Greetings from India!

Hello readers

I am currently visiting India, and will hopefully upload some good content based on any cases I hear about when I am here.....keep an eye out!

Vik

Cardio4mrcp is now free...but not for long!!

Hey there readers !

I am pleased to inform you that for a limited time only, our website is completely free to access! With over 300 questions covering various aspects of cardiology tailored to the MRCP part 1 exam, now is a better time than ever to join!

I hope all of you will make the most of this opportunity and register for free and enjoy our site. While you are there, feel free to check out our new book store which has some of the best books there are for preparation for the exam.

We look forward to seeing you there. Go to www.cardio4mrcp.com and register today!

Warm wishes

 Vik

We have an online bookstore!!

Hi everyone!

We are pleased to inform you that we now have an online bookstore! Here we have listed some of the best books available for the MRCP, all the way from preparatory text books for the MRCP part 1 to clinical scenarios for PACES.

Click on the link below to access our bookstore!

Cardio4MRCP bookstore

Warm wishes

Cardio4MRCP team.

Congratulations to my friend Dr Prem Alva!

I would like to heartily congratulate my dear friend Dr Prem Alva (Consultant pediatric cardiologist) for his amazing work saving the life of a one day old baby girl with congenital pulmonary stenosis. Our common friends and I are extremely proud of him, and look forward to see him work wonders saving children like he does on a daily basis.

He made national news! Check out the article here.

We will be asking Dr Alva to write a brief article on congenital pulmonary stenosis for all our readers. Keep an eye out for it!!!

Well done Alva!

We are on twitter!

Yes, we are on twitter! Follow us @Cardio4MRCP.

Look forward to seeing you there!

Vik

Support a charity - make a difference!

Dear all

Charity has always been close to my heart, and today I have added a SocialVibe widget on the right hand side of this blog. You do not have to donate any money or even take out your wallet. All you need to do is click on the widget and the window that opens may ask you to rate a movie trailer or something along those lines. All it takes it a couple of minutes of your time, and it is for a good cause. The money is donated by big corporations like Apple or Colgate etc.

This month, I am supporting 'Children mending hearts'. Check them out on www.childrenmendinghearts.org. The widget states otherwise, but whatever it says, it still is for a noble and worthy cause.

I hope you all click on the widget and support the charities. If it asks you to return at a later date, please do so.

Thank you all for your time.

Warm wishes

Vik

Medical Mnemonics

Oh, how we all loved mnemonics during medical school. Remember the carpal bones - 'She Looks Too Pretty, Try To Catch Her'?? Well, for the MRCP basic sciences section, what better way to remember the facts than with a book on mnemonics! Given that you are a seasoned medical student (or a junior doctor, as most of us call it!), get yourself a book with good mnemonics to remember all those bones, tissues, tendons, physiological pathways, biochemical pathways etc. We found one on Amazon that seems to be going strong. A quick preview and it looks good, packed with illustrations and interesting anecdotes. Here is the link for you:

For those of you who have a kindle, or have the software on your computer, you can download the book straight away -

The book combines mnemonics with humour, so it most certainly is a good read. Remember, a lot of questions in the MRCP part 1 exam cover topics from years ago. In addition to the books we have recommended in other posts, this appears to be a good accompaniment. Reviews by other users are great as well.

Enjoy it!

Book reviews

Hey everyone

Over the next few weeks to months, I will be posting book reviews on various books that have been used by senior house officers and registrars for exams, and will also include reviews of books from medical school. They will be written by various experienced doctors, and will hopefully give you an insight into what to look for in the books, what is good, what is bad, what could make you fall asleep etc. We hope that these reviews help you make an informed decision on purchasing them if you wish. We will also provide you with links to purchase them as well - just to make life easy for you :-)

Until the next post....

Answer to clinical scenario - April 30th

Hi readers

You may have seen this question recently :

A 60 year old Asian man with a history of type 2 diabetes on insulin and hypertension presents with deteriorating renal function and is referred by his GP to the renal clinic. In the renal clinic, he is found to have leg oedema, elevated JVP with rapid x-descent, ascites, mild jaundice and bi-basal dullness. Chest X-ray shows cardiomegaly. ECG shows left ventricular hypertrophy with strain.  Resting heart rate was 100 bpm and BP of 90/70. The definitive cardiac diagnosis can be obtained by -

a. Cardiac MRI
b. CT pulmonary angiography
c. Ventilation-perfusion scan
d. Transthoracic Echocardiography
e. Right and left heart catheterisation

In the patient above, which of the following observation is likely to be true?

a. Absent contrast reflux into the hepatic vein on CTPA
b. Pulsus paradoxus of 30 mmHg on clinical examination
c. Paradoxical septal motion on transthoracic echocardiography
d. Myocardial speckling on CMR
e. Pulmonary capillary wedge pressure of 15mmHg on cardiac catheter


Here are the answers to the questions


Question 1 - d
Question 2 - b


Explanation


In the clinical scenario, the leg oedema, elevated JVP and ascites indicate high right ventricular pressures. Mild jaundice could be secondary to hepatic congestion and the bibasal dullness is likely due to pleural effusions. The rapid x-descent on JVP raises the suspicion of pericardial effusion, which is likely in this patient with renal failure. Hence option D is the investigation of choice.


Gadolinium contrast should be used with caution for cardiac MRI in the presence of significant renal impairment, so is not indicated in this patient. The clinical history makes acute pulmonary embolism unlikely, and hence CTPA and V/Q scan are not indicated. Right and left heart catheterisation is indicated in the absence of pericardial effusion, and aid in the diagnosis of restrictive cardiomyopathy of constrictive pericarditis.


 Reflux of contrast into the hepatic vein on CTPA is indicative of tricusid regurgitation and high RV pressure. A pulsus paradoxus of 30 mmHg indicates cardiac tamponade which is likely in this patient with hypotension, tachycardia and clinical features of severe pericardial effusion. Paradoxical septal motion on transthoracic echo is indicative of pulmonary hypertension (which could be secondary to other causes). Myocardial speckling on CMR is seen in amyloidosis. 


A PCWP of 15mmHg on cardiac catheter indicates minimally elevated left atrial pressure, which is unlikely to be the case in this patient. Therefore the answer to the second question is B.


Note : In patients with pulmonary hypertension and cardiac tamponade, the classic echo features of right atrial and right ventricular collapse may be delayed. 


Our sincere thanks to Dr Ramachandra, senior registrar in interventional cardiology for his input.


New questions coming soon!!!

A question from our website

Q. The normal resting membrane potential of ventricular myocardium is

a. 85 to 90 mV
b. -85 to -90 mV
c. 70 to 80 mV
d. -70 to -80 mV
e. -30 to -40 mV





A. b. -85 to -90 mV

The resting membrane potential is corresponds to stage 4 of cardiac myocyte contraction. It is primarily due K+ channels. The resting membrane potential corresponds to diastole in cardiac contraction, and the normal potential is between -85 to -90 mV. When the myocyte is stimulated during the resting membrane potential, it results in influx of Na+ ions and the start of contraction.

As is seen in the above image, the cardiac action potential consists of 5 stage, beginning with phase 4 all the way back to phase 4.

Phase 4 - corresponds to resting membrane potential. K+ channels are open, and an electrolyte balance is achieved to maintain the potential between -85 to -95 mV

Phase 0 - This corresponds to the start of the action potential, and is due to rapid influx of Na+ ions and a rise in membrane potential. In essence, this is the depolarisation phase.

Phase 1 - The Na+ channels close, and the membrane potential reaches a plateau.

Phase 2 - The L-type Ca2+ channels open and calcium influx occurs. Outward movement of K+ starts in this phase.

Phase 3 - The Ca2+ channels close, and K+ efflux continues. This is the relaxation / repolarisation phase of the myocyte action potential.


For more questions like these, including various aspects of Cardiology for the MRCP part 1 exam, go to www.cardio4mrcp.com or click here.

Rivoroxaban

Good knowledge of drug pharmacology forms the basis of good clinical practice. While discussing each and every drug there is out there is out of the scope of this blog, today we shall talk briefly about Rivoroxaban.


Rivoroxaban

• Direct anti-Xa inhibitor
• Administered orally and has good bioavailability
• Unlike warfarin, it does NOT require regular monitoring, and the dose remains the same to achieve adequate anti-coagulation
• It is currently approved for use in Atrial fibrillation (ROCKET-AF)
• It is also useful in prevention of venous thromboembolism

From an MRCP point of view, clinical pharmacology forms a reasonable proportion of the exam. Make sure you get a good book with questions, rather than read a textbook. There are not many out there, here are a few:

There are more books available, but they all remain rather ancient, with no recent editions in the last 5 years.  The books listed about are cheap and affordable. Definitely spend a lot of time with clinical pharmacology. It is as important as basic sciences (see our basic sciences post), so find a study partner, and study hard! Its well worth studying pharmacology this way rather than reading a huge textbook with a lot of unnecessary information - well, from an exam point of view.

All the best! Next exam 11th September (kind of a jinxed date, isn't it!)

PACES review on your computer??

While scouring for good information and books on Amazon, I came across a Kindle version of the PACES book we featured in this blog. Well, it more of 'an aid' to the existing books, but sometimes that's just what you need for last minute revision. Did you know you can access Kindle books on your computer, though its great own a Kindle and revise on the go! Here it is my friends -

Carrying heavy books around can be frustrating. This book on your Kindle or on your computer is brilliant to revise when travelling about. I am assuming that you all possess a Kindle - if you don't have it, get one! Its great - why do you think it remains the number one seller on Amazon!! :-)




Best wishes y'all!

Sales pitch!

Hey! Why not subscribe to over 300 questions in Cardiology for the MRCP part 1 exam! We are currently offering 3 months access for the price of 2 - £4 only!

Visit www.cardio4mrcp.com and subscribe today! Also, do follow this blog for new questions by experienced cardiology registrars!


There ended the sales pitch! Sorry, had to be done.... :-)


Regards


Vik

Book review - MRCP part 1 Basic sciences

OK, for those of you preparing for the part 1 exam, here is a valuable tip. Basic sciences - spend a lot of time with that. Not just a few days, not a weekend, but at least a good fortnight of solid reading. I say this as it carries the highest number of marks in the part 1 exam, and believe me when I tell you can score full in that section as its all about remembering facts.

 Now, you can go out there, dig out all your old books from medical school days and start from page one. What we suggest is to read 'Basic sciences for the MRCP part 1' by Phillipa Easterbrook. This book is brilliant. It covers all the basic science that is relevant to the exam, starting from anatomy to biochemistry and physiology. Also covered is immunology, a subject that a lot of medical students find extremely hard to understand and remember. Of course, bear in mind this is not a textbook, it's more of a 'fact book'. It's brief, concise and precise. It's an easy read too, but we would recommend group study when it comes to basic science as its a good idea to quiz each other when preparing for the exam. You will find it to be to the point, covering just those topics that are important from an exam point of view. Easterbrook also has a 'Best of five' book as well, which is a valuable accompaniment to the original book.

Everyone uses it, so we recommend you get yourself a copy from the bookstore or online. We have included the links on Amazon where you can buy it from - ensure you have the latest edition and not a hand me down from a senior who did the exam donkeys years ago! Score full in basic sciences, and it is highly likely you will pass the exam. A lot of us ignored this advice from our seniors, and have failed the exam miserably, or just by that one dreaded mark! So go get this book! - if you don't believe us, go check out the user reviews on Amazon, they speaks for themselves!

We hope you enjoy these books - we are confident you will find them useful.

Happy reading!

Clinical scenario - as promised!

Today's question is courtesy of Dr Ramachandra, senior SpR Cardiology, Leeds.

A 60 year old Asian man with a history of type 2 diabetes on insulin and hypertension presents with deteriorating renal function and is referred by his GP to the renal clinic. In the renal clinic, he is found to have leg oedema, elevated JVP with rapid x-descent, ascites, mild jaundice and bi-basal dullness. Chest X-ray shows cardiomegaly. ECG shows left ventricular hypertrophy with strain.  Resting heart rate was 100 bpm and BP of 90/70. The definitive cardiac diagnosis can be obtained by -

a. Cardiac MRI
b. CT pulmonary angiography
c. Ventilation-perfusion scan
d. Transthoracic echocardiography
e. Right and left heart catheterisation

In the patient above, which of the following observation is likely to be true?

a. Absent contrast reflux into the hepatic vein on CTPA
b. Pulsus paradoxus of 30 mmHg on clinical examination
c. Paradoxical septal motion on transthoracic echocardiography
d. Myocardial speckling on CMR
e. Pulmonary capillary wedge pressure of 15mmHg on cardiac catheter

Put your thinking caps on! Answer in a week!

Cardio4mrcp team.

Launch of Echo4exams - visit now!

Hey there readers!

We are pleased to announce the launch of our site Echo4exams, the online site for questions for basic echocardiography exams. The questions are in true/false format, and cover everything from ultrasound physics to complex congenital heart disease and valvular heart disease. Included is a *FREE* quick revision document which you can download (as pdf) which contains a snippet of the content on the site. We have had a large number of people already register, so check it out at

www.echo4exams.co.uk

Try our question of the day as well on the site! Look forward to seeing you there!

Warm wishes

E-Medilearn.org Limited

Answer to clinical scenario 27.03.2012

Hey everyone,

You may remember the clinical scenario that was posted on the 27th of last month. Well, for those of you who were wondering what the actor was asked to do - if the candidate apologised for the accident with the lignocaine and stated that it was contraindicated in her father, the actor would stand up and shout 'you killed my father' and leave the room! Imagine that.

The correct way to handle that situation is to explain the situation in its totality, and explain that at the local anaesthetic concentration, lignocaine pretty much has no effect on the heart, so would play no role in contributing toward the patient's death. Of course, you would also get a senior to discuss the situation with you and the family together.

MRCP clinical scenarios only appear scary on paper. They are no more than regular scenarios encountered in clinical practice. Keep a cool head, and they are all a walk in the park.

More scenarios soon!

Cardio4mrcp team.

Book Review - Anatomy!

Hello readers, hope all of you are well. Sorry it has been a while since my last post, but not only have I been travelling a bit but have been attending numerous meetings - been hectic! Its good to be back and see that the blog has had over 1000 views so far!! Thank you to all who have visited the blog.

Later today, I will be posting a clinical scenario for you all to discuss - something that is relevant to the MRCP exam. But for now, I will be quickly reviewing a book that got me (and many others) started in medical college. I do this as it brings back great memories - one of excitement of starting medical school, confusion as to what the difference between a tendon and aponeurosis is, and of course the beginning of a long career of healing.

So yes, the book I am referring to in the title is not Greys anatomy, but what we considered to be our Greys anatomy text book - 'Human anatomy' by BD Chaurasia. Best thing about the book - the simple, reproducible diagrams. Of course, anatomy is tedious and difficult, and memorising what nerve goes through what canal under what bone and over what muscle is hard, but the simple figure in this textbook just make memorising such facts easy. And as a first year medical student at the tender age of 16, I don't think I could have handled a huge textbook with complicated 3D figures - don't you agree?!!

I submit this post is probably not relevant to my readers as most of you are way past medical school and probably practising in you area of expertise, but a trip down memory lane never hurt anyone! Feels kinda nice :-)

Well, I am sure that myself and my 300 classmates, and everyone from most universities who have used this book would recommend it - we pretty much considered it the 'bible' of human anatomy. You can purchase your copy from Amazon, and I have attached a link below that should avoid the hassle of searching for the book and take you directly to the page -

It is definitely worth it, especially if you are preparing for entrance exams - the diagrams (though may appear redundant) are packed with information and are great to memorise facts. A lot of them I still remember, 12 years post graduation!

Clinical scenario coming up next!

Warm wishes

Vik.

Back after easter!

Sorry folks, away at the moment, hope you are all enjoying your Easter holidays! See you all soon! Later...

Ticagrelor

Those of you who are keeping up to date will have no doubt heard about Ticagrelor, a new antiplatelet drug. Below are key points regarding this revolutionary drug

Mechanism of action - Reversible platelet ADP receptor blocker (P2Y12)

Unlike Clopidogrel, it is not a thienopyridine drug.

Advantages over Clopidogrel include a more rapid onset of action and its platelet inhibition is more pronounced.  Bleeding risks are not different from Clopidogrel either.

From the MRCP point of view

1. Its a reversible P2Y12 inhibitor
2. More rapid onset of action compared with clopidogrel
3. More potent platelet inhibition.

There are recent studies looking at the role of Ticagrelor in ACS. The NEJM published the PLATO study that compared Ticagrelor and Clopidogrel in patients with ACS. The primary end points were significantly reduced. Interestingly, dyspnoea was a side effect seen more often with Ticagrelor.

It is a good idea to know what this study involved. Read the study here.

Pharmacology is a big part of the MRCP part 1 exam. Read a good book and thou shalt pass! Here are a few

Enjoy!

Our facebook page!

Hi! Check out our facebook page and 'like' us!

www.facebook.com/cardio4mrcp

Vik.

Case 1 - How will you handle this?

You are called to casualty to see an 81 year old man who has a background history of ischemic heart disease and hypertension. He is admitted with acute shortness of breath and is in atrial fibrillation with a ventricular rate of 162 bpm. His blood pressure is only 80/60 mmHg. He is in heart failure. He is being given oxygen, but the staff are having a lot of difficulty obtaining peripheral access. You insert a central line in, flush it to ensure it's patency, and give him some frusemide to help shift the fluid. Unfortunately a short while later, he arrests, and despite the best resuscitation efforts, he dies. While cleaning up the area, the staff mentions to you that the patient's daughter is in the waiting area and has no idea what is going on. While preparing yourself to go and speak to her, you notice that you injected lignocaine (used to anaesthetise the skin) into central line while flushing it instead of saline. Knowing fully what the effects of intravenous lignocaine can be in such a situation, you have to now speak to the daughter, who is anxious to know what is going on, as she is his main carer.

How will you go about handling this scenario? Submit your answers in the comments box and I will tell you what the daughter was instructed to do!

By the way, this was an actual scenario that I wrote for the exams. Good luck!

Vik

Passing the PACES

Right, once you have passed the written exam, then comes the toughest part of the MRCP - (drumroll!) the PACES. 5 stations, tough clinical cases and some moody examiners! But go in with the right preparation, and you will absolutely wing it! Its really not that hard; just think of it as a ward round  or an on-call shift where you are asked to see complicated and sick patients. Beware however, sometimes you could get a normal case, like I did in my exam 6 years ago. I remember it well - abdominal station, normal abdomen but she was pseudocushingoid. Don't know how, but I got it! Phew!

Well, actually I do know how. Like many of us who passed, we had the right tutors and the right books to prepare. While you may get some old books handed down by registrars to you, just remember that newer editions and new books that emerge have new cases and sometimes provide you with valuable tips on picking up ceratin things. Of course, the whole inspection-palpation-percussion-auscultation rule always applies, but its the little things that these books will help you with.

I have listed a few books below that will no doubt be useful. Once you have these, ensure you have a study partner who will critique you every time you examine a patient. I tell you, it helps.

I have organised the MRCP PACES exam in the past, and I have seen first hand what the examiners can mark you down on, and what you can score full on. Remember the steps in examination and be cool and calm. No patient wants to see a nervous doctor!!

Books to read :

I would strongly recommend these.  Study well and you can score full marks. In my next post, I will be placing a tough clinical scenario that was in the MRCP communication station a few years ago. I look forward to hearing how you will handle it!

Happy reading!

Vik

Visit our website!

Hi there! If you are looking for high quality questions to help you with the cardiology section of the MRCP part 1 exam, you have come to the right place!! With over 300 questions of varying difficulty, our course is guaranteed to provide you with an excellent overview of Cardiology, that is not only useful for the part 1 exam, but as a great revision course for any other exam and for doctors in training. Included in the course is a mock exam that is based on recent evidence and includes some tough questions written by experienced Cardiology registrars.

So why not visit our site at www.cardio4mrcp.com today! Register for free and give the free trial questions a shot. 2 months access to the site is only £4!

All the very best, and we look forward to seeing you at www.cardio4mrcp.com!

Warm wishes

Vik
Director, E-Medilearn.org Limited

Mnemonic #1

Mnemonics are invaluable in remembering features and facts about different conditions in Cardiology. From time to time, I will post some mnemonics I have found on the internet on this blog. I hope you find them useful. I will try and keep them 'clean', but you all know that mnemonics that we all tend to remember are the 'inappropriate' ones :-) ! We kick off this thread with

Causes of Atrial Fibrillation (ARITHMATIC)

• Alcohol
• Rheumatic fever
• Idiopathic
• Thyrotoxicosis
• Hypertension
• Mitral stenosis / Myxoma
• Atrial septal defect
• Toxins
• Ischemic heart disease
• Cardiomyopathy (commonly dilated)

I got this online from here

Vik

Director E-Medilearn.org Limited

Website - www.cardio4mrcp.com

Cardiac anatomy

While preparing for the MRCP, it is important to spend ample time on basic sciences. These carry tremendous weight in the exam, and if you prepare well, you can score full marks! I know people who have done that, and it is the reason why they did not fail the exam by that ever so annoying '1 mark'!

Cardiac anatomy is simple, 4 chambers, 4 valves, 2 great arteries, 3 great veins. Simple. Pericardium lines the heart, and contains 30 ml or so of fluid to aid cardiac movement. Remember the valves, the muscles, chambers and finally all those elusive sinuses.

Make sure you give the right amount of importance to these subjects. Candidates tend to concentrate on all the specific subjects, but basic sciences is where you can nail it.

There are some great courses you can purchase online to revise. Try reading the textbooks that you did a while ago to revise, or subscribe to a course like this online - Click Here!

As always, all the very best!

Cardio4mrcp team

Website: www.cardio4mrcp.com

Book review 1 - Nick Fisher 'Frontline Cardiology'

Sometimes it is important to have a good guide that tells you 'what to do next'. I was digging out some books I had accumulated over the years, and found one by Nicholas Fisher titled 'Frontline cardiology'. I cannot believe I stashed this one away! Absolutely brilliant! Its clear, concise and precise, and most certainly answers that aforementioned all important question. As the book description itself states - 'Its no-nonsense advice..' - I agree. It has some great tables, simple line diagrams and emphasises basic facts that are important in daily practice and impressing your boss on a ward round :-). While I am all for reading big textbooks with memorising complicated diagrams as well, reading a book like Nick Fisher's is just as great. I am a huge fan of line diagrams / clear hand drawn diagrams, as they not only help remember facts but also can be used to explain facts to patients and family. Totally invaluable.

I would strongly recommend this book to anyone who is at junior doctor level all the way to junior fellow or specialist registrar level. Its not only me who would recommend this, a ton of my friends who have used it have found it useful too! Most of all, its costs close to nothing!

Click here to purchase it - 

Vik
Director E-Medilearn.org Ltd

Wilsons disease

So yes, I know, nothing to do with Cardiology. But I had to post this - This weeks New England Journal has a great image of KF rings seen in Wilson's disease. Check it out here!

Vik.

Computer skills and the physician

These days a lot of application forms for registrar jobs (or even junior doctor ones for that matter) ask whether the candidate has any experience in IT or has completed a course in Microsoft word. While a lot of us have actually just learnt how to use these tools from others, obtaining a certificate of some sort can add to your portfolio, and increase the number of 'points' you receive when you apply. A Google search will help, but there are some good courses online which are reasonably priced and look good. In addition, they provide certification which is definitely of benefit. While I have not personally done these courses, I have had a look through them and what they offer and they do look good.

A few are

1. European Computer driving licence - Click here!
2. Training centre - Click Here!
3. Excel training - Click Here! - cheap course, no certification, have not used it so can't comment.
4. Excel training - Click Here! - this is from a Microsoft excel certified trainer.

Take a look and see what you think. If you find anything interesting other than the others listed above, do leave a comment!

Intramural hematoma

Recently the concept of acute aortic syndromes has encompassed a range of pathological changes in the wall of the aorta leading to a myriad of clinical presentations, all of which are not only worrying to the patient, but can be a doctor's nightmare! One particular type of acute aortic syndrome (which you may remember includes aortic dissection) is IMH - Intramural Hematoma.

Intramural hematomas are preceded by atherosclerotic plaques. In fact, over time, atherosclerotic plaques in the proximal aorta can develop penetrating ulcers. These eventually invade the vasa vasorum lining the tunica media, and result in bleeding. The blood accumulates in the wall of the aorta in a characteristic crescentic shape. It is important to keep in mind that IMH does not involve the tunica intima, which is the site of involvement in aortic dissection. In other words, there is no intimal flap.

Common symptoms include chest pain and interscapular pain. Neurological and vascular complications may occur, but are rare.

Over time, IMH may lead to aortic dissection. Diagnosis can be made by echocardiography, though CT would provide more information. MRI is also useful.

Surgical treatment is required. IMH carries a high mortality so requires prompt treatment.

Key points for MRCP regarding IMH

1. No intimal flap
2. Can progress to aortic dissection
3. CT is a good test, MRI is useful as well.
4. Prompt surgical treatment is required.

Here is a good review.

Put away that can of coke!

Oh dear!!... a piece of advice..when preparing for the MRCP, try not to consume sugary soft drinks. I remember drinking a can a day as a student to stay awake - the high caffeine content helps! However, a recent study conducted has shown that drinking a can of sugary pop a day increases your risk for coronary heart disease by 20%, even after correcting for other risk factors!! It obviously has to do with its sugar content, and interestingly drinks with artificial sweeteners does not seem to have that effect, though it is associated with higher risk of weight gain and metabolic diseases.

Also of note, sugary pop can also increase triglyceride levels and levels of inflammatory markers, which are directly related to development of cardiovascular disease. There are a number of studies that have shown inflammation to play a key role in development of atherosclerosis and endothelial dysfunction.

So what to do? Just cut down on intake :-) . Easy peasy!

Read the article here.

Vik
Director, E-Medilearn.org Limited

Peripartum cardiomyopathy

There is an excellent article in the Cleveland Clinic Journal of Medicine on peripartum cardiomyopathy, and it is definitely worth knowing a bit about this. Though not commonly asked (probably because the condition is rare), you never know!!...

Key points

• Occurs in last trimester or up to 5 months after delivery (ESC definition)
• Can be due to myocarditis, inflammation, viral infections (parvovirus B19, HHV-6)
• Risk factors
• Advanced maternal age
• Multiparity
• Gestational hypertension / pre-ecclampsia
• Symptoms are that of heart failure

Diagnostic criteria

• Heart failure in the last trimester or within 5 months of delivery, without other causes of heart failure identified and no previous heart disease
• Reduced ejection fraction < 45%

Diagnosis

• Echocardiogram
• Cardiac MRI

Treatment

• AVOID ACE inhibitors and ARBs during pregnancy. They can be used in post partum period
• Digoxin
• Spironolactone
• Beta blockers.

That's just a brief overview. For the purposes of the MRCP , remember the diagnostic criteria, and the drugs to avoid.

Read the full article here. Enjoy doctors!

Pulmonary stenosis

Just a few points regarding causes of pulmonary stenosis. Firstly, remember that it is a rare condition.

1. Congenital pulmonic stenosis is the commonest type of PS.
2. Amongst the acquired causes, carcinoid syndrome is the commonest cause
3. Though rheumatic fever causes valve stenosis, it rarely afects the pulmonary valve.
4. As a part of eponymous syndrome - Noonans syndrome, Tetralogy of Fallot and Williams syndrome.

Short, and simple. As Sean Connery said in 'The Untouchables' - 'There ended the lesson'.

Read the New England Journal, Heart and Circulation

Hi all

'Medicine is an ever changing science...' - how many times have you seen this in prefaces of textbooks? Why? Because its true. Evidence is constantly changing as are management guidance, and its in the doctors best interest to keep abreast with new developments.

For the purposes of the MRCP, I would strongly recommend reading cases from the New England Journal of Medicine, and subscribing to their weekly updates. In addition to publishing interesting cases, they also publish clinical reviews which could be incredibly useful for the MRCP. The heart journal (education in Heart) is brilliant, as is Circulation.

Of course there are a ton of journals you can read, but these are great! Guidance is always changing, so its good to know what's new and what's not.

Best wishes

Vik
Director, E-Medilearn.org Limited.

Patent Foramen Ovale

A commonly asked question in the exam, a PFO is associated with a number of clinical conditions and may require closure. A review published in the British Journal of Cardiology provides a good overview of this, and can be found here.

The indications for closure of a PFO include the following:

1. Paradoxical embolisation - This is where a thrombus migrates from the right heart to the left, and then can lead to a stroke (cryptogenic stroke). Closure of the PFO is indicated, and patient may require warfarin.

2. Decompression sickness - Neurological symptoms in decompression sickness has been associated with PFO, and closure is indicated

3. Migraine with aura - There is no strongly established relationship between PFO and migraine with aura, as some studies have disproved this link. The exact etiology is unclear, and has been attributed to serotonin that bypasses metabolism due to the right to left shunt.

4. Platypnoea Orthodeoxia Syndrome (POS) - A rare condition characterised by breathlessness in upright position, relieved when supine. It is seen in patients with liver cirrhosis, aortic aneurysm and following a pneumonectomy. This condition has been associated with a PFO, and closure has shown to be of benefit.

For the MRCP exam

1. The relation between migraine and PFO must be remembered for the purpose of the exam. There may be a question on this. Keep in mind however the weak association.

ACE inhibitors, ARBs and angioedema

You may remember, while doing the course that there is a question on angioedema secondary to angiotensin converting enzyme inhibitors. Well, the New England journal has an amazing picture published along with an interesting case history, which you can access here.

Angioedema due to ACE inhibitors is due to selective increase in bradykinin levels, which results in vasodilatation and subsequent edema. Upper respiratory tract involvement can result in breathlessness. Treatment is with anti-histamines and steroids.

It has been noted that patients who develop angioedema secondary to ACE inhibitors can also develop the same with angiotensin receptor blockers, though the mechanism is not clear.

For the purposes of the MRCP

1. Remember that ACE inhibitors (ramipril, perindopril etc) can cause angioedema.
2. There is no way of predicting whether ACE inhibitors will cause angioedema, so do not withold prescribing unless there has been a previously documented incident.
3. Patients who have had angioedema secondary to ACE inhibitors can have the same reaction to angiotensin receptor blockers, so be cautious.

For further information, this article should help.

Tricuspid regurgitation and JVP - Large 'CV' waves

The New England Journal of Medicine has a great image of the giant 'CV' wave seen in tricuspid regurgitation, which they published in January 2012. Included with the image is a short video. It is absolutely brilliant, and we would strongly recommend reading the case and watching the video. Included with the video of the JVP is the echocardiogram showing severe TR with a dilated RA. The view is foreshortened a bit to demonstrate the right heart clearly. It is seen that the tricuspid valve leaflets fail to coapt, resulting in the severe TR. In addition, though not clearly evident, there is mitral stenosis, likely rheumatic in origin.

Rheumatic heart disease is the primary cause for mitral stenosis. Though uncommon in the western world, it is highly prevalent in India and in other South Asian countries. You may notice this patient is probably from South Asia, given the colour of his skin. Then of course, the authors are doctors from India as well!

Do try to read this article. It is free to access for non-subscribers as well.

For the MRCP exam

Remember everything about the JVP. It is very likely there will be a question regarding it - be it normal waves or abnormal appearances. 

Click here to access the article.

Cardiac biomarkers, stroke and atrial fibrillation

Just quickly read through an abstract in Circulation (28th Feb 2012) published by Ziad et al, who performed a substudy analysis of the Randomised Evaluation of Long Term Anticoagulation Therapy (RE-LY) trial. While the original trial looked at Dabigatran Etixilate Vs Warfarin in management of patients with atrial fibrillation, the substudy published by Ziad's group analysed the prevalence of cardiac biomarkers Troponin I and NT-proBNP and their association with major cardiovascular events in atrial fibrillation.

After adjusting for other cardiovascular risk factors (as guided by the CHAD2 and CHA2DS2-VASc scoring system), they analysed biomarkers in 6189 patients. Patients with a higher troponin I level and NT-proBNP levels were at a higher risk of developing stroke when compared to those patients who had lower levels of these markers. A high troponin was defined as values >= 0.04microg/L and high NT-proBNP levels were defined as values >1402 ng/L. Vascular mortality rates showed a similar association. These results have shown that elevated troponin and NT-proBNP seen commonly in patients with atrial fibrillation are independently related to high risk of stroke and mortality. These would thus be useful for risk prediction.

So the question is - will these markers be eventually added to the risk scoring system to risk stratify patients and decide on anticoagulation treatment? Probably yes, but it appears a lot more research needs conducting.


Key messages for MRCP exam -

1. Remember the CHA2DS2-VASc score. In the choices if you see a high troponin level or elevated NT-proBNP level, these too are predictors of risk and should be considered based on this RE-LY substudy.
2. There is always a question or two regarding atrial fibrillation and anticoagulation - be it management of anticoagulation or management of bleeding secondary to anticoagulation. Know this well.

You can access the study at the following link - Ziad et al

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Hi there! Thanks for subscribing to cardio4mrcp, your guide to cardiology questions for the MRCP exam. For those of you who have come across this blog while generally browsing the internet, this blog is linked to our exam site www.cardio4mrcp.com. We host around 300 questions for the part 1 MRCP exam, and intend to expand it further in the future. Feel free to snoop around!

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Vik
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