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Yr 4 - PassMed Corrections > Cardio > Flashcards

Cardio Flashcards

1
Q

In what 2 situations would statins be provided without calculating QRISK?

A

1) CKD

2) T1DM for ≥10 years or ≥40 y/o

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2
Q

What investigations are required after starting statins?

A

Lipid profile & LFTs 3 months after

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3
Q

What are 4 serious adverse effects of statins?

A

1) Myopathy
2) Rhabdomyolysis
3) T2DM
4) Haemorrhagic stroke

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4
Q

What is used for 2ary prevention of CVD? (4)

A

1) Statins
2) ACEi
3) Beta blocker
4) Aspirin

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5
Q

In what 2 situations would clopidogrel be used instead of aspirin in 2ary prevention of CVD?

A

1) PAD
2) Ischaemic stroke

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6
Q

What is a key exam finding in familial hypercholesterolaemia?

A

Tendon xanthomata

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7
Q

What 3 investigations can be done in angina?

A

1) Stress testing
2) CT coronary angiography
3) Invasive coronary angiography

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8
Q

Medical mx of stable angina?

A

1) aspirin and a statin in the absence of any contraindication

2) GTN for acute attacks

3) beta blocker or CCB (note, if CCB is used as monotherapy, use verapamil or diltiazem)

Note - beta-blockers should not be prescribed concurrently with verapamil (risk of complete heart block)

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9
Q

In stable angina, if a patient is on monotherapy and cannot tolerate the addition of a calcium channel blocker or a beta-blocker, addition of what drugs can be considered?

A

1) a long-acting nitrate e.g. isosorbide mononitrate

2) ivabradine

3) nicorandil

4) ranolazine

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10
Q

2 treatment options for stable angina?

A

1) PCI
2) CABG

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11
Q

What are 2 key ECG findings in NSTEMI?

A

1) T wave inversion
2) ST depression

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12
Q

What ECG leads are affected in MI affecting left coronary artery?

A

I, aVL, V3-V6

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13
Q

What ECG leads are affected in MI affecting left circumflex artery?

A

I, aVL, V5-V6

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14
Q

2 key ECG findings in pericarditis?

A

1) Saddle shaped ST elevation
2) PR depression

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15
Q

Mx of pericarditis? (2)

A

Acute –> NSAIDs

Reduce risk of recurrence –> colchicine

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16
Q

4 CXR findings in CHF?

A

1) Bilateral pleural effusions

2) Cardiomegaly

3) Fluid in septal lines (Kerley B lines)

4) Upper lobe venous diversion

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17
Q

What can be used to increase heart function in HF?

A

Inotropes e.g. dobutamine

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18
Q

At home BP readings for stage 1 vs stage 2 HTN?

A

Stage 1 –> 135/85

Stage 2 –> 150/95

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19
Q

What 2 findings indicate malignant HTN on fundoscopy?

A

1) Retinal haemorrhages
2) Papilloedema

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20
Q

What murmur is heard best with patient leaning forward and holding expiration?

A

Aortic regurg

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21
Q

What murmur is heard best with patient lying on left?

A

Mitral stenosis

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22
Q

What pulse abnormality can aortic stenosis cause?

A

Narrow pulse pressure

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23
Q

Murmur heard in mitral stenosis?

A

Mid diastolic, low pitched rumbling

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24
Q

Murmur heard in mitral regurg?

A

Pansystolic high pitched whistling

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25
Q

Murmur heard in tricuspid regurg?

A

Pansystolic & split S2

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26
Q

1st line therapy in HF with reduced EF?

A

ACEi + beta blocker

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27
Q

2nd line therapy in HF with reduced EF?

A

1) Aldosterone antagonist e.g. spironolactone

2) Increasing role for SGLT-2 inhibitors e.g. dapagliflozin

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28
Q

Mx of of warfarin in intracranail haemorrhage?

A

Stop warfarin, give IV vitamin K 5mg + PCC

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29
Q

1st line treatment of bradycardia + adverse features?

A

Atropine 500 micrograms

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30
Q

What type of heart valves tend to be given to younger patients?

A

Metallic valves –> last longer

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31
Q

What investigations can you do in aortic dissection?

A

1) CXR

2) CT angiography of the chest, abdomen and pelvis

3) Transoesophageal echocardiography (TOE)

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32
Q

What is the investigation of choice in aortic dissection?

A

CT angiography of the chest, abdomen and pelvis (but is only suitable for stable patients and for planning surgery).

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33
Q

What is the investigation of choice in unstable patients with aortic dissection?

A

Transoesophageal echocardiography (TOE)

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34
Q

Key finding on CXR in aortic dissection?

A

Widened mediastinum

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35
Q

Key finding on CT angiography of the chest, abdomen and pelvis in aortic dissection?

A

False lumen

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36
Q

What is Beck’s triad?

A

Indicates cardiac tamponade:

1) Persistent hypotension

2) Raised JVP

3) Muffled heart sounds

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37
Q

What are some causes of pericarditis?

A

1) viral infections (Coxsackie)

2) TB

3) uraemia

4) post-MI:
- early (1-3 days): fibrinous pericarditis
- late (weeks to months): autoimmune pericarditis (Dressler’s syndrome)

5) radiotherapy

6) connective tissue disease:
- SLE
- RA

7) hypothyroidism

8) malignancy e.g. lung cancer, breast cancer

9) trauma

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38
Q

Regarding cardiac catheterisation results, what condition does a jump in O2 saturation from the RA to RV indicate?

A

Ventricular septal defect (indicating that oxygenated blood is travelling from the LV into the RV).

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39
Q

Regarding cardiac catheterisation results, what is the normal O2 saturation levels for all 4 chambers?

A

RA: 70%
RV: 70%
LA: 100%
LV: 100%

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40
Q

Regarding cardiac catheterisation results, what is the normal O2 saturation levels for all 4 chambers in an ASD?

A

RA: 85%
RV: 85%
LA: 100%
LV: 100%

The oxygenated blood in the LA mixes with the deoxygenated blood in the RA, resulting in intermediate levels of oxygenation from the RA onwards.

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41
Q

What are the 2 most common causes of a bisferiens pulse?

A

1) Mixed aortic valve disease (i.e. aortic regurgitation and stenosis)

2) HOCM

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42
Q

What is a bisferiens pulse?

A

A double pulse felt in systole

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43
Q

Mx of stage 1 HTN (ABPM/HBPM >= 135/85 mmHg)?

A

Treat if <80 years of age AND any of the following apply:
- target organ damage
- established CVD
- renal disease
- diabetes
- QRISK ≥10%

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44
Q

Mx of stage 2 HTN (ABPM/HBPM >= 150/95 mmHg)?

A

offer drug treatment regardless of age

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45
Q

Mx of HTN in patients <40?

A

consider specialist referral to exclude secondary causes

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46
Q

In general, how many days before surgery is warfarin stopped?

A

Normally 5 days before surgery.

Once the INR is <1.5, surgery can go ahead.

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47
Q

What is the complication if a patient develops acute heart failure around 5 days after an MI?

A

VSD

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48
Q

How does a VSD following an MI present?

A

Features of acute HF:
1) Severe SOB
2) Bibasal crackles
3) Raised JVP
4) New-onset pan-systolic murmur

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49
Q

What does rheumatic fever develop following?

A

Rheumatic fever develops following an immunological reaction to a recent (2-4 weeks ago) Strep. pyogenes (GAS) infection.

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50
Q

What is diagnosis of rheumatic fever based on?

A

Evidence of recent streptococcal infection accompanied by:

2 major criteria, or;

1 major with 2 minor criteria

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51
Q

What are the 5 major criteria for rheumatic fever?

A

1) erythema marginatum

2) Sydenham’s chorea: this is often a late feature

3) polyarthritis

4) carditis and valvulitis (eg, pancarditis)

5) subcutaneous nodules

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52
Q

What are the 4 minor criteria for rheumatic fever?

A

1) raised ESR or CRP

2) pyrexia

3) arthralgia (not if arthritis a major criteria)

4) prolonged PR interval

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53
Q

Mx of rheumatic fever?

A

1) Oral penicillin V

2) NSAIDs

3) Treatment of any complications that develop e.g. heart failure

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54
Q

What is a broad complex tachycardia following an MI almost always due?

A

Ventricular tachycardia

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55
Q

Mx of a witnessed cardiac arrest in a monitored patient (e.g. in a coronary care unit)?

A

Deliver up to 3 quick successive shocks.

(rather than 1 shock followed by CPR)

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56
Q

Infective endocarditis in IVDU most commonly affects which valve?

A

Tricuspid

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57
Q

In infective endocarditis, what is the most commonly affected valve?

A

Mitral valve

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58
Q

What is the strongest risk factor for developing infective endocarditis?

A

A previous episode of endocarditis

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59
Q

What is the most commonly affected valve in endocarditis in IVDU?

A

Tricuspid valve

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60
Q

What is the half life of adenosine?

A

8-10 seconds

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61
Q

What is the investigation of choice for suspected aortic dissection (in stable patients)?

A

CT angiograph

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62
Q

What is the treatment of Mobitz type II?

A

Pacemaker

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63
Q

What is an alternative to anticoagulation for 3 weeks prior to cardioversion in a patient who has been in AF for >48 hours?

A

Transoesophageal echo (TOE) to exclude a left atrial appendage thrombus

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64
Q

What investigation is indicated in clinically unstable patients with a suspected aortic dissection?

A

Transoesophageal echocardiography (TOE)

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65
Q

An opening snap is considered pathognomonic of which condition?

A

Mitral valve stenosis

An opening snap indicates the leaflets still have some mobility.

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66
Q

What is an opening snap?

A

This is a high pitched early diastolic sound (just after S2) due to the sudden contraction of the valve leaflets after their initial opening.

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67
Q

What are the 3 layers to the aorta?

A

1) intima
2) media
3) adentitia

68
Q

What 2 systems can be used to classify aortic dissection?

A

1) Stanford system

2) DeBakey system

69
Q

Describe the Stanford system of aortic dissection classification

A

Type A –> ascending aorta, typically affects brachiocephalic artery

Type B –> descending aorta, typically affects left subclavian

70
Q

Which condition is giant cell arteritis often linked to?

A

Polymyalgia rheumatica

71
Q

Where is the most commonplace for the initial tear to occur in aortic dissection?

A

Ascending aorta

72
Q

What is the most common risk factor for aortic dissection?

A

Chronic HTN

73
Q

Aortic dissection can be triggered by events that temporarily cause a dramatic increase in blood pressure.

What can cause this?

A

1) heavy weightlifting

2) cocaine use

3) emotional stress

74
Q

Why are connective tissue disorders a risk factor for aortic dissection?

A

Due to inherent weakness in walls of aorta

75
Q

What are 2 inflammatory conditions that can predispose to aortic dissection?

A

1) giant cell arteritis

2) Takayasu arteritis

76
Q

What type of MI does aortic dissection typically cause?

A

Inferior MI - due to RCA involvement

77
Q

How often should BP be measured in patients with T2DM?

A

Annually

78
Q

What 2 eye signs may be seen in malignant HTN?

A

Papilloedema
Retinal haemorrhages

79
Q

What LFT results would indicate that statins would need to be stopped?

A

Rise in ALT/AST >3x upper limit of normal

80
Q

Atorvastatin 20mg is offered as 1ary prevention to which 3 groups of patients?

A

1) QRISK ≥10%

2) CKD (eGFR <60)

3) T1D for ≥10y or aged ≥40 y/o

81
Q

What is the antiplatelet of choice in peripheral arterial disease and following an ischaemic stroke?

A

Clopidogrel

82
Q

What medication can be used in cardiac stress testing?

A

Dobutamine

83
Q

How many doses of GTN spray can patients take?

A

Up to 3, then call an ambulance.

Take them 5 minutes apart.

84
Q

Why are statins contraindicated in pregnancy?

A

As cholesterol is essential for foetal development.

85
Q

How is familial hypercholesterolaemia inherited?

A

Autosomal dominant

86
Q

Which group of medications can lead to atherosclerosis?

A

Atypical antipsychotics

87
Q

What investigation can be done following anaphylaxis to confirm?

A

Serum trypsin

88
Q

What is the BP target for patients with CKD?

A

<130/80

89
Q

What are 2 causes of a raised BNP?

A

1) HF

2) Renal dysfunction (eGFR <60)

90
Q

Why can raised BNP be seen in CKD?

A

Due to reduced excretion

91
Q

What are 3 factors that may affected eGFR result?

A

1) pregnancy

2) muscle mass (e.g. amputees, body-builders)

3) eating red meat 12 hours prior to the sample being taken –> can increase levels of creatinine

92
Q

Next steps in BP ≥180/120:

a) + no worrying signs

b) + signs of retinal haemorrhage or papilloedema OR life-threatening symptoms e.g. new-onset confusion, chest pain, signs of HF or AKI

A

a) admit for specialist assessment

b) arrange urgent investigations for end-organ damage (e.g. bloods, urine ACR, ECG)

93
Q

What OGTT results indicate impaired glucose tolerance?

A

7.8-11

94
Q

What does a diagnosis of diabetes require? (2)

A

1) fasting plasma glucose level ≥7.0 mmol/l

or

2) an HbA1c ≥48 mmol/mol (6.5%)

95
Q

What ECG leads will be affected in an MI affecting the lateral heart?

A

I, aVL, V5-V6

96
Q

What ECG leads will be affected in an MI affecting the anterolateral heart?

A

I, aVL, V3-V6

97
Q

Which antiplatelet carries a higher bleeding risk: clopidogrel or ticagrelor?

A

Ticagrelor

98
Q

What does the GRACE score give?

A

6m risk of mortality following an NSTEMI

99
Q

Management of Dressler’s syndrome?

A

NSAIDs

100
Q

What does of ticagrelor is given in NSTEMI?

A

180mg

101
Q

What can be seen on an echo in Dressler’s syndrome?

A

Pericardial effusion

102
Q

What is a type 4 MI?

A

Associated with procedures e.g. PCI, CABG

103
Q

What investigations are needed in the diagnosis of Dressler’s syndrome?

(3)

A

1) ECG

2) Echo

3) Inflammatory markers

104
Q

2 key ECG features in Dresslers syndrome?

A

1) Global ST elevation

2) T wave inversion

105
Q

What system is used to stratify risk post myocardial infarction?

A

Killip class

106
Q

What is often the first ECG sign in an MI?

A

hyperacute T waves

107
Q

What is a type 3 MI?

A

Sudden cardiac death or cardiac arrest suggestive of an ischaemic event

108
Q

Describe Killip class I-IV

A

Class I - no clinical signs of HF

Class II - lung crackles

Class III - frank pulmonary oedema

Class IV - cardiogenic shock

109
Q

What is the most specific ECG marker for pericarditis?

A

PR depression

110
Q

How does LV aneurysm following MI typically present?

A

Persistent ST elevation + LV failure

111
Q

What mx is required for patients with LV aneurysm after MI?

A

Anticoagulation (as thrombus may form within the aneurysm increasing the risk of stroke).

112
Q

When starting ACEi, renal function should be measured.

What are 2 key features that should be measured?

A

1) K+ –> increase up to 5.5 mmol/L is ok

2) Creatinine –> increase up to 30% from baseline is ok

113
Q

What is a sinusoidal ECG pattern indicative of?

A

Severe hyperkalaemia (>9 mmol/L)

114
Q

What can over rapid aspiration/drainage of a pneumothorax result in?

A

Re-expansion pulmonary oedema

115
Q

What is the most common cause of mitral stenosis?

A

Rheumatic fever

116
Q

With an irregularly irregular pulse, what does a regular heart rate during exercise suggest a diagnosis of ?

A

Ventricular ectopics

These disappear when HR gets above a certain threshold

117
Q

What are the 2 main differentials for an irregularly irregular pulse?

A

1) AF

2) Ventricular ectopics

118
Q

Cardioversion in AF can be electrical or pharmacological.

What are 2 options for pharmacological cardioversion?

A

1) Amiodarone

2) Flecainide

119
Q

What is the drug of choice for pharmacological cardioversion in patients with structural heart disease?

A

Amiodarone

120
Q

What can be considered before and after electrical cardioversion to prevent AF from recurring?

A

Amiodarone

121
Q

What is reversal agent for apixaban and rivaroxaban?

A

Andexanet alfa

122
Q

How long should the patient should be anticoagulated for before delayed cardioversion?

A

At least 3 weeks

123
Q

What score is used or assessing the risk of major bleeding in patients with atrial fibrillation taking anticoagulation?

A

ORBIT score

O - older age (>75)
R - renal impairment (eGFR <60)
B - bleeding previously (history of GI or intracranial bleeding)
I - iron (low Hb or haematocrit)
T - taking antiplatelet

124
Q

What is an option for patients with contraindications to anticoagulation and a high stroke risk in AF?

A

Left atrial appendage occlusion

125
Q

What is the aim of left atrial appendage occlusion?

A

Aimed at closing off the appendage, reducing the ability of thrombus formation and risk of embolism.

126
Q

If a CHA2DS2-VASc score suggests no need for anticoagulation, what investigation is important?

A

Echo –> to exclude valvular heart disease

AF + valvular heart disease –> absolute indication for anticoagulation (even if CHA2DS2-VASc score is low).

127
Q

When should digoxin be considered in AF? (2)

A

1) Only considered if the person does no or very little physical exercise or other rate-limiting drug options are ruled out because of comorbidities.

2) May have a role if there is coexistent HF.

128
Q

Which part of the QRS complex is used for synchronisation in DC cardioversion?

A

R wave

129
Q

In what 2 situations is cardioversion used in AF?

A

1) electrical cardioversion as an emergency if the patient is haemodynamically unstable

2) electrical or pharmacological cardioversion as an elective procedure where a rhythm control strategy is preferred.

130
Q

Adenosine and asthmatics?

A

Adenosine causes bronchospasm

131
Q

At what EF is cardiac resynchronisation therapy considered in HF?

A

<35%

132
Q

2 key actions of BNP?

A

1) Relaxes smooth muscle in blood vessels –> reduces systemic vascular resistance

2) Acts on kidneys as diuretic

133
Q

What defines cardiomegaly on a CXR?

A

Cardiothoracic ratio >0.5

134
Q

What drugs should be offered after an MI (i.e. 2ary prevention)?

A

1) High dose statin

2) Dual antiplatelet

3) ACEi

4) Beta blocker

135
Q

What is torsades de pointes?

A

Torsades de pointes (‘twisting of the points’) is a form of polymorphic ventricular tachycardia associated with a long QT interval.

It may deteriorate into ventricular fibrillation and hence lead to sudden death.

136
Q

What 3 ECG features are seen in Wolff-Parkinson White?

A

1) Short PR interval (<0.12s)

2) Wide QRS complex (>0.12s)

3) Upsloting delta waves

137
Q

What condition is Wolff-Parkinson White associated with?

A

HOCM

138
Q

Mechanism of furosemide?

A

inhibits the Na-K-Cl cotransporter in the thick ascending limb of the loop of Henle

139
Q

What is the investigation of choice in PE in renal impairment?

A

V/Q scan

140
Q

Mx of patients on warfarin with INR 5.0-8.0 with no bleeding?

A

Withhold 1-2 doses, restart at a lower dose

141
Q

In which type of heart defect is there Quincke’s sign (nailbed pulsation)?

A

Aortic regurgitation

142
Q

In which type of heart defect is there De Musset’s sign (head bobbing)?

A

Aortic regurgitation

143
Q

What can be given alongside furosemide in patients with acute heart failure with concomitant myocardial ischaemia or severe HTN?

A

GTN

144
Q

What scale can be used to grade the intensity of murmurs?

A

Levine scale

145
Q

Mx of patients on warfarin undergoing emergency surgery?

A

Give four-factor prothrombin complex concentrate

146
Q

How does IV adenosine need to be infused?

A

via a large-calibre cannula (e.g. 16G) or central route

147
Q

What is the most common cause of 2ary HTN?

A

1ary hyperaldosteronism

148
Q

Which type of HTN medication can worsen glucose control?

A

Thiazide diuretics

149
Q

What is the next step in mx if patients treated with PCI for MI are experiencing pain or haemodynamic instability post PCI?

A

CABG

150
Q

Mx of intracranial haemorrhage on warfarin?

A

Give IV vitamin K 5mg + PCC and stop warfarin

151
Q

Most common valvular defect associated with rheumatic fever?

A

Mitral stenosis

152
Q

Most common cause of mitral stenosis?

A

Rheumatic fever

153
Q

What is myocarditis in young people typically preceded by?

A

Viral illness

154
Q

Triad of symptoms in aortic stenosis?

A

1) SOB
2) Chest pain
3) Syncope

155
Q

1st line investigation in phaeochromocytoma?

A

Plasma & urinary metanephrines

156
Q

Typical triad of symptoms in phaeochromocytoma?

A

1) sweating
2) headaches
3) palpitations

in association with severe HTN

157
Q

Mx of phaeochromocytoma?

A

Surgery is the definitive management.

The patient must first however be stabilised with medical management:

1) alpha-blocker (e.g. phenoxybenzamine), given before a

2) beta-blocker (e.g. propranolol)

158
Q

What protein are Abs targeted against with GAS infection?

A

M protein on Strep. pyogenes molecule

159
Q

What is most common clinical feature of rheumatic fever?

A

Migratory polyarthritis

160
Q

What is the most common cause of death in acute rheumatic fever?

A

Myocarditis - leads to HF

161
Q

What is the name of the diagnostic criteria used in rheumatic fever?

A

Jones critiera

162
Q

What is the 5 major diagnostic criteria for rheumatic fever?

A

Previous strep infection plus:

1) Polyarthritis
2) Carditis
3) SC nodules
4) Erythema marginatum
5) Sydenham chorea

163
Q

How soon after strep infection do symptoms of rheumatic fever appear?

A

2-3 weeks after

164
Q

What causes a raised ESR?

A

During inflammation, fibrinogen causes RBCs to stick together.

These clumped up RBCs fall to bottom of test-tube faster –> raised ESR

165
Q
A

Yr 4 - PassMed Corrections (36 decks)

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