CARDIO Flashcards
1
Q
Cardiac catheter: what happens to O2 concentrations when:
- ASD
- VSD
- PDA
- Above with Eisenmengers
A
Check notes
2
Q
Cardiac catheterisation in restrictive CM vs constrictive pericarditis
A
Check notes
3
Q
Cardiac catheterisation in HOCM vs AS
A
Check notes
4
Q
What happens to PV loop when:
- DCM
- LVH
- AS
- MS
- AR
- MR
- positive ionotropy
- incr/decr afterload
A
Check notes
5
Q
CAD treatment: when invasive vs medical?
A
Medical: Stable CAD
PCI: uncontrolled symptoms on medical, pt wish (outcomes = better angina relief)
CABG: L main, triple vessel including prox LAD, 2/3 vessel with LV dysfunction
6
Q
Tx of angina
A
BB
CCB
CTN patch/ISMN
Nicorandil
Perhexilline: inhibits cartinine palmitoytransferse –> mteabolism of glucose instead of FAs –> more efficient
- careful Caucasians 6-10% poor metabolisters
- CYP2D6
- peripheral neuropathy
7
Q
Arrhythmias post MI?
A
VF
AIVR: ectopic pacemaker
AV block: SA node affected in RCA block
cMRI best predictor
8
Q
LV aneurysm presentation?
A
cardiac failure
persistent ST elevation
stroke
9
Q
LV rupture presentation?
A
tamponade
heart failure
10
Q
Which arteries supply which parts of the heart?
A
Inferior Right coronary
Anteroseptal Left anterior descending
Anteroapical Left anterior descending (distal)
Anterolateral Circumflex
Posterior Right coronary artery
11
Q
Wellen’s: describe
A
Deep T in V2-V3
Or biphasic T waves
Indication of critical stenosis in LAD
12
Q
Cardiac pathology of rheumatic heart disease?
A
Aschoff bodies: granulomas
Anitschkow cells: macrophages
13
Q
When to intervene in rheumatic MS?
A
Small MVA
Symptomatic
14
Q
Cardiac arteries from RCA + LCA?
A
LCA
§ Circumflex
§ LAD
§ L marginal
RCA
§ Right ant ventricular
§ Right marginal
§ Posterior intraventricular artery
§ SA nodal branch in 60% of cases
§ AV nnodal branch 80% cases
15
Q
SA/AV node action potential?
A
Slow influx Na
Fast influx Ca
Slow outflow K
16
Q
Ventricular AP?
A
Fast Na influx
Slow Ca influx
K outflow
Refractory period
17
Q
Conduction system: describe from SA –> Purkinje
A
SA –>AV ring (held there) –> AV node –> Bundle of His –> R and L branches –> moderator band –> Purkinje
18
Q
Alpha 1 and 2 receptors: effect
A
Alpha 1: Vasocontriction
Alpha 2: venoconstriction
19
Q
Beta 1 and 2 receptors: effect
A
Beta 1: HR, contractility, conduction increased
Beta 2: smooth muscle relaxation
20
Q
Indications for PM?
A
-SND: pace only if symptomatic - there is no too slow
- Dual chamber
- AV block: pace even if asymptomatic in 2nd degree type 2, high degree AB block, CHB
- otherwise only asymptomatic
- Dual chamber
- LBBB: more likely to have underlying structural heart disease
- HIS bundle pacing: RV pacing can worsen LVEF in LV dysfunction
21
Q
ICD indications?
A
- Secondary
Patients who have experienced a previous sudden cardiac arrest or ventricular arrhythmia - Primary
Patients who have not previously experienced sudden cardiac arrest or ventricular arrhythmia, but are at risk- Patients at least 40 days post-MI LVEF ≤ 35% NYHA class II or III
LVEF ≤ 30% NYHA class I
LVEF ≤ 40% non-sust VT, inducible VT/VF at EPS
- Patients at least 40 days post-MI LVEF ≤ 35% NYHA class II or III
- Non-ischemic patients
LVEF ≤ 35%
NYHA class II or III
“DANISH study”-NEJM Sept 2016 –no mortality benefit in NICM patients (subgp analysis <70yrs benefit) - Patients at risk of SCA due to genetic disorders
Long QT syndrome
Brugada syndrome
Hypertrophic cardiomyopathy (HCM)
Arrhythmogenic right ventricular cardiomyopathy (ARVC)
Catecholaminergic polymorphic VT
22
Q
CRT indications?
A
- Left ventricular systolic dysfunction: EF ≤35%
- Wide LBBB ≥150ms
Class 2 to ambulatory class 4 heart failure symptoms - QRS > 120
- Wide LBBB ≥150ms
23
Q
Rheumatic heart disease affects which valves?
A
Aortic
Mitral
Tricuspid
24
Q
Pathology in RHD?
A
Aschoff bodies: granulomas with giant cells
Anitschkow cells: macrophages with wavy nucleus
25
When do you start anticoagulation in a patient with rheumatic MS and AF?
CHADS VASc does not apply -->anticoagulate
26
When to intervene in Rheumatic MS? CI?
Severe stenosis <1.5cm and symptomatic
Not surgical candidate OR pliable valve: PMBC
Is: MV surgery
Exertional symptoms
Asymptomatic but PASP > 50 or new AF
CI: NO CLOT
27
DEFIB Indications?
* No clear reversible cause
* long QT syndrome
* arrhythmogenic right ventricular dysplasia
* hypertrophic obstructive cardiomyopathy
* Cardiac sarcoidosis
* previous cardiac arrest due to VT/VF
* previous myocardial infarction with non-sustained VT on 24 hr monitoring, inducible VT on electrophysiology testing and ejection fraction < 35%
* Heart failure + reduced LVEF
* Brugada syndrome
28
Antiarrhythmic classes?
1: Na channel blockers (1a quinidine procainamide) (1b lidocaine phenytoin) (1c flecanide propafenone)
4: Ca (Verapamil, Diltiazem)
3: K (amiodarone, sotalol)
2: BB (propanol, metoprolol)
Fleicanide has no effect on ventricle
29
Digoxin MoA?
Slows heart rate and reduces AV nodal conduction by an increase in vagal tone and a reduction in sympathetic activity.
Increases the force of myocardial contraction by increasing the release and availability of stored intracellular calcium.
30
Amiodarone MoA?
Decreases sinus node and junctional automaticity, slows atrioventricular (AV) and bypass tract conduction and prolongs refractory period of myocardial tissues
31
Adenosine MoA?
Causes transient heart block in AV node
Causes hyperpolarisation: increases outward K flux
32
Ivabradine MoA?
inhibits a current regulating the interval between depolarisations of the sinoatrial (SA) node.
- Blocks influx of Na --> reduction in AP slope
It reduces heart rate (by about 10 beats/minute) which in turn lowers cardiac workload and myocardial oxygen demand.
33
Antiplatelets MoA? and significant SE's
Dypyridamole
Aspirin
Ticag
Clop/prasugrel
Tirofibran
Dypyridamole
Non specific phophodiesterase inhibitor that decreases cellular uptake of adenosine
- Antiplatelet and vasodilating properties
Apirin
Inhibition of COX 1 + 2
- THROMBOXANE inhibitors indirectly
Ticagrelor
P2Y12 receptor blocker (activates platelets usually)
- Better than clopi
○ Reducing CV death, MI, stroke without incr in bleeding risk
- Reversible
CI: due to buildup of adenosine
- 2nd/3rd AV block
- asthmaCOPD
Clopi/ PRASUGREL
Metabolites inhibits binding of ADP to platelet P2Y12 receptor
- ADP unable to bind to glycoprotein GPIIb/IIA which inhibits platelet aggregation
- Irreversible
Tirofibran (T for 2)
Glycoprotein Iib/IIIa inhibitors
34
CPVT genetics?
RYR2 gene: MAJORITY
* Gain of function mutation
* Calcium channel ion
* Autosomal dominant inheritance
Rare --> CASQ2 gene (autosomal recessive inheritance)
35
CPVT features?
Bidirectional VT
Induced by exercise/stress
36
CPVT treatment?
BB
ICD
37
ARVC mutaitons?
Autosomal dominant
Desmoglein
Plakkophil
Cardiac desmosomal proteins
38
ARVC features?
Exercised induced
Can sometimes have thick skin, curly hair
ECG: epsilon wave, TWI V1-V3
39
Brugada syndrome features?
SCN5A LOSS mutation: Na channel, sometimes Ca and K
ECG: coved ST, inducible VT, syncope, family history cardiac death
40
Brugada management?
ICD
Treat fevers
Catheter ablation
41
Long QT features (1,2,3)
K channel in 1,2 Na channel in 3
1: exercise, young males
2: emotion/ auditory: females
3: sleep, males > 18
42
Greatest risk of SCD in LQT?
QRS > 500
43
Treatment LQT
BB
ICD
44
Use of flueicanide/ ajmaline challenge?
Given NA channel blocker (fleicanide) if suspected clinically in Brugada type 2/3
○ Converts it to type 1
45
What can be used in LQT as a provocation challenge?
Adrenaline
46
Indications for ICD?
1. Secondary
Patients who have experienced a previous sudden cardiac arrest or ventricular arrhythmia
2. Primary
Patients who have not previously experienced sudden cardiac arrest or ventricular arrhythmia, but are at risk
1. Patients at least 40 days post-MI LVEF ≤ 35% NYHA class II or III
LVEF ≤ 30% NYHA class I
LVEF ≤ 40% non-sust VT, inducible VT/VF at EPS
2. Non-ischemic patients
LVEF ≤ 35%
NYHA class II or III
“DANISH study”-NEJM Sept 2016 –no mortality benefit in NICM patients (subgp analysis <70yrs benefit)
3. Patients at risk of SCA due to genetic disorders
Long QT syndrome
Brugada syndrome
Hypertrophic cardiomyopathy (HCM)
Arrhythmogenic right ventricular cardiomyopathy (ARVC)
Catecholaminergic polymorphic VT
47
Fe replacement effect on CCF?
MPROVES SYMPTOMS AND QOL
REDUCES HOSPIRALISATIONS
DOES NOT IMPROVE MORTALITY
HAS TO BE IV --> ORAL HAS MINIMAL EFFECT
Fe failure strongly assoc with incr mortality
48
Indications for ionotropes in CCF
If symptoms/sign of peripheral hypoperfusion + BP < 90mmHg
* Increases mortality regardless of agent
Take off ASAP
49
Indications for CRT?
Class II - IV CCF
wider QRS = better remodelling = more likely to have symptomatic response
PREVENTS ARRHYTHMIC DEATHS
50
Treatment for HEFpEF
Low dose spironolactone
SGLT2
51
Heart transplant complications?
- First 30 days
○ Graft failure
- 6-12 months
○ Opportunistic infections
- After 1 year
○ Vasculopathy
- Beyond 5 years
- Lymphoma + other malignancies common
51
Heart transplant complications?
BIGGEST CAUSE OF DEATH = CAS
- First 30 days
○ Graft failure
- 6-12 months
○ Opportunistic infections
- After 1 year
○ Vasculopathy
- Beyond 5 years
- Lymphoma + other malignancies common
52
DCM CAUSES?
Ischemic
Infectious
- Parvovirus
- Herpes
- Influenza
Toxins
- Alcohol
- Cocaine
CTD
Hypothyroidism
Muscular dystrophy
HTN
Infiltrative
- Haemachromatosis
- Sarcoidosis
Metabolic disorders
Mitochondrial disorders
Syndromal
- Alstrom
- Barth syndrome
Peripartum CM
53
DCM gene associations?
TTN: TITIN gene (autosomal dominant)
LMNA gene
54
DCM treatment?
ICD/CRT
Heart failure medications
Treat arrhythmias
55
Restrictive CM: sign of poor prognosis?
Syncope
56
How to differentiate restrictive CM with constrictive pericarditis?
Features suggesting restrictive cardiomyopathy rather than constrictive pericarditis
* prominent apical pulse
* absence of pericardial calcification on CXR
* the heart may be enlarged
* ECG abnormalities e.g. bundle branch block, Q waves
57
CM investigations: what do you see?
ECHO: bilateral atrial enlargment, severe diastolic dysfunction
- Increased early diastolic filling to Atrial filling ratio
Cardiac catheter: increased ventricular diastolic pressure
Sr protein electrophoresis: Ig light chain amyloidosis
58
Factor most predictive of SCD in HOCM?
Septal thickness > 30mm
59
How does HOCM examine?
Related to valve-septum interaction: mitral regurgitation
Systolic cresc decresc murmurs
- Best heard at L lower sternal border
Increased intensity with swuating --> standing / Valsalva
60
ECG + echo signs of HOCM? Which one is most specific?
ECG:
- q waves in I, aVL, V5-6 + inferior (II III aVF) leads
- LVH
- Non specific T wave changes in lateral leads
○ Progressive T wave inversion
- Episodic AF/ VT
ECHO:
- systolic anterior motion of mitral valve, asymmetric hypertrophy , LVOT obstruction
- Septum >15mm proband = MOST SPEICFIC SIGN
- LVH typically asymmetric
Non dilated LV with L/R hypertrophy
61
Which drugs worsen HOCM?
Ionotropes
Diuretics
Vasodilators
ACE
62
Indications for ICD in high risk patients?
- Sudden death in first degree relative
- Sustained VT
- Unexplained syncope
- Abnormal BP response to exercise
- NSVT
- Resuscitated sudden death event
- LV thickness > 30mm
63
HOCM management?
* Amiodarone
* Beta-blockers or verapamil for symptoms
* Cardioverter defibrillator
- Only one to prevent death
* Dual chamber pacemaker
64
Aortic dissection management?
- Type A (ascending aorta): surgery
- Type B (descending aorta): medical therapy: control HR + reduce HR, pain control
○ Beta blocker (1)
○ CCB, ACEI (2)
○ AVOID HYDRALAZINE
§ INCREASES STRESS ON SORTIC WALL
65
Aortic aneurysm: when to intervene?
Ascending: > 55m
BAV with risk factors (Fox, HT, coarctation, growth > 3-5mm year): >50 mm
Marfan: > 50mm
Loeys Dietz: > 42
Turner: > 27mm
66
FH:
- most common sign?
- are females protected?
- genetic mutations?
- most common sign: corneal arcus
- are females protected: pre menopausal ONLY
- genetic mutations: LDL, PCSK9, ApoB100
67
What is Eisenmenger syndrome?
When L --> R becomes L --> R
pHTN --> RVH --> pressure becomes greater
68
Outcome for adults with small VSD?
often high rate of sport closure in early years
good prognosis if NO ventricular dilatation/ pHTN
69
Which syndrome is AV septal defect assoc with
Downs
70
Disorders that can cause EIsenmenger's
ASD
VSD
PDA
71
Which syndromes are PS associated with?
Noonan
William
72
Tetralogy of Fallot
VSD
Overriding aorta
RVH
PS
73
Bicuspid aortic value associations
Turners
74
When to intervene on Aortic aneurysm
>55 ALL PATIENTS
> 50 MARFANS
>45 MARFANS + risk factor
