Cardio

Question 1

Heart Sounds

S1

Answer 1

S1
closure of mitral and tricuspid valves
soft if long PR or mitral regurgitation
loud in mitral stenosis

Question 2

Heart Sounds

S2

Answer 2

S2
closure of aortic and pulmonary valves
soft in aortic stenosis
splitting during inspiration is norma

Question 3

Heart Sounds

S3

Answer 3

S3 (third heart sound)
caused by diastolic filling of the ventricle
considered normal if

Question 4

Heart Sounds

S4

Answer 4

S4 (fourth heart sound)
may be heard in aortic stenosis, HOCM, hypertension
caused by atrial contraction against a stiff ventricle
in HOCM a double apical impulse may be felt as a result of a palpable S4

Question 5

Supra-Ventricular Tachycardia

Answer 5

Sudden onset narrow complex tachycardia

Acute MX: vagal manoeuvres
IV adenosine (CI in asthmatics, use verapamil instead)
Cardioversion

Prevention:
Beta-blockers
Radio-ablation

Question 6

ECG: normal variants in athletes

Answer 6

Sinus bradycardia
Junctional rhythm
First degree heart block
Wenckebach phenomenon (2nd Deg AV block)

Question 7

Heart failure: drug management

Answer 7

First-line treatment for all patients is both an ACE-inhibitor and a beta-blocker

Second-line treatment is now either an aldosterone antagonist, angiotensin II receptor blocker or a hydralazine in combination with a nitrate

If symptoms persist cardiac resynchronisation therapy or digoxin.

(Digoxin doesn’t improve mortality but improves symptoms because it is an inotrope)

Question 8

HTN MX

Step 4 treatment

Answer 8

consider further diuretic treatment

if potassium 4.5 mmol/l add higher-dose thiazide-like diuretic

consider an alpha- or beta-blocker

Question 9

Atrial Flutter:

A form of SVT characterised by rapid atrial depolarisation

ALWAYS THINK OF ATRIAL FLUTTER WHEN HR = 150 BPM
(this is due to AV block going from 300bpm in atria to 2:1 block causing 150bpm in ventricles.)

Answer 9

ECG: saw tooth and flutter waves

Flutter waves may be visible following carotid sinus massage or adenosine

More sensitive to cardioversion that atrial fibrillation

Question 10

ECG CORONARY TERRITORIES

Anterior
Lateral
Inferior
Posterior

Answer 10

Anterior: V1-4
Lateral: V5-6, I, AVL
Inferior: II, III, AVF
Posterior: tall R waves in V1-2

Question 11

Driving after Cardiac Events

Answer 11

Elective angioplasty - 1 week
CABG - 4 weeks
ACS - 4 weeks; 1 week if treated with PCI
ICD - 6 months
Ablation for arrhythmia - 2 days

Question 12

Rhythm control in AF:

Favoured in paroxysmal AF
(spontaneous resolution within 7 days)

Sotalol/amiodarone/fleicanide

Answer 12

Symptomatic patients
Younger patients
Presenting for the first time with lone AF.
Secondary to a treated or corrected precipitant.
Patients with congestive heart failure.

Question 13

Rate control in AF:

Favoured in persistent/permanent AF
(longer than 7 days/longer than 1 year respectively)

BB/rate limiting CCB and thromboprophylaxis
?Digoxin

Answer 13

Over 65s
With coronary heart disease
With contraindications to antiarrhythmic drugs.
Unstable for cardioversion.

Question 14

DVT Wells Score:

DVT likely if 2 or more
DVT unlikely if score = 1

Answer 14

Active cancer
Paralysis, paresis or plaster immobilisation of lower limb
Bedridden for 3 or more days
Major surgery within 12 weeks
Localised tenderness
Swollen leg
Calf swelling 3cm more than asymptomatic side
Pitting oedema
Previous DVT

Question 15

Prolonged PR interval (>0.2s)

1:1 A:V conduction

Answer 15

First degree AV block

Question 16

Progressive prolongation of the PR interval until a QRS is dropped.

Answer 16

Second degree AV block - Mobitz type 1

Question 17

Constant PR interval

Ratio of P:QRS could be 2:1 or 3:1 depending on degree of conduction block

Answer 17

Second degree AV block - Mobitz type 2

Question 18

Complete dissociation of atrial and ventricular rhythms

Answer 18

Third degree (Complete) Heart Block