AKT – Cardiovascular

Greg Thompson, aged 58, presents with increasing exertional dyspnoea and fatigue over the past six months. He reports occasional chest tightness when climbing stairs but denies palpitations or syncope. He has a history of hypertension and hyperlipidaemia, and is a former smoker. He is on atorvastatin and perindopril.

On examination, his BP is 145/85 mmHg, HR 72 bpm. Cardiovascular exam reveals a slow-rising pulse, a sustained apex beat in the 6th intercostal space, and a harsh ejection systolic murmur loudest at the right upper sternal border radiating to the carotids. There is no ankle oedema.

What is the most appropriate next step in his management?

Susan Wallace, a 68-year-old woman, presents for a routine check. She has hypertension and type 2 diabetes, both well controlled. She mentions recent mild leg discomfort when walking uphill, which resolves with rest. She is otherwise well, does not smoke, and has a BMI of 31.

On examination, her femoral pulses are present but pedal pulses are diminished bilaterally. There are no ulcers or skin changes. Capillary refill is slightly prolonged in the toes. ABPI in both legs is 0.75.

What is the most appropriate next step in management?

Michael Thompson, aged 67, presents to your rural general practice clinic with worsening dyspnoea over the past 3 months. He reports needing to sleep with 3 pillows and occasional orthopnoea. He denies chest pain. He has a past history of hypertension and a myocardial infarction 5 years ago. He is compliant with medications including perindopril, bisoprolol, and atorvastatin.

BP 138/78 mmHg
HR 88 bpm, regular
JVP elevated
Bilateral ankle oedema
Heart sounds: S3 present
Lungs: Bibasal crackles

What is the most appropriate next step in the management of this patient?

Susan Blake, aged 58, presents with a sudden onset of palpitations while gardening. She denies chest pain or shortness of breath. Her past history includes type 2 diabetes and hypertension. She takes metformin and amlodipine.

BP 122/82 mmHg
HR 160 bpm, irregularly irregular
SaO2 98%

She is alert and oriented with no swelling of the ankles

An ECG is performed.

What is the most appropriate next step in management?

Isaac Doolan, a 52-year-old Aboriginal man from a remote community, presents with fatigue and decreased exercise tolerance over 6 months. He has a history of rheumatic fever as a child and no regular GP follow-up. No current medications.

BP 110/68 mmHg
HR 72 bpm, irregularly irregular
Mild ankle oedema
Heart sounds: Loud S1, mid-diastolic murmur at apex
No respiratory distress

What is the most likely diagnosis?

Angela Russo, aged 74, presents with sudden-onset severe chest pain radiating to her back. She describes it as tearing. She has a history of poorly controlled hypertension. Examination reveals unequal radial pulses and BP of 180/95 mmHg in the right arm and 145/90 in the left.

HR 102 bpm
No murmurs
Peripheral pulses reduced on the left
No neurological deficit

What is the most appropriate next investigation?

Jamie Lin, a 46-year-old man, presents with new-onset central chest tightness that occurs when he walks uphill and resolves with rest. He smokes 10 cigarettes per day and has a family history of early coronary artery disease. He has no previous cardiac history and takes no medications.

BP 132/82 mmHg
HR 78 bpm, regular
Physical examination normal
Resting ECG: Normal

What is the most appropriate next step in investigation?

Theresa Moore, aged 83, presents to your clinic with dizziness and two recent episodes of near-syncope. Her medications include ramipril and hydrochlorothiazide. She has no chest pain.

On examination, her pulse is 35 bpm and regular. BP 98/62 mmHg. No signs of heart failure.

What is the most appropriate management?

Ahmed Saleh, 39, presents with sudden-onset chest pain and shortness of breath while lifting weights. He is tall and thin with a history of Marfan syndrome. No past cardiac history.

BP 130/80 mmHg
HR 95 bpm
Auscultation: early diastolic murmur at left sternal edge
ECG: Normal
Chest X-ray (see image)

What is the most likely diagnosis?

Maria Zelenko, aged 76, is brought in by her daughter after a sudden collapse at home. She regained consciousness quickly. No seizure activity was witnessed.

Past history: hypertension and atrial fibrillation.

She takes digoxin and warfarin.

BP 102/64 mmHg
ECG: (see image)

What is the most likely cause of her collapse?

Jared Ngata, a 19-year-old Aboriginal man, presents for a routine check-up. He feels well. His mother had a myocardial infarction at age 42. His BMI is 31 kg/m², and he smokes. BP 136/88 mmHg. Lipids: TC 6.5 mmol/L, LDL 4.2 mmol/L, HDL 0.8 mmol/L.

No diabetes
Normal renal function
Non-fasting glucose: 5.6 mmol/L

What is the most appropriate next step in cardiovascular risk management?

Elizabeth Tan, aged 69, presents with increasing breathlessness and occasional palpitations. She had rheumatic fever as a child. Examination reveals a tapping apex beat, loud S1 and an opening snap followed by a diastolic murmur at the apex.

ECG shows atrial fibrillation
No peripheral oedema
No orthopnoea

What is the most likely diagnosis?

Barry Weston, aged 59, presents to your practice with a 2-week history of bilateral leg swelling. He denies chest pain or breathlessness. He recently started amlodipine for hypertension.

BP 140/86 mmHg
HR 74 bpm
Peripheral pitting oedema to mid-shin
JVP not elevated
Lungs clear

What is the most likely cause of his symptoms?

Lauren Pike, 32, presents with a 4-month history of episodes of pounding heartbeat, sweating and tremor. They last 20–30 minutes and are not related to exercise. She has no significant past history and takes no regular medications.

BP 160/102 mmHg
HR 104 bpm
No murmur
Normal ECG

What is the most appropriate next investigation?

Harry Donnelly, 81, presents with fatigue and worsening ankle swelling. He is known to have chronic heart failure. You review his medications and note he is on furosemide and enalapril, but has run out of spironolactone.

BP 118/74 mmHg
HR 88 bpm
JVP elevated
S3 present

Which medication class has the greatest proven mortality benefit in this patient group?

Rebecca Stokes, aged 42, presents with chest pain lasting a few hours, worse with deep breathing and relieved by sitting forward. She recently had a viral illness.

Temp: 37.8°C
Normal troponin
BP and HR stable

ECG (see image)

What is the most likely diagnosis?

Henry Black, aged 64, attends for follow-up after a routine check identified a systolic murmur. He is asymptomatic.

On examination, he has a slow-rising pulse, narrow pulse pressure and a harsh ejection systolic murmur loudest at the right upper sternal border, radiating to the carotids.

No signs of heart failure
Normal ECG and CXR

What is the most appropriate next investigation?

Imran Yusuf, aged 47, presents with palpitations, fatigue, and mild shortness of breath.

On examination, his pulse is irregularly irregular at 112 bpm. ECG confirms atrial fibrillation with no evidence of ischaemia.

He has hypertension and takes amlodipine. CHA2DS2-VASc score is 2.

What is the most appropriate initial management?

Nina Tran, 66, presents for a cardiovascular risk assessment. She has no symptoms.

BP 122/76 mmHg, non-smoker, total cholesterol 5.4 mmol/L, HDL 1.1 mmol/L.

Her father had an MI at age 58.

She has type 2 diabetes managed with metformin.

Fasting BGL 6.8 mmol/L
eGFR normal
No albuminuria

What is the most appropriate next step?

George Franklin, aged 70, presents with chest discomfort at rest and dyspnoea.

BP 90/60 mmHg
HR 104 bpm
Diaphoretic and pale

ECG (see image)

What is the most appropriate immediate management?

Jessica Nguyen, 27, presents with an episode of sudden palpitations while playing netball. It lasted 15 minutes and resolved spontaneously.

She has no medical history and is otherwise well.

ECG in clinic is normal.

HR 74 bpm
BP 120/70 mmHg
No murmurs or abnormal signs

What is the most appropriate initial investigation?

Tom Wallace, 82, presents with worsening shortness of breath and reduced exercise tolerance.

Past history includes heart failure with preserved ejection fraction (HFpEF) and chronic kidney disease.

He is on furosemide and bisoprolol.

BP 118/72 mmHg
HR 76 bpm
JVP elevated
Lungs: bibasal crackles

What is the most appropriate additional pharmacologic management?

Sarah Delaney, 58, presents with exertional chest tightness and mild breathlessness. She has a history of type 2 diabetes and is a current smoker.

Examination reveals a systolic murmur loudest at the second right intercostal space, radiating to the neck. The carotid upstroke is delayed.

BP 132/76 mmHg
HR 82 bpm
Normal ECG

What is the most appropriate next investigation?

Declan O’Rourke, 62, presents with sudden-onset left leg pain while walking.

The leg is pale and cold with absent dorsalis pedis and posterior tibial pulses. He takes no medications.

BP 140/85 mmHg
HR 110 bpm, irregularly irregular
No murmurs

What is the most likely cause of his symptoms?

Meera Sharma, aged 50, presents with fatigue and exertional dyspnoea.

On auscultation, she has a loud P2 and a systolic murmur at the left upper sternal edge.

ECG (see image)

Chest X-ray (see image)

What is the most likely diagnosis?

Arjun Singh, 36, presents after an episode of collapse while running. He had no prodrome.

Family history reveals sudden cardiac death in a brother at age 29.

The examination is normal.

ECG (see image)

What is the most likely diagnosis?

Jeanette Kauri, 73, presents with bilateral leg swelling and abdominal distension. She has a history of COPD.

On examination, she has raised JVP, hepatomegaly and peripheral oedema. No lung crepitations are heard.

BP 116/68 mmHg
HR 92 bpm
Heart sounds: normal
Lungs: clear

What is the most likely cause of her symptoms?

Callum Wright, 57, presents with progressive dyspnoea and ankle swelling. He has a history of myocardial infarction 2 years ago.

Medications: ramipril, bisoprolol, and atorvastatin.

On examination: displaced apex beat, S3 gallop, bilateral basal crackles, pitting oedema.

BP 110/72 mmHg
HR 92 bpm
ECG (see image)

What is the most likely diagnosis?

Alison Dunn, aged 80, presents with light-headedness and several falls.

Her medications include verapamil and simvastatin.

ECG shows sinus bradycardia at 42 bpm.
BP is 90/60 mmHg.

She is alert and oriented. No focal neurological signs.

What is the most appropriate next step?

Samira Noor, 45, presents with fatigue and mild exertional breathlessness.

Examination reveals a wide fixed split of the second heart sound and an ejection systolic murmur at the upper left sternal border.

ECG (see image)
Chest X-ray: Prominent pulmonary arteries

What is the most likely diagnosis?

Peter Sotiropoulos, 67, presents with exertional angina. He had a previous stent placed 3 years ago.

He takes aspirin, atorvastatin, and perindopril. Today, he asks about using GTN spray more frequently for chest discomfort.

BP 125/78 mmHg
HR 70 bpm
Normal physical exam

What additional medication should be considered to reduce anginal episodes?

Tracey Miller, aged 34, presents with acute pleuritic chest pain and mild dyspnoea. She recently returned from a long-haul flight.

Vitals: HR 108 bpm, RR 22, SpO2 95% RA, BP 126/76 mmHg.

No calf tenderness.

ECG: sinus tachycardia.

What is the most appropriate next step?

William Zhou, 54, presents for assessment after a recent episode of central chest pain lasting 15 minutes while mowing the lawn. It resolved spontaneously.

He has hypertension and hyperlipidaemia.

BP 130/82 mmHg
HR 84 bpm
ECG is normal.

What is the most appropriate next step in assessment?

Kylie Sands, aged 48, presents with dyspnoea and fatigue. She has a known history of systemic lupus erythematosus.

Exam shows elevated JVP and muffled heart sounds

BP 86/54 mmHg
HR 108 bpm
No lung crackles

ECG (see image)

What is the most likely diagnosis?

Amelia Greer, 61, presents for follow-up of newly diagnosed hypertension. She is asymptomatic.

Clinic BP readings over 3 visits range 148–156/90–94 mmHg.

She has no diabetes or CVD, and her 5-year absolute cardiovascular risk is 8%.

What is the most appropriate management?

Anthony Briggs, 72, presents with episodes of chest pain and shortness of breath while walking. He had a CABG 12 years ago.

ECG shows normal sinus rhythm.

He is on aspirin, atorvastatin, and metoprolol.

What is the most appropriate investigation at this stage?

Jacob Waite, aged 29, presents with palpitations and light-headedness. He has no chest pain or past cardiac history.

BP 112/70 mmHg
SpO2 98% RA
Alert and oriented

ECG (see image)

Vagal manoeuvres are unsuccessful.

What is the most appropriate next step?

Leanne O’Keefe, 64, presents with dizziness and palpitations. She is known to have persistent atrial fibrillation and is anticoagulated with apixaban.

ECG in clinic shows AF with a ventricular rate of 132 bpm. BP 110/70 mmHg. No signs of heart failure.

What is the most appropriate next step?

Mick Turner, 49, presents to your practice after a high blood pressure reading at a health check.

Repeated clinic readings are 170/104 mmHg.

He has no symptoms, no history of CVD, and takes no medications. No proteinuria or haematuria on dipstick.

What is the most appropriate next step?

Emily Davis, 8 years old, is brought in for fatigue and poor exercise tolerance. Her parents report that she often squats after running.

On exam: wide pulse pressure, bounding pulses, continuous murmur below the left clavicle.

What is the most likely diagnosis?

George Singh, 73, presents with progressive shortness of breath. He had a bioprosthetic aortic valve replacement 12 years ago.

On exam: ejection systolic murmur, reduced air entry at bases, mild pedal oedema.

BP 128/72 mmHg
HR 82 bpm
JVP mildly elevated

What is the most appropriate next investigation?

Olivia Chan, 26, presents with intermittent palpitations.

She is asymptomatic today and haemodynamically stable.

ECG (see image)

What is the most appropriate next step?

Thomas Liu, 58, presents with a 3-month history of dyspnoea on exertion. He has a history of chronic alcohol use and a 40-pack-year history of smoking.

Exam shows elevated JVP, displaced apex beat, S3 gallop, and bilateral basal crackles.

ECG: sinus rhythm with non-specific ST changes.

What is the most likely diagnosis?

Rachel Green, aged 37, presents with increasing fatigue. She has a history of systemic sclerosis.

Exam reveals raised JVP, loud P2, and peripheral oedema.

ECG (see image)

What is the most likely cardiovascular complication?

Mark Fong, 71, presents to your rural DEM with 30 minutes of central chest pain radiating to the jaw and nausea.

He takes no tablets or medicines and has no significant past medical history.

You are 2 hours from the nearest hospital with PCI facilities.

BP 124/80 mmHg
HR 88 bpm

ECG (see image)

What is the most appropriate immediate management?

Bianca Marino, 65, presents with ongoing breathlessness and fatigue. She had a myocardial infarction 8 months ago.

ECG: Q waves in leads II, III, aVF.

Echo shows EF 35% with hypokinesis of the inferior wall. She’s on aspirin, atorvastatin, and perindopril.

What is the next most appropriate medication to add?

Alex Hart, 45, presents with sudden severe tearing chest pain radiating to the back.

BP is 190/100 mmHg in the right arm and 160/92 in the left.

Exam: early diastolic murmur at left sternal edge.

ECG: normal.

What is the most appropriate initial investigation?

Lily Evans, 52, presents with a 6-month history of progressive breathlessness and orthopnoea. She has no chest pain.

Exam reveals a pansystolic murmur at the apex radiating to the axilla, bibasal crackles, and mild ankle oedema.

What is the most likely diagnosis?

Chris McEwan, 60, presents for cardiovascular risk assessment.

BP 138/84 mmHg, total cholesterol 5.8 mmol/L, HDL 1.0, non-smoker.

Fasting BGL 6.2 mmol/L. No known CVD.

His father died from an MI at age 52.

What is the most appropriate primary prevention strategy?

Angela Park, 25, presents with palpitations and anxiety. She drinks 5 coffees daily.

Exam: HR 106 bpm, BP 122/76 mmHg.

No murmurs, clear lungs.

ECG: sinus tachycardia.

What is the most appropriate management?

Jackson Tui, aged 70, presents with dyspnoea, orthopnoea, and fatigue.

He takes Sacubitril/valsartan, Bisoprolol, Epleranone and Empaliflozin.

He has a past history of MI.

ECG: Q waves in anterior leads. Echo: EF 30%, globally impaired LV function.

What is the next step in management?

Ashleigh Peters, 31, presents with sharp pleuritic chest pain and mild breathlessness. She has no cough.

She is on the combined oral contraceptive pill.

Exam: HR 106, RR 20, SpO2 96%.

D-dimer is elevated. Wells score is 4.5.

What is the most appropriate next step?