Cardiology: Presentations

• Presentations: Chest Pain — Prioritised Differential and First Tests | Breathlessness, Orthopnoea and Oedema | Palpitations | Syncope — Cardiac, Reflex or Orthostatic
• Skills and investigations: Cardiovascular Examination and Murmurs | The 12-lead ECG — A Practical Routine | Echo, Troponin, BNP and Imaging
• Emergencies: ABCDE Assessment of Cardiovascular Instability | Shock | Cardiac Arrest and Peri-arrest Rhythms
• Safe practice: Safe Cardiovascular Prescribing and Monitoring | Counselling, Safety Netting and Shared Decisions | Mini-cases and Diagnostic Traps
• Revision: Cardiovascular Presentations at a Glance | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🫀 Cardiovascular presentations, emergencies and MLA skills — mapped to the GMC MLA content map applying from September 2026. Patients don't arrive with a diagnosis — they arrive with chest pain, breathlessness, palpitations or collapse. This page works from the presentation: what to exclude first, which test discriminates, and when to call for help. Emergencies are taught as recognition and escalation — follow local protocols and current specialist guidance.
Your four questions for every cardiovascular presentation: Is the patient stable — and what must I exclude first? Which single test best discriminates between the likely causes? What immediate safety actions are needed? Who needs to know — and what safety-net advice does the patient need?

Chest Pain — Prioritised Differential and First Tests

• Exclude the life-threatening causes first:

  Cause	Clues	Key test
  Acute coronary syndrome	Central heavy pain, radiation to arm or jaw, sweating, risk factors	ECG, serial high-sensitivity troponin
  Aortic dissection	Sudden tearing pain to the back, BP difference between arms, pulse deficit, new aortic regurgitation, neurology	CT aortogram
  Pulmonary embolism	Pleuritic pain, breathlessness, tachycardia, DVT, risk factors	Wells — D-dimer or CTPA
  Tension pneumothorax	Breathless, absent breath sounds, tracheal deviation, hypotension	Clinical — decompress
  Cardiac tamponade	Hypotension, raised JVP, muffled sounds, pulsus paradoxus	Bedside echo
  Oesophageal rupture	Pain after vomiting, surgical emphysema	CT

• Then consider — pericarditis (sharp, positional, better sitting forward; rub; saddle ST elevation), pneumonia, oesophageal reflux and spasm, musculoskeletal pain, shingles, anxiety.
• Immediate assessment — ABCDE, observations, onset and nature of pain, risk factors, associated breathlessness, syncope or neurological symptoms.
• First tests — 12-lead ECG within 10 minutes (repeat if pain persists or changes), serial high-sensitivity troponin per local pathway, chest X-ray; further tests by pretest probability — not a universal battery.

💡 MLA trap: A normal ECG or a normal first troponin does not rule out early ACS. Repeat the troponin at the interval your pathway specifies, and repeat the ECG if the pain returns.

Breathlessness, Orthopnoea and Oedema

• Cardiac causes — acute pulmonary oedema, chronic heart failure, valve disease, arrhythmias, PE, tamponade.
• Common alternatives — COPD and asthma, pneumonia, pneumothorax, anaemia, metabolic acidosis, anxiety, obesity and deconditioning.
• Assessment — SpO₂, respiratory rate, JVP, chest auscultation (crackles, wheeze, effusion), peripheral perfusion, ECG; then chest X-ray, natriuretic peptides (BNP or NT-proBNP) and echo where appropriate.
• Orthopnoea and paroxysmal nocturnal dyspnoea — suggest raised left-sided filling pressures (left heart failure).
• Peripheral oedema alone is non-specific:
  • Heart failure (with raised JVP).
  • Venous insufficiency, DVT.
  • Renal disease (nephrotic), liver disease (low albumin).
  • Drugs — calcium channel blockers (amlodipine), NSAIDs, steroids, pioglitazone.
  • Immobility, hypothyroidism, lymphoedema.
• Priority — treat hypoxia and shock immediately (oxygen, sit up, IV furosemide for pulmonary oedema, CPAP) before specialist investigations.

Palpitations

• History:
  • Onset and offset (sudden — re-entrant tachycardia; gradual — sinus tachycardia).
  • Regular or irregular (ask the patient to tap it out).
  • Duration, frequency, triggers (exercise, caffeine, alcohol, drugs — salbutamol, thyroxine, stimulants).
  • Associated syncope, chest pain or breathlessness.
  • Known structural heart disease; family history of sudden death.
  • Terminating manoeuvres (Valsalva — suggests SVT).
• Tests — 12-lead ECG during symptoms if possible (look for pre-excitation, long QT, Brugada pattern, heart block at rest); FBC, U&E, TFTs; ambulatory monitoring matched to symptom frequency (24-hour Holter for daily symptoms, event recorder or patch for weekly, implantable loop recorder for rare); echo if structural disease suspected.
• Red flags — haemodynamic instability, syncope, chest pain, sustained broad-complex tachycardia, exertional symptoms, family history of sudden death — urgent assessment.
• Reassure only after excluding important arrhythmia; give safety-net advice (return if collapse, chest pain or prolonged palpitations).
• Common benign causes — ectopic beats, sinus tachycardia (anxiety, caffeine).

Syncope — Cardiac, Reflex or Orthostatic

• Syncope — transient loss of consciousness from global cerebral hypoperfusion, with rapid, spontaneous, complete recovery.
• Types:

  Type	Typical features	Examples
  Reflex (vasovagal)	Trigger (prolonged standing, pain, emotion, heat); prodrome (sweating, nausea, tunnel vision); quick recovery	Vasovagal, situational (micturition, cough), carotid sinus hypersensitivity
  Orthostatic	On standing; BP falls (20 systolic or 10 diastolic within 3 minutes)	Drugs (antihypertensives, diuretics, alpha-blockers), dehydration, autonomic failure (diabetes, Parkinson's)
  Cardiac	During exertion, while lying down, without warning, preceded by palpitations or chest pain	Arrhythmia (heart block, VT), aortic stenosis, HCM, PE

• Assessment — witness history (colour, duration, jerking, recovery), medication review, lying and standing BP, 12-lead ECG for everyone, cardiac examination (murmurs).
• Seizure vs syncope — seizures: prolonged confusion afterwards, tongue biting (lateral), head turning, cyanosis; brief myoclonic jerks are common in syncope.
• Red flags (NICE CG109 — urgent specialist assessment within 24 hours) — abnormal ECG, heart failure or structural disease, exertional syncope, family history of sudden death under 40, new breathlessness, syncope while lying down, unexplained syncope over 65 without prodrome, new murmur.
• Driving — DVLA rules depend on the type (simple faint — usually no restriction; unexplained or cardiac — restrictions).

Cardiovascular Examination and Murmurs

• Routine — general inspection (breathlessness, pallor, cyanosis, scars), hands (clubbing, splinter haemorrhages), radial pulse (rate, rhythm, radio-radial delay), BP, carotid pulse character, JVP, apex beat (position, character), heaves and thrills, heart sounds, murmurs (timing, site, radiation, manoeuvres), lung bases, sacral and ankle oedema, peripheral pulses.
• Timing murmurs — palpate the carotid while listening: systolic murmurs coincide with the pulse; diastolic murmurs fall between pulses.
• Common murmurs:

  Lesion	Murmur	Other signs
  Aortic stenosis	Ejection systolic, right 2nd intercostal space, radiates to carotids	Slow-rising pulse, narrow pulse pressure, soft A2 (severe)
  Mitral regurgitation	Pansystolic at the apex, radiates to axilla	Displaced apex, AF
  Aortic regurgitation	Early diastolic, left sternal edge, sitting forward in expiration	Collapsing pulse, wide pulse pressure
  Mitral stenosis	Mid-diastolic rumble at the apex, left lateral position, opening snap	Malar flush, AF, tapping apex
  Tricuspid regurgitation	Pansystolic, lower left sternal edge, louder on inspiration	Giant v waves, pulsatile liver

• Manoeuvres — right-sided murmurs louder in inspiration; left-sided in expiration; HCM murmur louder with Valsalva and standing.
• Intensity doesn't equal severity — a severe aortic stenosis murmur may become quieter as cardiac output falls; new symptoms matter more than a quiet murmur.
• Echo for any new murmur with symptoms, or a diastolic murmur.

The 12-lead ECG — A Practical Routine

• Every time, in order:
  • Check — patient identity, date and time, calibration (10 mm/mV, 25 mm/s).
  • Rate — 300 ÷ large squares between R waves (or count QRS in 10 seconds × 6).
  • Rhythm — regular or irregular; P wave before every QRS?
  • Axis — leads I and aVF (normal −30° to +90°).
  • Intervals — PR (120–200 ms), QRS (under 120 ms), QTc (under about 450 ms men, 460 ms women).
  • Chamber enlargement — P waves (P mitrale, P pulmonale), LVH voltage criteria.
  • Q waves and R-wave progression.
  • ST segments — elevation or depression; reciprocal changes.
  • T waves — inversion, peaking (hyperkalaemia), flattening (hypokalaemia).
• Look for immediately actionable findings — STEMI, VT, complete heart block, hyperkalaemia, very prolonged QT, Wolff–Parkinson–White with AF.
• Extra leads — posterior (V7–V9 — ST depression in V1–V3 may be a posterior STEMI) and right-sided (V4R — inferior STEMI with RV infarction — avoid nitrates).
• STEMI equivalents — new LBBB with symptoms (Sgarbossa criteria), de Winter T waves, posterior MI.
• Compare with old ECGs and interpret within the clinical context — the commonest error is reading an ECG in isolation.

Echo, Troponin, BNP and Imaging

• Troponin:
  • Detects myocardial injury — not its cause.
  • MI needs a rise and/or fall above the 99th centile plus evidence of ischaemia (symptoms, ECG changes, imaging).
  • Other causes of raised troponin — sepsis, tachyarrhythmia, PE, myocarditis, heart failure, CKD, stroke, extreme exercise (type 2 MI and non-ischaemic injury).
• BNP / NT-proBNP — reflect ventricular wall stress; used to triage suspected heart failure (NICE NG106 — NT-proBNP over 2,000 ng/L — echo and specialist within 2 weeks; 400–2,000 — within 6 weeks); raised by age, AF, CKD; lowered by obesity, diuretics, ACE inhibitors.
• Echocardiography — valves, ejection fraction, regional wall motion, pericardial effusion, RV function, filling pressures.
• Imaging for specific questions:

  Test	Question it answers
  CT coronary angiography	Stable chest pain — is there coronary artery disease? (NICE CG95 first line)
  CTPA	Pulmonary embolism
  CT aortogram	Aortic dissection or aneurysm
  Cardiac MRI	Cardiomyopathy, myocarditis, infiltration, viability, MINOCA
  Functional imaging (stress echo, perfusion MRI, SPECT)	Ischaemia when coronary anatomy is uncertain
  Invasive angiography	ACS; definitive coronary anatomy with intervention

• Choose tests that change management, and document who will chase the results.

ABCDE Assessment of Cardiovascular Instability

• Airway — talking? Obstruction? Call for help early.
• Breathing — RR, SpO₂, chest expansion, breath sounds; oxygen to target saturations.
• Circulation — HR, BP, capillary refill, peripheral temperature and mottling, JVP, heart sounds, urine output; cardiac monitor, IV access (two large-bore), bloods (FBC, U&E, troponin, lactate, clotting, cross-match), 12-lead ECG.
• Disability — AVPU or GCS, pupils, capillary glucose.
• Exposure — rashes, bleeding, leg swelling, temperature.
• Recognise danger — hypoxia, hypotension, altered mental state, cool or mottled peripheries, rising lactate.
• Repeat observations after every intervention; escalate early (NEWS2, senior, critical care, resuscitation team).
• Don't be falsely reassured by a normal BP in compensated shock (young patients) or a normal heart rate in patients on beta-blockers or with pacemakers.

Shock

• Judge perfusion by mental state, skin (cold, mottled, capillary refill), urine output, lactate and organ function — not BP alone.
• JVP helps — raised in cardiogenic and obstructive shock; low in hypovolaemic and distributive shock.
• Bedside echo quickly shows a failing LV, a dilated RV (PE) or tamponade.
• Fluids — help hypovolaemic and distributive shock; can worsen cardiogenic shock (pulmonary oedema).
• See the Acute Medicine chapter for sepsis and shock management.

Cardiac Arrest and Peri-arrest Rhythms

• Recognise arrest — unresponsive with absent or abnormal (agonal) breathing — call the resuscitation team, start high-quality CPR (30:2, 5–6 cm depth, 100–120 a minute), attach a defibrillator, follow Resuscitation Council UK ALS guidance.
• Shockable rhythms — VF and pulseless VT — defibrillate, CPR for 2 minutes; adrenaline 1 mg and amiodarone 300 mg after the 3rd shock.
• Non-shockable rhythms — PEA and asystole — CPR, adrenaline 1 mg as soon as possible, then every 3–5 minutes.
• Reversible causes — 4 Hs and 4 Ts:
  • Hypoxia, Hypovolaemia, Hypo/hyperkalaemia and metabolic, Hypothermia.
  • Thrombosis (coronary or pulmonary), Tamponade, Toxins, Tension pneumothorax.
• Peri-arrest rhythms:
  • Unstable tachyarrhythmia (shock, syncope, myocardial ischaemia, heart failure) — synchronised DC cardioversion (up to 3 attempts), then amiodarone.
  • Stable tachyarrhythmia — narrow regular (vagal manoeuvres, adenosine), narrow irregular (AF — rate control), broad regular (VT — amiodarone).
  • Unstable bradycardia — atropine 500 micrograms (repeat to 3 mg), then adrenaline or isoprenaline infusion, transcutaneous pacing, transvenous pacing; risk of asystole — Mobitz II, complete heart block, pauses over 3 seconds.
• Always check drug doses and shock sequences against current algorithms and local policy.
• See the Acute Medicine chapter for full ALS.

Safe Cardiovascular Prescribing and Monitoring

• Before prescribing antithrombotics, diuretics, RAAS inhibitors and antiarrhythmics — check renal function, electrolytes, heart rate, BP, pregnancy status, interacting medicines and the indication.
• Anticoagulant prescriptions must state — indication, agent, dose, renal adjustment, interactions, duration and bleeding plan; take particular care with mechanical valves (warfarin only — DOACs contraindicated), pregnancy (LMWH) and triple-positive antiphospholipid syndrome (warfarin).
• Monitoring:
  • ACE inhibitors, ARBs, MRAs (spironolactone) — check K⁺ and creatinine before and 1–2 weeks after starting or increasing (accept a creatinine rise up to 30%).
  • Digoxin — renal function, potassium, levels if toxicity suspected.
  • Amiodarone — TFTs, LFTs, chest X-ray, eye and skin effects.
  • Warfarin — INR; many interactions (antibiotics, azoles, amiodarone).
  • Statins — lipids and ALT; muscle symptoms.
• Avoid — verapamil and diltiazem in HFrEF (negatively inotropic) unless a specialist advises; NSAIDs in heart failure; QT-prolonging combinations.
• Sick-day rules — temporarily stop ACE inhibitors, ARBs, diuretics, SGLT2 inhibitors and metformin during dehydrating illness — give individualised advice, not blanket instructions.

Counselling, Safety Netting and Shared Decisions

• Explain the diagnosis and any uncertainty in plain language; check understanding (teach-back); invite the patient's priorities; agree a plan and follow-up.
• Explicit red flags to return with — recurrence of severe chest pain (call 999 if lasting over 15 minutes despite GTN), syncope, severe breathlessness, new focal neurological symptoms, haemoptysis with circulatory symptoms, a cold, painful limb.
• Discuss as relevant — driving (current DVLA guidance for the specific condition — e.g. after ACS, ICD, syncope), work, exercise and cardiac rehabilitation, sexual activity, medication adherence and side effects, smoking cessation.
• Shared decision-making — present options (including doing nothing), benefits and risks in absolute terms; respect informed choices.
• Document consent and the reasons investigations or treatments were chosen or deferred.
• MLA clinical skills (CPSA) — examiners reward a clear structure, empathy, avoiding jargon, a summary and a clear safety net.

Mini-cases and Diagnostic Traps

• Examiners reward — a prioritised differential, immediate safety actions, the most discriminating test, and recognising when specialist help is needed.

Cardiovascular Presentations at a Glance

Spot the Diagnosis

Exam-style Scenarios

1. A 58-year-old man has 40 minutes of central chest pain. His first ECG is normal and the first high-sensitivity troponin is within the normal range.
Answer: ACS not yet excluded.

• Repeat ECG (and if pain recurs); repeat troponin at the interval in the local pathway.
• Aspirin if ACS likely and no contraindication; analgesia; consider dissection and PE.
• Discharge only when the pathway rules out MI; arrange further assessment of stable angina if needed (CT coronary angiography).

2. A 22-year-old footballer collapsed during a match and recovered within a minute. His father died suddenly at 35.
Answer: Exertional syncope with a family history of sudden death — high risk of cardiac cause.

• 12-lead ECG (HCM, long QT, Brugada, WPW, ARVC), echo, urgent cardiology review.
• Stop competitive sport until assessed; DVLA advice.
• Family screening through an inherited cardiac conditions service.

3. A 65-year-old woman has sudden tearing chest pain radiating to the back. BP 180/90 in the right arm and 140/80 in the left; there is a new early diastolic murmur.
Answer: Type A aortic dissection with aortic regurgitation.

• Don't give antiplatelets, anticoagulants or thrombolysis.
• Analgesia; control heart rate and BP (IV labetalol — target systolic 100–120 mmHg).
• Urgent CT aortogram; emergency cardiothoracic surgery.

4. A 75-year-old man has HR 34 and BP 78/44. The ECG shows complete heart block. He is drowsy.
Answer: Unstable bradycardia — complete heart block.

• ABCDE, oxygen, IV access; atropine 500 micrograms IV (repeat to 3 mg).
• If no response — adrenaline or isoprenaline infusion and transcutaneous pacing; arrange transvenous pacing.
• Look for causes — inferior MI, drugs (beta-blockers, digoxin), hyperkalaemia; permanent pacemaker.

5. A 70-year-old woman with HFrEF on ramipril, bisoprolol and spironolactone has potassium 6.2 mmol/L and creatinine up 40% from baseline after a diarrhoeal illness.
Answer: Hyperkalaemia and AKI from RAAS blockade during dehydrating illness.

• ECG; treat hyperkalaemia per protocol; fluids.
• Withhold spironolactone and ramipril (and diuretics) temporarily; review drug interactions.
• Restart carefully when recovered with repeat U&E; give sick-day advice.

Key Points

• In chest pain, exclude ACS, dissection, PE, tension pneumothorax and tamponade first.
• A normal first ECG and troponin don't rule out early ACS.
• Orthopnoea and PND suggest left heart failure; oedema alone is non-specific.
• Capture an ECG during palpitations; match monitoring to symptom frequency.
• Exertional, supine or warning-free syncope, or an abnormal ECG, is cardiac until proven otherwise.
• Time murmurs against the carotid pulse; intensity isn't severity.
• Read every ECG systematically and in clinical context.
• Troponin shows injury, not its mechanism.
• Judge shock by perfusion, not BP; bedside echo distinguishes the types.
• Know shockable vs non-shockable rhythms and the 4 Hs and 4 Ts.
• Check renal function and potassium with RAAS drugs; avoid rate-limiting CCBs in HFrEF.
• Safety-net explicitly and document decisions.

Guidelines and Further Reading

• GMC: MLA content map (applying from September 2026)
• NICE CG95: Recent-onset chest pain of suspected cardiac origin; NICE NG185: Acute coronary syndromes
• NICE NG106: Chronic heart failure in adults; NICE NG136: Hypertension in adults
• NICE CG109: Transient loss of consciousness ("blackouts") in over 16s
• NICE NG158: Venous thromboembolic diseases; NICE CG147: Peripheral arterial disease; NICE NG156: Abdominal aortic aneurysm
• NICE CG64: Prophylaxis against infective endocarditis
• Resuscitation Council UK: Adult advanced life support guidelines (current edition)
• DVLA: Assessing fitness to drive — cardiovascular disorders
• BNF — for current doses