Cardiology

A 45-year-old man attends for review. He has been suffering increasing shortness of breath over the past few years. He is a non-smoker who drinks 20 units per week of alcohol and has no significant past cardiovascular history. Now he presents with what seems to have been a transient ischaemic attack (TIA), with weakness and co-ordination problems affecting his left side, which have resolved over the past 24 hours. On examination blood pressure is 142/95 mmHg and he is in sinus rhythm. There is no opening snap, but a diastolic murmur is heard which changes in character according to posture. Bloods are unremarkable, including C-reactive protein (CRP), which is in the normal range. Which of the following diagnoses fit best with this clinical picture? Right atrial myxoma Left atrial myxoma Aortic stenosis Mitral stenosis Mitral regurgitation Correct answer

This patient has suffered a TIA, most likely due to embolus from an intra-cardiac cause. One possible clinical explanation could be mitral stenosis, left atrial enlargement and atrial fibrillation, leading to clot formation within the atrium, but this patient is in sinus rhythm, there is no opening snap on auscultation, and the murmur changes in character with posture. This suggests the possibility of another cause, and left atrial myxoma would fit the bill. Myxoma can occur in any cardiac chamber, but occurs most commonly in the left atrium. It is a gelatinous, friable tumour, which leads to transient signs of mitral stenosis that only occur if the tumour approaches the mitral valve orifice. There is no opening snap. There may be an early diastolic plop as the tumour prolapses through the mitral valve. X-ray may show calcification within the tumour if it is long standing. Definitive treatment involves surgical excision; recurrence rate is extremely low, but follow up is recommended for a period of 5 years. Right atrial myxomas are more rare and difficult to identify clinically; there may be evidence of multiple pulmonary infarcts due to formation of emboli. You are designing a study for a new agent that may reduce myocardial necrosis after myocardial infarction. The agent is specifically thought to reduce early myonecrosis. Which of the following enzymes is most appropriate to measure early myocardial necrosis? Glycogen phosphorylase isoenzyme BB (GPBB) Myoglobin Creatinine kinase Troponin Lactate dehydrogenase Glycogen phosphorylase exists in a number of isoforms, but GPBB exists in heart and brain tissue. During a period of ischaemia GPBB is released and is elevated 1-3 hrs after the event. Myoglobin levels become significantly elevated 2hrs after ischaemia, for CK the level may not be markedly elevated until 4hrs or more after an infarct. LDH is a late marker of myocardial infarction which remains elevated for a few days after infarct. Troponin is the current gold standard marker for myocardial infarction, although levels only become elevated after 6hrs; conventional practice is to measure levels at 6 and 12hrs after a period of chest pain. Correct answer Your answer

A 45-year-old man with a strong family history of ischaemic heart disease presents with atypical chest pains. Electrocardiographic (ECG) exercise testing shows J point depression of 1 mm with a heart rate of 120 beats/min (bpm). What is the most appropriate next step? Coronary angiography Dobutamine stress echocardiography Radionuclide myocardial perfusion scanning Reassure and discharge Repeat ECG exercise testing on anti-anginal medication J point depression is a physiological response to an increase in heart rate and ST segments should, therefore, be measured 80 ms post-J. J point depression produces upward sloping ST depression which has little predictive value for coronary artery disease. Horizontal and downward sloping segments are more predictive than upward sloping ones. In a young man with atypical chest pain, this exercise test would be reassuring and there would be no indication for further investigation or treatment. A 25-year-old woman is seen in outpatients and is found to have loud first heart sound, an early diastole sound followed by a mid-diastolic murmur. What is the likely diagnosis? Mitral stenosis with a fourth heart sound Mitral stenosis with atrial fibrillation Mitral stenosis with mobile leaflets Mitral stenosis with pulmonary hypertension Mitral valve prolapse Correct answer Correct answer

From the information given, the diagnosis is mitral stenosis with mobile leaflets. There is no information regarding atrial fibrillation or pulmonary hypertension. There is a loud first heart sound and when an opening snap is heard this indicates that the mitral valve is mobile. The snap occurs when the superior systolic bowing of the anterior mitral valve leaflet is rapidly reversed towards the left ventricle in early diastole, due to the high left atrial pressure. S4 is classically late diastolic or presystolic. It occurs when augmented atrial contraction causes presystolic ventricular distension so that the ventricle then contracts with greater force. Atrial myxoma can produce an early diastolic sound (tumour plop), which is due to the abrupt diastolic seating of the tumour within the right A 50-year-old-professor of economics presents with a 6-week history of progressive breathlessness and bilateral ankle swelling. The ECG shows inverted p in V1 and partial LBBB. Echocardiography confirms dilated cardiomyopathy. Which of the following statements is true? There is no relevance of history of alcohol abuse. A family history of similar problem is unrelated Past cytotoxic drug therapy is relevant Correct answer

Viral illness in the past is unrelated History of pulmonary tuberculosis in the past is relevant Dilated cardiomyopathy (DCM) is characterised by dilatation and impaired systolic function of the left and/or right ventricle. The aetiology is idiopathic in the majority of cases. DCM is familial (autosomal dominant) in at least 20% of cases and a role of autoimmunity is proposed in the pathogenesis of this disease. About 3040% of patients with DCM have organ-specific antibodies and these may become negative with disease progression. There is an association with viral (coxsackievirus or HIV) infection, which may be immune-related. Many patients with systemic heart disease present with features of DCM: Alcohol abuse Cytotoxic drug therapy, eg doxorubicin, cyclophosphamide Primary heart muscle diseases, eg amyloidosis End-stage cardiovascular disease (ischaemic, rheumatic, congenital, systemic hypertension) Generalised disease, eg haemachromatosis, sarcoidosis Connective tissue disorders, eg systemic sclerosis, systemic lupus erythematosus A 40-year-old woman presents with a 1-year history of increasing exertional dyspnoea and swollen ankles. Her GP has performed an ECG, which shows evidence of right ventricular hypertrophy and right axis deviation. Examination in clinic reveals the following: body mass index of 30, sinus rhythm 90 bpm, blood pressure 110/60 mmHg, elevated jugular venous pressure, left parasternal heave, peripheral oedema and a loud P2. There is no prior medical or family history of note. She is a non-smoker and drinks little alcohol. Whilst she denies current drug use, she has in the past used stimulant drugs purchased over the Internet to help her lose weight (previous body mass index of 34). What is the likely diagnosis? Isolated Cor pulmonale Chronic pulmonary emboli Primary pulmonary hypertension Mitral stenosis Tricuspid valve endocarditis Correct answer

This woman has clinical features of pulmonary hypertension. The onset of symptoms (eg dyspnoea, syncope, chest pain) is usually insidious. Other clinical findings may include murmurs of tricuspid or pulmonary regurgitation, ascites and hepatomegaly. It is important to exclude a secondary cause such as chronic pulmonary emboli, underlying collagen vascular disease, left-sided heart disease and chronic obstructive pulmonary disease. Primary pulmonary hypertension is diagnosed by exclusion and is around three times more common in females. The aetiology is uncertain but a genetic component with additional triggering factors seems likely. There appears to be a clear-cut relationship between the use of appetite suppressants (fenfluramine) and the development of primary pulmonary hypertension. This would fit in with the clinical scenario described above. A young computer programmer suddenly develops dysphasia and right-sided weakness. Cardiac examination is normal and he is afebrile. Which investigation would confirm the underlying cardiological diagnosis? Chest X-ray

12-lead ECG 2-D echocardiography Carotid Doppler study Transoesophageal echocardiogram Correct answer

A young, otherwise healthy person who suddenly develops a stroke is likely to have a paradoxical embolism due to a patent foramen ovale (PFO or ostium secundum defect). PFOs are relatively common and may be present in 30% of the general population. PFOs greater than 4 mm and associated with shunting are more likely to be associated with systemic emboli. A chest X-ray may show enlargement of the heart and pulmonary artery as well as pulmonary plethora. Incomplete right bundle branch block is seen on ECG. Echocardiography may demonstrate the defect and show right ventricular dilatation and hypertrophy and pulmonary artery dilatation. However, PFOs may be missed on 2-D echocardiogram. The precise size and location of the defect can be shown on transoesophageal echocardiography. A transoesophageal echocardiogram with Doppler colour-flow imaging would be the investigation of choice in this case. A 60-year-old man with NYHA (New York Heart Association) class II heart failure, is taking angiotensinconverting enzyme (ACE) inhibitors and -blockers for his heart failure. He is generally well in himself. On direct questioning at his routine outpatient visit, it is noticed that his exercise tolerance has decreased over the last year. Which of the following drugs should be added to his list of medications? Digoxin Frusemide Isosorbide mononitrate Spironolactone Valsartan Correct answer

The European Society of Cardiology recommends the addition of spironolactone for improving the survival of patients who are in the transition from well-controlled class II to class III or IV heart failure. Diuretics are only indicated if there is fluid retention. Angiotensin-receptor blockade in addition to ACE (angiotensin-converting enzyme) inhibitors is not recommended at this stage. Digoxin helps to relieve symptoms to some extent, and is more useful if the patient is in atrial fibrillation. Similarly, nitrates and hydralazine help to improve symptoms in patients with class III and IV heart failure. A 30-year-old man with known hypertrophic obstructive cardiomyopathy (HOCM) presents to casualty with an episode of witnessed syncope: a passer-by provided initial resuscitation. On admission he is unwell with pulse rate of 160 bpm, blood pressure 70/40 mmHg and decreased conscious level. ECG confirms ventricular tachycardia. Sinus rhythm is restored with a DC shock. What would be the most appropriate strategy for the long term? Amiodarone Automatic implantable cardioverter defibrillator Dual-chamber pacemaker Sotalol Correct answer

Verapamil

This man has survived an out-of-hospital cardiac arrest and therefore an automatic implantable cardioverter defibrillator (AICD) is warranted. Overall, patients with HOCM have an annual mortality rate of around 1%. Identifying those at greatest risk of sudden cardiac death (SCD) is challenging. However, several factors have been identified that are associated with an increased risk: maximum wall thickness > 30 mm non-sustained ventricular tachycardia on a 48-hour tape a history of SCD in a relative under 45 years of age and a history of syncope resting, left ventricular outflow-tract gradient > 30 mmHg abnormal blood-pressure response to exercise. Although a single risk factor does not, on its own, have a particularly high positive-predictive accuracy, the presence of two or more risk factors does identify a much higher risk population. Dual-chamber pacing, -blockers or verapamil may be used to reduce symptoms in patients with a left ventricular outflow-tract obstruction. Which one of the following features is MORE common in constrictive pericarditis than in cardiac tamponade? Pulsus paradoxus Kussmauls sign Prominent x trough 4-chamber diastolic equilibrium Hypotension Correct answer

An inspiratory increase in venous pressure (Kussmauls sign) and a steep y descent in the jugular pulse are features of constrictive pericarditis. Pericardial knock in early diastole is often seen in constrictive pericarditis. Both conditions cause failure of either side of the heart and the diastolic pressure in all cardiac chambers are equal. A paradoxical pulse and prominent x trough in the jugular pulse are more common in tamponade than in constrictive pericarditis. A 75-year-old-man presents to A&E with a history of sudden collapse. This occurred unexpectedly while he was walking his dog. There have been no similar episodes in the past. On examination there were no positive findings. An ECG performed with carotid sinus massage revealed a 5-second pause. Which of the following statements is true? Carotid sinus hypersensitivity is due to atherosclerosis Carotid sinus massage is contraindicated in patients with carotid vascular disease A permanent pacemaker has no role in the management of these patients Carotid sinus hypersensitivity is related to vertebrobasilar ischaemia Carotid sinus massage is contraindicated in patients taking Correct answer

-blockers

Carotid sinus baroreceptors consist of sensory nerve endings located in the internal carotid artery just above the bifurcation of the common carotid artery. Cardioinhibitory carotid sinus hypersensitivity is defined as cardiac asystole of > 3 s. The pure vasodepressor type is defined as a systolic blood pressure drop of > 50 mmHg (in the absence of significant bradycardia). A mixed type consists of a combination of cardioinhibitory and vasodepressor responses. As AV block can occur during the periods of hypersensitive carotid reflex, some form of ventricular pacing, with or without atrial pacing, is generally required. The mechanism responsible for carotid sinus hypersensitivity is unknown, but possibilities

include a high level of resting vagal tone, hyperresponsiveness to acetylcholine or an excessive release of acetylcholine. A 70-year-old man is referred by his GP for advice regarding optimisation of secondary prevention. He has a history of angina, with excellent control of symptoms on a combination of aspirin, dipyridamole MR, atenolol 50 mg od, simvastatin 40 mg od and isosorbide mononitrate 20 mg bd. His pulse rate is 70 bpm and blood pressure is 144/86 mmHg. The only other relevant past history includes an ischaemic stroke 2 years ago from which he made a complete recovery. What additional therapy would you consider adding?

Bendroflumethiazide Diltiazem Doxazosin Nicorandil Perindopril Correct answer

Most clinicians would now recommend the addition of ACE inhibitors for patients with vascular disease, irrespective of left ventricular function. This is based on evidence from large trials, such as PROGRESS (perindopril) and HOPE (ramipril). Favourable outcomes were found to be independent of a blood pressure effect. As such, the benefit of ACE inhibition seems to be not purely related to a reduction in blood pressure; beneficial local vascular and myocardial effects are also seen. Blood pressure is not yet optimised in this patient and further antihypertensive therapy is warranted. The addition of an ACE inhibitor should bring this to the desired level (< 140/85 mmHg). A patient with left ventricular failure undergoes echocardiography. Which is the correct formula for calculating the ejection fraction (EF)? EF = [end diastolic volume (EDV) end-systolic volume (ESV)]/EDV EF = [end diastolic volume (EDV) end-systolic volume (ESV)]/heart rate (HR) EF = [heart rate (HR) end diastolic volume (EDV)]/end-systolic volume (ESV) EF = [heart rate (HR) end-systolic volume (ESV)]/end diastolic volume (EDV) EF = [end-systolic volume (ESV) end diastolic volume (EDV)]/EDV Correct answer

Ejection fraction (EF) is calculated using the following equation: EF = [end diastolic volume (EDV) - end-systolic volume (ESV)] / EDV A 45-year-old asthmatic patient presents with palpitations. An ECG shows supraventricular tachycardia, with narrow QRS complexes. Carotid sinus massage is not successful. His BP is maintained at 128/72 mmHg. What would you do next? Administer intravenous adenosine Administer intravenous verapamil Correct answer

Administer intravenous digoxin Administer intravenous sotolol DC cardioversion

Although adenosine is the drug of choice for terminating paroxysmal supraventricular tachycardia, it can cause bronchospasm and is thus contraindicated in patients with asthma, sotolol should be avoided for the same reason. Verapamil would therefore be the drug of choice in this case. However, verapamil should not be used for tachyarrhythmias where the QRS complex is wide. It is also contraindicated in patients with the WolffParkinsonWhite syndrome. A 72-year-old man presents with 15 min of central crushing chest pain. ECG shows 0.5 mm ST elevation in leads V1 and V2. You are in a peripheral hospital with no acute cardiac catheterisation lab. What is the most appropriate treatment? Accelerated tissue plasminogen activator (tPA) + aspirin Aspirin + heparin and repeat electrocardiogram (ECG) in 15 min Heparin only No treatment and repeat ECG in 15 min Streptokinase + aspirin Correct answer

The criteria for thrombolysis are 1 mm ST elevation in two or more limb leads or 2 mm ST elevation in adjacent chest leads, so thrombolysis is not indicated here. However, in the context of a good history of cardiac pain and borderline ECG, an acute coronary event should be strongly suspected and aspirin and heparin given prophylactically, with a repeat ECG in 15 min. A 60-year-old man underwent a coronary angiogram for unstable angina. The next day whilst recovering in hospital he complains of severe pain in his right foot and partial loss ofsight in the left eye. On examination the lower limb peripheral pulses are present and of good volume. There is gangrene of the lateral two toes on the right foot. Fundoscopy reveals cholesterol emboli in a branch of the central retinal artery in the left eye. Which one of the following is the most probable diagnosis in this case? Atheroembolic disease Polyarteritis nodosa Buergers disease Arterial thromboembolism Disseminated intravascular coagulopathy Although each of the mentioned options is a valid possible underlying cause behind this presentation, it is clear that the picture is more typical of atheroembolic disease. It is due to cholesterol emboli lodged in peripheral arteries, commonly as a result of angiographic or other surgical vascular procedures. Clearly the clinical features will depend on the site of embolisation. The most common clinical findings are cutaneous features, renal failure and worsening hypertension. The presence of foot pulses with gangrenous toes should suggest cholesterol embolisation. The retina provides a unique opportunity to visualise the cholesterol emboli. Renal failure may manifest as gradual deterioration of renal function following angiography or may be acute (this may mimic acute dissection of the renal artery during renal Correct answer

angiography). Eosinophilia, eosinophiluria, a raised ESR and hypocomplementinaemia have been found in atheroembolic disease. Arterial thromboembolism is related to distal embolisation of proximal, preexisting atheroma. A 75-year-old-man presents to A&E with a history of sudden collapse. This occurred unexpectedly while he was walking his dog. There have been no similar episodes in the past. On examination there were no positive findings. An ECG performed with carotid sinus massage revealed a 5-second pause. Which of the following statements is true? Carotid sinus hypersensitivity is due to atherosclerosis Carotid sinus massage is contraindicated in patients with carotid vascular disease A permanent pacemaker has no role in the management of these patients Carotid sinus hypersensitivity is related to vertebrobasilar ischaemia Carotid sinus massage is contraindicated in patients taking Correct answer

-blockers

Carotid sinus baroreceptors consist of sensory nerve endings located in the internal carotid artery just above the bifurcation of the common carotid artery. Cardioinhibitory carotid sinus hypersensitivity is defined as cardiac asystole of > 3 s. The pure vasodepressor type is defined as a systolic blood pressure drop of > 50 mmHg (in the absence of significant bradycardia). A mixed type consists of a combination of cardioinhibitory and vasodepressor responses. As AV block can occur during the periods of hypersensitive carotid reflex, some form of ventricular pacing, with or without atrial pacing, is generally required. The mechanism responsible for carotid sinus hypersensitivity is unknown, but possibilities include a high level of resting vagal tone, hyperresponsiveness to acetylcholine or an excessive release of acetylcholine. An 18-year-old young man presents to A&E having developed palpitations while playing football. ECG shows rapid atrial fibrillation with a ventricular rate of around 250 bpm. QRS duration is prolonged at around 130 ms. DC cardioversion is performed. Subsequent ECG in sinus rhythm demonstrates a PR interval of 100 ms, positive R wave in V1 and the presence of a delta wave. What further treatment would you recommend? Atrial defibrillator implantation Intravenous and then oral loading with amiodarone Radiofrequency ablation of the accessory pathway Radiofrequency ablation of the AV node Surgical ablation of the accessory pathway Correct answer

This young man has WolffParkinsonWhite (WPW) syndrome. The most common arrhythmia is an atrioventricular re-entry tachycardia (AVRT). This is a narrow complex with anterograde conduction through the AV node and retrograde conduction via the accessory pathway. Patients who develop AF are at risk of rapid anterograde conduction to the ventricles via the accessory pathway, and this may subsequently degenerate to VF. The extremely rapid conduction with broad QRS duration is typical of this complication. Radiofrequency ablation of the accessory pathway is recommended in this setting and is potentially curative. A 58-year-old mans ECG shows a combination of a prolonged QT interval with tall T waves. What is this suggestive of?

Uraemia Hypocalcaemia Hypokalaemia

Correct answer

Hypermagnesaemia Metabolic alkalosis

A prolonged QT interval is due to hypocalcaemia and tall T waves to hyperkalaemia and/or acidosis, which can be caused by uraemia. The main ECG change resulting from hypocalcaemia is a long QT interval due to prolongation of the ST segment. Hypokalaemia is caused by potassium-wasting diuretics, potassium-wasting diarrhoea and hypokalaemic periodic paralysis. The hallmark of the effect of hypokalaemia on the ECG is the development of large U waves (positive deflection after the T wave). The normal U wave is produced by repolarisation of the HisPurkinje system. Which of the following is a characteristic feature of troponin? It is an integral component of pericardial cells Levels rise immediately or even prior to the onset of chest pain due to myocardial infarction About 30% of infarct patients show a rise in levels at 12 hours from the onset of symptoms 1 ng/ml is the cut off above which a myocardial infarction is indicated Levels act as a prognostic factor following an acute coronary syndrome Correct answer

The troponin complex is part of the cardiac myofibril and is released in myocardial damage. Levels rise about 4 hours after the onset of chest pain. 100% of patients are positive for troponin at 12 hours after the onset of pain. A level of > 0.1 ng/ml is considered as a significant rise. Levels of troponin have a strong relationship to clinical outcomes, such as progression to myocardial infarction and death. patient presents with congestive heart failure. Which drug may be effective in reducing mortality? Enalapril Aspirin Digoxin Frusemide Lidocaine Correct answer

Standard drugs like digitalis and diuretics have not been shown to improve survival rates. A number of studies have conclusively demonstrated that reduction in left ventricular afterload prolongs survival rates in congestive heart failure. Vasodilators such as angiotensin-converting enzyme (ACE) inhibitors are thus effective by inhibiting the formation of angiotensin II and thus affecting coronary artery tone and arterial wall hyperplasia. Lidocaine and other antiarrhythmic agents are useful only when there is arrhythmia associated with heart failure. Aspirin is indicated only in cases of coronary occlusion or myocardial infarction.

A 54-year-old man is 48-h postmyocardial infarction. You are asked to review him as he is suffering worsening cardiac failure. On examination he has a pansystolic murmur, loudest at the apex. What complication of his myocardial infarction is most likely to have occurred? Ventricular septal defect Atrial septal defect Acute mitral regurgitation Acute pulmonary regurgitation Ventricular rupture Acute mitral regurgitation associated with myocardial infarction may occur due to ruptured chordae tendineae. Other causes of mitral regurgitation include papillary muscle dysfunction, infective endocarditis, rheumatic heart disease, idiopathic myxomatous valve degeneration, left atrial myxoma, systemic lupus erythematosus (SLE) and drugs (fenfluramine and dexfenfluramine). The investigation of choice is echocardiography, which may identify left atrial and left ventricular dilatation and confirm the diagnosis of chordae tendineae rupture. Mitral regurgitation associated with chordal rupture in MI may be catastrophic and require emergency surgery for valve replacement. Acute medical management involves treatment with angiotensinconverting enzyme (ACE) inhibition, diuretic therapy and possible anticoagulation. The prognosis for patients with mitral regurgitation is generally good, except in the post-MI situation. Correct answer

A 30-year-old-man presents to the outpatient clinic with a 2-month history of progressive effort intolerance. Some three weeks ago he experienced an episode of shortness of breath at rest, suggestive of paroxysmal nocturnal dyspnoea. Examination reveals a JVP raised up to his earlobes, a soft tender hepatomegaly and a bilateral pitting oedema up to his knees. Chest examination reveals bibasal crepitations, and an audible S3 on auscultation of the heart. The chest X-ray shows cardiomegaly with interstitial infiltrates. Echocardiography shows global left ventricular hypokinesia with an ejection fraction of 2530%. Which of the following is the LEAST likely aetiological factor? Alcohol abuse Genetic factor Adenovirus Eosinophilic states Correct answer HIV infection

Dilated cardiomyopathy encompasses a heterogeneous group of conditions. Alcohol abuse is an important aetiological factor in a significant number of patients. About 25% of cases are inherited as an autosomal-dominant trait. A substantial group is due to a late autoimmune reaction to viral myocarditis. Up to 10% of patients with advanced HIV infection develop dilated cardiomyopathy. Eosinophilic states are associated with obliterative cardiomyopathy. A 62-year-old man with two previous myocardial infarctions and a history of LVF controlled with ramipril and furosemide presents to his GP with palpitations. On examination his BP is 100/72 mmHg, pulse 85/min AF, with bibasal crackles consistent with heart failure. Investigations; Hb 12.1 g/dl

WCC PLT Na+ K

+

5.4 x109/l 234 x109/l 140 mmol/l 5.0 mmol/l 130 mol/l

Creatinine ECHO - Dilated left atrium and left ventricle

Which of the following would be the most appropriate agent to control his AF? Diltiazem Sotalol Amiodarone Digoxin Verapamil Correct answer

Verapamil, diltiazem and sotalol are all to a greater or lesser extent negatively inotropic and may worsen cardiac failure. Given that his systolic blood pressure is only 100, any further reduction in cardiac output is likely to further worsen his BP. Amiodarone is useful for chemical cardioversion and as such is not the best choice here. Digoxin is less useful for rate control in AF than calcium antagonists or betablockers, but is the most appropriate choice here as it does improve symptoms in patients with cardiac failure, and given the enlarged left atrium, successful cardioversion is unlikely. A 32-year-old woman who is known to be 17 weeks pregnant presents for review. She has periods of paroxysmal supraventricular tachycardia (SVT) and on this occasion has a ventricular rate of 165/min and a blood pressure of 90/50 mmHg, feeling faint and unwell. Which of the following anti-arrhythmics would be the most appropriate prophylaxis for her? Metoprolol Amiodarone Digoxin Phenytoin Propafenone Correct answer

This patient has paroxysmal supraventricular tachycardia (SVT). While digoxin slows the ventricular rate in patients with chronic atrial fibrillation, it does not maintain sinus rhythm in patients with paroxysmal tachycardia. Amiodarone is known to be teratogenic and is contraindicated in pregnancy. Guidelines suggest that metoprolol is potentially the most appropiate option for SVT in pregnancy.