Cardiology Flashcards
2 options for pharmacological cardioversion of AF
Amiodarone
Flecianide
Urgent rate control for AF options
IV beta blocker
IV verapamil
Choice of longterm rate control in AF ?
Beta blockers (NOT SOTALOL)
Verapamil
[Can use digoxin if they are sedentary and want it]
How long should anticoagulate in AF that has been going on for >48hrs
3 weeks
1st line rhythm control in patients with AF? What if heart failure / or LV impairment?
Beta blockers
Dronaderone / amiodarone
Pill in the pocket drug for AF
Flecainide
AF ongoing symtoms despite rate and rhythm control or where drugs contra indicated. What management
Radiofrequency point by point ablation
How to assess stroke risk in AF
CHA2-DS2-VASc
Offer anticoagulation to whom with AF?
How to assess bleeding score?
Men with a score of 1 CHADSVASC
Women with a score of 2
ORBIT score
Should you contact DVLA if you have AF
Yes
What is virchows triad?
Triad of venous thromboembolism
Hypercoagulable state
endothelial damage
blood stasis
Pharmacological management of patient in acute HF with pulm oedema.
Furosemide
Importantly Vasodilators
GTN (Short half life)
Diamorphine
ACEi
What is HF-PEF. Breifly explain pathophsiogy
‘diastolic’ heart failure.
Impaired cardiac filling due to ventricular stiffness
->blood backing up in circulatory system -> Fluid overload + oedema (similar to right-sided cardiac failure)
BNP scores for echo
> 400 - For echo in 6 weeks
2000 - For echo in 2 weeks
Vaccines in Heart failure
pneumococcal + influenza
Which drugs improve mortality in HF
ACEi
BBs
ARBs - eg sprinolactone
[NOT DIRURETICS ]
How does ivabradine work
HCN channel blocker -> Selectively inhibits funny current in sinus node to slow sinus rhythm
4 surgical options in HF
Cardiac resynchronisation therapy
ICD
LV assist device
Transplant
Why IV furosemide in severe oedema
Gut wall oedema inhibits absorption
Most common cause of HF
IHD - Coronary artery disease
Most common bug endocardiits ?
Second most ?
Where are they usually from?
S aureus - most common
Often from Skin eg vascuar access / infections / IVDU / abscesses
Strep viridans
Upper Respiratory - dental treatment, chewing, brushing teeth
Rx Endocarditis for native valve ?
Prosthetic valve?
Amox + gent (unless s aureus suspected)
Prosthetic - vanc/gent/rifampicin
Which cause of endocaridtis always requires surgical intervention
Pseudomonas argenosa
Some causes of culture negative endocaridits
brucella
bartonella
coxiella
Chlamydia
leigonella
mycoplasma
Whipples disease
Fungal organisms
2 main causes of non-infective endocarditis
SLE
Metastatic
Most common location endocaridits
mitral valve
Common risk factors for endocarditis
Acquired structural disease - eg rheumatic
valve replaced
structural disease [NOT isolated ASD or repaired VSD/PDA]
HCM
Prev IE
Rx if staph aureus endocaridits?
Methicillin-resistant ?
Strep ?
if resistant ?
HACEK?
Rx if staph aureus endocaridits? Fluclox
Methicillin-resistant ? Vanc + rifampicin
Strep ? Benpen
if resistant ? add gent
HACEK? amox + gent
Is clorhexidine mouthwash reccomended as IE prophlyaxis for dental procedures ?
No (not any more)
How do vagal manoeuvres help identify the site of heart block
AV node has good vagal autonomic innervation -> responds to an increase in vagal tone
When might atropine worsen heart block in brady?
If not from AV node in origin
-Will improve AV node block
-Will worsen block from his/purkinje system
Which types of heart block require permenant pacing
Mobitz type 2
type 3
Types of block 1/2/3
1st degree: Prolonged PR
2nd: Type 1- prolonging PR until one p wave doesn’t conduct
Type 2 - Constant PR with occasional dropped p Eg 2:1/3:1 block
3rd: no association between p and qrs
[Sick sinus - signal node dysfunction]
Non cardiac causes of block
Hypothermia
Hypothyroid
HyperK
Vasovagal syncope
Drug induced causes of heart block
Digoxin
B blockers
Amiodarone
Diltiazem
Dem BAD
2 locations for cause of AV block
AV node
His-purkinje
Who can not get atropine
cardiac transplant patients
Severe asthma
Dose of atropine
0.5mg (repeated up to 3mg)
Who gets atropine in brady even if no adverse features
Mobitz type 2
type 3 Heart block
Recent asystole
Recent pause >3s
first shock strength for VF if biphasic defib?
Monophasic?
150-200J
360J
Which thrombolytic agent has lowest risk of haemorrhagic stroke
Streptokinase
Normal Sa02 in right side of heart? Left side ?
75%
>95%
Are primum or secundum ASDs more common?
90% are secundum
When are ostium secundum ASDs usually diagnosed? Common patient features?
Early adulthood.
Slim and not suffering from cyanosis
What do ostium primum ASDs involve? When are they diagnosed? O2 sats in these?
Defect involving mitral/tricuspi valves as well as a VSD..
Usually diagnosed in early childhood and have signs of congestive heart failure.
O2 sats would VARY in RV/RA
Ostium secundum ASD. O2 sats vary between what?
SVC would have lower O2 sats than RA/RV
O2 sats in Patent ductus arteriosus chambers? Basic physiology?
Oxygenated blood flows from aorta -> pulm artery.
SVC/RA/RV would have the same sats and be >75%
Left side heart sats would be NORMAL (>95%) as shunt only from Left to right
ASD with a triphalangeal thumb (extra joint)? Inheritance?
Holt-oram syndrome
Autosomal dominant (with incomplete penetration)
ASD with mitral stenosis syndrome name? What causes the MS
Lutembacher syndrome
Likely rheumatic
What is the syndrome ASDs can end up with in later age? Pathophysiology?
Eisenemenger syndrome
Chronic L->R shunt causes pulm vascular injury -> increased pulm resistance - > reversal of shunt
Auscultation of ASD ?
Fixed splitting of second heart sound
[May have left parasternal heave and ESM due to increased blood flow]
Fixed splitting of second heart sound found in what defect?
ASD
ECG of ASD
Secundum?
Primum?
Both have increased P-waves (atrial enlargement)
Secundum? Incomplete RBBB, Right axis deviation
Primum? RBBB, Left axis deviation, 1st degree heart block
[First read left to right]
VSD vs ASD vs PDA.
Auscultation? Risk of endocardits? Common arrythmiass? Emboli
VSD: Pansystolic murmur, high-risk endocarditis. None
ASD: Fixed splitting second heart sound, low-risk endocarditis, AF/Fibrillation -> Risk of emboli
PDA: Continuous murmur. High-risk endocaridits.
How does echo calculate the degree of AS
Calculating pressure gradient across valve
Pharmacological Rx of VSDs
Digoxin - positive inotropic effect
If Heart failure - diuretics. ACEi (reduce afterload)
Indications for surgical closure of VSD
Significant shunt
Elevated R heart pressures causing pulm hypertension
Endocarditis
Membranous VSD
Mid systolic click best heart at apex and a mid to late systolic mumur heart in?
Common patient features ?
Mitral valve prolapse
Young females, slim, low/normal BP
[Marfans, ehlers-danlos, pectus excavatum, autoimmune thyroid]
Most common SVT? Seen in who?
Atrioventricular nodal reentry tachycardia (AVNRT)
Young women
AVNRT Vs AVNT pathophysiology
Atrioventricular nodal re-entry tachycardia (AVNRT)
- re-entry circuit around the AV node (more than one conduction pathway) which allows a re-entry pathway -> regular tachycardia
Atrioventricular Nodal Tachycardia
An accessory pathway between atria and ventricles some DISTANCE away from the AV node
Eg WPW syndrome
The prominence of x and y jugular descents indicates?
Restrictive cardiomyopathy
Pathophysiology of restrictive cardopmyopathy?
Fibrosis / infiltrates of myo/endocardium
->Failure of ventricles to relax
->Increased ventricular end-diastolic pressures
->Atrial enlargement
Systolic function is NORMAL
Name a couple of causes of restrictive cardiomyopathy
Sarcoidosis
Amyloidosis
Haemochromatosis
endomyocardial fibrosis
Storage disorders
Most common thing to develop with restrictive cardiomyopathy
75% develop AF
Most common cause of restrictive cardiomyopathy?
Amyloidosis
Diagnosis of cardiac amyloidosis
Biopsy and staining with congo-red
Drug to avoid in amyloid (restrictive) cardiomyopathy?
Digoxin
-Binds to amyloid fibrils and can reach toxic level even in normal ranges
When does BNP get released by heart tissue? What does BNP do?
In response to raised intra-cardiac pressures.
Increased sodium excretion and decreased systemic vascular resistance
s3/4 gallop rhythm auscultated in ?
heart failure
ECG of LBBB 2 features
QRS duration > 120ms
Dominant S wave in V1
Broad monophasic R wave in lateral leads (I, aVL, V5-6)
Absence of Q waves in lateral leads
Prolonged R wave peak time > 60ms in leads V5-6
Contraindications to thrombolysis in MI
[Timing for head trauma? stroke? BP score?]
PCI available in 90 mins
Active internal bleeding, uncontrolled external bleeding
Suspected aortic dissection
Head trauma <2weeks
haemorrhagic / ischemic stroke <2months
Uncontrolled BP >200/120
Who should prasugrel be avoided in?
It works better than clopidogrel
Avoid if:
- >75
- <60kg
- history of stroke / TIA
Which vessle supplies the SN and AVN? Significance?
R coronary
[Occlusion can cause complete heart block]
Therefore, inferior MI are high risk for needing paced
Webbing of neck and failure of secondary sexual development? Cardiac abnormality ?
Turners syndrome
Bicuspid aoric valve, Coarctation of aorta, VSD, ASD….
Features of coarcation?
Difference between Infantile and adult type coarctation of aorta?
Hypertension
Intermittent claudication of legs / tiredness
LV failure
angina
Infantile - Stenosis proximal to L subclavian
-> Hypertension in right arm only
Adult - Stenosis distal to Subclavian
-> Both arm hypertensive
Upper body more developed than lower.
In an infant with coarcation what medication can you give and why to bridge to surgery?
Prostaglandin E1
-Keeps ductus arteriosus patent
Notching of ribs on CXR
Coarctation
Turners syndrome. Which abnormality if systolic murmur at right sternal edge? Left infrascapular?
Right edge - bicuspid
Left infrascapular - coarctation
Following diagnosis of bicuspid aortic valve, what investigation must be done?
Cardiac MRI / CT to assess for coarctation
[bicuspid valves are found in 50% of cases of coarctation]
When do you need surgery for bicuspid AV
When get stenosis + symptoms and a mean paravalvular gradient >40mmHg, AVA <1cm
Best way to capture a paroxsysmal arrythmia
Loop recorder - you can press it when you’re having symptoms.
With a holter - may miss the arrythmia if doesn’t occur in the 24/72hr period
improve outcomes with HCM who are at high risk of tachyarrhythmias ?
What drug can be used ?
ICD
Amiodarone
HCM murmur? Why? How to make murmur more?
Ejection systolic due to dynamic outflow tract obsturction
[This causes exersional symptoms and the risk of sudden death]
Murmur increases with Valsalva, decreases with squatting
HCM: finding on JVP wave?
Large A waves
Banana / spade shaped ventricle in systole during cardiac catheterization?
HCM
Swordfish narrowing of LAD seen in?
HCM
Which is the bad one? LDL or HDL
LDL
[Low density -> take up more space -> obstruct vessels more]
When do you offer atorvostatin in hyperlipidaemia
When QRISK2 score >10%
Drug for primary hypercholesterolaemia if statins inappropriate?
Ezetimibe
[Inhibits absorption of cholesterol from gut]
Inferior MI. Then develops shock: no murmurs and nothing auscultated on the chest.
What cause?
RV infarction
[Pooling of blood in RV -> reduces preload and therefore hypovolaemic shock.
Inferior infarction affecting circumflex. The develops Pulm oedema 2 hours later. What has happened? Pathophysiology? Auscultation?
Papillary muscle rupture (supplied by circumflex).
Papillary muscle rupture -> Severe mitral regurg -> Acute pulm oedema
Loud pansystolic murmur + bibasal creps from pulm oedema
Cardiac abnormality with no findings on the exam and allows an R to left shunt occasionally
Patent foramen ovale
[In 1 out of 4 people - very common]
Management of coronary artery spasm?
Nitrates / CCBs
First line treatment for angina?
BBs
[+GTN for symtom relief]
CCBs second line
Transient ST elevation, usually at rest, with to without underlying atherosclerotic lesions ?
Varient (Prinzmetals) angina. Due to coronary artery vasospasm
Angina when lying down or often when dreaming?
Decubitis angina
[Due to an increase in L ventricular diastolic pressure]
Difference in systolic BP in arms vs legs?
If Aortic regurg?
10-20mmHg
60-100mmHg
Blood pressure with exercise in HCM
Stays the same or falls
Common murmur in aortic dissection
Diastolic - from aortic regurg
Trop / d dimer in aortic dissection
Trop - normal or mildly raised
D dimer - very high
Common cardiac abnormality with ankylosing spond
Aortic regurg
AR signs
Collapsing radial pulse
Wide pulse pressure
Early diastolic murmur on left sternal edge
AR signs
Corrigans?
De Muzet
Quincke
Duroziez
Corrigans - Visible pulsations in neck
De Muzet - Head bobbing (due to neck pulsations)
Quincke - Subtle pulsation of capillary nail bed
Duroziez - Diastolic murmur proximal to femoral artery compression
Drug class to avoid in AR and why
B blockers - prolong diastole -> increases regurg
Prolong QT electrolytes
HYPO k/mg/ca
Inherited syndromes that cause prolonged QT ? If question mentions Swimming? Sensory-neural deafness? Periodic paralysis & facial abnormalities? Autism?
Romano ward [Swimming] dominant
Jervell and lang nielson [deaf] recessive
Anderson tawil - [Paralysis + facial/skeletal]
Timothy [autism]
JVP - loss of x descent, large V waves
Tricuspid regurg
JVP prominent x descent
contrictive pericardiits
sarcomere protein gene mutation seen in
HOCM
Avoid CCBs for long term rx of heartfailre when?
presence of significant LV dysfunction
Causes of primary PH ?
Secondary PH?
Primary - nil: diagnosis of exclusion
Secondary - Chronic PE, Collagen/vascular disease, LV dysfunction, COPD, cirrhosis, ASD/VSDs
PAH on echo
Peak Tricuspid regurg
Treatment of PPH
Anticoag
Digoxin - even if SR
PDE5 inhibitors - eg sildenafil
Diruetics
How long does tropnin remain elevated?
up to 2 weeks
First line management to prevent recurrence of NON-sustained VT
Sotalol
Brugada syndrom ECG
ST elevation >1 of v1-v3 followed by T wave inversion
[usually with Incomplete RBBB]
Neurological mediated postural hypotension drug?
Midodrine
[Fludrocortisone + adequate Na diet usuals]
Othostatic hypotension following meals drug?
ocretitde
CABG which vessels used. usual complications of the harvest of each?
LAD = Left internal mammary artery
-May damage phrenic (crosses at rib 1) -> diaphragm paralysis
Others usually - long saphenous vein
-Damage saphenous nerve Sensory loss over leg
[or radial artery following phallens - sensory loss over stuff box]
Post op cabg infections commonly caused by what bugs
MRSA or SA
Or gram neg
Common time for cholesterol emboli? Common blood finding? Urine microscopy?
Post angiogram
Eosinophilia
Eosinophilia + hyaline casts
Which cardiac abnormality is heavily associated with GI bleeding and angiodysplasia?
Aortic stenosis (heydes syndrome)
-Though do do with high sheer stress around stenosed valve
Overdose of B blockers with brady. No response to atropine. What drug could you use while getting transcut pacing set up
glucagon
[glyco similar effect to atropine]
Implanted ICD for VT. driving rules
No driving car for 6 months post op
NEVER bus / HGV
Occlusive disease of extremities linked heavily with smoking. Complain of claudication / ulcers / diminished pulses
buergers disease
Murmur in VSD
pansystolic. left sternal edge
Main thing that increases HDL levels
Alcohol
WPW most common arrhythmia? Seen on ECG after cardioversion
AV re-entry tachycardia
Delta wave
Loud pansystolic murmur and pulm oedema after MI = ? Which vessel?
acute mitral regurg from ruptured cordae tendonae
(supplied by circumflex usually)
When and why would an angiogram worsen hyperthyroidism? How to work this out pre-procedure? Rx during and post-procedure?
Cardiac angiography uses iodine
-worsens toxic multinodular goitre
-Makes graves a little better
Radioisotope scan to identify the cause (TMN vs Graves)
TMN - needs antithyroid meds pre-procedure and to be continued for minimum 2 weeks
RV failure (peripheral oedema but minimal pulm oedema)
ECG showing small complexes. Prev radiotherapy
= constrictive pericarditis
Most common cause of pericarditis? In low income countries?
coxsackie B virus
TB
What is pathagnomic of pericarditis
pericardial friction rub
-‘ high-pitched scratching sound’ on left sternal border during expiration
-may be described as walking on fresh snow OR rubbing leather on leather
Most common drug causing pericarditis
hydralazine
What position is pericarditis most sore in?
Laying down
Relived by sitting forward (reduces contact with pericardium )
What does cardiac tamponade leading to compression of lingular lobe let you find on the exam?> Called?
Left lower lobe bronchial breathing
Ewart’s sign
Constrictive and restrictive cardiomyopathy have some similarities…? differences?
Similar
-Raised JVP with prominent x and y descents
-AF
-Normal systolic function
Differences
-No LVH in constrictive
-Calcification in constrictive (CforC)
What is common ecg in pericarditis
widespread ST elevation / PR depression
Management of viral pericarditis
NSAIDs
colchicine if NSAIDs contra indicated
[steroids second line]
In HCM what is most associated with risk of sudden death
Degree of septal hypertrophy
[even more than outflow tract gradient]
Found on ECG WPW?
Slurred up stroke QRS (delta wave)
Short PR
What is Kussmaul’s sign? Seen in?
Inspiratory increase in venous pressure
(pericarditis)
Prominent S3 heard over apex
Aortic regurg
SVT prophylaxis in pregnancy drug?
Metoprolol (TDS)
Differentiate primium and secundum ASD on ECG.
Pri - often LAD
Sec - Often RAD
Trop in peri vs myocarditis
Very high in myocarditis (therefore diagnostic)
When is verapamil contraindicated
Accessory pathways Eg WPW
LVSD
2nd / 3rd degree block
Kussmaul’s sign seen usually in which MI
proximal occlusion of the right coronary artery -> RV
J-point depression of 1mm on ETT. Significance?
J point depression is normal physiological response to exercise
PPH and pregnancy?
Absolute CI to pregnancy - should be advised as PPH will rapidly worsen in preg
Systolic murmur loudest at apex most likely? Effect of isometric handgrip exercises?
Mitral regurg
Handgrip exercises increase afterload -> make AR/MR/VSD murmurs louder
isometric handgrip exercises and mitral prolapse
Increases LV volume -> delays click and murmur
Unstable angina due to Which lipid/cholesterol most?
LDL
When is NT-proBNP unreliable
Renal dysfunction (95% renal cleared)
BNP is only 5% renal cleared
AS - what concurrent issue would make murmur quieter
AF
LV failure (less blood)
WPW / other pre-excitation pathway in fast AF drug?
Procainamide
(adeonsine may -> VT/VF)
Class of drug CI with sildenafil
Nitrates
[may precipitate fatal hypotension]
Self terminating SVT in preg
Reassure - don’t need to check nothing
ECG characteristic finding in moderate hypothermia
J waves
Which are the rate-limiting CCBs
Verapamil and Diltiazem
Poorly controlled AF and symptomatic despite medical therapy Rx
Radiofrequency pulmonary vein ablation
BP in preg physiological change?
Tend to get a 10mmHg diastolic drop in 2nd trimester (then normalises
When can you use IV lidocaine?
Resistant haemodynamically stable VT
New Fast AF Strucually normal heart first-line drug?
If LVH?
Significant IHD?
Flecianide
Amiodarone if LVH
Soltalol if IHD
Where is the 1st heart sound on ECG? what is it?
R wave
mitral and tricuspid closure
Complete heart block what is heard on auscultation
Variable intensity of first heart sound (mitral / tricuspid closure)
[First heart sound is related to PR interval. This varies in complete HB)
First degree HB auscultation
Quiet S1 [due to long PR]
Pulm HTN auscultation
Loud S2
MR vs MS heart sound
MR quiet first heart sound
MS loud first heart sound
Mitral prolapse. what happens to the murmur if the patient is standing
The mid-systolic click and murmur will occur earlier
Statins post MI
Shown to lower risk of CV death even if normal cholesterol
Really severe AS auscultation
Quiet or even loss of S2
Handgrip in AS vs MR?
murmur of aortic stenosis decreases
murmur of mitral regurgitation increases.
HR / SBP in MRCP to be classed as unstable?
HR >150
SBP <90
Find a member of public in cardiac arrest. What first
Call 999
Then shart compression
RCA occlusion ST elevation where? If RV completely infarcted?
II, III, AVF (+ depression aVL)
STe also in V1 and V4
Aortic valve gradient to be classes as significant
> 70mmHg
Right arm higher BP than the left with systolic murmur =
Supravalvular aortic stenosis
-> Blood preferentially sent up to R brachiocephalic
Differentiate subclavian steal syndrome and supravalvular aortic stenosis from pt history
In subclavian steal, there would be significant Hx of neuro eg syncopal episodes / memory issues alongside the difference in arm BPs
AS + anaemia =
Which clotting factor is involved?
What are they at key risk?
Rx?
Heyde syndrome
High stress over AV leads to the unfolding and activation of VWF
->Aquired VWF deficiency
GI bleeding from angiodysplasia
AV replacement
Someone going for a hip replacement and can’t walk due to pain. How do you test their CV function for the operation?
Dobutamine stress echo - with ECG
[Need to discontinue BB 3 days in advance]
Atrial Myxoma
Usual location?
Key symptoms / issues?
Dx?
L atrium attached to atrial septum 75%
Parts of tumour break off and act as clots
Can get intra cardiac obstruction
Diagnose with echo
Bar ASD what else causes a wide fixed splitting of S2?
When in normal people is the splitting of S2 heard?
RBBB with heart failure
Pulm stenosis
In normal people, s2 is split during inspiration -> increased venous return to the right heart
-> delayed pulm valve closure (relative to AV)
Reversed split of S2
LBBB
AS
[PDA / HCM]
Which is the key thing auscultated in LV failure
S4
Unstable angina - how to get your HGV license back
ETT
[Need to complete 8 mins of bruce protocol]
New AF with no adverse features or Hx drug?
Felcanide
Cranberry Fruit juice affects?
Warfarin mostly
[ Amitriptyline, diazepam and ARBs]
What does graprefruit juice do
P450 inhibitor
Triad of AS symptoms
Angina, LVF, syncope
WPW Type A vs B on ECG
Both have:
Short PR, d-wave, wide QRS but normal QT
A - tall R wave in V 1
B - Deep S wave v1
Adenosine mechanism
G-coupled protein receptor agonist
[Also K channel agonist and Ca channel blocker]
Flecanide mechanism
Sodium channel blocker
Amiodarone mechanism
Potassium channel blocker
When does the balloon pump inflate
When aortic valve closes (diastole
LBBB and history of IHD what 2 things on auscultation
Soft s1
Reversed splitting of S2
Known bad asthmatic in fast AF without instability
Verapamil
[or diltiazem]
Does amlodipine affect HR
No effect on heart rate
Only affects BP
Why digoxin only really in AF in sedentary people
Dignoxin only affects heart rate at rest, not when active
Being treated for PCP with septrin. Develops erythema multiform, then acute raised JVP, muffled heart sounds and hypotension. What has happened?
Allergic myocarditis from co-trimoxazole
[and probably ruptured myocardium]
3-year vague history of Raynaud’s, PE. tricuspid stenosis murmur =
R atrial myxoma
Type of echo to confirm PDA
Toe with bubble study
Most common sarcomere mutation in HCM affects what?
beta-myosin heavy chain
Mix of SVTs / brady arrhythmias and short sinus arrest? Usual cause? Rx?
Sick sinus syndrome
Fatty deposits / fibrosis of node - often due to atherosclerosis
Pacemaker + medical Rx of SVTs if needed Eg bisoprolol
Clopidogrel mechanism
ADP blocker
Aspirin mechanism for anti-platelet effects
Thromboxane inhibitor
Abciximab, Tirofiban, Eptifibatine mechanism
Glycoprotein IIb/IIIa inhibitors
Heparin / LMWH mechanism
Potentiate antithrombin III
MI. now on ETT. What would make you refer for an angio?
Manage <6 mins with ECG changes
Which antiarrhythmic class work on SA/AV node
Class IV - CCBs
Flecanide class?
Na channel blocker (Class I)
How do B blockers slow HR
Slow conduction through AV node
Irregular cannon waves on JVP
Complete heart block
[Cannon waves caused by atria contracting against closed TV]
AVR. Has ischemic stroke on warfarin (INR therapeutic Eg 3) acute Rx?
Nothing - continue warfarin
Which murmur is reduced in pregnancy? Why?
Which new murmur may occur?
Aortic regurg - due to reduced diastolic bp
[Ie. The difference in pressure of the Aorta and LV is less]
May develop a pulm systolic murmur / 3rd heart sound
All stenosis murmurs will get louder due to increased blood flow
Why splitting of S2 in normal inspiration
Increased venous return overloads RV and delays closure of pulm valve
Which drug causes short QT
Digoxin
Which antiarrhythmics cause long QT
Class 1, 3
Pressure for pulm HTN
Pressure >25mmHg
Normal pulm capilliary wedge pressure
<12
Abx prolonging QT
Macrolide
Quinolones
3 feautres of ECG for vt
Wide QRS
Tachycardia
AV dissociation
Which type of pacemaker for symptomatic biventricular failure?
Brady / sick sinus syndrome?
Biventricular
Dual chamber for bradies
-goes in Ra / RV
DVT -> stroke. Which abnormality is the most common?
Patent foromen ovale
ST elevation of 0.5mm in V1/2 with central chest pain Rx
Aspirin + heparin and repeat ECG in 15 mins
LVH due to which valvular issues?
RVH
BVH
LVH - AS/MR
RVH - PS/TR
BVH - VSD
Long QT genotypes and long term Rx
LQT1 - B blocker first -> defib
LQT2, LQT3 - Defib
Goes for CABG. Now has direct and indirect hyperbilirubinemia, but no other deranged LFTs. Why?
Haemolysis on bypass
Inferior MI 3/7 ago. Now pan systolic murmur is worse on inspiration and hypotensive. High right atrial pressure. Diagnosis
Tricuspid regurg
-High right atrial pressure indicating right heart issue
-Murmur that is worse on inspiration = Right heart
liver that pulses on systole indicates which valv issue?
Tricuspid regurg
What class of antiarrhythmic worst for torsades
Class III eg Sotalaol / amiodarone
What class of antiarrhythmic worst for torsades
Class III eg Sotalaol / amiodarone
Which cardiac enzyme needs to be measured within the first 3 hours of an MI
Glycogen Phosphorylase isoenzyme BB
AF with RVR and known reduced ejection fraction. Brittle asthma. rx?
Digoxin
Does someone with lime disease complete AV block need a pacemaker?
No, it is usually reversible
-They do need observation until recovered though
Tricuspid stenosis vs regurg in jugular waves
Stenosis = Prominent A wave
[Atrial contraction against stenosed valve]
Regurg = Prominent V waves
Complete heart block usual rate? Auscultation?
25-30
Basal systolic flow murmur
[due to increased stroke volume - compensatory mechanism]
Prothetic valve endocarditis Abx?
Vanc, gent and rifampicin
2nd degree heart block where is type 1 vs type 2 issue?
2nd-degree type 1 - at AV node
Type 2 - bundle of his/ Purkinje
Most common gene in long QT syndrome? chromosome? Codes for?
LQT1 - most common type
Gene - KCNQ1 on chromosome 11
Slow delayed rectifier potassium channel mutation
When HTN pres existing and when pre-eclampsia
Before or after 20 weeks gestation
How long sinus pause for a pacemaker?
Which types of block
> 3s
Mobitz 2 / complete
Trifasicular
The most anterior valve of the heart and most likely to be injured in stabbing?
Pulmonary
Develops tachy - has p waves
Rate accelerates once arrhythmia started
Automatic supraventricular tachyarrhythmia
[this if rate accelerates]
Who has a CK basline 3 times normal people
Afro caribean
Most common cardiac abnormality in downs
AVSD
[VSD>ASD]
When in partum cycle do mothers get most VTEs
6 weeks postpartum
Where on ECG are epsilon potentials seen? Indicate?
RV leads - Little blip after QRS in V1,2
RV dysplasia
[Due to displacement of myocytes by fat -> delays depolarisation of other myocytes]
Old Atrial enlargement with reduced EF. In AF rate 100, has asthma and myasthenia gravis[lol]. Rx?
Digoxin
Congenital myotonic dystrophy most common ECG abnormality
Prolonged PR
Old. Collapse, pulseless for couple of seconds. Normal 7 day ECG = ? Dx?
Carotid sinus syndrome
Supine carotid sinus massage with ECG monitoring -> 3s pause / drop in BP >50mmHg
[Ovs cant do if carotid disease or stroke Hx]
Which valve lesion would lead to increased end diasolic LV pressure
MR
When might pulseless alterans be heard
Acute LVF - Alternating strength of pulse
[Also in low-output states Eg pericarditis ]
PDA character of pulse
Collapsing
[Think similar to AR in whats happening to blood flow]
Main agent for controlled reduction of BP in hypertensive crisis
IV labetalol
[If they having a phat stroke and reduced conciousness -> sodium nitroprusside ]
Myeloma and secondary cardiac amyloid. What is the typical cardiomyopathy here
Restrictive
Known ASD with progressive cyanosis, haemoptysis and episodes of syncope probably has
Pulm HTN
55 years. Claudication in legs.
BP difference in arms but no radial-radial or radial-femoral delay =
PVD
Coarctation would expect to have RR /RF delay
Pericarditis - 2 things found in stage one ? Then what?
Stage 1: Concave ST elevation, PR depression
2: ST baseline, T wave flattening
3: TWI
4: resolution
Endocarditis rank valves in likelihood order
Mitral
Aortic
Tricuspid
Pulm
Obviously, any abnormality Eg MS or AR etc increases the risk
ASD VSD endocarditis risk
ASD low
VSD high
Palmar crease xanthomas are pathognomic of
Type III hyperlipidaemia
[broad B disease]
Loud S1, then early diastole sound then mid-diastolic murmur
MS with mobile leaflets
[probably from rheumatic fever]
HTN Rx steps
ACE (or ARB) or CCB
ACE + CCB
+thiazide
+Spironolactone if K+ <4.5 OR increase thiazide otherwise
V5 V6 TWI with MI Hx features which vessle=
Critical stenosis of cricumflex
Severe AS heart sound
Soft S2
Prev chemoradio
Raised JVP with steep Y descent, pulsatile liver, low voltage complexes
Post radiation constrictive pericarditis
Aortic dissection - going for an operation
2 drugs to give IV urgently
Opiates
Labetalol
Pharyngitis, fever, polyarthritis, new murmur =?
Ix?
Rx?
Rheumatic fever
Echo + anti streptolysin O titre
Penicillin and supportive
On warfarin for AF going for a dental procedure INR 2. plan?
Go ahead
Acute chest pain looks unwell. Unequal BP in arms, AR on auscultation =
Aortic dissection
