Cardiology
The cardiology block tests whether you can convert a presentation into a time-critical decision: read the ECG, choose the reperfusion strategy, and start guideline-directed therapy without delay.
Acute coronary syndromes
- STEMI: reperfusion if within 12 h of symptom onset. Primary PCI is preferred when it can be delivered within 120 min of first medical contact; otherwise fibrinolysis within 30 min of arrival, provided there is no contraindication (prior intracranial haemorrhage, ischaemic stroke within 6 months, aortic dissection, active bleeding, BP >180/110).
- NSTEMI/unstable angina: risk-stratify with GRACE; early invasive strategy (<24 h) for refractory ischaemia, instability, or high-risk features.
- Dual antiplatelet therapy plus parenteral anticoagulation; avoid NSAIDs.
Heart failure with reduced ejection fraction
Four pillars, started early and together: ARNI (or ACE inhibitor/ARB), an evidence-based beta-blocker (bisoprolol, carvedilol, metoprolol succinate), an MRA, and an SGLT2 inhibitor. Loop diuretics relieve congestion but do not change mortality. Assess for ICD/CRT after at least 3 months of optimised therapy.
Worked example
A 60-year-old man has 2 h of retrosternal pressure with 3 mm ST elevation in V2-V4, BP 150/90, no prior stroke. The catheter laboratory is 40 min away, so proceed to primary PCI. If the laboratory were 3 h away and there were no contraindication, give fibrinolysis within 30 min and transfer for angiography. Reasoning: myocardium is lost with time, and PCI wins whenever it can be delivered inside the 120-min window.
Traps that cost marks
- Labelling a wide-complex tachycardia as SVT with aberrancy and giving verapamil.
- Missing posterior infarction (ST depression V1-V3) or right ventricular involvement (nitrates are harmful; give fluids).
- Withdrawing beta-blockade in a decompensated patient instead of treating the congestion.