Adult Cardiology
Adult cardiology on the OMSB exam tests pattern recognition under time pressure: acute coronary syndromes, heart failure, arrhythmias, valvular disease and hypertension.
Ischaemic syndromes
- STEMI: reperfuse immediately - primary PCI with door-to-balloon ≤90 min, or ≤120 min if the patient must be transferred. Fibrinolysis is reserved for when PCI cannot be delivered within 120 min of first medical contact, symptoms are <12 h old and there is no contraindication.
- Dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor) with a parenteral anticoagulant.
- NSTEMI/unstable angina: risk-stratify with GRACE; fibrinolysis is contraindicated.
Heart failure
- HFrEF: quadruple therapy - ARNI or ACE inhibitor, an evidence-based beta-blocker (bisoprolol, carvedilol, metoprolol succinate), a mineralocorticoid receptor antagonist and an SGLT2 inhibitor. Loop diuretics relieve congestion but do not improve survival.
Arrhythmia and valves
- Atrial fibrillation: anticoagulate according to CHA2DS2-VASc; rate control with a beta-blocker or a non-dihydropyridine calcium channel blocker.
- Severe symptomatic aortic stenosis is an indication for valve replacement.
Worked example
A 62-year-old man has 3 hours of crushing chest pain. The ECG shows ST elevation in V1–V4 with reciprocal depression in II, III and aVF. This is an anterior STEMI, localising to the left anterior descending artery. Activate the catheterisation laboratory, give chewed aspirin 300 mg, a P2Y12 inhibitor and heparin, and give oxygen only if saturation is below 90%. Nitrates are withheld because of the risk of right ventricular involvement and hypotension.
Traps
Diffuse ST elevation with PR depression suggests pericarditis, not STEMI. Fibrinolysis in NSTEMI is a classic error. Beta-blockers harm patients in decompensated heart failure or cardiogenic shock. Forgetting the SGLT2 inhibitor heart-failure indication loses marks.