cardiology

Question 1

ECG features of trifascicular block?

Answer 1

1st degree heart block
AND
RBBB
AND
LAFB or LPFB

LAFB: qR complex leads 1 and AVL, RS complex II, III, aVF, LAD

LPFB: rS complex leads 1 and AVL, qR complex leads II, III, aVF, RAD. NO RVH.

Question 2

Indications for ICD in ischemic HFrEF as primary prevention

Answer 2

• LVEF ≤35% + NYHA II or III
• LVEF ≤30% + NYHA I*
• LVEF ≤40% + non-sustained VT assoc. with previous MI + inducible sustained VT/VF on EP*

Can be beneficial if syncopal episodes occurring suspected to be due to ventricular arrythmia

*Must be post acute phase of MI i.e. 40 days post MI AND >3/12 post revascularization + medical therapy

Question 3

Indications for ICD in ischemic HFrEF as secondart prevention

Answer 3

Sustained VT/VF after reversible causes excl;uded (i.e. AMI, electrolyte disturbances, medication effects)

Question 4

Lipid profile seen with diabetes and CKD

Answer 4

High triglycerides and LDL, low HDL

Question 5

Lipid profile seen with alcohol excess

Answer 5

Isolated hypertriglyceridemia

Question 6

Lipid profile seen with hypothyroidism

Answer 6

predominantly high LDL, sometimes high triglycerides

Question 7

Rates of stroke post coronary angiography? Associated 30 day mortality?

Answer 7

1 in 100

30 day mortality = 20%

Question 8

Normal ECG variants in young athletes?

Answer 8

RBBB
Wenchebach phenomena (2nd degree heart block, mobitz 1 i.e. progressive PR prolongation)
Dominant R wave in V1
LVH 
Bradycardia
Junctional rhythm
1st degree heart block

Question 9

Which antihypertensive should be avoided in aortic dissection?

Answer 9

Hydralazine

Question 10

Mechanism of action/class of amiodarone

Which other drug is in this class?

Answer 10

Class 3 antiarrythmic - potassium channel blocker, acts on phase 3 of AP
Prolongs refractory period of atrial, nodal and ventricular myocardium by prolonging the the action potential
Decreases sinus node automaticity
Decreases rate of impulse conduction through the AV node

Other class 3 antiarrythmic - sotalol

Question 11

Mehchanism of action/class of verapamil?

Answer 11

Class 4 antiarrhythmic acting on phase 2 of AP

Central (non-dihydropyridine) calcium channel blocker -
Prevents calcium from entering voltage sensitive areas of myocardium/vascular SM cells (via slow channels) during depolarization
Slows automatacity and conduction of AV node

Question 12

Indications for surgery in type B aortic dissection

Answer 12

Recurrent chest pain
Persistent severe HTN
Aneurysm expansion
Dissection propogation
Expanding hematoma
Rupture
Occlusion of a major aorta branch leading to end organ ischemia

Question 13

What is the murmur in acute aortic dissection? Which type of aortic dissection is it seen in?

Answer 13

Type A dissection

Decrescendo diastolic murmur, best heard over the right sternal edge and exentuated on expiration (left sided murmur)

Question 14

What is the most common cause of aortic regurgitation?

Answer 14

Rheumatic heart disease (developing world)

Calcified aortic valve, bicuspid aortic valve, aortic root dilation (developed world)

Question 15

Indications for pace maker

Answer 15

Symptomatic Sinus node dysfunction (SND)
Advanced 2nd degree block (Mobitz Type II) or intermittent 3rd degree block
Symptomatic Hypersensitive carotid sinus syndrome and neurocardiogenic syncope
Persistent inappropriate or symptomatic bradycardia not expected to resolve after cardiac transplantation
Sustained pause dependent VT with or without QT prolongation.

Question 16

What are the effects of carvedilol?

Answer 16

Beta-1, Beta-2 and alpha-1 antagonist

Non selective HOWEVER has evidence in HFREF

Question 17

What are the effects of metoprolol?

Answer 17

Selective beta 1 antagonist

Question 18

What medications should be avoided in torsades?

Answer 18

Class IA agents + 1c (moderate + strong Na channel blockers)

• A: quinidine, procainamide, disopyramide),
• C: (eg,flecainide),

Class III agents potassium channel blockers ( eg, sotalol, amiodarone).

Question 19

Contraindications to stress ECG (name 10)

Answer 19

LBBB
Severe HOCM
Severe AS
Recent AMI (3-4 days)
Unstable angina with recent rest pain or increased symptoms.
Untreated life threatening cardiac arrhythmia
Advanced AV block
Uncontrolled systemic HT (>220/120)
Acute systemic illness ie: PE, aortic dissection
Unable to perform test ie: gait disturbance,severe OA.

Question 20

Which enzyme is required to convert clopidogrel to it’s active form?

Answer 20

CYP2C19
Higher rates of loss of function seen in chinese populations –> poor metabolizers
Choose prasugrel or ticagrelor isntead

Question 21

Typical echo and MRI findings of cardiac amyloidosis

Answer 21

Echo: relative apical sparing of longitudinal strain

MRI: subendocardial late gadolinium enchancement (early); later transmural late gadolinium enhancement

Question 22

Key investigation for diagnosing transthyretin cardiac amyloid (ATTR)

Answer 22

Bone scintigraphy

Question 23

Effects of alpha 1 receptors

Answer 23

Peripheral vasoconstriction

Increased heart rate

Question 24

Effects of beta 1 receptors

Answer 24

Poisitve chonotropy and inotropy

Question 25

Effects of beta 2 receptors

Answer 25

Skeletal muscle relaxation
Bronchodilation
Mast cell stabilization

Question 26

ECG findings of dextrocardia

Answer 26

R) axis deviation
Positive QRS in aVR
Lead I → inversion of all complexes
Absent R wave progression in chest leads, dominant S waves

Question 27

ECG findings of ASD

Answer 27

R) axis deviation
“Incomplete” RBBB due to RVH
RV strain (TWI/ST depression V1-V4)
Characteristic R wave notching in inferior leads II, III, aVF (Crochetage sign)

Question 28

ECG findings digoxin toxicity

Answer 28

Increased automaticity with slow ventricular response
I.e. AF with slow VR

Bidirectional VT

Question 29

ECG findings sodium channel blockage

Answer 29

Wide QRS
Terminal R wave in AVR
RAD

Question 30

ECG findings posterior infarct

Answer 30

V1-V3 changes → INVERTED ANTERIOR STEMI: ST depression (i.e. elevation), tall R waves (i.e. pathologic Q waves), upright T waves

Question 31

Definition of low flow low gradient aortic stenosis

Answer 31

mean gradient <40 mmHg
valve area <1 cm2
LVEF <50%
SVi <35 mL/m2

Question 32

What class of drugs are abciximab, tirofiban and eptifibatide?
When can they be use?
When should they not be used?

Answer 32

GIIb/GIIIa receptor inhbitors
Can be used in high risk patients pre PCI or for treating thrombotic complications among patients with ACS

Should not be used in combination with thrombolysis

Question 33

3 beta blockers with proven effiacy in HFREF treatment

Answer 33

carvedilol, bisoprolol, metoprolol

carvedilol may have greatest survival benefit

Question 34

Indications for emergency reperfusion in STEMI

Answer 34

Sx onset within 12hrs REGARDLESS of if sx have resolved at time of presentation
No advanced age, frailty and significant co-morbidities influencing overall survival

Sx onset >12hrs but ongoing chest pain –> should be considered for salvage PCI (fibrinolysis not recommended, bleeding+++ and lower benefit)

Question 35

Metabolic syndrome criteria

Answer 35

Low HDL
High triglycerides
HTN
Central obesity
High fasting glucose (>5.6) or T2DM

Question 36

Genes associated with familial hypercholesterolemia

Answer 36

LDLR
APOB (previously apoB100)
PCSK9

Question 37

CXR findings of aortic coarctation

Answer 37

Notching of the posterior ⅓ of ribs 3-8

Indentation of the aortic wall - produces a “3” sign