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Y3 Medicine > Cardiology > Flashcards

Cardiology Flashcards

1
Q

Helpful mnemonics for acute and longer term management of MI?

A

MONA:
Morphine and anti-emetic
O2 if hypoxic
Nitrates (GTN spray)
Aspirin

DABS:
Dual antiplatelet therapy
ACEi
BB
Statin

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2
Q

When can PCI be carried out?

A

If the MI presents within 12 hours of onset AND PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given

If PCI cannot be delivered in 120 mins give immediate fibrinolysis

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3
Q

Poor prognostic factor in ACS?

A

Cardiogenic shock

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4
Q

ECG changes in pericarditis? Tx?

A

‘saddle-shaped’ ST elevation (concave)
PR depression: most specific ECG marker for pericarditis

Tx is NSAIDs

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5
Q

How should suspected aortic dissection be investigated?
What is the key finding?

A

CT angiography of the chest, abdomen and pelvis is the investigation of choice

TOE for unstable patients who are too risky to take to the scanner

the key finding suggestive of aortic dissection on CT angiography is a false lumen
Will also see widening of the mediastinum on CXR

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6
Q

How do you treat acute onset AF?

A

If haemodynamically stable you do not need to cardiovert immediately

If the patient is stable and onset ≥ 48 hours - rate control initially (e.g. bisoprolol) and delay cardioversion until they have been maintained on therapeutic anticoagulation (e.g. apixaban) for a minimum of 3 weeks

If very unstable with acute onset AF- can do TOE to look for left atrial thrombi before urgent cardioversion

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7
Q

Tx for angina where BB contraindicated?

A

Nicorandil - can cause ulcers along the GI tract

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8
Q

What protein marker is most useful for determining reinfarction in the weeks following MI?

A

Creatine kinase (CK-MB)
- it remains elevated for only 3 to 4 days following infarction. Troponin remains elevated for 10 days.

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9
Q

Main ECG change in hypercalcaemia?

A

shortening of the QT interval

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10
Q

How do you manage HOCM (hypertrophic obstructive cardiomyopathy)?

A

ABCDE:

Amiodarone
Beta-blockers or verapamil for symptoms
Cardioverter defibrillator (If they have arrested once, implant a cardioverter defibrillator to prevent recurrence)
Dual chamber pacemaker
Endocarditis prophylaxis

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11
Q

Outline the acute management of key peri-arrest rhythms : unstable VT, stable VT, and SVT

A

Unstable VT (dropping bp)= cardioversion, then maybe IV amiodarone

Stable VT = IV amiodarone

Supraventricular tachy= IV adenosine

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12
Q

How do you determine the cause of orthostatic htn?
How do you treat?

A

Orthostatic hypotension (A fall in SBP of >20mmHg on standing) accompanied by an exaggerated increase in HR = due to anaemia or hypovolemia

Orthostatic hypotension with minimal/no change in heart rate = neurogenic (e.g. due to diabetes)

Tx= Fludrocortisone and midodrine

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13
Q

Outline the key points of PE investigation

A
  1. Wells score

Wells score 4 or less = D-dimer to exclude PE
Wells score- over 4 = likely PE

  1. Do an ECG - sinus tachy commonest finding in PE (S1Q3T3 characteristic but rare)
  2. Do a CXR - clear/ wedge shaped opacification in PE
  3. Do a CTPA (unless contraindicated e.g. allergy to contrast/renal impairment in which case VQ scan used as an alternative)

Strong suspicion of PE but delay in the scan - start tx dose anticoagulant and monitor closely in the meantime

If CTPA +ve proceed with treatment (thrombolyse or give DOAC)
If CTPA -ve but DVT strongly suspected then consider a proximal leg vein ultrasound scan

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14
Q

Outline the key points of PE management
What is the target INR for pts with recurrent PEs?

A

Tx:

If there is massive PE + hypotension - thrombolyse immediately

For haemodynamically stable PE (not hypotensive/tachycardic):

3 months DOAC for provoked PE (obvious temporary risk factor)
6 months DOAC for people with active cancer and confirmed proximal DVT/PE
Lifelong tx for patients with unprovoked PE or persistent risk factors such as antiphospholipid syndrome, active cancer or thrombophilia

Target INR for patients with recurrent PEs is 3.5

If the patient has a PESI class 1 or 2 (very low risk PE) and do not want to be admitted, they can be managed as an outpatient with rivaroxaban.

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15
Q

Key contraindications to thrombolysis?

A

Contraindications to thrombolysis:
active internal bleeding
recent haemorrhage, trauma or surgery (including dental extraction)
bleeding disorders
intracranial neoplasm
recent head injury
stroke < 3 months
aortic dissection
severe hypertension

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16
Q

What is Takayasu’s arteritis? Give features, association and tx

A

Common in young Asian women - fibrous thickening of aortic branches

Features:
systemic features of a vasculitis e.g. malaise, headache
carotid bruit and tenderness
unequal blood pressure in the upper limbs
limb claudication on exertion
absent/ weak peripheral pulses

Associations: renal artery stenosis

Management: steroids

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17
Q

1st and 2nd line tx for patients with stable impaired LV function? Vaccinations offered?

A

1st: ACE inhibitor + beta-blocker
2nd: aldosterone antagonist

Yearly flu jab and one off pneumococcal

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18
Q

Posterior MIs cause reciprocal changes in V1-3 - describe them

A

Remember- ‘ugh don’t STRRT”

horizontal ST depression
tall, broad R waves
dominant R wave in V2
upright T waves

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19
Q

Outline the tx for the 2 types of aortic dissection

A

type A - ascending aorta - control BP (IV labetalol) + surgery*
type B - descending aorta - control BP(IV labetalol)

*Proximal aortic dissections are generally managed with surgical aortic root replacement as opposed to stenting

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20
Q

What do p mitrale (bifid p wave) and p pulmonale (tall p wave) represent ?

A

P mitrale- left atrial hypertrophy/strain e.g. in mitral stenosis (seen more in lead 2)
P pulmonale- right atrial hypertrophy e.g. tricuspid regurgitation and pulmonary hypertension

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21
Q

What part of the ECG is DC cardioversion synchronised with? Why?

A

the R wave to minimise the risk of inducing ventricular fibrillation

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22
Q

A patient develops acute heart failure 10 days following a myocardial infarction.
On examination he has a raised JVP, pulsus paradoxus (dramatic drop in bp on inspiration) and diminished heart sounds- what is the diagnosis?

A

left ventricular free wall ruputure- Urgent pericardiocentesis and thoracotomy are required.

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23
Q

ECG features in hypokalaemia?

A

“In Hypokalaemia, U have no T, but a long PR and a long QT”
U waves
Small/absent T waves
prolonged PR and QT intervals

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24
Q

What is a CHA2DS2-VASc score?

A

Used to determine need for anticoagulation in AF

one point would be allocated for each of the following:
Congestive heart failure
Hypertension (controlled or uncontrolled)
Age of 65-74 years
Diabetes
Vascular disease
Sex (female)

2 points for:
An age of 75 years or over
Prior stroke or thromboembolism.

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25
Q

How do you differentiate between cardiac tamponade and constrictive pericarditis? (both present with dyspnoea and signs of HF)

A

Kussmaul’s sign positive in c. pericarditis - JVP that raises/ doesn’t drop on inspiration

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26
Q

What drugs are given to someone receiving PCI?

A

prasugrel + unfractionated heparin + bailout glycoprotein IIb/IIIa inhibitor

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27
Q

When should statins be taken to improve efficacy?

A

at night as this is when the majority of cholesterol synthesis takes place

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28
Q

What is Dressler’s syndrome?

A

Dressler’s syndrome (postmyocardial pericarditis) is secondary pericarditis

If a pt presents with central, pleuritic chest pain and fever 2-6 weeks following a myocardial infarction and the ESR is elevated - think Dressler’s syndrome!!

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29
Q

Describe Beck’s triad for cardiac tamponade

How is cardiac tamponade investigated?

A

muffled heart sounds, hypotension and a raised jugular venous pressure

an echocardiogram. It can show an enlarged pericardium or collapsed ventricles.

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30
Q

Give causes of ejection systolic murmur that are louder on inspiration and louder on expiration

A

Ejection systolic

louder on inspiration:
- pulmonary stenosis
- atrial septal defect
also: tetralogy of Fallot

louder on expiration:
- aortic stenosis
- hypertrophic obstructive cardiomyopathy

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31
Q

Sign of hypothermia on ECG? On bloods?

A

J waves

Bloods can show high haemoglobin due to haemoconcentration, and low platelets and WCC due to splenic sequestration

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32
Q

First line management of acute pericarditis?

A

combination of NSAID and colchicine

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33
Q

What is Torsades de points? risk factors? tx?

A

a form of polymorphic ventricular tachycardia associated with a long QT interval- can lead to v fib and death

presents with dizziness, shortness of breath, palpitations

increased risk with macrolides e.g. azithromycin

tx with IV magnesium sulphate

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34
Q

Give 3 causes of pansystolic murmur and differentiate between them

A

mitral/tricuspid regurgitation (high-pitched and ‘blowing’ in character)

  • tricuspid regurgitation becomes louder during inspiration, unlike mitral regurgitation (bc during inspiration, the venous blood flow into the right atrium and ventricle are increased)

ventricular septal defect (‘harsh’ in character)

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35
Q

What can cause a late systolic murmur?

A

mitral valve prolapse
coarctation of aorta

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36
Q

Outline the referral criteria for people presenting to the GP with chest pain

A

current chest pain or chest pain in the last 12 hours with an abnormal ECG: emergency admission

chest pain 12-72 hours ago: refer to hospital the same-day for assessment

chest pain > 72 hours ago: perform full assessment with ECG and troponin measurement before deciding upon further action

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37
Q

How do you categorise angina as typical or atypical?

A

NICE define anginal pain as the following:

  1. constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms
  2. precipitated by physical exertion
  3. relieved by rest or GTN in about 5 minutes

patients with all 3 features have typical angina
patients with 2 of the above features have atypical angina
patients with 1 or none of the above features have non-anginal chest pain

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38
Q

How should you manage angina ?

A

Medication:

all patients should receive aspirin and a statin in the absence of any contraindication

NICE recommend using either a beta-blocker or a calcium channel blocker first-line

sublingual glyceryl trinitrate to abort attacks

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39
Q

How can you treat Pulseless electrical activity and asystole?

A

They are non-shockable rhythms and therefore are unresponsive to defibrillation.

The patient should immediately receive 1mg of IV adrenaline whilst continuing high-quality CPR.

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40
Q

For a person < 80, with stage 1 hypertension, only treat medically if:

A

diabetic, renal disease, QRISK2 >10%, established coronary vascular disease, or end organ damage

Otherwise patients with stage 1 are given lifestyle advice

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41
Q

What is Eisenmenger’s syndrome?

A

reversal of a left-to-right shunt in a congenital heart defect due to pulmonary hypertension

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42
Q

Give 5 key features of aortic regurgitation

A
  1. early diastolic murmur: intensity of the murmur is increased by the handgrip manoeuvre
  2. collapsing pulse
  3. wide pulse pressure
  4. Quincke’s sign (nailbed pulsation)
  5. De Musset’s sign (head bobbing)
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43
Q

Outline the acute management of SVT

A

vagal manoeuvres:
- Valsalva manoeuvre: e.g. trying to blow into an empty plastic syringe
- carotid sinus massage

intravenous adenosine
- rapid IV bolus
- 6mg → 12mg → 18 mg escalation if rhythm isn’t terminated

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44
Q

Broad complex tachycardia following a myocardial infarction is almost always due to…

A

ventricular tachycardia

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45
Q

Who should be prescribed a statin?
How should patients be monitored after this prescription?
When should it be discontinued?

A

all people with established cardiovascular disease

anyone with a Q-risk >= 10%

patients with T1DM who were diagnosed > 10 years ago OR are > 40 OR have established nephropathy

Monitoring:
LFTs at baseline, 3 months and 12 months

Treatment should be discontinued if serum transaminase concentrations rise to and persist at 3 times the upper limit of the reference range

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46
Q

Patient presents with poorly controlled hypertension, already taking an ACE inhibitor, calcium channel blocker and a standard-dose thiazide diuretic. K+ > 4.5mmol/l (in normal range). What is the next step?

What about if the potassium is low (< 4.5)?

A

add an alpha- or beta-blocker

K+ < 4.5mmol/l - add spironolactone

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47
Q

How should you manage patients on warfarin with an INR over 5 and minor bleeding?

A

Stop warfarin
Give intravenous vitamin K 1-3mg
Restart warfarin when INR < 5.0

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48
Q

How should you manage patients on warfarin with an INR of 5.0 - 8.0 but no bleeding?

A

Withhold 1 or 2 doses of warfarin
Reduce subsequent maintenance dose

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49
Q

How do you manage patients on warfarin who have a major bleed?

A

Stop warfarin
Give intravenous vitamin K 5mg
Prothrombin complex concentrate

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50
Q

The ORBIT score is now the recommended scoring tool to assess bleeding risk in patients with AF who are being considered for anticoagulation. What are its five parameters?

A
  1. age (75+ years)
  2. anaemia (haemoglobin <130 g/L in males, <120 g/L in females)
  3. bleeding history
  4. renal impairment (eGFR <60 mL/min)
  5. tx with antiplatelets
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51
Q

Acute heart failure not responding to treatment -

A

CPAP

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52
Q

What is the treatment for acute onset heart failure?

A

IV loop diuretics
e.g. furosemide or bumetanide

May add O2
May add vasodilators (not if hypotensive)

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53
Q

How should you treat complete heart block following an inferior MI ?

How would this be different if it was following anterior MI?

A

Atropine - AV block and bradyarrhythmias are usually transient (hours to days) when caused by inferior MI so external pacing is not usually required

Anterior MI is more likely to cause prolonged or permanent arrhythmia so more likely to need external pacing

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54
Q

What is NSTEMI management for patients with a GRACE score > 3% ?

A

coronary angiography within 72 hours of admission, NOT emergency PCI as this is reserved for STEMIs

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55
Q

What type of heart failure can occur with HOCM?

A

HFpEF- Hypertrophic obstructive cardiomyopathy typically causes diastolic dysfunction

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56
Q

Tx for hypertensive emergencies?

A

IV:
1. Sodium nitroprusside
2. Labetalol
3. GTN (1 - 10 mg/hr)
4. Esmolol

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57
Q

Give the major causes of heart failure

A
  1. Ischaemic heart Disease (most common)
  2. Hypertension
  3. Valvular heart disease (Rheumatic fever in elderly)
  4. Atrial fibrillation
  5. Chronic lung disease
  6. Cardiomyopathy (Hypertrophic, dilated and right ventricular, post viral, post-partum)
  7. Previous cancer chemo drugs
  8. HIV
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58
Q

How is infective endocarditis treated?

A

Endocarditis caused by streptococci eg. Viridans streptococci: benzylpenicillin IV (or vancomycin if penicillin-allergic) plus low dose gentamicin

Endocarditis caused by enterococci eg. Enterococcus faecalis: amoxicillin IV (or vancomycin if penicillin-allergic) plus low-dose gentamicin IV

Endocarditis caused by staphylococci eg. Staph. aureus, Staph. Epidermidis: flucloxacillin (or vancomycin if penicillin allergic or MRSA) plus gentamicin

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59
Q

What underlying pathology is indicated by a sawtooth appearance on ECG? What is the most common aetiology?

A

Atrial flutter - a form of supraventricular tachycardia characterised by a succession of rapid atrial depolarisation waves

The most common aetiology for this is re-entry circuits around the tricuspid annulus

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60
Q

What is Brugada syndrome?
How does it appear on ECG? What clinical criterion must it be associated with?

A

A sodium channelopathy which is a cause of sudden death in patients with structurally normal hearts

On ECG: ‘coved’ (concave) ST-segment elevation in V1-V3, followed by T wave inversion

must be associated with one clinical criterion:

  1. documented v fib or polymorphic ventricular tachycardia
  2. family history of sudden cardiac death at <45 years old 3. coved-type ECGs in family members
  3. inducibility of VT with programmed electrical stimulation
  4. syncope
  5. nocturnal agonal respiration
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61
Q

High-output heart failure refers to a situation where a ‘normal’ heart is unable to pump enough blood to meet the metabolic needs of the body.

What can cause this? (AAPPTT)

A

Causes
anaemia (severe)
arteriovenous malformation
Paget’s disease
Pregnancy
thyrotoxicosis
thiamine deficiency (wet Beri-Beri)

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62
Q

How is aortic stenosis managed?

A

If symptomatic, automatically qualifies for AVR surgery

If asymptomatic, the cut-off for surgery is an aortic valve gradient of 40 mmHg

surgical AVR for low/medium operative risk patients
transcatheter AVR for high operative risk patients

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63
Q

Infective endocarditis in intravenous drug users most commonly affects…

A

the tricuspid valve

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64
Q

Why is Hypertrophic obstructive cardiomyopathy associated with sudden death in young athletes?

A

Causes ventricular arrhythmia

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65
Q

How should you treat pulseless VT?

A

a single shock ASAP followed by 2 minutes of CPR

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66
Q

In AF, if a CHA2DS2-VASc score suggests no need for anticoagulation, what is the next step?

A

do an echo to exclude valvular heart disease

67
Q

Wolff-Parkinson White syndrome is caused by a congenital accessory conducting pathway between the atria and ventricles leading to an AVRT. It carries a risk of rapid degeneration into VF.

How does it present on an ECG?
How can it be treated?

A

Possible ECG features include:
short PR interval
wide QRS complexes with a slurred upstroke - ‘delta wave’
left axis deviation if right-sided accessory pathway
right axis deviation if left-sided accessory pathway

definitive treatment: radiofrequency ablation of the accessory pathway
medical therapy: sotalol, amiodarone, flecainide

68
Q

If a patient treated with PCI for MI is experiencing extreme pain or haemodynamic instability in the hours post PCI, what does this suggest? How is it managed?

A

suggests the procedure has failed and that myocardial ischaemia is ongoing

urgent coronary artery bypass graft (CABG) is recommended

69
Q

In ALS, once adrenaline has been initially given, how often should it be repeated ?

A

it should be repeated every 3-5 minutes whilst ALS continues

70
Q

How much of an increase in serum creatinine is acceptable when starting ACEi?

A

An increase in serum creatinine up to 30% from baseline is acceptable

71
Q

New onset LBBB is…

A

always pathological and NEVER normal

72
Q

Cushing’s triad (hypertensive, bradycardic, tachypnoeic with signs of Cheyne-Stokes breathing) is a sign of what?
Associated ECG changes?

A

Brain herniation

widespread T wave inversion, also known as ‘cerebral T waves’ - ‘Global’ T wave inversion (not fitting a coronary artery territory) - think non-cardiac cause of abnormal ECG

73
Q

Give some signs and symptoms of malignant hypertension

A

Papilloedema (must be present before a diagnosis of malignant hypertension can be made)
Retinal bleeding
Increased cranial pressure causing headache and nausea
Chest pain due to increased workload on the heart
Haematuria due to kidney failure
Nosebleeds which are difficult to stop

74
Q

How should you manage a witnessed cardiac arrest while on a monitor?

A

up to three successive shocks before CPR initiated

Example: Deliver three quick successive stacked unsynchronised DC shocks followed by 2 minutes of 30:2 compressions

75
Q

In a newly diagnosed patient with hypertension (> 55 years), what drug should be offered?

A

CCB

76
Q

signs of right-sided heart failure:

A

raised JVP, ankle oedema and hepatomegaly

77
Q

How should T2DM be managed in ACS patients on CCU?

A

Stop other diabetes medications e.g. metformin and convert to IV insulin for tight glycaemic control

78
Q

How should palpitations be investigated after initial bloods/ECG?

A

Holter monitoring

79
Q

It is said that the causes of mitral stenosis are rheumatic fever, rheumatic fever and rheumatic fever!

Give 6 key features it presents with.

A

atrial fibrillation
secondary to ↑ left atrial pressure → left atrial enlargement

dyspnoea
↑ left atrial pressure → pulmonary venous hypertension

haemoptysis
- due to pulmonary pressures and vascular congestion
& ranges from pink frothy sputum to sudden haemorrhage secondary to rupture of dilated bronchial veins

mid-late diastolic murmur (best heard in expiration)
loud S1, opening snap

low volume pulse

malar flush

80
Q

How should mitral stenosis be managed?

A

asymptomatic patients:
monitored with regular echocardiograms
percutaneous/surgical management is generally not recommended

symptomatic patients:
percutaneous mitral balloon valvotomy
mitral valve surgery (commissurotomy, or valve replacement)

81
Q

Causes of pulsus paradoxus? (decrease in bp on inspiration)

A

severe asthma, cardiac tamponade

82
Q

Causes of a collapsing pulse?

A

aortic regurgitation
patent ductus arteriosus
hyperkinetic states (anaemia, thyrotoxic, fever, exercise/pregnancy)

83
Q

What causes a ‘jerky’ pulse?

A

HOCM

84
Q

Give the ECG changes for thrombolysis or percutaneous intervention:

A

ST elevation of > 2mm (2 small squares) in 2 or more consecutive anterior leads (V1-V6) OR

ST elevation of greater than 1mm (1 small square) in greater than 2 consecutive inferior leads (II, III, avF, avL)

OR

New Left bundle branch block

85
Q

What drugs should be considered during CPR if a PE is suspected?

A

Thrombolytics e.g. alteplase

86
Q

What is the STEMI ECG criteria?

A

≥ 2 contiguous leads of:

2.5 mm (i.e ≥ 2.5 small squares) ST elevation in leads V2-3 in men < 40 years, or ≥ 2.0 mm ST elevation in leads V2-3 in men > 40 years

1.5 mm ST elevation in V2-3 in women

1 mm ST elevation in other leads

new LBBB

87
Q

Rupture of the papillary muscle due to a myocardial infarction →

A

acute mitral regurgitation → widespread systolic murmur, hypotension, pulmonary oedema

88
Q

What may exacerbate orthostatic hypotension in day to day life?

A

venous pooling during exercise (exercise-induced), after meals (postprandial hypotension) and after prolonged bed rest (deconditioning)

89
Q

Define syncope

A

Syncope may be defined as a transient loss of consciousness due to global cerebral hypoperfusion with rapid onset, short duration and spontaneous complete recovery.

90
Q

Give reflex (neural) causes of syncope

A

vasovagal: triggered by emotion, pain or stress. Often referred to as ‘fainting’
situational: cough, micturition, gastrointestinal
carotid sinus syncope

91
Q

Give orthostatic causes of syncope

A

primary autonomic failure: Parkinson’s disease, Lewy body dementia
secondary autonomic failure: e.g. Diabetic neuropathy, amyloidosis, uraemia
drug-induced: diuretics, alcohol, vasodilators
volume depletion: haemorrhage, diarrhoea

92
Q

Give cardiac causes of syncope

A

arrhythmias: bradycardias (sinus node dysfunction, AV conduction disorders) or tachycardias (supraventricular, ventricular)
structural: valvular, myocardial infarction, hypertrophic obstructive cardiomyopathy
others: pulmonary embolism

93
Q

Sxs and signs of acute pericarditis?
How should a patient with these features be investigated?

A

sxs:
chest pain: may be pleuritic. Is often relieved by sitting forwards and exacerbated by lying down
non-productive cough, dyspnoea and flu-like symptoms

Signs:
pericardial rub
tachypnoea
tachycardia

transthoracic echocardiography

94
Q

What should be given to patients with bradycardia and signs of shock?

A

Atropine (500mcg IV) is the first line treatment in this situation.

If there is an unsatisfactory response the following interventions may be used:
atropine, up to maximum of 3mg
transcutaneous pacing
isoprenaline/adrenaline infusion titrated to response

95
Q

What are the most common causes of endocarditis?

A

Staphylococcus aureus
Staphylococcus epidermidis if < 2 months post valve surgery

96
Q

What should be done if the blood pressure is >= 180/120 mmHg?

A

admit for specialist assessment if:
- signs of retinal haemorrhage or papilloedema (accelerated hypertension) OR
- life-threatening symptoms such as new-onset confusion, chest pain, signs of heart failure, or acute kidney injury OR
- if a phaeochromocytoma is suspected

if none of the above then arrange urgent investigations for end-organ damage (e.g. bloods, urine ACR, ECG)

97
Q

What is the recommended blood pressure target for type 2 diabetics?
What is the first line drug for achieving this?

A

< 140/90 mmHg

ACE inhibitors/A2RBs are first-line regardless of age

Patients should be treated even with only stage 1 htn

98
Q

How might coarctation of the aorta present in a newborn? Management?

A

Growth failure, tachycardia and tachypnoea in the context of weak femoral pulses

While surgery is the only definitive treatment, IV prostaglandins are used in neonates to maintain a patent ductus arteriosus to allow adequate circulation until it is possible to attempt corrective surgery

99
Q

Persistent ST elevation and left ventricular failure after previous MI is very suggestive of what ?

A

a left ventricle aneurysm

Blood stagnates around a left ventricle aneurysm, thereby promoting platelet adherence and thrombus formation. Embolisation of left ventricular thrombi can lead to embolic stroke or other systemic embolisms.

100
Q

How should AF be managed longer term post stroke?

A

warfarin or a direct thrombin or factor Xa inhibitor

101
Q

Patients should all be offered dual antiplatelet therapy prior to PCI in the form of aspirin and one other anticoagulant. How do you know which anticoagulant to give?

A

Prasugrel is offered if the patient is not taking an oral anticoagulant, whereas clopidogrel is offered if they are.

102
Q

If fibrinolysis is given for an ACS, what is the most appropriate plan regarding revascularisation?

A

Repeat ECG in 60-90 minutes and transfer for urgent PCI if ST-elevation has not resolved

103
Q

A patient develops acute heart failure 5 days after a myocardial infarction. A new pan-systolic murmur is noted on examination →

A

Ventricular septal defect

104
Q

Define stage 1, stage 2 and severe hypertension

A

1: Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg

2: Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg

severe: Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 120 mmHg

105
Q

What drugs can cause Long-QT syndrome ?

A
  • amiodarone, sotalol, class 1a antiarrhythmic drugs
  • tricyclic antidepressants, SSRIs (especially citalopram)
  • methadone
  • chloroquine
  • erythromycin
  • haloperidol and ondanestron
106
Q

First line investigation for stable angina?

A

Contrast-enhanced CT coronary angiogram

107
Q

Concerning features in patient presenting with an abnormal ECG?

A

shock, syncope, myocardial ischaemia or heart failure

108
Q

Occlusion of which coronary artery is more likely to cause arrhythmias? Why?

A

RCA- it supplies the AVN

Right coronary infarcts (e.g. inferior STEMI) can often cause arrhythmias including sinus bradycardia and atrioventricular block.

109
Q

Occlusion of which coronary artery is associated with left ventricular thrombus formation?

A

LAD as this supplies the majority of the left ventricle

A left ventricular thrombus can occur after MI due to ‘stunning’ of the myocardium resulting in blood pooling and clotting.

110
Q

Occlusion of which coronary artery is associated with arrhythmias that originate below the AVN e.g. RBBB?

A

LAD- Anterior MIs

111
Q

Occlusion of which coronary artery is associated with ventricular free wall rupture? (relatively uncommon)

How does it present?

A

LAD- Anterior MIs

Rupture tends to occur within the first few weeks after the event and can present as cardiac tamponade or with cardiac arrest.

112
Q

When should beta blockers be stopped in acute HF?

A

if the patient has heart rate < 50/min, second or third degree AV block, or shock

113
Q

Coarctation of the aorta describes a congenital narrowing of the descending aorta, that is more common in males (despite association with Turner’s syndrome).

What features does it present with?

A

infancy: heart failure
(acute circulatory collapse at 2 days of age when the duct closes- heart failure & absent femoral pulses.)

adult: hypertension

radio-femoral delay
mid systolic murmur, maximal over back
apical click from the aortic valve
notching of the inferior border of the ribs (due to collateral vessels) is not seen in young children

114
Q

What are the key associations of coarctation of the aorta?

A

Turner’s syndrome
bicuspid aortic valve
berry aneurysms
neurofibromatosis

115
Q

In a patient of Black African ethnicity, which is the next step on the tx ladder for htn after CCB?

A

ARB- more effective than ACEi

116
Q

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited CVD which may present with syncope or sudden cardiac death. It is the second most common cause of sudden cardiac death in the young after hypertrophic cardiomyopathy.

What is the inheritance pattern?
How does it present?
What is the classical ECG finding?
Tx?

A

Autosomal dominant

Presentation:
- palpitations
- syncope
- sudden cardiac death

Epsilon wave (a small positive deflection at the end of the QRS complex)
T wave inversion in V1-V3

Tx: sotalol, catheter ablation to prevent vtach, implantable cardioverter-defibrillator

117
Q

What is Buerger’s disease (also known as thromboangiitis obliterans)?

A

a small and medium vessel vasculitis that is strongly associated with smoking, often present in younger people

Features:
extremity ischaemia
- (intermittent claudication and ischaemic ulcers)
superficial thrombophlebitis
Raynaud’s phenomenon

118
Q

Give a major drug interaction for statins

A

macrolides (e.g. erythromycin, clarithromycin) are an important interaction. Statins should be stopped until patients complete the course

119
Q

Which murmur is heard loudest over the apex?

A

Mitral stenosis

120
Q

What are the key ECG features of digoxin toxicity?

A

down-sloping ST depression (‘reverse tick’, ‘scooped out’)
flattened/inverted T waves
short QT interval
arrhythmias e.g. AV block, bradycardia

121
Q

What is the first line investigation for chronic heart failure?

A

All patients with suspected chronic heart failure should have an NT‑proBNP test first-line

if levels are ‘high’ arrange specialist assessment (including transthoracic echocardiography) within 2 weeks
if levels are ‘raised’ arrange specialist assessment (including transthoracic echocardiography) echocardiogram within 6 weeks

122
Q

What can be used to reverse:
1.warfarin
2.unfractionated heparin
3.dabigatran

A
  1. Vit K
  2. Protamine sulphate
  3. Idarucizumab- monoclonal ab
123
Q

Outline NYHA classification for HF

A

NYHA Class I
no symptoms
no limitation: ordinary physical exercise does not cause undue fatigue, dyspnoea or palpitations

NYHA Class II
mild symptoms
slight limitation of physical activity: comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea

NYHA Class III
moderate symptoms
marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms

NYHA Class IV
severe symptoms
unable to carry out any physical activity without discomfort: symptoms of heart failure are present even at rest with increased discomfort with any physical activity

124
Q

Widespread joint hypermobility, skin changes indicated by striae and mitral regurgitation -

A

think collagen disorders e.g. Marfans and Ehlers-Danlos

125
Q

Atrial myxoma is a benign tumour most commonly occurring in the left atrium. How does it present?

A

triad of mitral valve obstruction, systemic embolisation and constitutional symptoms such as breathlessness, weight loss and fever.

126
Q

Asymmetric septal hypertrophy and systolic anterior movement (SAM) of the anterior leaflet of mitral valve on echocardiogram or cMR support what diagnosis?

A

HOCM

127
Q

Myocarditis describes inflammation of the myocardium. How does it present?
What is seen on investigation?

A

Usually young patient with an acute history
Often following viral infection

Chest pain (often sharp) that does not change with position
SOB
Dull heart sounds due to inflamed and thickened myocardium

On investigation:

Bloods:
↑ inflammatory markers,↑cardiac enzymes,↑ BNP
ECG:
tachycardia/arrhythmias
ST/T wave changes including ST-segment elevation and T wave inversion

128
Q

How are murmurs graded?

A

The Levine Scale:
Grade 1 - Very faint murmur, frequently overlooked
Grade 2 - Slight murmur
Grade 3 - Moderate murmur without palpable thrill
Grade 4 - Loud murmur with palpable thrill
Grade 5 - Very loud murmur with extremely palpable thrill. Can be heard with stethoscope edge
Grade 6 - Extremely loud murmur - can be heard without stethoscope touching the chest wall

129
Q

What causes a continuous machine-like murmur?

A

patent ductus arteriosus

130
Q

If a patient presents acutely with muscle weakness and hypotonia as a drug reaction it is most likely to be what?

A

Electrolyte disturbance - hypokalaemia , hypophosphataemia, hypomagnesiaemia e.g. due to potent diuretic

131
Q

What criteria is used for definitive diagnosis of infective endocarditis?

A

Duke criteria

Major criteria:
2 positive blood cultures, persistent bacteraemia, positive serology for known cause of endocarditis

Minor criteria:
predisposing heart condition or IV drug use
fever > 38ºC
vascular phenomena: major emboli, splenomegaly, clubbing, splinter haemorrhages, Janeway lesions, petechiae or purpura
immunological phenomena: glomerulonephritis, Osler’s nodes (pulps of fingers), Roth spots (retina)

132
Q

What valvular abnormality is associated with PKD?

A

Mitral valve prolapse

133
Q

What is Wellen’s syndrome?

A

Critical occlusion of the LAD

ECG finding of deeply inverted or biphasic T waves in V2-3 in a person with the previous history of angina is characteristic.

134
Q

What is a pathological Q wave?

A

Q wave more than 2 small squares broad or deeper than the following R wave , seen in V1-V3

Indicates previous MI in that territory

135
Q

If a patient with AF has a stroke or TIA what should be the anticoagulant of choice? When should it be started?

A

warfarin or a direct thrombin or factor Xa inhibitor

After haemorrhage excluded:
2 weeks later in stroke
Immediately in TIA

136
Q

Rheumatic fever develops following an immunological reaction to recent (2-6 weeks ago) Streptococcus pyogenes infection.

Diagnosis is based on evidence of recent streptococcal infection accompanied by:
2 major criteria
1 major with 2 minor criteria

What are the major and minor criteria?
How is it treated?

A

Major criteria:
erythema marginatum
Sydenham’s chorea: this is often a late feature
polyarthritis
carditis and valvulitis
subcutaneous nodules

Minor criteria:
raised ESR or CRP
pyrexia
arthralgia
prolonged PR interval

Tx: Oral Penicillin V

137
Q

If new BP >= 180/120 mmHg + new-onset confusion, chest pain, signs of heart failure, or acute kidney injury, what should the immediate management be?

A

admit for specialist assessment

138
Q

What are the differentials for a broad complex tachycardia? How would you manage?

A

Regular:
assume ventricular tachycardia (unless previously confirmed SVT with bundle branch block)
loading dose of amiodarone followed by 24 hour infusion

Irregular:
seek expert help. Possibilities include:
atrial fibrillation with bundle branch block - the most likely cause in a stable patient
atrial fibrillation with ventricular pre-excitation
torsade de pointes

139
Q

What are the differentials for a narrow complex tachycardia?

A

Regular:
sinus tachycardia, SVT or atrial flutter

Irregular:
AF

140
Q

Which are the lateral leads?

A

I, aVL +/- V5-6

141
Q

Which drug is contraindicated in VT?

A

Verapamil- may precipitate cardiac arrest!!!

142
Q

In heart failure if the patient has sinus rhythm > 75/min and a LVEF < 35% and have not responded to to ACE-inhibitor, beta-blocker and aldosterone antagonist therapy, what drug should be considered next?

A

Ivabradine

143
Q

Outline acute NSTEMI tx

A

BATMAN
BB
Aspirin 300mg stat dose
Ticagrelor 180mg stat dose
Morphine
Anticoagulant e.g. enoxaparin 1mg/kg BD
Nitrates

144
Q

Give the 6 major complications of MI

A

DREAD

Death
Rupture of septum or papillary muscle
oEdema
Arrythmia and Aneurysm
Dressler’s syndrome

145
Q

What can cause a raised BNP other than HF?

A

tachycardia
sepsis
PE
renal impairment
COPD

146
Q

Immediate management of acute LVF?

A

Pour SOD
pour away IV fluids (stop)
Sit up
O2
Diuretics

147
Q

What is cor pulmonale?
Key causes?
Presentation?
Signs on examination?

A

Right sided HF caused by respiratory disease- pulmonary hypertension means RV has to strain to pump blood against resistance

COPD most common
PE
ILD
CF
Primary pulmonary htn

Early cor pulmonale: asymptomatic or SOB
May also have chest pain, syncope & peripheral oedema

Signs:
Cyanosis
Raised JVP
Peripheral oedema
3rd heart sound and murmur (e.g. pan-systolic in tricuspid regurge)
Hepatomegaly due to back pressure

148
Q

Wha is first line for pharmacological cardioversion in AF?

A

flecainide / amiodarone if there is no evidence of structural or ischaemic heart disease
or
amiodarone if there is evidence of structural heart disease

149
Q

What is needed to diagnose orthostatic hypotension?

A

a drop in BP (usually >20/10 mm Hg) within three minutes of standing

150
Q

3 key symptoms of aortic stenosis?

A

SAD
syncope, angina, dyspnoea on exertion

151
Q

most likely cause of an irregular broad complex tachycardia in a stable patient?

A

AF with bundle branch block

152
Q

Signs of Left Heart Failure?

A

Cyanosis
Tachycardia
Elevated jugular venous pressure
Displaced apex beat
Chest signs: classically bibasal crackles but may also cause a wheeze
S3-heart sound

153
Q

What dose of statin should be given in cardiovascular disease?

A

atorvastatin 20mg for primary prevention, 80mg for secondary prevention

154
Q

How long before planned surgery should warfarin be stopped?

A

5 days

once the person’s INR is less than 1.5 surgery can go ahead

Warfarin is usually resumed at the normal dose on the evening of surgery or the next day if haemostasis is adequate.

155
Q

When should you use rhythm control to treat AF?

A

when there is coexistent heart failure, first onset AF or an obvious reversible cause

156
Q

first-line for patients with atrial fibrillation that are being anticoagulated?

A

DOACs e.g. rivaroxaban

157
Q

Which anti-hypertensive drug should you avoid prescribing in a patient with a poorly controlled Hba1c?

A

thiazides - can worsen glucose tolerance

158
Q

What is the most common cause of death in patients following a myocardial infarction?

A

V fib

159
Q

What abnormality in the heart is the most common cause of Long-QT syndrome?

A

loss-of-function/blockage of K+ channels

160
Q

How should you manage a patient with worsening HF and deranged electrolytes?

A

160mg IV fuoresmide infusion

The patient has cardiorenal syndrome

Increased doses of loop diuretics may be required in patients with poor renal function to ensure sufficient concentration is achieved within the tubules

161
Q

What murmur may HOCM present with?

A

ejection systolic murmur, louder on performing Valsalva and quieter on squatting

(due to subaortic hypertrophy of the ventricular septum resulting in left ventricular outflow tract obstruction and functional aortic stenosis)

162
Q

most common cause of aortic stenosis?

A

younger patients < 65 years: bicuspid aortic valve
older patients > 65 years: calcification

163
Q

DVLA advice post MI ?

A

should not drive for 4 weeks

Y3 Medicine (9 decks)

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