100 Challenges in Cardiology

David R Ramsdale, Simon Modi

• Publisher: WSPC
• Year: 2010
• ISBN:
  9789814360845
• Topic: Medicine
• Subtopic: Cardiology

100 Challenges in Cardiology comprises one hundred well-illustrated clinical scenarios covering a wide spectrum of cardiology cases — hypertension, stable and unstable angina, non-ST elevation and ST-elevation myocardial infarction, coronary intervention, percutaneous aortic and mitral valve treatment, ASD closure, complications of MI, valvular heart disease, pericardial disease, cardiomyopathies, HOCM ablation, haemodynamic assessment in catheterisation laboratory, aortic dissection, infective endocarditis and its complications. Cardiac pacing, arrhythmia diagnosis and management, electrophysiology, CT and MRI scans, and transthoracic and transoesophageal echocardiography images are also included for interpretation.

This book will serve as an ideal study aid for medical students and junior doctors who are preparing for their clinical examinations in medicine as it presents the relevant investigations corresponding to each case in an interesting and easy-to-read Q&A format concerning diagnosis and management. This text will also be particularly useful for clinical fellows and specialist senior house officers and registrars who are training in cardiology and its subspecialties. By solving the problems posed by these challenging cases, the reader will gain additional knowledge as well as extra practice in diagnosis and treatment strategies in this exciting specialty of cardiology.

Readership: Medical students and junior doctors who are preparing for clinical examinations; clinical fellows, specialist senior house officers and registrars who are training in cardiology; general physicians; general practitioners; ancillary and technical staff in cardiology.

Case 1

This 58-year-old man was involved in a car-jacking incident and suffered minor trauma to his limbs with bruising and skin abrasions. A cardiologist was asked to provide a medico-legal report on his health as the patient had been found to have an irregular pulse by his general practitioner.

During the consultation, the patient admitted to having become progressively more breathless on exertion over the past 18 months and had noticed some ankle swelling in the past six months. On examination, he had an irregular pulse and a tachycardia of 120 bpm. The jugular venous pressure was elevated to the angle of the jaw and he had marked hepatomegaly and bilateral leg oedema extending to just below knee level. There was reduced air entry at both lung bases. The ECG and chest X-ray are shown below. There was no significant past medical history except that he had been stabbed in the chest at the age of 15 years.

Q

Questions:

1.   What does the ECG show?

2.   What does the chest X-ray show?

3.   What initial treatment should be given?

4.   What other investigation should be ordered?

 

A

Answers:

1.    Cardiomegaly, pulmonary venous congestion, bilateral pleural effusions (right > left).

2.    Atrial flutter with 2:1 block.

3.   In-hospital bed rest, diuretics (intravenous or oral) and a rate controlling agent such as digoxin. Anticoagulant therapy should be commenced.

4.    Echocardiography—to assess right and left ventricular function/ size, valve function, atrial size, presence/absence of septal defects or pericardial disease.

The echocardiogram was unremarkable and did not show any evidence of valvular disease or septal defects.

Q

Question:

5.   What further imaging test might be helpful?

 

A

Answer:

5.   CT scan of the thorax.

The CT scan is shown here.

Q

Questions:

6.   What does the CT scan show?

7.   What is the diagnosis?

8.   What other investigation should be organised and what five characteristic features would confirm the diagnosis?

9.   What treatment is appropriate?

 

A

Answers:

6.   Dense pericardial calcification and right-sided pleural effusion.

7.   Calcific constrictive pericarditis.

8.   Cardiac catheterisation of the right and left heart (after stopping anticoagulants).

 

(i)     Elevated right and left atrial pressures, elevated right and left ventricular end-diastolic pressures.

(ii)    Equalisation of RV and LV diastolic pressures; equalisation of RA and LA pressures.

(iii)   Rapid X and Y descent in RA and LA pressure trace.

(iv)    Typical “dip and plateau” waveform in RV and LV pressure recording.

(v)     Increase in RA/LA/RVedp/LVedp with inspiration.

9.   Pericardiectomy.

Case 2

This 40-year-old man presented with left praecordial chest pain which was not regularly related to exertion. There were no abnormalities on physical examination and his resting ECG was normal. An exercise stress test produced–1.3 mm of upsloping ST-segment depression in V5 and V6 at a heart rate of 156 bpm in the third stage of a Bruce protocol. Diagnostic cardiac catheterisation was performed. Simultaneous injections into the right and left coronary artery (left lateral view) are shown below.

Q

Questions:

1.    What is the diagnosis?

2.    What conclusions can be drawn from the investigation?

 

A

Answers:

1.    Anomalous left circumflex coronary artery, originating from an ectopic, non-dominant right coronary artery.

2.    The symptoms are not due to coronary artery disease. The exercise test should be regarded as a negative test.

Case 3

A 60-year-old man required permanent pacemaker implantation.

Q

Questions:

1.    What investigation has been performed here?

2.    What abnormality is shown?

3.    What specific precautions should be taken during the implantation procedure?

 

A

Answers:

1.    Simultaneous contrast venography from catheters inserted into the right and left arms.

2.    Right- and left-sided superior vena cava are present, only discovered during implantation of the first lead which took an abnormal course on fluoroscopy.

3.    The pacemaker electrodes should be active fixation leads (particularly the atrial lead) in order to reduce the likelihood of lead displacement post-procedure.

Case 4

A 74-year-old man presented with dyspnoea and fever of 38.8°C. The chest X-ray and CT scan are shown below.

Q

Questions:

1. What do the chest X-ray and the CT scan show?

2. What is the diagnosis and the likely cause?

3. What two investigations would you perform to confirm the diagnosis?

4. What is the treatment?

A

Answers:

1. The chest X-ray shows a permanent pacemaker with atrial and ventricular leads and a ring-shaped opacity in the left mid-zone.

The CT sca...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Dedication Page
• Acknowledgements
• Case 1
• Case 2
• Case 3
• Case 4
• Case 5
• Case 6
• Case 7
• Case 8
• Case 9
• Case 10
• Case 11
• Case 12
• Case 13
• Case 14
• Case 15
• Case 16
• Case 17
• Case 18
• Case 19
• Case 20
• Case 21
• Case 22
• Case 23
• Case 24
• Case 25
• Case 26
• Case 27
• Case 28
• Case 29
• Case 30
• Case 31
• Case 32
• Case 33
• Case 34
• Case 35
• Case 36
• Case 37
• Case 38
• Case 39
• Case 40
• Case 41
• Case 42
• Case 43
• Case 44
• Case 45
• Case 46
• Case 47
• Case 48
• Case 49
• Case 50
• Case 51
• Case 52
• Case 53
• Case 54
• Case 55
• Case 56
• Case 57
• Case 58
• Case 59
• Case 60
• Case 61
• Case 62
• Case 63
• Case 64
• Case 65
• Case 66
• Case 67
• Case 68
• Case 69
• Case 70
• Case 71
• Case 72
• Case 73
• Case 74
• Case 75
• Case 76
• Case 77
• Case 78
• Case 79
• Case 80
• Case 81
• Case 82
• Case 83
• Case 84
• Case 85
• Case 86
• Case 87
• Case 88
• Case 89
• Case 90
• Case 91
• Case 92
• Case 93
• Case 94
• Case 95
• Case 96
• Case 97
• Case 98
• Case 99
• Case 100
• Back Cover