Cardiac station

Question 1

Cardiac causes of clubbing

Answer 1

Infective endocarditis
Congenital cyanotic heart disease
Atrial myxoma

Question 2

causes of AF

Answer 2

Sepsis, mitral valve stenosis, ischaemic heart disease, thyrotoxicosis, hypertension

Question 3

Treatment of AF haemodynamically unstable

Answer 3

urgent DC cardioversion

Question 4

stable AF treatment

Answer 4

rate = if onset >48 hours or uncertain
= b-blockers, rate limiting CCB e.g. diltiazem or digoxin

Rhythm = if reversible cause, <48 hours, heart failure caused by AF
= flecainide, sotalol, amiodarone, AF ablation

Question 5

CHA2DS2VASC

Answer 5

Congestive HF
hypertension
age >65
diabetes
stroke
vascular disease (MI, PAD, atherosclerosis)
age >75
sex

Question 6

CHF investigations

Answer 6

Bloods, ECG, CXR
Measure NT-proBNP
<400 = HF unlikely
400-2000 = referral for echo + specialist review 6w
>2000 = referral + review 2w

Question 7

CHF treatment

Answer 7

1st line = B-Blocker bisoprolol + ACEi ramipril or ARB losartan, furosemide for symptomatic relief from volume overload

2nd line – still symptomatic = mineralcorticoid antagonist = spironolactone

3rd line = specialist = ivabradine, entresto

Question 8

CHF signs/symptoms

Answer 8

Sob, reduced ET, orthopnoea, peripheral oedema, raised JVP, crackles lung bases

Question 9

RVF signs

Answer 9

raised JVP, hepatomegaly, pedal oedema, sacral oedema, ascites

Question 10

LVF signs

Answer 10

pulmonary oedema, tachypnoea, tachycardia

Question 11

CHF presentation

Answer 11

“Today I examined this gentleman’s cardiovascular system. He had tar staining on his fingers and appeared short of breath. His respiratory rate was 16, and heart rate was 120. He had an irregularly irregular pulse and his JVP was raised at 5cm above the sternal angle. The apex beat was displaced in the 6th intercostal space, anterior axillary line, Heart sounds were normal and there were no added sounds. There were bi-basal fine end inspiratory crackles and peripheral oedema present to the mid thigh” These signs are consistent with congestive cardiac failure secondary to ischaemic heart disease. I would like to take a full history to assess symptoms, and order a CXR”

Question 12

acute and chronic causes of RVF

Answer 12

Acute = MI, PE, infective endocarditis,
chronic = left ventricular failure, cor pulmonale

Question 13

Acute and chronic causes of LVF

Answer 13

Acute = MI, Infective endocarditis.
Chronic = ischaemic cardiomyopathy, hypertensive cardiomyopathy, valvular disease

Question 14

STEMI treatment

Answer 14

1st = primary PCI (<12 hours from onset + <120 mins for PCI)
2nd = fibrinolysis (<12 hours, >120 mins for PCI) = alteplase

Question 15

Initial management of ACS

Answer 15

Analgesia
Antiemetics
Aspirin 300mg
Oxygen if <94%
GTN infusion if pain, HTN or oedema

Question 16

NSTEMI

Answer 16

Positive troponin no ECG changes

Question 17

NSTEMI treatment

Answer 17

aspirin 300mg + fondaparinux
PCI if GRACE score >3% (within 72 hours)

Question 18

Unstable angina treatment

Answer 18

aspirin 300mg + fondaparinux

Question 19

reversible MI causes

Answer 19

Hypoxia
hypovolaemia
hypothermia
hypokaelamia or hyperkalamia
hypoglycaemia
Tamponade
tension pneumo
thrombosis
toxins

Question 20

Broad complex arrythmias

Answer 20

VT
Torsades de Pointes = iV magnesium sulphate

Question 21

Narrow complex arrythmias

Answer 21

SVT, sinus tachy, AF

Question 22

Aortic stenosis signs

Answer 22

Slow rising pulse, narrow pulse pressure, Ejection Systolic Murmur, loudest on expiration, radiates to carotids DDx = aortic stenosis, HOCM, mitral regurg Causes = age related = calcification, RHD

Question 23

AS symptoms (ASH)

Answer 23

angina, syncope, heart failure

Question 24

AS investigations

Answer 24

ECG, CXR, echo + doppler, coronary angio

Question 25

AS management

Answer 25

general = MDT, RF modification, QRISK, statin, antiplatelet, HTN, angina
Surgical = open replacement (ball in cage = 3 sounds) (bileaflet = 1 sound)

Question 26

AS surgery and indications for surgery

Answer 26

TAVI or balloon valvuloplasty
Indications for surgery = symptomatic, CCF, pressure gradient <40%

Question 27

MR signs

Answer 27

Displaced apex, S1 quiet, pansystolic murmur, radiates to axilla, valvotomy scar, atrial fibrillation also present
severe if displaced/thrusting apex, LVF

Question 28

MR other DDx

Answer 28

aortic stenosis, VSD

Question 29

MR management

Answer 29

conservative= MDT, RF mod
Medical = AF = rate/rhythm Reduce afterload = ACEi, B-blocker, diuretics
surgery= repair or replace valve

Question 30

MR causes

Answer 30

RHD, IE, IHD, Papillary muscle rupture

Question 31

MR presentation

Answer 31

“Today I examined this gentleman’s cardiovascular system. On general inspection he looked alert and comfortable in bed. He had a normal pulse, and his apex beat was non-displaced. Heart sounds I + II were heard and he had a pansystolic murmur, intensity 3/6, loudest at the apex, which radiated to the axilla. There were bibasal fine end inspiratory crackles and peripheral oedema present to the mid thigh. These are consistent with mitral regurgitation with congestive cardiac failure. I would like to take a history to assess for impact on the patient’s life and request a CXR”

Question 32

AR signs

Answer 32

Collapsing pulse, head nodding with pulse = De Musset’s sign, Corrigan’s = neck pulses, ejection diastolic murmur at LSE, loudest on expiration

Question 33

AR DDx

Answer 33

Mitral stenosis

Question 34

AR management

Answer 34

conservative= MDT, RF mod,
Medical = ACEi + B-blocker, + diuretics,
Surgery = valve replacement

Question 35

AR causes

Answer 35

IE, rheumatic heart disease, aortic dissection

Question 36

MS signs

Answer 36

Mid diastolic murmur, Atrial fibrillation

Question 37

MS differentials

Answer 37

Aortic regurg

Question 38

MS causes

Answer 38

IE, RHD

Question 39

MS management

Answer 39

conservative= MDT, RF mod.
Medical = RHD prophylaxis, AF = rate control + DOAC,
Surgery = balloon valvuloplasty

Question 40

Valve presentation

Answer 40

“I examined this Gentleman’s cardiovascular system. He had a midline sternotomy scar and there was warfarin at the bedside. He had irregularly irregular pulse. There was a metallic click with the first heart sound and the second heart sound was normal. There were no additional sounds and no features of cardiac failure. These signs are consistent with atrial fibrillation and a metallic mitral valve replacement that is functioning well.”

Question 41

Post CABG signs

Answer 41

tar staining, midline sternotomy scar, scar over left saphenous vein

Question 42

Post CABG presentation

Answer 42

“Today I examined this gentlemen’s cardiovascular system. He had tar staining on his fingers, a midline sternotomy scar and a scar over his left saphenous vein. Heart sounds were normal with no additional sounds, and there were no features of cardiac failure. These signs are consistent with previous coronary artery bypass graft using the left great saphenous vein”

Question 43

Vessel used in CABG

Answer 43

Great saphenous = scar on calf
Internal thoracic artery / internal mammary artery = more common

Question 44

post-CABG management

Answer 44

DAPT = aspirin and clopidogrel for 12 months then aspirin life long
Beta blocker = bisoprolol
ACEi = ramipril or ARB = Losartan

Question 45

IE

Answer 45

Staph aureus, strep viridians, mitral valve most common, IVDU = tricuspid, fever, murmur, clubbing, petechiae, splenomegaly, haematuria, roth’s spots, Janeway lesions, osler’s nodes
Treatment = amoxicillin and gentamicin

Question 46

normal cardiac exam presentation

Answer 46

Today I performed a cardiovascular examination of X year old Y.
On general inspection the patient was comfortable at rest, did not seem breathless or in pain and did not have monitoring attached.
On closer inspection of the hands and arms, the patient did not exhibit any stigmata of cardiovascular disease such as splinter haemorrhages or Osler’ nodes.
Extremities were warm with normal capillary refill.
Pulse was regular at Z bpm, and there was no radio-radial delay or collapsing pulse.
On closer inspection of face and chest, no anaemia or scars were identified.
JVP was non raised, and carotid pulse had normal volume and character.
No heaves of thrills were identified and apex beat was non displaced at the mid clavicular line.
On auscultation of the heart, hearts sound I and II were audible with no additional sounds.
Lung bases were clear and there was not sacral or peripheral pitting oedema.
In conclusion this was a normal cardiovascular examination. To complete my examination, I would like to take full history and perform a respiratory examination.
I would like to take a full set of observations, including lying and standing BP, take an ECG reading as well as capillary glucose and take bloods, including FBC, U&Es and LFTs for baseline, and cardiac markers if indicated.

Question 47

ECG presentation

Answer 47

This is a 12 lead ECG of X year old Y.
It was taken a Z hrs on the date. The quality is adequate, and the calibre is 25mm/s.
The rate is W bpm and regular and there is no/R/L axis deviation.
Every p wave is followed by a QRS complex; thus, this is sinus rhythm.
PR interval is normal, 0.12-0.2 ms, not slurred.
The Q wave is normal (non-pathological).
The QRS complex is narrow (0.8-0.12 ms) and not prolonged. The R waves are equal in size, and there is progression in the chest leads.
The ST interval is normal/elevated/depressed/saddle elevation.
The QT interval is normal/prolonged, the T waves is normal/tall and tented/inverted/biphasic…
In conclusion this is a normal/abnormal ECG…
My main differential is…

Question 48

What are advantages and disadvantages of tissue heart valves?

Answer 48

• Advantages: No need for warfarin anticoagulation, thus safer in women of child-bearing
  age and in the elderly.
• Disadvantages: Reduced lifespan of prosthesis compared to mechanical valves, due to
  degeneration and calcification.