100 ECG’s
IHD ECGs: (28 questions)

Questions

• 1
  A 62 year old man is admitted to the emergency department with central crushing chest pain of 1 hour duration. An ECG is done immediately (shown) and a troponin level which comes back positive. He is given a cocktail of medications including Tirofiban. Which class of drugs is Tirofiban in ?
  
  Difficulty: Medium     Topic: Ischaemic Heart Disease
  a

  ACE inhibitors

  b

  Cycloxygenase inhibitors

  c

  GP VI inhibitors

  d

  GP IIb/IIIa inhibitors

  e

  Factor Xa inhibitor
  Explanation: Tirofiban is a GP IIb/IIIa inhibitor, that is, it inhibits platelet aggregation. It is useful in this scenario because the patient's ECG shows T-wave inversion with chest pain and a positive troponin, indicating a diagnosis of NSTEMI. NICE guidelines recommend the use of GP IIb/IIIa antagonists in these patients to prevent progression to a complete occlusion (an ST-elevation MI)
• 2
  A 55 year old man attends his GP practice complaining of shortness of breath on exertion. He is a current smoker with hypercholesterolaemia and hypertension. He reports feeling shortness of breath after walking for 100 yards. This is relieved when he rests for 1-2 minutes and lasts no longer than 5-10 minutes at a time. Sometimes it is accompanied by chest tightness. His ECG is shown. The prescribes glyceryl trinitrate spray for this patient. What is the primary mechanism of action of this medication ?
  
  Difficulty: Medium     Topic: Ischaemic Heart Disease
  a

  Coronary vasodilation

  b

  Inhibition of the renin-angiotensin system

  c

  Negative Chronotrope

  d

  Negative Inotrope

  e

  Preload reduction
  Explanation: Glyceryl trinitrate is a vascular smooth muscle relaxanat given to relieve the symptoms of angina pectoris (which is what this patient is describing). The ECG in this case shows normal sinus rhythm with no ischaemic changes, further confirming the reversible nature of this disease. The main mechanism of action by which GTN brings about pain relief is via venous dilation which causes preload reduction. This decreases myocardial oxygen demand and allows the heart to recover from the temporary ischaemia. Whilst it does cause some coronary vasodilation, this is not the primary mechanism as in states of ischaemia the coronary vasculature is maximally dilated.
• 3
  A 70 year old man is brought to the emergency department by ambulance after complaining of central crushing chest pain of 50 minutes duration. His pain radiates to the left shoulder and is associated with shortness of breath. An ECG is done immediately (shown) and a troponin sample is taken which comes back positive. He is given aspirin, heparin and tirofiban. What is the mechanism of action of tirofiban ?
  
  Difficulty: Hard     Topic: Ischaemic Heart Disease
  a

  ADP receptor antagonist

  b

  GPVI receptor antagonist

  c

  GPIIbIIIa antagonist

  d

  Factors IIa and Xa inhibitor

  e

  Cycloxygenase inhibitor
  Explanation: There are many "blood thinning" drugs that are used in Cardiology. Generally they can be divided into anti-coagulants and anti-platelets. Both of these groups are used in the management of Non-ST-elevation MI (which is what the ECG is showing in the antero-inferior leads). Tirofiban is an anti-platelet medication that works by inhibiting the platelet glycoprotein GPIIb/IIIa. By doing so, it decreases the risks of death, new MIs and refractory ischaemia during the in-hospital stay.
• 4
  A 64 year old man is rushed to the emergency department by his son after complaining of central crushing chest pain of 45 minute duration. His pain radiates to the left shoulder and is associated with shortness of breath. An ECG is done immediately (shown) and a troponin sample is taken which comes back positive. He is given aspirin, clopidogrel and unfractionated heparin. What is the mechanism of action of heparin ?
  
  Difficulty: Medium     Topic: Ischaemic Heart Disease
  a

  ADP receptor antagonist

  b

  ADP receptor antagonist

  c

  GPVI receptor antagonist

  d

  Factors IIa and Xa inhibitor

  e

  Factors IIa and Xa inhibitor
  Explanation: There are many "blood thinning" drugs that are used in Cardiology. Generally they can be divided into anti-coagulants and anti-platelets. Whilst anti-platelets are used for all types of ACS, anti-coagulants are used mainly in the management of Non-ST-elevation MI (which is what the ECG is showing in the antero-inferior leads). Heparin is an anticoagulant medication which acts as an inhibitor of Factor Xa and IIa. Low molecular weight heparins are derivatives of heparin but work by inhibiting factor Xa only with no direct activity on factor IIa, but have a better pharmacodynamic and side effect profile making them more preferable to unfractionated heparin.
• 5
  A 64 year old man is rushed to the emergency department by his son after complaining of central crushing chest pain of 45 minute duration. His pain radiates to the left shoulder and is associated with shortness of breath. An ECG is done immediately (shown) and a troponin sample is taken which comes back positive. He is given aspirin, clopidogrel and fondaparinux. What is the mechanism of action of fondaparinux ?
  
  Difficulty: Medium     Topic: Ischaemic Heart Disease
  a

  ADP receptor antagonist

  b

  GPVI receptor antagonist

  c

  GPIIbIIIa antagonist

  d

  Factor Xa inhibitor

  e

  Cycloxygenase inhibitor
  Explanation: There are many "blood thinning" drugs that are used in Cardiology. Generally they can be divided into anti-coagulants and anti-platelets. Whilst anti-platelets are used for all types of ACS, anti-coagulants are used mainly in the management of Non-ST-elevation MI (where this ECG just shows sinus tachycardia). Fondaparinux is an anticoagulant medication (a low molecular weight heparin) which acts as an inhibitor of Factor Xa.
• 6
  A 55 year old man phones the ambulance complaining of central crushing chest pain of one hour duration associated with sweating and nausea. The pain is radiating to his left arm. His past medical history includes diabetes and hypertension. His ECG is shown. The ambulance crew immediately administer aspirin 300mg and activate the PCI lab. What is the mechanism of action of Aspirin ?
  
  Difficulty: Easy     Topic: Ischaemic Heart Disease
  a

  ADP receptor antagonist

  b

  ADP receptor antagonist

  c

  GPIIbIIIa antagonist

  d

  Factor Xa inhibitor

  e

  Cycloxygenase inhibitor
  Explanation: There are many "blood thinning" drugs that are used in Cardiology. Generally they can be divided into anti-coagulants and anti-platelets, the latter group is the most common group used in the management of ST-elevation MI (which is what the ECG is showing in the inferior leads). Anti-platelets can be subdivided into ADP antagonists, COX inhibitors (Aspirin), and GPIIb/IIIa inhibitors.
• 7
  A 55 year old man attends the emergency department with central crushing chest pain of one hour duration associated with sweating and nausea. The pain is radiating to his left arm. His past medical history includes diabetes and hypertension. His ECG is shown. He receives the appropriate treatment which includes prasugrel. What is the mechanism of action of prasugrel ?
  
  Difficulty: Hard     Topic: Ischaemic Heart Disease
  a

  ADP receptor antagonist

  b

  GPVI receptor antagonist

  c

  GPVI receptor antagonist

  d

  Factor Xa inhibitor

  e

  Cycloxygenase inhibitor
  Explanation: There are many "blood thinning" drugs that are used in Cardiology. Generally they can be divided into anti-coagulants and anti-platelets, the latter group is the most common group used in the management of ST-elevation MI (which is what the ECG is showing in the inferior leads). Anti-platelets can be subdivided into ADP antagonists (of which Prasugrel is one), COX inhibitors (Aspirin), and GPIIb/IIIa inhibitors.
• 8
  A 76 year old man phones the ambulance complaining of central crushing chest pain of one hour duration associated with sweating and nausea. The pain is radiating to his left arm. His past medical history includes diabetes and hypertension. His ECG is shown. He receives the appropriate treatment which includes clopidogrel. What is the mechanism of action of clopidogrel ?
  
  Difficulty: Hard     Topic: Ischaemic Heart Disease
  a

  ADP receptor antagonist

  b

  GPVI receptor antagonist

  c

  GPVI receptor antagonist

  d

  Factor Xa inhibitor

  e

  Cycloxygenase inhibitor
  Explanation: There are many "blood thinning" drugs that are used in Cardiology. Generally they can be divided into anti-coagulants and anti-platelets, the latter group is the most common group used in the management of ST-elevation MI (which is what the ECG is showing in the antero-lateral leads). Anti-platelets can be subdivided into ADP antagonists (of which Clopidogrel is one), COX inhibitors (Aspirin), and GPIIb/IIIa inhibitors.
• 9
  A 78 year old patient presents with sudden onset central sharp chest pain that has been ongoing since he started mowing the lawn 2 hours ago. The patient is immediately given aspirin, nitrates, oxygen and morphine. An ECG is done (shown). His blood pressure is 134/81 and his heart rate is 90. What is the diagnosis ?
  
  Difficulty: Medium     Topic: Ischaemic Heart Disease
  a

  Inferior ST-elevation MI

  b

  Lateral ST-elevation MI

  c

  Anterior ST-elevation MI

  d

  Costochondritis

  e

  Angina
  Explanation: In this scenario, an elderly patient has come in with sudden onset central chest pain of 2 hours duration following exertion. It is appropriate to assume this is ACS until proven otherwise. The ECG shows some ST elevations in the anterior-lateral chest leads. However, these ST elevations are less than 2mm in height and therefore are not diagnostic of an ST-elevation MI. In limb leads, ST elevations need to be in excess of 1mm to be diagnostic. Therefore, in this patient, the ECG is within normal limits and there is no ST-elevation MI. This is likely to be angina as the pain is still ongoing and has lasted for more than 30 minutes. The only remaining option is Costochondritis, which is consistent with the sharp nature of the pain.
• 10
  A 75 year old woman with a history of transient ischaemic attacks is brought in by ambulance complaining of central crushing chest pain. Her medications are co-codamol, vesicare and gaviscon. Her ECG is shown. Her troponin is raised and she is rushed into the cath lab for an angiogram. Her angiogram shows no significant vessel stenosis and traces of a distal clot in her left anterior descending. What is the cause of this ECG appearance ?
  
  Difficulty: Hard     Topic: Ischaemic Heart Disease
  a

  Atherosclerotic plaque rupture

  b

  Embolus

  c

  Pericarditis

  d

  Paradoxical embolus

  e

  Aortic dissection
  Explanation: In this ECG, the patient has ST elevations in the anterior leads, suggestive of an ST-elevation MI, and an irregularly irregular rhythm, suggestive of Atrial Fibrillation. Her CHA2DS2VASc score is 4 (2 for age, 1 for TIA, 1 for Sex category) which suggests that she is at high risk of developing AF-related emboli. Therefore, the clinical picture and the ECG findings are suggestive of an ST-elevation MI that is caused by an AF related embolus that has lodged in the left anterior descending artery. The fact that there is no stenosis on angiogram does not rule out an MI, but suggests that the culprit clot has probably partially dissolved and lodged distally in the vessel, either spontaneously, or as a result of ACS treatment.
• 11
  A 63 year old man is admitted to the coronary care unit with the ECG shown. He receives the appropriate treatment and is discharged. Nine months later, he complains of increasing exercise intolerance and he gets short of breath after walking up 5 to 6 steps of stairs. Echocardiography shows a dilated heart, ejection fraction of 29%, and dysynchronous ventricles. ECG shows a wide QRS complex secondary to left bundle branch block. He is on maximum medical therapy. Which of the following interventions is most appropriate to improve the patient’s condition ?
  
  Difficulty: Hard     Topic: Ischaemic Heart Disease
  a

  Left Anterior Descending revascularisation

  b

  Coronary Artery Bypass Graft

  c

  Dual-chamber pacemaker (PPM)

  d

  Implantable Cardioverter Defibrillator (ICD)

  e

  Biventricular pacemaker (CRT)
  Explanation: The ECG in this patient shows an acute inferior ST-elevation MI, which indicates a full thickness infarct. Patients with such infarcts are at risk of developing dilated ischaemic cardiomyopathy as a complication a few months down the line which may put them in heart failure. In these patients, treatment can either be medical, and if that fails device therapy can be considered. The most appropriate device in this patient, who has an LV ejection fraction <30%, a wide QRS complex, and symptoms of heart failure, is a biventricular pacemaker, otherwise known as Cardiac Resynchronisation therapy device (CRT). This type of pacemaker paces both ventricles allowing them to contracting in synchrony which is shown to improve symptoms of heart failure significantly.
• 12
  A 55 year old man is admitted to the coronary care unit with the ECG shown. He receives the appropriate treatment and is discharged. Nine months later, he attends the emergency department with an episode of ventricular arrhythmia which is treated successfully. Echocardiography shows a dilated heart. He is on maximum medical therapy. Which of the following interventions will make the biggest mortality benefit ?
  
  Difficulty: Medium     Topic: Ischaemic Heart Disease
  a

  Left Anterior Descending revascularisation

  b

  Coronary Artery Bypass Graft

  c

  Permanent Pacemaker (PPM)

  d

  Implantable Cardioverter Defibrillator (ICD)

  e

  Holter Monitor
  Explanation: The ECG in this patient shows an acute anterior ST-elevation MI, which indicates a full thickness infarct. Patients with such infarcts are at risk of developing dilated ischaemic cardiomyopathy as a complication a few months down the line which may be accompanied by life-threatining ventricular arrhythmias. The best way to prevent future arrhythmias from causing sudden cardiac death is by implanting an ICD device which provides a mortality benefit. Revascularisation would have been useful at the time of the infarct and it is likely that this patient has already had a percutaneous coronary intervention. Holter monitor is not required as we have a confirmed diagnosis of ventricular arrhythmia.
• 13
  A 69 year old woman with central crushing chest pain and an extensive history of diabetes and hypertension is admitted to the coronary care unit with the ECG shown. She receives the appropriate treatment. 24 hours later, she becomes unwell and is very drowsy and pale. On examination, her blood pressure is 86/40 and her heart rate is 134. Her heart sounds are distant and muffled and her jugular venous pressure is elevated. What is the diagnosis ?
  
  Difficulty: Medium     Topic: Ischaemic Heart Disease
  a

  Papillary muscle rupture

  b

  LV free wall rupture

  c

  Reinfarction

  d

  Ventricular septal rupture

  e

  AV node infarct
  Explanation: The sudden drop in blood pressure and the acute confusion (probably secondary to decreased perfusion) shortly after an anterior ST-elevation MI (on ECG) points to haemodynamic instability secondary to a mechanical complication of MI. In this scenario, the raised JVP and muffled heart sounds (two of the three Beck's triad) point to a diagnosis of cardiac tamponade secondary to Left Ventricular (LV) free wall rupture.
• 14
  A 62 year old man with central crushing chest pain and the ECG shown is admitted to the coronary care unit following treatment. 24 hours later, he develops sudden onset shortness of breath. On examination, his blood pressure is 87/49 and pulse is 130. There is an audible systolic murmur over the apex. What is the most likely diagnosis ?
  
  Difficulty: Medium     Topic: Ischaemic Heart Disease
  a

  Papillary muscle rupture

  b

  LV free wall rupture

  c

  Reinfarction

  d

  Ventricular septal rupture

  e

  AV node infarct
  Explanation: The sudden drop in blood pressure and shortness of breath shortly after an Anterolateral ST-elevation MI (on ECG) points to haemodynamic instability due to a mechanical complication of MI. In this scenario, the symptoms and the systolic murmur over the apex point to acute mitral regurgitation secondary to papillary muscle rupture.
• 15
  A 50 year old man experiences severe crushing chest pain whilst cleaning the house. He has a history of angina and is on GTN for that. His GTN did not help him on this occassion and the pain lasted 30 minutes. He was taken to hospital via ambulance for primary angioplasty and following that was admitted to the coronary care unit for monitoring. His ECG on admission to the coronary care unit is shown. Which artery is the most likely culprit ?
  
  Difficulty: Medium     Topic: Ischaemic Heart Disease
  a

  Proximal Left anterior descending

  b

  Distal Left anterior descending

  c

  Left main stem

  d

  Right coronary artery

  e

  Aortic Root
  Explanation: Despite the angioplasty, this patient is still showing residual ST segment elevation in leads II, III and aVF. This indicates an inferior wall myocardial infarction which is most commonly in the territory of the right coronary artery in right-dominant coronary circulation (80% of individuals). In the other 20% of individuals (left-dominant) the posterior wall is supplied by the Circumflex artery (which is not an option here). Left main stem and left anterior descending arteries would cause anterior/lateral ST elevations when infarcted.
• 16
  A 76 year old retired civil servant attends the emergency department with sudden onset central crushing chest pain of 60 minute duration. His past medical history includes hypertension and diabetes. He is an ex-smoker. You review the ECG (shown). Which of the following is the best step to improve mortality outcomes in these patients ?
  
  Difficulty: Medium     Topic: Ischaemic Heart Disease
  a

  Give Aspirin

  b

  Give Morphine and Metoclopramide

  c

  Start transcutaneous pacing

  d

  Give Nitrates

  e

  Give Oxygen
  Explanation: The ECG shows Left Bundle Branch Block, which when accompanied by a typical history of acute coronary syndrome makes the diagnosis an ST-elevation myocardial infarction (STEMI). Aspirin is the only option from the list which is proven to have a mortality benefit in these patients - give it as soon as you make a diagnosis of an MI.
• 17
  A 65 year old man presents to hospital with central crushing chest pain. He has a history of hypertension, diabetes, hyperlipidaemia and is a current smoker. His systolic blood pressure is 150 and his heart rate is 90. His overall GRACE score is consistent with a 5% mortality rate at 6 months. His ECG is shown. His troponin is elevated. What is the best course of action ?
  
  Difficulty: Medium     Topic: Ischaemic Heart Disease
  a

  Exercise tolerance test

  b

  Manage medically and discharge

  c

  Manage medically and perform angiography in 6 weeks

  d

  Manage medically and perform immediate angiography

  e

  Watch and wait for symptom recurrence
  Explanation: This patient's ECG shows T-wave inversion in inferior and anterior leads, which when combined with a raised troponin suggests a diagnosis of a NSTEMI. The GRACE score is a measure that predicts the mortality of patients with NSTEMI by looking at variables such as heart rate, blood pressure creatinine and ECG changes. According to NICE, patients who have a predicted mortality rate of >3% at six months require urgent angiography within 96 hours of onset of pain.
• 18
  A 55 year old man attends the emergency department with chest pain and shortness of breath on exertion. He complains that he normally gets very short of breath after walking 500 metres, however in the last few weeks his exercise tolerance has decreased to 200 metres on the flat associated with central crushing chest pain. His pain remits when he rests for a few minutes. His ECG is shown. His troponin I comes back as 0.02 (Normal <0.03). What is the best combination of medications for him?
  
  Difficulty: Medium     Topic: Ischaemic Heart Disease
  a

  Aspirin and Clopidogrel

  b

  Aspirin and Metoprolol

  c

  Metoprolol and GTN

  d

  Clopidogrel and GTN

  e

  Clopidogrel and Fondaparinux
  Explanation: This patient clearly has exertional symptoms of chest pain and shortness of breath. His ECG shows T-wave inversion in inferior and anterior leads indicating ischaemic heart disease. The fact that his troponin is normal and his pain episodes only come during exertion for a brief time leads us towards a diagnosis of Angina Pectoris. The best medical treatment for angina is symptomatic with beta-blockers and nitrates. Angina that is resistant to medical treatment requires coronary intervention.
• 19
  A 62 year old gentleman presents to the cardiology clinic for follow up after having had an MI 6 months ago. His ECG from the original admission is shown. He has now developed signs of heart failure and his echo is showing a reduced ejection fraction. Which of the following beta-blockers is proven to provide a mortality benefit in such patients ?
  
  Difficulty: Hard     Topic: Ischaemic Heart Disease
  a

  Atenolol

  b

  Acebutolol

  c

  Carvedilol

  d

  Labetalol

  e

  Timolol
  Explanation: The ECG in this case shows an extensive anterolateral STEMI. There are only three beta-blockers indicated in the management of heart failure, the prevention of heart failure in post-MI patients and the association with a mortality benefit. These are Carvedilol, Bisoprolol, and Metoprolol. These beta blockers have a cardiac protective effect and protect infarcted hearts from developing heart failure; other beta-blockers are not yet proven to have any mortality benefit.
• 20
  A 57 year old patient presents to the emergency department with central crushing chest pain radiating to the left arm and associated with shortness of breath for 1 hour duration. His ECG is shown. Which of the following medications given to ACS patients has the best mortality benefit ?
  
  Difficulty: Hard     Topic: Ischaemic Heart Disease
  a

  Morphine

  b

  Metoclopramide

  c

  Oxygen

  d

  Nitrates

  e

  Aspirin
  Explanation: All of these drugs are rightly used in the management of Acute Coronary Syndrome patients. This patient has a posterior ST-elevation MI (STEMI), shown as ST-depression in V1-V3. The drug that is shown to have a proven mortality benefit in all ACS patients is Aspirin 300mg which is commonly given to ACS patients in the ambulance before they arrive to the emergency department, but in cases where patients self-present to the hospital it is important to administer it as soon as possible.
• 21
  A 62 year patient presents to the emergency department with central crushing chest pain. He has a long history of hypertension, asthma and duodenal ulcer. He also sees his GP for obsessive compulse disorder. The admitting doctor performs an ECG and implements the appropriate treatment. What are the ECG findings (shown) ?
  
  Difficulty: Hard     Topic: Ischaemic Heart Disease
  a

  Left bundle branch block with inferior MI

  b

  Right bundle branch block, left axis deviation and inferior MI

  c

  Right bundle branch block, right axis deviation and inferior MI

  d

  Left bundle branch block, right axis deviation and inferior MI

  e

  Left axis deviation and inferior MI
  Explanation: This patient has an inferior ST-elevation MI (leads II, III and aVF). He also has right bundle branch block (rSR pattern in right chest leads) and left axis deviation (NB: Leads I, aVF and II). Remember, when a patient is in Left Bundle Branch block, the rest of the ECG becomes uninterpretable for ischaemic changes.
• 22
  A 52 year old man attends the emergency department complaining of central crushing chest pains. He has not seen a doctor for 20 years. The admitting doctor does an ECG (shown). What is the diagnosis ?
  
  Difficulty: Medium     Topic: Ischaemic Heart Disease
  a

  Left bundle branch block with anterior MI

  b

  Left bundle branch block with no ischaemic changes

  c

  Right bundle branch block with anterior MI

  d

  Right bundle branch block with no ischaemic changes

  e

  Uninterpretable as it has right bundle branch block pattern
  Explanation: The ECG shows right bundle branch block with ST elevations in the anterior leads (Leads V2-V3). The Right bundle branch block does NOT render the ECG uninterpretable for ischaemic changes, unlike Left Bundle Branch block. The best treatment at this stage is primary angioplasty.
• 23
  An 80 year old retired gentleman is admitted to the coronary care unit with chest pain and the following ECG (Shown). He undergoes the appropriate therapy and is placed in a monitored bed. 48 hours later, the nurse notes a deterioration in his state with a drop of blood pressure from 125/89 to 84/60. He is tachycardic and tachypnoeaic. On examination he has a new pansystolic murmur heard loudest at the lower left sternal edge. What is the most likely diagnosis ?
  
  Difficulty: Medium     Topic: Ischaemic Heart Disease
  a

  Reinfarction

  b

  AV node infarct

  c

  Papillary muscle rupture

  d

  Ventricular septal rupture

  e

  LV free wall rupture
  Explanation: The ECG is consistent with an extensive anterior ST elevation MI (ST elevations in V1-V5). Patients are normally taken straight to the cath lab for revascularisation via percutaneous coronary intervention (PCI), but may still suffer from post-MI complications which is why they are admitted for at least 3 days post-procedure. In this gentleman, the sudden drop in blood pressure and the new murmur points to a mechanical complication of MI, particularly that of a ventricular septal rupture (the clue is the left lower sternal edge pansystolic murmur).
  
  Careful not to be caught-out here. In many questions that give a pan-systolic murmur post-MI the answer is papillary muscle rupture, but the two main differentials are ventricular septal rupture and free wall rupture. The clues are:
  
  Papillary muscle rupture is usually the posteromedial papillary muscle because it receives only supply from the posterior interventricular (PIV) artery, whereas the anterolateral papillary muscle is supplied by both the anterior intervetricular and left circumflex. So, given that this ECG suggests an anterior MI, it wouldn’t affect the PIV. Its an inferior MI that represents a PIV occlusion and is associated with papillary muscle rupture.
  
  The other clue is that the murmur is heard best at the lower left sternal edge, typical for a VSD, rather than at the apex and radiating up to the axilla.
  
  Free wall rupture is more common later (5-14 days) and has a higher incidence after thrombolysis (its very rare, though)
• 24
  A 57 year old man presents to the emergency department complaining of central crushing chest pain and sweating. His heart rate is 120 and his blood pressure is 90/70. His ECG is shown. Which of the following ACS treatments is contraindicated in this case?
  
  Difficulty: Medium     Topic: Ischaemic Heart Disease
  a

  Morphine

  b

  Oxygen

  c

  GTN

  d

  Aspirin

  e

  IV Fluids
  Explanation: This patient is presenting with an ST elevation MI in the inferior leads (II, III, aVF) associated with hypotension. In these cases, caution has to be taken when using GTN (especially IV infusions) as the blood pressure is already compromised and we don’t want to make it any worse. In fact, seeing as the inferior wall corresponds to the right ventricular, it is likely that the hypotension is due to reduced cardiac output secondary to decreased preload, therefore in these cases it is best to give IV fluids to increase right heart preload which will in term increase left heart preload. There is no risk of pulmonary oedema as the left-ventricle remains normal.
• 25
  A 72 year old man attends the emergency department with central chest tightness, shortness of breath and sweating of thirty minutes duration. His past medical history includes hypertension and diabetes. His is an ex-smoker of 20 pack year. An ECG is done in the emergency room (shown). A decision on treatment is being made because this hospital does not do percutaneous coronary intervention (PCI). Which is the most appropriate treatment?
  
  Difficulty: Medium     Topic: Ischaemic Heart Disease
  a

  Give Aspirin, Clopidogrel and Fondaparinux and management medically

  b

  Manage medically with GP IIb/IIIa antagonist Tirofiban

  c

  Thrombolyze if the troponin is positive

  d

  Thrombolyze regardless of troponin

  e

  Transfer to another hospital 3 hours away for PCI
  Explanation: In this case, the patient clearly has an ST-elevation MI (on the ECG - ST elevations in V1-V4). The best treatment for this is PCI, although not all hospitals in the UK offer this service 24 hours a day. When it is not possible to do PCI within 90 minutes of patient presentation, it is best to thrombolyze (regardless of troponin, as it is irrelevant in a definitive diagnosis of STEMI) as "time is muscle". If thrombolysis is not successful (no ST-segment resolution/improvement), then a rescue PCI could be attempted.
• 26
  A 75 year old retired carpenter presents to the emergency department with profuse sweating, chest heaviness and palpitations. He has a history of diabetes, hypertension and is an ex-smoker. His ECG is shown. What is the most likely culprit artery?
  
  Difficulty: Easy     Topic: Ischaemic Heart Disease
  a

  Left main stem

  b

  Left anterior descending artery

  c

  Circumflex artery

  d

  Right coronary artery

  e

  Posterior interventricular artery
  Explanation: This patient's ECG shows ST elevations in the anterior leads (V1-3), plus right bundle branch block, likely a consequence of mid-distal left anterior descending occlusion.
• 27
  A 57 year old accountant is brought by ambulance complaining of central crushing chest pain. He has a longstanding history of hypertension and is a smoker. His ECG is shown. Which is the most likely culprit artery ?
  
  Difficulty: Easy     Topic: Ischaemic Heart Disease
  a

  Proximal Left anterior descending

  b

  Distal Left anterior descending

  c

  Right coronary artery

  d

  Acute Marginal

  e

  Obtuse marginal
  Explanation: This patient's ECG is consistent with an anterolateral STEMI (ST elevations in V3-6, I and aVL). The most likely culprit artery is the proximal left anterior descending (LAD).
• 28
  A 25-year old rockstar is rushed into hospital at 3am complaining of severe crushing chest pain and palpitations of 15 minutes duration. He has been partying prior to that at his city penthouse with his fellow artists and fans. He has no past medical history except for ENT follow up for a necrotic nasal septum of one year duration. He has a family history of premature ischaemic heart disease and smokes 20 cigarettes per day. He hesitantly admits to using a cocktail of drugs on a regular basis including cannabis, ecstasy, cocaine and crystal meth. ECG is shown. Which cardiac drug is contraindicated in this patient ?
  
  Difficulty: Hard     Topic: Ischaemic Heart Disease
  a

  Ramipril

  b

  Metoprolol

  c

  Nifedipine

  d

  GTN

  e

  Atorvastatin
  Explanation: This is a case of cocaine-induced myocardial ischaemia. Cocaine causes severe acute coronary vasospasm by inhibiting the reuptake of noradrenaline and dopamine at presynaptic terminals leading to a build up of catecholamines which lead to acute vasospasm (alpha adrenergic receptors) and tachydysrhythmias (beta adrenergic receptors). Giving this patient GTN would ease his pain by dilating the coronary arteries. Beta blockers are contraindicated as they can worsen the vasospasm by blocking beta adrenergic receptors and shunting all the excess catecholamines to the alpha adrenergic receptors. The necrotic nasal septum is probably due to excess and regular "snorting" of cocaine which cases vasospasm and necrosis in the nasal cartilage.