed: Na+ 139 mmol/L (135 - 145) K+ 4.8 mmol/L (3.5 - 5.0) Urea 7.5 mmol/L (2.0 - 7.0) Creatinine 140 µmol/L (55 - 120) eGFR 47 ml/min/1.73m2 One month later the GP requests repeat U+Es: Na+ 139 mmol/L (135 - 145) K+ 6.1 mmol/L (3.5 - 5.0) Urea 8.5 mmol/L (2.0 - 7.0) Creatinine 150 µmol/L (55 - 120) eGFR 43 ml/min/1.73m2 An ECG is normal. Which of the following represents the most appropriate management plan, in addition to re- checking the U+E's? Initiate calcium resonium therapy 15% Stop ramipril and restart at a lower dose 7% Swap ramipril for another anti-hypertensive 67% Increase dose of furosemide 5% Advise on a low potassium diet 7% https://www.passmedicine.com/v7/question/questions.php?q=0 1/7 ‫ ص‬10:50 2022/‫‏‬10/‫‏‬25 PassMedicine A potassium above 6mmol/L should prompt cessation of ACE inhibitors in a patient with CKD (once other agents that promote hyperkalemia have been stopped) Important for me Less important NICE Clinical Guideline 182 - in patients with CKD, potassium above 6mmol/L should prompt cessation of ACE inhibitors in a patient with CKD (once other agents that promote hyperkalemia have been stopped). In this case, there is no other medicine that can be stopped first in an attempt to bring down the potassium. All the other options would decrease serum potassium, but would not conform to the NICE guidelines in this situation. Discuss (9) Improve Next question ACE inhibitors Angiotensin-converting enzyme (ACE) inhibitors are now the established first-line treatment in younger patients with hypertension and are also extensively used to treat heart failure. They are known to be less effective in treating hypertensive Afro-Caribbean patients. ACE inhibitors are also used to treat diabetic nephropathy and have a role in the secondary prevention of ischaemic heart disease. Mechanism of action: inhibit the conversion angiotensin I to angiotensin II ACE inhibitors are activated by phase 1 metabolism in the liver Side-effects: cough occurs in around 15% of patients and may occur up to a year after starting treatment thought to be due to increased bradykinin levels angioedema: may occur up to a year after starting treatment hyperkalaemia first-dose hypotension: more common in patients taking diuretics Cautions and contraindications pregnancy and breastfeeding - avoid https://www.passmedicine.com/v7/question/questions.php?q=0 2/7 ‫ ص‬10:50 2022/‫‏‬10/‫‏‬25 PassMedicine renovascular disease - may result in renal impairment aortic stenosis - may result in hypotension hereditary of idiopathic angioedema specialist advice should be sought before starting ACE inhibitors in patients with a potassium >= 5.0 mmol/L Interactions patients receiving high-dose diuretic therapy (more than 80 mg of furosemide a day) significantly increases the risk of hypotension Monitoring urea and electrolytes should be checked before treatment is initiated and after increasing the dose a rise in the creatinine and potassium may be expected after starting ACE inhibitors acceptable changes are an increase in serum creatinine, up to 30% from baseline and an increase in potassium up to 5.5 mmol/l. significant renal impairment may occur in patients who have undiagnosed bilateral renal artery stenosis Flow chart showing the management of hypertension as per current NICE guideliness https://www.passmedicine.com/v7/question/questions.php?q=0 3/7 ‫ ص‬10:50 2022/‫‏‬10/‫‏‬25 PassMedicine PassMedicine Question 4 of 101 A 79-year-old female, newly diagnosed as hypertensive is taken to the emergency department with collapse. She recalls feeling 'giddy' moments before. She had just started a new medication from her GP. Her past medical history includes: type II diabetes mellitus, glaucoma, diverticular disease. Which of the following medications is she most likely to have just started? Ramipril 58% Prochlorperazine 17% Fludrocortisone 7% Metformin 2% Timolol eye drops 16% ACE inhibitors can cause first dose hypotension Important for me Less important The prodrome of feeling 'giddy' should raise suspicions of syncope. ACE inhibitors (eg ramipril) can characteristically cause first-dose hypotension. It is also the first line anti-hypertensive in diabetics. Prochlorperazine is a medication used to treat vertigo, amongst other indications. It is not used in the treatment of any of this lady's medical problems. Additionally, it is unlikely to result in syncope. Fludrocortisone acts to increase blood pressure and therefore would not lead to syncope. Metformin rarely causes hypoglycaemia and is therefore unlikely to cause collapse. While beta-blockers could cause syncope this is very unlikely after application of eye drops. https://www.passmedicine.com/v7/question/questions.php?q=0 1/6 ‫ ص‬10:50 2022/‫‏‬10/‫‏‬25 PassMedicine Discuss (4) Improve Next question ACE inhibitors: side-effects Side-effects: cough: occurs in around 15% of patients and may occur up to a year after starting treatment. Thought to be due to increased bradykinin levels angioedema: may occur up to a year after starting treatment hyperkalaemia first-dose hypotension: more common in patients taking diuretics Cautions and contraindications pregnancy and breastfeeding - avoid renovascular disease - significant renal impairment may occur in patients who have undiagnosed bilateral renal artery stenosis aortic stenosis - may result in hypotension patients receiving high-dose diuretic therapy (more than 80 mg of furosemide a day) - significantly increases the risk of hypotension hereditary or idiopathic angioedema Monitoring urea and electrolytes should be checked before treatment is initiated and after increasing the dose a rise in the creatinine and potassium may be expected after starting ACE inhibitors. Acceptable changes are an increase in serum creatinine, up to 30%* from baseline and an increase in potassium up to 5.5 mmol/l*. *Renal Association UK, Clinical Knowledge Summaries quote 50% which seems rather high. SIGN advise that the fall in eGFR should be less than 20%. The NICE CKD guidelines suggest that a decrease in eGFR of up to 25% or a rise in creatinine of up to 30% is acceptable Next question                https://www.passmedicine.com/v7/question/questions.php?q=0 2/6 ‫ ص‬10:50 2022/‫‏‬10/‫‏‬25 PassMedicine PassMedicine Question 5 of 101 A 57-year-old man comes to the emergency department with severe, central, crushing chest pain. By the time he arrives on the medical admissions unit he is pain-free. He had a myocardial infarction (MI) two years ago; additionally he has type 2 diabetes mellitus, hypertension and hypercholesterolaemia. His brother died of a MI at a similar age. His repeat prescriptions include aspirin, metformin, ramipril, amlodipine and atorvastatin. On examination he looks pale and sweaty. On auscultation he has vesicular breathing and normal heart sounds. He is overweight. His oxygen saturations are 98% on air; respiratory rate 14 breaths per minute; blood pressure 150/88 mmHg, heart rate 90 beats per minute. His blood sugar (BM) is 22.5. There are no ischaemic changes on his ECG; however a 12 hour troponin is elevated. The admitting doctor has already given aspirin, clopidogrel and fondaparinux. What is the next step in the management of this patient? IV GTN infusion 6% 15L oxygen via non-rebreathe mask 1% Primary PCI within 4 hours 28% Additional dose metformin 2% Angiography within 72 hours 64% This man is having an NSTEMI. His myriad risk factors him categorise him as high risk, and therefore he should have definitive angiography +/- stenting within 72 hours. He is maintaining his oxygen saturations, is pain-free and has no ST elevation, making the other options incorrect. Metformin is actually best avoided in acute tissue ischaemia due to its association with lactic acidosis. Discuss (4) Improve https://www.passmedicine.com/v7/question/questions.php?q=0 1/11 ‫ ص‬10:50 2022/‫‏‬10/‫‏‬25 PassMedicine Next question Acute coronary syndrome: initial management Acute coronary syndrome (ACS) is a very common and important presentation in medicine. The management of ACS has evolved over recent years, with the development of new drugs and procedures such as percutaneous coronary intervention (PCI). Emergency departments often have their own protocols based on local factors such as the availability of PCI and hospital drug formularies. The following is based on the 2020 update to the NICE ACS guidelines. Acute coronary syndrome can be classified as follows: ST-elevation myocardial infarction (STEMI): ST-segment elevation + elevated biomarkers of myocardial damage non ST-elevation myocardial infarction (NSTEMI): ECG changes but no ST-segment elevation + elevated biomarkers of myocardial damage unstable angina The management of ACS depends on the particular subtype. NICE management guidance groups the patients into two groups: 1. STEMI 2. NSTEM/unstable angina Common management of all patients with ACS Initial drug therapy aspirin 300mg oxygen should only be given if the patient has oxygen saturations < 94% in keeping with British Thoracic Society oxygen therapy guidelines morphine should only be given for patients with severe pain previously IV morphine was given routinely evidence, however, suggests that this may be associated with adverse outcomes nitrates can be given either sublingually or intravenously useful if the patient has ongoing chest pain or hypertension should be used in caution if patient hypotensive https://www.passmedicine.com/v7/question/questions.php?q=0 2/11 ‫ ص‬10:50 2022/‫‏‬10/‫‏‬25 PassMedicine The next step in managing a patient with suspected ACS is to determine whether they meet the ECG criteria for STEMI. It is, of course, important to recognise that these criteria should be interpreted in the context of the clinical history. STEMI criteria clinical symptoms consistent with ACS (generally of ≥ 20 minutes duration) with persistent (> 20 minutes) ECG features in ≥ 2 contiguous leads of: 2.5 mm (i.e ≥ 2.5 small squares) ST elevation in leads V2-3 in men under 40 years, or ≥ 2.0 mm (i.e ≥ 2 small squares) ST elevation in leads V2-3 in men over 40 years 1.5 mm ST elevation in V2-3 in women 1 mm ST elevation in other leads new LBBB (LBBB should be considered new unless there is evidence otherwise) Management of STEMI Diagram showing the simplified management of STEMI according to NICE guidelines. A number of assumptions (listed at the bottom) are made. Once a STEMI has been confirmed the first step is to immediately assess eligibility for coronary reperfusion therapy. There are two types of coronary reperfusion therapy: percutaneous coronary intervention should be offered if the presentation is within 12 hours of the onset of symptoms AND PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given (i.e. consider fibrinolysis if there is a significant delay in being able to provide PCI) if patients present after 12 hours and still have evidence of ongoing ischaemia then PCI should still be considered drug-eluting stents are now used. Previously 'bare-metal' stents were sometimes used but have higher rates of restenosis https://www.passmedicine.com/v7/question/questions.php?q=0 3/11 ‫ ص‬10:50 2022/‫‏‬10/‫‏‬25 PassMedicine radial access is preferred to femoral access fibrinolysis should be offered within 12 hours of the onset of symptoms if primary PCI cannot be delivered within 120 minutes of the time when fibrinolysis could have been given a practical example may be a patient who presents with a STEMI to a small district general hospital (DGH) that does not have facilities for PCI. If they cannot be transferred to a larger hospital for PCI within 120 minutes then fibrinolysis should be given. If the patient's ECG taken 90 minutes after fibrinolysis failed to show resolution of the ST elevation then they would then require transfer for PCI If patients are eligible this should be offered as soon as possible. Percutaneous coronary intervention for patients with STEMI Further antiplatelet prior to PCI this is termed 'dual antiplatelet therapy', i.e. aspirin + another drug if the patient is not taking an oral anticoagulant: prasugrel if taking an oral anticoagulant: clopidogrel Drug therapy during PCI patients undergoing PCI with radial access: unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor (GPI) - this is the action of using a GPI during the procedure when it was not intended from the outset, e.g. because of worsening or persistent thrombus patients undergoing PCI with femoral access: bivalirudin with bailout GPI Other procedures during PCI thrombus aspiration, but not mechanical thrombus extraction, should be considered complete revascularisation should be considered for patients with multivessel coronary artery disease without cardiogenic shock Fibrinolysis for patients with STEMI Fibrinolysis used to be the only form of coronary reperfusion therapy available. However, it is used much less commonly now given the widespread availability of PCI. The contraindications to fibrinolysis and other factors are described in other notes. https://www.passmedicine.com/v7/question/questions.php?q=0 4/11 ‫ ص‬10:50 2022/‫‏‬10/‫‏‬25 PassMedicine Patients undergoing fibrinolysis should also be given an antithrombin drug. An ECG should be repeated after 60-90 minutes to see if the ECG changes have resolved. If patients have persistent myocardial ischaemia following fibrinolysis then PCI should be considered. Management of NSTEMI/unstable angina Diagram showing the simplified management of NSTEMI/unstable angina according to NICE guidelines. A number of assumptions (listed at the bottom) are made. The management of NSTEMI/unstable angina is complicated and depends on individual patient factors and a risk assessment. The summary below provides an overview but the full NICE guidelines should be reviewed for further details. Further drug therapy antithrombin treatment fondaparinux should be offered to patients who are not at a high risk of bleeding and who are not having angiography immediately if immediate angiography is planned or a patients creatinine is > 265 µmol/L then unfractionated heparin should be given Risk assessment The Global Registry of Acute Coronary Events (GRACE) is the most widely used tool for risk assessment. It can be calculated using online tools and takes into account the following factors: age heart rate, blood pressure cardiac (Killip class) and renal function (serum creatinine) https://www.passmedicine.com/v7/question/questions.php?q=0 5/11 ‫ ص‬10:50 2022/‫‏‬10/‫‏‬25 PassMedicine cardiac arrest on presentation ECG findings troponin levels This results in the patient being risk stratified as follows: Predicted 6‑month mortality Risk of future adverse cardiovascular events 1.5% or below Lowest > 1.5% to 3.0% Low > 3.0% to 6.0% Intermediate > 6.0% to 9.0% High over 9.0% Highest Based on this risk assessment key decisions are made regarding whether a patient has coronary angiography (with follow-on PCI if necessary) or has conservative management. The detailed pros/cons of this decision are covered in other notes. Which patients with NSTEMI/unstable angina should have coronary angiography (with follow-on PCI if necessary)? immediate: patient who are clinically unstable (e.g. hypotensive) within 72 hours: patients with a GRACE score > 3% i.e. those at intermediate, high or highest risk coronary angiography should also be considered for patients if ischaemia is subsequently experienced after admission Percutaneous coronary intervention for patients with NSTEMI/unstable angina Further drug therapy unfractionated heparin should be given regardless of whether the patient has had fondaparinux or not further antiplatelet ('dual antiplatelet therapy', i.e. aspirin + another drug) prior to PCI if the patient is not taking an oral anticoagulant: prasugrel or ticagrelor if taking an oral anticoagulant: clopidogrel Conservative management for patients with NSTEMI/unstable angina https://www.passmedicine.com/v7/question/questions.php?q=0 6/11 ‫ ص‬10:50 2022/‫‏‬10/‫‏‬25 PassMedicine Further drug therapy further antiplatelet ('dual antiplatelet therapy', i.e. aspirin + another drug) if the patient is not at a high risk of bleeding: ticagrelor if the patient is at a high risk of bleeding: clopidogrel Next question                Search Search textbook... Go Google search on "Acute coronary syndrome: initial management" Links SIGN 5 4 2016 Acute coronary syndrome guidelines NICE 15 11 2020 Acute coronary syndromes guidelines Report broken link Media YouTube Acute Coronary Syndrome DETAILED Overview (MI, STEMI, NSTEMI) Armando Hasudungan - YouTube 12 3 YouTube https://www.passmedicine.com/v7/question/questions.php?q=0 7/11 ‫ ص‬10:51 2022/‫‏‬10/‫‏‬25 PassMedicine PassMedicine Question 6 of 101 A 55-year-old man is admitted with central chest pain. His ECG shows ST depression in the inferior leads and the chest pain requires intravenous morphine to settle. Past medical history includes a thrombolysed myocardial infarction 2 years ago, asthma and type 2 diabetes mellitus. Treatment with aspirin, clopidogrel and unfractionated heparin is commenced. Which one of the following factors should determine if an intravenous glycoprotein IIb/IIIa receptor antagonist is to be given? High GRACE (Global Registry of Acute Cardiac Events) risk score + whether a 71% percutaneous coronary intervention is to be performed Degree of ST depression 2% High GRACE (Global Registry of Acute Cardiac Events) risk score 16% Presence of a left ventricular thrombus 7% The presence of recurrent cardiac chest pain 4% Discuss (3) Improve Next question Acute coronary syndrome: initial management Acute coronary syndrome (ACS) is a very common and important presentation in medicine. The management of ACS has evolved over recent years, with the development of new drugs and procedures such as percutaneous coronary intervention (PCI). Emergency departments often have their own protocols based on local factors such as the availability of PCI and hospital drug formularies. The following is based on the 2020 update to the NICE ACS guidelines. Acute coronary syndrome can be classified as follows: https://www.passmedicine.com/v7/question/questions.php?q=0 1/11 ‫ ص‬10:51 2022/‫‏‬10/‫‏‬25 PassMedicine ST-elevation myocardial infarction (STEMI): ST-segment elevation + elevated biomarkers of myocardial damage non ST-elevation myocardial infarction (NSTEMI): ECG changes but no ST-segment elevation + elevated biomarkers of myocardial damage unstable angina The management of ACS depends on the particular subtype. NICE management guidance groups the patients into two groups: 1. STEMI 2. NSTEM/unstable angina Common management of all patients with ACS Initial drug therapy aspirin 300mg oxygen should only be given if the patient has oxygen saturations < 94% in keeping with British Thoracic Society oxygen therapy guidelines morphine should only be given for patients with severe pain previously IV morphine was given routinely evidence, however, suggests that this may be associated with adverse outcomes nitrates can be given either sublingually or intravenously useful if the patient has ongoing chest pain or hypertension should be used in caution if patient hypotensive The next step in managing a patient with suspected ACS is to determine whether they meet the ECG criteria for STEMI. It is, of course, important to recognise that these criteria should be interpreted in the context of the clinical history. STEMI criteria clinical symptoms consistent with ACS (generally of ≥ 20 minutes duration) with persistent (> 20 minutes) ECG features in ≥ 2 contiguous leads of: 2.5 mm (i.e ≥ 2.5 small squares) ST elevation in leads V2-3 in men under 40 years, or ≥ 2.0 mm (i.e ≥ 2 small squares) ST elevation in leads V2-3 in men over 40 years 1.5 mm ST elevation in V2-3 in women 1 mm ST elevation in other leads new LBBB (LBBB should be considered new unless there is evidence otherwise) Management of STEMI https://www.passmedicine.com/v7/question/questions.php?q=0 2/11 ‫ ص‬10:51 2022/‫‏‬10/‫‏‬25 PassMedicine Diagram showing the simplified management of STEMI according to NICE guidelines. A number of assumptions (listed at the bottom) are made. Once a STEMI has been confirmed the first step is to immediately assess eligibility for coronary reperfusion therapy. There are two types of coronary reperfusion therapy: percutaneous coronary intervention should be offered if the presentation is within 12 hours of the onset of symptoms AND PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given (i.e. consider fibrinolysis if there is a significant delay in being able to provide PCI) if patients present after 12 hours and still have evidence of ongoing ischaemia then PCI should still be considered drug-eluting stents are now used. Previously 'bare-metal' stents were sometimes used but have higher rates of restenosis radial access is preferred to femoral access fibrinolysis should be offered within 12 hours of the onset of symptoms if primary PCI cannot be delivered within 120 minutes of the time when fibrinolysis could have been given a practical example may be a patient who presents with a STEMI to a small district general hospital (DGH) that does not have facilities for PCI. If they cannot be transferred to a larger hospital for PCI within 120 minutes then fibrinolysis should be given. If the patient's ECG taken 90 minutes after fibrinolysis failed to show resolution of the ST elevation then they would then require transfer for PCI If patients are eligible this should be offered as soon as possible. Percutaneous coronary intervention for patients with STEMI Further antiplatelet prior to PCI this is termed 'dual antiplatelet therapy', i.e. aspirin + another drug https://www.passmedicine.com/v7/question/questions.php?q=0 3/11 ‫ ص‬10:51 2022/‫‏‬10/‫‏‬25 PassMedicine if the patient is not taking an oral anticoagulant: prasugrel if taking an oral anticoagulant: clopidogrel Drug therapy during PCI patients undergoing PCI with radial access: unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor (GPI) - this is the action of using a GPI during the procedure when it was not intended from the outset, e.g. because of worsening or persistent thrombus patients undergoing PCI with femoral access: bivalirudin with bailout GPI Other procedures during PCI thrombus aspiration, but not mechanical thrombus extraction, should be considered complete revascularisation should be considered for patients with multivessel coronary artery disease without cardiogenic shock Fibrinolysis for patients with STEMI Fibrinolysis used to be the only form of coronary reperfusion therapy available. However, it is used much less commonly now given the widespread availability of PCI. The contraindications to fibrinolysis and other factors are described in other notes. Patients undergoing fibrinolysis should also be given an antithrombin drug. An ECG should be repeated after 60-90 minutes to see if the ECG changes have resolved. If patients have persistent myocardial ischaemia following fibrinolysis then PCI should be considered. Management of NSTEMI/unstable angina https://www.passmedicine.com/v7/question/questions.php?q=0 4/11 ‫ ص‬10:51 2022/‫‏‬10/‫‏‬25 PassMedicine Diagram showing the simplified management of NSTEMI/unstable angina according to NICE guidelines. A number of assumptions (listed at the bottom) are made. The management of NSTEMI/unstable angina is complicated and depends on individual patient factors and a risk assessment. The summary below provides an overview but the full NICE guidelines should be reviewed for further details. Further drug therapy antithrombin treatment fondaparinux should be offered to patients who are not at a high risk of bleeding and who are not having angiography immediately if immediate angiography is planned or a patients creatinine is > 265 µmol/L then unfractionated heparin should be given Risk assessment The Global Registry of Acute Coronary Events (GRACE) is the most widely used tool for risk assessment. It can be calculated using online tools and takes into account the following factors: age heart rate, blood pressure cardiac (Killip class) and renal function (serum creatinine) cardiac arrest on presentation ECG findings troponin levels This results in the patient being risk stratified as follows: Predicted 6‑month mortality Risk of future adverse cardiovascular events https://www.passmedicine.com/v7/question/questions.php?q=0 5/11 ‫ ص‬10:51 2022/‫‏‬10/‫‏‬25 PassMedicine Predicted 6‑month mortality Risk of future adverse cardiovascular events 1.5% or below Lowest > 1.5% to 3.0% Low > 3.0% to 6.0% Intermediate > 6.0% to 9.0% High over 9.0% Highest Based on this risk assessment key decisions are made regarding whether a patient has coronary angiography (with follow-on PCI if necessary) or has conservative management. The detailed pros/cons of this decision are covered in other notes. Which patients with NSTEMI/unstable angina should have coronary angiography (with follow-on PCI if necessary)? immediate: patient who are clinically unstable (e.g. hypotensive) within 72 hours: patients with a GRACE score > 3% i.e. those at intermediate, high or highest risk coronary angiography should also be considered for patients if ischaemia is subsequently experienced after admission Percutaneous coronary intervention for patients with NSTEMI/unstable angina Further drug therapy unfractionated heparin should be given regardless of whether the patient has had fondaparinux or not further antiplatelet ('dual antiplatelet therapy', i.e. aspirin + another drug) prior to PCI if the patient is not taking an oral anticoagulant: prasugrel or ticagrelor if taking an oral anticoagulant: clopidogrel Conservative management for patients with NSTEMI/unstable angina Further drug therapy further antiplatelet ('dual antiplatelet therapy', i.e. aspirin + another drug) if the patient is not at a high risk of bleeding: ticagrelor if the patient is at a high risk of bleeding: clopidogrel Next question https://www.passmedicine.com/v7/question/questions.php?q=0 6/11 ‫ ص‬10:51 2022/‫‏‬10/‫‏‬25 PassMedicine PassMedicine Question 7 of 101 You review a patient who has been admitted with a non-ST elevation myocardial infarction in the Emergency Department. They have so far been treated with aspirin 300mg stat and glyceryl trinitrate spray (2 puffs). Following recent NICE guidance, which patients should receive ticagrelor? Patients < 75 years of age 6% Patients who have a history of hypertension, ischaemic heart disease or diabetes mellitus 11% Those who have a predicted 12 month mortality > 10% 12% Those who have a predicted 6 month mortality < 10% 5% All patients 67% Discuss (3) Improve Next question Acute coronary syndrome: initial management Acute coronary syndrome (ACS) is a very common and important presentation in medicine. The management of ACS has evolved over recent years, with the development of new drugs and procedures such as percutaneous coronary intervention (PCI). Emergency departments often have their own protocols based on local factors such as the availability of PCI and hospital drug formularies. The following is based on the 2020 update to the NICE ACS guidelines. Acute coronary syndrome can be classified as follows: ST-elevation myocardial infarction (STEMI): ST-segment elevation + elevated biomarkers of myocardial damage https://www.passmedicine.com/v7/question/questions.php?q=0 1/11 ‫ ص‬10:51 2022/‫‏‬10/‫‏‬25 PassMedicine non ST-elevation myocardial infarction (NSTEMI): ECG changes but no ST-segment elevation + elevated biomarkers of myocardial damage unstable angina The management of ACS depends on the particular subtype. NICE management guidance groups the patients into two groups: 1. STEMI 2. NSTEM/unstable angina Common management of all patients with ACS Initial drug therapy aspirin 300mg oxygen should only be given if the patient has oxygen saturations < 94% in keeping with British Thoracic Society oxygen therapy guidelines morphine should only be given for patients with severe pain previously IV morphine was given routinely evidence, however, suggests that this may be associated with adverse outcomes nitrates can be given either sublingually or intravenously useful if the patient has ongoing chest pain or hypertension should be used in caution if patient hypotensive The next step in managing a patient with suspected ACS is to determine whether they meet the ECG criteria for STEMI. It is, of course, important to recognise that these criteria should be interpreted in the context of the clinical history. STEMI criteria clinical symptoms consistent with ACS (generally of ≥ 20 minutes duration) with persistent (> 20 minutes) ECG features in ≥ 2 contiguous leads of: 2.5 mm (i.e ≥ 2.5 small squares) ST elevation in leads V2-3 in men under 40 years, or ≥ 2.0 mm (i.e ≥ 2 small squares) ST elevation in leads V2-3 in men over 40 years 1.5 mm ST elevation in V2-3 in women 1 mm ST elevation in other leads new LBBB (LBBB should be considered new unless there is evidence otherwise) Management of STEMI https://www.passmedicine.com/v7/question/questions.php?q=0 2/11 ‫ ص‬10:51 2022/‫‏‬10/‫‏‬25 PassMedicine Diagram showing the simplified management of STEMI according to NICE guidelines. A number of assumptions (listed at the bottom) are made. Once a STEMI has been confirmed the first step is to immediately assess eligibility for coronary reperfusion therapy. There are two types of coronary reperfusion therapy: percutaneous coronary intervention should be offered if the presentation is within 12 hours of the onset of symptoms AND PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given (i.e. consider fibrinolysis if there is a significant delay in being able to provide PCI) if patients present after 12 hours and still have evidence of ongoing ischaemia then PCI should still be considered drug-eluting stents are now used. Previously 'bare-metal' stents were sometimes used but have higher rates of restenosis radial access is preferred to femoral access fibrinolysis should be offered within 12 hours of the onset of symptoms if primary PCI cannot be delivered within 120 minutes of the time when fibrinolysis could have been given a practical example may be a patient who presents with a STEMI to a small district general hospital (DGH) that does not have facilities for PCI. If they cannot be transferred to a larger hospital for PCI within 120 minutes then fibrinolysis should be given. If the patient's ECG taken 90 minutes after fibrinolysis failed to show resolution of the ST elevation then they would then require transfer for PCI If patients are eligible this should be offered as soon as possible. Percutaneous coronary intervention for patients with STEMI Further antiplatelet prior to PCI this is termed 'dual antiplatelet therapy', i.e. aspirin + another drug if the patient is not taking an oral anticoagulant: prasugrel https://www.passmedicine.com/v7/question/questions.php?q=0 3/11 ‫ ص‬10:51 2022/‫‏‬10/‫‏‬25 PassMedicine if taking an oral anticoagulant: clopidogrel Drug therapy during PCI patients undergoing PCI with radial access: unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor (GPI) - this is the action of using a GPI during the procedure when it was not intended from the outset, e.g. because of worsening or persistent thrombus patients undergoing PCI with femoral access: bivalirudin with bailout GPI Other procedures during PCI thrombus aspiration, but not mechanical thrombus extraction, should be considered complete revascularisation should be considered for patients with multivessel coronary artery disease without cardiogenic shock Fibrinolysis for patients with STEMI Fibrinolysis used to be the only form of coronary reperfusion therapy available. However, it is used much less commonly now given the widespread availability of PCI. The contraindications to fibrinolysis and other factors are described in other notes. Patients undergoing fibrinolysis should also be given an antithrombin drug. An ECG should be repeated after 60-90 minutes to see if the ECG changes have resolved. If patients have persistent myocardial ischaemia following fibrinolysis then PCI should be considered. Management of NSTEMI/unstable angina https://www.passmedicine.com/v7/question/questions.php?q=0 4/11 ‫ ص‬10:51 2022/‫‏‬10/‫‏‬25 PassMedicine Diagram showing the simplified management of NSTEMI/unstable angina according to NICE guidelines. A number of assumptions (listed at the bottom) are made. The management of NSTEMI/unstable angina is complicated and depends on individual patient factors and a risk assessment. The summary below provides an overview but the full NICE guidelines should be reviewed for further details. Further drug therapy antithrombin treatment fondaparinux should be offered to patients who are not at a high risk of bleeding and who are not having angiography immediately if immediate angiography is planned or a patients creatinine is > 265 µmol/L then unfractionated heparin should be given Risk assessment The Global Registry of Acute Coronary Events (GRACE) is the most widely used tool for risk assessment. It can be calculated using online tools and takes into account the following factors: age heart rate, blood pressure cardiac (Killip class) and renal function (serum creatinine) cardiac arrest on presentation ECG findings troponin levels This results in the patient being risk stratified as follows: Predicted 6‑month mortality Risk of future adverse cardiovascular events https://www.passmedicine.com/v7/question/questions.php?q=0 5/11 ‫ ص‬10:51 2022/‫‏‬10/‫‏‬25 PassMedicine Predicted 6‑month mortality Risk of future adverse cardiovascular events 1.5% or below Lowest > 1.5% to 3.0% Low > 3.0% to 6.0% Intermediate > 6.0% to 9.0% High over 9.0% Highest Based on this risk assessment key decisions are made regarding whether a patient has coronary angiography (with follow-on PCI if necessary) or has conservative management. The detailed pros/cons of this decision are covered in other notes. Which patients with NSTEMI/unstable angina should have coronary angiography (with follow-on PCI if necessary)? immediate: patient who are clinically unstable (e.g. hypotensive) within 72 hours: patients with a GRACE score > 3% i.e. those at intermediate, high or highest risk coronary angiography should also be considered for patients if ischaemia is subsequently experienced after admission Percutaneous coronary intervention for patients with NSTEMI/unstable angina Further drug therapy unfractionated heparin should be given regardless of whether the patient has had fondaparinux or not further antiplatelet ('dual antiplatelet therapy', i.e. aspirin + another drug) prior to PCI if the patient is not taking an oral anticoagulant: prasugrel or ticagrelor if taking an oral anticoagulant: clopidogrel Conservative management for patients with NSTEMI/unstable angina Further drug therapy further antiplatelet ('dual antiplatelet therapy', i.e. aspirin + another drug) if the patient is not at a high risk of bleeding: ticagrelor if the patient is at a high risk of bleeding: clopidogrel Next question https://www.passmedicine.com/v7/question/questions.php?q=0 6/11 ‫ ص‬10:52 2022/‫‏‬10/‫‏‬25 PassMedicine PassMedicine Question 8 of 101 You are an SHO working at district general hospital in Cornwall. A 56-year-old man presents to the emergency department with crushing central chest pain that started 30 minutes ago. His ECG demonstrates ST elevation in the anterior leads and he is treated for an ST-elevation myocardial infarction (STEMI). So far he has been given aspirin, clopidogrel, low-molecular weight heparin (LMWH) and his chest pain has significantly improved with sublingual GTN and IV morphine + metoclopramide. There is no cath-lab on site and and the nearest percutaneous coronary intervention (PCI) centre in Truro is approximately 2 ½ hours away. Which of the following is the most appropriate course of action? Transfer to PCI centre 15% Give bivalirudin 1% Start infusion of unfractionated heparin and transfer to PCI centre 16% Give alteplase 65% Give ticagrelor 3% STEMI management: fibrinolysis should be offered within 12 hours of onset of symptoms if primary PCI cannot be delivered within 120 minutes Important for me Less important In the management of STEMI fibrinolysis with a drug such as alteplase should be offered if primary PCI cannot be delivered within 120 minutes of the time when fibrinolysis could have been given. This problem is most often encountered when a patient initially presents to a district general hospital that lacks a PCI centre. Ambulances are generally directed to PCI centres in cases of chest pain and this has reduced the frequency with which this occurs. If a repeat ECG at 90 minutes does not show resolution of ST elevation the patient will require transfer to a PCI centre regardless. 1- This is inappropriate. The transfer time is over 120 minutes from when fibrinolysis could be given. This would therefore be an unacceptable delay. https://www.passmedicine.com/v7/question/questions.php?q=0 1/11 ‫ ص‬10:52 2022/‫‏‬10/‫‏‬25 PassMedicine 2- This is a direct thrombin inhibitor. It has a role in STEMI management but would not address the main issue which is the need for PCI/fibrinolysis. 3- Though sometimes used in STEMI again, fibrinolysis or PCI are needed. Additionally, the patient has already had LMWH so this would not make a difference 4- Correct! As the time to PCI is more than 120 minutes from the time at which fibrinolysis (with alteplase in this example) could be given, fibrinolysis should be offered. 5. This is an antagonist of the P2Y12 adenosine diphosphate receptor like clopidogrel, which has already been given. Adding ticagrelor would therefore confer no benefit in this scenario Discuss (6) Improve Next question Acute coronary syndrome: initial management Acute coronary syndrome (ACS) is a very common and important presentation in medicine. The management of ACS has evolved over recent years, with the development of new drugs and procedures such as percutaneous coronary intervention (PCI). Emergency departments often have their own protocols based on local factors such as the availability of PCI and hospital drug formularies. The following is based on the 2020 update to the NICE ACS guidelines. Acute coronary syndrome can be classified as follows: ST-elevation myocardial infarction (STEMI): ST-segment elevation + elevated biomarkers of myocardial damage non ST-elevation myocardial infarction (NSTEMI): ECG changes but no ST-segment elevation + elevated biomarkers of myocardial damage unstable angina The management of ACS depends on the particular subtype. NICE management guidance groups the patients into two groups: 1. STEMI 2. NSTEM/unstable angina https://www.passmedicine.com/v7/question/questions.php?q=0 2/11 ‫ ص‬10:52 2022/‫‏‬10/‫‏‬25 PassMedicine Common management of all patients with ACS Initial drug therapy aspirin 300mg oxygen should only be given if the patient has oxygen saturations < 94% in keeping with British Thoracic Society oxygen therapy guidelines morphine should only be given for patients with severe pain previously IV morphine was given routinely evidence, however, suggests that this may be associated with adverse outcomes nitrates can be given either sublingually or intravenously useful if the patient has ongoing chest pain or hypertension should be used in caution if patient hypotensive The next step in managing a patient with suspected ACS is to determine whether they meet the ECG criteria for STEMI. It is, of course, important to recognise that these criteria should be interpreted in the context of the clinical history. STEMI criteria clinical symptoms consistent with ACS (generally of ≥ 20 minutes duration) with persistent (> 20 minutes) ECG features in ≥ 2 contiguous leads of: 2.5 mm (i.e ≥ 2.5 small squares) ST elevation in leads V2-3 in men under 40 years, or ≥ 2.0 mm (i.e ≥ 2 small squares) ST elevation in leads V2-3 in men over 40 years 1.5 mm ST elevation in V2-3 in women 1 mm ST elevation in other leads new LBBB (LBBB should be considered new unless there is evidence otherwise) Management of STEMI https://www.passmedicine.com/v7/question/questions.php?q=0 3/11 ‫ ص‬10:52 2022/‫‏‬10/‫‏‬25 PassMedicine Diagram showing the simplified management of STEMI according to NICE guidelines. A number of assumptions (listed at the bottom) are made. Once a STEMI has been confirmed the first step is to immediately assess eligibility for coronary reperfusion therapy. There are two types of coronary reperfusion therapy: percutaneous coronary intervention should be offered if the presentation is within 12 hours of the onset of symptoms AND PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given (i.e. consider fibrinolysis if there is a significant delay in being able to provide PCI) if patients present after 12 hours and still have evidence of ongoing ischaemia then PCI should still be considered drug-eluting stents are now used. Previously 'bare-metal' stents were sometimes used but have higher rates of restenosis radial access is preferred to femoral access fibrinolysis should be offered within 12 hours of the onset of symptoms if primary PCI cannot be delivered within 120 minutes of the time when fibrinolysis could have been given a practical example may be a patient who presents with a STEMI to a small district general hospital (DGH) that does not have facilities for PCI. If they cannot be transferred to a larger hospital for PCI within 120 minutes then fibrinolysis should be given. If the patient's ECG taken 90 minutes after fibrinolysis failed to show resolution of the ST elevation then they would then require transfer for PCI If patients are eligible this should be offered as soon as possible. Percutaneous coronary intervention for patients with STEMI Further antiplatelet prior to PCI this is termed 'dual antiplatelet therapy', i.e. aspirin + another drug if the patient is not taking an oral anticoagulant: prasugrel if taking an oral anticoagulant: clopidogrel Drug therapy during PCI patients undergoing PCI with radial access: unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor (GPI) - this is the action of using a GPI during the procedure when it was not intended from the outset, e.g. because of worsening or persistent thrombus patients undergoing PCI with femoral access: bivalirudin with bailout GPI https://www.passmedicine.com/v7/question/questions.php?q=0 4/11 ‫ ص‬10:52 2022/‫‏‬10/‫‏‬25 PassMedicine Other procedures during PCI thrombus aspiration, but not mechanical thrombus extraction, should be considered complete revascularisation should be considered for patients with multivessel coronary artery disease without cardiogenic shock Fibrinolysis for patients with STEMI Fibrinolysis used to be the only form of coronary reperfusion therapy available. However, it is used much less commonly now given the widespread availability of PCI. The contraindications to fibrinolysis and other factors are described in other notes. Patients undergoing fibrinolysis should also be given an antithrombin drug. An ECG should be repeated after 60-90 minutes to see if the ECG changes have resolved. If patients have persistent myocardial ischaemia following fibrinolysis then PCI should be considered. Management of NSTEMI/unstable angina Diagram showing the simplified management of NSTEMI/unstable angina according to NICE guidelines. A number of assumptions (listed at the bottom) are made. The management of NSTEMI/unstable angina is complicated and depends on individual patient factors and a risk assessment. The summary below provides an overview but the full NICE guidelines should be reviewed for further details. https://www.passmedicine.com/v7/question/questions.php?q=0 5/11 ‫ ص‬10:52 2022/‫‏‬10/‫‏‬25 PassMedicine Further drug therapy antithrombin treatment fondaparinux should be offered to patients who are not at a high risk of bleeding and who are not having angiography immediately if immediate angiography is planned or a patients creatinine is > 265 µmol/L then unfractionated heparin should be given Risk assessment The Global Registry of Acute Coronary Events (GRACE) is the most widely used tool for risk assessment. It can be calculated using online tools and takes into account the following factors: age heart rate, blood pressure cardiac (Killip class) and renal function (serum creatinine) cardiac arrest on presentation ECG findings troponin levels This results in the patient being risk stratified as follows: Predicted 6‑month mortality Risk of future adverse cardiovascular events 1.5% or below Lowest > 1.5% to 3.0% Low > 3.0% to 6.0% Intermediate > 6.0% to 9.0% High over 9.0% Highest Based on this risk assessment key decisions are made regarding whether a patient has coronary angiography (with follow-on PCI if necessary) or has conservative management. The detailed pros/cons of this decision are covered in other notes. Which patients with NSTEMI/unstable angina should have coronary angiography (with follow-on PCI if necessary)? immediate: patient who are clinically unstable (e.g. hypotensive) within 72 hours: patients with a GRACE score > 3% i.e. those at intermediate, high or highest risk https://www.passmedicine.com/v7/question/questions.php?q=0 6/11 ‫ ص‬10:52 2022/‫‏‬10/‫‏‬25 PassMedicine coronary angiography should also be considered for patients if ischaemia is subsequently experienced after admission Percutaneous coronary intervention for patients with NSTEMI/unstable angina Further drug therapy unfractionated heparin should be given regardless of whether the patient has had fondaparinux or not further antiplatelet ('dual antiplatelet therapy', i.e. aspirin + another drug) prior to PCI if the patient is not taking an oral anticoagulant: prasugrel or ticagrelor if taking an oral anticoagulant: clopidogrel Conservative management for patients with NSTEMI/unstable angina Further drug therapy further antiplatelet ('dual antiplatelet therapy', i.e. aspirin + another drug) if the patient is not at a high risk of bleeding: ticagrelor if the patient is at a high risk of bleeding: clopidogrel Next question                Search Search textbook... Go Google search on "Acute coronary syndrome: initial management" Links SIGN 5 4 2016 Acute coronary syndrome guidelines https://www.passmedicine.com/v7/question/questions.php?q=0 7/11 ‫ ص‬10:52 2022/‫‏‬10/‫‏‬25 PassMedicine PassMedicine Question 9 of 101 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? History of diabetes mellitus 11% Loss of heart rate variability 17% Left ventricular ejection fraction of 40% 58% Diastolic blood pressure of 110 mmHg 7% Male sex 8% Discuss (7) Improve Next question 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 age development (or history) of heart failure peripheral vascular disease reduced systolic blood pressure Killip class* initial serum creatinine concentration elevated initial cardiac markers https://www.passmedicine.com/v7/question/questions.php?q=0 1/6 ‫ ص‬10:52 2022/‫‏‬10/‫‏‬25 PassMedicine cardiac arrest on admission ST segment deviation *Killip class - system used to stratify risk post myocardial infarction Killip class Features 30 day mortality I No clinical signs heart failure 6% II Lung crackles, S3 17% III Frank pulmonary oedema 38% IV Cardiogenic shock 81% Next question                Search Search textbook... Go Google search on "Acute coronary syndrome: prognostic factors" Media Acute Coronary Syndrome DETAILED Overview (MI, STEMI, NSTEMI) Armando Hasudungan - YouTube 12 3 Report broken media https://www.passmedicine.com/v7/question/questions.php?q=0 2/6 ‫ ص‬10:52 2022/‫‏‬10/‫‏‬25 PassMedicine PassMedicine Question 10 of 101 A 36-year-old male presents with chest pain, the chest pain is left-sided and dull in nature. It has been present for a period of five days. There is no associated shortness of breath, cough, collapse or pleuritic nature of the chest pain. He describes a recent sore throat and headache last week which has since resolved. There is no family history in a first-degree relative of sudden cardiac death and the patient has never smoked. Blood pressure 125/89 mmHg, heart rate 95/min, temperature 37.3ºC, oxygen saturations 97% on room air. Pulsus paradoxus is not present. Blood results reveal: Male: (135-180) Hb 154 g/L Female: (115 - 160) Platelets 425 * 109/L (150 - 400) WBC 11.5 * 109/L (4.0 - 11.0) Na+ 137 mmol/L (135 - 145) K+ 4.6 mmol/L (3.5 - 5.0) Urea 6.4 mmol/L (2.0 - 7.0) Creatinine 100 µmol/L (55 - 120) CRP 40 mg/L (< 5) Troponin T 13 ng/L ( 65 years) bicuspid aortic valve (most common cause in younger patients < 65 years) William's syndrome (supravalvular aortic stenosis) post-rheumatic disease subvalvular: HOCM Management if asymptomatic then observe the patient is a general rule if symptomatic then valve replacement if asymptomatic but valvular gradient > 40 mmHg and with features such as left ventricular systolic dysfunction then consider surgery options for aortic valve replacement (AVR) include: surgical AVR is the treatment of choice for young, low/medium operative risk patients. Cardiovascular disease may coexist. For this reason, an angiogram is often done prior to surgery so that the procedures can be combined transcatheter AVR (TAVR) is used for patients with a high operative risk balloon valvuloplasty may be used in children with no aortic valve calcification in adults limited to patients with critical aortic stenosis who are not fit for valve replacement Next question                Search Search textbook... Go https://www.passmedicine.com/v7/question/questions.php?q=0 2/7 ‫ ص‬11:10 2022/‫‏‬10/‫‏‬25 PassMedicine PassMedicine Question 70 of 101 A 68-year-old man with a past history of aortic stenosis is reviewed in clinic. Which one of the following features would most guide the timing of surgery? Symptomatology of patient 68% Aortic valve gradient of 36 mmHg 12% Pulse pressure 2% Loudness of murmur 3% Left ventricular ejection fraction 14% Aortic stenosis management: AVR if symptomatic, otherwise cut-off is gradient of 40 mmHg Important for me Less important Discuss (4) Improve Next question Aortic stenosis Clinical features of symptomatic disease chest pain dyspnoea syncope / presyncope (e.g. exertional dizziness) murmur an ejection systolic murmur (ESM) is classically seen in aortic stenosis classically radiates to the carotids this is decreased following the Valsalva manoeuvre https://www.passmedicine.com/v7/question/questions.php?q=0 1/7 ‫ ص‬11:10 2022/‫‏‬10/‫‏‬25 PassMedicine Features of severe aortic stenosis narrow pulse pressure slow rising pulse delayed ESM soft/absent S2 S4 thrill duration of murmur left ventricular hypertrophy or failure Causes of aortic stenosis degenerative calcification (most common cause in older patients > 65 years) bicuspid aortic valve (most common cause in younger patients < 65 years) William's syndrome (supravalvular aortic stenosis) post-rheumatic disease subvalvular: HOCM Management if asymptomatic then observe the patient is a general rule if symptomatic then valve replacement if asymptomatic but valvular gradient > 40 mmHg and with features such as left ventricular systolic dysfunction then consider surgery options for aortic valve replacement (AVR) include: surgical AVR is the treatment of choice for young, low/medium operative risk patients. Cardiovascular disease may coexist. For this reason, an angiogram is often done prior to surgery so that the procedures can be combined transcatheter AVR (TAVR) is used for patients with a high operative risk balloon valvuloplasty may be used in children with no aortic valve calcification in adults limited to patients with critical aortic stenosis who are not fit for valve replacement Next question                https://www.passmedicine.com/v7/question/questions.php?q=0 2/7 ‫ ص‬11:11 2022/‫‏‬10/‫‏‬25 PassMedicine PassMedicine Question 71 of 101 Which one of the following features would best indicate severe aortic stenosis? Valvular gradient of 35 mmHg 15% Quiet first heart sound 14% Loudness of ejection systolic murmur 16% Fourth heart sound 45% Development of an opening snap 10% Aortic stenosis - S4 is a marker of severity Important for me Less important Discuss (4) Improve Next question Aortic stenosis Clinical features of symptomatic disease chest pain dyspnoea syncope / presyncope (e.g. exertional dizziness) murmur an ejection systolic murmur (ESM) is classically seen in aortic stenosis classically radiates to the carotids this is decreased following the Valsalva manoeuvre Features of severe aortic stenosis https://www.passmedicine.com/v7/question/questions.php?q=0 1/7 ‫ ص‬11:11 2022/‫‏‬10/‫‏‬25 PassMedicine narrow pulse pressure slow rising pulse delayed ESM soft/absent S2 S4 thrill duration of murmur left ventricular hypertrophy or failure Causes of aortic stenosis degenerative calcification (most common cause in older patients > 65 years) bicuspid aortic valve (most common cause in younger patients < 65 years) William's syndrome (supravalvular aortic stenosis) post-rheumatic disease subvalvular: HOCM Management if asymptomatic then observe the patient is a general rule if symptomatic then valve replacement if asymptomatic but valvular gradient > 40 mmHg and with features such as left ventricular systolic dysfunction then consider surgery options for aortic valve replacement (AVR) include: surgical AVR is the treatment of choice for young, low/medium operative risk patients. Cardiovascular disease may coexist. For this reason, an angiogram is often done prior to surgery so that the procedures can be combined transcatheter AVR (TAVR) is used for patients with a high operative risk balloon valvuloplasty may be used in children with no aortic valve calcification in adults limited to patients with critical aortic stenosis who are not fit for valve replacement Next question                Search https://www.passmedicine.com/v7/question/questions.php?q=0 2/7 ‫ ص‬11:11 2022/‫‏‬10/‫‏‬25 PassMedicine PassMedicine Question 72 of 101 Which one of the following clinical signs would best indicate severe aortic stenosis? Valvular gradient of less than 30 mmHg 11% Soft second heart sound 53% Quiet first heart sound 7% Development of an opening snap 10% Carotid radiation of ejection systolic murmur 19% Questions may sometimes refer to a soft A2 rather than a soft S2 (second heart sound), specifically mentioning the aortic component. Discuss (6) Improve Next question Aortic stenosis Clinical features of symptomatic disease chest pain dyspnoea syncope / presyncope (e.g. exertional dizziness) murmur an ejection systolic murmur (ESM) is classically seen in aortic stenosis classically radiates to the carotids this is decreased following the Valsalva manoeuvre Features of severe aortic stenosis narrow pulse pressure slow rising pulse delayed ESM https://www.passmedicine.com/v7/question/questions.php?q=0 1/7 ‫ ص‬11:11 2022/‫‏‬10/‫‏‬25 PassMedicine soft/absent S2 S4 thrill duration of murmur left ventricular hypertrophy or failure Causes of aortic stenosis degenerative calcification (most common cause in older patients > 65 years) bicuspid aortic valve (most common cause in younger patients < 65 years) William's syndrome (supravalvular aortic stenosis) post-rheumatic disease subvalvular: HOCM Management if asymptomatic then observe the patient is a general rule if symptomatic then valve replacement if asymptomatic but valvular gradient > 40 mmHg and with features such as left ventricular systolic dysfunction then consider surgery options for aortic valve replacement (AVR) include: surgical AVR is the treatment of choice for young, low/medium operative risk patients. Cardiovascular disease may coexist. For this reason, an angiogram is often done prior to surgery so that the procedures can be combined transcatheter AVR (TAVR) is used for patients with a high operative risk balloon valvuloplasty may be used in children with no aortic valve calcification in adults limited to patients with critical aortic stenosis who are not fit for valve replacement Next question                Search Search textbook... Go https://www.passmedicine.com/v7/question/questions.php?q=0 2/7 ‫ ص‬11:11 2022/‫‏‬10/‫‏‬25 PassMedicine PassMedicine Question 73 of 101 A 53-year-old man is reviewed in the cardiology clinic with a history of chest pain and syncope. On examination he has an ejection systolic murmur radiating to the carotid area. What is the most likely cause of his symptoms? Bicuspid aortic valve 47% Aortic root abscess 4% Post rheumatic fever 4% Posterior myocardial infarction 2% Calcification of the aortic valve 43% Aortic stenosis - most common cause: younger patients < 65 years: bicuspid aortic valve older patients > 65 years: calcification Important for me Less important Discuss (2) Improve Next question Aortic stenosis Clinical features of symptomatic disease chest pain dyspnoea syncope / presyncope (e.g. exertional dizziness) murmur an ejection systolic murmur (ESM) is classically seen in aortic stenosis https://www.passmedicine.com/v7/question/questions.php?q=0 1/7 ‫ ص‬11:11 2022/‫‏‬10/‫‏‬25 PassMedicine classically radiates to the carotids this is decreased following the Valsalva manoeuvre Features of severe aortic stenosis narrow pulse pressure slow rising pulse delayed ESM soft/absent S2 S4 thrill duration of murmur left ventricular hypertrophy or failure Causes of aortic stenosis degenerative calcification (most common cause in older patients > 65 years) bicuspid aortic valve (most common cause in younger patients < 65 years) William's syndrome (supravalvular aortic stenosis) post-rheumatic disease subvalvular: HOCM Management if asymptomatic then observe the patient is a general rule if symptomatic then valve replacement if asymptomatic but valvular gradient > 40 mmHg and with features such as left ventricular systolic dysfunction then consider surgery options for aortic valve replacement (AVR) include: surgical AVR is the treatment of choice for young, low/medium operative risk patients. Cardiovascular disease may coexist. For this reason, an angiogram is often done prior to surgery so that the procedures can be combined transcatheter AVR (TAVR) is used for patients with a high operative risk balloon valvuloplasty may be used in children with no aortic valve calcification in adults limited to patients with critical aortic stenosis who are not fit for valve replacement Next question                https://www.passmedicine.com/v7/question/questions.php?q=0 2/7 ‫ ص‬11:11 2022/‫‏‬10/‫‏‬25 PassMedicine PassMedicine Question 74 of 101 An elderly man with aortic stenosis is assessed. Which one of the following would make the ejection systolic murmur quieter? Left ventricular systolic dysfunction 48% Thyrotoxicosis 2% Mixed aortic valve disease 21% Expiration 22% Anaemia 7% Left ventricular systolic dysfunction will result in a decreased flow-rate across the aortic valve and hence a quieter murmur. Discuss (4) Improve Next question Aortic stenosis Clinical features of symptomatic disease chest pain dyspnoea syncope / presyncope (e.g. exertional dizziness) murmur an ejection systolic murmur (ESM) is classically seen in aortic stenosis classically radiates to the carotids this is decreased following the Valsalva manoeuvre Features of severe aortic stenosis narrow pulse pressure slow rising pulse https://www.passmedicine.com/v7/question/questions.php?q=0 1/7 ‫ ص‬11:11 2022/‫‏‬10/‫‏‬25 PassMedicine delayed ESM soft/absent S2 S4 thrill duration of murmur left ventricular hypertrophy or failure Causes of aortic stenosis degenerative calcification (most common cause in older patients > 65 years) bicuspid aortic valve (most common cause in younger patients < 65 years) William's syndrome (supravalvular aortic stenosis) post-rheumatic disease subvalvular: HOCM Management if asymptomatic then observe the patient is a general rule if symptomatic then valve replacement if asymptomatic but valvular gradient > 40 mmHg and with features such as left ventricular systolic dysfunction then consider surgery options for aortic valve replacement (AVR) include: surgical AVR is the treatment of choice for young, low/medium operative risk patients. Cardiovascular disease may coexist. For this reason, an angiogram is often done prior to surgery so that the procedures can be combined transcatheter AVR (TAVR) is used for patients with a high operative risk balloon valvuloplasty may be used in children with no aortic valve calcification in adults limited to patients with critical aortic stenosis who are not fit for valve replacement Next question                Search Search textbook... Go https://www.passmedicine.com/v7/question/questions.php?q=0 2/7 ‫ ص‬11:12 2022/‫‏‬10/‫‏‬25 PassMedicine PassMedicine Question 75 of 101 An 82-year-old man is referred to cardiology by his GP with increasing dyspnoea on exertion and a systolic murmur. Examination demonstrates a blood pressure of 100/80 mmHg and a slow rising pulse. What is the most likely cause of his underlying condition? Bicuspid aortic valve 9% Ventricular septal defect 1% Post rheumatic fever 2% Calcification of the aortic valve 84% Hypertrophic obstructive cardiomyopathy 5% Aortic stenosis - most common cause: younger patients < 65 years: bicuspid aortic valve older patients > 65 years: calcification Important for me Less important This patient has aortic stenosis. Discuss (2) Improve Next question Aortic stenosis Clinical features of symptomatic disease chest pain dyspnoea syncope / presyncope (e.g. exertional dizziness) murmur an ejection systolic murmur (ESM) is classically seen in aortic stenosis https://www.passmedicine.com/v7/question/questions.php?q=0 1/7 ‫ ص‬11:12 2022/‫‏‬10/‫‏‬25 PassMedicine classically radiates to the carotids this is decreased following the Valsalva manoeuvre Features of severe aortic stenosis narrow pulse pressure slow rising pulse delayed ESM soft/absent S2 S4 thrill duration of murmur left ventricular hypertrophy or failure Causes of aortic stenosis degenerative calcification (most common cause in older patients > 65 years) bicuspid aortic valve (most common cause in younger patients < 65 years) William's syndrome (supravalvular aortic stenosis) post-rheumatic disease subvalvular: HOCM Management if asymptomatic then observe the patient is a general rule if symptomatic then valve replacement if asymptomatic but valvular gradient > 40 mmHg and with features such as left ventricular systolic dysfunction then consider surgery options for aortic valve replacement (AVR) include: surgical AVR is the treatment of choice for young, low/medium operative risk patients. Cardiovascular disease may coexist. For this reason, an angiogram is often done prior to surgery so that the procedures can be combined tr