AS PACES Cardio

Question 1

DDx Cardiac clubbing

Answer 1

Congenital Cyanotic Heart Disease (FoF, TGV)
Atrial Myxoma
Subacute bacterial endocarditis

Question 2

Takayasu’s arteritis

Answer 2

“Pulseless arteritis”

Question 3

Heart sounds

Answer 3

S1 - mitral
S2 - aortic
S3 - rapid ventricular filling of dilated LV
S4 - atrial contraction against stiff ventricle

Question 4

AS - clinical symptoms and prognosis

Answer 4

Angina - 50% at 5 years
Syncope - 50% in 3 years
Dyspnoea - 50% in 2 years

Question 5

Echo features of severe AS

Answer 5

Valve area <1cm
Pressure gradient >40mmHg
Jet velocity >4m/s

Question 6

AR - signs (eponymous)

Answer 6

Quincke’s - capillary pulsation
Corrigan’s - vigorous carotic pulsation
De Musset’s - head bobbing
Muller’s - uvula pulsation
Traube’s - pistol shot sound over femora’s
Durozier’s - systolic murmur over femoral artery on proximal compressions
Rosenbach’s - systolic pulsations of the liver

Question 7

Causes AR

Answer 7

Bicuspid AV
Rheumatic HD
AI - Ank Spond, RA
CTD - Marfan's, Ehler's Danlos
(if acute think IE, type A aortic dissection)

Question 8

Echo features of AR

Answer 8

Jet width (>65% outflow tract = severe)
Regurgitant jet volume
Premature closing of mitral valve

Question 9

Mitral Stenosis - cause for malar flush

Answer 9

CO –> backpressure + vasoconstriction

Question 10

Mitral Stenosis - causes and echo features of severe disease

Answer 10

Rheumatic heart disease, prosthetic valve

Valve orifice <1cm; pressure gradient >10mmHg, pulmonary artery systolic pressure >50mmHg

Question 11

Mitral stenosis - treatment

Answer 11

Medical - optimise RF

Surgical - in mod/sev AS, percutaneous balloon valvuloplasty, valvotomy, replacement if repair not possible

Question 12

Pathophysiology of rheumatic fever

Answer 12

Ab X reacting following Group A S. pyogenes, molecular mimicry. Myosin, muscle glycogen and SM cells. Path: aschoff bodies and anitschkow myocytes

Question 13

Rheumatic fever - Jones Criteria

Answer 13

GAS infection + 2 major or 1 major and 2 minor
Major - pancarditis, arthritis, subcut nodules, erythema marginatum, sydenham’s chorea
Minor - fever, ESR/CRP, arthralgia, prolonged PR, Hx rheumatic fever

Question 14

Rheumatic fever - management

Answer 14

Bed rest until CRP normal 
BenPen 0.6-1.2mg IM for 10 days
Analgesia - NSAIDs
± Oral Prednisolone if CCF, CM, 
Chorea - diazepam

Question 15

IE - Dukes criteria

Answer 15

2 major; 1 major + 3 minor; all 5 minor
Major: Positive cultures, endocardial involvement - new murmur, vegetation
Minor: predisposition (IVDU, cardiac lesion), fever >38, emboli (septic infarcts, splinters), immune (GM, roth spots, RF), positive blood culture not meeting criteria

Question 16

Types of valve replacements

Answer 16

Ball and cage, tilting disc, bileaflet, porcine valves, bovine valves
Biological are less durable (±10years) but do not require long term anti coagulation

Question 17

Complications of valve replacement

Answer 17

TE: 1-2% per annum even on warfarin
Anaemia: warfarin and haemolysis
Bleeding
IE 
Failure

Question 18

Atrial fibrillation - management

Answer 18

Acute <48hrs, if unstable DC cardioversion, if stable: rate, LMWH, cardiovert (DC, fled or amiodarone)
Paroxysmal - pill in pocket (flecainide or amiodarone), prevention (BB)
Persistant - rhythm: treat precipitant, 3wks warfarin then DC/medical. Rate: BB, rate limiting CCD, 2nd line digoxin

Question 19

AF - scores

Answer 19

CHADVASC - determines necessity of anticoagulation in AF
HASBLED - determines risk of bleeding if anti coagulated
ABCD2 score - after TIA what is the risk of CVA

Question 20

Pacemaker - indications

Answer 20

HB - Mobitz T2, Complete
Symptomatic bradycardia - sick sinus syndrome
Drug resistant tachyarrythmias
BV pacing in CHF

Question 21

Pacemaker - letters

Answer 21

1 - chamber paced (AVD)
2 - chamber sensed (AVD)
3 - response (Inhibited, Triggered, Dual)

Question 22

Medical management of CCF

Answer 22

1st - BB + ACEi + loop diuretic
2nd - Add spironolactone (or epleranone)
3rd - Digoxin
4th - Cardiac resynchronisation therapy