A 52-year-old man presented with a history of sudden onset diplopia. On neurological examination, the only abnormality was a right-sided oculomotor (third nerve) palsy. A brain CT was performed and reported as showing no abnormality. He was discharged to be investigated as an outpatient. He presented 1 month later with a new expressive dysphasia and confusional state. MRI was performed which revealed multiple cerebral infarcts. He was discharged on secondary stroke prevention medication. Six months elapsed, before a transthoracic echocardiogram was performed. This showed a large left atrial myxoma. The patient underwent an emergency resection and made a good postoperative recovery. This case report showed the importance of considering a cardiogenic source of emboli in patients who present with cerebral infarcts. Performing echocardiography early will help to detect treatable conditions such as atrial myxoma, and prevent further complications.

identified 119/138 (86%) patients that met the minimum requirement for palliative care input. However, the SHF model predicted that only 6/138 patients (4.3%) had a predicted life expectancy of less than 1 year. Patients who met GSF criteria for palliative care had significantly more hospital admissions (p¼0.001) and had significantly lower predicted survival rates at 1 year (p¼0.038) than those patients that did not meet GSF criteria. At follow-up, 43/138 patients had died (31%). Of these, 58% (25/43) died in hospital, following an acute admission. The sensitivity and specificity for the GSF and SHF model were 22%/83% and 98%/12% respectively. Overall, the patients renal function (eGFR<35 ml/min) was the best predictor of mortality, (sensitivity/specificity¼82%/56%). Discussion Neither the GSF nor the SHF were very accurate in predicting which patients were in the last year of life, in this selected sample. Despite the increasing drive towards palliation in heart failure, clinicians are still faced with a substantial prognostic barrier. Therefore, the progress of palliative care in heart failure patients may require a shift away from the traditional "end of life" model developed in cancer treatment, and focus instead on a patient 9 s increasing needs coupled with an understanding that death, itself, may remain unpredictable.

The acute coronary syndromes form a clinical spectrum, which ranges from unstable angina without myocardial injury, non-ST segment elevation and ST segment elevation myocardial infarction. All three conditions share a common pathophysiological basis. The management of acute ST segment elevation myocardial infarction however, is distinct from the other syndromes and therefore forms the basis of another article in this series. In this article we concentrate on the recognition and management of unstable angina and Non ST-segment elevation myocardial infarction (NSTEMI).