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MRCP part 2 > Cardio > Flashcards

Cardio Flashcards

1
Q

Native valve empirical IE abx

A

Amox / benpen + gent

Vanc + gent if penicillin allergic / MRSA / severe sepsis

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2
Q

Prosthetic valve empirical IE abx

A

Vanc + gent + rifampicin

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3
Q

Native valve + staph IE abx

A

Fluclox

Vanc + rifampicin - MRSA or penicillin allergic

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4
Q

Prosthetic valve staph IE abx

A

Fluclox (or vanc) + rifampicin + gent

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5
Q

Fully sensitive strep viridans IE mx

A

Benzylpenicillin

Vanc + gent - penicillin allergic

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6
Q

Less sensitive strep viridans IE Mx

A

Benzylpenicillin + gent

Vanc + gent - penicillin allergic

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7
Q

Permanent pacemaker indications

A
  • persistent symptomatic bradycardia e.g. sick sinus syndrome
  • AV pauses >3s when awake
  • AV pauses <3s when awake with symptoms
  • mobitz 2
  • complete heart block
  • persistent AV block post MI
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8
Q

Normal AV gradient

A

25mmHg

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9
Q

MV gradient calculation

A

capillary wedge pressure - LV diastolic pressure

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10
Q

Normal MV gradient

A

<5mmHg

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11
Q

Arrhythmogenic right ventricular dysplasia features

A
  • AD inheritance
  • palpitations, syncope, sudden death
  • V1-3 TWI
  • epsilon wave (positive depolarisation after QRS)

Mx
- sotalol / catheter ablation (VT) / ICD

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12
Q

Indications for surgical prophylaxis for IE

A
  • Prosthetic cardiac valve or prosthetic material used for cardiac valve repair
  • Previous infective endocarditis
  • Cardiac transplantation with the subsequent development of cardiac valvulopathy

Congenital heart disease but only if it involves:

  • Unrepaired cyanotic defects, including palliative shunts and conduits
  • Completely repaired defects with prosthetic material or devices whether placed by surgery or catheter intervention, during the first 6 months after the procedure (after which the prosthetic material is likely to have been endothelialised)
  • Repaired defects with residual defects at or adjacent to the site of a prosthetic patch or device (which inhibit endothelialisation)
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13
Q

WPW type / side differentiation

A

Type 1 - right axis deviation, left sided pathway

Type 2- left axis deviation, right sided pathway

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14
Q

AF + WPW mx

A

1) Flecainide

2) Amiodarone if structural heart disease

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15
Q

Angina management

A

All: aspirin, statin, SL GTN

Long term

1) B blocker / CCB
2) + CCB / B blocker
3) ISMN

Alternatives:

  • ivabradine: HR>70
  • nicorandil: avoid in hypotension
  • ranolazine: avoid in severe liver / renal dysfunction
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16
Q

Trifascicular block

A

1) prolonged PR
2) RBBB

3) LAFB (LAD)
OR
LPFB (RAD)

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17
Q

Cardiac amyloidosis ECG

A

Low voltage QRS

Poor R wave progression

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18
Q

LAD MI ECG changes

A

V1-4

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19
Q

Right coronary ECG changes and territory

A

II, III, avF

Inferior

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20
Q

Anterolateral vessels and ECG changes

A

LAD OR left circumflex

V4-6, I, aVL

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21
Q

Lateral vessel & ECG changes

A

I, aVL +/- V-6

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22
Q

Posterior vessel & ECG changes

A

Tall R waves V1-2
Usually left circumflex
Sometimes right coronary
(NB: may have inferior ECG changes as well if RCA involved OR lateral changes if LCirc involved)

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23
Q

Peripartum cardiomyopathy definition

A
  • HF towards the end of pregnancy / within 5 months postpartum
  • no other cause of HF
  • LVEF <45% or 45-50% if classical HF symptoms
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24
Q

Peripartum cardimyopathy treatment

A
  • salt and fluid restriction
  • diuresis
  • consider digoxin if AF co-existing
  • anticoagulate with heparins
  • avoid ACEi / ARB / mineralocorticoids
  • beta blockers when stable
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25
Q

Hypertension - stages / values in clinic and ambulatory

A

Stage 1
- ≥140/90 in clinic and ≥135/85 ambulatory

Stage 2
- ≥160/100 in clinic and ≥150/95

Stage 3
- ≥180 systolic or ≥110 diastolic

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26
Q

Hypertension: when to treat and targets

A 
Treat stage 1 (≥140/90 clinic / ≥135/85 ambulatory) if 
<80 yrs old AND
- hypertensive retinopathy
- ACR >2.5 men / >3.5 women
- CKD
- DM
- other CV disease
- Qrisk ≥10%

Treat all stage 2 hypertension (≥160/100 in clinic and ≥150/95 ambulatory)

Target bp <80: 140/90 clinic AND 135/85 ambulatory

Target bp >80 150/90 clinic AND 145/85 ambulatory

Uncomplicated DM 140/90 clinic and 135/85 home

DM with end organ damage 130/80 clinic AND 125/80 home

CKD: higher target if uncomplicated

CKD + DM2 OR ACR >70: lower target

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27
Q

Hypertensive encephalopathy management

A
  • IV mx e.g. sodium nitroprusside, labetalol

- aim 10-15% decrease MAP w/i few hours, 25% decrease within 1 day

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28
Q

Causes qt prolongation

A
  • hypokalaemia
  • hypomagnesaemia
  • hypocalcaemia
  • hypothermia
  • MI
  • raised ICP
  • congenital
  • > Jervell-Lange-Nielson syndrome (deafness)
  • > Romano ward (no deafness)
  • drugs: antipsychotics, TCAs, amiodarone, macrolides e.g. erythromycin, abx e.g. chloroquine, hydroxychloroquine

NB: females are more likely to have torsades as a result

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29
Q

Investigating aortic stenosis in association with left ventricular dysfunction

A

Dobutamine stress echo OR cardiac catheterisation with dobutamine distinguishes between true severe AS and apparent severe AS in the context of LV failure
True severe AS: dobutamine -> increased transvalvular pressure with the same valve area
Apparent /pseudo-severe AS: dobutamine -> increased valve area

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30
Q

Duke’s criteria infective endocarditis

A

Diagnosis definite if:

  • 2 major
  • 1 major + 3 minor
  • 5 minor

Diagnosis possible if:

  • 1 maj + 1 minor
  • 3 minor

Major criteria

  • 2x positive blood cultures for typical organisms: S aureus, S viridans, Streptococcus bovis/gallolyticus, HACEK organisms
  • 3+ +ve blood cultures of skin contaminant organisms
  • positive echo findings: vegetation / abscess / valve dehiscence
  • new valvular regurgitation

Minor criteria

  • predisposition e.g. IVDU, prosthetic valve, other cardiac lesion -> turbulence
  • fever >38C
  • vascular phenomena e.g. septic emboli, splinter haemorrhages, janeway lesions
  • immunological phenomena: GN, roth spots, osler nodes, RF +ve
  • micro/serological evidence of infection not meeting major criteria
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31
Q

Chemical cardioversion in AF

A

1) Flecainide - unless structural heart disease. Best chance of cardioversion
2) Amiodarone if structural heart disease

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32
Q

Heart failure and new pansystolic murmur after inferior MI

A
  • 30% inferior MI -> right ventricular wall involvement -> RV failure +/- VSD/TR
33
Q

Management of familial hypercholesterolaemia

A

1) high dose statin
2) ezetimibe (can be added to statin)
3) evolucumab - if LDL peristently >3.5

34
Q

Management of hypertriglyceridaemia

A

Fenofibrate

Nicotinic acid can also be used

35
Q

Statins and pregnancy

A

Discontinue 3 months prior to conception

36
Q

Viral myocarditis

A

Features: chest pain with or without heart failure, arrhythmias

Ix: elevated trop, elevated crp, non specific ECG changes, bnp may be elevated

Mx:

1) Diuresis
2) CV support as required - inotropes / IABP
3) Early ACE
4) Beta blocker when no longer in acute heart failure

AVOID

  • NSAIDs
  • heavy etoh
  • exercise
37
Q

Pulmonary hypertension and pregnancy

A
  • high mortality risk -> give advice and consider termination
  • if they want to keep: anticoagulation, prostacyclin, close monitoring
38
Q

VT/VF following full thickness MI (q waves)

A

day 1 - no significance

delayed VT/VF -> ICD

39
Q

Causes of reverse split S2

A

(AV closure after PV)

  • LBBB
  • severe AS
40
Q

S2 in normal individuals

A

Expiration - single sound

Inspiration - 1) AV 2) PV

41
Q

Louder P2 than A2

A

Pulmonary hypertension

ASD

42
Q

Wide split S2

A
  • RBBB

- Pulmonary stenosis

43
Q

Fixed split S2

A
  • ASD

- RV failure

44
Q

U waves

A
  • follow T waves
  • hypoK/Ca/Mg
  • hypothermia
  • digoxin, amiodarone, sotalol, procainamide, TCAs
45
Q

ECG features in severe hypoK

A
  • Increased p wave width/amplitude
  • PR prolongation
  • St depression
  • T wave flattening/inversion
46
Q

Ebstein anomaly

A
  • assoc w/ maternal lithium usage
  • assoc w/ WPW syndrome
  • TV anomalies
  • ASD
  • atrialisation of RV
  • may present late with reduced exercise tolerance, cyanosis, AF, right heart failure
  • ECG: RBBB, small R waves V1-2
47
Q

WPW + FAF mx

A
  • DO NOT GIVE: verapamil, metoprolol, digoxin, sotalol, adenosine (blocks AV conduction -> VF)
  • GIVE: flecainide / amiodarone / procainamide
48
Q

Posterior STEMI ECG

A

V1-4 st depression
upright t waves
prominent r wave

49
Q

pAF mx

A

Bisoprolol > digoxin in prophylaxis

50
Q

Chronic aortic regurgitation managment

A

All

  • yearly follow up with echo at least every 2 years
  • 3-6 monthly follow up if rapidly deteriorating or approaching surgery criterial

In general:

  • ACEi -> prolongs deterioration into LV dysfunction
  • Bblockers - if heart failure
  • Mineralocorticoids esp if heart failure

Surgery should be considered if

  • asymptomatic with
    • LVEF <50%
    • LV external diastolic diameter > 70mm
    • LVESD > 50mm
  • all symptomatic patients
  • significant ascending aorta enlargement
51
Q

When to use thallium myocardial perfusion imaging vs dobutamine stress echo vs CT calcium scoring in stable angina ix

A

CAD consortium score

  • high risk (61-90%) -> invasive coronary angiogram
  • intermediate (30-60%) -> non-invasive evaluation (thallium / dobutamine)
  • low (10-29%) -> CT calcium scoring
  • thallium has greater sensitivity
  • dobutamine has greater specificity
  • therefore use thallium in intermediate risk CAD cases
  • never use dobutamine in WPW cases / other conduction abnormalities
52
Q

JVP: causes of prominent a waves

A

Any cause of RV hypertrophy e.g. pulmonary stenosis, tricuspid stenosis

53
Q

JVP: causes of cannon a waves

A

AV dissociation - atria contracting against closed tricuspid

54
Q

Endocarditis associated with bowel cancer

A

Strep bovis, bacterioides fragilis

55
Q

Digoxin toxicity management

A

1) Activated charcoal
2) Measure levels
3) Digibind
4) If VT develops - IV lignocaine / procainamide can be used
5) IV phenytoin is also an option

56
Q

Anticoagulation with DC cardioversion

A
  • start anticoagulation prior to cardioversion
  • review anticoagulation at 1 month post procedure -> still in sinus? any symptoms suggestive of interim AF?
  • consider stopping anticoagulation if nad
57
Q

Indications for surgery in infective endocarditis

A
  • congestive cardiac failure e.g. acute valvular regurgitation or obstruction by vegetation
  • peri-annular extension - abscess formation
  • recurrent systemic embolism
  • large vegetations >10mm with systemic embolism
58
Q

Dominant v waves

A

Tricuspid regurgitation

Right heart failure

59
Q

Management of severe symptomatic mitral stenosis

A

Percutaneous balloon valvotomy, unless

  • mod-sev MR
  • LA thrombus
  • heavily calcified MV
  • other valve disease / coronary artery disease requiring surgery

IN WHICH CASE
- mitral valve replacement

60
Q

Type of lipid abnormality with palmar xanthomas

A

dysbetaliporoteinaemia (type III hyperlipoproteinaemia)

61
Q

Drugs for primary pulmonary hypertension

A

AIM: pulmonary vasculature vasodilation

1) CCBs
Later stage options: sildenafil, endothelin receptor antagonists (beware hepatotoxicity), prostacyclin infusions

62
Q

Goals of statin therapy

A

If high CV risk patient

  • LDL <1.8
  • or decrease by 50% if baseline 1.8-3.5
63
Q

Stable patient with regular tachycardia where unsure if ventricular or SVT - which drug?

A

Adenosine - no effect on VT so it is safe

64
Q

Management of prosthetic valve thrombosis

A

Critically unwell?

  • thrombolysis
  • surgery in select cases

Stable?

  • heparin infusion
  • surgery in select cases
65
Q

HOCM ECG features

A
  • LVH -> non specific ST / T wave abnormalities
  • RBBB
  • inferolateral Q waves
  • P mitrale due to LV diastolic dysfunction
66
Q

Indications for anticoagulation in very low EF

A
  • previous thromboembolism
  • intracardiac thrombus
  • LV aneurysm
67
Q

High altitude pulmonary oedma mx

A

Prophylaxis = acetazolamide

Acute treatment
- high flow oxygen
nifedipine if unavailable
- descent

68
Q

Indications for myomectomy in HOCM

A
  • symptomatic HOCM despite beta blockers

- LVOT >50

69
Q

Heyde syndrome

A

Triad

  • calcific aortic stenosis
  • anaemia
  • acquired coagulopathy

vW factor is depleted by passing through calcific AS -> acquired vW syndrome and anaemia secondary to GI bleeding from any angiodysplasia

Mx: aortic valve replacement

70
Q

Long QT mx

A
  • reduce symptoms associated with non-sustained arrhythmias - bblocker e.g. metoprolol
  • reduce sudden death from VT - ICD
71
Q

Familial hypercholesterolaemia

A
  • total chol >7.5 and LDL >4.9

AND

  • tendon xanthomata (or in 1st/2nd degree relative)

OR

  • LDL receptor mutation, apo-B or PCSK9 mutations

homozygotes present before 20

heterozygotes present after 30

72
Q

Digoxin in amyloidosis patients

A

use with caution as it irreversibly binds to amyloid fibrils

73
Q

1st line drug for vasoreactive pulmonary hypertension

A

Non-cardioselective CCBs e.g. amlodipine

74
Q

Drug treatment of PVEs causing symptoms

A

Bblocker

75
Q

Becker’s muscular dystrophy cardiac features

A

Dilated cardiomyopathy
May present ages 5-15, but sometimes later
Cardiac features may be in presentation
Less significant proximal muscle weakness vs Duchenne’s

76
Q

Factors to differentiate VT from broad complex SVT…

VT is more likely if:

A
  • no typical LBBB / RBBB morphology
  • extreme NW axis deviation
  • complexes >160ms
  • fusion / capture beats
  • positive or negative concordance i.e. chest leads all show either negative or positive deflections, no combination
  • left rabbit ear of RSR’ complex is taller (right ear taler in RBBB)
77
Q

Isoprenaline in complete heart block secondary to MI

A

Contraindicated!

78
Q

Driving post ACS

A
  • cars: drive after 1 week if free of symptoms

- lorry: stop driving, inform DVLA, in 6 weeks he must pass exercise tolerance test (stop beta blockers 48hrs before)

79
Q

CRT-P vs CRT-D in heart failure patients

A
  • LVEF <35% required for either
  • NYHA IV AND QRS >120ms -> CRT-P
  • NYHA II or below -> CRT-D if LBBB or QRS >150ms
  • NYHA III CRT-P or D

MRCP part 2 (11 decks)

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