Cardiology Flashcards
1
Q
Definition of hypertension (Stage 1)?
A
140/90
2
Q
Long term antiplatelet for PAD (no allergies)?
A
Clopidogrel
3
Q
HOCM presenting features?
A
Exertional dyspnoea
Angina
Syncope- typically following exercise
Sudden death (most commonly due to ventricular arrhythmias), arrhythmias, heart failure jerky pulse, large 'a' waves, double apex beat.
Ejection systolic murmur
4
Q
Features of hypokalaemia on ECG?
A
ST depression
U waves
a long QT interval
a prolonged PR interval
5
Q
Side effects of ACEI?
A
cough
occurs in around 15% of patients and may occur up to a year after starting treatment
angioedema: may occur up to a year after starting treatment
hyperkalaemia
first-dose hypotension: more common in patients taking diuretics
6
Q
Auscultation and pulse pressure signs for pulmonary regurgitation?
A
would present with a diastolic murmur but it would be the loudest over the 2nd intercostal space on the left and would not have the wide pulse pressure.
7
Q
Auscultation and pulse pressure signs for aortic stenosis?
A
present with a systolic murmur with narrow pulse pressure
8
Q
Auscultation and pulse pressure signs for Aortic regurgitation?
A
diastolic murmur loudest over the aortic valve and wide pulse pressure
9
Q
Auscultation and pulse pressure signs for Mitral stenosis?
A
would present with a diastolic murmur it would be loudest over the mitral valve and would not have wide pulse pressure.
10
Q
When would you offer fibrinolysis in STEMI?
A
Fibrinolysis should be offered within 12 hours of onset of symptoms if primary PCI cannot be delivered within 120 minutes
11
Q
First line PE treatment (haemodynamically stable)?
A
DOAC
12
Q
When are ACEI first line in diabetes (to treat HTN)
A
Ramipril should be used first-line for treating hypertension in diabetics, exceptions to this are people of Afro-Caribbean origin and women for whom there is a possibility of becoming pregnant.
13
Q
What is the ABCD2 score used for?
A
ABCD2 is used to triage patients presenting with an acute Transient Ischaemic Attack (TIA).
14
Q
Target INR for mechanical heart valves?
A
aortic: 3.0
mitral: 3.5
15
Q
SCOFF questionnaire use?
A
Questionnaire used to detect eating disorders and aid treatment
16
Q
IPSS questionnaire score?
A
International prostate symptom score
17
Q
Gleason scoring system use?
A
Indicates prognosis in prostate cancer
18
Q
Bishop scoring system use?
A
Used to help assess the whether induction of labour will be required
19
Q
Waterlow scoring use?
A
Risk of pressure sore
20
Q
Ranson criteria use?
A
Acute pancreatitis
21
Q
Dose of atorvastatin to use?
A
Atorvastatin 20mg for primary prevention, 80mg for secondary prevention
22
Q
When to give statin in T1DM pts?
A
- Older than 40 years of age
- Have had diabetes for more than 10 years
- Have established nephropathy
- Have other CVD risk factors (such as obesity and hypertension)
23
Q
Factors in the GRACE score?
A
AGE
ECG
Troponin
Renal function
24
Q
Bloods monitoring for statins?
A
LFTs at baseline , 3 months and 12 months
25
Becks triad of cardiac tamponade?
Falling BP, raised JVP and muffled HS
26
Persistent ST elevation following recent MI, no chest pain?
left ventricular aneurysm.
27
Peri-arrest tachycardia - Signs to indicate DC cardioversion (unstable)
shock: hypotension (systolic blood pressure < 90 mmHg), pallor, sweating, cold, clammy extremities, confusion or impaired consciousness
syncope
myocardial ischaemia
heart failure
28
Treatment of peri-arrest tachycardias? (not unstable)
Determine of tachycardia is broad or narrow:
Broad - Regular
- assume ventricular tachycardia (unless previously confirmed SVT with bundle branch block)
loading dose of amiodarone followed by 24 hour infusion
Broad - Irregular
- seek expert help. Possibilities include:
atrial fibrillation with bundle branch block - the most likely cause in a stable patient
atrial fibrillation with ventricular pre-excitation
torsade de pointes
Narrow - Regular (SVT)
vagal manoeuvres followed by IV adenosine
if above unsuccessful consider diagnosis of atrial flutter and control rate (e.g. beta-blockers)
Narrow - Irregular
probable atrial fibrillation
if onset < 48 hr consider electrical or chemical cardioversion
rate control: beta-blockers are usually first-line unless there is a contraindication
29
CHA2DS2VASC score factors?
C Congestive heart failure 1
H Hypertension (or treated hypertension) 1
A2 Age >= 75 years 2
Age 65-74 years 1
D Diabetes 1
S2 Prior Stroke, TIA or thromboembolism 2
V Vascular disease (including ischaemic heart disease and peripheral arterial disease) 1
S Sex (female) 1
30
ECG features of WPW?
short PR interval
wide QRS complexes with a slurred upstroke - 'delta wave'
left axis deviation if right-sided accessory pathway*
right axis deviation if left-sided accessory pathway*
Non-specific ST-T changes - looks like ischaemia (ST depression/T wave inversion)
31
Bradycardia treatment options?
Atropine (500mcg IV) is the first line treatment if unstable (shock; impaired consciousness; syncope; myocardial ischaemia; heart failure)
If there is an unsatisfactory response the following interventions may be used:
- atropine, up to maximum of 3mg
- transcutaneous pacing
- isoprenaline/adrenaline infusion titrated to response
If failing may have to do transvenous pacing.
32
If patient has acute HF if not responding to furosemide what would you consider?
Acute heart failure not responding to treatment - consider CPAP
33
What is the mnemonic SAD for Aortic stenosis?
Syncope, angina, dyspnoea on exertion
34
What medication is contraindicated in VT ?
Verapamil is contraindicated in VT as intravenous administration of a calcium channel blocker can precipitate cardiac arrest.
35
Length of treatment for PE? Provoked vs unprovoked?
if the VTE was provoked the treatment is typically stopped after the initial 3 months (3 to 6 months for people with active cancer)
If the VTE was unprovoked then treatment is typically continued for up to 3 further months (i.e. 6 months in total)
36
Management of angina?
All patients should receive aspirin and a statin in the absence of any contraindication.
Sublingual glyceryl trinitrate to abort angina attacks.
NICE recommend using either a beta-blocker or a calcium channel blocker first-line based on 'comorbidities, contraindications and the person's preference'.
if a calcium channel blocker is used as monotherapy a rate-limiting one such as verapamil or diltiazem should be used. If used in combination with a beta-blocker then use a long-acting dihydropyridine calcium-channel blocker (e.g. modified-release nifedipine). Remember that beta-blockers should not be prescribed concurrently with verapamil (risk of complete heart block).
if there is a poor response to initial treatment then medication should be increased to the maximum tolerated dose (e.g. for atenolol 100mg od).
if a patient is still symptomatic after monotherapy with a beta-blocker add a calcium channel blocker and vice versa.
if a patient is on monotherapy and cannot tolerate the addition of a calcium channel blocker or a beta-blocker then consider one of the following drugs: a long-acting nitrate, ivabradine, nicorandil or ranolazine.
if a patient is taking both a beta-blocker and a calcium-channel blocker then only add a third drug whilst a patient is awaiting assessment for PCI or CABG.
37
CCF management (3 options)?
The first-line treatment for all patients is both an ACE-inhibitor and a beta-blocker
generally, one drug should be started at a time. NICE advise that clinical judgement is used when determining which one to start first
beta-blockers licensed to treat heart failure in the UK include bisoprolol, carvedilol, and nebivolol.
ACE-inhibitors and beta-blockers have no effect on mortality in heart failure with preserved ejection fraction
Second-line treatment is an aldosterone antagonist
these are sometimes referred to as mineralocorticoid receptor antagonists. Examples include spironolactone and eplerenone
it should be remembered that both ACE inhibitors (which the patient is likely to already be on) and aldosterone antagonists both cause hyperkalaemia - therefore potassium should be monitored
Third-line treatment should be initiated by a specialist. Options include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin and cardiac resynchronisation therapy
38
What are janeway lesions and oslers nodes?
Janeway lesions - erythematous macular or nodular lesions caused by septic emboli
Osler nodes - painful erythematous lesions caused by immune complex deposition
39
What abx can cause long QT (and progress to torsades)?
Erythromycin, clarithromycin, ciprofloxacin
40
What should you do with UEs changes when started on ACEI?
Up to 30% is acceptable.
If within 30% then check in 3 months.
UEs should be checked at baseline, after 2 weeks and then 1 3 and 6 months
41
When do people need to notify DVLA re blood pressure
BUS DRIVERS - above 180 sys or 100 diastolic consistently
42
Angina vs atypical angina vs non-cardiac cp diagnostic criteria?
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
43
Investigation of choice for ?stable angina?
CT angiogram
44
What is Buerger's disease, or thromboangiitis obliterans?
Condition characterised by progressive inflammation and thrombosis of the small and medium arteries in the hands and feet. It can present as acute ischaemia or chronic progressive ischaemic changes to the skin/tissues. Ultimately it may result in gangrene of the affected area, often needing amputation. It is strongly associated with an extensive smoking history. The exact pathophysiology is not fully understood.
Associated with Raynauds.
45
Definitive treatment for WPW?
Accessory pathway ablation.
46
Most common cause of Cardiac arrest in MIs?
Going into VF.
VT is also common.
47
When cardiac arrest witnessed (and shockable rhythm) what is the most appropriate management?
The correct answer is to deliver three shocks. When a cardiac arrest is witnessed, and the patient is monitored, up to three successive shocks can be given, followed by commencing cardiopulmonary resuscitation (CPR).
48
Most specific ECG change for pericarditis?
PR depression: most specific ECG marker for pericarditis
49
Examples of macrolides?
Clarithromycin, erythromycin, azithromycin
50
when do you anticoagulate in AF?
Anticoagulation should be considered for the following:
Men: CHA2DS2-VASC >= 1
Women CHA2DS2-VASC >= 2
51
Treatment for bradycardia with shock?
IV atropine 500mcg.
52
What abx should you not prescribe with statins?
Macrolides
53
SEs of nicorandil?
Headache
Flushing
Skin, mucosal and eye ulceration
Gastrointestinal ulcers including anal ulceration
54
If a patient develops new AF (and chasvasc +ve) and is on an antiplatelet for stable CVD what should you do with anticoagulation?
DOAC, stop the antiplatelet
55
Method of inheritance of HOCM?
Autosomal dominant.
56
NYHA class system for HF?
NYHA Class I
no symptoms
no limitation: ordinary physical exercise does not cause undue fatigue, dyspnoea or palpitations
NYHA Class II
mild symptoms
slight limitation of physical activity: comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea
NYHA Class III
moderate symptoms
marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms
NYHA Class IV
severe symptoms
unable to carry out any physical activity without discomfort: symptoms of heart failure are present even at rest with increased discomfort with any physical activity
57
VF or VT more common after MI? What is the leadi
VT
58
Who should you NOT use rate control to control AF?
Whose atrial fibrillation has a reversible cause.
Who have heart failure thought to be primarily caused by atrial fibrillation.
With new‑onset atrial fibrillation (< 48 hours).
(With atrial flutter whose condition is considered suitable for an ablation strategy to restore sinus rhythm
for whom a rhythm‑control strategy would be more suitable based on clinical judgement)
59
AF with valvular disease should get what anticoag drug?
Warfarin
60
ECG changes in LVH?
T wave inversion in V5 and 6 is classic
ST elevation may be seen in anterior leads
Large R waves in v5-6 is common
61
NSTEMI medical management?
aspirin, plus either:
ticagrelor, if not high bleeding risk
clopidogrel, if high bleeding risk
Fondaparinux/LMWH
62
Most common cause of secondary HTN?
Primary hyperaldosteronism including Conn's disease is the most common cause of secondary hypertension occurring in between 5-10% of new diagnosis of hypertension.
63
What might reduce BNP levels?
Factors which reduce BNP levels include treatment with ACE inhibitors, angiotensin-2 receptor blockers and diuretics.
64
Limb ischaemia Sx in a young male smoker is likely what?
Buerger's disease
65
Post MI medical management?
dual antiplatelet therapy (aspirin plus a second antiplatelet agent)
ACE inhibitor
beta-blocker
statin
If reduced EF then Aldosterone antagonist (Spiro)
66
What type of drug are Diltiazem and verapamil?
Calcium channel antagonists, both negative chronotropes (non-dihydropyridine) and should not be given with b-blockers
67
What is ivabradine?
neagtive chronotropic drug used in CCF/Angina
68
What is nicorandil?
Vasodilator - used in HF
69
Electrolyte abnormalities with thiazide diuretics?
hyponatraemia, hypokalaemia, hypercalcaemia
70
What might increase BNP levels?
```
Left ventricular hypertrophy
Ischaemia
Tachycardia
Right ventricular overload
Hypoxaemia (including pulmonary embolism)
GFR < 60 ml/min
Sepsis
COPD
Diabetes
Age > 70
Liver cirrhosis
```
71
Most common causes of IE?
The vast majority of cases of bacterial endocarditis are caused by gram positive cocci.
```
Streptococcus viridans
Staphylococcus aureus (in intravenous drugs uses or prosthetic valves)
Staphylococcus epidermidis (in prosthetic valves)
```
72
What patients should be receiving a statin?
All people with established cardiovascular disease (stroke, TIA, ischaemic heart disease, peripheral arterial disease)
Anyone with a 10-year cardiovascular risk >= 10%
Patients with type 2 diabetes mellitus should now be assessed using QRISK2 like other patients are, to determine whether they should be started on statins
Patients with type 1 diabetes mellitus who were diagnosed more than 10 years ago OR are aged over 40 OR have established nephropathy
High lipids and QRISK >10%
73
MI with no complications advice re: driving ?
acute coronary syndrome- 4 weeks off driving
| 1 week if successfully treated by angioplasty
74
When would you prescribe digoxin in HF?
Co-existent AF - definitely
| Could still start by cardiology if at third step
75
What type of antidepressants can cause QT prolongation?
TCAs and SSRIs
76
When would you offer PCI in STEMI?
PCI if presents within 12 hours of onset AND PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given
