89 year old gentleman with history of Syncope - What should be the next step in management ?

A 89 years old gentleman with a history of hypertension and osteoarthritis presents to the ED with an episode of syncope while listening to music. He has felt generally lethargic for the past one week. He denies  chest pain, shortness of breath, or fever. His medications include Metoprolol and celecoxib. The blood pressure is 120/60 mmHg, H/R 42/min, R/R 15/min, and he is afebrile. His physical examination reveals normal lung sounds, a regular, bradycardic rhythm with varying intensities of the S1 heart sound on auscultation, and intermittent large cannon A waves in the jugular venous pulsation. His laboratory studies are normal. The ECG of the patient is depicted below. What is the next step in management of this patient?

 A) Observation

 B) Stop Metoprolol

 C) Permanent pacemaker implantation

 D) AICD Implantation

Answer-
Diagnosis -2nd degree AV block - high grade - Mobitz II 
Next Step in Management - Stop Metprolol and be ready for PPI 

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A 62 year old gentleman found unresponsive - What should be the Best Course of Action?

A 62 year old gentleman with a history of diabetes mellitus, hypertension, and a renal transplant presents to the ED after being found unresponsive at office. His temperature is 37.6 C, blood pressure is 80/30, heart rate 130, respirations 25, and oxygen saturation 75% on room air. Physical examination reveals bilateral pulmonary rales, a S4 heart sound is present, and no murmurs could be auscultated. He is intubated for airway protection. ECG reveals sinus tachycardia with a LBBB. 



A Swan-Ganz catheter is inserted and the values are below:

Right atrial presssure - 8 mmHg
Right ventricular pressure - 38/8 mmHg
Pulmonary artery pressure - 42/22 mmHg
Pulmonary capillary wedge pressure - 26 mmHg
Cardiac output - 4.0 L/min
Cardiac index - 2.0 L/min/BSA

Which of the following is best course of action?

 A) Emergency Echocardiography

 B) Emergent cardiac catheterization

 C) Tissue plasminogen activator infusion (tPA)

 D) Glycoprotein IIb/IIIa infusion

Answer: B - Emergent Cardiac Catheterization

The patient depicted in the question presents with severe shock. His Swan-Ganz pressure readings shows low cardiac output and elevated PCWP which reflects cardiogenic shock.Late stage septic shock can actually appear similar when the heart begins to fail, however the presentation is more acute in case of septic shock. This patient is most likely having a large myocardial infarction causing left ventricular dysfunction and reduced cardiac output leading to hypotension. He must be taken emergently for cardiac catheterization to revascularize the culprit coronary artery. Cardiac catheterization with stenting has been shown to be superior to thrombolytics in patients with cardiogenic shock. Inotropes could sometimes be helpful to stimulate inotropy and cardiac output, however this can worsen ongoing myocardial ischemia as well. 

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Cardiology Case Scenario - Make Your Diagnosis

A 68-year-old gentleman is admitted with an Anterior myocardial infarction (MI) and receives thrombolysis, aspirin, atenolol, atorvastatin and lisinopril. His ECG shows good ST segment resolution.

The next day he develops some pain in the legs and a dusky discolouration of the lower limbs. On closer examination there is a diffuse petechial rash over the lower limbs, particularly the feet, but all peripheral pulses are palpable.

Investigations reveal:

Haemoglobin	13.3 g/dl	(12-16)
Platelets	145 ×109/l	(150-400)
White cell count	12.1 ×109/l	(4-11)
Neutrophils	6.5 ×109/l	(1.5-7)
Lymphocytes	3.5 ×109/l	(1.5-4)
Eosinophils	1.2 ×109/l	(0.04-0.4)
IgE antibody	3 kU/l	(<2 br="br">

Which of the following is the most likely cause for his current situation?

1. Polyarteritis Nodosa
2. Aspirin Allergy
3. Periphral Vascular Disease
4. Cholesterol Emboli
5. Post Thrombolysis Allergy

Answer

The  above patient is an arteriopath as suggested by the acute Myocardial Infarction, and one day after thrombolysis he develops a petechial rash in the lower limbs with raised white cell count - marked eosinophilia and raised IgE. This suggests cholesterol embolisation syndrome rather than allergy. 

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Cardiology Case Scenario with ECG -Make Diagnosis

An 75-year-old female presented with community acquired Pneumonia. She has been successfully treated with Erythromycin and nebulised salbutamol. She has taken furosemide 40 mg/day and digoxin 0.25 mg /day for a number of years.

she developed a brief episode of chest pain in the ward. An electrocardiogram was taken.

Make your Diagnosis....

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Answer

The diagnosis is Second Degree AV block

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Cardiology MCQs - Choose the Appropriate Beta Blocker

A 50 year old gentleman with severe asthma is having a Acute Myocardial Infarction. Which of the following beta-blockers can potentially treat his MI while causing minimal Bronchoconstriction?

        Metoprolol

        Propranolol

        Carvedilol

                                                               Nadolol








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All You need to Know About Digoxin

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MCQ - Choose the Culprit Drug

A 60 year old male with a history of congestive heart failure and atrial fibrillation states his vision has been mostly yellow recently. He has noted lack of appetite and weight loss. Laboratory studies reveal and elevated potassium level. Which of the following is the likely causing his symptoms?

Nitroglycerine

Digoxin

Amiodarone

Spironolactone

Sildenafil

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Cardiology MCQ- Cause of Sudden Cardiac Death

A 19 year old girl is noted to have a reduced upper to lower body segment ratio, positive Walker and Steinberg signs, and pectus carinatum. Her father died suddenly at the age of 32. She is subsequently diagnosed with Marfan’s syndrome. Which of the following was the likely cause of death of her father?

Congestive heart failure

Aortic dissection

Myocardial infarction

Aortic valve regurgitation

Mitral valve prolapse

Click The appropriate Option

Echocardiography- Massive Pericardial Effusion

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Cardiology MCQ - Make your Diagnosis

A 72 year old female with a history of breast cancer and tobacco use complains of dizziness and dyspnea on exertion. Her heart sounds are distant and her systolic blood pressure is noted to markedly decrease with inspiration. Which of the following is the most likely diagnosis?

A) Constrictive cardiomyopathy

B) Mitral valve Stenosis

C) Congestive heart failure

D) Pulmonary embolus

E) Cardiac Tamponade

Answer    E

                 Cancer is the most common cause of pericardial effusion and when enough fluid accumulates in the pericardial space, cardiac tamponade occurs. “Pulsus paradoxus” is when there is a decrease in systolic blood pressure during inspiration due to failure of the right ventricle to accept the normal increased venous return that occurs with inspiration. This also results in a “Kussmal’s sign” or elevated jugular venous distension during inspiration (normally the opposite occurs). Treatment is with emergent pericardiocentesis.

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