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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