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Cardiology in a heartbeat
Your hosts: Malik ‘heart throb’ Fleet and
Thomas ‘heart ache’ McLeod
Objectives
 Be able to perform in a cardio related osce.
 Describe the key features and management
of:
 Atrial Fibrilla...
Outline of session
 20 minutes OSCE and debrief
 40 minutes tutorial
 20 minutes SBAs
 Answer any questions
Notes from the OSCE scenario
 DR ABCDE: (Before ‘D’!)
 Ask examiner for observations
 Does patient meet PERT criteria? ...
Notes from the OSCE scenario
 D - anger
 R - esponse
 A -irway
 B- reathing
 C - irculation
 D - isability (AVPU)
 ...
Notes from the OSCE scenario
 A - irway:
 Look
 Feel
 Listen
 Measure
 Treat
Often patient is breathing
so able to s...
Notes from the OSCE scenario
 B- reathing
 Look: cyanosed? Trachea central? Chest expansion?
 Feel: symmetrical chest m...
Notes from the OSCE scenario
 C- irculation
 Look: cyanosed? General appearance? JVP? Pain?
 Feel: Peripheries- cool? C...
Notes from the OSCE scenario
 D- isability: AVPU + BM
Patient responds to:
 A - lert
 V - oice
 P - ain
 U - nrespons...
Notes from the OSCE scenario
 E- xposure:
 Expose patient from head to toe looking for
any other clue for deterioration....
Notes from the OSCE scenario:
 8 Reversible causes of VT: The 4 ‘H’s and 4 T’s.
4 T’s:
T-hrombosis (coronary or
pulmonary...
Notes from the OSCE scenario:
 2 shockable rhythms:
 Pulseless Ventricular Tachycardia
 Ventricular Fibrillation
 2 no...
Notes from the OSCE scenario:
Tutorial: Atrial Fibrillation
AF: Objectives
By the end of this session you should be able to:
 Identify how AF presents and establish an appropriate d...
Case: “Jo-Jo”
“Joe”
 Joe is a 45 year old professional clown.
 He has recently returned from a boozy working
holiday in Magaluf.
 He ...
Differential Diagnosis at this
stage?
 Anxiety induced palpitations (panic attack)
 Atrial Fibrillation
 (hyperthyroidi...
Examination
“irregularly irregular”*
*NICE recognise as very ‘sensitive’ sign for dx of AF. Regular radial pulse= 96% nega...
Investigations:
 ECG: (Please present)
Joseph Jackson D.O.B: 16/3/ 1967
AF: ECG findings and
pathophysiology
 ECG findings:
 Absent p waves ~ no identifiable p waves throughout trace.
 Narrow...
AF: ECG findings and
pathophysiology
 Pathophysiology:
Diagnosis= AF. What are you
worried about?
 AF:
 Risk of: EMBOLISM STROKE
 Haemodynamic compromise
Other investigations:
+/-
Case development
 History: diagnosed with hypertension 10 years ago. Stopped taking ‘useless
tablets’ after 6 months. Fat...
AF: Management: “The Blender”
 “Rate” or “Rhythm” Control
AF: Management: Acute Onset

If HAEMODYNAMIC INSTABILITY:
Non Life threatening:
-RATE (if major contributor to haemodynam...
AF: Rhythm Control: Cardioversion
 Pharmacological Electrical
< 48 hours > 48 hours
AF: Rhythm: Cardioversion:
WARNING!
 AF = clot generator
 Normal rhythm (cardiac output restored)
 clots disseminated t...
AF: Rhythm: Cardioversion: VTE
prophylaxis
<48 hours
-Heparin
-PCV (or ECV)
-Confirm onset of AF:
-If definitely <48hours:...
AF: Rhythm: Cardioversion: VTE
prophylaxis
AF: Rhythm: Cardioversion:
PHARMACOLOGICAL
<48 hours
 Flecainide Amiodarone
NO structural heart disease* YES structural h...
AF: Rhythm: Cardioversion:
ELECTRICAL
>48 hours
 ECV (= low grade shock to heart):
 1st line: > 48 hours
 If doubts ove...
Atrial fibrillation: “3 p’s”
Classification
 Paroxysmal:
 Spontaneous self termination
 <7 days (often <48hours)
 Pers...
AF: Management: Paroxysmal
 Classified as…
 Therapeutic objective: SUPPRESSION OF
PAROXYSMS
 Paroxysm defined as…
 Fro...
AF: Management: Paroxysmal
 Classified as…
 Spontaneous self termination
 <7 days (often <48hours)

Paroxysm defined a...
AF: Management: Paroxysmal
 Suppression of paroxysms:
CONSERVATIVE:
 1.there is a known precipitant of paroxysm
 E.g. A...
AF: Management: Paroxysmal
 Suppression of paroxysms:
MEDICAL/ PHARMACOLOGICAL:
-If patient is symptomatic
-Frequent paro...
AF: Management: Persistent
 Classified as…

Therapeutic objective: think blender: control the rate or rhythm.
AF: Management: Persistent
RHYTHM vs RATE
AF: Management: Persistent:
RATE
 RATE control strategy should be preferred 1st line option in:
 Over 65s
 Coronary art...
AF: Management: Persistent:
RATE
 RATE control 1st line option: Beta blocker/ rate limiting Ca channel blocker
 Monother...
AF: Management: Persistent:
RHYTHM
 RHYTHM control strategy should be preferred 1st line option in:
 Younger patients
 ...
AF: Management: Persistent:
RHYTHM
 RHYTHM control strategy 1st line option is:
 Cardioversion + Anticoagulation
If recu...
AF: Management: Permanent
 Classified as…

Therapeutic objective: think blender: control rate as rhythm functions are
br...
AF: Management: Permanent
RATE only!
AF: Management: Permanent:
RATE
 RATE control 1st line option: Beta blocker/ rate limiting Ca channel blocker
 Monothera...
AF: Management:
ANTICOAGULATION
 Acute:
 Commence heparin until full risk assessment of emboli has been performed.
 >48...
AF: Summary
You should now be able to:
 Identify how AF presents and establish an appropriate differential
 Suggest sens...
Tutorial: Acute Coronary
Syndrome
Case
 57 year old Gavin stumbles into A&E
complaining of severe chest pain. He’s grey
and very sweaty.
Objectives
 Pathophysiology
 Definitions
 Presentation
 Investigations
 Management of STEMI
What causes ischaemic heart
disease?
Fatty streak > Simple plaque > Complicated
Risk Factors
Non-modifiable
 Age
 Gender (males are at greater risk)
 family history of IHD
Modifiable
Definitions
Acute Coronary Syndrome
Unstable Angina NSTEMI STEMI
Ischaemia
Reduced perfusion. Purely symptomatic. No cell
death
Infarction
Reduced perfusion exceeding tolerance of cells. ...
Ischaemia
Reduced perfusion. Purely symptomatic. No cell
death
• Stable Angina
• Unstable Angina
Infarction
Reduced perfus...
Acute Coronary Syndrome
Unstable Angina NSTEMI STEMI
Differentiate?
ECG
Troponin
 0Hrs
 12Hrs
Unstable angina
 ST elevation
 Troponin +ve
NSTEMI
Troponin +ve
STEMI
ST elevation
Troponin +ve
Back to the case
What next?
History and Examination
Investigation.
ECG & Troponin
Anatomy
ST: Elevation: Localisation
Right Left
ST: Elevation: Localisation
ST: Elevation
Mechanism behind ECG changes:
 Complete occlusion of coronary vessel leads to ischaemia/infarction which
is...
Gavin’s ECG
Initial Treatment
 Morphine – 5-10mg IV (+ metoclopramide)
 Oxygen – aim for SaO2 > 95%
 Nitrate – 2 puffs or 1 tablet
...
Restore Coronary Perfusion
 Primary PCI
 Rx of choice if within 12h
 Thrombolysis
 Contraindicated beyond 24hr
 Strep...
Gavin has Primary PCI at the London Heart
Hospital. He survives and is very grateful.
What is the next stage of his manage...
Subsequent Management
 Modifiable risk factors
 Antiplatelet – Aspirin, Clopidogrel
 B-blockers
 Statin
 ACE
Summary
 Pathophysiology
 Definitions
 Presentation
 Investigations
 Management of STEMI
A 45 year old man suffers sudden central
chest pain while at rest. It spreads across
his chest and up to his neck. After 2...
What is the single most accurate classification of
this event?
A. Acute Coronary Syndrome
B. Non-ST elevation myocardial i...
What is the single most accurate classification of
this event?
A. Acute Coronary Syndrome
B. Non-ST elevation myocardial i...
A 55 year-old woman has noticed her heart
beating fast. It happens infrequently and is not
assosciated with any other symp...
Which is the single most appropriate
treatment?
A. Amiodarone 100mg PO once daily
B. Digoxin 62.5mcg PO once daily
C. Flec...
Which is the single most appropriate
treatment?
A. Amiodarone 100mg PO once daily
B. Digoxin 62.5mcg PO once daily
C. Flec...
SBAs:
Which of the following is not a reversible
cause of cardiac arrest?
 Hypoxia
 Hypo/Hyperkalaemia
 Tension Pneumot...
SBAs:
Which of the following is not a reversible
cause of cardiac arrest?
 Hypoxia
 Hypo/Hyperkalaemia
 Tension Pneumot...
SBAs:
A 67 year old lady has just been diagnosed with persistent AF.
Cardioversion has previously failed. She is symptomat...
SBAs:
A 67 year old lady has just been diagnosed with persistent AF.
Cardioversion has previously failed. She is symptomat...
A 48-year old patient gives a 5 day history of dyspnoea.
He is found to be in atrial fibrillation. Which is the most
appro...
A 48-year old patient gives a 5 day history of dyspnoea.
He is found to be in atrial fibrillation. Which is the most
appro...
Cardiology in a Heartbeat
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Cardiology in a Heartbeat

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Cardiology in a Heartbeat

  1. 1. Cardiology in a heartbeat Your hosts: Malik ‘heart throb’ Fleet and Thomas ‘heart ache’ McLeod
  2. 2. Objectives  Be able to perform in a cardio related osce.  Describe the key features and management of:  Atrial Fibrillation  Acute Coronary Syndrome  Answer SBAs related to this week’s teaching
  3. 3. Outline of session  20 minutes OSCE and debrief  40 minutes tutorial  20 minutes SBAs  Answer any questions
  4. 4. Notes from the OSCE scenario  DR ABCDE: (Before ‘D’!)  Ask examiner for observations  Does patient meet PERT criteria? They always do so call for help!  (PERT criteria=
  5. 5. Notes from the OSCE scenario  D - anger  R - esponse  A -irway  B- reathing  C - irculation  D - isability (AVPU)  E - xposure LOOK FEEL LISTEN MEASURE TREAT
  6. 6. Notes from the OSCE scenario  A - irway:  Look  Feel  Listen  Measure  Treat Often patient is breathing so able to say airway is patent. If not, suggest ensuring airway e.g Guedel airway
  7. 7. Notes from the OSCE scenario  B- reathing  Look: cyanosed? Trachea central? Chest expansion?  Feel: symmetrical chest movement? Percussion?  Listen: auscultate chest (ask examiner for findings)  Measure:  a. Resp rate  B. O2 sats on air  Treat:  Give oxygen: high flow (e.g. 15L/min) - non rebreathe mask (unless C/I e.g COPD)
  8. 8. Notes from the OSCE scenario  C- irculation  Look: cyanosed? General appearance? JVP? Pain?  Feel: Peripheries- cool? Clammy?; Pulse  Listen: heart sounds  Measure:  Heart rate  Blood pressure  Cap refill  Urine output  Temp.  ECG  Treat:  IV access (“two wide bore cannulae”)  Bloods (FBC/ U and E)  Fluid Challenge  (MONA if acute coronary syndrome)
  9. 9. Notes from the OSCE scenario  D- isability: AVPU + BM Patient responds to:  A - lert  V - oice  P - ain  U - nresponsive  Ask examiner for BM
  10. 10. Notes from the OSCE scenario  E- xposure:  Expose patient from head to toe looking for any other clue for deterioration.  + “ending exam”: write notes, hand over to team etc.
  11. 11. Notes from the OSCE scenario:  8 Reversible causes of VT: The 4 ‘H’s and 4 T’s. 4 T’s: T-hrombosis (coronary or pulmonary) T-amponade T-oxins T-ension pneumothorax 4 H’s: H-ypoxia H-ypovolaemia H-ypo/er kalaemia (metabolic) H-ypothermia
  12. 12. Notes from the OSCE scenario:  2 shockable rhythms:  Pulseless Ventricular Tachycardia  Ventricular Fibrillation  2 non shock:  -Pulseless electrical activity  -Asystole
  13. 13. Notes from the OSCE scenario:
  14. 14. Tutorial: Atrial Fibrillation
  15. 15. AF: Objectives By the end of this session you should be able to:  Identify how AF presents and establish an appropriate differential  Suggest sensible investigations as relating to your differential  Recognise and describe the classic ECG findings and the pathophysiology of AF.  Classify AF as according to its pattern and amenability to cardioversion (‘the 3 P’s)  Describe the management options in terms of Rate and Rhythm control and list suitable examples of patients and medications accordingly.
  16. 16. Case: “Jo-Jo”
  17. 17. “Joe”  Joe is a 45 year old professional clown.  He has recently returned from a boozy working holiday in Magaluf.  He has the biggest performance of his career at the Brent Cross circus tomorrow. He feels terribly unprepared and begins to sweat when talking about it.  He presents to you in A and E complaining of being aware that his heart is doing ‘funny things’ and feels short of breath.
  18. 18. Differential Diagnosis at this stage?  Anxiety induced palpitations (panic attack)  Atrial Fibrillation  (hyperthyroidism)
  19. 19. Examination “irregularly irregular”* *NICE recognise as very ‘sensitive’ sign for dx of AF. Regular radial pulse= 96% negative predictive value.
  20. 20. Investigations:  ECG: (Please present) Joseph Jackson D.O.B: 16/3/ 1967
  21. 21. AF: ECG findings and pathophysiology  ECG findings:  Absent p waves ~ no identifiable p waves throughout trace.  Narrow QRS (AV conduction in tact)
  22. 22. AF: ECG findings and pathophysiology  Pathophysiology:
  23. 23. Diagnosis= AF. What are you worried about?  AF:  Risk of: EMBOLISM STROKE  Haemodynamic compromise
  24. 24. Other investigations: +/-
  25. 25. Case development  History: diagnosed with hypertension 10 years ago. Stopped taking ‘useless tablets’ after 6 months. Father died at 60 from hypertensive heart disease/failure.  Ix:  No echo done  Bloods: TFTs: negative Troponin: negative  Joe begins to feel worse, his heart rate increases to 150 bpm and he has slight pain. No ST elevation on ECG.
  26. 26. AF: Management: “The Blender”  “Rate” or “Rhythm” Control
  27. 27. AF: Management: Acute Onset  If HAEMODYNAMIC INSTABILITY: Non Life threatening: -RATE (if major contributor to haemodynamic instability): -Beta Blocker / Ca Channel Blocker -Amiodarone -RHYTHM: -PCV* (or ECV if available) *Pharmacological Cardioversion: I.V Amiodarone -ANTICOAGULATION: -start heparin - commence oral warfarin depending on outcome of CV/ onset of AF. Life threatening: -RHYTHM: Emergency electrical cardioversion -(Anticoagulation should not delay intervention).
  28. 28. AF: Rhythm Control: Cardioversion  Pharmacological Electrical < 48 hours > 48 hours
  29. 29. AF: Rhythm: Cardioversion: WARNING!  AF = clot generator  Normal rhythm (cardiac output restored)  clots disseminated to brain etc. CARDIOVERSION
  30. 30. AF: Rhythm: Cardioversion: VTE prophylaxis <48 hours -Heparin -PCV (or ECV) -Confirm onset of AF: -If definitely <48hours: no need for further anticoagulation. -If unsure: warfarin for 4 weeks >48hours a. ANTI COAGULATE (3 weeks) or b. TRANS OESOPHAGEAL ECHO (TOE) -detects whether a thrombus is present or not. -If not: heparin + cardioversion -If present: warfarin for 3 weeks and repeat TOE. * Continue warfarin for 4 weeks post cardioversion
  31. 31. AF: Rhythm: Cardioversion: VTE prophylaxis
  32. 32. AF: Rhythm: Cardioversion: PHARMACOLOGICAL <48 hours  Flecainide Amiodarone NO structural heart disease* YES structural heart disease* (<8 hours) (>8 hours) *Structural heart disease defined as: “coronary artery disease or LV dysfunction”
  33. 33. AF: Rhythm: Cardioversion: ELECTRICAL >48 hours  ECV (= low grade shock to heart):  1st line: > 48 hours  If doubts over success (e.g. previous failure to cardiovert; early recurrence of AF):  Give AMIODARONE or SOTALOL for 4 weeks prior to ECV.  Improves rates of cardioversion
  34. 34. Atrial fibrillation: “3 p’s” Classification  Paroxysmal:  Spontaneous self termination  <7 days (often <48hours)  Persistent:  Lasts > 7 days  NOT self terminating  Permanent  Does not terminate  Not amenable to cardioversion  (NOTE: can return to sinus rhythm if cure underlying pathology e.g. hyperthyroidism)
  35. 35. AF: Management: Paroxysmal  Classified as…  Therapeutic objective: SUPPRESSION OF PAROXYSMS  Paroxysm defined as…  From the Greek…
  36. 36. AF: Management: Paroxysmal  Classified as…  Spontaneous self termination  <7 days (often <48hours)  Paroxysm defined as…"sudden attack, outburst"  From the Greek… (παροξυσμός paroxusmos), "irritation, exasperation".[
  37. 37. AF: Management: Paroxysmal  Suppression of paroxysms: CONSERVATIVE:  1.there is a known precipitant of paroxysm  E.g. Alcohol; caffeine.  2. the patient asymptomatic/few symptoms  3. No history of left ventricular dysfunction/ ischaemic heart disease Rx: -drug free / “pill in the pocket” strategy: Pill in a pocket= “Flecainide” (or other Class 1c agent)
  38. 38. AF: Management: Paroxysmal  Suppression of paroxysms: MEDICAL/ PHARMACOLOGICAL: -If patient is symptomatic -Frequent paroxysms -No known precipitant  1st Line: Beta Blocker  2nd line (symptoms not controlled): Sotalol  3rd line/ if poor left ventricular function: Amiodarone
  39. 39. AF: Management: Persistent  Classified as…  Therapeutic objective: think blender: control the rate or rhythm.
  40. 40. AF: Management: Persistent RHYTHM vs RATE
  41. 41. AF: Management: Persistent: RATE  RATE control strategy should be preferred 1st line option in:  Over 65s  Coronary artery disease  C/I to antiarrhthymic drugs  Not suitable for cardioversion  No heart failure
  42. 42. AF: Management: Persistent: RATE  RATE control 1st line option: Beta blocker/ rate limiting Ca channel blocker  Monotherapy:  Beta blocker  Ca Channel Blocker  (Digoxin ~ if sedentary)  If require more than monotherapy:  Beta blocker/ Ca channel blocker + Digoxin
  43. 43. AF: Management: Persistent: RHYTHM  RHYTHM control strategy should be preferred 1st line option in:  Younger patients  Symptomatic  AF secondary to treated/ corrected precipitant (e.g. chest infection)  With heart failure
  44. 44. AF: Management: Persistent: RHYTHM  RHYTHM control strategy 1st line option is:  Cardioversion + Anticoagulation If recurrence/ unsuccessful/ requires drug to maintain sinus rhythm: 1st line:  Beta Blocker 2nd Line (I.e. not effective/ contraindicated): + structural heart disease :AMIODARONE - NO structural heart disease: FLECAINIDE (or Sotalol)
  45. 45. AF: Management: Permanent  Classified as…  Therapeutic objective: think blender: control rate as rhythm functions are broken!
  46. 46. AF: Management: Permanent RATE only!
  47. 47. AF: Management: Permanent: RATE  RATE control 1st line option: Beta blocker/ rate limiting Ca channel blocker  Monotherapy:  Beta blocker  Ca Channel Blocker  (Digoxin ~ if sedentary)  If require more than monotherapy:  Beta blocker/ Ca channel blocker + Digoxin
  48. 48. AF: Management: ANTICOAGULATION  Acute:  Commence heparin until full risk assessment of emboli has been performed.  >48 hours- 3 weeks of oral anticoagulation (warfarin) prior to cardioversion  NO anticoagulation if:  Stable sinus rhythm has been restored  <48 hours  No risk factors for emboli  Chronic:  Discuss with patient risks and benefits of anticoagulation.  CHADS 2 = predictor of stroke.  C= congestive cardiac failure (1)  H= hypertension (1)  A = age (>75) (1)  D= Diabetes (1)  S= stroke/ previous TIA (2)  Warfarin : aim for therapeutic INR 2 -3  (If warfarin C/I : Aspirin 300 mg/day) CHADS 2 score of: % risk of stroke 0: 1.9% 6: 18.2%
  49. 49. AF: Summary You should now be able to:  Identify how AF presents and establish an appropriate differential  Suggest sensible investigations as relating to your differential  Recognise and describe the classic ECG findings and the pathophysiology of AF.  Classify AF as according to its pattern and amenability to cardioversion (‘the 3 P’s)  Describe the management options in terms of Rate and Rhythm control and list suitable examples of patients and medications accordingly.
  50. 50. Tutorial: Acute Coronary Syndrome
  51. 51. Case  57 year old Gavin stumbles into A&E complaining of severe chest pain. He’s grey and very sweaty.
  52. 52. Objectives  Pathophysiology  Definitions  Presentation  Investigations  Management of STEMI
  53. 53. What causes ischaemic heart disease?
  54. 54. Fatty streak > Simple plaque > Complicated
  55. 55. Risk Factors
  56. 56. Non-modifiable  Age  Gender (males are at greater risk)  family history of IHD
  57. 57. Modifiable
  58. 58. Definitions
  59. 59. Acute Coronary Syndrome Unstable Angina NSTEMI STEMI
  60. 60. Ischaemia Reduced perfusion. Purely symptomatic. No cell death Infarction Reduced perfusion exceeding tolerance of cells. Cell death
  61. 61. Ischaemia Reduced perfusion. Purely symptomatic. No cell death • Stable Angina • Unstable Angina Infarction Reduced perfusion exceeding tolerance of cells. Cell Death • NSTEMI • STEMI Clinical Application
  62. 62. Acute Coronary Syndrome Unstable Angina NSTEMI STEMI
  63. 63. Differentiate?
  64. 64. ECG
  65. 65. Troponin  0Hrs  12Hrs
  66. 66. Unstable angina  ST elevation  Troponin +ve
  67. 67. NSTEMI Troponin +ve
  68. 68. STEMI ST elevation Troponin +ve
  69. 69. Back to the case What next?
  70. 70. History and Examination
  71. 71. Investigation. ECG & Troponin
  72. 72. Anatomy
  73. 73. ST: Elevation: Localisation Right Left
  74. 74. ST: Elevation: Localisation
  75. 75. ST: Elevation Mechanism behind ECG changes:  Complete occlusion of coronary vessel leads to ischaemia/infarction which is seen as ST elevation.  The mechanism is, however, poorly understood.  Injury wave hypothesis= abnormal currents are generated between normal and infarcted tissue and detected as an ‘injury wave’.  Localisation:  Right Coronary Artery (Post. Descending/ Marginal): Inferior STEMI: Leads II, III, avF  Left Anterior Descending: Anterior STEMI: V1-V4  Left circumflex: Lateral STEMI: I, aVL, V5, V6
  76. 76. Gavin’s ECG
  77. 77. Initial Treatment  Morphine – 5-10mg IV (+ metoclopramide)  Oxygen – aim for SaO2 > 95%  Nitrate – 2 puffs or 1 tablet  Aspirin – 300mg PO  Restore coronary perfusion
  78. 78. Restore Coronary Perfusion  Primary PCI  Rx of choice if within 12h  Thrombolysis  Contraindicated beyond 24hr  Streptokinase, Alteplase
  79. 79. Gavin has Primary PCI at the London Heart Hospital. He survives and is very grateful. What is the next stage of his management?
  80. 80. Subsequent Management  Modifiable risk factors  Antiplatelet – Aspirin, Clopidogrel  B-blockers  Statin  ACE
  81. 81. Summary  Pathophysiology  Definitions  Presentation  Investigations  Management of STEMI
  82. 82. A 45 year old man suffers sudden central chest pain while at rest. It spreads across his chest and up to his neck. After 20 mins, the pain has not eased and he is increasingly sweaty and short of breath. This is the third such episode in the last 3 months 12hr Troponin I <0.05 ug/L
  83. 83. What is the single most accurate classification of this event? A. Acute Coronary Syndrome B. Non-ST elevation myocardial infarction C. ST elevation myocardial infarction D. Stable angina E. Unstable angina
  84. 84. What is the single most accurate classification of this event? A. Acute Coronary Syndrome B. Non-ST elevation myocardial infarction C. ST elevation myocardial infarction D. Stable angina E. Unstable angina
  85. 85. A 55 year-old woman has noticed her heart beating fast. It happens infrequently and is not assosciated with any other symptoms. She is anxious about the cause of these attacks as she has no other medical problems. HR 80bpm, BP 115/75mmHg After a normal ECG, a 24hr tape is performed
  86. 86. Which is the single most appropriate treatment? A. Amiodarone 100mg PO once daily B. Digoxin 62.5mcg PO once daily C. Flecainide 150mg PO as required D. Metoprolol 25mg PO twice daily E. Sotalol 40mg PO twice daily
  87. 87. Which is the single most appropriate treatment? A. Amiodarone 100mg PO once daily B. Digoxin 62.5mcg PO once daily C. Flecainide 150mg PO as required D. Metoprolol 25mg PO twice daily E. Sotalol 40mg PO twice daily
  88. 88. SBAs: Which of the following is not a reversible cause of cardiac arrest?  Hypoxia  Hypo/Hyperkalaemia  Tension Pneumothorax  Hyperthyroidism  Tamponade
  89. 89. SBAs: Which of the following is not a reversible cause of cardiac arrest?  Hypoxia  Hypo/Hyperkalaemia  Tension Pneumothorax  Hyperthyroidism  Tamponade
  90. 90. SBAs: A 67 year old lady has just been diagnosed with persistent AF. Cardioversion has previously failed. She is symptomatic, has coronary artery disease but no heart failure. What1st line treatment would you prescribe?  Paracetamol  Beta Blocker  Flecainide  Sotalol  Amiodarone
  91. 91. SBAs: A 67 year old lady has just been diagnosed with persistent AF. Cardioversion has previously failed. She is symptomatic, has coronary artery disease but no heart failure. What1st line treatment would you prescribe?  Paracetamol  Beta Blocker  Flecainide  Sotalol  Amiodarone
  92. 92. A 48-year old patient gives a 5 day history of dyspnoea. He is found to be in atrial fibrillation. Which is the most appropriate management plan? A. Chemical cardioversion with IV amiodarone B. Chemical cardioversion with IV flecainide C. Anticoagulation with warfarin and rate control D. Transthoracic echocardiogram to exclude thrombus followed by DC cardioversion E. Anticoagulation with warfarin then initiation of oral amiodarone
  93. 93. A 48-year old patient gives a 5 day history of dyspnoea. He is found to be in atrial fibrillation. Which is the most appropriate management plan? A. Chemical cardioversion with IV amiodarone B. Chemical cardioversion with IV flecainide C. Anticoagulation with warfarin and rate control D. Transthoracic echocardiogram to exclude thrombus followed by DC cardioversion E. Anticoagulation with warfarin then initiation of oral amiodarone

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