One stop doc cardiology

ONE STOP DOC Cardiology One Stop Doc Titles in the series include: Cardiovascular System – Jonathan Aron Editorial Advisor – Jeremy Ward Cell and Molecular Biology – Desikan Rangarajan and David Shaw Editorial Advisor – Barbara Moreland Endocrine and Reproductive Systems – Caroline Jewels and Alexandra Tillett Editorial Advisor – Stuart Milligan Gastrointestinal System – Miruna Canagaratnam Editorial Advisor – Richard Naftalin Musculoskeletal System – Bassel Zebian, Wayne Lam and Rishi Aggarwal Editorial Advisor – Alistair Hunter Nutrition and Metabolism – Miruna Canagaratnam and David Shaw Editorial Advisors – Barbara Moreland and Richard Naftalin Respiratory System – Jo Dartnell and Michelle Ramsay Editorial Advisor – John Rees Renal and Urinary System and Electrolyte Balance – Panos Stamoulos and Spyridon Bakalis Editorial Advisors – Alistair Hunter and Richard Naftalin Statistics and Epidemiology – Emily Ferenczi and Nina Muirhead Editorial Advisor – Lucy Carpenter Immunology – Stephen Boag and Amy Sadler Editorial Advisor – John Stewart Gastroenterology and Renal Medicine – Reena Popat and Danielle Adebayo Contributing Author – Thomas Chapman Editorial Advisor – Stephen Pereira Volume Editor – Basant Puri ONE STOP DOC Cardiology Rishi Aggarwal MBBS Graduate of Guy’s, King’s and St Thomas’ Medical School and Senior House Officer in Accident and Emergency Medicine, Wexham Park Hospital, Slough, UK Emily Ferenczi BA (Cantab) BMBCh (Oxon) FY1 Hammersmith Hospital Academic Foundation Programme, London, UK Nina Muirhead BA (Oxon) BMBCh (Oxon) FY1 Royal Berkshire Hospital, Reading, UK Darrel Francis MA (Cantab) MB BChir MD MRCP Clinical Academic in Cardiology, International Centre for Circulatory Health, Imperial College of Science and Medicine, London and Honorary Consultant Cardiologist, St Mary’s Hospital, London, UK Volume Editor: Basant K Puri MA (Cantab) PhD MB BChir BSc (Hons) MathSci MRCPsych DipStat MMath Professor and Consultant in Imaging and Psychiatry and Head of the Lipid Neuroscience Group, Hammersmith Hospital, London, UK Series Editor: Elliott Smock MBBS BSc (Hons) FY2, University Hospital Lewisham, Lewisham, UK A MEMBER OF THE HODDER HEADLINE GROUP First published in Great Britain in 2007 by Hodder Arnold, an imprint of Hodder Education and a member of the Hodder Headline Group, an Hachette Livre UK Company, 338 Euston Road, London NW1 3BH http://www.hoddereducation.com © 2007 Edward Arnold (Publishers) Ltd All rights reserved Apart from any use permitted under UK copyright law, this publication may only be reproduced, stored or transmitted, in any form, or by any means with prior permission in writing of the publishers or in the case of reprographic production in accordance with the terms of licences issued by the Copyright Licensing Agency In the United Kingdom such licences are issued by the Copyright Licensing Agency: Saffron House, 6–10 Kirby Street, London EC1N 8TS Whilst the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made In particular, (but without limiting the generality of the preceding disclaimer) every effort has been made to check drug dosages; however it is still possible that errors have been missed Furthermore, dosage schedules are constantly being revised and new side-effects recognized For these reasons the reader is strongly urged to consult the drug companies’ printed instructions before administering any of the drugs recommended in this book British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data A catalog record for this book is available from the Library of Congress ISBN 978 0340 925577 10 Commissioning Editor: Sara Purdy Project Editor: Jane Tod Production Controller: Lindsay Smith Cover Design: Amina Dudhia Indexer: Indexing Specialists (UK) Ltd Typeset in 10/12pt Adobe Garamond/Akzidenz GroteskBE by Servis Filmsetting Ltd, Manchester Printed and bound in Spain What you think about this book? Or any other Hodder Arnold title? Please visit our website at www.hoddereducation.com CONTENTS PREFACE vi ABBREVIATIONS vii SECTION HISTORY AND EXAMINATION SECTION SYMPTOMS 11 SECTION INVESTIGATIONS 21 SECTION THE ELECTROCARDIOGRAM 33 SECTION CONDITIONS 71 SECTION TREATMENTS 117 APPENDIX 127 INDEX 129 PREFACE From the Series Editor, Elliott Smock Are you ready to face your looming exams? If you have done loads of work, then congratulations; we hope this opportunity to practice SAQs, EMQs, MCQs and Problem-based Questions on every part of the core curriculum will help you consolidate what you’ve learnt and improve your exam technique If you don’t feel ready, don’t panic – the One Stop Doc series has all the answers you need to catch up and pass There are only a limited number of questions an examiner can throw at a beleaguered student and this text can turn that to your advantage By getting straight into the heart of the core questions that come up year after year and by giving you the model answers you need this book will arm you with the knowledge to succeed in your exams Broken down into logical sections, you can learn all the important facts you need to pass without having to wade through tons of different textbooks when you simply don’t have the time All questions presented here are ‘core’; those of the highest importance have been highlighted to allow even sharper focus if time for revision is running out In addition, to allow you to organize your revision efficiently, questions have been grouped by topic, with answers supported by detailed integrated explanations On behalf of all the One Stop Doc authors I wish you the very best of luck in your exams and hope these books serve you well! From the Authors, Rishi Aggarwal, Emily Ferenczi and Nina Muirhead The horizons of cardiology are expanding at an astonishing rate with the use of medicines such as statins, thrombolytics and antiplatelet antibodies; interventions such as percutaneous angioplasty and surgery to implant artificial hearts, to name but a few recent developments Patients with congenital cardiac defects are now living well into adulthood, creating a new subspecialty of ‘adult congenital cardiac disease’ For those interested in public health, an increase in understanding of the importance of primary prevention and early modification of cardiac risk factors has led to a plethora of new guidelines and targets for cardiac care in the community The WHO has said that by 2020, the leading cause of global disease burden will be ischaemic heart disease As a result, every doctor must expect to face patients with cardiological problems, no matter what specialty they eventually decide to pursue For this reason it is essential to have a thorough understanding of the basic principles of cardiac physiology, many of which are based on simple laws of physics – pressures, resistances and volumes or electrical currents, voltages and conductance In this book we aim to inform and to inspire medical students by providing a simple but comprehensive summary of clinical cardiology with questions and explanations side by side to make learning relevant to the clinical practice that they will be witnessing on a daily basis We would like to thank Dr Darrel Francis, Professor Basant Puri, our friends and families, and Hodder Arnold, for making this book possible ABBREVIATIONS 2D ABC ACE ACS ADH AF AIDS AR ASD ASO AV AVNRT AVRT b.d BM BMI BP bpm CABG CCU CK CK-MB CNS COPD CPAP CPR CRP CT CXR DC DVLA DVT ECG ESR ETT FBC GP Two-dimensional Airway, breathing, circulation Angiotensin-converting enzyme Acute coronary syndrome Anti-diuretic hormone Atrial fibrillation Acquired immune deficiency syndrome Aortic regurgitation Atrial septal defect Antistreptolysin-O Atrioventricular Atrioventricular node re-entry tachycardia Atrioventricular re-entry tachycardia Twice daily Boehringer Mannheim (test) Body mass index Blood pressure Beats per minute Coronary artery bypass graft Coronary care unit Creatine kinase Creatinine kinase, myocardial isoenzyme Central nervous system Chronic obstructive pulmonary disease Continuous positive airway pressure Cardiopulmonary resuscitation C-reactive protein Computed tomography Chest radiography Direct current Driver and Vehicle Licensing Agency Deep vein thrombosis Electrocardiography Erythrocyte sedimentation rate Exercise treadmill test Full blood count General practitioner GTN HDL HIV HOCM ICS ICU IHD INR ISMN IV JVP LA LAD LBBB LCA LCx LDH LDL LMWH LV LVH MI MR MRI NSAID NSTEMI PCI PE PET POBA PTCA RA RBBB RCA RV RVH S1 S2 S3 Glyceryl trinitrate High-density lipoprotein Human immunodeficiency virus Hypertrophic obstructive cardiomyopathy Intercostal space Intensive care unit Ischaemic heart disease International Normalized Ratio Isosorbide mononitrate Intravenous Jugular venous pressure Left atrium Left anterior descending Left bundle branch block Left coronary artery Left circumflex Lactate dehydrogenase Low-density lipoprotein Low molecular weight heparin Left ventricle Left ventricular hypertrophy Myocardial infarction Mitral regurgitation Magnetic resonance imaging Non-steroidal anti-inflammatory drug Non-ST elevation myocardial infarction Percutaneous coronary intervention Pulmonary embolism Positron emission tomography ‘Plain old balloon angioplasty’ Percutaneous transluminal coronary angioplasty Right atrium Right bundle branch block Right coronary artery Right ventricle Right ventricular hypertrophy First heart sound Second heart sound Third heart sound viii S4 SA SK SLE SSRI STEMI SVT ABBREVIATIONS Fourth heart sound Sinoatrial Streptrokinase Systemic lupus erythematosus Selective serotonin re-uptake inhibitor ST elevation myocardial infarction Supraventricular tachycardia TB TOE tPA U&Es VF VSD VT ZN Tuberculosis Transoesophageal echocardiography Tissue plasminogen activator Urea and electrolytes Ventricular fibrillation Ventricular septal defect Ventricular tachycardia Ziehl–Neelsen SECTION HISTORY AND EXAMINATION • CARDIOVASCULAR HISTORY • SIGNS ON EXAMINATION (I) • SIGNS ON EXAMINATION (II) • MURMURS AND THE CARDIAC CYCLE • LEFT-SIDED HEART MURMURS 10 ONE STOP DOC 122 10 Regarding drugs used in the treatment of hypertension, answer true or false a Diuretics are a first-line treatment in hypertension b Beta-blockers are more effective in younger patients c Angiotensin II antagonists can be used if angiotensin-converting enzyme inhibitors cause a dry cough d Calcium channel antagonists may cause angio-oedema e Patients with asthma and hypertension should be given beta-blockers 11 Which of the following drugs used to treat angina have been proven to reduce mortality? a b c d e Nitrates Statins Angiotensin-coverting enzyme inhibitors Beta-blockers Aspirin 12 Regarding the treatment of heart failure, answer true or false a b c d Nitrates work by increasing venous return to the heart Inotropic agents have been proven to reduce mortality from heart failure Beta-blockers are contraindicated in chronic heart failure Angiotensin-converting enzyme inhibitors act by reducing preload and afterload on the heart e Frusemide may cause hyperkalaemia 13 Regarding the treatment of AF, answer true or false a b c d e Anticoagulation is usually necessary Rhythm and rate control should be obtained in all cases of atrial fibrillation Digoxin is effective at controlling ventricular rhythm Amiodarone is a potent agent for rhythm control Sotalol is used in paroxysmal atrial fibrillation AF, atrial fibrillation; ISMN, isosorbide mononitrate Treatments 123 EXPLANATION: EVIDENCE-BASED PHARMACOLOGICAL TREATMENT OF COMMON CARDIOVASCULAR CONDITIONS Condition Drug aims Drug Example Trial that tested the class of drug Hypertension Diuretics Vasodilators Thiazides ACE inhibitors Angiotensin II antagonists Ca2ϩ channel blockers ␣-blockers ␤-blockers Bendroflumethiazide Ramipril Losartan Amlodipine Doxazosin Bisoprolol MRC, ALLHAT HOPE LIFE ASCOT Antiplatelet agents Aspirin ACE inhibitors Clopidogrel Glycoprotein IIb/IIIa antagonists Perindopril Physicians’ Health Study CURE TARGET Lipid-lowering agents Simvastatin ␤-blockers Nitrates Calcium channel blockers Atenolol GTN, ISMN Amlodipine, diltiazem ACE inhibitors Angiotensin II antagonists ␤-blockers Aldosterone blockade Nitrates and hydralazine Cardiac glycosides Loop diuretics Inotropes Enalapril Candesartan CONSENSUS CHARM Bisoprolol Spironolactone CIBIS-II RALES V-HeFT, A-HeFT DIG-1 Negative inotropes/ chronotropes Ischaemic Reduce mortality heart disease Reduce symptoms Heart failure Improve prognosis Reduce symptoms AF Rate control Rhythm control (acute AF) Anticoagulation Cardiac glycosides ␤-blockers Ca2ϩ channel blockers Anti-arrhythmics Coumarins Antiplatelet agents Digoxin Furosemide Vesnarinone Digoxin Atenolol Verapamil MRC HOPE, PROGRESS, EUROPA Scandinavian Simvastatin Study, Heart Protection Study ASIST VEST (showed increased mortality) DIG-1 Amiodarone, sotalol AFFIRM Warfarin (INR 2–3) Aspirin (if warfarin contraindicated) EAFT Answers 10 T T T F (ACE inhibitors cause angio-oedema) F 11 b, c (HOPE and EUROPA), d, e Nitrates provide symptomatic relief only 12 F (decrease VR to heart) F F (reduce mortality in chronic heart failure) T F (may cause hypokalaemia) 13 T (about 50 per cent of acute AF lasts Ͼ24 to 48 hours, when embolic risk rises, so most clinicians anticoagulate from the outset) F F (rate not rhythm) T T ONE STOP DOC 124 14 Match the following side effects to the most appropriate drug class Options A B C D E F Gynaecomastia Gastritis Bleeding Dry cough Thyroid dysfunction Bronchospasm Beta-blockers Warfarin Amiodarone Spironolactone Aspirin Angiotensin-converting enzyme inhibitors 15 Answer the following as true or false a b c d e f Beta-blockers are contraindicated in renal artery stenosis Porphyria is an indication for spironolactone Beta-blockers are suitable only for use in asthmatics Warfarin is contraindicated in patients who are likely to fall often Warfarin is contraindicated in the second trimester of pregnancy Thiazide diuretics are contraindicated in Addison’s disease COPD, chronic obstructive pulmonary disease; HOCM, hypertrophic obstructive cardiomyopathy Treatments 125 EXPLANATION: SIDE EFFECTS OF AND CONTRAINDICATIONS TO COMMON CARDIOVASCULAR DRUGS Common drugs Contraindications Major adverse effects ACE inhibitors Renal artery stenosis and aortic stenosis Dry cough, first-dose hypotension, angio-oedema, hyperkalaemia Angiotensin II antagonists Cholestasis (with candesartan) Hyperkalaemia, postural hypotension Alpha-blockers Postural hypotension, micturition syncope Headache, postural hypotension Amiodarone Bradycardia, history of thyroid disease or iodine sensitivity Thyroid dysfunction, photosensitivity, pulmonary fibrosis Aspirin Ͻ16 years old (Reye’s syndrome), peptic ulcer disease Gastritis, bleeding, contraindicated in peptic ulcer disease ␤-blockers Asthma and COPD (relative) Bronchospasm, cold peripheries, bradycardia, rising glucose, rising lipids Ca2ϩ channel blockers Cardiogenic shock, severe aortic stenosis Flushing, fatigue, ankle swelling, postural hypotension Digoxin Heart block, HOCM Bradyarrhythmia, complete heart block Loop diuretics Severe liver cirrhosis Hypokalaemia, postural hypotension, impotence Nitrates Hypotension, aortic/mitral stenosis, constrictive pericarditis/tamponade, HOCM, glaucoma Headache, hypotension Sotalol Asthma, peripheral arterial disease, long QT syndrome, torsade de pointes Bradycardia, hypotension, arrhythmia, cold peripheries, fatigue, insomnia Spironolactone Hyperkalaemia, hyponatraemia, Addison’s disease, porphyria Hyperkalaemia, gynaecomastia Statins Liver disease Myositis, deranged liver function Thiazide diuretics Hypokalaemia, hyponatraemia, Addison’s disease Dehydration and postural hypotension, hypokalaemia, impotence Verapamil SA node block, second-/third-degree heart block Constipation, hypotension, heart failure Warfarin (INR 2–3) Active bleeding, high risk of bleeding (e.g frequent falls), early pregnancy Haemorrhage, 1% risk of stroke Answers 14 A – 4, B – 5, C – 2, D – 6, E – 3, F – 15 F F F T F T This page intentionally left blank APPENDIX CHOOSING DRUGS FOR PATIENTS NEWLY DIAGNOSED WITH HYPERTENSION Abbreviations: A = ACE inhibitor (consider angiotonsin-II receptor antagonist if ACE intolerant) C = calcium-channel blocker D = thiazide-type diuretic Black patients are those of African or Caribbean descent and not mixed-race, Asian or Chinese patients Younger than 55 years 55 years or older or black patients of any age A C or D Step A + C or A + D Step A+C+D Step Add • further diuretic therapy or • alpha-blocker or • beta-blocker Consider seeking specialist advice Step Reproduced from: National Collaborating Centre for Chronic Conditions Hypertension: management in adults in primary care: pharmacological update London: Royal College of Physicians, 2006 Copyright © 2006 Royal College of Physicians Reproduced by permission Also, National Institute for Health and Clinical Excellence (NICE) and the British Hypertention Society (2006) ‘Choosing drugs for patients newly diagnosed with hypertension’, Hypertension: management of hypertension in adults in primary care (Quick reference guide); London: NICE Available from www.nice.org.uk/page.aspx?oϭCG034quickrefguide Reproduced with permission 128 ONE STOP DOC CHARACTERISTICS OF THE THREE MAIN CORONARY SYNDROMES Unstable angina NSTEMI STEMI Pathophysiology Ischaemia without necrosis Subendocardial infarct Transmural infarct Presentation (not specific) Increasing severity and frequency of angina symptoms, partially relieved by GTN Severe angina pain lasting Ͼ20 minutes Severe chest pain, lasting Ͼ30 minutes, nausea, vomiting, sweating, not relieved by GTN ECG No ST segment or T wave changes No ST segment changes T wave inversion may be present ST elevation or depression: Ͼ2 mm in chest leads, Ͼ1 mm in limb leads, Q waves, T wave inversion, new left bundle branch block Thrombolysis status Not eligible Not eligible Thrombolysis indicated, if emergency angiography unavailable Cardiac biomarkers Cardiac markers are not raised More than two-fold increase in serum levels of cardiac proteins Troponin T and I rise within 4–8 hours and remain elevated for 4–7 days Creatine kinase MB rises within 4–8 hours, peaks at 24 hours, returns to normal at 2–3 days As for NSTEMI INDEX 2-D echocardiography 28, 29 12-lead electrocardiography 35, 37 24-hour ambulatory monitoring 17 abdominal swelling abscesses 95, 97 accelerated hypertension 104–5 ACE see angiotensin-converting enzyme acidosis 109 acute coronary syndrome (ACS) 72–7, 128 acute heart failure 108–9 adenosine 59, 63, 65 AF see atrial fibrillation African descent 127 alcohol 3, 61, 115 aldosterone blockade 123 allergies alpha-blockers 123, 125 ambulatory monitoring 17 amiodarone 61, 63, 123, 125 amlodipine 123 amyloidosis 115 anaemia angina pectoris 79 chronic heart failure 107 full blood count 23 infective endocarditis 95, 97 mid-systolic/ejection systolic murmurs anatomy of coronary arteries 54–7 angina 13, 73, 75, 78–81, 128 angiography 27, 73, 77, 81 angioplasty 27, 77, 81 angiotensin-converting enzyme (ACE) inhibitors acute coronary syndrome 77 angina pectoris 81 cardiomyopathy 115 chronic heart failure 107 chronic hypertension 103 evidence-based treatments 123 mitral regurgitation 89 newly diagnosed hypertension 127 side effects and contraindications 125 tricuspid regurgitation 93 angiotensin II antagonists 103, 107, 123, 125 ankle swelling anti-arrhythmics 69, 123 antibiotics 89, 97, 101, 119 antibodies 101 anticoagulants 77, 121, 123 antidepressants 69 antiplatelet therapy 77, 81, 123 aortic dissection 13, 75 aortic regurgitation (AR) 9, 10, 86–7, 107 aortic stenosis 10, 17, 79, 82–5, 107 aortic valve replacement 53, 85, 87 aortography 87 AR see aortic regurgitation arrhythmias acute heart failure 109 ECG 58–9 syncope 17 see also individual types arterial blood gases 109 arthralgia 99 arthritis 95, 101 artificial stenosis 113 ascites ASD see atrial septal defect Aspergillus 95 aspirin 77, 109, 123, 125 asynchronous contraction 43 atenolol 123 atrial fibrillation (AF) acute heart failure 109 angina pectoris 79 cardiomyopathy 115 ECG 60–1 evidence-based treatments 123 mitral stenosis 91 permanent pacemakers 119 tricuspid regurgitation 93 atrial flutter 63 atrial hypertrophy 39 atrial septal defect (ASD) 9, 51, 110–11 atrioventricular (AV) block 44–9, 119 atrioventricular (AV) nodal artery 57 atrioventricular (AV) node first-degree atrioventricular block 45 junctional tachycardias 63 second-degree atrioventricular block 47 third-degree atrioventricular block 49 atrioventricular node re-entry tachycardia (AVNRT) 63 atrioventricular re-entry tachycardia (AVRT) 63 atropine 47, 49, 59 augmented leads 35 Austin Flint murmur 9, 10, 87 AV see atrioventricular avascular platelet-fibrin aggregates 95 AVNRT see atrioventricular node reentry tachycardia AVRT see atrioventricular re-entry tachycardia axis 42–3 balloon aortic valvuloplasty 85 balloon catheter 81 balloon mitral valvuloplasty 91 bendrofluazide 123 benign murmurs benzylpenicillin 119 beriberi 107 beta-blockers acute coronary syndrome 77 cardiomyopathy 115 chronic heart failure 107 chronic hypertension 103 evidence-based treatments 123 first-degree atrioventricular block 45 junctional tachycardias 63 malignant/accelerated hypertension 105 130 ONE STOP DOC beta-blockers (cont.) mitral valve prolapse 89 side effects and contraindications 125 third-degree atrioventricular block 49 biomarkers 22–3, 73, 77, 128 bipolar leads 35 bisoprolol 123 biventricular pacemakers 115 black patients 127 Blalock–Taussig shunt 113 blood cultures 97 blood pressure see hypertension blood tests 22–3 acute heart failure 109 atrial fibrillation 61 chronic hypertension 103 see also individual test types blue babies 113 body mass index (BMI) bradycardia acute heart failure 109 drug-induced 119 ECG 58–9 permanent pacemakers 119 pulse examination breathlessness see dyspnoea broad complex tachycardia 66–9 Bruce protocol 25 Brugada syndrome 51 B-type natriuretic peptide 23 bundle branch block 39, 50–3, 70 bundle of His 45, 47, 51, 63 bypass grafting 121 CABG see coronary artery bypass graft calcification 83, 91 calcium channel blockers angina pectoris 81 chronic hypertension 103 evidence-based treatments 123 first-degree atrioventricular block 45 hypertrophic cardiomyopathy 115 malignant/accelerated hypertension 105 newly diagnosed hypertension 127 side effects and contraindications 125 third-degree atrioventricular block 49 calibration signal for ECG 37 candesartan 123 Candida 95 capillary refill time capture beats 67 cardiac biomarkers 22–3, 73, 77, 128 cardiac catheterization 26–7, 111 cardiac cycle 8–9 cardiac glycosides 123 cardiac magnetic resonance imaging (MRI) 30, 31, 87 cardiac tamponade 109 cardiac transplantation 113, 115 cardiomyopathy 53, 61, 107, 114–15 cardiopulmonary bypass 121 cardiovascular drugs see drugs cardiovascular-related syncope 16–17 carditis 101 Caribbean descent 127 carotid pulse 6–7 carotid sinus massage 59, 63 carotid sinus syndrome 17 catheterization 26–7, 81, 111 cavotricuspid isthmus ablation 63 central nervous system (CNS) 101 cerebral disease 39 Chalmydia 95 chest leads 34–5 chest pain 12–13, 78–81 chest radiography (CXR) acute coronary syndrome 77 aortic regurgitation 87 aortic stenosis 85 atrial septal defect 111 mitral regurgitation 89 mitral stenosis 91 pericardial disease 99 right heart valve diseases 93 ventricle septal defect 113 cholesterol 23 chronic heart failure 106–7 chronic hypertension 102–3 chronic infection 95 chronic obstructive pulmonary disease (COPD) 61 chronotropes 123 cirrhosis 19 CK see creatine kinase clicks 89 clopidogrel 77, 123 clubbing 4, 5, 95 CNS see central nervous system collapsing pulse 10, 87 colour Doppler echocardiography 29 combination therapy 97 complete heart block 48–9 complications acute coronary syndrome 73 aortic stenosis 83 surgery 121 computed tomography (CT) 30, 31 concordance 67 conditions 71–115 acute coronary syndrome 72–7, 128 acute heart failure 108–9 angina pectoris 13, 78–81 aortic regurgitation 9, 10, 86–7, 107 aortic stenosis 10, 17, 79, 82–5, 107 atrial septal defect 9, 51, 110–11 cardiomyopathy 53, 61, 107, 114–15 chronic heart failure 106–7 chronic hypertension 102–3 congenital cardiac disease 110–13 infective endocarditis 93, 94–7 malignant/accelerated hypertension 104–5 mitral regurgitation 9, 10, 88–9, 107 mitral stenosis 9, 10, 90–1, 107 mitral valve prolapse 88–9 pericardial disease 98–9 right heart valve diseases 92–3 ventricular septal defect 9, 107, 109, 112–13 see also hypertension; rheumatic fever Index conduction system fibrosis 53 congenital cardiac disease 110–13 congestive cardiac failure 107 conjunctival pallor constrictive pericarditis 99 continuous murmurs contraindications of drugs 124–5 COPD see chronic obstructive pulmonary disease coronary angiography 27, 73, 77, 81 coronary angioplasty 27, 77, 81 coronary arteries ECG 54–7 narrowing 79 coronary artery bypass graft (CABG) 27, 81, 121 coronary artery disease exercise treadmill test 25 left bundle branch block 53 risk factors coronary revascularization 81 coronary stenting 27, 81 cor pulmonale 51, 61, 107 corrected QT (QTC) interval 41 Corrigan’s sign 87 coumarins 123 Coxiella 95 C-reactive protein (CRP) 97, 101 creatine kinase (CK) 22, 23, 128 creatinine 97 CRP see C-reactive protein CT see computed tomography culture-negative endocarditis 95, 97 CXR see chest radiography cyanosis DC see direct current D-dimer test 22, 23 decrescendo murmur 93 deep vein thrombosis (DVT) 22, 23, 109 defibrillation 69 delta waves 65 de Musset’s sign 87 dextrocardia 39 diamorphine 109 diastolic dysfunction 99, 115 diastolic murmurs 8–10, 87, 91, 93 diastolic pericardial knock 99 DIGAMI regime 77 digital clubbing 4, digoxin chronic heart failure 107 evidence-based treatments 123, 125 first-degree atrioventricular block 45 third-degree atrioventricular block 49 tricuspid regurgitation 93 dilated cardiomyopathy 115 diltiazem 123 direct current (DC) cardioversion 61 diuretics chronic heart failure 107 chronic hypertension 103 evidence-based treatments 123 loop 123, 125 malignant/accelerated hypertension 105 side effects and contraindications 125 thiazide 123, 125, 127 tricuspid regurgitation 93 dopamine 47 Doppler echocardiography 29, 121 downward deflection 37, 39 doxazosin 123 Dressler’s syndrome 73 drug-induced bradycardia 119 drug-resistant tachyarrhythmia 119 drugs evidence-based treatments 122–3 first-degree atrioventricular block cause 45 newly diagnosed hypertension 127 previous medication history side effects and contraindications 124–5 see also individual types dual-chamber pacing 115, 119 Duchenne muscular dystrophy 51 Duke criteria 97 Duroziez’s sign 87 DVT see deep vein thrombosis dyspnoea 14–15 131 aortic regurgitation 87 exertional 3, 15, 87 functional classification 15 mitral regurgitation 89 paroxysmal nocturnal 3, 15 pericardial effusion 99 early diastolic murmurs 9, 87 ECG see electrocardiography echocardiography 28–9 acute coronary syndrome 77 aortic regurgitation 87 aortic stenosis 85 atrial septal defect 111 cardiomyopathy 115 infective endocarditis 97 mitral regurgitation 89 mitral stenosis 91 pericardial disease 99 preoperative work-up 121 right heart valve diseases 93 stress 30, 31 effusion 39, 99 Einthoven’s triangle 35 Eisenmenger’s syndrome 113 ejection systolic murmur 9, 10 aortic stenosis 85 atrial septal defect 111 pulmonary stenosis 93 electrocardiography (ECG) 33–70 acute coronary syndrome 73, 77, 128 angina pectoris 81 aortic regurgitation 87 aortic stenosis 85 arrhythmias 58–9 atrial fibrillation 60–1 atrial septal defect 111 atrioventricular block 44–9 axis 42–3 basic interpretation 38–41 bradycardia 58–9 broad complex tachycardia 66–9 coronary arteries anatomy/territories 54–7 exercise treadmill test 24–5, 81 first-degree atrioventricular block 44–5 132 ONE STOP DOC electrocardiography (cont.) heart rate 42–3 leads 34–7, 42, 55, 57 left bundle branch block 52–3, 70 mitral regurgitation 89 mitral stenosis 91 narrow complex tachycardia 62–5 paper 36–7 pericardial disease 99 pointers 70 preoperative work-up 121 recording 34–5 right bundle branch block 50–1, 53, 70 right heart valve diseases 93 second-degree atrioventricular block 46–7 tachycardia 58–9, 62–9 third-degree atrioventricular block 48–9 ventricle septal defect 113 electrodes 35 electrolytes 23, 45, 69 emphysema 39 enalapril 123 encephalopathy 105 endocarditis 109 endocrine disorders 103 endomyocardial fibrosis 115 enterococci 95, 97 epinephrine 47 episodic chest pain 79 erythrocyte sedimentation rate (ESR) 97 essential hypertension 102–3 ethnicity 3, 127 ETT see exercise treadmill test evidence-based pharmacological treatments 122–3 examinations 4–10 acute coronary syndrome 75 angina pectoris 79 atrial septal defect 111 ventricle septal defect 113 see also investigations exercise rehabilitation 107 exercise treadmill test (ETT) 24–5, 81 exertional dyspnoea 3, 15, 87 exertional fatigue 89 exertional syncope 17 eyes 4–5 fainting 17 FBC see full blood count fever 95, 97, 99 first-degree atrioventricular block 44–5 flecainide 61 flucloxacillin 119 fluid restriction 107 frontal plane QRS axis 43 frusemide 105, 109, 123 full blood count (FBC) 22–3, 97 functional dyspnoea classification 15 fundoscopy 103 fungal infections 95, 97 fusion beats 67 gastro-oesophageal chest pain 13 gender glomerulonephritis 95 glyceryl trinitrate (GTN) acute coronary syndrome 75 acute heart failure 109 angina pectoris 81 evidence-based treatments 123 malignant/accelerated hypertension 105 glycoprotein IIb/IIIa antagonists 123 glycosides 123 Graham Steell murmur 93 GTN see glyceryl trinitrate haemochromatosis 115 haemorrhages, splinter 5, 95 hands 4–5 heart block 40, 41 heart failure 106–9, 123 heart and lung transplantation 113 heart rate on ECG 42–3 heart transplantation 113, 115 heparin 109, 121 hepatic cirrhosis 19 hepatojugular reflux 6–7 hexaxial wheel 35, 37, 42 high-flow murmurs His bundle see bundle of His history 2–3 acute coronary syndrome 75 angina pectoris 79 aortic regurgitation 87 aortic stenosis 83 arrhythmias 59 His–Purkinje system 45, 47 HOCM see hypertrophic obstructive cardiomyopathy Holter monitoring 17 hydralazine 123 hypercalcaemia 39 hypercapnia 109 hyperdynamic displaced apex 89 hyperkalaemia 39 hypertension acute heart failure 109 atrial fibrillation 61 chronic 102–3 coronary artery disease evidence-based treatments 123 left bundle branch block 53 newly diagnosed drug choice 127 hypertensive retinopathy 4, 5, 103 hypertrophic cardiomyopathy 115 hypertrophic obstructive cardiomyopathy (HOCM) 17 hypoalbuminaemia 19 hypocalcaemia 41 hypokalaemia 39, 41, 103 hypomagnesaemia 41 hypoxia 109 immune complex deposition 95, 97 incompetent valves 101 infections acute pericarditis 99 aortic regurgitation 87 infective endocarditis 93, 94–7 mitral regurgitation 89 see also rheumatic fever infective endocarditis 93, 94–7 inflammatory conditions 99 INR see international normalized ratio internal mammary artery 121 Index international normalized ratio (INR) 61 interpretation of ECG 38–41 investigations acute coronary syndrome 77 additional cardiac scans 31–2 angina pectoris 81 aortic regurgitation 87 aortic stenosis 85 atrial septal defect 111 cardiac catheterization 26–7, 111 chronic heart failure 107 exercise treadmill test 24–5, 81 infective endocarditis 97 mitral stenosis 91 pericardial disease 99 preoperative work-up 121 see also blood tests; echocardiography; electrocardiography; examinations ionotropes 123 ischaemic heart disease 61, 123 ISMN see isosorbide mononitrate isoprenaline 59 isosorbide mononitrate (ISMN) 123 Janeway lesions 5, 95 Jones criteria 101 jugular venous pressure (JVP) 6–7, 99 junctional pacemaker 49 junctional tachycardias 63 JVP see jugular venous pressure Kearns Sayre syndrome 51 koilonychia Kussmaul’s sign 6–7, 99 LAD see left anterior descending Lancefield group A haemolytic streptococci 101 late systolic murmur 89 LBBN see left bundle branch block LCA see left coronary artery LCx see left circumflex LDL see low density lipoprotein leads for ECG 34–7, 42, 55, 57 left anterior descending (LAD) artery 55, 57 left atrial hypertrophy 10 left bundle branch block (LBBB) 52–3, 70 left circumflex (LCx) artery 55, 57 left coronary artery (LCA) 55, 57 left coronary sinus 55 left-sided heart failure 2–3, 15, 107 left-sided heart murmurs 10 left ventricle (LV) dilation 89 left ventricle (LV) dysfunction 53 left ventricular hypertrophy (LVH) atrial fibrillation 61 chronic heart failure 107 chronic hypertension 103 murmurs 10 ventricular septal defect 113 lifestyle changes 103 limb leads 34–5, 42, 55, 57 lipid-lowering agents 123 lips liver 93 LMWH see low molecular weight heparin long murmur 89 long saphenous vein 121 loop diuretics 123, 125 loop recorders 17, 20 losartan 123 low density lipoprotein (LDL) cholesterol 23 low molecular weight heparin (LMWH) 109 lung and heart transplantation 113 LV see left ventricle LVH see left ventricular hypertrophy magnesium 23 magnetic resonance imaging (MRI) 30, 31, 87 malaise 99 malar flush 91 malignant hypertension 104–5 management see treatments markers 22–3, 73, 77, 128 mean frontal plane QRS axis 43 mechanical valves 87, 121 133 medication see drugs; individual drugs memory loop recorders 17, 20 meningococcal septicaemia 95 MI see myocardial infarction micturation syncope 17 mid-diastolic murmurs 9, 91, 93 mid-systolic click 89 mid-systolic murmurs mitral regurgitation (MR) 9, 10, 88–9, 107 mitral stenosis 9, 10, 90–1, 107 mitral valve atrial fibrillation 61 atrial septal defect 111 prolapse 88–9 reconstruction/replacement 89, 91, 111 M-mode echocardiography 29 Mobitz I (Wenckebach) block 47 Mobitz II block 47, 119 modifiable risk factors 81 monitoring syncope 17, 20 monomorphic ventricular tachycardia 67 morphine 77 MR see mitral regurgitation MRI see magnetic resonance imaging murmurs 8–9 aortic regurgitation 87 Austin Flint 9, 10, 87 benign continuous decrescendo 93 diastolic 8–10, 87, 91, 93 early diastolic 9, 87 ejection systolic 9, 10, 85, 93, 111 Graham Steell murmur 93 high-flow murmurs late systolic murmur 89 left-sided heart 10 long 89 mid-diastolic 9, 91, 93 mid-systolic mitral regurgitation 89 mitral stenosis 91 pansystolic 9, 89, 93 presystolic pulmonary regurgitation 93 134 ONE STOP DOC murmurs (cont.) systolic 8–10, 85, 87, 89, 93, 111 ventricle septal defect 113 musculoskeletal chest pain 13 myocardial infarction (MI) acute coronary syndrome 75 acute heart failure 109 acute pericarditis 99 chest pain 13 chronic heart failure 107 first-degree atrioventricular block 45 left bundle branch block 53 ST segment 41 myocardial ischaemia 13, 41, 51, 79 myocardial perfusion imaging 30, 31 myocarditis 45, 107, 109, 115 myotonic dystrophy 51 myoxamatous degeneration 89 narrow complex tachycardia 62–5 natriuretic peptide 23 nicotine staining nifedipine 105 nitrates acute coronary syndrome 75, 77 acute heart failure 109 angina pectoris 79, 81 evidence-based treatments 123 malignant/accelerated hypertension 105 side effects and contraindications 125 nocturnal dyspnoea 87, 89 non-ST elevation myocardial infarction (NSTEMI) 73, 128 non-steroidal anti-inflammatory drugs (NSAIDs) 99, 101 normochromic normocytic anaemia 97 NSAIDs see non-steroidal antiinflammatory drugs NSTEMI see non-ST elevation myocardial infarction obesity 3, 39 oedema peripheral 3, 18–19, 93 pulmonary 15, 91 oligaemic lung fields 93 orthopnoea 3, 15, 87, 89 orthostatic hypotension 17 Osler’s nodes 5, 95 oxygen 77 pacemaker cells 49 pacemakers 47, 59, 115, 118–19 palpitations 89 pancarditis 101 pansystolic murmurs 9, 89, 93 paper for ECG 36–7 paroxysmal nocturnal dyspnoea 3, 15 past medical history 2–3 patent ductus arteriosus pathological dyspnoea 15 pathway evaluation of syncopal episodes 20 PCI see percutaneous coronary intervention PE see pulmonary embolism percutaneous closure 111 percutaneous coronary intervention (PCI) 27 percutaneous transluminal coronary angioplasty (PTCA) 77, 81 perfusion pressure 105 pericardial constriction 107 pericardial disease 98–9 pericardial effusion 39, 99 pericardial friction rub 99 pericardial tamponade 99 pericardiocentesis 99 pericarditis 13, 61, 99 perindopril 123 perioperative complications 121 peripheral cyanosis peripheral oedema 3, 18–19, 93 peripheral vascular disease 79 permanent pacemakers 118–19 PET see positron emission tomography pharmacological treatments see drugs pharyngeal infection 101 plain old balloon angiography (POBA) 27 pleuritic chest pain 13 pneumonia 61 POBA see plain old balloon angiography pointers for ECG examination 70 polymorphic tachycardia 67, 69 positron emission tomography (PET) 30, 31 postoperative care 119 postural syncope 17 potassium 23 potassium channel openers 81 precordial leads 34, 35, 55, 57 precordium 75 pregnancy 9, 105 preoperative work-up 121 pressure overload 91, 93 presyncope 17 presystolic murmurs primary angioplasty 77 primum atrial septal defect 111 PR interval arrhythmias 59 ECG interpretation 40, 41 first-degree atrioventricular block 45 second-degree atrioventricular block 47 third-degree atrioventricular block 49 Wolff–Parkinson–White syndrome 65 prosthetic heart valves see valve replacement proteinurea 103 PTCA see percutaneous transluminal coronary angioplasty pulmonary embolism (PE) 51, 61, 107, 109 pulmonary hypertension 93, 107, 113 pulmonary oedema 15, 91 pulmonary regurgitation 9, 93 pulmonary stenosis 9, 93, 107 pulmonary valvotomy 93 pulse 5, 6–7, 10, 87 pulsus paradoxus 99 Purkinje fibres 45, 49 Index P waves arrhythmias 59 ECG interpretation 39 supraventricular tachycardia 63 third-degree atrioventricular block 49 tricuspid stenosis 93 QRS axis 43 QRS complex arrhythmias 59 atrial fibrillation 61 broad complex tachycardia 67 bundle branch block 53, 70 ECG interpretation 39, 40, 41, 43 narrow complex tachycardia 63 right bundle branch block 51 second-degree atrioventricular block 47 third-degree atrioventricular block 49 QTC see corrected QT QT interval 41, 59 Quincke’s sign 87 Q waves 39 radial pulse radionucleide scintigraphy 81 ramipril 123 ramus intermedius 55 rate of heart on ECG 42–3 RBBB see right bundle branch block (RBBB) RCA see right coronary artery recording electrocardiograms 34–5 recurrent effusions 99 renal dysfunction 103 renal failure 109 renal ultrasonography 103 resections 99 respiratory failure 109 respiratory signs of acute coronary syndrome 75 restenosis 27, 81 restrictive cardiomyopathy 115 retinopathy 4, 5, 103 reversible myocardial ischaemia 79 revised Jones criteria 101 rheumatic fever 100–1 aortic regurgitation 87 mitral regurgitation 89 mitral stenosis 10, 91 tricuspid regurgitation/stenosis 93 rhythm strip, ECG 43 right bundle branch block (RBBB) 50–1, 53, 70 right coronary artery (RCA) 55, 57 right-sided heart failure 2–3, 7, 15, 107 right-sided heart valve diseases 92–3 right ventricle (RV) failure 91 right ventricular hypertrophy (RVH) 113 risk factors acute coronary syndrome 75 angina pectoris 81 aortic regurgitation 87 aortic stenosis 83 coronary artery disease mitral regurgitation 89 RV see right ventricle RVH see right ventricular hypertrophy R waves 39, 53, 70 SA nodal artery 55 SA node 45 sarcoidosis 115 scleroderma 115 secondary hypertension 102–3 second-degree atrioventricular block 46–7 secundum atrial septal defect 111 sepsis 95 septal ablation 115 septic embolization 95 severe aortic regurgitation severe aortic stenosis 17 side effects adenosine 65 cardiovascular drugs 124–5 signs on examination 4–7 simple faint 17 simvastatin 123 sinus rhythm 61 sinus tachycardia 63, 75 135 SK see streptokinase skin 101 smoking snap 91 social history sodium retention 19 sotalol 123, 125 spironolactone 107, 115, 123, 125 splenomegaly 95 splinter haemorrhages 5, 95 Staphylococcus aureus 95, 97 statins 77, 81, 125 ST elevation myocardial infarction (STEMI) 73, 77, 128 stenosis aortic 10, 17, 79, 82–5, 107 artificial 113 mitral 9, 10, 90–1, 107 pulmonary 9, 93, 107 restenosis 27, 81 rheumatic fever 101 tricuspid 9, 93 stenting 27, 81 sternal angle 35 Stokes–Adams attacks 17 streptococcal infections 95, 101 streptokinase (SK) 77 stress echocardiography 30, 31 ST segment acute coronary syndrome 73, 77, 128 ECG interpretation 40, 41 exercise treadmill test 25 left bundle branch block 53 subvalvular disease 89 supraventricular tachycardia (SVT) 17, 59, 63, 67 surgery 120–1 atrial septal defect 111 complications 121 Eisenmenger’s syndrome 113 mitral regurgitation 89 mitral stenosis 91 resections 99 Tetralogy of Fallot 113 ventricle septal defect 113 see also individual procedures S waves 39 136 ONE STOP DOC symptoms cardiovascular-related syncope 16–17 chest pain 12–13 dyspnoea 14–15 peripheral oedema 18–19 syncope 16–17, 20 Syndenham’s chorea 101 syphilis 87 systemic hypertension 107 systolic click 89 systolic dysfunction 115 systolic murmurs 8–10, 85, 87, 89, 93, 111 systolic thrill 85, 89, 93 tachyarrhythmia 119 tachycardia acute heart failure 109 atrioventricular node re-entry tachycardia 63 atrioventricular re-entry tachycardia 63 broad complex 66–9 ECG 58–9, 62–9 junctional 63 monomorphic ventricular 67 narrow complex 62–5 pericardial effusion 99 polymorphic 67, 69 pulse examination sinus 63, 75 supraventricular 17, 59, 63, 67 ventricular 17, 67, 69 tachypnoea 99 territories of coronary arteries 54–7 Tetralogy of Fallot 93, 113 thiamine deficiency 115 thiazide diuretics 123, 125, 127 third-degree atrioventricular block 48–9 thromboembolism 91, 109 thrombolysis 73, 77, 128 thyrotoxicosis 9, 61, 107, 115 tilt testing 17, 20 tissue valves 87, 121 TOE see transoesophageal echocardiography tongue torsades de pointes 69 transoesophageal echocardiography (TOE) 29, 97 transplantation 113, 115 transthoracic imaging 29 Traube’s sign 87 treatments 117–25 acute coronary syndrome 77 acute heart failure 109 angina pectoris 81 aortic regurgitation 87 cardiomyopathy 115 chronic heart failure 107 infective endocarditis 97 malignant/accelerated hypertension 105 mitral regurgitation 89 rheumatic fever 101 tricuspid regurgitation 93 trials 123 tricuspid damage 107 tricuspid regurgitation 9, 93 tricuspid stenosis 9, 93 triglycerides 23 troponins 22–3, 77, 128 Turner’s syndrome 93 T waves acute coronary syndrome 73, 77, 128 ECG interpretation 39 left bundle branch block 53 12-lead electrocardiography 35, 37 24-hour ambulatory monitoring 17 2-D echocardiography 29 ultrasonography 103 unstable angina 73, 75, 128 upward deflection 37, 39 U waves 39 vagal manoeuvres 59, 63, 65 vagal tone 45 Valsalva manoeuvre 59 valve replacement aortic 53, 85, 87 atrial septal defect 111 infective endocarditis 97 mechanical 87, 121 mitral 89, 91, 111 prosthetic heart 121 right heart valve diseases 93 surgery 121 tissue valves 87, 121 valves acute heart failure 109 atrial septal defect 111 echocardiography 29 incompetent 101 infective endocarditis 95, 97 leaflets 89 right heart valve diseases 92–3 subvalvular disease 89 valvotomy 91, 93 valvuloplasty 85, 91 see also aortic ; mitral valvotomy 91, 93 valvuloplasty 85, 91 vasculitic lesions 95 vasodilators 123 vasomotor syncope 17 vasovagal syncope 17 vegetations 95 vein grafts 121 vena caval obstructions 19 venous hum ventricular arrhythmias 109 ventricular hypertrophy 39 ventricular rate 43, 61 ventricular septal defect (VSD) 9, 107, 109, 112–13 ventricular tachycardia (VT) 17, 67, 69 verapamil 123, 125 vesnarinone 123 volume overload 87, 89, 93, 107 VSD see ventricular septal defect VT see ventricular tachycardia V waves 93 warfarin 61, 109, 115, 123, 125 Wenckebach block 47 white cell count 23 Wolff–Parkinson–White syndrome 59, 65 xanthelasma [...]... blood Answers 3 4 5 6 a – Digital clubbing, b – Congenital heart disease, bacterial endocarditis or atrial myxoma a – Koilonychia, b – Ischaemic heart disease, c – A, Nail fold infarction, B, Splinter haemorrhages 1 – C, 2 – B, 3 – C, 4 – C, 5 – A, 6 – D (grade 4 most severe) a (conventionally given in g/dL) ONE STOP DOC 6 7 Concerning the JVP, true or false? a The jugular venous pressure is measured... aortic dissection, unstable angina, pulmonary embolism, b – Tension pneumothorax, oesophageal rupture, c – ECG, CXR, cardiac enzymes/troponin T ONE STOP DOC 14 Case study: dyspnoea Mrs Crane, a 66-year-old woman known to suffer from heart failure, attends your cardiology clinic Currently, her medical treatment includes diuretics Over the last few weeks she has become progressively short of breath, so... sympathetic nerves + VOLUME RECEPTORS ADH Activate renin – angiotensin – aldosterone system Renal + peripheral resistance Sodium + water retention Extracellular volume expansion Venous pressure OEDEMA 10–15% increase in extracellular volume PERIPHERAL OEDEMA Answers 10 T T T T T 11 b 12 Gravity See explanation 20 ONE STOP DOC A PATHWAY FOR THE EVALUATION OF SYNCOPAL EPISODES SYNCOPE History, physical... RV filling (e.g constrictive pericarditis and cardiac tamponade) Pneumothorax Pleural effusion Emphysema Answers 7 F F T T T 8 See explanation 9 See explanation 10 See explanation 11 b 12 T T T T T ONE STOP DOC 8 13 Match each of the cases described with the most appropriate cardiac defect/murmur listed below You may use the options more than once or not at all Options A B C D E F Tricuspid stenosis... (tricuspid stenosis may coexist, but extremely difficult to detect on auscultation), 3 – F, 4 – E, 5 – G, 6 – C 14 1 – B, 2 – D, 3 – B, 4 – E, 5 – G, 6 – E 15 Mitral stenosis and tricuspid stenosis ONE STOP DOC 10 EXPLANATION: LEFT-SIDED HEART MURMURS Carotids S1 S2 SYSTOLE ATRIOVENTRICULAR VALVE CLOSURE 1 ST 2ND M I T R A L T R I C U S P I D S1 DIASTOLE SEMILUNAR VALVE CLOSURE A ATRIOVENTRICULAR VALVES... clubbing: may be the result of congenital heart disease, bacterial endocarditis or atrial myxoma • Splinter haemorrhages: linear haemorrhages in the nail bed, parallel to the length of the nail, that can present in endocarditis • Osler’s nodes: painful, pink, pea-sized papules over the finger pads; assoPulse annotation ciated with bacterial endocarditis • Janeway lesions: non-tender maculae on the palms and... 3 4 5 6 7 New York Heart Association classification of heart failure, class III F T F F Orthopnoea a – Ascites and hepatomegaly, b – ↓ Vital capacity Paroxysmal nocturnal dyspnoea See explanation ONE STOP DOC 16 8 (a) Define presyncope (b) Define syncope (c) Describe the role of Holter monitoring and memory loop recorders in gathering information about presyncopal or syncopal episodes In what circumstances... patients with a prominent fall in heart rate before syncope who may benefit from implantation of a pacemaker Answers 8 See explanation 9 1 – J, 2 – A, 3 – E (diuretic treatment), 4 – F, 5 – H, 6 – I ONE STOP DOC 18 10 The following may result in peripheral oedema True or false? a b c d e Hypoalbuminaemia Sodium retention Hepatic cirrhosis Vena caval obstruction Heart failure 11 Best response Peripheral... (thrombolytic agent) for MI See also the explanation on treatments (see page 77) Answers 1 (i) b, d, e; (ii) a, c, e 2 a – 30.1, indicating that he is obese, b – See explanation, c – 50 pack-years ONE STOP DOC 4 3 (a) What is the name given to the clinical sign that is depicted in this series of diagrams? (b) State two cardiac-related conditions that may cause it Normal Early 160° Late Gross Angle obliterated... and 2 mmol/L LDL cholesterol’ for high-risk populations such as those who have required coronary intervention (5) Answers 1 2 3 4 5 F T F F b T T T F F (i) a, b, c; (ii) e; (iii) d See explanation ONE STOP DOC 24 A 55-year-old barman has a two-week history of chest pain on exertion The pain is not associated with diaphoresis, shortness of breath, nausea or palpitations Over the last week, he has been .. .ONE STOP DOC Cardiology One Stop Doc Titles in the series include: Cardiovascular System – Jonathan Aron Editorial... Contributing Author – Thomas Chapman Editorial Advisor – Stephen Pereira Volume Editor – Basant Puri ONE STOP DOC Cardiology Rishi Aggarwal MBBS Graduate of Guy’s, King’s and St Thomas’ Medical School and... the One Stop Doc authors I wish you the very best of luck in your exams and hope these books serve you well! From the Authors, Rishi Aggarwal, Emily Ferenczi and Nina Muirhead The horizons of cardiology