Cardiology: Ischaemic Heart Disease, Heart Failure and Arrhythmias
Core concepts
Candidates must master ischaemic heart disease (stable angina, unstable angina, NSTEMI, STEMI), heart failure with reduced or preserved ejection fraction, atrial fibrillation and other arrhythmias, valvular disease, pericardial disease, hypertension and syncope. Know ECG patterns, troponin kinetics and the immediate management of acute coronary syndromes. Heart failure teaching centres on congestion versus hypoperfusion, ACE inhibitors or ARNI, beta-blockers, mineralocorticoid antagonists, SGLT2 inhibitors and diuretics. AF requires stroke-risk assessment with CHA2DS2-VASc and bleeding-risk review; anticoagulate unless contraindicated.
Traps
Atypical ACS is common in diabetes, women and older adults. A single early normal troponin does not exclude MI. Inferior STEMI can signal right ventricular infarction: hypotension, raised JVP and clear lungs mean nitrates may cause profound hypotension. Digoxin toxicity is worsened by hypokalaemia and renal impairment. Hyperkalaemia produces peaked T waves, widened QRS and sine-wave morphology. Do not label pericardial chest pain as ACS without considering position, pleurisy and diffuse ST elevation with PR depression.
Worked example / rule of thumb
A 60-year-old with 2 hours of crushing chest pain has ST elevation in II, III and aVF, BP 80/50, raised JVP and clear lungs. Treat as inferior STEMI with possible RV involvement: activate reperfusion, give aspirin, a P2Y12 inhibitor and anticoagulation; avoid nitrates; give cautious fluid boluses. Rule: hypotension plus raised JVP plus clear lungs in inferior STEMI suggests RV infarction, not left heart failure.