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Photo from Dr Tanzeel Bukhari

Photo from Dr Tanzeel Bukhari

*🩺 Symptom Snapshot 6 – Orthopnoea* (by pace your MRCP – Dr Tanzeel Bukhari) *1️⃣ Left Ventricular Failure* Breathlessness when lying flat Improves on sitting upright or using multiple pillows Due to pulmonary congestion *2️⃣ Obesity / Obstructive Sleep Apnoea* Difficulty breathing when supine Loud snoring, daytime somnolence Often co-exists with heart failure *3️⃣ Diaphragmatic Weakness / Ascites* Worse on lying flat due to reduced lung expansion Seen in neuromuscular disease or tense ascites

*🩺 Symptom Snapshot 6 – Orthopnoea* (by pace your MRCP – Dr Tanzeel Bukhari) *1️⃣ Left Ventricular Failure* Breathlessness when lying flat Improves on sitting upright or using multiple pillows Due to pulmonary congestion *2️⃣ Obesity / Obstructive Sleep Apnoea* Difficulty breathing when supine Loud snoring, daytime somnolence Often co-exists with heart failure *3️⃣ Diaphragmatic Weakness / Ascites* Worse on lying flat due to reduced lung expansion Seen in neuromuscular disease or tense ascites

*🩺 Management Essentials 7* (by pace your MRCP – Dr Tanzeel Bukhari) *Ventricular Tachycardia (Stable vs Unstable)* • Assume VT until proven otherwise in any wide-complex tachycardia in adults • Unstable VT (shock, hypotension, ischaemic chest pain, acute heart failure, syncope) → immediate synchronised cardioversion • Pulseless VT → treat as cardiac arrest: CPR + defibrillation + ALS • Stable VT: o Continuous monitoring, IV access, check electrolytes (K/Mg), treat reversible causes o IV amiodarone is commonly first-line (or lidocaine per local protocol) • Correct precipitants: o Hypokalaemia / hypomagnesaemia, ischaemia, drug toxicity • Early cardiology/ICU input; consider ICD assessment in structural heart disease Pitfalls: mislabeling VT as SVT with aberrancy and giving inappropriate AV-nodal blockers

🩺 Management Essentials 6 (by pace your MRCP – Dr Tanzeel Bukhari) Supraventricular Tachycardia (SVT) • Initial approach: ABCDE, monitor, IV access, 12-lead ECG (but don’t delay treatment if unstable) • Unstable (hypotension, chest pain, pulmonary oedema, shock, syncope) → synchronised DC cardioversion • Stable, narrow-complex regular tachycardia: o Vagal manoeuvres first (modified Valsalva preferred) o If unsuccessful → IV adenosine in escalating doses (with full monitoring + resus readiness) • If adenosine contraindicated/ineffective: o IV beta-blocker or diltiazem/verapamil (avoid non-DHP CCBs in LV failure) • Always look for and treat triggers: infection, pain, dehydration, stimulants, thyrotoxicosis • Post-episode: consider electrophysiology referral if recurrent (ablation is definitive for AVNRT/AVRT) Pitfalls: giving AV-nodal blockers in pre-excited AF (irregular wide-complex) → deterioration. ________________________________________

👉 IMPORTANT 815👈 The most typical laboratory abnormality in GCA is increased ESR and CRP. Pace your MRCP-PACES.

👉 IMPORTANT 814👈 Visual loss in GCA may occur due to occlusion of posterior ciliary artery which can be a serious presentation. pace your MRCP-PACES

👉 IMPORTANT 813👈 Many rheumatologists consider GCA and PMR as different manifestations of the same underlying disorder. pace your MRCP-PACES

*Management Essentials No 5* *Atrial Fibrillation – Long-Term Management* • *Three pillars* : Rate control, Rhythm control, Anticoagulation • CHA₂DS₂-VASc guides stroke prevention (not symptom severity) • DOACs preferred unless contraindicated • *Rhythm control considered in:* o Young patients o First episode o AF causing heart failure • *Lifestyle optimisation:* weight loss, BP control, sleep apnoea treatment • *Rate control is acceptable long-term in many patients*

*Investigation Pearl 5 – D-dimer: Rule-Out Test, Not Rule-In* *Key Principle* : Normal D‑dimer rules out VTE in low‑risk patients; raised D‑dimer does not confirm VTE. Raised in infection, trauma, surgery, cancer, pregnancy and with age. *Correct use* : assess clinical probability first; high probability → imaging (CTPA) without relying on D‑dimer. *Exam tip* : Imaging confirms VTE, not D‑dimer.

Photo from Dr Tanzeel Bukhari

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Photo from Dr Tanzeel Bukhari

Photo from Dr Tanzeel Bukhari

Photo from Dr Tanzeel Bukhari

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