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MRCP > Cardiology > Flashcards

Cardiology Flashcards

1
Q 
JVP - a wave
Cause?
Absent?
Large?
Cannon?
A 
Cause = Atrial contraction
Absent = AF
Large = TS, R heart failure, pulmonary HTN
Cannon = AV dissociation (atrial flutter/tachycardia, complete heart block, VT)
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2
Q

JVP - v wave
Cause?
Giant?

A 
Cause = passive atrial filling against closed tricuspid
Giant = TR
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3
Q

JVP - x descent
Cause?
Steep?

A 
Cause = Downward heart movement with ventricular contraction --> atrial stretch
Steep = constriction (steep x & y) or tamponade (steep x only)
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4
Q

JVP - y descent
Cause?
Steep?
Slow?

A 
Cause = Tricuspid opening --> passive blood movement into ventricle
Steep = Cardiac constriction
Slow = TS
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5
Q

Raised JVP
Normal waveform?
Raise on inspiration & drop on expiration?
Loss of normal pulsation?

A 
Normal = HF, overload, severe bradycardia
Kussmaul's = Failure of R heart to inc. in size for venous return (constriction, pericardial effusion, tamponade)
Loss = SVC syndrome
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6
Q

Causes of loud S1

A

Open mitral leaflets at end of ventricular diastole which are shut forcefully on systole. Occurs when:

  • rapid flow at end of diastole e.g. MR, short diastole with tachycardia, L to R shunt
  • Short PR = open valve at time of ventricular contraction

Causes: AF, tachycardia, MS, premature atrial beat

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7
Q 
Mitral stenosis
Definition?
Causes?
Features (auscultation, CXR)?
Associated rhythm?
Management?
A

Valve area under 2cm^2 (severe <1cm) on echo

Causes: RHEUMATIC FEVER. Also: mucopolysaccharidosis, carcinoid, SLE

Auscultation: mid-late diastolic murmur, opening snap, loud S1
CXR: LA/RV enlargement, subcarinal angle >90 degrees

Associated = AF

Mx = balloon valvuloplasty in suitable cases

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8
Q

Mitral Regurgitation
Causes?
Signs?
COMPLETE THIS CARD

A

Causes = prolapse, myxomatous degeneration, ischaemic papillary muscle rupture, congenital, rheumatic HD, enddocarditis
Functional (caused by annulus stretch secondary to dilation)

Signs

  • Pansystolic murmur
  • Soft S1 (incomplete valve closure)
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9
Q 
Cardioversion in AF
Types?
When?
AF onset <48h?
AF onset >48h?
A

Electrical - DC cardioversion timed to the R wave
pharmacology - amiodarone if structural heart disease, flecainide/amiodarone without structural heart disease

When:

  • Electrical as an emergency when haemodynamically unstable
  • Electrical or pharmacological as an elective when rhythm control preferred

<48h
may electrical cardiovert. heparinise before. stroke risk factors = lifelong anticoagulation. Following electrical if onset definitely <48h then anticoagulation can be stopped

> 48h
Electrical preferred
Anticoagulation for at least 3/52 before OR perform TOE to exclude thrombus is L atrial appendage (they can then be heparinised and cardioverted)
High failure risk = 4/52 amiodarone/sotalol prior
Following cardioversion, anticoagulate for at least 4 weeks

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10
Q

Infective endocarditis aetiology

1) Most common?
2) Associated with poor dental hygiene/post procedure?
3) Most common following prosthetic valve surgery?
4) Associated with colorectal cancer?
5) culture negative?

A

1) Stapylococcus aureus
2) Stapylococcus mitis/sanguinis
3) Coagulase-negative Stapylococci e.g. epidermidis
4) Stapylococcus bovis
5) Prev Abx, Bartonella, Brucell, Coxiella burnetti, HACEK

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11
Q 
Hypertension management
Step 1?
Step 2?
Step 3?
Step 4?
A

1:
<55/T2DM = ACE-I/ARB
>55 + no T2DM/african ethnicity = Ca blocker

2:
Add in other step 1 or thiazide diuretic

3:
ACE-I/ARB + Ca blocker + thiazide diuretic

4:
K <4.5 = add spiro
K >4.5 = add alpha/beta blocker
Uncontrolled with 4 drugs = specialist review

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12
Q

Tricuspid regurgitation
Signs?
COMPLETE

A

Signs: pan-systolic murmur, prominent V wave, pulsatile hepatomegaly, L parasternal heave

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13
Q

Prolonged PR interval
Definition?
Causes?

A

Duration >200ms

Causes: MILD RASH
Myotica dystrophica
IHD
Lyme
Digoxin toxicity
Rheumatic fever
Aortic abscess
Sarcoidosis
Hypokalemia
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14
Q

VTE treatment
Agent of choice? In renal impairment?
Length of anticoagulation?

A

1st line = apixaban/rivaroxaban
2nd = LMWH followed by dabigatran/edoxaban/wafarin
Severe renal impairment = LMWH/heparin followed by warfarin
NB antiphospholipid syndrome = LMWH followed by warfarin

Length

  • All Pts at least 3 months
  • Cancer Pts = 3-6 months
  • Provoked VTE = ?stop after 3 months
  • Unprovoked = ?continue for 6 months
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15
Q

Statins
Indications & recommended doses?
Mechanism?
Adverse effects?

A

Indications

  • Established CVD
  • 10-year cardiovascular risk >= 10% (inc. Pts with T2DM)
  • T1DM diagnosed > 10 years ago/aged > 40/have established nephropathy

Primary prevention = 20mg atorvastatin
Secondary prevention = 80mg atorvastatin

Inhibit the action of HMG-CoA reductase, the rate-limiting enzyme in hepatic cholesterol synthesis.

Adverse

  • Myopathy (Risk factors: thin old diabetic lady)
  • Deranged LFTs. Stop if persistently >3x upper limit
  • ?inc. risk of intracerebral haemorrhage. Avoid in Pts with Hx of of intracerebral haemorrhage
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16
Q

MI Complications?

A
  • Cardiac arrest
  • Cardiogenic shock
  • Chronic HF
  • Tachyarrythmia
  • Bradyarrythmia - AV block more common following inferior infarction
  • Pericarditis - Common in 48h following transmural MI. Dressler’s syndrome tends to occur 2-6/52 after ?due to autoimmune reaction to antigens as myocardium recovers
  • LV aneurysm - tends to be associated with persistent ST elevation + LV failure. Thrombus may form in aneurysm
  • LV rupture - tends to occur after 1-2/52. Presents with acute failure + tamponade
  • VSD - usually occurs in the first week. Features: acute heart failure associated with a pan-systolic murmur. mitral regurgitation presents in a similar way. Urgent surgery needed.
  • Acute MR - More common with infero-posterior infarction, may be due to ischaemia/rupture of papillary muscle. Acute hypotension + pulmonary oedema may occur. Early-to-mid systolic murmur typically heard. Treated with vasodilator therapy, often require emergency surgical repair.
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17
Q

ECG coronary territories
V1-V4?
II, III, aVF?
I, aVL +/- V5-6?

A

V1-V4 = anteroseptal = LAD
II, III, aVF = inferior = R coronary
I, aVL +/- V5-6 = lateral = left circumflex

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18
Q

Components of CHA2DS2-VASc?

A 
C - Congestive HF
H - HTN
A2 - age >75 (2), age 65-75 (1)
D - DM
S2  - prev. stroke
V - vascular disease
S - sex
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19
Q

Ventricular tachycardia
Main types?
Management?

A

Monomorphic - commonly caused by MI
Polymorphic - Includes torsades de pointes (caused by prolonged QT)

Management

  • Adverse signs (BP<90, chest pain, HF) = electrical cardioversion. Otherwise drugs
  • Drugs: amiodarone, lidocaine (caution in severe LV impairmen), procainamide.
  • DO NOT use verapamil (acts only on nodal tissue, inc. risk of VF)
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20
Q

Causes of prolonged QT

A

GENRALLY RELATED TO BLOCKAGE/LOSS OF K CHANNEL FUNCTION

Congenital

  • Jerval-Lange-Nielson syndrome (associated with deafness. Cause = K channel defect)
  • Romano-Ward syndrome

Drugs
- Amiodarone, TCAs, fluoxetine, chloroquine, erythromycin

Electrolyte abnormalities
- Hypo K/Ca/Mg

Other
- Hypothermia, MI, myocarditis, subarach haemorrhage

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21
Q

Pulmonary HTN management
Which test to perform?
Drug therapy?

A

Test = Acute vasodilator testing

+ve vasodilator response = Ca channel blockers

  • ve vasodilator response:
  • Prostacycline analogues (e.g. iloprost)
  • Endothelin receptor antagonists (e.g. bosentan, ambrisentan)
  • Phosphodiesterase inhibitors (e.g. sildefanil)
22
Q

Indications for implantable cardiac defibrillator?

A 
Long QT
HOCM
Prev. arrest due to VT/VF
Brugada syndrome
previous myocardial infarction with non-sustained VT on 24 hr monitoring, inducible VT on electrophysiology testing and ejection fraction < 35%
23
Q

LBBB

Causes?

A

Causes: MI, HTN, AS, cardiomyopathy, idiopathic fibrosis, digoxin toxicity, hyperkalaemia

24
Q

ECG changes in hypokalaemia?

A 
U waves
small or absent T waves (occasionally inversion)
prolong PR interval
ST depression
long QT

U have no Pot and no T, but a long PR and a long QT

25
Q

Patent ductus arteriosus
Definition?
Features?
Treatment?

A

Connection usually between pulmonary trunk and descending aorta

Features

  • Cont. machinery like murmur
  • L subclavian thrill
  • large volume, bounding, collapsing pulse
  • wide pulse pressure
  • heaving apex beat
  • Late: cyanosis in lower extremities

Mx
indomethacin/ibuprofen (inhibits prostaglandin synthesis)
if associated with another congenital defect amenable to surgery then prostaglandin E1 to keep the duct open until after repair

26
Q

Multifocal atrial tachycardia
Definition?
Management?

A

Irregular rhythm arising from at least three atrial sites (morphologically distinct P waves)

Management

  • Correct hypoxia/electrolyte disturbance
  • 1st line = rate limiting Ca blockers (e.g. verapamil)
  • Not useful: cardioversion, digoxin
27
Q

Peri-arrest: Bradycardia
Adverse signs?
Management?
Asystole risk factors?

A

Shock, syncope, myocardial ischaemia, HF

Mx

  • 1st line: Atropine 500mcg IV, repeated up to 6x
  • Transcutaneous pacing
  • Adrenaline infusion
  • ?transvenous pacing if no response to above or risk factors for asystole

Asystole RFs

  • Complete block with broad QRS
  • Recent asystole
  • Mobitz type II AV block
  • Ventricular pause >3s
28
Q

Ebstein’s anomaly
Definition?
Associations?
Features?

A

Congenital. Low tricuspid insertion –> large atrium, small ventricle

Associations: WPW, PFO/ASD

Features: Tricuspid regurg, prominent ‘a’ wave, hepatomegaly, RBBB

29
Q

Ventricular septal defect
Aetiology?
Complications?

A

Aetiology - chromosomal disorders 9e.g. Down’s), congenital infections, acquired (e.g. post MI)

Complications

  • AR (poorly supported R coronary cusp –> prolapse)
  • IE
  • R heart failure
  • Pulmonary HTN
  • Eisenmenger’s complex (prolonged pulm HTN from L to R shunt –> R vent hypertrophy + inc pressure –> exceeding LV pressure causing reversal of flow –> cyanosis)
30
Q 
Brugada syndrome
Definition?
Cause?
Criteria?
Management?
A

ECG abnormality with high incidence of sudden cardiac death in structurally normal hearts

Cause: mutation in cardiac Na gene. Tends to be autosomal dominant

Criteria for type 1 (BOTH ECG & CLINICAL)

  • ECG: coved ST elevation >2mm in >1 V1-3 followed by -ve T wave
  • Clinical: VF/polymorphic VT, coved ECG in family, FHx sudden cardiac death, syncope, nocturnal agonal respiration, inducible VT

Mx = ICD

31
Q

Atrial fibrillation: rate & rhythm control

  1. When to not offer rate control?
  2. Medication choice for rate?
  3. Medication choice for rhythm?
  4. Catheter ablation: anticoagulation, complications?
A
  1. Reversible cause, HF caused by AF, onset <48h, flutter suitable for ablation
  2. 1st line = beta-blocker.
    Digoxin if limited physical exercise (limited rate control during exercise) or other options ruled out
    Avoid Ca blockers in HFrEF due to -ve inotropic effect
  3. beta-blockers, dronedarone, amiodarone (esp. if co-existing HF), flecainide
  4. Anticoag: 4/52 before. Ablation does not reduce stroke risk even in sinus so Pts require anticoag based on CHADVASC score (0 = 2/12, >1 = longterm)
    Complications: cardiac tamponade, stroke, pulmonary vein stenosis
32
Q

Angina medical management
Prophylaxis?
Avoiding nitrate tolerance?

A

All Pts on aspirin & statin
SL GTN to abort attacks

Prophylaxis (improve perfusion/reduce metabolic demand)
1st line: beta blockers, Ca antagonists
CA antag monotherapy = verapamil/diltiazem (rate limiting)
If used with BB then long-acting dihydropyridine
NB: beta blocker + verapamil = complete heart block risk
2nd line: long-acting nitrate, ivabradine, nicorandil, ranolazine
? 3 drugs If uncontrolled with 2 drugs + awaiting revascularisation/revasc not appropriate

Nitrate tolerance = asymmetric ISMN dosing interval to maintain nitrate free period

33
Q

Broad complex tachycardia

Features suggestive of VT rather than SVT with abnormal conduction?

A

Suggestive of VT:

  • Absence of LBBB/RBBB
  • Extreme axis deviation
  • Very borad complex (>160ms)
  • AV dissociation
  • Capture beat (SAN “captures” ventricles in the midst of AV dissociation –> normal QRS)
  • Fusion beat (when a sinus and ventricular beat coincide to produce a hybrid complex)
  • Positive/negative concordance in precordial leads
  • Clinical: IHD, structural heart disease, Hx MI, FHx sudden cardiac death
  • marked L axis deviation
  • Hx of IHD
  • QRS > 160ms
  • AV dissociation
Use Brugada algorithm
Suggestive of VT: 
- Absent RS in precordial leads 
- RS interval >100ms in 1 lead
- AV dissociation
34
Q

High INR

  1. Major bleeding
  2. INR >8 minor bleeding
  3. INR >8 no bleeding
  4. INR 5-8 minor bleeding
  5. INR 5-8 no bleeding
A
  1. Stop warfarin, IV vit K 5mg, PCC (FFP if unavailable)
  2. Stop warfarin, IV vit K 1-3mg. Start warfarin when INR <5
  3. Stop warfarin, PO vit K 1-5mg. Start warfarin when INR <5
  4. Stop warfarin, IV vit K 1-3mg. Start warfarin when INR <5
  5. Withhold 1/2 doses. Reduce maintenance dose
35
Q 
Wolf-Parkinson-White
Definition?
ECG features?
Management?
Drugs to avoid?
A

Accessory pathway between atria/ventricles –> AV re-entry tachy

ECG: short PR, wide QRS with slurred upstroke (delta wave), R axis deviation (L side pathway), L axis deviation (R side pathway)

Mx

  • Definitive: ablation
  • Medical: sotalol (UNLESS AF: prolonging AV refractory –> inc. accessory pathway transmission –> inc. ventricular rate –> VF), amiodarone, flecainide

AVOID: verapamil, digoxin. May precipitate VF/VT

36
Q

MI secondary prevention
Drugs?
Another drug if signs of HF?

A

Drugs: DAPT, ACE-I, beta blocker, statin

Aldosterone antagonist e.g. eplerenone

37
Q

Arrythmogenic right ventricular cardiomyopathy
Definition?
Investigations?
Management?

A

Inherited (autosomal dominant, variable expression), RV myocardium replaced with fatty & fibrofatty tissue

Ix:

  • ECG: V1-3 TWI, epsilon wave (notch in QRS)
  • Echo: RV enlarged, hypokinetic/thin wall
  • MRI

Mx

  • Drugs: sotalol
  • Catheter ablation
  • ICD
38
Q

Infective endocarditis
Indications for surgery?
ECG change to monitor?

A

Severe CHF
Overwhelming sepsis/Recurrent emboli despite Abx
Aortic abscess
Pregnancy

ECG: PR prolongation, indicated aortic abscess

39
Q

4th heart sound
Cause?
Seen in which conditions?

A

Atrial contraction against a stiff ventricle. Occurs in late diastole. Coincides with P wave on ECG (PS4)

AS, HOCM, HTN

40
Q

Atrial septal defect
Features generally?
Ostium primum features?
Ostium secundum features?

A

Ejection systolic murmur, fixed split S2

Primum
associated with abnormal AV valves
ECG: RBBB with LAD, prolonged PR interval

Secundum
associated with Holt-Oram syndrome (tri-phalangeal thumbs)
ECG: RBBB with RAD
“something not RIGHT with the thumb”

41
Q

Therapy required after insertion of a drug-eluting stent?

A

12 months of DAPT

42
Q

Dilated cardiomyopathy

Associated valve abnormality?

A

Mitral regurg

43
Q

Exercise tolerance test

Indications to stop?

A

23 rule

2mm ST elevation
3mm ST depression
SBP >230
SBP fall by >20
HR >20% of starting
44
Q

Investigations of stable anginal chest pain?

A

1st line: CT coronary angiography
2nd line: non-invasive functional imaging (?reversible myocardial ischaemia)
3rd line: Invasive coronary angiography

45
Q 
Second heart sound
Loud?
Soft?
Fixed split?
Reversed split?
A

Loud = HTN
Soft = AS
Fixed split = ASD
Reversed split = LBBB

46
Q

Pregnancy and hypertension
BP changes during pregnancy?
Gestational hypertension definition?
pre-eclampsia definition?

A

BP falls in first half of pregnancy before rising to pro-pregnancy levels before term

Gestational HTN

  • HTN in second half of pregnancy (>20/40)
  • SBP >140/DBP>90 or rise of SBP>30/DBP>15

Pre-eclampsia

  • Pregnancy induced HTN + proteinuria
  • Occurs after 20 weeks
47
Q

ECG changes in hypothermia?

A

J wave (hump at end of ORS)
Irregular rhythm (long QT, arrythmias)
Bradycardia
First/other degree heart blocks

“Jesus, It’s Bloody Freezing”

48
Q

Pulmonary embolism: indication for thrombolysis?

A

Massive PE + haemodynamic instability

49
Q

Cyanotic congenital heart disease causes?

A 
5Ts:
Tetralogy of Fallot 
Transposition of great arteries
Trunctus arteriosus
Total anomalous pulmonary venous return
Tricuspid valve abnormalities & hypoplastic R heart syndrome
50
Q

Ivabradine
Indications?
Mechanism?
Common side effect?

A

Indications: symptomatic angina relief (HR >70), CHF (HR >75)

Mechanism
If channel inhibition (funny channel), found in SAN, triggered by hyperpolarisation, responsible for spontaneous myocyte activity.
Inhibition –> delayed depolarisation –> selectively slowed HR.

SE: visual disturbance e.g. bright spots

51
Q

Valve replacement
Types & who they are given to?
Disadvantages?
Anticoagulation?

A

Bioprosthetic - older Pts (>65/70) due to deterioration over time
Mechanical

Bio - degrade over time
Mech - Inc. thrombosis risk

Bio - Long term anticoag not usually needed ?3/12 warfarin depending on patient factor
Mech - Long term. Warfarin > DOAC. INR 3 for aortic, 3.5 for mitral

52
Q 
Adult advanced life support
Reversible causes?
Defibrillation principles?
Adrenaline principles?
Amiodarone principles?
A

4 ‘H’s - Hypoxia, Hypovolaemia, Hypokalaemia/calcaemia/glycaemia (other metabolic causes), Hypothermia
4 ‘T’s - Thrombosis, Tension pneumothorax, Tamponade, Toxins

Defibrilation

  • SIngle shock for VF/VT then 2 mins CPR
  • If on monitored Pt, can give up to 3 shocks then CPR

Adrenaine

  • 1mg ASAP for non-shockable
  • VT/VF arrest: 1mg after 3rd shock then repeat every 3-5 mins

Amiodarone

  • VT/VF: 300mg after 3 shocks. Further 150mg after 5 shocks
  • Lidocaine as an alternative

MRCP (6 decks)

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