Cardiology

Question 1

Prolonged QRS in the setting of monomorphic VT episode is an indicated for what type of pacing?

Answer 1

ICD with BIVENTRICULAR pacing

Question 2

What is the normal vital sign response to exercise?

Answer 2

Increase in HR and BP

Question 3

A patient gets angina during a stress test what is the next step

Answer 3

Stop test and order angiogram

Question 4

NICE guidelines for daytime BP goals?

Answer 4

< 80 yrs : < 135/85
> 80 yrs : < 145/85

Question 5

RCA myocardial infarction will produce an ECG with ST change in which leads

Answer 5

Inferior leads (II, III and aVF)

Question 6

5 diseases associated with aortic dissection

Answer 6

SLE
Syphilis
Marfan’s
Ehlers Danlos
Turners

Question 7

How to differentiate between a post MI VSD vs papillary muscle rupture

Answer 7

Measure the RA and PA O2 sats

Note: VSD and papillary rupture are difficult to distinguish clinically. The diagnosis is established by demonstration of a left to right shunt.
The presence of a VSD would be confirmed by detecting a step-up in the oxygen saturation between the RA and PA; if there is no step-up, the diagnosis is probably papillary muscle rupture.

Question 8

In a patient who needs both a CABG and a CEA which should be done first?

Answer 8

CABG

Note: outcome of endarterectomy is significantly better in those patients who have significant coronary artery disease attended to beforehand

Question 9

Digoxin is often used as an anti arrhythmic in WPW T/F

Answer 9

F

Beta blockers, digoxin, and calcium channel antagonists should be avoided as they may accelerate tachycardia and increase the risk of VT by driving conduction preferentially down the accessory pathway

Question 10

Anti arhythmic of choice in WPW

Answer 10

Flecanide if structurally normal heart

Amiodarone if structurally abnormal

Question 11

Patients with heart failure who are asymptomatic with a LBBB and QRS of more 150 ms should be considered for a CRT.T/F

Answer 11

T

Question 12

In new onset a fib without haemodyanamic compromise and echo showing structurally normal heart what is the initial treatment of choice?

Answer 12

bolus of flecanide

NB: where there is no structural cardiac valve abnormality, which has been confirmed by echocardiography.

Question 13

Patients with a predicted 10 year cardiovascular risk of more than __% should be considered for statin therapy

Answer 13

More than 10%

Question 14

Which anti arrhythmic causes a shorted QT interval

Answer 14

Digoxin

Question 15

The addition of digoxin in patients with symptomatic heart failure has been shown to result in an improvement in symptoms, whether they are in AF or not. T/F

Answer 15

T

Question 16

Spironolactone at doses greater than ___ has no proven impact on mortality in patients with heart failure.

Answer 16

25 mg od

Question 17

Clinical and ECG features of Pacemaker Syndrome? Tx?

Answer 17

AKA AV dyssynchronisation
Syncope, dizziness, hypotension and peripheral oedema (2ndary to HF).
ECG: Small P waves with dissociation from QRS complex
Tx: replace device with dual chamber device

Question 18

In the setting of HF what increase in Cr/decease in EGFR is acceptable after staring an ACEi?

Answer 18

30% increase in the serum creatinine OR
25% reduction in the eGFR
is tolerable and should not lead to changes in dosing.

Note: ACE inhibitors should be stopped or dose adjusted if is there is a rise in the serum potassium level to greater than 6 mmol/l.

Question 19

Wide pulse pressure (eg BP 160/45) is suggestive of what cardiac disease?

Answer 19

Aortic regurg

Note: early diastolic murmur

Question 20

Tx of aortic dissection

Answer 20

Adequate analgesia and urgently reduce the blood pressure with intravenous antihypertensives: beta blockers first line, and then nitroprusside.
Then cardiothoracic surgeon referral

Question 21

Aspirin + clopidogrel is the best DAPT post STEMI T/F

Answer 21

F

Note: aspirin 75 mg OD and ticagrelor 90 mg BD. In a subset of the Plato trial, ticagrelor was associated with a 13% relative reduction in cardiovascular events versus a conventional clopidogrel based regimen. This has driven use of ticagrelor in place of clopidogrel in major guidelines on anti-platelet therapy post STEMI.

Question 22

For how long should a pt continue on DAPT after placement of a drug eluting stent post MI?

Answer 22

12 months

Question 23

Which is likely to cause gynaecomastia: aspirin, lisinopril or furosemide?

Answer 23

Linsinopril

Note: Many drugs can cause gynaecomastia including inhibitors of testosterone synthesis( ketoconazole
metronidazole
cimetidine
etomidate, and
cisplatin.)

Oestrogens (digitalis, OCP)

Mechanism unknown:
isoniazid
diazepam
omeprazole
ca-channel blockers
ACE i
amiodarone
TCA
Efavirenz
busulphan
marijuana
heroin
spironolactone

Question 24

Initial mgmt of cardiac device related infective endocarditis

Answer 24

Urgent extraction of the implanted device followed by prolonged antibiotic therapy

Note: Percutaneous extraction is recommended in most patients with cardiac devices even those with large (>10 mm) vegetations
After device extraction, reassessment of the need for reimplantation is recommended
Routine antibiotic prophylaxis is recommended before device implantation.

Question 25

In treatment of SVT, what is a relative CI to adenosine? What should then be used second line?

Answer 25

Asthma

2nd line: verapamil

Question 26

right sided failure, ascites and pericardial calcification on x ray suggest a diagnosis of _____

Answer 26

Constrictive pericarditis

Note: also may hear a pericardial ‘knock’ (might be described as an added diastolic sound)

Question 27

In a patient with aortic stenosis, what will lead to an overestimation of the severity of the problem when assessed by echocardiography?

Answer 27

Large volumes of blood passing over the valve at high velocities, which occurs in aortic regurgitation.

Question 28

In patients who cannot have a TTE (eg poor study due to obesity) what are other options to evaluate for heart failure?

Answer 28

Radionuclide angiography
Cardiac magnetic resonance imaging
TOE

Question 29

Indications for valve replacement in AS

Answer 29

Gradient of 50 mmHg or more, or associated symptoms such as syncope, breathlessness and episodes of pulmonary oedema.

Question 30

Pt underwent angioplasty and bare metal stent implantation for single vessel coronary artery disease five months before presenting with a 3 month hx of angina. Most likely cause?

Answer 30

In-stent re-stenosis due to neointimal proliferation

Note:Another ddx is Subacute stent thrombosis. But it would occur occurs acutely rather than over months, and typically presents with an acute MI.

Question 31

An intra-aortic balloon pump is inserted under echocardiographic guidance.
At which point of the ECG should balloon inflation be timed?

Answer 31

Middle of the T wave

Note: aortic regurgitation is an CI

Question 32

DC cardioversion is contraindicated in patients with pacemakers T/F

Answer 32

F

Note: It is not CI, although it is prudent to have the pacemaker function and settings rechecked after cardioversion

Question 33

Medical mgmt of a symptomatic bradycardia in pt with heart transplant?

Answer 33

Slow infusion theophylline

Note: transplanted heart is denervated so not role for atropine

Question 34

Where should internal jugular CVC lie?

Answer 34

In the lower superior vena cava

Note: If the catheter tip is above the carina on a post-procedure radiograph then it is generally accepted that the catheter lies outside the right atrium in the lower superior vena cava

Question 35

Persistent ST segment elevation occurring 6 weeks after a known transmural myocardial infarction (usually an anterior MI)

Answer 35

LV aneurysm formation

Note: can mimic MI