Cardio Flashcards
1
Q
‘global speckled’ pattern on ECHO
A
Cardiac amyloidosis
2
Q
Psuedoinfarction pattern on ECG appears as
A
Low-voltage complexes with poor R wave progression
3
Q
Pseudoinfarction pattern on ECG associated with
A
Cardiac amyloidosis
4
Q
Normal PR interval
A
120 - 200 ms
5
Q
Anteroseptal - ECG changes
A
V1 - V4
6
Q
Inferior - ECG changes
A
II, III, aVF
7
Q
Anterolateral - ECG changes
A
V4-V6, I, aVL
8
Q
Lateral - ECG changes
A
I, aVL +/- V5-V6
9
Q
Posterior - ECG changes
A
Tall R waves V1-V2
10
Q
Coronary artery affected: Anteroseptal changes
A
Left anterior descending
11
Q
Coronary artery affected: Inferior changes
A
Right coronary
12
Q
Coronary artery affected: Anterolateral changes
A
Left anterior descending,
or,
Left circumflex
13
Q
Coronary artery affected: Lateral changes
A
Left circumflex
14
Q
Coronary artery affected: Posterior changes
A
Usually left circumflex, also right coronary
15
Q
Long QT1
A
Adrenergic surge due to physical activity
16
Q
Long QT2
A
Adrenergic surge due to intense emotion
17
Q
Long QT3
A
Death during sleep
18
Q
Kussmaul’s sign looks like
A
JVP rises during inspiration
19
Q
Kussmails sign associated with
A
Constrictive pericarditis
20
Q
Definition of pulmonary arterial hypertension
A
Resting mean pulmonary artery pressure is >= 25 mmHg
21
Q
Wellen’s syndrome - appearance on ECG
A
Deeply inverted/biphasic T waves in V2 - V3
22
Q
Wellen’s syndrome - suggests
A
Critical LAD stenosis
23
Q
Aortic stenosis - Criteria for aortic valve surgery
A
Symptomatic
Valvular gradient > 40 mmHg and features of LV systolic dysfunction
24
Q
Dabigatran MOA
A
Inhibits thrombin
25
Dabigatran reversal agent
Idarucizumab
26
Blood pressure target - patient with hypertension without other comorbidity
< 140/90 mmHg
27
Blood pressure target - patient with diabetes and end organ damage
< 130/80 mmHg
28
Normal QRS duration
< 120 ms
29
INR > 8.0 with No bleeding
Oral Vitamin K 1-5 mg
Repeat dose vitamin K if INR still too high after 24hr
Restart warfarin when INR < 5
30
ECG findings associated with ostium primum
RBBB + LAD, prolonged PR
31
ECG findings associated with ostium secundum
RBBB + RAD
32
Heart failure - 1st-line management for all patients
ACEi + beta-blocker
| start one, then add other
33
Heart failure - 2nd-line
```
Aldosterone antagonist
(spironolactine/eplerenone)
```
34
Heart failure - 3rd-line options
Ivabradine
Sacubitril-valsartan
Digoxin
Hydralazine with nitrate
Cardiac resynchroniziiton therpy
35
Heart failure management -- criteria for ivabridine
Sinus rhythm >75 bpm +
| LVEF <35%
36
Heart failure management - criteria for sacubitril-valsartan
LVEF <35%
| Initiate following ACEi, ARB washout period
37
Heart failure management - indication for digoxin
Coexistant AF
38
Heart failure management - indication for hydralazine with nitrate
Afro-Caribbean patient
39
Heart failure management - indication for cardiac resynchronization therapy
Widened QRS complex >130ms
40
Infective endocarditis- empiric treatment for prosthetic valve
Vancomycin + rifampicin + low-dose gentamicin
41
Infective endocarditis- empiric treatment for native valve
Amoxicillin + consider low-dose gentamicin
42
Infective endocarditis- empiric treatment for native valve (Penicillin allergy)
Vancomycin + low-dose gentamicin
43
Mitral regurgitatiion with new AF - management?
Refer for mitral valve replacement
44
Features of cholesterol embolism
- Eosinophilia
- Purpura
- Renal failure
- Livedo reticularis
45
Causes of LBBB
- IHD
- HTN
- Aortic stenosis
- Cardiomyopathy
46
Epsilon wave looks like
Small positive deflection at end of QRS complex
47
Infective endocarditis - treatment for prosthetic valve, caused by staphylococci
Flucloxacillin + rifampicin + low-dose gentamicin
48
Prolonged QTc in men
>450ms
49
Infective endocarditis - treatment for native valve, caused by staphylococci (PEN ALLERGIC)
Vancomycin + rifampicin
50
Acceptable increase in creatinine when starting AECi
Up to 30% increase
51
Infective endocarditis - treatment for prosthetic valve, caused by MRSA
Vancomycin + rifampicin + low-dose gentamicin
52
Secundum atrial septal defects occur where
Middle of atrial septum
53
Infective endocarditis - treatment if caused by fully-sensitive streptococci eg viridans (PEN ALLERGIC)
Vancomycin + low-dose gentamicin
54
Infective endocarditis - treatment if caused by less-sensitive streptococci (PEN ALLERGIC)
Vancomycin + low-dose gentamicin
55
Infective endocarditis - treatment if caused by less-sensitive streptococci
Benzylpenicillin + low-dose gentamicin
56
Causes of LBBB
- IHD
- HTN
- Aortic stenosis
- Cardiomyopathy
57
Culture-negative causes of infective endocarditis
```
Coxiella burnetii
Bartonella
Brucella
HACEK
Prior antibiotics
```
58
Which pre-excitation disorder shows ECG with a short PR interval, and normal QRS complex
Lown-Ganong-Levine syndrome
59
ECG findings in Wolff-Parkinson-White syndrome
Short PR interval, wide QRS complex with slurred upstroke (delta wave)
60
PMH contraindications to adenosine use in SVT
Asthma
Taking dipyridamole
61
ECG findings in dextrocardia
Inverted P wave in lead I
RAD
Loss of R wave progression
62
Patient with WPW in AF - which medication for cardioversion
Flecainide
63
Unifying diagnosis: Constrictive pericarditis + nephrotic syndrome + mononeuritis multiplex
Amyloidosis
64
Digoxin contraindication
Cardiac amyloidosis (digoxin binds to amyloid > toxicity)
65
1st line management of acute idiopathic/viral pericarditis
NSAID + colchicine
66
HACEK agents
```
Haemophilus
Actinobacillus
Cardiobacterium
Eikenella
Kingella
```
67
Culture-negative causes of infective endocarditis
```
Coxiella burnetii
Bartonella
Brucella
HACEK
Prior antibiotics
```
68
Which pre-excitation disorder shows ECG with a short PR interval, and normal QRS complex
Lown-Ganong-Levine syndrome
69
Contraindication to adenosine use in SVT
Asthma
70
ECG findings in dextrocardia
Inverted P wave in lead I
RAD
Loss of R wave progression
Shift of p axis (+120 degrees)
71
Patient with WPW in AF - which medication for cardioversion
Flecainide
72
Unifying diagnosis: Constrictive pericarditis + nephrotic syndrome + mononeuritis multiplex
Amyloidosis
73
Digoxin contraindication
Cardiac amyloidosis (digoxin binds to amyloid > toxicity)
74
1st line management of acute idiopathic/viral pericarditis
NSAID + colchicine
75
ECG findings in dextrocardia
Small complexes in chest leads vs the limb leads
| Inverted complexes in I and aVL
76
ECG findings in Second-degree AV block type 1 (Mobitz I, Wenckebach)
Progressive prolongation of PR interval until a dropped beat occurs
77
ECG findings in Second-degree AV block type 2 (Mobitz II)
P waves are often not followed by a QRS complex.
Where a QRS complex does follow, the PR interval is NORMAL
78
CHA2DS2-VASc
CCF - 1
HTN - 1
Age:
=>75 - 2
65-74 - 1
DM - 1
Stroke/TIA - 2
IHD/PAD - 1
Female - 1
79
Hypertension - 4th line medical management
(already taking A + C + D)
- K < 4.5 mmol/l
Add low-dose spironolactone
80
Hypertension - 4th line medical management
(already taking A + C + D)
- K > 4.5 mmol/l
Add alpha-blocker (doxazosin) or beta-blocker (nebivolol, carvedilol)
81
Beta-blockers in systemic sclerosis
May worsen Raynauds
82
Hypertension - 3rd line management, already taking ACEi + CCB
Thiazide-like diuretic (Indapamide)
83
Hypertension - 1st line management <55 years old and not AFC
ACEi/ARB
84
Hypertension - 1st line management any age, with T2DM, not AFC
ACEi/ARB
85
Hypertension - 1st line management >55 years old not T2DM
Calcium channel blocker (amlodipine)
86
Hypertension - 1st line management any age, AFC, not T2DM
Calcium channel blocker (amlodipine)
87
Hypertension - 2nd line management - already taking ACEi/ARB
Add:
CCB (amlodipine)
or
TLD (indapamide)
88
Hypertension - 2nd line management - already taking CCB
Add:
ACEi or ARB (ARB if AFC)
or
TLD (indapamide)
89
Hypertension - 3rd line management, already taking ACEi + TLD
Add CCB
90
Patient with AF, already on dual anti-platelet
Still needs formal anticoagulation (Warfarin/DOAC)
91
Which anti-coagulant for AF, in patient with CKD?
Rivaroxaban
| Reduced dose if GFR 15-50
92
Dabigatran in renal impairment
Not safe, high risk of bleeding
93
Cardiac monitor shows 'short runs of polymorphic VT'
Torsades de pointes
94
Management of Torsades de pointes
IV Magnesium sulphate
95
Causes of long QT (therefore increase risk of Torsades de pointes)
```
Amiodarone, sotalol
Erythromycin/clarithromycin
Low Ca, K, Mg
TCA/antipsychotics
Chloroquine
Fluconazole
```
96
Management of monomorphic VT - no adverse signs
Amiodarone/
Lidocaine/
Procainamide
97
Management of monomorphic VT - with adverse signs
DC cardioversion
98
ECG findings in Brugada syndrome
Coved ST elevation in >1 of V1-V3 followed by negative T wave
99
Diagnostic tool for Brugada
Fleicanide challenge
100
Management of Brugada syndrome
ICD
101
Long-term management of WPW
Radiofrequency ablation
102
Medical management of SVT in WPW
Sotalol, adenosine, fleicanide, amiodarone
103
CI to use of sotalol/adenosine in for SVT in WPW
Possible underlying AF
104
Which type of atrial septal defect is most common
Ostium secundum defect
105
ST elevation without reciprocal depression, shortly after myocardial infarction, suggests
Left ventricle aneurysm
106
Feature that suggests vascular claudication (over neurogenic claudication)
No relief from leaning forward/sitting down.
| Only relieved with rest
107
ABPI > 1.2
Calcified stiff arteries
| May be PAD or normal in old age
108
ABPI 1.0 - 1.2
Normal
109
ABPI 0.9 - 1.0
Acceptable
110
ABPI < 0.9
Likely PAD
111
ABPI < 0.5
Severe PAD - urgent referral
112
ABPI required for compression bandaging
>= 0.8
113
ECG features of trifascicular block
RBB + LAD/RAD + prolonged PR
114
Management of sick sinus syndrome with bradarrhythmia
Pacemaker (AAIR)
115
Inherited long QT and sensorineural hearing loss seen in
Jervell & Lange-Nielson syndrome
116
Congenital syndrome with long QT (no hearing loss)
Romano-Ward syndrome
117
Most helpful distinguishing feature of pericarditis on ECG?
PR segment depression (best seen in Lead II and V6)
118
Drugs to avoid in restrictive cardiomyopathy?
Digoxin, Nitrates, Atropine, Inotropes, Diuretics (unless LVF)
119
Minor Criteria for Rheumatic Fever?
```
Fever
Arthralgia
Raised ESR/CRP
ECG showing heart block
Previous Rheumatic Fever
```
120
Prophylaxis against further episodes of paroxysmal Atrial Fibrillation?
1) Beta Blockers (e.g Bisoprolol)
2) Diltiazam can be used if there is no evidence of structural heart disease on Echo or if patients have severe asthma
NB: due to long term commitment with the medications most patients now opt for electrophysiological studies and ablation
121
What ECG abnormality is seen in ARVC?
T-wave inversions in V1-V3
122
Criteria for Aortic Valve Replacement in AR?
1. All symptomatic patients
2. Asymptomatic patients with EF < 55% or LV dilations (end-diastolic dimension > 70mm and end systolic dimension > 50mm)
3) Significant enlargement of ascending aorta
123
Anticoagulation in patients with HF and low EF should be considered especially if they have what properties?
1. previous VTE event
2. Intracardiac thrombus
3. Left ventricular aneurysms
But consider bleeding vs clotting risk
124
What are the recommendations for follow up in patients with AR?
1. Asymptomatic patients with severe AR and normal LV function: every year
2. First diagnosis or LV diameter close to surgery threshold: 3-6 months
3. Can consider BNP as increased BNP during follow up related to deterioration in LV function
Mild/Moderate AR: review on yearly basis and echo every 2 years
125
How long should you continue LWMH for when bridging for warfarin?
Until INR > 2
126
Features of Eikenella?
Gram negative bacilli
| part of human commensal in mouth
127
When is percutaneous mitral balloon valvotomy recommended in patients with mitral stenosis?
Severe MS (area 1.5mm^2), favourable valve morphology in the absence of intra-atrial thrombus
128
When is surgery recommended for mitral valve in patients with mitral stenosis?
```
Mitral valve area < 1
Severely symptomatic patients (NYHA class III-IV), who are not at risk of surgery, or who have failed mitral balloon valvotomy before.
```
129
What is the anticoagulation guidelines for mitral valve surgery or valvotomy?
Valvular AF- warfarin
130
what is the anticoagulation guidelines for successful outpatient cardioversion?
Continue for one month then review
131
Secondary prevention of MI?
Dual Antiplatelet, ACEi, Beta Blockers, Statins
132
Lifestyle advice for secondary prevention of MI?
Diet: Mediterranean, switch butter and cheese for plant oil products. Don't routinely offer omega 3 supplements and fish oil
Exercise: 20-30 mins until patients are "slightly breathless"
133
DAPT after ACS event?
Aspirin + Ticagrelor, Stop Ticagrelor after 12 months
134
DAPT after PCI?
Aspirin + Ticagrelor/Prasugrel, stop 2nd antiplatelet after 12 months
135
People with MI who have heart failure/evidence of LVF?
Initiate aldosterone antagonist after 3-14 days of MI (preferably after ACEi)
136
How should you refer a patient with current chest pain or chest pain in last 12 hours with abnormal ECGs?
Emergency
137
How should you refer a patient with chest pain in last 12-72hours?
Same day assessment
138
If someone has chest pain > 72 hours how should you proceed?
ECG + Troponin
139
What are the 3 features of anginal pain?
1. constricting pain in front of chest radiating to arm/jaw
2. Precipitated by physical activity
3. Relieved by rest/GTN spray within 5 minutes
3 symptoms = typical angina pain
2 symptoms= atypical angina pain
1/0 symptoms= NOT ANGINA
140
Organisms associated with colonic carcinoma and bowel resection?
```
Strep Bovis
Bacteroides fragilis (Mx= Metronidazole)
```
141
Hypertensive Encephalopathy Rx
Sodium Nitroprusside
| Aim of Rx: lower BP to 110-115 DIASTOLIC within 2-4hrs
142
Cut off for SBP and DBP for orthostatic hypotension?
Fall in Systolic by >20mmHg
Fall in diastolic > 10 mmgHg
All within 3 minutes
143
If a patient has peripheral arterial disease (i.e very high CV risk) hat is the LDL cholesterol goal?
< 1.8mmol/l
144
What is the Simon Broome Criteria to diagnose Familial Hypercholesterolaemia?
Total Cholesterol >7.5 and LDL > 4.9
Tendon Xanthomata or evidence of these in 1st or 2nd degree relative or
DNA evidence of an LDL receptor mutation, familal defective apo-b100 or a PCSK9 mutation
145
BP target for < 80 years in clinic?
<140/<90
146
BP target for < 80 years at home?
<135/85
147
BP target for > 80 years in clinic?
<150/90
148
BP target for > 80 years at home?
<145/90
149
Female patient with ASD, Left axis deviation and RBBB. WHat is the risk to pregnancy?
No significant increase in risk compared to the general population.
NB: in the presence of Eisenmener syndrome maternal mortality is approximately 40% and pregnancy is contraindicated
150
For marfant's when is intervention indicated as per ESC guidelines for thoracic aneurysms?
Dilated aortic root >50mm
| Dilated aortic root > 45mm in presence of other risk factors
151
If patient comes to clinic at what level of BP would it be reasonable to commence HTN medications without home monitoring?
>160/100
If 140-160/90-100 then offer home BP
152
Diagnostic Criteria for RBBB?
Broad QRS >120, RSR atter in leads V1-3 and wide, slurred S wave in lateral leads
153
Carotid sinus Hypersensitivity Rx?
Dual Chamber Pacemaker
154
Criteria for valve replacement in aortic stenosis?
1) Symptomatic
| 2) valve gradient >40 (50-60)mmHg
155
Time frame for peripartum cardiomyopathy?
last month of pregnancy- 6 months postpartum
156
The systemic use of B2 agonists like terbutaline and salbutamol to interrupt preterm labour is associated with what cardiac complication?
Tocolysis-associated pulmonary oedema
157
Tissue vs Metallic valve- when to use each?
Young Patient- Metallic
| Older patient- tissue (lasts about 10 years)
158
Treatment for Xanthelasma?
Topical Trichloracetic acid
159
accelerated idioventricular rhythm is common after what
post MI
160
accelerated idioventricular rhythm ECG findings?
P waves present but not associated with QRS, wide QRS (>120) rate 50-100bpm.
NB: p waves can or cannot be present
161
What is the MIBG test used for?
Phaeochromocytoma.
uses radioactive iodine as a tracer which is detected through the use of a gamma camera
162
Long QT treatment?
1s line Beta blockers
If further palpitations then ICD
163
Ventricular Tachycardia secondary to Digoxin
| what is the treatment?
Lignocaine
164
Management of prosthetic valve thrombus in an haemodynamically unwell patient?
Ideally urgent surgery
| If surgery not immediately available--> IV alteplase
165
Managment of prosthetic valve thrombus in a haemodynamically well patient?
Heparin +/- aspirin with regular follow up
166
What is the range for normal Central Venous Pressure (CVP)
8 to 12 mmHg
167
First line treatment for Bradycardia and haemodynamic compromise?
Atropine.
| Initially 500 microgram IV and repeated to a maximum for 3mg
168
How to differentiate post MI VSD vs Mitral Regurg?
Mitral Regurgitation- Pansystolic murmur heard loudest at apex
VSD- heard loundest at lower left sternal edge + parasternal thrill
169
Causes of J wave?
Hypothermia, Hypercalcaemia, subarachnoid haemorrhage
170
Patient < 75 years with mitral valve prolapse, atrial fibrillation or echo of LVF- what is the management?
Refer for valve replacement!
171
```
In a patient with congestive heart failure, which of the following carries the worst prognosis?
A) Cardiomegaly on CXR
B) Mitral Regurgitation on Echo
C) Ejection Fraction < 50% on echo
D LVH on ECG
E) Serum Sodium of 129 mmol/l
```
Serum Sodium of 129- indicates significant fluid overload
172
Thallium scan vs dobutamine stress echo
| which one is more sensitive and specific for CAD?
Thallium- sensitive
| Dobutamine- specific
173
Indications for a CABG?
More than 50% narrowing of coronary artery plus:
- angina refractory to medical management
- ST depression on exercise ECG
- Left Main Stem narrowing
- Severe Triple vessel disease
- Angina with Left ventricular dysfunction
174
NSTEMI Mx?
Aspirin, Ticagrelor and Fondaparinux
175
NSTEMI Mx in renal impairment (GFR <20)
Aspiri, ticagrelor + LMWH (1mg/kg)/ unfractionated heparin (doesn't require dose reduction)
if GFR < 15 then don't use LMWH
176
Post infarct which is more common; Ruptured ventricular septum or ventricular free wall rupture?
Ventricular free wall rupture more common (occurs 10 times more frequently than post infarction ventricular septal rupture)
177
Indications for ICD?
1) Familial cardiac conditions with high risk of sudden cardiac death, e.g Long QT, HOCM, Brugada, ARVC and following repair of Tetralogy of Fallot
2) Primary prevention of sudden cardiac death in patients who have a history of prior MI and ALL OF THE FOLLOWING:
- Non sustained VT
- Inducible arrythmia on EP testing
- LV EF < 35% and no worse than New York Class III functionally
178
Indications for permanent pacemaker?
- Persistent SYMPTOMATIC bradycardia (e.g sick sinus)
- complete heart block
- Mobitz type II AV block
- Persistent AV block after MI
179
Indications for temporary pacemaker?
- Symptomatic/haemodynamically unstable bradycardia not responding to atropine
- Post Anterior MI (type 2 or CHB)
- Trifasicular block prior to surgery
Post-inferior MI CHB is common and can be managed conservatively if asymptomatic and haemodynamically stable
180
What is the Rx for patient with Long QT syndrome not responding to beta blockers and receiving frequent shocks from the ICD?
Left stellate cardiac ganglionectomy
181
HOCM and outflow gradient < 50mm rx?
Beta Blocker
182
HOCM and outflow gradient > 50mm Rx?
Myomectomy
183
Criteria for Left Ventricular Hypertrophy?
S wave in V1 + R wave in V5/6 > 40mm (7/8 boxes)
184
Normal Capillary Wedge pressure?
4-12mmHg
185
How is the mitral valve gradient calculated?
Capillary wedge pressure (left atrial pressure) MINUS diastolic left ventricular pressure
186
Normal mitral valve gradient?
5mmHg
187
What vaccination would you offer to someone with heart Failure?
1) Annual Influenza vaccine
| 2) one-off pneumococcal vaccine
188
Treatment for Orthostatic hypotension and their MoA?
Midodrine (alpha 1 agonist)
| Fludrocortisone
189
Contraindication for CCBs in angina?
First degree heart block and relative bradycardia
190
When should reperfusion therapy considered in patients with angina?
In patients requiring more than 2 antiangials
191
Contraindication for ivabradine?
Sick Sinus Syndrome
192
Contraindication for Ranolazine?
liver dysfunction (think if patient has been a heavy alcohol drinker)
193
Contraindication for nicorandil?
LV failure and cardiogenic shock
