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Tutor4 of 2003:13

Inspect

Finding · Kerley B lines, congestion

Portable chest radiograph · Cardiogenic pulmonary oedema

From the stem

RRRespiratory rate: 34/min
O₂ satOxygen saturation: 86%room air
HRHeart rate: 112/min, regular
BPBlood pressure: 198/112mmHg
TempTemperature: Afebrile

Difficulty: Hard

Question 4Cardiovascular

A 72-year-old man is brought to a metropolitan emergency department with sudden, severe breathlessness that woke him from sleep two hours earlier. He has a history of hypertension and ischaemic heart disease. He is sitting bolt upright, distressed and diaphoretic, and can speak only in single words. His respiratory rate is 34 breaths/min, oxygen saturation is 86% on room air, heart rate is 112 beats/min and regular, and blood pressure is 198/112 mmHg. He is afebrile. Auscultation reveals widespread fine inspiratory crackles to the mid-zones bilaterally and an audible third heart sound; there is no wheeze. His jugular venous pressure is elevated. An electrocardiogram shows sinus tachycardia with left ventricular hypertrophy and no acute ischaemic changes, and his initial high-sensitivity troponin is mildly elevated. He is placed on high-flow oxygen. His portable chest radiograph is shown.

Which of the following is the most appropriate initial pharmacological management?

Administer nebulised salbutamol 5 mg via continuous nebulisation

Commence an intravenous glyceryl trinitrate infusion, titrated to blood pressureCorrect answer

Give an intravenous bolus of furosemide 40 mgYour answer

Inject intravenous metoprolol 5 mg over five minutes

Start an intravenous morphine infusion at 2 mg per hour

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AAdminister nebulised salbutamol 5 mg via continuous nebulisation

BCommence an intravenous glyceryl trinitrate infusion, titrated to blood pressureCorrect

CGive an intravenous bolus of furosemide 40 mgDiuretics are commonly co-administered but in the hypertensive redistributive phenotype the primary problem is afterload/fluid shift, not total-body overload; diuresis acts more slowly and does not address the elevated filling pressures as the best initial step.Common pick

DInject intravenous metoprolol 5 mg over five minutes

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Post-ACS LDL-C target (2025 Australian guideline)?

Cardiovascular · Acute coronary syndromes

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Cardiovascular

Dual antiplatelet therapy in ACS

For primary PCI / routine invasive NSTE-ACS → default P2Y12 is a potent agent (ticagrelor or prasugrel) over clopidogrel
For a selective invasive (non-PCI / conservative) strategy → ticagrelor OR clopidogrel (NOT prasugrel — prasugrel is procedure-bound)

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