Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

MRCP Part 1 > Cardiology #1 > Flashcards

Cardiology #1 Flashcards

1
Q

A 65yo lady presents with exertional chest pain, radiating to the left shoulder. Pain disappears on resting.
PMH: OA, Brittle Asthma. Cholesterol 4 years ago was normal. Non-smoker.
O/E: appears well and pain free.
Resting ECG is normal.
What is the next step in the investigation of this lady’s symptoms?

A

Contrast-enhanced coronary CT angiography.

This is first line for investigation of stable chest pain of suspected coronary artery disease aetiology.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

A 65yo lady presents with exertional chest pain, radiating to the left shoulder. Pain disappears on resting.
PMH: OA, Brittle Asthma. Cholesterol 4 years ago was normal. Non-smoker.
O/E: appears well and pain free.
Resting ECG is normal.
Why might she not be suitable for exercise (stress) echocardiogram?

A

Due to OA.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is the advice regarding using an Adenosine stress-CMR test for the investigation of suspected Angina in patients with Asthma?

A

Adenosine stress-CMR test is contraindicated in patients with Asthma due to the risk of Bronchospasm.

In patients without Asthma, the test can be used and has a high sensitivity.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is the immediate management of a patient presenting with Acute Chest Pain?

A
  • Glyceryl trinitrate
  • Aspirin 300mg (NICE do not recommend giving other antiplatelet [eg. Clopidogrel] agents out of hospital).
  • Give Oxygen if sats < 94%
  • ECG as soon as possible, but do not delay transfer to hospital.
    • A normal ECG does not exclude ACS.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

When should you accept an emergency admission for a patient with chest pain?

A

Current chest pain OR chest pain in the last 12 hours with an abnormal ECG.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

When should you refer a patient with chest pain to the hospital for same-day assessment?

A

Chest pain 12 - 72 hours ago.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

In a patient with chest pain, when should you ‘perform a full assessment with ECG and troponin measurement before deciding upon further action’?

A

Chest pain > 72 hours ago

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is the NICE guidance with regards to Oxygen therapy and Acute Coronary Syndrome?

A
  • Do not routinely administer Oxygen, but monitor Oxygen saturation using pulse oximetry, ideally before hospital admission.
    Only offer supplemental Oxygen to:
  • people with SpO2 < 94% who are not at risk of hypercapnic respiratory failure, aiming for SpO2 94 - 98%
  • People with COPD who are at risk of hypercapnic respiratory failure, to achieve a target SpO2 88-99% until blood gas analysis is available.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

How do NICE define pain typical of Angina?

A
  1. Constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms
  2. Precipitated by physical exertion
  3. Relieved by rest or GTN in about 5 minutes.
  • Patients with all 3 features have TYPICAL angina
  • Patients with 2 of the above features have ATYPICAL angina
  • Patients with 1 or none of the above features have non-anginal chest pain.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Describe the 1st, 2nd and 3rd line investigations in a patient for whom stable angina cannot be excluded by clinical assessment alone (eg. symptoms consistent with typical/atypical angina OR ECG changes).

A

1st line: CT Coronary Angiography

2nd Line: Non-invasive functional imaging (looking for reversible myocardial ischaemia)

3rd Line: Invasive Coronary Angiography.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

List some examples of Non-Invasive function imaging which might be used as 2nd Line in a patient for whom clinical assessment cannot exclude Stable Angina.

A
  • MPS with SPECT (‘Myocardial Perfusion Scintigraphy’ with ‘Single Photon Emission Computed Tomography’) or
  • Stress echocardiography
  • First-pass contrast-enhanced Magnetic Resonance (MR) perfusion or
  • MR imaging for stress-induced wall motion abnormalities.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

You review a 51yo male hypertensive patient who you started on Ramipril 2.5mg one month ago. He complains of a tickly cough since starting the medication, which is keeping him awake at night. However, his blood pressure is now within normal limits.
What should you advise him? Which drug category should you prescribe instead?

A

Stop Ramipril.

Prescribe an Angiotensin Receptor Blocker (ARB) eg. Candesartan.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

For a patient who is under 55 and is intolerant to an ACEi, which drug category should you offer next?

A

Angiotensin Receptor Blocker (ARB) eg. Candesartan.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What are the numerical values for ‘Stage 1 Hypertension’?

A

Clinic BP >= 140/90

Subsequent ABPM daytime average or HBPM average BP >= 135/85mmHg

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What are the numerical values for ‘Stage 2 Hypertension’?

A

Clinic BP >= 160/100mmHg

Subsequent ABPM daytime average or HBPM average BP >= 150/95mmHg

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What are the numerical values ‘Severe Hypertension’?

A

Clinic systolic BP >= 180mmHg
OR
Clinic Diastolic BP >= 110mmHg

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What comprises ‘lifestyle advice’ when you are counselling a patient with Hypertension?

A
  • Low salt diet (Less than 6g/day, ideally less than 3g/day)
  • Reduce caffeine intake
  • Stop smoking
  • Drink less alcohol
  • Eat a balanced diet rich in fruit and vegetables
  • Exercise more
  • Lose weight
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

When should you treat Stage 1 Hypertension (ABPM/HBPM >= 135/85)?

A

Treat if < 80 years AND if any of the following apply:

  • Target organ damage
  • Established cardiovascular disease
  • Renal disease
  • Diabetes
  • 10-year Cardiovascular risk equivalent to 10% or greater
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

When should you ‘consider, rather than treat’ antihypertensive treatment in people with Stage 1 Hypertension?

A

‘Consider antihypertensive drug treatment in addition to lifestyle advice for adults aged under 60 with stage 1 hypertension and an estimated 10-year risk below 10%.’

  • This seems to be due to evidence that QRISK may underestimate the lifetime probability of developing Cardiovascular disease.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

When should you treat Stage 2 Hypertension (ABPM/HBPM >= 150/95mmHg)?

A

Offer drug treatment regardless of age.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What should you consider if a patient under 40 presented with hypertension?

A

Consider a specialist referral to exclude secondary causes.

22
Q

Describe Step 1 treatment for Hypertension.

A
  • Patients < 55y or a background of T2DM: ACEi or ARB (ARB used where ACEi is not tolerated).
  • Patients > 55y or of Afro-Caribbean origin: CCB
  • ACEi have reduced efficacy in patients of Afro-Caribbean origin and therefore are not used first-line.
23
Q

Describe Step 2 treatment for Hypertension.

A

(A + C) or (A + D):

  • If already taking an ACEi or ARB, add CCB or Thiazide-like Diuretic.
  • If already taking a CCB, add ACEi or ARB
  • For patients of Afro-Caribbean origin taking a CCB, if they require a second agent, consider an ARB in preference to an ACEi.
24
Q

Describe Step 3 treatment for Hypertension.

A

Add a third drug to make (A + C + D)

  • If already taking ACEi + CCB, add a Thiazide-like Diuretic
  • If already taking ACEi + Thiazide-like diuretic, add a CCB.
25
Q

Describe Step 4 treatment for Hypertension.

A

NICE define Step 4 as Resistant Hypertension, and suggest adding a 4th drug or seeking specialist advice.

First, check for:

  • Confirm elevated clinic BP with ABPM or HBMP
  • Assess for postural hypotension
  • Discuss adherence

If Potassium < 4.5mmol/l, add low dose Spironolactone

If Potassium > 4.5mmol/l, add an Alpha- or Beta- blocker.

26
Q

What action should you take if a patient fails to respond to step 4 measures to treat their hypertension?

A

Refer to a Specialist:
‘If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, seek expert advice if it has not yet been obtained.’

27
Q

Explain the action of Direct Renin Inhibitors in treating hypertension.

A

Direct Renin Inhibitors eg. Aliskiren (Rasilez).
By inhibiting Renin, blocks the conversion of Angiotensinogen to Angiotensin 1.
- Trials suggest the drugs reduce blood pressure at a similar extent to ACEi and ARBs.
- Adverse effects uncommon. Diarrhoea occasionally seen.

  • Only current role would seem to be in patients who are intolerant of more established antihypertensive drugs.
28
Q

A 24yo female develops transient slurred speech following a flight from Australia to the UK. Both CT head and ECG are normal. Which of the following tests is most likely to reveal the underlying cause?

  • Transoesophageal Echo
  • MRI brain
  • Carotid USS Doppler
  • Cerebral Angiogram
  • Transthoracic Echo
A 
Transoesophageal Echo (TOE)
- Patient has a paradoxical embolus.  Patent foramen ovale is the most common cause.
  • TOE provides superior views of the atrial septum and therefore is preferred to Transthoracic Echocardiography for detecting a Patent Foramen Ovale.
29
Q

Describe the physiology leading to a Paradoxical Embolus.

A

For a right-sided thrombus (eg. DVT) to cause a left-sided embolism (eg. a stroke) it must pass from the right-to-left side of the heart.

The following cardiac lesions may cause such events:

  • Patent Foramen Ovale (present in around 20% of the population)
  • Atrial Septal Defect (a much less common cause).
30
Q

A 65yo man is admitted to the Emergency Department with Chest Pain, Nausea and feeling lethargic.
PMH: Type 1 Diabetes, CKD Stage 4 (secondary to diabetic nephropathy).
ECG on admission shows widespread ST elevation.
Bloods: Hyperkalaemia (5.8), Elevated Urea (26), Elevated Creatinine (305).
An echocardiogram shows a small effusion. What is the most appropriate next step in management?
- Oral Colchicine
- Pericardiectomy
- Pericardiocentesis
- IV Corticosteroids
- Haemodialysis

A

Haemodialysis

Patient has Uraemic Pericarditis. Haemodialysis is urgently required to correct the Uraemia, which will in turn improve the symptoms of pericarditis.

31
Q

List 5 features of Pericarditis

A
  • Chest pain: may be pleuritic. Is often relieved by sitting forwards
  • Other symptoms: non-productive cough, dyspnoea, flu-like symptoms
  • Pericardial rub
  • Tachypnoea
  • Tachycardia
32
Q

List 8 causes of Pericarditis.

A
  • Viral infections (Coxsackie)
  • Tuberculosis
  • Uraemia (causes ‘fibrinous’ pericarditis)
  • Trauma
  • Post MI -> Dressler’s syndrome
  • Connective tissue disease
  • Hypothyroidism
  • Malignancy
33
Q

What investigations should you conduct if you suspect Pericarditis? What should you look for in the results of these investigations?

A

1) ECG changes
- The changes in Pericarditis are often global / widespread, as opposed to the ‘territories’ seen in ischaemic events
- Saddle-shaped ST elevation
- PR depression: most specific EG marker for Pericarditis

2) Transthoracic Echocardiography (TTE)
- All patients with suspected acute pericarditis should have TTE.

34
Q

How should you manage a patient with Pericarditis?

A
  • Treat the underlying cause
  • A combination of NSAIDs and Colchicine is now generally used 1st line for patients with acute idiopathic or viral pericarditis.
35
Q

Which one of the following clinical signs would best indicate severe aortic stenosis?

  • Valvular gradient of less than 30mmHg
  • Soft 2nd heart sound
  • Quiet 1st heart sound
  • Development of an opening snap
  • Carotid radiation of ejection systolic murmur.
A

Soft 2nd heart sound

Note: Questions may sometimes refer to a soft A2 rather than a soft S2 (second heart sound), specifically mentioning the aortic component.

36
Q

List 3 clinical features of symptomatic Aortic Stenosis.

A
  • Chest pain
  • Dyspnoea
  • Syncope
37
Q

Which murmur is seen in Aortic stenosis? How is this decreased?

A

Ejection Systolic Mumur.

Decreased following the Valsalva manoeuvre.

38
Q

List 8 features of Severe Aortic Stenosis.

A
  • Narrow pulse pressure
  • Slow rising pulse
  • Delayed ejection systolic murmur
  • Soft/Absent S2
  • S4
  • Thrill
  • Duration of murmur
  • Left ventricular hypertrophy or failure
39
Q

List 5 causes of Aortic Stenosis.

A
  • Degenerative calcification (most common in older patients > 65 years)
  • Bicuspid aortic valve (most common in younger patients < 65 years)
  • William’s Syndrome (Supravalvular Aortic Stenosis)
  • Post-Rheumatic disease
  • Subvalvular: Hypertrophic Obstruct Cardiomyopathy.
40
Q

Describe the management of a patient with Aortic Stenosis.

A
  • If asymptomatic: observe the patient
  • If symptomatic: Valve replacement
  • If asymptomatic but valvular gradient > 40 mmHg and with features such as LVSD then consider surgery.
  • Cardiovascular disease may co-exist. For this reason, an angiogram is often done prior to surgery so that the procedures can be combined.
  • Balloon valvuloplasty is limited to patients with critical aortic stenosis who are not fit for valve replacement.
41
Q

You are considering prescribing an antibiotic to a 28yo male who tells you he had Long QT syndrome. Which antibiotic is most important to avoid?

  • Doxycycline
  • Trimethoprim
  • Erythromycin
  • Rifampicin
  • Co-amoxiclav
A

Erythromycin: can prolong the QT interval.

42
Q

Describe the physiology of Long QT syndrome.

A

Long QT syndrome is an inherited condition associated with delayed repolarisation of the ventricles.

It is important to recognise as it may lead to Ventricular Tachycardia / Torsade de pointes, and can therefore cause collapse / sudden death.

43
Q

Which are the most common variants of Long QT syndrome? What are they caused by?

A

LQT1 and LQT2:

Caused by defects in the alpha subunit of the slow delayed rectifier potassium channel.

44
Q

What are the values (in males and females) for a Normal Corrected QT interval?

A

Less than 430ms in Males.

Less than 450ms in Females.

45
Q

List 2 congenital causes of a Prolonged QT interval.

A
  • Jervell-Lange-Nielsen syndrome (includes deafness and is due to an abnormal Potassium channel)
  • Romano-Ward syndrome (no deafness)
46
Q

List some drugs which cause a Prolonged QT interval.

A
  • Amiodarone, Sotalol, Class 1a Anti-arrhythmic drugs
  • Tricyclic antidepressants, SSRIs (especially Citalopram)
  • Methadone
  • Chloroquine
  • Terfenadine
  • Erythromycin
  • Haloperidol
  • Ondansetron
47
Q

List some non-drug causes of Long QT syndrome.

A
  • Electrolyte imbalances: hypocalcaemia, hypokalaemia, hypomagnesaemia
  • Acute MI
  • Myocarditis
  • Hypothermia
  • Subarachnoid Haemorrhage
48
Q

How might Long QT1 present?

A

Usually associated with exertional syncope, often swimming

49
Q

How might Long QT2 present?

A

Often associated with syncope occurring following emotional stress, exercise or auditory stimuli

50
Q

How might Long QT3 present?

A

Events often occur at night or at rest.

-> sudden cardiac death

51
Q

How would you manage a patient with Long QT?

A
  • Avoid drugs which prolong the QT interval and other precipitant if appropriate (eg. Strenuous exercise)
  • Beta blockers
    (Note that Sotalol may exacerbate Long QT syndrome)
  • Implantable Cardioverter Defibrillators in high risk cases

MRCP Part 1 (16 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions