cardiology

Question 1

inidcation for ICD

Answer 1

symtomatic heart failure
EF<35%
no LBBB
QRS 120-149

risk of VT is high

Question 2

myxoma

Answer 2

murmur, low grade fever, raised ESR and AF

leads to mitral stenosis

Question 3

side effect of atypical antipsychotics

Answer 3

olanzapine/risperidone/clozapine have been associated with hyperglycaemia and insulin resistance

Question 4

HOCM

Answer 4

ECG: TWI, Deep q waves, AF occasionally, LVO

Angina
SOB
heart failure
Aortic stenosis
jerky pulse
double apex beat
mitral regurg
syncope following exercise
Pulsus bisferiens

MR SAM ASH

Biopsy: myofibrillar hypertrophy, defect in B mysoin

Rx: ICD, amiodraone, beta-blockers/verapamil

Question 5

Brugada syndrome

Answer 5

STE in V1-V3, partial RBBB

mutated Na channels, mutation of SCNSA gene, AD

Rx: ICD

Question 6

ASD ECG

Answer 6

primum: LAD and RBBB
secundum: RAD & RBBB

Question 7

cocaine and mI

Answer 7

Avoid beta-blockers

give GTN infusion or calcium cahnnel blocker

Question 8

prolonged AT and torsades managment

Answer 8

If any adverse features are present, synchronised DCCV is the treatment of choice. In this case, the patient is stable and may need DCCV.

The initial management of torsade with no adverse features present is:

Stop all drugs which prolong QT
Correct any electrolyte abnormalities
Give IV magnesium (2 g IV over 10 minutes)

causes: hypokalemia, amiodarone

Question 9

right sided failure, ascites and pericardial calcification on x ray
third/fourth heart sound

Answer 9

constrictive pericarditis.

The added sound is the pericardial ‘knock’ rather than a third/fourth heart sound.

Question 10

causes of restrictive cardiomyopathy

Answer 10

Sarcoidosis would, like amyloidosis, be expected to cause a restrictive cardiomyopathy.

Question 11

VSD with eisenmengers on cardiac catheterisation

Answer 11

RV systolic pressures exceeding LV systolic pressures is very suggestive of Eisenmenger’s syndrome in context of a VSD.
left ventricular oxygen saturation is low, which raises the possiblity of a right to left cardiac shunt mixing desaturated RV blood with LV saturated blood (due to right ventricular pressures exceeding left ventricular pressure).

Question 12

Ebsteins anomaly

Answer 12

Ebsteins anomaly there should be elevated RA pressure due to significant tricuspid regurgitation.

Question 13

2:1 AV block

Answer 13

two P waves for each QRS.

The conducted PR intervals are constant.

2:1 AV block cannot be classified as Mobitz type 1 or type 2 AV block since it would not be known whether the second P wave would be conducted with the same or a prolonged PR interval.

Question 14

characteristic of aortic incompetence

Answer 14

: there is a wide pulse pressure in the aorta accompanied by a very high left ventricular end-diastolic pressure (LVEDP); a LVEDP greater than 20 mmHg is suggestive of irreversible LV dysfunction.

Question 15

target BP

Answer 15

People aged under 80 years: lower than 135/85 mmHg

People aged over 80 years: lower than 145/85 mmHg

Question 16

ventricular pre excitation

Answer 16

Ventricular pre-excitation (if there were a history of tachycardia it would be Wolff-Parkinson-White syndrome) commonly masquerades as other conditions, such as bundle branch block or ischaemia.

Question 17

intracranial bleed ECG changes

Answer 17

Intracranial haemorrhage can cause changes in the ECG which are typically deep symmetrical T-wave inversion and prolonged QT interval.

Question 18

HOCM and cardiac catherisation

Answer 18

Left ventricular pressures are high with a steep drop-off between the LV and aortic systolic pressures are suggestive of hypertrophic cardiomyopathy. pressure in LV is normally 150 could up to 250 = LVO

Question 19

investigating for heart failure, NICE guidelines

Answer 19

ICE guidelines recommend that patients with previous myocardial infarction who have suspected heart failure should be referred for an echocardiogram and specialist review within two weeks.

Patients who do not have a history of infarction, but who have suspected heart failure, should be risk stratified using serum natriuretic peptides, such as BNP.

Patients with raised and high BNP concentrations should be referred for echo and specialist review within six weeks and two weeks respectively.

Patients with normal BNP concentrations should be investigated for other causes of their symptoms as a normal BNP makes heart failure unlikely.

BNP is also raised in the following:

Hypertension
Atrial fibrillation (AF)
Aortic stenosis
Diastolic dysfunction
Acute coronary syndromes
Cor pulmonale, and
Stable angina
It is therefore a marker of structural heart disease rather than specifically a marker of systolic dysfunction.

Elevated BNP is also seen in:

Acute and chronic renal failure
Liver cirrhosis
Hyperaldosteronism, and
Cushing's syndrome.
Approximately 40% of patients with raised BNP will turn out to have left ventricular systolic dysfunction (LVSD) on echocardiographic assessment.

Many of the remaining patients with elevated BNP will be shown to have other significant cardiac abnormalities such as valvular heart disease, AF, left ventricular hypertrophy (LVH) or diastolic dysfunction.

BNP rises with age and is higher in women than men. ACE inhibitors and diuretics can reduce BNP levels, so ideally BNP testing should be carried out before instigating therapy with these drugs.

Question 20

investigating for heart failure, NICE guidelines

Answer 20

ICE guidelines recommend that patients with previous myocardial infarction who have suspected heart failure should be referred for an echocardiogram and specialist review within two weeks.

Patients who do not have a history of infarction, but who have suspected heart failure, should be risk stratified using serum natriuretic peptides, such as BNP.

Patients with raised and high BNP concentrations should be referred for echo and specialist review within six weeks and two weeks respectively.

Patients with normal BNP concentrations should be investigated for other causes of their symptoms as a normal BNP makes heart failure unlikely.

BNP is also raised in the following:

Hypertension
Atrial fibrillation (AF)
Aortic stenosis
Diastolic dysfunction
Acute coronary syndromes
Cor pulmonale, and
Stable angina
It is therefore a marker of structural heart disease rather than specifically a marker of systolic dysfunction.

Elevated BNP is also seen in:

Acute and chronic renal failure
Liver cirrhosis
Hyperaldosteronism, and
Cushing's syndrome.
Approximately 40% of patients with raised BNP will turn out to have left ventricular systolic dysfunction (LVSD) on echocardiographic assessment.

Many of the remaining patients with elevated BNP will be shown to have other significant cardiac abnormalities such as valvular heart disease, AF, left ventricular hypertrophy (LVH) or diastolic dysfunction.

BNP rises with age and is higher in women than men. ACE inhibitors and diuretics can reduce BNP levels, so ideally BNP testing should be carried out before instigating therapy with these drugs.

Question 21

ablation indication

Answer 21

Modern guidance recommends moving to early ablation in patients who suffer from paroxysmal AF, because it is associated with a much greater chance of success when performed earlier.