Cardiology Cases

Topic

Page

Ischaemic Heart Disease

Valvular Heart Disease

10

Infective Endocarditis

15

Cardiac Rhythm Disorders

18

Hypertension

21

Heart Failure

24

Cardiomyopathies

27

Aortic Dissection

29

Pericardial Disease

31

Appendices

33-34

ISCHAEMIC HEART DISEASE

KEY AREAS TO BE COVERED
The atherosclerotic plaque
Plaque rupture and thrombosis in the setting of acute myocardial infarction and
unstable angina
Clinical features of stable angina, unstable angina and acute myocardial infarction
Drug therapy of angina
Management of acute myocardial infarction, including the use of thrombolytic
drugs
Complications of acute myocardial infarction, including ventricular fibrillation
Resuscitation including defibrillation of ventricular fibrillation
Cardiac investigations - ECG, exercise stress test, echocardiography, angiography
Interventional cardiology - PTCA / stent implantation
Coronary artery bypass grafting
LEARNING OBJECTIVES
On completion of the attachment the student should be able to:
List the recognised risk factors for the development of coronary atherosclerosis
and explain the pathological processes involved in plaque progression and the
development of unstable angina / acute myocardial infarction
Describe the anatomy and physiology of the coronary circulation and its
relevance to acute myocardial infarction
Explain the physiological basis of the regulation of cardiac output and blood
pressure in both the normal and the diseased heart
Describe the typical clinical symptoms of a patient presenting with angina / acute
myocardial infarction, the potential complications associated with acute
myocardial infarction, and the management of these conditions.
List the major classes of drugs available for the treatment of ischaemic heart
disease and discuss the indications for and potential side-effects of these drugs [blockers, calcium channel blockers, ACE inhibitors, angiotensin receptor
blockers, nitrates, potassium channel activators, anti-platelet agents (aspirin,
clopidogrel), fibrinolytic drugs (streptokinase, t-PA), heparins (unfractionated,
low molecular weight), oral anticoagulants (warfarin), and statins].
The student should have observed and / or be able to describe the following procedures:
Recording of 12 lead electrocardiogram
Exercise stress test (where possible, with radionuclide perfusion imaging)
Cardiac catheterisation (and where possible PTCA) {for those students attached
to hospitals other than the Royal Victoria Hospital and Belfast City Hospital a
visit to the Cardiac Catheterisation laboratories can be arranged after discussion
with your Supervising Consultant}
The student should be able to interpret the following investigations:
Common / basic ECG abnormalities: acute myocardial infarction presenting with
ST elevation
Common CXR abnormalities: cardiomegaly, pulmonary oedema
Results of cardiac enzyme/marker estimations: CK, CK-MB, AST, LDH,
Troponins

CASE 1
A 52 year old man is referred by his family doctor to the Cardiac Outpatient Department
complaining of recurrent chest discomfort on exertion over the preceding six months. His
father died age 58 years of a myocardial infarction. He works as a Taxi Driver and
smokes 20 cigarettes per day. He is married with four children. There is no other medical
history of note. He is not on any regular medication although his family doctor has
prescribed GTN for sublingual use as required.
1. What additional information would you wish to obtain from the patient?

2. Which investigations would you wish to perform on this patient? Should this patient
have an exercise stress test performed or should the severity of his disease be judged
by clinical history and response to therapy?

3. What general advice would you give him?

4. What are the therapeutic options for the management of this patient? Discuss the
different pharmacological therapies and their potential side-effects.

5. Are there any implications for this gentlemans employment?

The gentleman has an exercise stress test performed using a standard Bruce protocol. He
exercises for only 5 minutes ( 4 METS) and stops because of chest pain. At peak exercise
there is 4mm ST depression noted on the ECG in leads V4 V6, I and aVL, which
normalises ten minutes into the recovery period.

6. What is meant by the term MET?

7. Should this gentleman have any further investigations performed and, if so, which
investigations would you recommend?

CASE 2
A 61 year old gentleman presents to the Accident and Emergency Department with a two
hour history of severe central chest pain unrelieved by his usual sublingual GTN therapy.
He gives a two year history of infrequent chest discomfort and states that his family
doctor had been treating him for mild angina. He has been a heavy smoker for many years
and was diagnosed as suffering from diabetes mellitus six months earlier (commenced on
diet). In his past history he had had appendectomy as a child. On examination he appears
pale and sweaty and is in obvious distress with pain. His pulse rate is 110/min, BP is
130/80, the heart sounds are unremarkable and there are a few bibasal crepitations on
chest examination.
An ECG was performed and is shown as Figure 1.
1. What is the diagnosis?

2. What is the appropriate management of this condition? Are there any additional
specific questions which you would like to ask the patient before administering
treatment?

3. What are the potential adverse effects of these therapies?

Figure 1

Shortly after admission to the Cardiac Unit the patient becomes suddenly unresponsive
and pulseless. A monitor strip is shown below.

4. What is the diagnosis and how would you manage the situation?

5. The gentleman suffers from maturity onset diabetes which is normally controlled by
diet. What will happen to his blood sugar control in the immediate post-infarction
period?

Over the next 36 hours the patient complains of mild dyspnoea and his CXR shows
pulmonary congestion? At this time he does not have any further chest pain.
6. How should heart failure be managed in this situation?

On the morning of the third day after admission he complains of further chest pain. He
states that the pain is different from that at the time of presentation and is worse when he
breathes.
7. What is the most likely diagnosis and how would you manage the situation? List other
complications which can commonly or occasionally occur after acute myocardial
infarction?

His condition improves over the next few days and he is fit for discharge on the eighth
day following admission.

8. Are there any other investigations which you would like to perform pre discharge?
Which treatments have been shown to improve prognosis after myocardial infarction?

9. What advice will you give him pre discharge? Is there any evidence to support a role
for cardiac rehabilitation in this situation?

10. The patients wife wishes to discuss her husbands condition with you pre-discharge.
What information will you impart to the wife?

Additional Reading
Relevant pharmacological texts on thrombolytic therapy.
Landmark articles on the role of thrombolytic therapy in the management of acute
myocardial infarction there is a huge number of studies published (ranging from
ASSET through GISSI, GUSTO, and ISIS to TAMI and TIMI). Three important
studies are listed below. Details of further studies can be accessed via Medline.
o ISIS II (Second International Study of Infarct Survival) Collaborative
Group: Randomised trial of intravenous streptokinase, oral aspirin, both,
or neither among 17,187 cases of suspected acute myocardial infarction.
Lancet 1988;2:349-360.
o ISIS III (Third International Study of Infarct Survival) Collaborative
Group: A randomised comparison of streptokinase vs tissue plasminogen
activator vs anistreplase and of aspirin plus heparin vs aspirin alone
among 41,299 cases of suspected acute myocardial infarction. Lancet
1992;339:753-770.
o The GUSTO Investigators: An international randomised trial comparing
four thrombolytic strategies for acute myocardial infarction. N Engl J
Med 1993;329:673.-682.
Recent publications on primary coronary intervention for myocardial infarction.
o Andersen HR et al. A comparison of coronary angioplasty with
fibrinolytic therapy in acute myocardial infarction. N Engl J Med
2003;349:733-742.
o Jacobs AJ. Primary angioplasty for acute myocardial infarction is it
worth the wait? N Engl J Med 2003;349:798-800.

VALVULAR HEART DISEASE

KEY AREAS TO BE COVERED

Aetiology of valvular heart disease

Symptoms in patients with valvular heart disease
Cardiac response to pressure / volume overload
Clinical examination in the following situations:
o Aortic stenosis / aortic incompetence
o Mitral stenosis / mitral incompetence
o Tricuspid incompetence
Echocardiography (transthoracic / transoesophageal) - its role in assessment of
valvular disease
Clinical management
Surgical therapy - prosthetic valves
Antibiotic prophylaxis

LEARNING OBJECTIVES
On completion of the attachment the student should be able to:
Summarise the characteristic clinical findings in patients with aortic stenosis /
aortic incompetence / mitral stenosis / mitral incompetence / tricuspid
incompetence, the common aetiologies of these conditions, the investigations
used in assessing the severity of the valvular disease, and the surgical procedures
available for management of valvular disease
List the major classes of drugs available for the treatment of valvular heart
disease and discuss the indications for and potential side-effects of these drugs
[diuretics, -blockers, calcium channel blockers, ACE inhibitors, angiotensin
receptor blockers, nitrates, anti-platelet agents (aspirin, clopidogrel), heparins
(unfractionated, low molecular weight), oral anticoagulants (warfarin)].
The student should have observed and / or be able to describe the following procedures:
Echocardiogram
The student should be able to interpret the following investigations:
Common CXR abnormalities: mitral heart

10

CASE 3
You are called in the Cardiac Ambulance to see a 75 year old lady who has collapsed
while shopping in town. For several years she has been treated by her family doctor for
angina. She states that she felt unwell while carrying her shopping. She took two puffs of
her GTN spray and then felt dizzy before collapsing to the ground. She did not sustain
any injuries and by the time you see her she feels well again. She takes 100 g Lthyroxine daily for hypothyroidism and has been on aspirin 75mg daily following one
episode of amaurosis fugax eight months earlier. On examination of the praecordium you
note a loud systolic murmur radiating to the neck.
1. What are the potential diagnoses in this situation?

2. Which investigations should be carried out?

The patient is admitted to hospital for further investigations. The ECG shows sinus
rhythm and there is evidence of left ventricular hypertrophy. An echocardiogram is
performed and shows thickening and reduced movement of the aortic valve with a peak
gradient across the aortic valve of 90mmHg and moderate concentric left ventricular
hypertrophy.
3. What are the potential mechanisms responsible for this ladys collapse and which is
the most likely in light of the clinical information available?

4. What is the appropriate management for this lady?

11

5.

List the aetiological causes of aortic stenosis and which is the most likely in this
age group.

6.

This lady has been complaining of angina-like symptoms. Discuss the potential
causes of such symptoms in this situation.

12

CASE 4
A 52 year old lady is admitted to the Medical Unit with a history of increasing dyspnoea
over the previous two months. She is a non-smoker and does not complain of any chest
pain. As a child she had been off school for several months because of growing pains.
She had required a heart operation at the age of 20 years. She has since remained well and
did not experience any difficulties during her three pregnancies (26, 24, 21 years earlier).
On examination her pulse is irregular and the radial rate is 90 beats/min. Praecordial
examination shows a left thoracotomy scar and auscultation reveals both a systolic
murmur radiating to the axilla and a mid-diastolic murmur audible just internal to the
apex.

1. What is the likely diagnosis?

2. How would you investigate this lady?

The ECG confirms the clinical impression of atrial fibrillation. The ventricular rate at rest
is 100/min.

3. What are the potential complications associated with atrial fibrillation?

4. Discuss the therapeutic options for management of atrial fibrillation.

13

The echocardiogram confirms mitral valve disease with moderate mitral regurgitation and
moderate mitral stenosis (estimated valve area 1.3 cm2). The pulmonary arterial pressure
is estimated at 40mmHg.

5. Why should this lady have evidence of pulmonary hypertension? What are the
mechanisms involved?

6. What is the appropriate long term management for this lady?

14

INFECTIVE ENDOCARDITIS
KEY AREAS TO BE COVERED

Symptoms and clinical findings in patients with endocarditis

Common aetiological organisms
Investigations, including the role of echocardiography
Management - antibiotic therapy, the role of surgery
Prevention - antibiotic prophylaxis, dental hygiene

LEARNING OBJECTIVES
On completion of the attachment the student should be able to:
Summarise the clinical features of infective endocarditis, list the common
microbiological organisms involved in this disease process, and discuss
appropriate management of this condition, including its prevention
List the major classes of antibiotics available for the treatment of infective
endocarditis disease and discuss the indications for and potential side-effects of
these drugs [ref section 5 of British National Formulary].
The student should have observed and / or be able to describe the following procedures:
Echocardiogram, showing a valvular vegetation

15

CASE 5
A 47 year old farmer is referred for admission complaining of lethargy, sweats, shivering
episodes and mild dyspnoea over the previous four weeks. He had previously been fit and
healthy although he states that he had been told at a routine medical examination some
years earlier that he had a soft murmur. He has not been on any recent foreign trips. On
examination his temperature is recorded at 38.4 0C, a few splinter haemorrhages are
present and a loud early diastolic murmur is audible.

1. What is the most likely diagnosis here? Give a list also of potential differential
diagnoses.

2. How would you proceed to investigate and manage this patient?

The day following admission you receive a call from the bacteriologist who says that an
organism has been grown from several blood culture bottles.
3. List the most common organisms associated with infective endocarditis.

4. Discuss appropriate pharmacological therapy of the condition.

16

The patient initially progresses well but two weeks following admission he develops
recurrent pyrexia.
5. Discuss potential mechanisms for this pyrexia.

6. What are the indications for surgical intervention in the setting of infective
endocarditis?

Additional Reading
1. British National Formulary:
Section 5, Table 1: Antibacterial Therapy Cardiovascular System
Section 5, Table 2: Antibacterial Prophylaxis - Endocarditis

17

CARDIAC RHYTHM DISORDERS

KEY AREAS TO BE COVERED
Anatomy of the cardiac conduction system
Bradycardias / heart block
Atrial tachycardia, including atrial fibrillation and atrial flutter - aetiological
factors, complications and management
Atrioventricular tachycardia - nodal / accessory pathways, Wolff-ParkinsonWhite syndrome
Ventricular tachycardia
Anti-arrhythmic drugs
Pacemakers
Electrophysiological Studies

LEARNING OBJECTIVES
On completion of the attachment the student should be able to:
List the common causes of and discuss the management of atrial and ventricular
rhythm disorders, including both bradycardias and tachycardias
List the major classes of drugs available for the treatment of valvular heart
disease cardiac arrhythmias [-blockers, calcium channel blockers, digoxin,
amiodarone, adenosine, lidocaine].
The student should have observed and / or be able to describe the following procedures:
Ambulatory monitoring
Cardiopulmonary resuscitation, including defibrillation
DC cardioversion
Pacemaker implantation / Electrophysiological Studies
The student should be able to interpret the following investigations:
ECG abnormalities: atrial fibrillation / ventricular fibrillation / heart block /
Wolff-Parkinson-White syndrome

18

CASE 6
A 77 year old lady is referred following a collapse in which she sustained a fractured
wrist and facial bruising. She has been in good health throughout her life and apart from
pregnancy has not previously been in hospital. She is a widow who lives alone
approximately two miles from the local village. She normally drives her car to do the
shopping and usually plays golf one to two times per week. She is not on any regular
medication. The admitting physician is concerned as her pulse rate is rather low at 30
beats / min. Examination of the praecordium reveals only a soft systolic murmur. An
ECG confirms the presence of complete heart block. The fractured wrist is undisplaced
and is treated with a standard plaster cast.

1. How would you manage the lady in this acute setting? What are the causes of
conduction system disease?

A permanent pacemaker is implanted and the patient mobilises well.

2. How does an artificial pacemaker work? What follow-up is required for a patient with
a permanent pacemaker?

3. When will she be able to drive again?

4. How would you arrange the discharge of this lady from the hospital and what
additional services could be mobilised to ensure that she could safely return home?

19

CASE 7
A 20 year old girl presents to the Emergency Department complaining of palpitations for
the past hour. She has had recurrent palpitations over the past three years but the attacks
normally last up to 10 minutes and have previously abated spontaneously. On this
occasion she also complains of mild shortness of breath. On examination she has a pulse
rate of 180 beats per minute and her blood pressure is normal at 110/84. The remainder of
the examination is unremarkable. An ECG is recorded and confirms a heart rate of 180 /
min with a regular narrow complex rhythm.

1. What is the most likely diagnosis?

2. How would you manage the tachyarrhythmia in the acute situation?

3. What are the long term management options for this problem?

20

HYPERTENSION
KEY AREAS TO BE COVERED

Definition of hypertension and epidemiological features

Causes of hypertension
Investigation of hypertension
Non-pharmacological therapy
Drug therapy

LEARNING OBJECTIVES
On completion of the attachment the student should be able to:
Summarise the causes of hypertension and discuss the investigation and
management of patients with hypertension
List the major classes of drugs available for the treatment of hypertension and
discuss the indications for and potential side-effects of these drugs [diuretics, blockers, calcium channel blockers, ACE inhibitors, angiotensin receptor
blockers, nitrates, -blockers].

21

CASE 8

A 37 year old gentleman is referred as his family doctor has had difficulty in achieving
optimal control of the patients hypertension. The patient had been noted to be
hypertensive during a routine medical examination for insurance purposes six months
earlier. He had been tried on several medications, including a -blocker and calcium
antagonist but these had either proved ineffective or the patient had stopped taking them
because of adverse effects.

1. Discuss the normal mechanisms involved in regulation of blood pressure.

2. What is hypertension?

3. List the common causes of hypertension and the appropriate methods of investigation.

4. Describe how you would investigate and manage this patient?

22

5. Discuss non-pharmacological therapy of hypertension.

6. What are the potential complications of uncontrolled hypertension?

Additional reading
European Society of Hypertension-European Society of Cardiology guidelines for
the management of arterial hypertension. J Hypertension 2003;21:1011-1054
The Seventh Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report. JAMA
2003;289:2560-2571.
1999 World Health Organization International Society of Hypertension
Gudelines for the Management of Hypertension. J Hypertension 1999;17:151183.
British Hypertension Society guidelines for hypertension management 1999:
summary. BMJ 1999;319:630-5.

23

HEART FAILURE
KEY AREAS TO BE COVERED

What is heart failure?

Congestive heart failure / left ventricular failure / pulmonary oedema
Acute and chronic heart failure
Epidemiological features
Appropriate Investigation
Neurohormonal responses
Management of heart failure diuresis versus vasodilatation
Prognosis

LEARNING OBJECTIVES
On completion of the attachment the student should be able to:
Describe the typical clinical features and management of both acute and chronic
heart failure
List the major classes of drugs available for the treatment of heart failure and
discuss the indications for and potential side-effects of these drugs [diuretics, blockers, ACE inhibitors, angiotensin receptor blockers, nitrates, digoxin,
inotropic agents].

24

CASE 9
A 67 year old man is admitted to the Emergency Department at 3am in acute respiratory
distress. He is unable to speak but appears very ill, cold and clammy. His wife, who has
accompanied the patient, states that her husband had woken complaining of feeling short
of breath and that his condition had deteriorated over the subsequent 30 minutes. She had
called an ambulance and the ambulance men had administered oxygen during the transfer
to the hospital. She also stated that her husband had not complained of chest pain but that
he had had a myocardial infarction four years earlier from which he had appeared to have
made a good recovery, although she had been told at that time that he had sustained a
moderate amount of heart muscle damage.

1. What is the likely diagnosis? Give a list of potential differential diagnoses.

2. Which emergency investigations would you like to perform?

3. What is your emergency management of the situation?

The patient responds well to your therapy in the Emergency Department and is admitted
to the Cardiology Unit.
4. Which investigations would you like to perform? What is your long term treatment
plan for this gentleman?

25

The patient has an echocardiogram performed and the report states that his left ventricular
ejection fraction is 30%. In addition, moderate mitral regurgitation is also noted.

5. What is meant by the term ejection fraction? What is the normal left ventricular
ejection fraction?

6. Why should this gentleman have associated mitral regurgitation?

26

CARDIOMYOPATHIES
KEY AREAS TO BE COVERED
Classification of the cardiomyopathies - hypertrophic / dilated / restrictive
The sarcomere
Aetiology / Mendelian inheritance in some forms of cardiomyopathy
Investigation and Management
LEARNING OBJECTIVES
On completion of the attachment the student should be able to:
List the different types of cardiomyopathies

27

CASE 10
You are asked to see the parents and sibs of an 18 year old university student who had
died suddenly while playing football some weeks earlier. The student had had no past
medical history of note. A post-mortem examination had been carried out and the
relatives were told that he had died of a cardiomyopathy and that this condition was
inherited in some cases.

1. List the types of cardiomyopathies

2. Which inheritance patterns have been described for cardiomyopathies?

3. How would you investigate the surviving family members?

28

AORTIC DISSECTION
KEY AREAS TO BE COVERED

Clinical presentation and differentiation from acute myocardial infarction

Aetiology, including discussion on Marfan Syndrome
Investigation: transoesophageal echocardiography vs CT scan vs MRI
Management: surgical vs medical
Control of blood pressure
Complications and prognosis

LEARNING OBJECTIVES
On completion of the attachment the student should be able to:
Summarise the aetiology, clinical features and management of aortic dissection

29

CASE 11
A 38 year old man presents with a sudden onset of severe chest and interscapular pain. He
has not experienced any similar pain in the past. He has been diagnosed as suffering from
Marfan syndrome but is not on any regular medication. On examination he is in obvious
distress with pain. His BP is recorded at 142/90. His peripheral pulses are all present.
Auscultation of the praecordium reveals a soft early diastolic murmur audible at the left
sternal edge.

1. What are the diagnostic features of Marfan syndrome? How is this syndrome
inherited and what is the responsible gene?

2. Which investigations would you use to confirm or refute your clinical diagnosis of
aortic dissection?

3. Is a blood pressure of 142/90 acceptable in this situation?

4. Why does this gentleman have an early diastolic murmur audible?

5. How would you manage this situation?

30

PERICARDIAL DISEASE
KEY AREAS TO BE COVERED

Aetiology and clinical presentation of acute pericarditis

Aetiology and clinical presentation of pericardial effusion
Clinical signs: pulsus paradoxus, Kussmauls sign
Constrictive pericarditis

LEARNING OBJECTIVES
On completion of the attachment the student should be able to:
List the clinical features of acute pericarditis / pericardial effusion / constrictive
pericarditis

31

CASE 12
A 56 year old lady presents with malaise and increasing shortness of breath over the
preceding two to three weeks. In her past medical history she had had surgical removal of
a breast lump three months earlier. The Casualty Officer arranged for a chest X-ray to be
performed This shows cardiomegaly and you are asked to see the patient as a possible
diagnosis of pericardial effusion.

1. What are the specific physical signs which you must look for on clinical examination?

2. Which investigations would you use to confirm or refute your clinical diagnosis of
pericardial effusion resulting in tamponade?

3. Pericardiocentesis is performed by the Consultant Cardiologist and you are asked to

send the appropriate samples to the laboratory. Which tests will you request?

32

APPENDIX 1
CASE HISTORY - CARDIOLOGY
Notes for Teachers and Students
The student should submit one Case History during the Cardiology attachment. The Case
History should contain the following:
History and Examination:
- as is standard for all cases (DO NOT LIST PATIENTS
NAME / ADDRESS)
- where part of the examination is not performed or not feasible
(for example, full neurological examination during the early days
after myocardial infarction) then please simply state that the
examination was not carried out and state the reason
- drugs should be listed (in CAPITAL LETTERS) according to
their generic name and the indication for the drug should be listed
Problem List and Differential Diagnosis:
- list all the patients problems (for example: 1. Chest pain
possible myocardial infarction; 2. Diabetes mellitus; 3. Smoker; 4.
Urinary frequency possible urinary tract infection; 5. Painful left
knee possible osteoarthrosis; 6. Poor housing; 7. Lives alone
etc)
- state the likely differential diagnoses (usually 3 to 6) for the
main medical problems in your patient rather than simply listing
all the possible causes
List Appropriate Investigations
- also give the results of these investigations in your patient (with
the appropriate reference range for the laboratory results) and
offer interpretation of the results
Management
- discuss the way in which your patient was managed
Discussion
-

you should centre this on your patient and relate the

presentation / clinical findings / investigations / management
to the standard descriptions of the condition and also to your
additional background reading remember that the most upto-date information will be available in journals rather than
older textbooks (please supply details of references).

33

APPENDIX 2
Assessment of the Case History

CRITERION REFERENCE MARKING SCHEME

MARK RANGE
8 10

CRITERIA
HISTORY all aspects covered in an accurate, focussed and
structured layout, with relevant, positive and negative features
included and irrelevant material omitted.
EXAMINATION FOCUSSED
To include all relevant features and evidence that all possible
clinical abnormalities were CONSIDERED.
CLINICAL ACUMEN
Ability to interpret clinical findings.
KNOWLEDGE
High level of knowledge of disease, pathophysiology, therapeutics
and pharmacology related to the patients conditions.

Most of above but with minor deficiencies in history, examination

or other features.

Occasional significant deficiencies. eg. (part of history omitted,

long or irrelevant material included).

Significant Omissions, missed or incorrect clinical signs. No

application of commentary to patient. Presentation of adequate
standing only.

1-4

Major deficiencies in 1 or 2 areas. Significant deficiencies in

many aspects. Poor knowledge of disease or management issues
including pharmacology and therapeutics.

34