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Cardiology Flashcards

1
Q

Acyanotic congenital heart disease

A 
VSD
ASD
Patent ductus arteriosus
Coarctation of the aorta
Aortic valve stenosis
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2
Q

Cyanotic congenital heart disease

A

Tetralogy of fallot
Transposition of the great arteries
Tricuspid atresia

Less common:
Pulmonary atresia
Hypoplastic left heart
Truncus arteriosus
Total anomolous pulmonary venous drainage
Ebstein anomaly
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3
Q

Presentation of ASD

A 
Asymptomatic in children
SOB
Palpitations
Exercise intolerance
Syncope
Oedema
Arrhythmia - AF and atrial flutter
Pulmonary HTN
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4
Q

ASD murmur

A

Soft systolic ejection murmur

pulmonary area, upper left sternal edge

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5
Q

Management of ASD

A

Closure of defect by catheter or surgical closure

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6
Q

VSD associations

A 
Edward's syndrome
Patau's syndrome
Down's syndrome
Diabetes in pregnancy
Fetal alcohol syndrome
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7
Q

Presentation of VSD

A 
Asymptomatic if small
Moderate have symptoms at 5-6 weeks
Dyspnoea on feeding
FTT
Recurrent respiratory infections
Heart failure
Very large VSD - pulmonary hypertension, right to left shunt and Eisenmenger's syndrome
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8
Q

Murmur in VSD

A

Loud, harsh, pansystolic murmur at the lower left sternal edge

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9
Q

CXR in VSD

A

Cardiomegaly

Increased pulmonary vasculature

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10
Q

Management of VSD

A 
Diuretics
High energy feeds
ACE-I to reduce afterload
Surgical repair if heart failure
Catheter closure
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11
Q

What is patent ductus arteriosus?

A

Patent duct at 3 months after term

Usually closes after 10-15 hours in term babies
Full anatomical closure in 2-3 weeks
Occurs in 50% of preterm babies

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12
Q

Presentation of PDA

A 
Small PDAs are asymptomatic
Recurrent respiratory infections
Feeding difficulties
FTT
Poor growth
Heart failure
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13
Q

Findings in PDA

A

Loud, machinery, continuous murmur loudest in the left upper sternal border
Bounding femoral pulses
Signs of heart failure

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14
Q

Management of PDA

A

Premature, small duct: indomethacin, observe
Premature, large duct: fluid restrict, diuretic, may need surgery
Term: unlikely to close itself. Diuretics, surgery

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15
Q

Associations of coarctation of the aorta (4)

A

Cerebral aneurysms - berry aneurysms in 10%
Turner’s syndrome
Patau’s syndrome (trisomy 13)
Edward’s syndrome (trisomy 18)

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16
Q

Presentation of coarctation of the aorta

A

In the first few weeks, becomes unwell after closure of ductus arteriosus

Poor feeding
Lethargy
Heart failure
Differential cyanosis
Features of Turner's syndrome
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17
Q

Findings in coarctation of the aorta

A

Systolic murmur in the left infraclavicular area
Reduced pulses and BP in legs
Differential cyanosis

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18
Q

CXR in coarctation of the aorta

A 
Heart failure
Rib notching (due to collaterals)
Indentation of the aortic shadow
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19
Q

Management of coarctation of the aorta

A 
Prostaglandin E1
Diuretics
Inotropes
Surgery or ballon angioplasty
In adults - beta blockers +/- ACE I
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20
Q

Causes of aortic stenosis

A 
Degenerative calcification
Bicuspid aortic valve
William's syndrome (supravalvular aortic stenosis)
Post-rheumatic disease
HOCM (subvalvular)
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21
Q

Presentation of aortic stenosis

A 
Only in childhood if severe
Fatigue
Chest pain
Syncope
Dyspnoea
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22
Q

Findings of aortic stenosis

A

Ejection systolic murmur radiating to the carotids
Soft or absent S2
Slow rising pulse (pulsus parvus et tardus)
Thrill

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23
Q

Management of aortic stenosis

A

Surgery if symptomatic or valvular gradient over 40 mmHg

Aortic valve replacement - usually transcatheter aortic valve implantation (TAVI)

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24
Q

Prognosis of aortic stenosis

A

Sudden cardiac death is rare if asymptomatic

Poor outcomes once symptomatic, 2 year survival without surgery around 50%

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25
Four findings in tetralogy of fallot
Right ventricular outflow tract obstruction Ventricular septal defect Overriding aorta Right ventricular hypertrophy Some children also have ASD
26
Features of tetralogy of fallot
``` FTT Feeding difficulties Agitation SOB SOBOE in older children Cyanotic episodes ```
27
Findings on examination in tetralogy of fallot
``` Small child Cyanosis Scoliosis Clubbing Ejection systolic murmur (due to pulmonary stenosis) Cause a right-to-left shunt ```
28
CXR in tetralogy of fallot
Boot shaped heart | Increased pulmonary vasculature
29
When does tetralogy of fallot present?
Age 1-2 months | Sometimes missed till 6 months
30
Associations with tetralogy of fallot
DiGeorge syndrome | Foetal alcohol syndrome
31
Treatment of tetralogy of fallot
Prostaglandin E1 Surgical repair in the first year Shunt may be used as interim or palliative measure Cyanotic episodes may be helped by beta blockers
32
What is transposition of the great arteries associated with?
Maternal diabetes
33
Presentation of transposition of the great arteries
``` Neonates Later presentation if mixing e.g. VSD Respiratory distress Cyanosis Heart failure Shock ```
34
Findings of transposition of the great arteries
Cyanosis Severe hypoxaemia and acidosis Murmur if no VSD: none, loud S2 Murmur if VSD: systolic Murmur if pulmonary stenosis: ejection systolic
35
CXR in transposition of the great arteries
'egg on a string' heart
36
Management of transposition of the great arteries
Prostaglandin infusion | Arterial switch operation at day 3
37
Presentation of tricuspid atresia
Cyanosis Heart failure Growth restriction
38
Findings in tricuspid atresia
``` Cyanosis Raised JVP Large and pulsatile liver If VSD - pansystolic murmur If surgically formed anastomoses - continuous murmur ```
39
CXR in tricuspid atresia
Cardiomegaly Prominent right heart border Reduced pulmonary vascular markings
40
Management of tricuspid atresia
``` Prostaglandin E1 infusion Surgical correction (Fontan's operation, 5% mortality) ```
41
Types of pulmonary atresia
Pulmonary atresia with intact ventricular septum Pulmonary atresia with VSD
42
Presentation of pulmonary atresia
Immediately after birth Cyanosis Feeding difficulties Dyspnoea Fatigue
43
Management of pulmonary atresia
Prostaglandin Surgical repair Temporary shunt Ultimately may need heart transplant
44
What chromosomal abnormality is pulmonary atresia with VSD associated with?
22q11 deletion syndrome
45
What are the abnormalities in hypoplastic left heart syndrome?
Mitral valve and/or aortic valve narrowed or blocked LV underdeveloped Aorta underdeveloped ASD
46
What are the abnormalities in truncus ateriosus?
Single large artery leaving the ventricles which then divides VSD
47
What are the abnormalities in total anomolous pulmonary venous drainage?
Pulmonary veins are not connected to the left atria but instead return to the right side of the heart
48
What are the abnormalities in Ebstein's anomaly?
Tricuspid valve is malformed Right ventricle is malformed
49
Presentation of Ebstein's anomaly
Usually age 10-30 Neonates: cyanosis, heart failure Adults: fatigue, SOBOE, cyanosis, right heart failure Supraventricular tachycardia Risk of cardiac death from ventricular arrhythmia
50
Findings in Ebstein's anomaly
Pansystolic murmur at the lower left parasternal edge due to tricuspid regurgitation Cyanosis Clubbing Signs of right heart failure
51
Signs of right heart failure
Peripheral oedema Hepatomegaly Ascites Raised JVP
52
CXR in Ebstein's anomaly
Cardiomegaly | Large RA
53
Management of Ebstein's anomaly
Manage heart failure Manage arrhythmia Early surgery
54
How long after MI can sexual activity resume?
4 weeks
55
How long after MI can you prescribe sildenafil? What drugs are contraindicated with sildenafil?
6 months AVOID if on nitrates or nicorandil
56
Causes of right bundle branch block
``` Normal variant Right ventricular hypertrophy Chronically increased RV pressure e.g. cor pulmonale PE MI Atrial septal defect Cardiomyopathy or myocarditis ```
57
How do statins work?
Inhibit HMG CoA reductase
58
At what time of day should patients take statins and why?
Night This is when the majority of cholesterol synthesis takes place
59
Which statin to prescribe and which dose?
Primary prevention = atorvastatin 20mg Secondary prevention = atorvastatin 80mg
60
When to increase statin dose in primary prevention? What should you increase it to?
If non-HDL has not reduced by >40% Consider increasing to 80mg
61
Contraindications to statins
Macrolides (erythromycin, clarithromycin) Pregnancy Previous intracranial haemorrhage
62
Who should be prescribed a statin?
``` Established cardiovascular disease 10 year cardiovascular risk greater than or equal to 10% (as per QRISK2) T1DM diagnosed >10 years ago T1DM age >40 T1DM with established nephropathy ```
63
Side effects of statins
Myopathy Liver impairment Possible increased risk of cerebral haemorrhage
64
Who is more at risk of myopathy from statins?
Increased age Female Low BMI More common with simvastatin/atorvastatin than rosuvastatin
65
When to check liver function when taking a statin? When should you then decide to stop the statin?
Baseline, 3 months and 12 months Stop if serum transaminase rise to and persist at 3 times upper limit
66
Normal QTc in men
<430ms
67
Normal QTc in females
<450ms
68
What is long QT syndrome?
Inherited condition with delayed repolarisation of the ventricles
69
Features of long QT syndrome
Sudden cardiac death Found on ECG or family screening Syncope after exercise or emotion
70
Management of long QT syndrome
``` Avoid precipitant drugs and exercise Beta blockers (NOT sotalol) Implantable cardioverter defibrillator ```
71
Causes of a long QT
``` Congenital Drugs Acute MI Myocarditis Hypothermia Low Ca, Low K, Low Mg ```
72
Congenital causes of long QT
Jervell-Lange-Nielson Syndrome (has deafness) Romano-Ward Syndrome (no deafness)
73
Drugs causing long QT
``` Amiodarone Sotalol Tricyclic antidepressants SSRI especially citalopram Methadone Chloroquine Erythromycin Haloperidol Ondansetron ```
74
ECG changes for an anteroseptal infarct
V1-V4
75
Vessels affected in an anteroseptal infarct
left anterior descending
76
What area and which artery is affected if the ischemic changes are in V1-V4?
Anteroseptal left anterior descending artery
77
ECG changes for inferior infarct
II, III, aVF
78
Vessels affected in an inferior infarct
right coronary
79
Which area and which vessel is affected if the ischaemic changes are in II, III, and aVF?
Inferior Right coronary artery
80
ECG changes for anterolateral infarct
V4-6, I, aVL
81
Vessels affected in an anterolateral infarct
left anterior descending or left circumflex
82
Which area and which vessel is affected if the ischaemic changes are in V4-6, I, aVL?
Anterolateral Left anterior descending artery or left circumflex artery
83
ECG changes in a lateral infarct
I, aVL +/- V5, V6
84
Vessels affected in a lateral infarct
Left circumflex
85
Which area and which vessel is affected if the ischaemic changes are in I, aVL +/- V5, V6?
Lateral left circumflex vessel
86
ECG changes in a posterior infarct
Tall R waves in V1-2
87
Vessels affected in a posterior infarct
Usually left circumflex | Also right coronary
88
Which area is affected if the ischaemic changes are in V1-2?
Posterior infarct Usually left circumflex, also right coronary
89
What does BNP stand for in cardiology?
B-type natriuretic peptide
90
What is BNP?
A hormone produced mostly by the left ventricle in response to strain
91
What causes raised BNP levels?
Heart failure MI Valvular disease CKD due to reduced excretion
92
Drugs that reduce BNP
ACE-I Angiotensin 2 receptor blockers Diuretics
93
Using BNP in heart failure
Unlikely if levels low <100 Good marker of prognosis Effective treatment lowers BNP
94
How do beta blockers work?
Antagonists of adrenergic beta receptors Located in heart, peripheral vasculature, bronchi, pancreas, liver
95
Side effects of beta blockers
``` Bronchospasm Cold peripheries Fatigue Sleep disturbance including nightmares Erectile dysfunction ```
96
Indications for beta blockers
``` Angina Post MI Heart failure Arrythmia HTN Thyrotoxicosis Migraine prophylaxis Anxiety ```
97
Contraindications to beta blockers
Uncontrolled heart failure Asthma Sick sinus syndrome Concurrent verapamil use
98
Why can't you use beta blockers and verapamil together?
May precipitate severe bradycardia
99
Stage 1 hypertension
Clinic BP ≥ 140/90 | ABPM ≥ 135/85
100
Stage 2 hypertension
Clinic BP ≥ 160/100 | ABPM ≥ 150/95
101
Severe hypertension
Clinic systolic ≥ 180 | Clinic diastolic ≥ 120
102
When to offer treatment of stage 1 hypertension?
<80 years AND any of: ``` Target organ damage Established cardiovasular disease Established renal disease Diabetes 10 year risk >10% ```
103
When should you admit in severe hypertension?
Signs of retinal haemorrhage or papilloedema (accelerated hypertension) New onset confusion, chest pain, acute kidney injury, heart failure
104
Management of severe hypertension
Admit if life threatening symptoms or accelerated hypertension Refer if pheochromocytoma suspected Urgent investigations for end organ damage - bloods, urine ACR, ECG
105
Lifestyle advice for management of hypertension
Low salt diet - less than 6g/day, ideally less than 3g/day Reduce caffeine General lifestyle advice
106
Patient <40 years diagnosed with hypertension?
Refer to secondary care to consider underlying causes
107
BP targets in T1DM
<135/85 Unless have albuminuria or 2 features of metabolic syndrome, then it is <130/80
108
Step 1 HTN management: <55 years or T2DM
ACE-I/ARB
109
Step 1 HTN management: >55 years or black/caribbean
CCB
110
Step 2 HTN management: <55 years or T2DM
ACE-I/ARB plus CCB OR thiazide like diuretic
111
Step 2 HTN management: >55 years or black/caribbean
CCB plus ACE-I/ARB OR thiazide like diuretic
112
Step 3 HTN management
ACE-I/ARB + CCB + thiazide like diuretic
113
Step 4 HTN management
K <4.5: low dose spironolactone | K >4.5: alpha or beta blocker
114
Clinic BP target age <80
140/90
115
ABPM BP target age <80
135/85
116
Clinic BP target age >80
150/90
117
ABPM BP target age >80
145/85
118
Hypokalaemia and hypertension - causes
``` Cushing's syndrome Conn's syndrome Liddle's syndrome 11-beta hydroxylase deficiency Carbenoxolone (anti-ulcer drug) Liquorice excess ```
119
Hypokalaemia without hypertension - causes
``` Diuretics GI loss Renal tubular acidosis type 1 and 2 Bartter's syndrome Gitelmann syndrome ```
120
What drugs should a patient be on following an MI?
Dual antiplatelet (aspirin + a second) ACE inhibitor Beta-blocker Statin
121
Exercise following an MI
20-30 minutes a day until slightly breathless
122
Sex following an MI
4 weeks post MI
123
What age would a patient get a biological heart valve rather than mechanical? Aortic and mitral
Aortic >65 years | Mitral >70
124
Anticoagulation in biological heart valves
Life long aspirin
125
What is the disadvantage of biological heart valves?
Structural deterioration and calcification over time
126
Target INR in mechanical heart valves - aortic and mitral
Aortic 3.0 | Mitral 3.5
127
Do patients with mechanical heart valves get aspirin along with warfarin?
Only if there is an additional factor e.g. IHD
128
How does digoxin work?
Increases myocardial contractility | Decreases conduction within the AV node
129
Indications for digoxin
AF and atrial flutter | Heart failure
130
Side effects of digoxin
``` GI upset Arrhythmia Confusion Dizziness Blurred vision ```
131
ECG features in digoxin
Down sloping ST/ reverse tick Flat/inverted T waves Short QT Arrhythmia
132
Features of digoxin toxicity
``` Generally unwell Nausea, vomiting, diarrhoea Confusion Yellow-green vision Arrhythmia - AV block, bradycardia Gynaecomastia ```
133
Precipitants of digoxin toxicity
``` Hypokalaemia Increasing age Renal impairment MI Low magnesium, low albumin High calcium, high sodium Hypothermia Hypothyroid ```
134
Drugs causing digoxin toxicity
``` Amiodarone Quinidine Verapamil Diltiazem Spironolactone Ciclosporin Drugs that reduce K+: thiazides, loop diuretics ```
135
Drugs for angina
1) Aspirin + statin + sublingual GTN 2) Beta blocker OR CCB 3) Both
136
DVLA - hypertension
If group 2 then disqualified if BP is persistently over 180/100
137
DVLA - angioplasty (elective)
1 week off
138
DVLA - CABG
4 weeks off
139
DVLA - MI
4 weeks off reduced to 1 week if sucessfully treated by angioplasty
140
DVLA - angina
Must stop driving if symptoms occur at the wheel
141
DVLA - pacemaker insertion
1 week off
142
DVLA - ICD for sustained ventricular arrhythmia
6 months off
143
DVLA - ICD prophylactically
1 month off
144
DVLA - group 2 drivers and ICD for sustained ventricular arrhythmia
Banned
145
DVLA - successful catheter ablation for arrhythmia
2 days off
146
DVLA - aortic aneurysm of 6 to 6.5cm
Notify DVLA | License subject to yearly review
147
DVLA - aortic aneurysm of 6.5cm or more
Banned
148
DVLA - heart transplant
6 weeks off
149
What is Wolff-Parkinson-White?
Congenital accessory conducting pathway between the atria and ventricles leading to AVRT As accessory pathway doesn't slow conduction, AF can degenerate to VF
150
ECG Features of Wolff Parkinson White
Short PR interval Wide QRS complexes with slurred upstroke - delta wave Left axis deviation if right sided accessory pathway Right axis deviation if left sided accessory pathway
151
Wolff Parkinson White - associations
``` HOCM Mitral valve prolapse Ebstein's anomaly Thyrotoxicosis Secundum ASD ```
152
Wolff Parkinson White - management
Radiofrequency ablation of the accessory pathway Sotalol (though NOT if have AF) Amiodarone Flecanide
153
Wolff Parkinson White - presentation
Asymptomatic | Episodes of SVT
154
HOCM inheritance
Autosomal dominant
155
HOCM symptoms
``` Asymptomatic Exertional dyspnoea Angina Syncope Sudden death ```
156
HOCM examination findings
Arrhythmia Jerky pulse Ejection systolic murmur - increases with valsalva, decreases with squatting
157
ECHO findings in HOCM
"MR SAM ASH" Mitral regurg Systolic anterior motion of the anterior mitral valve leaflet Asymptomatic hypertrophy
158
ECG findings in HOCM
``` LVH Non specific ST segment and T wave abnormalities Progressive T wave inversion Deep Q waves May sometimes see AF ```
159
HOCM associations
Friedreich's ataxia | Wolff Parkinson White
160
Investigations for angina
1st: CT coronary angiography 2nd: non-invasive imaging 3rd: angiography
161
Statins and pregnancy
Stop when trying to conceive | Remain off whilst breastfeeding
162
Moderate to severe aortic stenosis and ACE-I
Contraindicated
163
When should you choose rate control when managing AF?
>65 years | Ischaemic heart disease
164
When should you choose rhythm control when managing AF?
<65 years Symptomatic 1st presentation Heart failure
165
Rate control for AF
1st line: beta blocker or rate limiting CCB (diltiazem) | 2nd line: Digoxin
166
Rhythm control options for AF
Electrical cardioversion Pharmacological cardioversion Catheter ablation
167
Drugs used for pharmacological cardioversion in AF
Flecanide Amiodarone if structural heart disease
168
Anticoagulation after catheter ablation in AF
Still need life long
169
CHADSVASC scoring system
``` Congestive heart failure = 1 HTN = 1 Age >75 = 2 Age 65-75 = 1 Diabetes = 1 Stroke/TIA/thrombus = 2 Vascular disease = 1 Sex female = 1 ```
170
What CHADSVASC score would you give treatment for?
``` 0 = none 1 = male consider, female none 2 = treat ```
171
What scoring system assesses bleeding risk when considering anticoagulation?
ORBIT
172
ORBIT scoring system
``` Hb <130 in men or <120 in women = 2 Age >74 = 1 Bleeding history = 2 Renal impairment = 1 Treatment with antiplatelets = 1 ```
173
Interpreting ORBIT scoring system
``` 0-2 = low risk 3 = medium risk 4-7 = high risk ```
174
Clotting factors blocked by warfarin
II, VII, IX and X | 2, 7, 9, 10
175
Side effects of warfarin
Haemorrhage Teratogenic but can be used in breastfeeding Skin necrosis Purple toes
176
Major bleeding on warfarin
Stop warfarin IV vit K 5mg Prothrombin concentrate or if not available FFP
177
INR >8 and minor bleeding
Stop warfarin IV vit K 5mg, repeat 24 hours if needed Restart warfarin when INR <5
178
INR >8 and no bleeding
Stop warfarin Oral vit K, repeat 24 hours if needed Restart warfarin when INR <5
179
INR 5-8 and minor bleeding
Stop warfarin IV vit K Restart warfarin when INR <5
180
INR 5-8 and no bleeding
Withhold 1/2 doses of warfarin | Restart at lower dose
181
Things that potentiate warfarin
``` Liver disease P450 enzyme inhibitors Cranberry juice Drugs that displace warfarin from albumin e.g. NSAIDs Drugs that inhibit platelets e.g. NSAIDs ```
182
Effect of P450 enzyme inhibitors on warfarin?
Increase INR
183
Effect of P450 enzyme inducers on warfarin?
Decrease INR
184
ECG findings in atrial flutter
Saw tooth pattern AV block e.g. 2 to 1 Flutter waves after adenosine
185
Management of atrial flutter
Similar to AF | Radiofrequency ablation of tricuspid valve isthmus
186
First degree heart block - ECG findings
PR >0.2 seconds
187
What are the names for second degree heart block type 1?
Mobitz type 1 | Wenckebach
188
Second degree heart block type 1 - ECG findings
Progressive prolongation of the PR interval until a dropped beat occurs
189
Second degree heart block type 2 - ECG findings
PR interval constant but P wave often not followed by QRS (i.e. random)
190
Complete heart block
No association between P waves and QRS
191
Features of complete heart block
``` Syncope Heart failure Bradycardia Wide pulse pressure Cannon waves in JVP Variable intensity of S1 ```
192
What is Takayasu's arteritis?
Large vessel arteritis causing occlusion of the aorta
193
What should an absent limb pulse make you think about?
Takayasu's arteritis
194
Features of Takayasu's arteritis
``` Systemic features Unequal BP in upper limbs Carotid bruit Intermittent claudication Aortic regurg ```
195
Management of Takayasu's arteritis
Steroids
196
Gives some examples of calcium channel blockers
``` Verapamil Diltiazem Amlodipine Nifedipine Felodipine ```
197
What type of drug is verapamil?
CCB
198
What type of drug is diltiazem?
CCB
199
What type of drug is amlodipine?
CCB
200
What type of drug is nifedipine?
CCB
201
What type of drug is felodipine?
CCB
202
Verapamil side effects and cautions
``` Can't use with beta blockers due to risk of heart block Heart failure Constipation Hypotension Bradycardia Flushing ```
203
Diltiazem side effects
Hypotension Bradycardia Heart failure Ankle swelling
204
Amlodipine side effects
Flushing Headache Ankle swelling
205
How do ACE inhibitors work?
Block angiotensin 1 to angiotensin 2 - reduce vasoconstriction - promote renal sodium and water excretion
206
Side effects of ACE inhibitors
Cough in 15% Angiooedema Hyperkalaemia 1st dose hypotension
207
Contraindications to ACE inhibitors
``` Pregnancy and breast feeding Renovascular disease Aortic stenosis Hereditary of idiopathic angioedema Need specialist advice if K over 5.0 ```
208
When to monitor U+Es when on an ACE inhibitor?
Before starting | After every dose increase
209
What changes are acceptable when monitoring U+Es on an ACE inhibitor?
Creatinine up to 30% from baseline | K up to 5.5
210
Examples of ARBs
Candesartan Losartan Irbesartan
211
What type of drug is candesartan?
Angiotensin 2 receptor blocker
212
What type of drug is losartan?
Angiotensin 2 receptor blocker
213
What type of drug is irbesartan?
Angiotensin 2 receptor blocker
214
Indication for ARBs
When ACE inhibitor not tolerated due to cough | Used preferentially in black/Caribbean
215
Side effects of ARBs
Hypotension | Hypokalaemia
216
Examples of thiazide like diuretics
Indapamide Chlortalidone Bendroflumethiazide
217
What type of drug is indapamide?
Thiazide like diuretic
218
What type of drug is chlortalidone?
Thiazide like diuretic
219
What type of drug is bendroflumethiazide?
Thiazide like diuretic
220
How do thiazide like diuretics work?
Block Na reabsorption in the DCT by blocking the Na/Cl symporter Increase K+ excretion due to more Na reaching the collecting duct
221
Side effects of thiazide like diuretics
``` Dehydration, low Na, low K, low Cl Postural hypotension Gout Impaired glucose tolerance Impotence ``` RARE: thrombocytopenia, agranulocytosis, pancreatitis, photosensitive rash
222
How do loop diuretics work?
Inhibit the Na/K/Cl cotransporter in the thick ascending limb of the loop of henle, reducing absorption of NaCl
223
Examples of loop diuretics
Furosemide | Bumetanide
224
What type of drug is furosemide?
Loop diuretic
225
What type of drug is bumetanide?
Loop diuretic
226
Indications for loop diuretics
Heart failure | Resistent hypertension
227
Side effects of loop diuretics
``` Hypotension Low Na, low K, low Mg, low Ca Ototoxicity Renal impairment Hyperglycaemia Gout ```
228
What type of drug is spironolactone?
Potassium sparing diuretic
229
What type of drug is eplerenone?
Potassium sparing diuretic
230
What type of drug is amiloride?
Potassium sparing diuretic
231
How does spironolactone work?
Aldosterone antagonist
232
Indications for spironolactone
Ascites Heart failure Nephrotic syndrome Conn's syndrome
233
What is the Jones criteria for?
Diagnosing rheumatic fever
234
What are the major criteria for the Jones criteria?
``` Erythema marginatum Sydenham's chorea Polyarthritis Carditis and valvulitis Subcutaneous nodules ```
235
What are the minor criteria for the Jones criteria?
Raised CRP/ESR Pyrexia Arthralgia Prolonged PR
236
What criteria must be met to diagnose rheumatic fever?
Evidence of recent strep infection AND 2 major criteria, OR 1 major + 2 minor
237
What is evidence of recent strep infection?
Raised/rising strep antibodies Positive throat swab Positive rapid group A strep antibody test
238
Management of rheumatic fever
Pen V if any signs of ongoing strep infection NSAIDs Management of any complications that arise
239
Thiazide diuretic impact on calcium
Hypercalcaemia | Hypocalciuria
240
Which angina medication is associated with GI ulcers?
Nicorandil | Particularly with perforation of diverticulum
241
At which egfr should you stop a thiazide diuretic?
30
242
Normal ECG changes in atheletes
Sinus bradycardia Junctional rhythm First degree heart block Wenckebach phenomenon
243
First line thiazide like diuretic
Indapamide
244
Anticoagulation post MI if already on warfarin
anticoagulant + 2 antiplatelets for 4 weeks till 6 months Then 1 antiplatelet + 1 anticoagulant till 12 months
245
Monitoring for amiodarone before starting and ongoing
Before starting: LFTs, TFTs, U+E, CXR Every 6 months: TFTs, LFTs
246
Half life of amiodarone
20-100 days
247
Effect of amiodarone on p450
Inhibitor (increases INR)
248
Effect of amiodarone on ECG
Lengthens QT | Bradycardia
249
Side effects of amiodarone
``` Hyper/hypo thyroidism Corneal deposits Pulmonary fibrosis Liver fibrosis/hepatitis Peripheral neuropathy Slate grey skin ```
250
Why are beta blockers used less in managing hypertension?
Less likely to prevent stroke and potential for impaired glucose tolerance
251
What type of drug is isosorbide mononitrate?
A nitrate
252
Side effects of nitrates
Hypotension Tachycardia Headaches Flushing
253
How do nitrates work?
Dilate coronary arteries | Reduce venous return to reduce oxygen demand in the left ventricle
254
First line drug management for angina
Beta blocker OR | CCB
255
Which CCB should be used if being used as monotherapy for angina?
Rate limiting CCB | Diltiazem or verapamil
256
Which CCB should be used if being used in combination with a beta blocker for angina?
Modified release nifedipine
257
Angina management if on beta blocker and CCB and still having symptoms?
Third drug only whilst waiting PCI or CABG
258
NYHA class I
No symptoms | No limitation on activity
259
NYHA class II
Mild symptoms | Slight limitation on activity - ordinary activity causes dyspnoea
260
NYHA class III
Moderate symptoms | Marked limitation on activity - less than ordinary activity causes symptoms
261
NYHA class IV
Severe symptoms even at rest | Unable to carry out any activity without discomfort
262
Which patients group need a five yearly pneumococcal booster?
Asplenia Splenic dysfunction CKD
263
1st line for heart failure
ACEI and beta blocker
264
2nd line for heart failure
Aldosterone antagonists | e.g. spironolactone
265
3rd line for heart failure
``` Specialist input Ivabradine Digoxin Hydralazine and nitrates Cardiac resynchronisation ```
266
Heart failure management if they also have AF
ACEI Beta blocker Digoxin
267
Referral pathway if BNP is 'high'
Specialist assessment including echo within 2 weeks
268
Referral pathway if BNP is 'raised'
Specialist assessment including echo within 6 weeks
269
What is a high BNP?
> 400
270
What is a raised BNP?
100-400
271
What is a normal BNP?
<100
272
What is a normal ejection fraction?
50-70%
273
What is a borderline ejection fraction?
41-49%
274
What is a low ejection fraction?
<40%

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