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MSRA 2022 > Cardiology > Flashcards

Cardiology Flashcards

1
Q

What is the most common group of organisms implicated in acute infective endocarditis?

A

GRAM POSITIVE COCCI:
Single most common organism in developed countries = Staph aureus
Staph epidermidis = the most common organism in the initial 2 month period following prosthetic valve replacement (and commonly colonises indwelling lines)
Strep viridans = colonise the mouth, often implicated in those with poor oral hygiene or after a dental procedure - more common causative organism in developing countries.
Strep bovus = associated with colorectal cancer

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2
Q

What is the 1st line Abx regimen for native valve endocarditis?

A

Amoxicillin + Gentamicin until blood cultures available - for 4-6 wks
If MRSA suspected, patient is severely septic or they have a penicillin allergy = Vancomycin + Gentamicin
Prosthetic valve endocarditis = Vancomycin + Gentamicin + Rifampicin

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3
Q

Which valve is most commonly affected valve in bacterial endocarditis in those without any prosthetic valves?

A

Mitral Valve

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4
Q

What are the most important risk factors for bacterial endocarditis?

A

Single most important risk factor = history of previous bacterial endocarditis
Others: rheumatic valve disease, prosthetic valves, congenital cardiac defect, IVDU, recent piercing

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5
Q

What are the typical ECG changes in hyperkalaemia?

A

Earliest manifestation = peaked T waves
Then = Flattening and widening of the P waves, prolonged PR interval, widening of the QRS with abnormal morphology, bradyarrythmias with conduction blocks.

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6
Q

What are the doses of atorvastatin used for primary v secondary prevention?

A

Primary prevention = 20mg
Secondary prevention = 80mg

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7
Q

What is HOCM

A

Hypertrophic Obstructive Cardiomyopathy
= an autosomal dominant disorder of the muscle tissue of the heart.
May present with exertional dyspnoea.
Echo findings = mitral regurg, LV outflow obstruction, assymetrical hypertrophy
Mx = Amiodarone
+/- beta blocker / verapamil for symptom control
May need dual chamber pacemaker.
AVOID ACEi and NITRATES IN HOCM AS REDUCES AFTERLOAD SO REDUCED LV GRADIENT.

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8
Q

Which two beta blockers are shown to reduce mortality in stable heart failure?

A

Bisoprolol and carvedilol

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9
Q

What is the classical presentation of digoxin toxicity?

A

Vague: fatigue, GI upset, yellow/green vision (xanthopsia), gynaecomastia, AV block/bradycardia

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10
Q

What is the mechanism of action of digoxin?

A

Na/K+/ATPase inhibitor.
= decreased AV node conduction (slow ventricular response in AF) + increased cardiac contractility (improves symptoms but not mortality in HF)

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11
Q

What are common precipitating factors for digoxin toxicity?

A

HYPOKALAEMIA (because digoxin competes with potassium at the Na/K/ATPase pump) -> thus thiazide and loop diuretics can trigger.
HYPERNATRAEMIA
HYPERCALCAEMIA
LOW ALBUMIN
LOW MAGNESIUM
RENAL FAILURE
HYPOTHERMIA
HYPOTHYROIDISM
DRUGS -> thiazide/loop diuretics (through hypokaelamia), spironolactone (because competes for excretion in the kidneys thus leads to higher levels of dig building up!), amiodarone, calcium channel blockers (verapamil and diltiazem), quinidine, ciclosporins

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12
Q

How would you monitor for digoxin toxicity?

A

Dig -> routine serum levels not check.
Toxicity can occur even with THERAPEUTIC LEVELS
If suspect toxicity, take dig levels 8-12 hrs after the last dose
Therapeutic level is <1. Toxicity is increasingly likely once >1.5

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13
Q

What is the typical presentation of crescendo, variant and decubitus angina?

A

Crescendo / unstable angina = comes on at rest or with minimal exertion / increasing severity + frequency of episodes.
Variant angina = comes on at rest
Decubitus angina = comes on when lying flat

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14
Q

What are the 1st line agents for SYMPTOM RELIEF in stable angina.

A

Sublingual GTN + a beta blocker or calcium channel blocker

If beta blocker + calcium channel blocker both contraindicated, isosorbide mononitrate is an alternative option

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15
Q

Which diagnoses are consistent with an ejection systolic murmur?

A

Aortic stenosis
Aortic sclerosis
Pulmonary stenosis
Hypertrophic cardiomyopathy
Flow murmurs (occur during high flow states eg pregnancy, do not warrant further investigation)

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16
Q

What diameter of AAA should be offered elective repair?

A

5.5cm or greater

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17
Q

What makes up the CHADVAS score when assessing re need for anticoagulation in AF?

A

Age (<65 = 0 65-74 = +1, 75 or older = +2)
Female gender +1
Diabetes = +1
Hypertension = +1
Congestive Heart Failure = +1
Prev TIA/STROKE/VTE = +2
Prev arterial event ie MI, aortic plaque or PAD) = +1

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18
Q

What is the typical presentation of an atrial myoxoma?

A

Benign overgrowth, most commonly in the LEFT ATRIUM
More common in females
= mitral valve obstruction = diastolic murmur, symptoms of heart failure, syncope and dizziness

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19
Q

Causes of LBBB?

A
  • Ischaemic heart disease (new LBBB fits the criteria for STEMI in the presence of symptoms of ACS)
  • Idiopathic fibrosis
  • Cardiomyopathy
  • Hypertension
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20
Q

Causes of RBBB?

A
  • Cor pulmonale
  • Cardiomyopathy
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21
Q

ECG changes in hyperkalaemia?

A
  • Tall tented T waves
  • Flattened P waves
  • Increased PR interval
  • Widened QRS complexes
    _> progression to VT or VF
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22
Q

ECG changes in hypokalaemia?

A

everything gets low!!

  • Flattened T waves
  • ST depression
  • prominent U waves (the wave after the T wave)
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23
Q

ECG changes in HYPOcalcaemia?

A

Intermittently increased QT interval

24
Q

ECG changes in HYPERcalcaemia

A

shortened QT interval

25
Q

Infarct patterns in STEMI?

A

V1-V2 = septal infarct
V1 - V4 = anteroseptal
V2-V5 = anterior
V3-6 + I + aVL = anterolateral

26
Q

How to distinguish the ejection systolic murmur of HOCM from aortic stenosis?

A

in HOCM the ej syst murmur does NOT radiate to the carotids
in AS it does radiate to the carotids! AS murmur also INCREASES WTH SQUATTING and REDUCES WITH STANDING

27
Q

Side effect profile of amiodarone

A
  • Hypo or hyperthyroidism
  • Grey skin discolouration
  • N+V
  • Derranged LFTs
  • Pulmonary fibrosis
  • Tremor
28
Q

Absolute contraindications to thrombolysis after MI?

A
  • Recent major surgery / trauma
  • Heavy internal or vaginal bleeding
  • Cerebral neoplasm
29
Q

Relative contraindications to thrombolysis after MI?

A
  • Pregnancy
  • Recent childbirth
  • Peptic ulcer disease
30
Q

Presenting features of aortic regurgitation?

A
  • Early diastolic murmur best heard when sitting forward and in expiration over the left sternal edge
  • Low diastolic BP
  • exaggerated arterial pulsations
31
Q

What is the new HTN guideline with regards to drug agents?

A

1st step
Age < 55 OR diabetic at ANY AGE = A drug
Age > 55 OR afrocarribean at ANY AGE = C drug

2nd step
Add in either a thiazide diuretic OR an A drug OR a C drug depending on what they’re already on

3rd step = A drug + C drug + Thiazide diuretic

4th Step = add in additional diuretics or alpha or beta blocker and consider seeking expert advice.

NOTE the A drug of choice: 1st line should be ACEi UNLESS THEY ARE AFRO-CARRIBEAN in which case 1st line of A drugs is ARB.
Thiazide drug - SHOULD NOT USE BENDROFLUMETHIAZIDE, instead should use INDAPAMIDE or other.

32
Q

HTN drug agents - special cases

A

Diabetic of any age = ACEi 1st line
Diabetic + Afrocarribean = ARB 1st line
Pregnant or TTC = AVOID ACEi/ARB - if BP stable with / already on calcium channel blocker then CONTINUE, if commencing HTN treatment then 1st line = Labetalol

33
Q

Murmurs?

A

SYSTOLIC
Ej systolic -> aortic stenosis, HOCM, pulmonary stenosis
Pansystolic > mitral regurg and tricuspid regurg
End systolic -> mitral prolapse
DIASTOLIC
early diastolic -> aortic regurg
end diastolic -> mitral stenosis

34
Q

At what Q risk score should you start primary prevention statin treatment ?

A

10% or over
Primary prevention dose = Atorvastatin 20mg

35
Q

when should you give high dose statin (Atorvastatin 80mg)

A

As SECONDARY prevention ie a cardiovascular event has already occured ie MI, stroke, peripheral vascular disease

36
Q

What are contraindications for exercise ECG testing?

A
  • MI within the past 7 DAYS
  • Unstable angina
  • Heart failure with pulmonary oedema
  • Electrolyte disturbances
  • Aortic stenosis
37
Q

What is the gold standard diagnostic test for aortic dissection?

A

CT

(less ideal but alternative options are: trans-oesophageal echo or MRI)

38
Q

How should patients with a non-diagnostic coronary angiography or CAD of uncertain significance be investigated further?

A

NON-INVASIVE FUNCTIONAL CARDIAC IMAGING (stress echo, myocardial perfusion scintigraphy)

39
Q

Typical presentation of Dressler’s syndrome?

A

Occurs after an MI or cardiac surgery.
= antibodies to heart muscle
= fever + chest pain +/- pericardial effusion
Mx = NSAIDS/aspirin + steroids

40
Q

Causes of long QTc?

A

Congenital -> (Jarvell + lange-nielson syndrome = congenital long QTc + sensorineural deafness. Romano-ward syndrome = congenital long QT and normal hearing)
Low magnesium
Low potassium
MI
Drug induced (sotalol, amiodarone, disopyramide)

Long QTc is a risk of progressing to torsade de pointes (a specific sub-type of polymorphic VT associated with progression from long QT) which you treat with IV 2g Mg infused over 10 mins

41
Q

Resus council guidelines - bradycardia in adult?

A

If signs of 1) Shock 2) Syncope 3) Myocardial Ischaemia 4) Heart Failure 5) Risk of asystole (prev asystole, mobitz type II, complete heart block with wide QRS, ventricular pause > 3 secs)

-> Atropine 500 micrograms IV
(can repeat upto a max of 3mg)

(blocks the parasymp innveration ie Atrop when you want the heart to chop chop)

-> once atropine has been given / in multiple doses -> alternative add-ons to consider =
* Isoprenaline
* Adrenaline
* Transcutaneous pacing

Seek expert help to consider transvenous pacing

If no immediate sign of shock/syncope/HF/ischaemia -> consider if at risk of progression to assystole:
* Recent asystole
* Mobitz type II block
* Complete heart block with broad QRS
* Ventricular pause > 3s

If risk factors -> start atropine

IF BRADYCARDIA CAUSED BY BETA BLOCKER OR CALCIUM CHANNEL BLOCKER -> CAN USE GLUCAGON

42
Q

Resus council guidelines 2021 - tachycardia in adult?

A

Any unstable features? (shock, syncope, ischaemia, severe heart failure) -> upto 3 synchronised DC shocks (50-200 joules depending on the type of tachyarrythmia) -> if doesn’t work then IV Amiodarone 300mg over 10-20 mins then repeat synchronised shock.

No unstable features -> is QRS narrow or broad (narrow = < 0.12 secs)

Narrow regular tachycardia - likely SVT - 1st line = Vagal maneuvre -> Adenosine (6mg bolus if doesnt work 12 mg bolus if doesn’t work 18mg bolus) -> if adenosine doesn’t work = consider verapamil or beta blocker

Narrow irregular tachycardia - likely AF - rate-control with beta blocker or if that fails / heart failure present then with digoxin or amiodarone.

Broad complex regular tachycardia -> likely monomorphic VT until proven otherwise -> Amiodarone 300mg IV over 10-60 mins
(if prev KNOWN SVT and suspected SVT with aberrant conduction/LBBB then can treat as per SVT)

Broad complex irregular tachycardia -> polymorphic VT / torsades des pointes until proven otherwise -> IV Magnesium 2mg over 10 mins
(if prev KNOWN AF and suspected AF with LBBB then treat as per AF)

43
Q

1st degree heart block?

A

constant prolonged PR intervals (>0.2 secs / > 5 small squares)

44
Q

2nd degree heart blocks?

A

Mobitz Type I (Wenckebach) -> progressively longer PR interval and then a dropped QRS
(Wenckeback gives you Warning)
Mobitz Type II - constantly prolonged PR interval and then a dropped beat (no warning! more dangerous / at risk of progression to complete block / assystole)

45
Q

3rd degree heart block?

A

Complete heart block
AV dissociation (the P-P interval and QRS-QRS intervals tend to be constant even though they are not related to each other)

46
Q

STEMI management (NICE 2020)

A

Assess if candidate for reperfusion therapy (Primary PCI or fibrinolysis) -> ie are they presenting within 12 hours of symptom onset

Primary PCI if can be performed within 2 hours of when fibrinolysis could be given, if within 12 hours of symptom onset OR if outwith 12 hours of symptom onset but signs of ongoing myocardial ischaemia or cardiogenic failure.

If going for primary PCI give:
-> dual antiplatelet = Prasugrel + 300mg Aspirin
(if already on anticoagulant then = clopidogrel + aspirin instead. if high bleeding risk then clopidogrel or ticagrelor + aspirin.)
-> during PCI -> if radial access (preferred) give unfractionated heparin + bailout glycoprotein IIb/IIIa -> if femoral access give bivalirudin + bailout glycoprotein

If for fibrinolysis give:
-> fibrinolytic agent (alteplase, streptokinase)
-> antithrombin (unfractionated heparin) at the same time
-> repeat ECG after 60-90 mins -> if ongoing STEMI then -> PCI

If STEMI but not candidate for PCI / fibrinolysis, give:
-> Ticagrelor + 300mg Aspirin
OR
-> Clopidogrel + 300mg Aspirin or Aspirin alone if high bleeding risk

47
Q

NSTEMI / unstable angina management (NICE 2020)

A

1) Aspirin 300mg stat + Fondaparinux as immediate antithrombin (unless unstable and -> immediate angiography or high bleeding risk)
2) Assess GRACE score (predicted 6 month mortality):
<3% = low risk
3-6% = intermediate risk
6-9% = high risk
>9% = highest risk

If intermediate risk or above (>3%):
If unstable = IMMEDIATE angiography (don’t give immediate fondaparinux on presentation)

If stable:
-> PCI within 72 hours
-> fondaparinux on presentation and then unfractionated heparin during the PCI
-> Dual antiplatelet (Prasugrel + Asprin. If high bleeding risk eg > 75 = consider ticagrelor + aspirin. if already on an oral anticoagulant = clopidogrel + aspirin)

If low risk (GRACE <3%)
-> Ticagrelor + Aspirin
(if high bleeding risk = Clopidogrel + Aspirin or Aspirin alone)

48
Q

Definition of malignant hypertension?

A

BP >180/110 mmHg with papilloedema or retinal haemorrhage

49
Q

Diagnostic criteria for rheumatic fever?

A

Rheumatic fever = a syndrome following a streptococcal infection
Need evidence of recent streptococcal infection PLUS either 2 major criteria or 1 major + 2 minor

Major: erythema marginatum (pink ring rash), sydenham’s chorea, polyarthritis, endocarditis/myocarditis/pericarditis, subcutaneous nodules

Minor: ^ CRP/ESR, fever, arthralgia, prolonged PR interval

50
Q

which murmurs are heard loudest on inspiration v expiration ?

A

Right-sided heart murmurs -> loudest on INSPIRATION
Left-sided heart murmurs -> loudest on EXPIRATION

51
Q

definiton of peripartum cardiomyopathy?

A

heart failure that develops either in the last month of pregnancy or the initial 5 months postpartum with NO OTHER CAUSES FOUND

52
Q

type of heart failure that develops in amyloidosis?

A

RESTRICTIVE CARDIOMYOPATHY -> DIASTOLIC HEART FAILURE

53
Q

when is driving restricted with a AAA?

A

Must iNFORM the DVLA when > 6cm
Must STOP DRIVING when > 6.5cm

Elective repair is offered if:
SYMPTOMATIC AT ANY SIZE
>4CM AND GROWN MORE THAN 1CM IN A YEAR
>5.5CM

Open surgical repair is generally first line unless other comorbidities or co-existent abdominal pathology eg stoma

AFTER LEAKING OF A AAA -> most people benefit more from EVAR (women of all age and men > 70).
Men > 70 benefit more from open repair after leak.

54
Q

What is Beck’s triad of cardiac tamponade?

A

1) Hypotension
2) ^ JVP
3) Muffled heart sounds

55
Q

which syndrome is associated with dextrocardia?

A

Kartagener’s syndrome

56
Q

1st line Mx of aortic stenosis in a child?

A

Balloon angioplasty first
Then only if this fails -> valve replacement

57
Q

Which conditions is pulsus parodoxus associated with? ( a drop in pulse pressure during inspiration)

A

acute asthma
cardiac tamponade

MSRA 2022 (23 decks)

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