1. A 45-year-old former rugby player is admitted to the Emergency Department
having collapsed whilst out jogging. He is usually well and runs approximately
20 miles per week, but suffered one other episode of pre-syncope two weeks
earlier. On this occasion, he reports having felt faint and lightheaded, with fast
palpitations, and then waking up when the paramedics arrived who were
called by a passer-by.On examination in the department, his BP is 110/70
mmHg, pulse is 80 bpm, regular. His heart sounds normal and chest is clear.
His abdomen is soft and nontender and his BMI is 24. Routine bloods are
normal and 12 lead ECG shows sinus rhythm with no acute changes and a
QT interval in the normal range. Chest radiograph shows a normal heart size
and no pulmonary signs of cardiac failure.Which of the following is the most
likely diagnosis?
A. Carotid sinus hypersensitivity
B. Brugada syndrome
C. Long qt syndrome
D. Exercise induced VT
E. Hypertrophic obstructive cardiomyopathy
Answer: D
Explanation: Key learning points
Cardiology
● VT associated with exercise is normally non-sustained and has no significant
impact on mortality.
Explanation
The answer is exercise-induced VT. The findings on examination, ECG, and CXR
effectively rule out structural heart disease or congenital rhythm disturbance,
meaning the other options must be incorrect. VT associated with exercise is normally
non-sustained and has no significant impact on mortality, but the syncopal episode
here should prompt further investigation including Holter and exercise ECG to
evaluate any need for beta blockade to prevent further episodes.
Carotid sinus hypersensitivity is most commonly seen in the elderly with syncopal
episodes associated with pressure on the neck/carotid body, long QT is ruled out by
the 12 lead ECG, and HOCM is associated with abnormal findings on clinical
examination.
,Brugada syndrome is also diagnosed by characteristic ECG findings: ST segment
elevation in the precordial leads (V1-3).
2. In most cardiac arrest situations 1 mg of adrenaline (epinephrine) is given
intravenously every three minutes.
What is the correct volume and concentration of the adrenaline?
A. 1 ml of 1 in 1000
B. 10 ml of 1 in 1000
C. 0.1 ml of 1 in 100
D. 1 ml of 1 in 10,000
E. 10 ml of 1 in 10,000
Answer: E
explanation:Key learning points
Cardiology
● 10 ml of 1 in 10,000 is the recommended dose and concentration and is
considered the optimum volume of adrenaline during cardiac arrest, and is
recommended by the UK Resuscitation Council.
Explanation
A 1 mg dose of adrenaline (epinephrine) would be administered with 0.1 ml of 1 in
100, 1 ml of 1 in 1000 and 10 ml of 1 in 10,000.
However, 10 ml of 1 in 10,000 is the recommended dose and concentration and is
considered the optimum volume of adrenaline during cardiac arrest, and is
recommended by the UK Resuscitation Council.
https://www.resus.org.uk/library/2015-resuscitation-guidelines/guidelines-adult-
advanced-life-support#:~:text=If%20ROSC%20is%20suspected%20during,at%20the
%20next%20rhythm%20check.&text=If%20a%20pulse%20is%20palpable,pulse
%20is%20present%2C%20continue%20CPR
,3. A 62-year-old male is admitted with an inferior myocardial infarction (MI) and
receives thrombolysis, aspirin, atenolol, simvastatin, and lisinopril. His ECG shows
good ST segment resolution.
The following day he develops some pain in the legs and a dusky discolouration of
the lower limbs. On closer examination there is a diffuse petechial rash over the
lower legs, particularly the feet, but all peripheral pulses are palpable.
Investigations reveal:
Haemoglobin 133 g/L (120-
160)
Platelets 145 ×109/L (150-
400)
White cell 12.1 (4-11)
count ×109/L
Neutrophils 6.5 ×109/L (1.5-7)
Lymphocytes 3.5 ×109/L (1.5-4)
Eosinophils 1.2 ×109/L (0.04-
0.4)
IgE antibody 3 kU/L (<2)
Which of the following is the most likely cause for his current problems?
A. Cholesterol emboli
B. Allergic reaction to thrombolysis
C. Peripheral vascular disease
D. Polyarteritis nodosa
E. Aspirin allergy
Answer: A
Explanation: Key learning points
Cardiology
● Cholesterol emboli can occur following thrombolysis, and result in a petechial
rash, marked eosinophilia and raised IgE.
, Explanation
This patient is an arteriopath as suggested by the acute MI, and one day after
thrombolysis develops a petechial rash in the lower limbs with raised white cell count
- marked eosinophilia and raised IgE.
Rather than allergy, this suggests cholesterol embolisation syndrome.
Peripheral pulses are intact because cholesterol emboli are microcrystals which are
too small to occlude medium sized arteries.
Eosinophilia is part of the typical inflammatory reaction to cholesterol.
Reference
Kronzon I, Saric M. Cholesterol embolization syndrome. Circulation. 2010;122:631-
41.
4. A 45-year-old lawyer is referred to clinic with a blood pressure diary for advice on
commencing therapy.
He first consulted his general practitioner for a flare of eczema in January (which
resolved with topical therapy) when hypertension was first identified. He is presently
asymptomatic, with no other medical complaints other than his longstanding eczema.
He has been visiting the gym regularly since February, and has a healthy diet. He is
a current infrequent smoker, and drinks sporadically. He is of Nigerian descent.
Electrocardiogram and urine dip are normal. His home blood pressure recordings are
as follows:
January 152/90
mmHg
Februar 147/85
y mmHg
having collapsed whilst out jogging. He is usually well and runs approximately
20 miles per week, but suffered one other episode of pre-syncope two weeks
earlier. On this occasion, he reports having felt faint and lightheaded, with fast
palpitations, and then waking up when the paramedics arrived who were
called by a passer-by.On examination in the department, his BP is 110/70
mmHg, pulse is 80 bpm, regular. His heart sounds normal and chest is clear.
His abdomen is soft and nontender and his BMI is 24. Routine bloods are
normal and 12 lead ECG shows sinus rhythm with no acute changes and a
QT interval in the normal range. Chest radiograph shows a normal heart size
and no pulmonary signs of cardiac failure.Which of the following is the most
likely diagnosis?
A. Carotid sinus hypersensitivity
B. Brugada syndrome
C. Long qt syndrome
D. Exercise induced VT
E. Hypertrophic obstructive cardiomyopathy
Answer: D
Explanation: Key learning points
Cardiology
● VT associated with exercise is normally non-sustained and has no significant
impact on mortality.
Explanation
The answer is exercise-induced VT. The findings on examination, ECG, and CXR
effectively rule out structural heart disease or congenital rhythm disturbance,
meaning the other options must be incorrect. VT associated with exercise is normally
non-sustained and has no significant impact on mortality, but the syncopal episode
here should prompt further investigation including Holter and exercise ECG to
evaluate any need for beta blockade to prevent further episodes.
Carotid sinus hypersensitivity is most commonly seen in the elderly with syncopal
episodes associated with pressure on the neck/carotid body, long QT is ruled out by
the 12 lead ECG, and HOCM is associated with abnormal findings on clinical
examination.
,Brugada syndrome is also diagnosed by characteristic ECG findings: ST segment
elevation in the precordial leads (V1-3).
2. In most cardiac arrest situations 1 mg of adrenaline (epinephrine) is given
intravenously every three minutes.
What is the correct volume and concentration of the adrenaline?
A. 1 ml of 1 in 1000
B. 10 ml of 1 in 1000
C. 0.1 ml of 1 in 100
D. 1 ml of 1 in 10,000
E. 10 ml of 1 in 10,000
Answer: E
explanation:Key learning points
Cardiology
● 10 ml of 1 in 10,000 is the recommended dose and concentration and is
considered the optimum volume of adrenaline during cardiac arrest, and is
recommended by the UK Resuscitation Council.
Explanation
A 1 mg dose of adrenaline (epinephrine) would be administered with 0.1 ml of 1 in
100, 1 ml of 1 in 1000 and 10 ml of 1 in 10,000.
However, 10 ml of 1 in 10,000 is the recommended dose and concentration and is
considered the optimum volume of adrenaline during cardiac arrest, and is
recommended by the UK Resuscitation Council.
https://www.resus.org.uk/library/2015-resuscitation-guidelines/guidelines-adult-
advanced-life-support#:~:text=If%20ROSC%20is%20suspected%20during,at%20the
%20next%20rhythm%20check.&text=If%20a%20pulse%20is%20palpable,pulse
%20is%20present%2C%20continue%20CPR
,3. A 62-year-old male is admitted with an inferior myocardial infarction (MI) and
receives thrombolysis, aspirin, atenolol, simvastatin, and lisinopril. His ECG shows
good ST segment resolution.
The following day he develops some pain in the legs and a dusky discolouration of
the lower limbs. On closer examination there is a diffuse petechial rash over the
lower legs, particularly the feet, but all peripheral pulses are palpable.
Investigations reveal:
Haemoglobin 133 g/L (120-
160)
Platelets 145 ×109/L (150-
400)
White cell 12.1 (4-11)
count ×109/L
Neutrophils 6.5 ×109/L (1.5-7)
Lymphocytes 3.5 ×109/L (1.5-4)
Eosinophils 1.2 ×109/L (0.04-
0.4)
IgE antibody 3 kU/L (<2)
Which of the following is the most likely cause for his current problems?
A. Cholesterol emboli
B. Allergic reaction to thrombolysis
C. Peripheral vascular disease
D. Polyarteritis nodosa
E. Aspirin allergy
Answer: A
Explanation: Key learning points
Cardiology
● Cholesterol emboli can occur following thrombolysis, and result in a petechial
rash, marked eosinophilia and raised IgE.
, Explanation
This patient is an arteriopath as suggested by the acute MI, and one day after
thrombolysis develops a petechial rash in the lower limbs with raised white cell count
- marked eosinophilia and raised IgE.
Rather than allergy, this suggests cholesterol embolisation syndrome.
Peripheral pulses are intact because cholesterol emboli are microcrystals which are
too small to occlude medium sized arteries.
Eosinophilia is part of the typical inflammatory reaction to cholesterol.
Reference
Kronzon I, Saric M. Cholesterol embolization syndrome. Circulation. 2010;122:631-
41.
4. A 45-year-old lawyer is referred to clinic with a blood pressure diary for advice on
commencing therapy.
He first consulted his general practitioner for a flare of eczema in January (which
resolved with topical therapy) when hypertension was first identified. He is presently
asymptomatic, with no other medical complaints other than his longstanding eczema.
He has been visiting the gym regularly since February, and has a healthy diet. He is
a current infrequent smoker, and drinks sporadically. He is of Nigerian descent.
Electrocardiogram and urine dip are normal. His home blood pressure recordings are
as follows:
January 152/90
mmHg
Februar 147/85
y mmHg
