Cardio Flashcards

1
Q

Broad complex tachycardia, BP 88/59, Rx?

A

DC cardioversion

If systolic BP <90 in tachyarrhythmia then DC cardioversion

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2
Q

When is a patient classified as stable or unstable in the context of tachyarrhythmia?

A

Unstable if any of the following adverse signs:

  • Shock (systolic BP <90, pallor, clammy, confusion, impaired consciousness)
  • Syncope
  • Myocardial ischaemia
  • Heart failure

If any of the above are present then give synchronised DC cardioversion. Rx following this is dependent on if it was broad or narrow complex, and if it was regular or irregular

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3
Q

What are potential causes of a broad complex tachycardia with regular and irregular rhythms?
What are their treatments (if stable)?

A

Regular:

  • Assume VT - amiodarone (300mg loading dose then 900mg over 24 hours)
  • SVT with BBB - treat as per SVT

Irregular:

  • AF with BBB - treat as per narrow complex tachycardia
  • Polymorphic VT (torsades de pointes) - IV Magnesium
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4
Q

Potential causes of narrow complex tachycardia with regular and irregular rhythms?
Treatments?

A

Regular:

  • SVT - vagal manoeuvres then IV adenosine
  • If unsuccessful, consider atrial flutter and control rate

Irregular:

  • Probably AF
  • If onset <48 hrs consider electrical/chemical cardioversion
  • Rate control (B blocker/Digoxin) and anticoagulation required
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5
Q

Treatment of acute native valve endocarditis?

A

IV Flucloxacillin 2g 6 hourly

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6
Q

Treatment of subacute (indolent) native valve endocarditis?

A

IV Amoxicillin + Gentamicin

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7
Q

Treatment of prosthetic valve endocarditis or suspected MRSA?

A

IV Vancomycin + Gentamicin + PO Rifampicin

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8
Q

4 common bacterial causes of endocarditis and their associations?

A

Staph Aureus - most common, IVDU

Staph epidermis - peri-operative, <2 months post-op

Strep Viridans - dental procedures

Strep Bovis - colorectal cancer

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9
Q

5 causes of culture negative endocarditis?

A
Previous antibiotic therapy
Coxiella burnetti
Bartonella
Brucella
HACEK (haemophilus, actinobacillus, cardiobacterium, eikenella, kingella)
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10
Q

common drugs which prolong QT interval?

A
Antipsychotics (mainly typical)
Type 1a, 1c and 3 arrhytmatics
Tricyclics
Other antidepressants (citalopram, moclobemide etc)
Loratadine
Hydroxychloroquine
Macrolides (clarithromycin)
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11
Q

How to tell between aortic stenosis and sclerosis?

A

Aortic sclerosis doesn’t radiate to carotids and has normal ECG

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12
Q

What 2 scenarios is cardioversion used in AF?

When should you offer rate/rhythm control?

A

Haemodynamically unstable - electrical

Electively where rhythm control strategy preferred - electrical or chemical

Offer rate/rhythm control if onset <48 hours
Offer rate control if >48 hours

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13
Q

Management of haemodynamically stable AF onset <48 hours?

A

Heparinise patient, then cardiovert

Electrical - synchronised DC
OR
Pharmacological:
- Amiodarone if structural heart disease
- Amiodarone/Flecainide without

If no other risk factors for ischaemic stroke, further anticoagulation unnecessary. If present, oral anticoagulation for life

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14
Q

Management of haemodynamically stable AF onset >48 hours?

A

Rate control and anticoagulation for at least 3 weeks.

If recurrent AF or previous cardioversion failure, amiodarone/sotalol for 4 weeks.

Electrical cardioversion

Anticoagulation continued for at least 4 weeks after - decision on continuation based on risk factors

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15
Q

Drugs to control rate in AF?

A

Bisoprolol
Verapamil/Diltiazem
Digoxin - normally not preferred, but 1st choice if co-existing heart failure as positive inotropic effect

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16
Q

Drugs to maintain sinus rhythm in Hx of AF?

A

Amiodarone
Sotalol
Flecainide

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17
Q

Factors favouring rate (2)/rhythm (4) control strategy in AF?

A

Rate - age >65, Hx of IHD

Rhythm - age <65, symptomatic, first presentation, CCF

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18
Q

Stroke risk score in AF?

A

CHA2DS2VascS

C - congestive HF
H - hypertension 
A - age 75 or above = 2
     age 65-74 = 1
D - diabetes
S - stroke or TIA (previous) = 2
V - vascular disease (IHD/PVD) 
S - sex (female)

0 = no anticoagulation
1 = males consider anticoagulation
females don’t (they got this score from their sex)
2 = offer anticoagulation

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19
Q

When is catheter ablation used in AF?
What medication must the patient take beforehand?
What does it do to stroke risk?
3 complications?

A

Failure to respond to cardioversion, or wish to avoid antiarrhythmatics

Anticoagulants for 4 weeks minimum beforehand

Whilst ablation might restore to sinus rhythm, it doesn’t reduce stroke risk

tamponade, stroke, pulmonary valve stenosis

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20
Q

How do thiazides cause hypokalaemia?

A

They block Na/Cl co-transporter in DCT, so more Na reaches collecting duct

More K lost in collecting duct as a result

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21
Q

Side effects of thiazide-like diuretics, such as indapamide and chlortalidone?

A

Same as thiazides

Hypokalaemia/Hyponatraemia
Hypercalcaemia
Gout
Postural hypotension 
Impaired glucose tolerance
Impotence

Rarely: agranulocytosis, pancreatitis, thrombocytopenia, photosensitive rash

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22
Q

Hypertension ladder?

A

1:
<55 OR T2DM - A
55+ or black, no T2DM - C

2: A+C or A+D
3: A+C+D

4: If K+ 4.5 or less - spironolactone
If K+ >4.5 B-blocker or A-blocker

5: Specialist

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23
Q

What tests should be done before starting amiodarone?

Monitoring after this?

A

TFT, LFT, U&E, baseline CXR

TFT and LFT every 6 months

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24
Q

Blood pressure targets for clinic and ABPM for someone:
<80 y/o?
>80 y/o?

A

<80:
clinic - <140/90
ABPM - <135/85

> 80:
clinic - <150/90
ABPM - <145/85

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25
7 causes of ST elevation?
STEMI Pericarditis/myocarditis Normal variant (high take off) LV aneurysm Coronary artery spasm (prinzmetal's angina) Takotsubo cardiomyopathy (octopus pot, floppy apical LV) Subarachnoid haemorrhage (rare)
26
Pathognomic ECG finding in cardiac tamponade?
Electrical alternans Waves are of alternating amplitude, 1st and 3rd will be same height, 2nd and 4th will be etc Amplitude may be small as well depending on how bad the tamponade is
27
Which antihypertensive can cause constipation and abdominal pain as a side effect?
Thiazides - hypercalcaemia ``` Bones - bone pain Stones - kidney stones Groans - abdo pain Thrones - constipation/urinary frequency Tones - muscle weakness and hyporeflexia Psychiatric moans - depression, anxiety, confusion ```
28
What is eisenmenger's syndrome? How can it present? Management?
Pulmonary hypertension as a result of an uncorrected VSD The RV hypertrophies until it overcomes the LV - this causes chronic pulmonary microvascular changes It causes R to L shunt and chronic cyanosis. This may be seen as: - blue tinge to nails/lips - clubbing/loss of nail fold - RV failure - original murmur may disappear - haemoptysis (from pul microvasc changes) Rx: heart and lung transplant needed eventually
29
VT without haemodynamic instability: - What is treatment? - What should be avoided?
Amiodarone - 1st line option Procainamide Lidocaine (use with caution, esp with severe LV impairment) NEVER use Verapamil (if drug therapy fails then synchronised DC cardioversion)
30
What symptom do most patients get following administration of adenosine?
Chest pain | due to increased coronary sinus blood flow
31
ECG of digoxin toxicity? (4)
- Downsloping ST depression widespread (like a reversed nike tick) - inverted/flattened T waves - Shortened QT interval - Can cause AV block/bradycardia
32
Course of action for patients presenting with acute chest pain: - <12 hours ago? - 12-72 hours ago? - >72 hours ago?
- take ECG and emergency admission to hospital - refer to hospital for same-day assessment - Full workup including ECG and troponin - use this to guide your judgement
33
Immediate management of suspected ACS?
- Morphine (if in pain) - Oxygen** - GTN spray - Aspirin - 300mg (high dose) - Clopidogrel or Ticagrelor once in hospital * * - if sats <94% and not at risk of T2 resp failure - if at risk of T2 resp failure, aim for 88-92%
34
3 criteria for angina? | What is unstable angina?
1. Constricting discomfort in chest, neck, shoulders, jaw or arms 2. Brought on by physical exertion 3. Relieved within 5 mins by GTN spray Atypical angina - 2/3 of these - e.g. if pain is 'stabbing' instead of 'constricting' (more common in women and diabetics) If only 1/3 - non-anginal chest pain
35
Investigations for angina if it cannot be diagnosed clinically alone?
1. CT coronary angiography 2. non-invasive functional imaging (e. g. perfusion scintigraphy, SPECT, stress echo, MR perfusion scan) 3. invasive coronary imaging
36
Angina pectoris treatment ladder?
All patients should receive aspirin 75mg, a statin and GTN (unless CI) 1. B-blocker or rate-limiting CCB 2. Once at max dose, add second drug: B-blocker + dihydropyridine CCB 3. If still symptomatic, refer for assessment for PCI/CABG and add a 3rd drug: - ivabradine (funny current HCN channel blocker) - long-acting nitrate - nicorandil (K channel opener/NO activity) - minoxidil (K channel opener/NO activity)
37
Usual 4 medications for pulmonary hypertension? | Other drug options (class + example)?
Warfarin/DOAC Diuretic High % oxygen Digoxin - CCB's - nifedipine, amlodipine, diltiazem - Endothelin ETa receptor antagonists - bosentan, ambrisentan - PDE5 inhibitors - sildenafil - Prostaglandins - iloprost - guanylate cyclase inhibitors - riocugat
38
What must you be careful of with nitrates? | Other SE? (4)
Tolerance - take second nitrate after 8 hours, not 12, leaving 4 hours nitrate free in body Effect not seen as much with modified release isosorbide mononitrate Headache Postural hypotension Tachycardia Flushing
39
``` 2 methods of ACS developement? What is ACS spectrum? Symptoms? Often mistaken for? Who gets silent MI? Signs? ```
- Gradual narrowing of lumen until occluded by atherosclerotic plaque (angina) - Rupture of plaque causing thrombosis Unstable angina NSTEMI STEMI ``` Central, crushing, heavy chest pain - to neck, jaw, shoulder, arm Stomach pain, nausea, vomiting Pale, clammy Sense of impending doom SOB ``` Often mistaken for dyspepsia Esp in diabetics/elderly, who may not get chest pain Often very little signs - BP, temp etc all normal May be tachycardia/tachypnoeic Signs of heart failure may begin to develop after a while
40
Criteria for a STEMI?
- Clinical symptoms consistent with ACS for >20 mins - ST elevation of 2 small squares (2mm) in at least 2 contiguous leads Can also have : - ST elevation of 1 small square (1mm) in other leads - New onset LBBB
41
Management of STEMI?
If presenting within 12 hours of symptom onset: If PCI can be accessed within 2 hours: - Aspirin + prasugrel (clopidogrel if already on oral anticoagulant) - PCI with heparin + abciximab cover - Place drug-eluting stent If PCI cannot be accessed within 2 hours: - Thrombolysis + LMWH/Fondaparinux - Repeat ECG 90 mins after delivery - if no improvement, organise transfer for PCI
42
NSTEMI/Unstable angina management?
Give aspirin Give Fondaparinux if no immediate PCI planned and no increased bleeding risk Calculate GRACE score (6 month mortality) If >3%: - Offer PCI within 72 hours - Prasugrel/Ticagrelor + heparin + drug-eluting stent If <3%: - Give Ticagrelor
43
Why does cardiac arrest occur after MI?
Most commonly VF | Also VT
44
Why does cardiogenic shock occur with MI?
If a large part of the LV myocardium is damaged, ejection fraction of heart may decrease massively May occur because of mechanical reasons such as LV free wall rupture
45
What chronic condition occurs commonly after MI?
Heart failure
46
Which type of MI does AV block occur with?
Most commonly inferior | Can cause bradyarrhythmias
47
2 types of pericarditis following MI?
<48 hours - due to transmural MI, occurs in 10%. Typical pericarditis features - worse on lying flat, pericardial rub, pericardial effusion 2-6 weeks - Dressler's Syndrome - autoimmune reaction against antigenic proteins. Fever, pleuritic pain, pericardial effusion, raised ESR. Rx: NSAIDs
48
Why might LV aneurysm form after MI? ECG and signs? What might it put patients at risk of?
Sustained weakness of myocardium Persistent ST elevation Signs of LV failure (pul oed) Thrombus forming and stroke - patients must be anticoagulated
49
When does LV free wall rupture occur following MI? Presentation? Treatment?
1-2 weeks (occurs in 3%) Acute heart failure secondary to tamponade - Raised JVP - Pulsus paradoxus - diminished heart sounds Urgent pericardiocentesis and thoracotomy
50
What type of MI does acute mitral regurg occur with? Why does it happen? Symptoms/signs? Treatment?
Infero-posterior MI Ischaemia/rupture of papillary muscle Acute hypotension and pulmonary oedema Early-mid diastolic murmur Vasodilator therapy and emergency surgical repair
51
What is plusus paradoxus? | 2 causes?
Greater than normal (>10mmHg) drop in systolic BP during inspiration (faint/absent pulse during inspiration) Cardiac tamponade Severe asthma
52
What causes a slow-rising/plateau pulse? (1)
Aortic stenosis | also narrow pulse pressure
53
What is a collapsing/water-hammer pulse? | Causes? (3)
Pulse which can be felt rapidly increasing in force through the bulk of the muscle in the forearm when the arm is raised above the head, and subsequently collapses Aortic regurgitation PDA Hyperkinetic states (anaemia, thyrotoxicosis, fever, exercise, pregnancy) Explanation: if hyperaemic/aortic regurg etc sluggish blood flow through artery in arm. Raising arm above head causes it to rapidly flow back towards the LV, increasing the EDV for the next cycle (valve regurgitates it) - increased stretch from increased volume increases the force of the next contraction via Frank-Starling mechanism
54
What is plusus alternans? | Cause?
Regular alternation of the force of arterial pulse Severe LVF
55
What is a bisferiens pulse? | What causes it? (2)
'double pulse' - 2 systolic peaks Mixed aortic valve disease Occasionally HOCM
56
What is a jerky pulse? | What causes it?
Seen in HOCM Pulse which has a rapid upstroke due to vigorous contraction of hypertrophic LV As volume of LV decreases there is abrupt blockage of outflow This causes a rapid fall in arterial pressure (HOCM may also sometimes be assoc w bisferiens pulse)
57
Causes of pericarditis? (8)
``` Viral (often coxsackie) Uraemia (causes fibrinous pericarditis) TB Trauma MI SLE Hypothyroidism Malignancy ```
58
ECG changes in pericarditis? What other investigation should all with suspected acute pericarditis get? Management?
Widespread: - 'Saddle-shaped' ST-elevation - PR depression (most specific) Transthoracic echo NSAID + Colchicine Treat underlying cause
59
Causes of constrictive pericarditis? Symptoms/Signs? Specific Ix? How to differentiate from tamponade?
Any cause of acute, particularly TB ``` Dyspnoea Pericardial knock (S3) Elevated JVP with x+y descent Kussmaul sign is positive (rise in JVP during inspiration) RV failure: - Elevated JVP - Ascites - Oedema - Hepatomegaly ``` CXR - shows pericardial calcification Pulsus paradoxus is ABSENT (present in tamponade)
60
Who should myocarditis be suspected in? Causes? (6) Presentation?
Esp young people with acute chest pain ``` Viral - coxsackie, HIV Bacteria - diphtheria, clostridia Spirochaetes: Lyme disease Protozoa: Chagas disease, toxoplasmosis Autoimmune Doxorubicin (chemo drug) ``` Typical presentation: - young person - acute chest pain - dyspnoea - arrhythmia
61
Ix for myocarditis? (2) Management? Complications? (3)
Bloods: - Inflam markers - cardiac enzymes - bnp ECG: - tachycardia - arrhythmia - ST elevation - T wave inversion Rx: - Supportive, treat cause Comp: - HF - Sudden death from arrhythmia - Dilated cardiomyopathy (late)
62
Underlying cause of VT? 2 types and what causes of each? Why is it important to treat?
Ventricular ectopic focus, leading to broad complex tachycardia Monomorphic - usually MI Polymorphic (Torsades de pointes) - Long QT interval Can lead to VF
63
Apart from drugs, what can cause long QT interval?
Congenital (random things including deafness) Electrolytes: - hypocalcaemia - hypokalaemia - hypomagnesaemia MI Myocarditis Hypothermia Subarachnoid haemorrhage
64
What is WPW syndrome? What can it cause? ECG features? (3) Management? (2)
Congenital accessory pathway between the atria and ventricles leading to AV re-entry tachycardia (current spreads up through ventricles and rather than stopping at top of ventricles it goes back into atrium) 1. Short PR interval 2. Wide QRS with slurred upstroke - delta wave 3. Axis deviation towards side of pathway (usually left) Definitive: ablation Medical: Sotalol/Amiodarone or Flecainide (avoid sotalol if concurrent AF as prolonging AV refractory encourages transmission through accessory)
65
What therapy should be initiated after MI? What if they have HF as well? Is this just for STEMI or for NSTEMI as well? When can sexual activity resume? When could sildenafil (viagra) be used?
``` Statin ACEI B blocker Aspirin Ticagrelor for 12 months (can extend if high risk) ``` Add aldosterone antagonist (eplerenone) within 2 weeks Both Sex after 4 weeks Sildenafil after 6 months - NOT if also taking nitrates or nicorandil
66
Timeline of ECG changes in MI?
Acutely: ST elevation/depression Within 24 hours: Q wave formation T wave inversion ST changes remain After week(s): ST back to normal Q waves and T wave inversion remain
67
Contraindications for thrombolysis? (8) | Potential SE?
- Active internal bleeding - Recent haemorrhage/trauma/surgery (including dental extraction) - Coagulation/bleeding disorders - Intracranial neoplasm - Stroke <3 months ago - Aortic dissection - Recent head injury - Severe hypertension SE: - Haemorrhage - Allergic reaction - esp streptokinase
68
Diagnosis of chronic heart failure? What causes release of BNP? What is its physiological effect? (4) What to do if raised/high levels?
BNP and NT-proBNP BNP: Normal <100 Raised 100-400 High >400 NT-proBNP: Normal <400 Raised 400-2000 High >2000 Released by LV myocardium in response to strain - causes vasodilation, diuresis, natriuresis, and suppresses RAAS Raised: specialist assessment within 6 weeks High: specialist assessment within 2 weeks
69
Treatment ladder of chronic heart failure? | Other treatments these patients should get?
All patients start on: ACEI + B1-blocker 2nd line: aldosterone antagonist (careful as these + ACEI can cause hyperkalaemia) 3rd line options - to be started by specialist: - Ivabradine - Digoxin - Hydralazine - Sacubitril-Valsartan - Cardiac resynchronisation therapy Other things: - annual influenza vaccine - One off pneumococcal vaccine (asplenic or CKD patients need booster every 5 years)
70
What is a preserved (normal) ejection fraction? What is a mildly reduced ejection fraction? What is a reduced ejection fraction?
Preserved: >50% Mildly reduced: 40-49% Reduced: <40%
71
NYHA classification?
1 - no symptoms/limitation 2 - mild - fatigue, palpitations or dyspnoea with activity 3 - mod - less than ordinary activities result in marked symptoms 4 - sev - symptoms at rest, unable to carry out any physical activity
72
When should someone receive statins for primary prevention? What dose and drug for primary and secondary prevention? What are the CI/interactions of statins?
QRISK 10% or more Primary prevention: Atorvastatin 20mg Secondary prevention: Atorvastatin 80mg CI: pregnancy Inter: macrocodes - choose other antibiotic if possible or stop statins during course
73
HOCM: - inheritance? - gene? - Echo abnormalities? (3)
AD beta-myosin heavy chain protein MR SAM ASH - Mitral regurgitation - Systolic anterior motion of anterior mitral valve - Asymmetrical septal hypertrophy
74
Arrhythmogenic RV dysplasia: - what is it? - ECG abnormalities?
RV myocardium replaced by fatty and fibrofatty tissue In V1-V3: - T-wave inversion - Epsilon wave (terminal notch in QRS)
75
7 common causes of dilated cardiomyopathy? Signs? (3) What is seen on echo and cxr?
``` Alcohol IHD Muscle disease e.g. DMD Coxsackie B virus Wet beri beri Doxorubicin (chemo drug) Infiltrative disease (e.g. haemochromatosis, sarcoidosis) ``` Dilated = most common, 90% of cardiomyopathies Signs: - Signs of HF - Systolic murmur (mitral/tricuspid regurg) - S3 Echo: all 4 chambers dilated CXR: 'balloon' shape of heart
76
2 most common causes of restrictive cardiomyopathy?
Amyloidosis | Radiotherapy
77
When does peripartum cardiomyopathy develop? | Who is it more common in?
Between last month of pregnancy and 5 months postpartum (dilated cardiomyopathy) Older women, greater parity
78
What causes takotsubo cardiomyopathy? Features? (2) Rx? (1)
'stress induced' e.g. bereavement then develop chest pain and heart failure Transient, apical ballooning of myocardium LV 'octopus pot' shape Rx: supportive
79
What is subclavian steal syndrome? Presentation? (2) Rx? (1)
Subclavian stenosis proximal to the origin of the vertebral arteries - resulting in retrograde blood flow from the vertebral arteries to the arm during exercise Presentation: - Dizziness/vertigo during exercise - Concurrent arm pain (typically posterior circulation symptoms) Rx: stent
80
What are the 3 types neurally-mediated syncope? | What occurs before it?
- Vasovagal episode - usually brought on by emotion, pain or stress ('fainting') - Situational - in response to coughing, micturition - Carotid sinus syncope - exaggerated response to pressure applied to carotid sinus Before: sweating, pallor, nausea/vomiting Then transient loss of consciousness Quick recovery, no post-ictal state
81
What can cause cardiac syncope? (3)
Arrhythmias (brady or tachy) Structural: valvular, MI, HOCM PE
82
Causes of orthostatic syncope?
Due to autonomic failure Primary: Parkinson's, LBD Secondary: diabetes, amyloid, uraemia Drug-induced: diuretics, alcohol, vasodilators Volume depletion: haemorrhage, diarrhoea
83
Definition of Syncope? | 3 broad types?
Transient LOC due to global cerebral hypo perfusion - rapid onset, short duration, quick and spontaneous recovery Reflex (neurally mediated) Orthostatic Cardiac
84
What is coarctation of aorta? How may it present in infancy? When to suspect coarctation of aorta in an adult? What is seen on CXR that is not seen in young children? 4 associations?
Congenital narrowing of descending aorta (most commonly post-ductal) Heart failure Young person with hypertension Radio-femoral delay BP difference between left arm and other limbs Notching of inferior rib borders (due to collaterals) ``` Turner's syndrome Bicuspid aortic valve Berry aneurysms NF (more common in males) ```
85
Warfarin reversal: - major bleeding? - INR >8 (minor+no bleeding)? - INR 5-8 + minor bleeding? - INR 5-8, no bleeding? - When to restart warfarin?
1: - IV VitK - Prothrombin complex concentrate (or FFP) 2: - VitK - IV if minor bleeding, PO if no bleeding - Repeat INR after 24 hours 3: - IV warfarin 4: - Withhold 1-2 doses, then reduce maintenance dose 5: - Restart warfarin once INR <5
86
What is Buerger's disease? | Features? (4)
Small-medium vessel vasculitis, strongly assoc w smoking (young male, smoker, limb ischaemia) Limb ischaemia Ischaemic ulcers Superficial thrombophlebitis Raynaud's
87
What is Buerger's test for? | How is it performed?
Limb arterial insufficiency - Lying down, raise both patents' legs to 45 degrees for 1 minute - They will become pale due to poor blood flow - Then ask patient to sit off edge of bed with legs hanging down - Skin first turns blue as deoxygenated blood returns to tissue, then red due to reactive hyperaemia from post-hypoxic dilation
88
Treatment of bradyarrhythmia (e.g. complete heart block) post-MI if: - anterior MI? - inferior MI?
Anterior - external pacing Inferior - atropine (because bradyarrhythmias post-inferior MI are normally transient and resolve in hours-days, so treat conservatively)
89
Indications for temporary external pacing? (3)
- symptomatic/haemodynamically unstable bradycardia not responding to atropine - post-ANTERIOR MI - if develop type 2 or complete heart block - trifascicular block prior to surgery
90
Anticoagulation after mechanical valve insertion? Target INR? Who is still given bioprosthetic valves (e.g. pig or cow)? Problems with these?
Warfarin Aortic 3.0 Mitral 3.5 Older people: >65 if aortic and >70 if mitral Long-term anticoagulation not needed, just 75mg aspirin Problems: deterioration & calcification over time
91
What to do if patient starts experiencing increasing chest pain or haemodynamic instability following PCI for STEMI?
Arrange urgent CABG Give nitrates and morphine in meantime
92
P wave changes - what causes: - increased amplitude? - broad, notched (bifid) p wave?
Cor pulmonale (P pulmonale) LA enlargement classically in mitral stenosis (P mitrale) Most commonly in lead II
93
5 acyanotic heart defects?
``` VSD (most common, 30%) ASD PDA Coarctation Aortic stenosis ``` VSD more common than ASD but ASD more common as a new diagnosis in adulthood
94
3 cyanotic heart defects?
Tetralogy of Fallot Transposition of Great Arteries Tricuspid atresia TOF more common but usually present at 1-2 months TGA more commonly recognised at birth (Pulmonary stenosis - presence of cyanosis depends on severity of stenosis and presence of coexistent defects)
95
How to determine if neonatal cyanosis is of cardiac origin? | What to do as initial supportive management if it is ductal dependent?
Nitrogen washout test - give 100% O2 for 10 mins then do ABG, pO2 <15kPa indicates cardiac cause If duct-dependent give PGE2
96
What is acrocyanosis?
Blue discolouration of mouth, hands and feet in a newborn caused by vasospasm. Benign, normal finding in healthy newborns. Lasts 24-48 hours Differentiated from other causes of neonatal cyanosis (e.g. sepsis) as it occurs straight after birth
97
PDA: - connection between what? - can it lead to cyanosis? - what is seen on praecordial exam? - pulse type? - murmur? - Rx?
- pulmonary trunk and descending aorta - yes, eventually, cyanosis of lower extremities (termed differential cyanosis, as upper limbs normal) - subclavicular thrill, heaving apex beat - large volume, bounding, collapsing pulse - continuous machine-like murmur - indomethacin/ibuprofen
98
TOF: - what are the 4 deformities? - when is it picked up? - what are tet spells? - murmur? - cxr/ecg? - management?
4 deformities: - VSD - RV hypertrophy - pulmonary stenosis/RV outflow tract obstruction - overriding aorta - 1-2 months - When baby becomes cyanotic when it cries/becomes agitated due to rapid decrease in blood oxygenation - ejection systolic murmur (due to pulmonary stenosis - VSD doesn't usually cause murmur) CXR: boot-shaped heart ECG: RV hypertrophy Management - surgical repair in 2 parts. B-blockers to reduce infundibular spasm
99
``` What is Ebstein's anomaly? What causes it? What is seen in 80% if patients with this? Clinical features? (5) Conductive problem? ```
Low insertion of the tricuspid valve resulting in a large atrium and small ventricle ('atrialisation of RV) Lithium PFO/ASD Features: - cyanosis - prominent 'a' woven JVP - hepatomegaly - tricuspid regurg (pan systolic murmur, worse on inspiration) - splitting of S1 & S2 RBBB (hence splitting of S1&S2)
100
HOCM: - what is the physical issue? - clinical features? - pulse? - murmur? - ECG?
LV hypertrophy, and sub aortic hypertrophy of ventricular septum, resulting in functional aortic stenosis Features: - syncope (following exercise) - angina-like pain - exertion dyspnoea - Often asymptomatic, until sudden death due to ventricular arrhythmia Pulse: jerky Murmur: ejection systolic ECG: - LV hypertrophy - Non-specific ST and T-wave changes, progressive T-wave inversion may be seen - deep Q waves
101
3 drugs to avoid in HOCM?
ACEI Nitrates Inotropes
102
``` What is brugada syndrome? Inheritance? Who is it most commonly seen in? ECG changes? What makes ECG changes more apparent? Rx? ```
Defect in sodium ion channel AD Asians ST elevation followed by negative T wave in V1-V3 Partial RBBB ECG changes more apparent with flecainide ICD
103
Pathophysiology of Rheumatic Fever? Major and minor diagnostic criteria? Management? (3)
Type II hypersensitivity reaction 2-6 weeks after strep pyogenes infection Diagnosis: Evidence of recent streptococcal infection by raised/rising streptococcal antibodies or positive throat swab, accompanied by 2 major diagnostic criteria or 1 major and 2 minor Major: - pancarditis (myocarditis + endocarditis) - erythema marginatum - polyarthritis - subcutaneous nodules - sydenham's chorea (late feature) Minor: - raised ESR/CRP - pyrexia - prolonged PR Rx: - Penicillin V - NSAIDs - Treat any complications e.g. heart failure
104
2 congenital causes of LQTS? What is LQTS 1, 2 and 3? What arrhythmia may arise?
Jarvell-Lange-Nielsen syndrome (deafness) Romano-Ward syndrome (no deafness) 1 - syncope after swimming 2 - syncope after emotional stress 3 - events occur at night or at rest Torsades de Pointes
105
Management of hyperglycaemia in STEMI?
Dose-adjusted insulin to ensure glucose <11
106
Immediate management of a STEMI?
Ticagrelor Aspirin (even if already taking aspirin) Heparin if going for PCI <2 hours after arrival at hospital tPA if PCI not available - perform ECG 90 mins after thrombolysis - if <50% improvement arrange transfer to PCI centre
107
What antihypertensive to avoid with hyperglycaemia?
Thiazides or thiazide-likes - can worsen glucose tolerance
108
Ix for PE in renal impairment?
V/Q scan
109
Presentation of LV free wall rupture post-MI?
Signs of L and R HF due to tamponade - lung crackles - pulsus paradoxus - ankle oedema - raised JVP - diminished heart sounds Usually 1-2 weeks later urgent pericardiocentesis required
110
Dissection: - features? - Ix? - types and management?
- tearing chest pain - BP variation >20mmHg between arms - aortic regurg - hypertension - may have other features depending on site and branching arteries - non-specific ECG changes, may have STE inferior leads Ix: CT angiography CAP Trans-oesophageal echo if unsuitable Type A - ascending aorta - surgical management but reduce BP to 100-120 systolic before Type B - descending - conservative, IV labetalol
111
Which drug is assoc w GI ulcers and can cause perforation?
Nicorandil
112
Heart failure treatment ladder?
1. ACEI or B blocker 2. Second of these 3. Spironolactone
113
ECG changes and arteries for MI: - Anteroseptal? - inferior? - anterolateral? - lateral? - posterior?
anterolateral: - V1-V4 - LAD inferior: - II, III, aVF - RCA anterolateral: - V4-V6, I, aVL - LAD or Left Circumflex Lateral: - I, aVL +/- V5-V6 - Left circumflex Posterior: - Tall R waves V1-V2 - May cause ST depression - Circumflex or Right Coronary Isolated new onset LBBB may also point to MI
114
Apart from HF, what causes raised BNP? | What can reduce it?
CKD (even with eGFR <60) due to reduced renal excretion ACEI and ARBs can also raise it Diuretics can reduce it
115
What to do with warfarin after successful treatment of AF with catheter ablation?
Continue treatment
116
2 main indications for loop diuretics? | SE?
- Heart failure - acute IV, chronic orally - resistant HTN, especially in those with renal impairment SE: Hypotension Low everything (Na, K, Mg, Cl, H, Ca) Ototoxicity Renal impairment (dehydration and direct toxicity) Hyperglycaemia (less common than thiazides) Gout
117
``` Management of acute HF for all pts? If hypoxic? If ischaemia? If no response to initial hypoxia treatment? If hypotensive? What to do with regular meds? Opiates? ```
IV loop diuretics Oxygen if sats <94% GTN if due to ischaemia or HTN If sats still low after O2 and Furosemide, CPAP If hypotension/cardiogenic shock: - inotrope e.g. dobutamine - vasopressor e.g. NA Continue regular medications such as B blocker/ACEI Do not give opiates
118
In VF/VT arrest, what is the shock:CPR ratio? When is it changed? When should adrenaline and amiodarone be given? What is an alternative if amiodarone not available? When should adrenaline be given for non-shockable rhythm?
Single shock followed by 2 mins CPR If witnessed on a monitor e.g. in CCU - 3 quick shocks can be given in succession followed by 1 min CPR Adrenaline: after the 3rd shock (not stacked) then every 3-5 mins after Amiodarone also after 3 shocks and after 5 shocks Lidocaine is alternative to amiodarone In non-shockable rhythm, give adrenaline ASAP and every 3-5 mins after
119
Adenosine: - who should it be avoided in? - what drugs can affect it? - what adverse cardiac effect can it have?
Asthmatics - can cause bronchospasm Theophylline - blocks its effects Dipyramidole - enhances its effects Enhance conduction along accessory pathways causing increased ventricular rate (e.g. WPW)
120
Can ECG changes occur in unstable angina?
Yes, can have T wave inversion or ST depression - but lack of troponin being raised or any changes in troponin at 3 and 6 hours differentiates from NSTEMI
121
What is Prinzmetal angina? | What drugs can cause it?
Angina due to coronary artery spasm Usually in younger people who smoke/take cocaine, occurs early in morning or during sleep, and can cause ST elevation. No pain during exercise Cocaine, Triptans and 5-FU can cause it
122
If ACEI causes hyperkalaemia when should it be stopped?
If K >6 switch to another drug, especially if CKD
123
3 main SE of GTN?
Hypotension Headache HR increase
124
Cause of hypertension in aortic dissection?
Catecholamine surge
125
Management of orthostatic hypotension?
Initially: - education - ensure adequate water and salt intake After that: - discontinue drugs such as nitrates, antihypertensives, neuroleptic agents, dopaminergic drugs Then: - Fludricortisone or midodrine - compression garments, counter-pressure manoeuvres, head tilt-up sleeping (fludricortisone increases renal Na and water reabsorption, midodrine; midodrine is an alpha agonist causing vasoconstriction)
126
Monitoring when commencing treatment with a statin?
LFT's at baseline, 3 months and 12 months Fasting lipid profile may tested at these points also to assess response to treatment
127
What is the only CCB licensed for use to manage hypertension with concurrent heart failure?
Amlodipine
128
Signs on examination of acute HF?
``` Bibasal crackles and wheeze Cyanosis Tachycardia Elevated JVP Displaced apex beat S3 heart sound ```
129
What causes S3?
It is caused by diastolic filling of the ventricle, considered normal if <30 y/o Occurs in: - Left ventricular failure (e.g. dilated) - Constrictive pericarditis (called pericardial knock) - mitral regurg
130
What causes S3?
It is caused by diastolic filling of the ventricle, considered normal if <30 y/o Occurs in: - Left ventricular failure (e.g. dilated) - Constrictive pericarditis (called pericardial knock) - mitral regurg
131
What causes S4?
Atrium contracting against a stiff, non-compliant ventricle (coincides with P wave on ECG) Occurs in aortic stenosis, HOCM, hypertension (HOCM may have a double apical beat caused by palpable S4)
132
How often is digoxin level monitored in blood? | How long after dose?
Not routinely monitored unless toxicity suspected 8-12 hours after dose
133
Dose of adrenaline for cardiac arrest?
10ml 1:10,000 OR 1ml 1:1000 (0.5ml 1:1000 in anaphylaxis)
134
Glycaemic control if admitted to hospital with ACS?
Stop oral glycaemics, start sliding scale insulin
135
Causes of long QT: - electrolytes? - drugs?
Electrolytes: Low Ca, Mg or K Drugs - amiodarone/sotalol - macrolides, ciprofloxacin - Citalopram, TCS's, neuroleptics (esp Haloperidol)
136
What drugs should be AVOIDED in people with HOCM?
ACEI Nitrates inotropes (ACEI and nitrates decrease preload making it worse)
137
4 week old infant presents with poor feeding, on exam tachycardia, tachypnoea, hypertension and weak femoral pulses, no cyanosis. Systolic murmur best heard at left sternal edge?
Coarctation of aorta
138
Valves most commonly affected in infective endocarditis in order?
1. Mitral 2. Aortic 3. Tricuspid 4. Pulmonary Tricuspid most commonly affected in IVDU Apart from that it's left side because bacteria generally need damage to latch on, and that is more common in left side due to higher pressure
139
What is stage 1, stage 2 and severe HTN? When to start medication? What are BP targets?
Stage 1 - ABPM >135/85 Stage 2 - ABPM >150/95 Severe - clinic BP >180/110 Stage 1 - treat only if <80 y/o and Q-RISK >10%, or evidence of organ damage Stage 2 - start medication for all Targets: 135/85 if <80, 145/85 if >80
140
BP 1st line treatment in diabetes?
ACEI no matter what age | ARB if black
141
If a patient has a BP >180/110?
``` Check for end-organ damage If none present, ambulatory/home and recheck after 7 days If evidence (e.g. blood/protein in urine, papilloedema, retinal haemorrhage) admit for specialist assessment ```