05-04-2024

A 55 year old woman presents with a history of acute, severe, constricting central chest pain
associated with anterior ST segment elevation on the 12-lead EGG. She immediately undergoes
coronary angiography, which shows no evidence of coronary artery disease and no coronary
occlusion. An echocardiogram shows left ventricular apical dilatation, with normal left
ventricular basal contraction. Which of the following factors is most likely to have precipitated
this illness?

A. Acute emotional stress

B. Cigarette smoking
C. Excessive alcohol consumption
D. Genetic factors
E. Viral infection
Answer: A
• Takotsubo (stress) cardiomyopathy occurs most often in females and is associated
with emotional stress. It can occur due to bereavement, acute non-cardiac illness,
natural disasters and other major life events. It is characterised by chest pain and ECG
changes that mimic myocardial infarction. Troponin elevation is common but
coronary angiography does not show occlusive coronary artery disease or
intracoronary thrombus. Echocardiography shows a characteristic left ventricular
appearance of apical dilatation, giving the appearance of an octopus trap or takotsubo!
Which of the following is associated with excessive alcohol consumption?

A. Atrial fibrillation
B. Diverticulitis
C. Hypertrophic cardiomyopathy
D. Hypotension
E. Supraventricular tachycardia
Answer: A.
• Alcohol has many negative effects on health. These include liver disease,
pancreatitis, hypertension and cognitive dysfunction. It also causes many behavioural
and social problems, particularly if alcohol dependency occurs. Cardiac effects
include atrial fibrillation and dilated cardiomyopathy, both of which may be
reversible if the patient abstains early enough.
Atrial myxoma is the most common primary cardiac tumour. Which of the following is
true of atrial myxoma?

A. Atrial myxomas are usually malignant

B. It occurs more commonly in the right atrium than in the left atrium
C. Surgery is not indicated because atrial myxomas are benign
D. Surgery is usually indicated to prevent embolic complications such as stroke
E. The tumour commonly obstructs the aortic valve
Answer: D
• Atrial myxoma is the most common cardiac tumour and 75% or more occur in the left
atrium. Large tumours may partially obstruct the mitral valve, affecting cardiac
output and causing a tumour 'plop' on auscultation. Tumours are benign but can be
associated with cerebral and peripheral embolism (which is how they often first
present), so surgery is usually indicated to prevent this.
Which of the following conditions may result in chronic pericardia! constriction?

A. Acute myocardial infarction

B. Dilated cardiomyopathy
C. Excessive alcohol consumption
D. Osteoarthritis
E. Tuberculosis
Answer: E.
• Chronic pericardia! constriction is a late complication of tuberculous and viral
pericarditis and is caused by pericardia! fibrosis, contraction and adhesion to the
epicardium. It can also complicate chronic inflammatory disorders such as
rheumatoid disease. Acute myocardial infarction can lead to acute post -infarct
pericarditis, but this almost never leads to pericardia! constriction.
A 75 year old male smoker presents with a 6-week history of progressive exertional breathlessness
and fatigue. Latterly he has noticed his ankles swelling in the afternoon. On examination, pulse is I
00 beats/min and regular; BP 92/60 mmHg. The JVP is elevated and rises on inspiration. Heart
sounds are quiet and there are no added sounds. There is bilateral pitting oedema to the knees. A
chest X-ray is requested, which shows apparent cardiomegaly with a globular cardiac silhouette. You
suspect a possible pericardia! effusion. Which of the following statements is true?

A. A large effusion can be a sign of malignancy

B. A pericardia! rub is always heard if the effusion is large
C. An EGG is the best investigation to confirm the diagnosis
D. High-dose diuretic therapy will resolve the pericardia! effusion
E. In symptomatic patients, cardiac surgery is required to remove the pericardia! fluid
Answer: A.
• Large pericardia! effusions are normally not associated with a pericardia! rub as the
pericardium and epicardium are well separated by pericardia! fluid and friction does
not occur. The ECG may show small complexes but is not a sensitive test, and an
echocardiogram is required to make the diagnosis. The chest X-ray may show a
spherical or globular cardiac silhouette. In symptomatic patients, percutaneous
pericardia! drainage is used to relieve symptoms and to obtain fluid for laboratory
analysis.
• Patients with pericardia! effusion are very dependent on high preload pressure to
maintain cardiac output, so diuretics may cause significant hypotension. Large
effusions may occur because of malignancy, usually metastatic disease from lung
or breast cancer.