Cardiology Flashcards
1
Q
What are the causes of aortic stenosis?
A
age related calcification (most common >65) bicuspid aortic valve (most common <65) rheumatic heart disease Williams syndrome (supravalvular AS) HOCM (subvalvular AS)
2
Q
What does an AS murmur sound like and where is it heard?
A
ESM
right 2nd ICS
loudest on expiration
radiates to the carotids
3
Q
what does the pulse feel like in AS?
A
slow rising, narrow pulse pressure (<30 mmHg)
4
Q
what are the S/S of severe AS?
A
SAD
syncope
angina
dyspnoea
5
Q
What are some differentials of AS?
A
aortic sclerosis
hOCM
MR
PS/TR
6
Q
What signs would be picked up with severe AS?
A
Absent S2, S4
narrow PP
LVF (decompensation)
7
Q
What investigations would you do for AS?
A
ECG (LCH, arrhythmia)
Bloods (FBC, U&E, BNP, lipids, glucose)
Blood culture
CXR (calcified valves, LVH, pul oedema)
Echo +/-doppler (assess severity, cause and LV function)
Coronary angiography - often done prior to surgery as cardiovascular disease may co-exist.
8
Q
What would be seen on echo in severe AS?
A
Valve area <1cm^2
Pressure gradient >40 mmHg
Jet velocity >4m/s
9
Q
What is the management of AS?
A
MDT - cardiologist, GP, SNP, cardiothoracic surgeon, dietician, OT/physio
RF modification
Regular f/u
Surgical:
- open replacement (biological or artificial valve)
- TAVI
- balloon valvuloplasty
- sutureless AV replacement
10
Q
What are the types of artificial valve?
A
- Starr-Edwards (ball in cage)
2. Tilting disc/bileaflet
11
Q
What do you hear in AR?
A
early diastolic murmur
loudest at left lower sternal edge 3rd ICS (Erbs point)
loudest sitting up on expiration
+/- mid diastolic murmur (austin flint of regurgitant jet causing MS)
12
Q
What peripheral signs may be seen in AR?
A
AORTIC MAN
Beckers sign (retinal artery pulsation)
Mueller signs (systolic pulsations of uvula)
De Musset’s sign (nodding head)
Corrigan’s sign (carotid pulsation)
Quincke’s sign (pulsatile nail bed)
Traube’s sign (pistol-shot femoral pulses)
Duroziez’s sign (femoral artery compression)
13
Q
What signs of AR may be identified in the pulse?
A
Corrigan's pulse (water hammer pulse) Wide PP (180/45)
14
Q
What are the signs of severe AR?
A
Collapsing pulse
Wide PP
LVF
15
Q
What are some causes of AR?
A
Acute:
Infective endocarditis
Aortic dissection (standard type A)
syphilis
Chronic: bicuspid aortic valve RHD autoimmune (anklyosing spondylitis, RhA, SLE) CTD (Ehler's danlos, Marfarns) HTN
16
Q
What are the investigations for AR?
A
ECG (LVH, LV strain - lateral lead TWI)
Bloods (FBC, U&E, NT-proBNP, lipids, glucose, ESR, HLA-B27, ANA)
CXR (cardiomegaly, LVH, pulmonary oedema)
Echo +/- doppler
Coronary angiography
17
Q
what would be seen on echo/doppler in severe AR?
A
Jet width >65% outflow tract
regurgitant jet volume
premature closing of mitral valve
18
Q
what is the management of AR?
A
General:
MDT
RF modification
Regular F/U
Medical:
reduce after load -> ACEi, BB, diuretics
Surgical:
valve replacement before LV dilatation and dysfunction
19
Q
what are indications for surgical management of AR?
A
NYHA >2 LV dysfunction: - pulse pressure >100 mmHg - ECG changes (TWI in lateral leads) - LV enlargement on CXR or EF <50%
20
Q
What are the peripheral signs of MS?
A
Malar flush
21
Q
what is the pulse like in MS?
A
Often irregular (AF) Can be normal
22
Q
What signs can be found on the precordium in MS?
A
Apex: tapping (palpable S1), non displaced, left parasternal heave (RVH secondary to pul.HTN)
Sounds: loud S1, early diastolic opening snap +/- loud S2 if pul HTN
23
Q
What does the murmur sound like in MS?
A
Mid diastolic murmur
loudest in left lateral at end expiration with bell
radiates to axilla
+/- Graham Steell murmur (EDM 2nd to PR)
24
Q
What signs are seen in severe MS?
A
Malar flush, longer murmur, LVF
25
What are some causes of MS?
Rheumatic heart diseases
austin flint murmur
Rare: prosthetic valve, congenital
26
What are some differentials of MS?
AR
TS
PR
27
What are some signs of pulmonary hypertension?
malar flush
JVP with large V waves
right ventricular heave
loud s2 (p2)
28
What are some investigations for MS?
ECG (p mitrale, AF)
Bloods (FBC, U&E, NT-proBNP, lipids, glucose)
CXR (LA hypertrophy (splaying of carina), calcified mitral valve, pul oedema)
Echo +/- doppler
Coronary angiography
29
what would you see on echo/doppler in severe MS?
Valve orifice <1cm^2
Pressure gradient >10 mmHg
Pul. artery SBP >50 mmHg
30
What is the management of MS?
General:
MDT
RF modification
Regular F/U
Medical:
RhF prophylaxis (benzylpenicillin)
AF (Rate control + DOAC)
Diuretics (symptomatic relief)
Surgical:
1st: balloon valvuloplasty
valvotomy/commissurotomy (valve repair)
Valve replacement (if repair not poss)
31
What are the indications for surgery in MS?
Moderate severe MS (symptomatic or non-symptomatic)
32
When is balloon valvulplasty contraindicated?
left atrial appendage thrombus, calcified valve
33
what pulse signs can be seen in MR?
irregular/AF
34
what signs may be present on the precordium in MR?
Apex: displaced (ventricle pumps SV and regurgitant volume), parasternal heave (RVH)
Sounds: soft S1 +/- loud S2
35
What murmur is heard in mitral regurgitation?
pansystolic murmur
loudest in left lateral position at end expiration in apex
radiates to axilla
36
What are the signs of severe AF?
LVF, AF
37
What are some differentials of MR?
AS,
VSD,
TR
PS
38
What are some causes of MR?
Acute:
IE
IHD (MI) - papillary muscle rupture, chord tendinae rupture
```
Chronic:
mitral valve prolapse (2% population - mid systolic murmur)
RHD
calcification
CTD (marfan's, Ehlers danlos)
```
39
What signs are seen in papillary muscle rupture?
new systolic murmur (MR)
hypotension
pulmonary oedema
40
What are the investigations for MR?
ECG (P mitrale, AF, LVH)
Bloods (FBC, U&E, NT-proBNP, lipids, glucose
CXR (LA/LV hypertrophy, calcified mitral valve, pulmonary oedema)
Echo +/- doppler assessing severity, cusp calcification and LV function
coronary angiography
41
what is seen on echo in severe MR?
Jet width >0.6 cm
systolic pulmonary flow reversal
regurgitant volume >60 ml
42
What is the management of MR?
General: MDT
RF modification
regular FU
Medical: reduce afterload
AF (control rate + rhythm + anticoagulant)
Reduce after load (ACEI, BB (carvedilol), diuretics)
Surgical:
valve replacement
repair
43
What are the indications for surgery in MR?
Symptomatic
44
Prognosis of MR?
Asymptomatic ->10 years
| Symptomatic - 25% mortality at 5 years
45
What are the immediate complications of MI?
- cardiac arrest
- cardiogenic shock
- tachyarrhythmia (vf, vt)
- bradyarrhythmia (av block)
46
What are the early complications of MI?
Pericarditis / Dresslers
Left ventricular free wall rupture
VSD and acute HF
47
What are the late complications of MI?
Chronic heart failure
| Left ventricular aneurysm
48
What classification can be used for heart failure?
New York Heart Association Classification
49
What are the stages of the NYHA?
I - no limitation of acitivty
II - comfortable at rest, dyspnoea on ordinary activity
III - marked limitation of ordinary activity
IV - dyspnoea at rest
50
what is a normal ejection fraction?
45-60%
51
Which drugs are contraindicated in heart failure?
```
thiozoladinediones
verapamil
NSAIDs (fluid retention)
Glucocorticoids (fluid retention)
Flecainide
```
52
What is the the management of heart failure
BASHeD up heart (BB, ACEi, spiro, hydralazine, digoxin)
1st line: ACEi + BB (reduced EF-carvedilol) or loop diuretic (preserved EF)
2nd line: spironolactone
3rd line (specialist); hydralazine + nitrate
ivabridine (EF <35%), HR >75
valsartan
digoxin
cardiac resynchronisation +/- ICD
Other:
offer annual influenza
one of pneumococcal vaccine
53
What are the s/s of angina
CP is sharp
CP precipitated by physical exertion
CP relieved by GTN within 5mins
Stable = 3/3
atypical = 2/3
non anginal = <1/3
54
What are the investigations for stable angina?
1. CTCA -> calcium score
2. non invasive functional imaging:
- Stress echo
- Contrast enhanced perfusion MR
- MR for stress induced wall motion abnormalities
- MPS SPECT
3. coronary angiography
55
What does calcium score show?
Risk of MI/stroke at 10 years
| percentiles(>75th = 15-20%)
56
What is the management of angina?
Conservative:
stop smoking
weight loss and exercise
healthy diet (fish, F+V, reduced sat fat)
Medical:
1st: GTN + BB or CCB (non-DHP e.g. verapamil/diltiazem)
2nd: GTN + BB + CCB (DHP)
3rd: long acting nitrate, ivabradine, nicorandil, ranolazine
```
Secondary prevention:
aspirin 75 OD
atojvastation
ACEi (if angina and DM)
antihypertensives
```
57
which CCBs should never be combined with beta blockers?
non-DHP CCBs:
verapamil
diltiazem
interacts with AV node conduction and may cause complete heart block
58
What are the contraindications to BB?
hypotension, bradycardia, asthma, HF
59
What are the contraindications to CCB?
hypotension, bradycardia, peripheral oedema
DHP>non-DHP for peripheral oedema
60
What are some causes of AF?
```
IHD
rheumatic HD (MR, MS)
Hyperthyroid
infection
PE
cardiomyopathy
alcohol
bronchial cancer
```
61
what are the types of AF?
```
acute (<48H)
Paroxysmal AF (<7d, recurs)
persistent AF (>7d, may recur even after cardioversion)
```
62
When should you rhythm control rather than rate control?
reversible af
Coexistent heart failure caused by AF
New onset AF
63
When should those with AF be anti coagulated and what with?
AF<48h - LMWH
AF >48h- apixaban ...
... for 3w before cardioversion
...for 4w after cardioversion or lifelong depending on CHASVASc
64
What are the rate control strategies for AF?
1st line: beta blocker or rate limiting CCB (verapamil>diltiazem)
2nd line: digoxin + CCB or BB; mono therapy in asthmatic with HF
3rd line: amiodarone
65
What are the acute rhythm control strategies for AF?
Acute:
1st: DC cardioversion
2nd: pharmacological cardioversion: flecainide if young and no structural heart disease, amiodarone if structural heart disease
66
what are the long term rhythm control strategies for AF?
```
1ST: BB
Paroxysmal: pill in pocket (flecainide or sotalol/amiodarone if structural heart)
Ablation of AV node
Maze procedure
pacing
```
67
what are the ix for HTN?
ABPM
| Home blood pressure monitoring
68
What are the S/S of severe HTN?
```
retinal haemorrhage
papilloedema
confusion
AKI
chest pain
ADMIT
```
69
what is severe HTN?
>180/110
70
What are the Ix for severe HTN?
Bedside: ECG, urine dip
| Bloods
71
What are the stages of HTN?
1: Clinic BP >140/90 AND ABPM/home BP >135/85
2: Clinic BP >160/100 AND ABPM/home BP >150/95
Severe: Clinic SBP> 180 OR clinic DBP >110
72
When do you treat HTN?
if <80yo + stage 1
| STAGE 2 ++
73
What is the preferred thiazide diuretic?
indapamide >bendroflumethiazide
74
What are the side effects of ACEi
ACE
Angioedema
Cough
Elevated K
75
What are the RF for IE?
- previously normal valves -> mitral valve most common
- RHD
- IVDU -> TRICUSPID
- prosthetic valves, congenital heart defects, recent piercings
76
Which organisms may cause IE?
S.aureus (acute, IVDU)
S.epidermidis (CoNS; prosthetic valves)
S. viridian's (sub-acute, developing world)
HACEK
77
What are some non infective causes of IE?
```
Libman-Sacks Endocarditis (SLE)
Marantic endocarditis (malignancy)
```
78
What are some culture negative organisms that cause IE?
```
HACEK (sub-acute presentation)
H.influenzae
Actinobacillus
Cardiobacterium
Eikenella corrodens
Kingella
```
79
When is surgery indicated for IE?
```
Severe valvular incompetence
aortic abscess (lengthening PR interval)
infections resistant to Abx
fungal infections
cardiac failure refractory to standard treatment
recurrent emboli after Abx
```
80
How is IE diagnosed?
Dukes criteria
2 majors OR
1 major + 3 minors OR
5 minors
81
What is the Duke's criteria?
BE FEVEER
Major:
Bacteraiemia [2 cultures, 12 hours apart]
Echo [vegetation, new murmur, abscess, dehisced prosthetic valve]
Minor:
Fever [>38]
Echo findings
Vascular phenomenon: emboli (stroke, PE, splenomegaly), splinter haemorrhages, janeway lesions
Evidence of immunological involvement: oslers nodes, roth sports, glomerulonephritis, rheumatoid factor
Evidence of micobiological involvement: 1 culture +ve
RF: IVDU, heart condition
82
What are the signs and symptoms of IE
```
FROM JANE
Fever
Roth spots
Oslers nodes
Murmur
```
Janeway lesions
Anaemia
Nail haemorrhages
Emboli
83
What is the management of IE
Blind therapy:
native valve:amoxicillin +/- low dose gentamicin
prosthetic: vancomycin + rifampicin + low dose gentamicin
Staph:
native: fluclox
prosthetic: fluclox+ rifampicin + gent
Strep:
fully sensitive: benpen
not fully sensitive: benpen + gent
84
What causes rheumatic fever/heart disease?
Group A beta haemolytic strep (S.pyogenes/GAS)
| Scarlet fever
85
What are the S/S of rheumatic fever/hd?
```
Laten interval of 2-6 weeks after pharyngeal infection:
PPE
Polyarthritis
Pericarditis
Erythema marginatum
```
Syndenhams chorea 2-6 months later
86
How is rheumatic fever diagnosed?
JONES CRITERIA
1. Evidence of GAS infection AND:
- throat culture test +ve
- rapid streptococcal antigen test +ve
- high ISO titre
- recent scarlet fever
2. 2major criteria
3. 1 major criteria + 2minors
87
What are the major Jones criteria?
```
CASES
Carditis
Arthritis
Subcutaneous nodules
Erythema marginatum
Syndenhams chorea
```
88
What are the minor Jones criteria?
```
FRAPP
Fever
Raised ESR/CRP
Arthrlagia
Prolonged PR
Previous RF
```
89
What investigations are done for RF?
Bedside: ECG
Bloods: FBC, ESR, ASOT
Imaging: echo
90
What is the management of RF?
Acute:
Bed rest - until CRP normal for 2 weeks
Analgesia (NSAIDs,aspirin)
Phenoxymethylpenicillin (penicillin V QDS 10/7), AZITHRO if pen allergy
Other:
CCF, cardiomegaly, 3rd degree HB -> corticosteriods
Syndenhams chorea -> haloperidol, diazepam
Prophylaxis:
once monthly benpen iM OR
BD PO phenoxymethylpenicillin
+/- surgical valve repair
91
Which valves are most affected by RF
Mitral valve (70%)
Aortic valve (40%)
Tricuspid (10%)
Pulmonic (2%)
92
What are the causes of pericarditis?
```
viral infections (coxsackie)
uraemia
post-MI, Dressler
Hypothyroid
TB
Trauma
CTD
Malignancy
```
93
What are the signs and symptoms of pericarditis?
```
Pleuritic CP
Pericardial rub
Tachypnoea, tachycardia
non productive cough
Dyspnoea
Flu like symptoms
```
94
What are the investigations for pericarditis?
ECG - widespread PR depression and saddle shaped ST elevation
TTE
troponin (may be raised)
95
What is the management of pericarditis
treat the cause
| 1st line: NSAIDs and colchicine
96
What are the cardiac causes of clubbing?
CIA
Cyanotic heart disease (TOF, TOGA)
Infective endocarditis
Atrial myxoma/LAME syndrome
97
What is LAME syndrome?
Lentigines (spotty skin pigmentation),
Atrial myxoma
Endocrine (pituitary) tumours
Schwannomas
98
What are the features of pulmonary hypertension?
```
Raised JVP
Left parasternal heave
Ascites/peripheral oedema
Loud S2 +/- PSM of TR
Pulsatile hypertrophy
```
99
What would cause a collapsing pulse?
AR
anaemia
thyrotoxicosis
pregnancy
100
What would cause an absent radial pulse?
Trauma
coarctation
thromboembolic
takayasu arteritis
101
What would cause an impalpable apex beat
COPD
Obesity
Pericardial effusion
Dextrocardia
102
What would cause a loud S1?
```
MS
high flow (anaemia, sepsis, thyrotoxic)
```
103
What would cause a loud S2?
systemic HTN
| pulmonary HTN
104
What would cause an S3 heart sound?
Compliant ventricle
young, athletes, pregnancy
HF, AR, MR, TR, dilated cardiomyopathy
105
What would cause an S4 heart sound?
LVH (AS, HTN)
| Cardiomyopathy (HOCM, restrictive)
106
what causes a split S1?
normal in 40-70% population
| RBBB
107
what causes a split S2?
```
deep inspiration (normal)
ASD, pul hon, ref, bbb
```
108
What are the ways of categorising cardiomyopathy
Primary and secondary
Genetic, mixed, acquired and other
109
What are the types of primary cardiomyopathy
Genetic:
HOCM
arrhythmogenic right ventricular dysplasia
Mixed:
Dilated
Restrictive
Acquired:
permpartum
takotsubocardiomyopathy
110
What are some causes of secondary cardiomyopathy?
```
mainly a response to systemic insult:
infective - coxsackie B, chagas
infiltrative - amyloidosis
storage - haemochromatosis
toxicity - doxorubicin, alcohol
inflammatory - sarcoidosis
endocrine - DM, thyrotoxicosis, acromegaly
NM - Friedrichs ataxia, Duchenne, mythic dystrophy
Autoimmune - SLE
```
111
What are the echo findings in HOCM?
1. MR
| 2. systolic anterior motion of the anterior mitral valve and asymmetric septal hypertrophy
112
What are 4 causes of dilated cardiomyopathy?
1. alcohol
2. coxsackie B
3. wet beri beri
4. doxorubicin
113
What are 3 causes of restrictive cardiomyopathy?
1. amyloidosis
2. post radiotherapy
3. Loefflers endocarditis
114
What is seen on ECG in arrhythmogenic right ventricular dysplasia?
ECG abnormalities V1-V3 (T wave inversion)
| epsilon wave
115
What is takotsubo cardiomyopathy?
stress induced cardiomyopathy
HF features
transient apical ballooning of myocardium
treatment is supportive
116
What are the types of long QT?
1: associated with exertion syncope e.g. swimming
2: syncope following emotional stress, exerciser auditory syncope
3: occurs at night or at rest
sudden cardiac death
117
What are some congenital causes of long QT?
1. Jervell-Lange-Nielsen syndrome (deafness)
| 2. Romano-ward syndrome (no deafness)
118
What are some drug causes of long QT?
```
METH CATS
Methadone
Erythromycine
Terfenadine
Haloperidol
Clarithromycine/chloroquine
Amiodarone/azithromycone
TCAs
SSRIs (citalopram)
```
119
What are some physiological causes of long QT?
HYPOcalcaemia
HYPOkalaemia
HYPOmagnesaemia
```
MI
Myocarditis
Hypothermia
SAH
Malnutrition
```
120
what are some complications of long QT
VT -> death
| torsades des pointes
121
What is the management of Torsades des pointes?
IV magnesium sulfate
avoid drugs prolonging QT and other precipitants
ICD
122
what is bifascicular block?
RBBB + LAD
123
What is incomplete trifascicular block ?
bifascicular + 1st/2nd degree HB
124
What is complete trifascicular block ?
bifascicular + 3rd degree HB
125
What is the definition of orthostatic hypotension?
drop of 20/10 after standing 3 mins
| 321
126
When is pulsus paradoxus seen?
severe asthma
| cardiac tamponade
127
When is pulsus alternates seen
LVF
128
When is a slow rising pulse seen?
AS
129
When is a bisferiens pulse seen?
mixed aortic valve disease
| HOCM
130
When is a jerky pulse seen?
HOCM
131
What is the indication for unipolar pacemakers?
SA node pathology (AV node unimpaired)
132
What is the indication for unipolar pacemakers?
synchronisation
133
What is the indication for dual atrial site pacemakers?
paroxysmal af
| one lead in SA node, one coronary sinus (both RA), one in RV
134
What is the indication for biventricular pacemakers?
HF (last line)
135
What is the indication for ICD?
Tachyarrhytmia
136
How does pacemaker nomenclature work?
```
letter 1: chamber that is paced
letter 2: chamber that is sensed
letter 3: response to sensed event
letter 4: rate response features
letter 5: anti-tachycardia facilities
```
137
How is HOCM inherited?
AD
138
What conditions are associated with HOCM?
WPW
| Friedrich's ataxia
139
What is seen on HOCM biopsy?
myofibrillar hypertrophy with chaotic and disorganised fashion myocytes and fibrosis
140
What are the symptoms and signs of HOCM?
- asymptomatic
- sudden death (commonly due to VF/ventricular arrhythmias)
- AF, VF (sudden death), VT (collapse)
- exertional: dyspnoea, angina, syncope due to LVH and functional aortic stenosis
141
What is seen on examination of HOCM
```
jerky pulse
large a waves
double apex beat
ESM (increased with valsalva)
PSM of mitral regurgitation
```
142
What is seen on echo of HOCM?
MR SAM ASH
MR
Systolic anterior motion (SAM) of mitral valve leaflet
Asymmetric hypertrophy
143
What is seen on HOCM ECG?
LVH - tall voltages
Non specific ST/T wave abnormalities (t wave inversion may be seen)
Deep Q wves
occasionally WPW delta wave, p mitrale, AF
144
What is the management HOCM?
```
abcde
Amiodarone
Beta blockers/verapamil for symptoms
Carioverter defibrillator
Dual chamber pacemaker
Endocarditis prophylaxis
```
avoid nitrates, ACEi, inotropes
145
What is the most specific ECG marker for pericarditis?
PR depression
146
What is the most common congenital heart defect found in adulthood?
ASD
147
What are the features of ASD
ejection systolic murmur, fixed splitting of S2
| embolism may pass from venous system to left side of heart causing a stroke
148
What are the features of osmium primum?
present earlier than ostium secundum defects
associated with abnormal AV valves
ECG: RBBB with LAD, prolonged PR interval
149
What are the features of osmium secundum?
associated with Holt-Oram syndrome (tri-phalangeal thumbs)
ECG: RBBB with RAD
70% ASDs
150
ECG findings hyperkalaemia?
```
Peaked or 'tall-tented' T waves (occurs first)
Loss of P waves
Broad QRS complexes
Sinusoidal wave pattern
Ventricular fibrillation
```
151
what condition is associated with bisferiens pulse?
HOCM
double pulse' - two systolic peaks
mixed aortic valve disease
152
Risk factors for asystole in bradycardia?
```
(? needs transvenous pacing)
complete heart block with broad complex QRS
recent asystole
Mobitz type II AV block
ventricular pause > 3 seconds
```
153
Warfarin management of major bleeding?
Stop warfarin
Give intravenous vitamin K 5mg
Prothrombin complex concentrate - if not available then FFP*
154
Mx warfarin INR > 8 and minor bleeding?
Stop warfarin
Give intravenous vitamin K 1-3mg
Repeat dose of vitamin K if INR still too high after 24 hours
Restart warfarin when INR < 5.0
155
Mx warfarin INR >8, no bleeding?
Stop warfarin
Give vitamin K 1-5mg by mouth, using the intravenous preparation orally
Repeat dose of vitamin K if INR still too high after 24 hours
Restart when INR < 5.0
156
Mx warfarin INR 5-8 and minor bleeding?
Stop warfarin
Give intravenous vitamin K 1-3mg
Restart when INR < 5.0
157
Mx warfarin INR 5-8 and no bleeding?
Withhold 1 or 2 doses of warfarin
| Reduce subsequent maintenance dose
158
What is seen on ECG with hyper and hypocalcaemia?
hyper - shortened QTc
| hypo - longer Qtc
159
what do fusion and capture beats on ECG suggest?
VT
160
what can be given to reverse bleeding on dabigatran?
idarucizumab
