Fifty emergency presentations, grouped by the syndrome a clinician thinks they are dealing with when the patient arrives rather than by the diagnosis that turns out to be correct. Each case is built around a decision made under time pressure, with incomplete information, and each names the mimic that most often catches people out.
Acute coronary syndromes — cases 1 to 12
Anterior STEMI with a delayed presentation and the infarct-size argument that follows. Inferior infarction with right ventricular involvement, where the usual nitrate reflex is exactly wrong. Posterior infarction read as anterior ischaemia. De Winter T waves in a patient sent to the waiting room. Wellens’ pattern in a currently pain-free patient. Left main occlusion presenting with widespread depression and aVR elevation. New left bundle branch block and whether it changes anything. Stent thrombosis at three days versus in-stent restenosis at three months. Type 2 myocardial infarction in sepsis, and the catheterisation that should not have happened. Spontaneous coronary artery dissection in a young woman post partum. Coronary spasm with a normal angiogram. Troponin elevation in a patient whose chest pain was never cardiac.
Cardiogenic shock and pump failure — cases 13 to 20
Shock complicating anterior infarction, and the timing of revascularisation. Acute mitral regurgitation from papillary muscle rupture, presenting as flash pulmonary oedema with a murmur nobody heard. Ventricular septal rupture on day four. Free wall rupture and tamponade. Right ventricular infarction with a clear chest film and a low pressure. Fulminant myocarditis in a previously well thirty-year-old. Decompensated chronic heart failure taken for a first presentation. Post-arrest shock and the temperature decision.
Arrhythmia emergencies — cases 21 to 30
Broad-complex tachycardia treated as supraventricular with aberrancy, and the consequences. Atrial fibrillation with pre-excitation, where the standard drug is contraindicated. Torsades in a patient on three QT-prolonging agents. Complete heart block as the presenting feature of cardiac sarcoidosis. Sinus node disease presenting as falls. Electrical storm after infarction. Bradycardia from a drug that was never reviewed. Syncope with an abnormal ECG that had already been recorded twice. Brugada pattern unmasked by fever. Pacemaker-mediated tachycardia mistaken for a primary arrhythmia.
Structural and valvular emergencies — cases 31 to 38
Critical aortic stenosis presenting as syncope during exercise. Low-flow low-gradient stenosis with discordant measurements. Acute prosthetic valve thrombosis. Infective endocarditis with an embolic presentation and a normal transthoracic study. Aortic dissection presenting with inferior infarction. Tamponade with a small effusion and a fast accumulation. Severe mitral stenosis decompensating in pregnancy. Prosthetic dehiscence after transcatheter implantation.
The mimics — cases 39 to 44
Takotsubo cardiomyopathy taken for anterior infarction. Pulmonary embolism with right heart strain read as inferior ischaemia. Acute pericarditis and the widespread elevation that is not infarction. Oesophageal rupture presenting as crushing central chest pain. Hyperkalaemia producing a sine-wave pattern. Early repolarisation in a young man discharged correctly, and the reasoning that made it safe.
Cases that turn on the patient rather than the disease — cases 45 to 50
Anticoagulation in a patient with a high HAS-BLED score and a genuinely high stroke risk. Antiplatelet strategy after PCI in a patient who must have surgery within a month. Acute coronary syndrome in the very elderly and frail. Chest pain in pregnancy. Cardiac arrest in a patient with an advance directive. An acute presentation where the nearest catheterisation laboratory is two hours away and thrombolysis is the real decision.
How to work through them
Read each case to the decision point and commit to an answer before continuing. A case read passively confirms what you already believe; a case where you have committed and been wrong is the one that stays with you. Candidates preparing for a viva should say the reasoning aloud, because the examination assesses how you argue as much as what you know.
Related material
Longer worked cases with full imaging are in the case studies; member-submitted cases in the case library; live discussion four times a week at the case discussion forum. The reference reading behind these presentations is in the interventional and acute care list, and taught systematically in the cardiac emergencies module of the course programme.