Cardiology
Cardiology in the IMM tests ECG literacy, rapid ACS decisions, heart-failure physiology, arrhythmia safety, and long-term risk reduction. The exam rewards a clear first-five-minutes plan and avoids esoteric subspecialty detail unless it changes immediate management.
Core rules
- ACS: 12-lead ECG within 10 minutes; high-sensitivity troponin; aspirin 300 mg chewed, P2Y12 inhibitor, anticoagulation; STEMI → primary PCI within 120 minutes of first medical contact; fibrinolysis if PCI is unavailable within 120 minutes and there is no contraindication.
- Acute heart failure: classify by congestion (wet/dry) and perfusion (warm/cold); IV loop diuretic for congestion, oxygen or NIV for pulmonary edema, inotropes/vasopressors for cardiogenic shock; stop NSAIDs.
- Atrial fibrillation: anticoagulate by CHA2DS2-VA (or VASc); DOAC preferred; rate control first with beta-blocker or non-dihydropyridine calcium-channel blocker; unstable → synchronized cardioversion.
- Wide-complex tachycardia: assume VT until proven otherwise; avoid verapamil; use amiodarone or procainamide if stable, defibrillate if pulseless.
- Hypertension: confirm with home or ambulatory readings; target <130/80 for most; combination ACE inhibitor/ARB plus CCB or thiazide.
Worked example
A 58-year-old man has crushing chest pain, ST elevation in II, III, aVF with reciprocal depression in I and aVL, BP 90/60, and clear lungs. This is an inferior STEMI: activate the cath lab, give aspirin, a P2Y12 inhibitor and anticoagulation. Check right-sided leads because RV infarction can cause hypotension; avoid nitrates if RV involvement is present, and give cautious fluids. Do not wait for troponin results before reperfusion.
Traps
- Missing posterior MI: ST depression in V1–V3 rather than elevation.
- Giving AV-nodal blockers in pre-excited AF.
- Nitrates in RV infarct or recent sildenafil use.
- NSAIDs in heart failure.
- Calling wide-complex tachycardia SVT with aberrancy and giving verapamil.