A 55-year-old woman with hypertension and hypercholesterolaemia complains of acute breathlessness one hour after a primary percutaneous intervention for an anterior ST-elevation myocardial infarction. She was successfully revascularized and access was gained using a radial approach. She appeared well immediately post-procedure and a beside trans-thoracic echocardiogram demonstrated preserved left ventricular function.
On examination, she appears unwell. She is diaphoretic and clammy with a respiratory rate of 33/min, blood pressure of 80/42mmHg, heart rate of 111/minute, oxygen saturation of 96% on air and temperature of 36.2ºC. Chest auscultation demonstrates good air entry bilaterally. Cardiovascular examination demonstrates a regular pulse, elevated jugular venous pulse (JVP) and quiet heart sounds. She has cool extremities. There are no murmurs or peripheral oedema. There is no clinical evidence of deep venous thrombosis in the lower limbs.
What intervention is most likely to be life-saving?
Inotropic support
Intravenous antibiotics
Intravenous fluids
Pericardiocentesis
Thrombolysis
Pericardiocentesis
What is a cardiac tamponade?
accumulation of pericardial fluid
Symptoms and signs of cardiac tamponade
Classical features - Beck’s triad: hypotension, raised JVP, muffled heart sounds
Other features include:
- Dyspnea
- Tachycardia
- an absent Y descent on the JVP: this is due to the limited right ventricular filling
- pulsus paradoxus
- Kussmaul’s sign - much debate about this
What is pulsus paradoxus
An abnormally large drop in BP during inspiration
What is Kussmaul’s sign?
a clinical observation where there is a paradoxical rise in jugular venous pressure during inspiration, which normally causes a decrease, or a failure in the appropriate fall of the JVP with inspiration
It is an inspiratory increase in central venous (or right atrial) pressure, a sign of impaired right ventricular filling or function
Kussmaul’s sign associated diseases
associated with conditions like constrictive pericarditis, restrictive cardiomyopathy, tricuspid stenosis, pericardial effusion, right ventricular infarction, and severe right-sided heart failure
ECG of cardiac tamponade
ECG: electrical alternans (where the QRS complex amplitude vary from beat to beat)
Which condition can mimic cardiac tamponade?
Constrictive pericarditis
Differences between constrictive pericarditis and cardiac tamponade
A commonly used mnemonic to remember the absent Y descent in cardiac tamponade is TAMponade = TAMpaX
Management of cardiac tampoande
urgent pericardiocentesis
A 72-year-old woman with no past medical history presents to the emergency department after becoming suddenly light-headed and breathless whilst playing golf. She does not report chest pain and has no other symptoms.
The examination is as below:
Blood pressure 88/55mmHg
Heat rate 150 beats/minute
Radial pulse irregularly irregular
Heart sounds 1 + 2 + 0
Chest clear to auscultate
No peripheral oedema
An ECG shows an irregularly irregular rhythm with no visible P waves.
What is the most appropriate immediate management?
Amiodarone
Bisoprolol
Digoxin
Flecainide
Synchronised DC cardioversion
Synchronised DC cardioversion
Acute presentation of atrial fibrillation: if signs of haemodynamic instability (e.g. hypotension, heart failure) → electrical cardioversion, as per the peri-arrest tachycardia guidelines
What is synchronized cardioversion synchronized to?
R wave
A 45-year-old man presents to his general practitioner concerned about his sex life. He is unable to get and maintain an erection and feel it is affecting him mentally.
He has a past medical history of atrial fibrillation and hypertension.
Which one of the following may be the underlying cause of erectile dysfunction in this patient?
L-arginine supplements
Avanafil
Paracetamol
Bisoprolol
Amlodipine
Bisoprolol
What are indications for beta blockers?
- angina
- post-myocardial infarction
- heart failure
- arrhythmias
- hypertension: the role of beta-blockers has diminished in recent years due to a lack of evidence in terms of reducing stroke and myocardial infarction.
- thyrotoxicosis
- migraine prophylaxis
- anxiety
Side effects of beta blockers
- bronchospasm
- cold peripheries
- fatigue
- sleep disturbances, including nightmares
- erectile dysfunction
Contraindications to beta blockers
- uncontrolled heart failure
- asthma
- sick sinus syndrome
- concurrent use with rate limiting calcium channel blockers
A 68-year-old woman is brought into the emergency department with shortness of breath. She has a past medical history of left ventricular systolic dysfunction with an ejection fraction of 20%. A chest x-ray confirms acute pulmonary oedema which is treated immediately with high dose IV furosemide. Her repeat observations are oxygen saturation 94% on 15L oxygen, heart rate 124 beats per minute, respiratory rate of 28 breaths per minute and blood pressure 74/50 mmHg.
What management option should be considered next?
- Biphasic positive airway pressure
- Give IV fluid for her hypotension
- Give an acute dose of bisoprolol
- Inotropic support on the high dependency unit (HDU)
- Start a rate-limiting calcium channel blocker
Inotropic support on the high dependency unit (HDU) is the correct answer. In acute pulmonary oedema, the primary aim of management is diuresis to offload excess fluid. In patients who have cardiogenic shock, diuresis would lower blood pressure further and worsen the picture of shock. Inotropes should therefore be considered in this patient group to promote increased cardiac contractility and support blood pressure whilst diuresis is ongoing.
Giving IV fluid for her hypotension would not be appropriate. In this scenario, her hypotension is secondary to cardiogenic shock, not hypovolaemic shock. Giving further fluid in this scenario would worsen the condition of the patient by contributing to the fluid overload.
A 56-year-old man attends the emergency department with a 3-hour history of chest pain radiating to his neck and left arm. He has an ECG which shows ST depression in the inferior leads. A troponin is sent and he is given aspirin and sublingual nitrates. He is suspected to have had a non-ST elevated myocardial infarction. The doctor performs a risk assessment to assess the patient’s 6-month mortality.
Which of the following are included in the doctor’s calculation?
- Age, ECG, heart rate, lactate
- Age, ECG, troponin, liver function tests
- Age, ECG, troponin, renal function
- Blood pressure, ECG, troponin, lactate
- Blood pressure, ECG, troponin, liver function tests
Age, ECG, troponin, renal function for GRACE score
Mnemonic to memorize which data to input for GRACE score
GRACE = A HEART
Arrest (cardiac)
Heart rate/blood pressure
ECG
Age
Renal function
Troponin
OR
G - Geriatric (Age)
R - Renal Fx
A - Arrest (Cardiac arrest on presentation)
C - Cardiac Enzymes (Troponin)
E - ECG
HB
heart rate, blood pressure
A 67-year-old woman presents to her GP as she is concerned that her hearing has deteriorated over the past 3 months. She also describes a constant ringing in her right ear and notices that she sometimes loses her balance.
She has a background of hypertension, congestive heart failure, type 2 diabetes and hypothyroidism.
Which medication may have contributed to her presentation?
Amlodipine
Atorvastatin
Furosemide
Levothyroxine
Metformin
Furosemide
Loop diuretics may cause ototoxicity
