The patient is experiencing polymorphic ventricular tachycardia, which is likely caused by an electrolyte imbalance. As a first step, all medications that may prolong the QT interval should be discontinued. The priority is to correct any electrolyte abnormalities, particularly hypokalemia. Administer 2 g of magnesium sulfate intravenously over 10 minutes (equivalent to 8 mmol).

If the patient exhibits adverse symptoms such as shock, syncope, myocardial ischemia, or heart failure, immediate synchronized cardioversion should be arranged.

Managing Ventricular Tachycardia

Ventricular tachycardia is a type of rapid heartbeat that originates in the ventricles of the heart. In a peri-arrest situation, it is assumed to be ventricular in origin. If the patient shows adverse signs such as low blood pressure, chest pain, heart failure, or syncope, immediate cardioversion is necessary. However, in the absence of such signs, antiarrhythmic drugs may be used. Amiodarone is the preferred drug and should be administered through a central line. Lidocaine should be used with caution in severe left ventricular impairment, and verapamil should not be used in VT. If drug therapy fails, an electrophysiological study (EPS) or implantable cardioverter-defibrillator (ICD) may be needed, especially in patients with significantly impaired LV function. It is important to note that a broad complex tachycardia may result from a supraventricular rhythm with aberrant conduction, so proper diagnosis is crucial.

Secondary Causes of Hypertension

Hypertension, or high blood pressure, can be caused by various factors. While primary hypertension has no identifiable cause, secondary hypertension is caused by an underlying medical condition. The most common cause of secondary hypertension is primary hyperaldosteronism, which accounts for 5-10% of cases. Other causes include renal diseases such as glomerulonephritis, pyelonephritis, adult polycystic kidney disease, and renal artery stenosis. Endocrine disorders like phaeochromocytoma, Cushing’s syndrome, Liddle’s syndrome, congenital adrenal hyperplasia, and acromegaly can also result in increased blood pressure. Certain medications like steroids, monoamine oxidase inhibitors, the combined oral contraceptive pill, NSAIDs, and leflunomide can also cause hypertension. Pregnancy and coarctation of the aorta are other possible causes. Identifying and treating the underlying condition is crucial in managing secondary hypertension.

Abnormal Connection between Right and Left Sides of the Heart

The oxygen saturation in the right atrium (RA) and superior vena cava (SVC) should be equal, but there is a rise in oxygen saturation at the low RA level. This can only occur due to the addition of oxygenated blood to the deoxygenated blood in the right heart circulation, indicating an abnormal connection between the right and left sides of the heart. The location of the rise suggests a primum atrial septal defect (ASD), which affects the function of the anterior leaflet of the mitral valve, leading to mitral regurgitation. Primum ASDs are more likely to cause high right ventricular pressures.

In ostium primum ASDs, the atrioventricular (AV) node is displaced posteriorly and inferiorly, and atrial and/or AV nodal conduction is often delayed. This can cause prolongation of the PR interval, leading to first-degree heart block. The QRS pattern is typically an rSr’ or rsR’, resulting from dilation and hypertrophy of the right ventricular outflow tract due to volume overload of the right heart. Left axis deviation with Q waves in leads I and aVL is also observed. On the other hand, secundum ASDs cause right axis deviation and RBBB.

Overall, an abnormal connection between the right and left sides of the heart can lead to various complications, including mitral regurgitation, high right ventricular pressures, and delayed conduction through the AV node. The location and type of ASD can also affect the QRS pattern and axis deviation.

Angiotensin-converting enzyme (ACE) inhibitors are commonly used as the first-line treatment for hypertension and heart failure in younger patients. However, they may not be as effective in treating hypertensive Afro-Caribbean patients. ACE inhibitors are also used to treat diabetic nephropathy and prevent ischaemic heart disease. These drugs work by inhibiting the conversion of angiotensin I to angiotensin II and are metabolized in the liver.

While ACE inhibitors are generally well-tolerated, they can cause side effects such as cough, angioedema, hyperkalaemia, and first-dose hypotension. Patients with certain conditions, such as renovascular disease, aortic stenosis, or hereditary or idiopathic angioedema, should use ACE inhibitors with caution or avoid them altogether. Pregnant and breastfeeding women should also avoid these drugs.

Patients taking high-dose diuretics may be at increased risk of hypotension when using ACE inhibitors. Therefore, it is important to monitor urea and electrolyte levels before and after starting treatment, as well as any changes in creatinine and potassium levels. Acceptable changes include a 30% increase in serum creatinine from baseline and an increase in potassium up to 5.5 mmol/l. Patients with undiagnosed bilateral renal artery stenosis may experience significant renal impairment when using ACE inhibitors.

The current NICE guidelines recommend using a flow chart to manage hypertension, with ACE inhibitors as the first-line treatment for patients under 55 years old. However, individual patient factors and comorbidities should be taken into account when deciding on the best treatment plan.

When dealing with ventricular tachycardia, it is recommended to follow the resuscitation council guidelines. If there are no signs of shock, syncope, myocardial ischaemia, or heart failure, the best course of action is to administer 300mg of amiodarone intravenously as the initial treatment.

Managing Ventricular Tachycardia

Ventricular tachycardia is a type of rapid heartbeat that originates in the ventricles of the heart. In a peri-arrest situation, it is assumed to be ventricular in origin. If the patient shows adverse signs such as low blood pressure, chest pain, heart failure, or syncope, immediate cardioversion is necessary. However, in the absence of such signs, antiarrhythmic drugs may be used. Amiodarone is the preferred drug and should be administered through a central line. Lidocaine should be used with caution in severe left ventricular impairment, and verapamil should not be used in VT. If drug therapy fails, an electrophysiological study (EPS) or implantable cardioverter-defibrillator (ICD) may be needed, especially in patients with significantly impaired LV function. It is important to note that a broad complex tachycardia may result from a supraventricular rhythm with aberrant conduction, so proper diagnosis is crucial.

Antibiotic Prophylaxis for Infective Endocarditis

Antibiotic prophylaxis is not recommended for people undergoing dental or non-dental procedures in the upper and lower gastrointestinal tract, genitourinary tract, and upper and lower respiratory tract. This includes procedures such as urological, gynaecological, obstetric, childbirth, ear, nose, throat, and bronchoscopy. Chlorhexidine mouthwash should also not be used as prophylaxis against infective endocarditis for those at risk undergoing dental procedures.

In summary, antibiotic prophylaxis is not necessary for most procedures, and chlorhexidine mouthwash should not be used as a substitute. It is important to consult with a healthcare professional to determine if antibiotic prophylaxis is necessary for specific procedures.

Differential Diagnosis for a Young Patient with Pulmonary Hypertension

Idiopathic pulmonary artery hypertension (IPAH), previously known as primarily pulmonary hypertension (PPH), is a rare condition characterized by elevated pulmonary artery pressure without a clear cause. A typical presentation for IPAH includes syncope and ECG findings of right ventricular hypertrophy. Treatment typically involves calcium channel blockers, anticoagulation, and nebulized prostacyclin.

Ischemic heart disease is unlikely in a young patient with no significant risk factors for coronary artery disease, despite intermittent chest pain on exertion. Chronic pulmonary emboli can lead to chronic pulmonary hypertension, but there are no risk factors for venous thromboembolism or DVT symptoms described. Loeffler syndrome, characterized by acute onset pulmonary eosinophilia, typically occurs secondary to an external trigger, which is not evident in this case. Hypertrophic cardiomyopathy (HCM) can cause significant breathlessness, but the ECG shows no features to suggest significant left ventricular hypertrophy, which would be expected if HCM was the underlying diagnosis.

In summary, the differential diagnosis for a young patient with pulmonary hypertension includes IPAH, but other conditions such as ischemic heart disease, chronic pulmonary emboli, Loeffler syndrome, and HCM should also be considered and ruled out.

In 2011, the National Institute for Clinical Excellence updated its guideline for managing hypertension, emphasizing the use of ambulatory blood pressure monitoring (ABPM) as the first line of diagnosis for those with elevated clinic readings. ABPM involves taking two measurements per hour during waking hours and using the average of at least 14 measurements to confirm hypertension.

Secondary causes of hypertension should be investigated in patients under 40 without traditional risk factors, those with other symptoms, and those with resistant hypertension. Hyperaldosteronism is the most common cause, and a trial of spironolactone may be used for both diagnosis and treatment.

Drug treatment for essential hypertension follows a stepwise approach, with ACE inhibitors recommended for those under 55 and calcium channel blockers for those over 55 or of black African or Caribbean origin. Combination therapy with ACE inhibitors and calcium channel blockers is recommended in step 2, followed by the addition of a thiazide-like diuretic in step 3. Further diuretics, beta-blockers, or alpha blockers may be considered in step 4, with expert advice sought. For more detailed information, see the provided link.

NICE released updated guidelines in 2019 for the management of hypertension, building on previous guidelines from 2011. These guidelines recommend classifying hypertension into stages and using ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM) to confirm the diagnosis of hypertension. This is because some patients experience white coat hypertension, where their blood pressure rises in a clinical setting, leading to potential overdiagnosis of hypertension. ABPM and HBPM provide a more accurate assessment of a patient’s overall blood pressure and can help prevent overdiagnosis.

To diagnose hypertension, NICE recommends measuring blood pressure in both arms and repeating the measurements if there is a difference of more than 20 mmHg. If the difference remains, subsequent blood pressures should be recorded from the arm with the higher reading. NICE also recommends taking a second reading during the consultation if the first reading is above 140/90 mmHg. ABPM or HBPM should be offered to any patient with a blood pressure above this level.

If the blood pressure is above 180/120 mmHg, NICE recommends admitting the patient for specialist assessment if there are signs of retinal haemorrhage or papilloedema or life-threatening symptoms such as new-onset confusion, chest pain, signs of heart failure, or acute kidney injury. Referral is also recommended if a phaeochromocytoma is suspected. If none of these apply, urgent investigations for end-organ damage should be arranged. If target organ damage is identified, antihypertensive drug treatment may be started immediately. If no target organ damage is identified, clinic blood pressure measurement should be repeated within 7 days.

ABPM should involve at least 2 measurements per hour during the person’s usual waking hours, with the average value of at least 14 measurements used. If ABPM is not tolerated or declined, HBPM should be offered. For HBPM, two consecutive measurements need to be taken for each blood pressure recording, at least 1 minute apart and with the person seated. Blood pressure should be recorded twice daily, ideally in the morning and evening, for at least 4 days, ideally for 7 days. The measurements taken on the first day should be discarded, and the average value of all the remaining measurements used.

Interpreting the results, ABPM/HBPM above 135/85 mmHg (stage 1 hypertension) should be

Acute Pericarditis: Causes, Features, Investigations, and Management

Acute pericarditis is a possible diagnosis for patients presenting with chest pain. The condition is characterized by chest pain, which may be pleuritic and relieved by sitting forwards. Other symptoms include non-productive cough, dyspnoea, and flu-like symptoms. Tachypnoea and tachycardia may also be present, along with a pericardial rub.

The causes of acute pericarditis include viral infections, tuberculosis, uraemia, trauma, post-myocardial infarction, Dressler’s syndrome, connective tissue disease, hypothyroidism, and malignancy.

Investigations for acute pericarditis include ECG changes, which are often global/widespread, as opposed to the ‘territories’ seen in ischaemic events. The ECG may show ‘saddle-shaped’ ST elevation and PR depression, which is the most specific ECG marker for pericarditis. All patients with suspected acute pericarditis should have transthoracic echocardiography.

Management of acute pericarditis involves treating the underlying cause. A combination of NSAIDs and colchicine is now generally used as first-line treatment for patients with acute idiopathic or viral pericarditis.

In summary, acute pericarditis is a possible diagnosis for patients presenting with chest pain. The condition is characterized by chest pain, which may be pleuritic and relieved by sitting forwards, along with other symptoms. The causes of acute pericarditis are varied, and investigations include ECG changes and transthoracic echocardiography. Management involves treating the underlying cause and using a combination of NSAIDs and colchicine as first-line treatment.

Cardiac Tumors and Mitral Stenosis

The combination of a murmur, atrial fibrillation, syncope, and raised erythrocyte sedimentation rate (ESR) may indicate the presence of a cardiac tumor leading to symptoms of mitral stenosis. Myxomas are more commonly seen than rhabdomyomas in this context, and surgical excision is the preferred treatment. However, rhabdomyomas are associated with tuberous sclerosis, which is not evident in this case. Additionally, the presence of raised ESR, clubbing, and pyrexia makes mitral stenosis alone unlikely. Rheumatic heart disease is also an unlikely explanation, as there is no history of rheumatic fever or a related illness. Finally, the absence of normochromic normocytic anemia and mitral regurgitation makes endocarditis less likely. Overall, the presence of a cardiac tumor should be considered in cases of mitral stenosis with these accompanying symptoms.