500 Single Best Answers in MEDICINE

QUESTIONS 1. Myocardial infarction A 65-year-old man presents with central crushing chest pain for the first time. He is transferred immediately to the closest cardiac unit to undergo a primary percutaneous coronary ...

QUESTIONS 1. Myocardial infarction A 65-year-old man presents with central crushing chest pain for the first time. He is transferred immediately to the closest cardiac unit to undergo a primary percutaneous coronary intervention. There is thrombosis of the left circumflex artery only. Angioplasty is carried out and a drug-eluding stent is inserted. What are the most likely changes to have occurred on ECG during admission? A. ST depression in leads V1–4 B. ST elevation in leads V1–6 C. ST depression in leads II, III and AVF D. ST elevation in leads V5–6 E. ST elevation in leads II, III and AVF 2. Heart failure (1) A 78-year-old woman is admitted with heart failure. The underlying cause is determined to be aortic stenosis. Which sign is most likely to be present? A. Pleural effusion on chest x-ray B. Raised jugular venous pressure (JVP) C. Bilateral pedal oedema D. Bibasal crepitations E. Atrial fibrillation 3. Valve lesion signs A patient is admitted with pneumonia. A murmur is heard on examination. What finding points to mitral regurgitation? A. Murmur louder on inspiration B. Murmur louder with patient in left lateral position C. Murmur louder over the right 2nd intercostal space midclavicular line D. Corrigan’s sign E. Narrow pulse pressure4 Section 1: Cardiovascular 4. CHAD2 score A 79-year-old woman is admitted to the coronary care unit (CCU) with unstable angina. She is started on appropriate medication to reduce her cardiac risk. She is hypertensive, fasting glucose is normal and cholesterol is 5.2. She is found to be in atrial fibrillation. What is the most appropriate treatment? A. Aspirin and clopidogrel B. Digoxin C. Cardioversion D. Aspirin alone E. Warfarin 5. Chest pain (1) A 55-year-old man has just arrived in accident and emergency complaining of 20 minutes of central crushing chest pain. Which feature is most indicative of myocardial infarction at this moment in time? A. Inverted T waves B. ST depression C. ST elevation D. Q waves E. Raised troponin 6. Shortness of breath (1) A 66-year-old woman presents to accident and emergency with a 2-day history of shortness of breath. The patient notes becoming progressively short of breath as well as a sharp pain in the right side of the chest which is most painful when taking a deep breath. The patient also complains of mild pain in the right leg, though there is nothing significant on full cardiovascular and respiratory examination. Heart rate is 96 and respiratory rate is 12. The patient denies any weight loss or long haulflights but mentions undergoing a nasal polypectomy 3 weeks ago. The most likely diagnosis is: A. Muscular strain B. Heart failure C. Pneumothorax D. Angina E. Pulmonary embolismQuestions 5 7. Murmurs (1) A 59-year-old man presents for a well person check. A cardiovascular, respiratory, gastrointestinal and neurological examination is performed. No significant findings are found, except during auscultation a mid systolic click followed by a late systolic murmur is heard at the apex. The patient denies any symptoms. The most likely diagnosis is: A. Barlow syndrome B. Austin Flint murmur C. Patent ductus arteriosus D. Graham Steell murmur E. Carey Coombs murmur 8. Chest pain (2) A 60-year-old man presents to accident and emergency with a 3-day history of increasingly severe chest pain. The patient describes the pain as a sharp, tearing pain starting in the centre of his chest and radiating straight through to his back between his shoulder blades. The patient looks in pain but there is no pallor, heart rate is 95, respiratory rate is 20, temperature 37°C and blood pressure is 155/95 mmHg. The most likely diagnosis is: A. Myocardial infarction B. Myocardial ischaemia C. Aortic dissection D. Pulmonary embolism E. Pneumonia 9. Chest pain management A 49-year-old man is rushed to accident and emergency complaining of a 20-minute history of severe, crushing chest pain. After giving the patient glyceryl trinitrate (GTN) spray, he is able to tell you he suffers from hypertension and type 2 diabetes and is allergic to aspirin. The most appropriate management is: A. Aspirin B. Morphine C. Heparin D. Clopidogrel E. Warfarin6 Section 1: Cardiovascular 10. Ventricular tachyarrhythmia While on call you are called by a nurse to a patient on the ward complaining of light headedness and palpitations. When you arrive the patient is not conscious but has a patent airway and is breathing with oxygen saturation at 97 per cent. You try to palpate a pulse but are unable to find the radial or carotid. The registrar arrives and after hearing your report of the patient decides to shock the patient who recovers. What is the patient most likely to have been suffering? A. Torsades de Pointes B. Ventricular fibrillation C. Sustained ventricular tachycardia D. Non-sustained ventricular tachycardia E. Normal heart ventricular tachycardia 11. Jugular venous pressure A 67-year-old man presents to accident and emergency with a 3-day history of shortness of breath. On examination you palpate the radial pulse and notice that the patient has an irregular heart beat with an overall rate of 140 bpm. You requestan electrocardiogram (ECG) which reveals that the patient is in atrial fibrillation. Which of the following would you expect to see when assessing the JVP? A. Raised JVP with normal waveform B. Large ‘v waves’ C. Cannon ‘a waves’ D. Absent ‘a waves’ E. Large ‘a waves’ 12. Heart failure (2) A 78-year-old woman is admitted to your ward following a 3-day history of shortness of breath and a productive cough of white frothy sputum. On auscultation of the lungs, you hear bilateral basal coarse inspiratory crackles. You suspect that the patient is in congestive cardiac failure. You request a chest x-ray. Which of the following signs is not typically seen on chest x-ray in patients with congestive cardiac failure? A. Lower lobe diversion B. Cardiomegaly C. Pleural effusions D. Alveolar oedema E. Kerley B linesQuestions 7 13. First degree heart block A 56-year-old man presents to your clinic with symptoms of exertional chest tightness which is relieved by rest. You request an ECG which reveals that the patient has first degree heart block. Which of the following ECG abnormalities is typically seen in first degree heart block? A. PR interval 120ms B. PR interval 300ms C. PR interval 200ms D. PR interval 200ms E. PR interval 120ms 14. Mitral stenosis You see a 57-year-old woman who presents with worsening shortness of breath coupled with decreased exercise tolerance. She had rheumatic fever in her adolescence and suffers from essential hypertension. On examination she has signs which point to a diagnosis of mitral stenosis. Which of the following is not a clinical sign associated with mitral stenosis? A. Malar flush B. Atrial fibrillation C. Pan-systolic murmur which radiates to axilla D. Tapping, undisplaced apex beat E. Right ventricular heave 15. Hypertension (1) A 48-year-old woman has been diagnosed with essential hypertension and was commenced on treatment three months ago. She presents to you with a dry cough which has not been getting better despite taking cough linctus and antibiotics. You assess the patient’s medication history. Which of the following antihypertensive medications is responsible for the patient’s symptoms? A. Amlodipine B. Lisinopril C. Bendroflumethiazide D. Frusemide E. Atenolol8 Section 1: Cardiovascular 16. Palpitations A 62-year-old male presents with palpitations, which are shown on ECG to be atrial fibrillation with a ventricular rate of approximately 130/minute. He has mild central chest discomfort but is not acutely distressed. He first noticed these about 3hours before coming to hospital. As far as is known this is his first episode of this kind. Which of the following would you prefer as first-line therapy? A. Anticoagulate with heparin and start digoxin at standard daily dose B. Attempt DC cardioversion C. Administer bisoprolol and verapamil, and give warfarin D. Attempt cardioversion with IV flecainide E. Wait to see if there is spontaneous reversion to sinus rhythm 17. Murmurs (2) A 76-year-old male is brought to accident and emergency after collapsing at home. He has recovered within minutes and is fully alert and orientated. He says this is the first such episode that he has experienced, but describes some increasing shortness of breath in the previous six months and brief periods of central chest pain, often at the same time. On examination, blood pressure is 115/88 mmHg and there are a few rales at both bases. On ECG there are borderline criteria for left ventricular hypertrophy. Which of the following might you expect to find on auscultation? A. Mid-diastolic murmur best heard at the apex B. Crescendo systolic murmur best heard at the right sternal edge C. Diastolic murmur best heard at the left sternal edge D. Pan-systolic murmur best heard at the apex E. Pan-systolic murmur best heard at the left sternal edge 18. Postmyocardial infarction (1) A 63-year-old male was admitted to accident and emergency 2 days after discharge following an apparently uncomplicated MI. He complained of rapidly worsening shortness of breath over the previous 48 hours but no further chest pain. He was tachypnoeic and had a regular pulse of 110/minute, which proved to be sinus tachycardia. The jugular venous pressure was raised and a pan-systolic murmur was noted, maximal at the left sternal edge. Which of the following is the most likely diagnosis? A. Mitral incompetence B. Ventricular septal defect C. Aortic stenosis D. Dressler’s syndrome E. Further myocardial infarctionQuestions 9 19. Hypertension (2) A 57-year-old male is admitted complaining of headaches and blurring of vision. His blood pressure is found to be 240/150 mmHg and he has bilateral papilloedema, but is fully orientated and coherent. He had been known to be hypertensive for about five years and his blood pressure control had been good on three drugs. However, he had decided to stop all medication two months before this event. Which of the following would be your preferred parenteral medication at this point? A. Glyceryl trinitrate B. Hydralazine C. Labetalol D. Sodium nitroprusside E. Phentolamine 20. Mid-systolic murmur A 16-year-old male is referred for assessment of hypertension. On average, his blood pressure is 165/85 mmHg, with radiofemoral delay. There is a mid-systolic murmur maximal at the aortic area, and radiating to the back. Clinical findings and the ECG are compatible with left ventricular hypertrophy. What is the most likely underlying pathology? A. Hypertrophic obstructive cardiomyopathy B. Congenital aortic stenosis C. Coarctation of the aorta D. Patent ductus ateriosus E. Atrial septal defect 21. Ventral septal defect A 16-year-old boy is diagnosed with a small ventricular septal defect, having been screened by echocardiography because of a family history of hypertrophic obstructive cardiomyopathy. He is entirely asymptomatic, plays several sports regularly and has no growth retardation. The echocardiogram also confirms a small left to right shunt, with pulmonary to systemic flow ratio only just above one. Which of the following is the most likely to be a significant complication of his condition? A. Pulmonary hypertension B. Heart failure C. Dysrhythmias D. Endocarditis E. Shunt reversal (right to left flow)10 Section 1: Cardiovascular 22. Microscopic haematuria A 52 year-old woman has been treated for several years with amlodipine and lisinopril for what has been presumed to be primary hypertension. She is seen by her GP having complained of persistent left loin pain. Her BP is 150/95 mmHg. She is tender in the left loin and both kidneys appear to be enlarged. On urine dipstick testing, there is microscopic haematuria. Which of the following is likely to be the most appropriate investigation at this point? A. Urinary tract ultrasound B. Abdominal and pelvic computed tomography (CT) scan C. Microscopy of the urine (microbial and cytological) D. Renal biopsy E. Intravenous urogram 23. Retrosternal chest pain A 61-year-old man presents with a 2-hour history of moderately severe retrosternal chest pain, which does not radiate and is not affected by respiration or posture. He complains of general malaise and nausea, but has not vomited. His ECG shows ST segment depression and T wave inversion in the inferior leads. Troponin levels are not elevated. He has already been given oxygen, aspirin and intravenous GTN; he is an occasional user of sublingual GTN and takes regular bisoprolol for stable angina. What would be the most appropriate next step in his management? A. IV low-molecular weight heparin B. Thrombolysis with alteplase C. IV nicardapine D. Angiography with stenting E. Oral clopidogrel 24. Pulmonary embolism management A 41-year-old woman is referred for assessment after suffering a second pulmonary embolus within a year. She has not been travelling recently, has not had any surgery, does not smoke and does not take the oral contraceptive pill. She is not currently on any medication as the diagnosis is retrospective and she is now asymptomatic. What should be the next step in her management? A. Initiation of warfarin therapy B. ECG C. Thrombophilia screen D. Insertion of inferior vena cava filter E. Duplex scan of lower limb veins and pelvic utrasoundQuestions 11 25. Mid-diastolic murmur A 32-year-old woman attends her GP for a routine medical examination and is noted to have a mid-diastolic murmur with an opening snap. Her blood pressure is 118/71 mmHg and the pulse is regular at 66 beats per minute. She is entirely asymptomatic and chest x-ray and ECG are normal. What would be the most appropriate investigation at this point? A. ECG B. Anti-streptolysin O titre C. Cardiac catheterization D. Thallium radionuclide scanning E. Colour Doppler scanning 26. Severe chest pain A 46-year-old man develops sudden severe central chest pain after lifting heavy cases while moving house. The pain radiates to the back and both shoulders but not to either arm. His BP is 155/90 mmHg, pulse rate is 92 beats per minute and the ECG is normal. He is distressed and sweaty, but not nauseated. What would you consider the most likely diagnosis? A. Pneumothorax B. MI C. Pulmonary embolism D. Aortic dissection E. Musculoskeletal pain 27. Decrescendo diastolic murmur A 49-year-old woman presents with increasing shortness of breath on exertion developing over the past three months. She has no chest pain or cough, and has noticed no ankle swelling. On examination, blood pressure is 158/61 mmHg, pulse is regular at 88 beats per minute and there are crackles at both lung bases. There is a decrescendo diastolic murmur at the left sternal edge. What is the most likely diagnosis? A. Aortic regurgitation B. Aortic stenosis C. Mitral regurgitation D. Mitral stenosis E. Tricuspid regurgitation12 Section 1: Cardiovascular 28. Supraventricular tachycardia A 21-year-old man is on his way home from a party when he experiences the sudden onset of rapid palpitations. He feels uncomfortable but not short of breath and has no chest pain. He goes to the nearest accident and emergency department, where he is found to have a supraventricular tachycardia (SVT) at a rate of 170/minute. Carotid sinus massage produced transient reversion to sinus rhythm, after which the tachycardia resumed. What would be the next step in your management? A. Repeat carotid sinus massage B. IV verapamil C. IV propranolol D. IV adenosine E. Synchronized DC cardioversion 29. Chest pain (3) A 44-year-old woman attends her local accident and emergency department with a history of at least six months of frequent central chest pain in the early morning or during the night. She had no chest pain on exertion. This had been a particularly severe attack, lasting over 2 hours. Her pulse rate is 84/minute in sinus rhythm, and blood pressure is 134/86 mmHg. The ECG shows anterior ST segment elevation, but troponin levels do not rise. Subsequent coronary angiography is normal. What is the most likely diagnosis? A. MI B. Stable angina C. Unstable angina D. Anxiety E. Variant angina 30. Shortness of breath (2) A previously fit 19-year-old man presents with unusual shortness of breath on exertion. At times, this is also associated with central chest pain. On examination there is a loud mid-systolic murmur at the left sternal edge. Heart rate and blood pressure are normal and there is no oedema. The ECG shows left axis deviation and the voltage criteria for left ventricular hypertrophy and the echocardiogram reveals a significant thickened interventricular septum, with delayed ventricular filling during diastole. There is a family history of sudden death below the age of 50. Which of the following would be your initial therapy? A. Digoxin B. Long-acting nitrates C. Beta-blockers D. Rate-limiting calcium channel blockers E. Partial excision of the septumQuestions 13 31. Hypertension (3) A 44-year-old woman presents with episodes of headaches, associated with anxiety, sweating and a slow pulse rate. At the time of her initial consultation, her blood pressure was 150/95 mmHg seated, but 24 hour ambulatory monitoring shows apeak of 215/130 mmHg, associated with the symptoms described above. Which ofthe following would be your initial diagnostic procedure? A. Magnetic resonance imaging (MRI) scans of the abdomen and pelvis B. Measurement of random plasma catecholamines C. Measurement of urinary metanephrines over several 24 hour periods D. Glucose tolerance test E. Pharmacological provocation using clonidine 32. Chest pain (4) A 56-year-old man presents to the accident and emergency department with a 2- hour history of central chest pain radiating to the left arm. He is anxious, nauseated and sweaty. His pulse rate is 120/minute in sinus rhythm and the ECG reveals ST elevation in leads II, III and aVF. The troponin level is significantly raised. This is certainly acute MI. Which is the most likely coronary vessel to be occluded? A. Circumflex artery B. Left anterior descending artery C. Right coronary artery D. Left main coronary artery E. Posterior descending artery 33. Constrictive pericarditis A 45-year-old woman complains of increasing shortness of breath on exertion, as well as orthopnoea, for the previous 3–4 months. She had apparently recovered from pericarditis about a year earlier. On ECG there is low voltage, especially in the limb leads, and the chest x-ray shows pericardial calcification. The presumptive diagnosis is constrictive pericarditis. Which of the following physical signs would be consistent with this? A. Increased jugular distention on inspiration B. Third heart sound C. Fourth heart sound D. Rales at both lung bases E. Loud first and second heart sounds14 Section 1: Cardiovascular 34. Visual disturbance A 71-year-old man is being treated for congestive heart failure with a combination of drugs. He complains of nausea and anorexia, and has been puzzled by observing yellow rings around lights. His pulse rate is 53/minute and irregular and blood pressure is 128/61 mmHg. Which of the following medications is likely to be responsible for these symptoms? A. Lisinopril B. Spironolactone C. Digoxin D. Furosemide E. Bisoprolol 35. Weight loss A 29-year-old woman goes to see her GP complaining of fatigue and palpitations. She says she has also lost weight, though without dieting. On examination, her pulse rate is approximately 120/min and irregularly irregular. Her blood pressure is 142/89 mmHg and her body mass index is 19. There are no added cardiac sounds. The ECG confirms the diagnosis of atrial fibrillation. What would you suggest as the most useful next investigation. A. Thyroid function tests (TSH, free T4) B. ECG C. Chest x-ray D. Full blood count E. Fasting blood sugar 36. Postmyocardial infarction (2) A 58-year-old man has made an excellent functional recovery after an anterior MI. He is entirely asymptomatic and there is no abnormality on physical examination. His blood pressure is 134/78 mmHg and he is undertaking a cardiac rehabilitation programme. Which of the following would you not recommend as part of his secondary prevention planning? A. Aspirin B. Lisinopril C. Simvastatin D. Bisoprolol E. Omega-3 fatty acidsQuestions 15 37. Mitral valve prolapse complication A 25-year-old woman with known mitral valve prolapse develops a low grade fever, malaise and night sweats within a couple of weeks of a major dental procedure. Examination reveals a pulse rate of 110/minute, which is regular, tender vasculitic lesions on the finger pulps and microscopic haematuria. Which investigation is most likely to provide a definitive diagnosis? A. Full blood count B. ECG C. Autoantibody screen D. Blood culture E. Coronary angiography 38. Mitral valve prolapse An asymptomatic 31-year-old woman has been referred for cardiological assessment. After her ECG she was told that she had mitral valve prolapse and would like further information on this condition. Which of the following statements is correct? A. Beta-blocker therapy is indicated B. Angiotensin-converting enzyme (ACE) inhibitor therapy is indicated C. One or both leaflets of the mitral valve are pushed back into the left atrium during systole D. Significant mitral regurgitation will eventually develop E. Exercise should be restricted 39. Paroxysmal atrial fibrillation A 69-year-old woman complains of intermittent palpitations, lasting several hours, which then stop spontaneously. She also suffers from asthma. Holter monitoring confirms paroxysmal atrial fibrillation. Which of the following statements is correct regarding the management of this patient? A. Digoxin effectively prevents recurrence of the arrhythmia B. Anticoagulation is not necessary C. Sotalol may be effective D. Amiodarone should be avoided E. Flecainide orally may be an effective as-needed treatment to abort an attack16 Section 1: Cardiovascular 40. Hypertension management A 57-year-old man is reviewed in a hypertension clinic, where it is found that his blood pressure is 165/105 mmHg despite standard doses of amlodipine, perindopril, doxazosin and bendroflumethiazide. Electrolytes and physical examination have been, and remain, normal. Which of the following would be your next stage in his management? A. Arrange for his medication to be given under direct observation B. Add spironolactone to his medication C. Arrange urinary catecholamine assays D. Request an adrenal CT scan E. Add verapamil to his medicationAnswers 17 ANSWERS Myocardial infarction 1 D Time equates to muscle. Judging from the urgency, this male presented with an ST elevation MI (STEMI) which is an indication for urgent primary percutaneous coronary intervention (PCI). Compare this to a non-ST elevation MI (NSTEMI) which indicates ischaemia rather than infarction and PCI should be carried out within 48 hours (answers A and C). The angiogram shows that the left circumflex artery is occluded, resulting in a lateral infarct. This area is represented by leads V5–6 (D). V1–4 represents the territory of the left anterior descending artery. If the entire left mainstem had been occluded, changes would have shown throughout leads V1–6 (B). Leads II, III and aVF (C and E) point to an inferior infarct and involvement of the right anterior descending artery (see Figure 1.1 below). (a) Chest leads (b) (c) Aorta Right coronary artery Pulmonary artery Circumflex coronary artery Left anterior descending coronary artery Fig. 1.1 (a,b) Chest leads. (c) Anatomy of coronary arteries (from Koppel and Naparus (2008) Thinking Medicine: Structure your knowledge for success in medical exams, Cavaye, with permission). Lateral18 Section 1: Cardiovascular The location of the changes tells you which part of the heart is affected as shown in the diagrams. These depict: 1 the position of the chest leads and the parts of the heart they investigate; 2 the position of the limb leads and the parts of the heart they investigate; 3 the anatomy of the coronary arteries. Putting all of these together will allow you to pinpoint the location of the lesion. Leads Area Supplied by V1–2 Anterior LCA: Diagonal branch of LAD V3–4 Septal LCA: Septal branch of LAD V5–6 Lateral LCA: Left circumflex artery V1–6 Anterolateral LCA: Left main stem disease II, III, aVF Inferior RCA: Posterior descending branch Heart failure 2 D Aortic stenosis will first result in left ventricular failure as a result of increased ventricular pressure as the ventricle tries to pump blood across a narrowed valve. Initially the pressure load will cause a backlog of blood into the lungs, resulting in pulmonary oedema – the first sign of which will be bibasal crepitations (D) before enough fluid accumulates as pleural effusions visible on chest x-ray (A). Earlier signs of pulmonary oedema include upper lobe blood diversion and Kerley B lines as fluid infiltrates the interstitium. If the backlog continues back into the right heart, eventually signs of right-sided heart failure will be evident including raised JVP (B) and bilateral pedal oedema (C). Atrial fibrillation (E) may coexist with aortic stenosis, however it is more commonly associated as a result of mitral stenosis as the enlarged atrium disrupts the normal electrical pathways. Valve lesion signs 3 B A murmur heard loudest on inspiration (A) points to a right-sided valve lesion. The right intercostal space midclavicular line (C) is the anatomical landmark for the aortic valve. The mitral area is over the apex. A murmur louder with the patient in the left lateral position (B) (as opposed to leaning forward) is associated with mitral lesions. If heard, you should determine whether the murmur radiates to the axilla. Corrigan’s sign (D) (visibly exaggerated pulsating carotids) is one of the many signs of a hyperdynamic circulation associated with aortic regurgitation (including de Mussets, Traubes, Quinkes, Duroziez and a whole host of others). A narrow pulse pressure (E) is a sign of aortic stenosis.Answers 19 CHAD2 score 4 E Ideally this patient should be started on antihypertensives, a beta blocker and a statin. There is no indication for hypoglycaemics at present. There isno indication that this is acute atrial fibrillation and she does not seem to be compromised in a female of this age, cardioversion (C) is unlikely to be successful. She should be rate-controlled but the beta blockade is more appropriate in light of her ischaemic heart disease. Whether to start anticoagulation (A) is a decision that has to be tailor-made for each individual patient. The CHAD2 score is a quick and dirty but very useful way of predicting risk of subsequent stroke as a result of atrial fibrillation and helps guide the prescription of prophylactic antiplatelets or anticoagulants. Other factors, such as ease of taking and monitoring warfarin, risk of falls and important risk factors, such as vascular disease, should be taken into account. C Congestive heart failure 1 H Hypertension: blood pressure consistently above 140/90 mmHg 1 A (or treated hypertension on medication) Age 75 years 1 D Diabetes mellitus 1 S2 Previous stroke or TIA 2 A score of 0 is low risk (2 per cent of patients/year will have a stroke without treatment), aspirin is considered adequate. A score of 1 is moderate risk (3 per cent annual stroke risk) and either warfarin or aspirin (D) is indicated according to the individual. A score of two or above (4 per cent annual stroke risk) is classified as high risk and warfarin (E) should be started unless there are clear contraindications. A patient with a full-house of risk factors (scores 6) has an almost 20 per cent chance of stroke/year. Chest pain 5 C Acute coronary syndrome is a spectrum of cardiac ischaemia-infarction determined by the presence of two out of three factors: chest pain, ECG changes and cardiac enzyme rise. Depending on these results, patients will fall into one of the following categories: unstable angina, NSTEMI or STEMI. Inverted T waves (A) and ST depression (B) are signs of ischaemia. ST elevation, Q waves and raised troponin are indicative of infarction. Initially, ‘ST elevation’ or ‘non ST elevation’ ECG changes are used to stratify each patient’s risk as the results of blood tests for troponin levels (E) (which should be carried out 12 hours after the pain started) are not known and Q waves have not had time to develop. ST elevation (C) is a very good predictor of imminent infarction (positive troponin). However, if this patient is treated quickly enough with thrombolysis or primary PCI, infarction can be avoided. A patient with STEMI who goes on to have