A 79yr old gentleman presents with a 1 day history of palpitations and light headedness to A&E. He states he has had similar episodes over the last few years, but they always went away after a short time and were never this bad. His BP is 146/81, and pulse rate 120bpm. Chest is clear, heart sounds normal but his pulse is irregularly irregular. There is no peripheral oedema. He has a PMH of: IHD, HTN and gout. He is normally fit and well, and enjoys walking with his wife. ECG shows an irregularly irregular rhythm, with no clear p waves. There are no obvious signs of ischaemia. Bloods and CXR grossly normal. What is the most suitable initial treatment for this man’s presentation?

A. Aspirin 300mg and clopidogrel 300mg

B. Digoxin 125micrograms

C. Metoprolol 50mg

D. Apixaban 5mg BD

E. Refer to cardiology for urgent electrical cardioversion

An 84yr old lady attends cardiology clinic for follow up of her recently diagnosed atrial fibrillation. She is on rate control with bisoprolol, and is currently asymptomatic with a heart rate of 76bpm. Her recent ECHO is grossly normal. She has a high CHA2DS2VASc score and the cardiologist is planning to start her on oral anticoagulation. She has a PMH of severe OA, HTN and TIA. Her mobility is very poor and finds it very difficult to attend her hospital appointments, and confides in the cardiologist that she does often forget to take her pills, although she is now using a special box from the pharmacy which contains all the day’s medication – and she finds that very helpful indeed! What would be the most suitable option for anticoagulation?

A. She is not suitable for anticoagulation

B. Aspirin 75mg OD

C. Warfarin, titrated to her INR

D. Apixaban 5mg BD

E. Enoxaparin 1.5mg/kg OD

A 22yr old man of Vietnamese descent is rushed into A&E after an episode of syncope while out walking the dog. He makes recovers spontaneously and is discharged several days later, with no clear cause for his syncope being identified. Serial resting ECGs over several days shows coved ST elevation with no chest pain or elevated cardiac enzymes. There is no other abnormality on his ECG and ECHO is normal. He is referred to cardiology for further investigation. At clinic he reveals that two of his uncles have suddenly died at a very young age, and is very concerned the same may happen to him. He mentions that his girlfriend has woken him up several nights to check he is okay and his breathing ‘goes funny’ sometimes during the night. What is the most likely underlying condition to explain this man’s symptoms?

A. Hypertrophic cardiomyopathy

B. Brugada syndrome

C. STEMI

D. Long QT syndrome

E. Complete heart block

An 81yr old lady is brought into A&E following a collapse at home. She reports blacking out for a few seconds after feeling light headed when getting up from her chair. She denies chest pain, palpitations or short of breath. It is the first time this has happened, but she does often get light headed on standing. She has a PMH of HTN, IHD and is an ex-smoker. Her medication history is aspirin 75mg OD, bisoprolol 2.5mg OD, ramipril 5mg OD, amlodipine 10mg OD, bendroflumethiazide 2.5mg OD. Other than a few cuts and scrapes, her examination is grossly normal. Her ECG and blood tests including cardiac enzymes are all grossly normal, other than slightly low sodium. What is the most likely cause of her collapse?

A. Postural hypotension, most likely secondary to antihypertensives

B. Paroxysmal fast AF

C. Syncope due to severe aortic stenosis

D. Inferior NSTEMI

E. Posterior circulation stroke

A 67yr old man presents to A&E with central chest pain radiating up his jaw. He describes it as a ‘heaviness’ and feels sweaty. It started an hour ago and has got progressively worse. He has never had a pain like this before. He has a past medical history of hypertension and takes amlodipine and for it. He smokes 30 cigarettes a day and has a 70pack year history. His ECG shows significant ST depression in leads II, III and aVF. Blood tests on arrival to A&E including trop T are all normal. What is the most likely diagnosis?

A. Hypokalaemia

B. Anterior NSTEMI from thrombus in left anterior descending coronary artery

C. Inferior NSTEMI from thrombus in left circumflex artery

D. Inferior NSTEMI from thrombus in right coronary artery

E. Anterolateral STEMI from occlusion of the left anterior descending coronary artery

A 70yr old man presents to A&E in a large tertiary hospital with a 3 hour history central chest tightness, radiating down his left arm. He is sweaty and nauseous. The pain has not responded to repeated doses of his own GTN. On examination he is pale and clammy, HR 110bpm, BP 107/59. Otherwise his examination is grossly normal. ECG shows ST elevation across leads V1 – V5, with reciprocal ST depression in lead III. Trop T is elevated at 430. What is the gold standard therapy for this man’s problem?

A. PCI

B. Aspirin 300mg and clopidogrel 300mg

C. Treatment dose enoxaparin 1mg/kg BD

D. Treatment dose enoxaparin 1.5mg/kg OD

E. GTN infusion

Busco Pan is a 55 year old man who presented to his GP with a productive cough. He is also short of breath on minimal exertion. He is wheezy on examination and his tympanic temperature is 38 degrees Celsius. On percussion there is some dullness in the left basal lung field, alongside bronchial breath sounds in the same region. He is started on amoxicillin for suspected community acquired pneumonia and goes home. 5 hours later, he is admitted to A&E following a collapse at home. An initial ECG performed by paramedics showed Torsade de Pointes and he was admitted to the coronary care unit for cardiac monitoring and further management. He has a history of poorly controlled asthma, requiring daily oral glucocorticoid therapy. Furthermore, he has AF and is anticoagulated on rivaroxaban. He was diagnosed with schizophrenia 12 years ago is currently on haloperidol to control his symptoms, though he occasionally acts erratically. Which of the following is most likely to be associated with torsade de pointes?

A. Amoxicillin

B. Flucloxacillin

C. Haloperidol

D. Prednisolone

E. Rivaroxaban

A 27 year old man presents to A&E. He is clearly uncomfortable and he gestures to his chest as if to suggest pain. He has a history of imprisonment for the supply for opiates. On examination, he is visibly sweaty. He has some painful nodules on his hands. There are no dark streaks beneath the fingernails. Examination of the retina is completely unremarkable. He has some bruising and track marks in his antecubital fossa. His blood pressure is 100/70 and his heart rate is 120 bpm. His respiratory rate is 25/minute and his oxygen saturations are 96% on room air. He is currently slightly confused but manages to suggest that he passed some blood in his urine when he last visited the toilet. His tympanic temperature is 38.3 degrees Celsius. His ECG shows the presence of normal P waves and narrow QRS complexes. T waves are present and uninverted. There is unconvincing evidence of ST depression or elevation in any contiguous leads. Initial blood tests show the following: Hb: 130 g/L White Cells: 24 x109 /L Platelets: 400 x109/L CRP: >5 ESR: within normal limits What is the most likely diagnosis?

A. Granulomatosis with polyangiitis

B. Hand Foot and Mouth Disease

C. Infective Endocarditis

D. Myocardial Infarction

E. Secondary Syphilis

A 14 year old girl presents to her GP with a productive cough and a fever. 7 years ago, she was admitted to hospital for bacterial pneumonia. She has always suffered with recurrent chest infections and a daily productive cough, the sputum of which is occasionally blood stained. Observations are normal albeit an elevated respiratory and a tympanic temperature of 37.7 degrees Celsius. Respiratory examination reveals widespread coarse crackles. A previous chest X-ray reveals a gastric bubble and cardiac apex on the right-hand side. What is the most likely diagnosis?

A. Alpha-1 anti-trypsin deficiency

B. Bronchiectasis

C. Cystic Fibrosis

D. Karteneger Syndrome

E. Viral Bronchiolitis

Perry Halodol is a 67 year old man who presents to A&E with central chest pain, radiating up into his jaw. The pain has persisted for 30 minutes and he is visibly sweaty. He has a 40 pack year history of cigarette smoking, and he drinks about 12 units of alcohol each week. He has a past medical history of hypertension, type 2 diabetes, hypercholesterolaemia, asthma and GORD. An ECG shows 5mm ST elevation in leads aVF, II and III. As such he is sent to the catheter lab for treatment of a STEMI. Given Perry’s presentation and past medical history, in which of the following conditions is atherosclerosis most likely to play a role in the underlying pathophysiology?

A. Acute Pulmonary Embolism

B. Granulomatosis with Polyangiitis

C. Prinzmetal Angina

D. Renal Artery Stenosis

E. Type 2 Myocardial Infarction

A 27 year old man presents to A&E. He is clearly uncomfortable and he gestures to his chest as if to suggest pain. He has a history of imprisonment for the supply for opiates. On examination, he is visibly sweaty. He has some painful nodules on his hands. There are no dark streaks beneath the fingernails. Examination of the retina is completely unremarkable. He has some bruising and track marks in his antecubital fossa. His blood pressure is 100/70 and his heart rate is 120 bpm. His respiratory rate is 25/minute and his oxygen saturations are 96% on room air. He is currently slightly confused but manages to suggest that he passed some blood in his urine when he last visited the toilet. His tympanic temperature is 38.3 degrees Celsius. His ECG shows the presence of normal P waves and narrow QRS complexes. T waves are present and uninverted. There is unconvincing evidence of ST depression or elevation in any contiguous leads. Initial blood tests show the following: Hb: 130 g/L White Cells: 24 x109 /L Platelets: 400 x109/L CRP: >5 ESR: within normal limits What is the next most appropriate investigation?

A. Blood cultures

B. Transoesophageal echocardiogram

C. Urea and Electrolytes

D. Sputum culture

E. Urine Culture