Cardiology Flashcards

Question

which other investigations are required for stable angina?

Answer 1

Physical Examination (heart sounds, signs of heart failure, BMI) ECG FBC (check for anaemia) U&Es (prior to ACEi and other meds) LFTs (prior to statins) Lipid profile Thyroid function tests (check for hypo / hyper thyroid) HbA1C and fasting glucose (for diabetes) Chest xray to investigate for other causes of chest pain and pulmonary oedema Echocardiogram after the event to assess the functional damage CT coronary angiogram to assess for coronary artery disease

Answer 2

Primary PCI (if available within 2 hours of presentation) Thrombolysis (if PCI not available within 2 hours) - injecting a fibrinolytic medication (they break down fibrin) that rapidly dissolves clots. There is a significant risk of bleeding which can make it dangerous. Some examples of thrombolytic agents are streptokinase, alteplase and tenecteplase.

Answer 3

B – Beta-blockers unless contraindicated A – Aspirin 300mg stat dose T – Ticagrelor 180mg stat dose (clopidogrel 300mg is an alternative if higher bleeding risk) M – Morphine titrated to control pain A – Anticoagulant: Fondaparinux (unless high bleeding risk) N – Nitrates (e.g. GTN) to relieve coronary artery spasm Give oxygen only if their oxygen saturations are dropping (i.e. <95%).

Answer 4

GRACE score - 6 month risk of death or repeat MI after having NSTEMI <5% Low Risk 5-10% Medium Risk >10% High Risk If they are medium or high risk they are considered for early PCI (within 4 days of admission) to treat underlying coronary artery disease.

Answer 5

D – Death R – Rupture of the heart septum or papillary muscles E – “Edema” (Heart Failure) A – Arrhythmia and Aneurysm D – Dressler’s Syndrome

Answer 6

post myocardial infarction syndrome 2-3 weeks after by localised immune response causes pericarditis pleuritic chest pain, low grade fever, pericardial rub on auscultation, can cause pericardial effusion ECG - global ST elevation and T wave inversion echo - pericardial effusion raised CRP, ESR managed with NSAIDS and steroids pericardiocentesis to remove fluids

Answer 7

Aspirin 75mg once daily Another antiplatelet: e.g. clopidogrel or ticagrelor for up to 12 months Atorvastatin 80mg once daily ACE inhibitors (e.g. ramipril titrated as tolerated to 10mg once daily) Atenolol (or other beta blocker titrated as high as tolerated) Aldosterone antagonist for those with clinical heart failure (i.e. eplerenone titrated to 50mg once daily) Dual antiplatelet duration will vary following PCI procedures depending on the type of stent that was inserted.

Answer 8

Type 1: Traditional MI due to an acute coronary event Type 2: Ischaemia secondary to increased demand or reduced supply of oxygen (e.g. secondary to severe anaemia, tachycardia or hypotension) Type 3: Sudden cardiac death or cardiac arrest suggestive of an ischaemic event Type 4: MI associated with PCI / coronary stunting / CABG

Answer 9

when left ventricle unableto adequately move blood through left side of heart and out so backlog increases pressure in ledt atrium, pulmonary veins and lungs. they leak fluid and unable to reabsorb it so causes pulmonary oedema, intefering with gas exchange

Answer 10

Iatrogenic (e.g. aggressive IV fluids in frail elderly patient with impaired left ventricular function) Sepsis Myocardial Infarction Arrhythmias

Answer 11

rapid onset breathless exacerbated by lying flat and improves sitting up causes type 1 resp failure SOB cough - frothy white/pink sputum look unwell Chest pain in ACS Fever in sepsis Palpitations in arrhythmias

Answer 12

Increase respiratory rate Reduced oxygen saturations Tachycardia 3rd Heart Sound Bilateral basal crackles (sounding “wet”) on auscultation Hypotension in severe cases (cardiogenic shock) Raised Jugular Venous Pressure (JVP) (a backlog on the right side of the heart leading to an engorged jugular vein in the neck) Peripheral oedema (ankles, legs, sacrum)

Answer 13

ECG ABG chest X ray bloods - routine for infection, kidney function, BNP, troponin echo - ejection fraction should be >50% if normal chest x ray - cardiomegaly, Upper lobe venous diversion. Usually when standing erect the lower lobe veins contain more blood and the upper lobe veins remain relatively small. In LVF there is such a back-pressure that the upper lobe veins also fill with blood and become engorged (referred to as upper lobe diversion). This is visible as increased prominence and diameter of the upper lobe vessels on a chest xray. or Bilateral pleural effusions Fluid in interlobar fissures Fluid in the septal lines (Kerley lines)

Answer 14

hormone released from the hearts ventricles when myocardium is stretched beyond normal range high = heart overloaded with blood BNP - relaxes smooth muscle in blood vessels, reduces systemic resistance, acts on kidneys as a diuretic, reducing circulating volume

Answer 15

Testing for BNP is sensitive but not specific. This means that when negative it is useful in ruling out heart failure, but when positive result can have other causes. Other causes of a raised BNP include: Tachycardia Sepsis Pulmonary embolism Renal impairment COPD

Answer 16

Pour away (stop) their IV fluids Sit up Oxygen Diuretics ay also use IV opiates, NIV CPAP, inotropes -for oedema or cardiogenic shock

Answer 17

chronic version of acute HF due to either impaired LV contraction -systolic HF, or LV relaxation - diastolic HF...chronci back pressure of blood

Answer 18

Breathlessness worsened by exertion Cough. They may produce frothy white/pink sputum. Orthopnoea (the sensation of shortness of breathing when lying flat, relieves by sitting or standing). Ask them how many pillows they use at night. Paroxysmal Nocturnal Dyspnoea (see below) Peripheral oedema (swollen ankles)

Answer 19

fluid settling across a large SA of their lungs as they lie flat, when stand up, sinks to lung bases and upper lungs clear also during sleep the resp centre in the brain becomes less responsive so their resprate does not increase in response to oxygen sats like it would do so hypoxic also less adrenalin during sleep, so myocardium more relaxed worsening CO

Answer 20

clinical diagnosis BNP blood test (specifically “N-terminal pro-B-type natriuretic peptide” – NT‑proBNP) Echocardiogram ECG

Answer 21

Ischaemic Heart Disease Valvular Heart Disease (commonly aortic stenosis) Hypertension Arrhythmias (commonly atrial fibrillation)

Answer 22

Refer to specialist (NT-proBNP > 2,000 ng/litre warrants urgent referral) Careful discussion and explanation of the condition Medical management (see below) Surgical treatment in severe aortic stenosis or mitral regurgitation Heart failure specialist nurse input for advice and support Additional management: Yearly flu and pneumococcal vaccine Stop smoking Optimise treatment of co-morbidities Exercise at tolerated

Answer 23

ACE inhibitor (e.g. ramipril titrated as tolerated up to 10mg once daily) or ARB (avoid ACEi in valvular heart disease) Beta Blocker (e.g. bisoprolol titrated as tolerated up to 10mg once daily) Aldosterone antagonist when symptoms not controlled with A and B (spironolactone or eplerenone) (when reduced EF and sx not controlled by ACEi and BB) Loop diuretics improves symptoms (e.g. furosemide 40mg once daily)

Answer 24

right side HF caused by respiratory disease increased pressure and resistance in pulmonary arteries cuasing pulmonary hypertension so unable to pump out of ventricle..back pressure in RA, vena cava, and venous system

Answer 25

COPD is the most common cause Pulmonary Embolism Interstitial Lung Disease Cystic Fibrosis Primary Pulmonary Hypertension

Answer 26

asx SOB peripheral oedema breathlesness of exertion syncope

Answer 27

Hypoxia Cyanosis Raised JVP (due to a back-log of blood in the jugular veins) Peripheral oedema Third heart sound Murmurs (e.g. pan-systolic in tricuspid regurgitation) Hepatomegaly due to back pressure in the hepatic vein (pulsatile in tricuspid regurgitation)

Answer 28

treat sx and underlying cause long term o2

Answer 29

140/90 in clinic or 135/85 with ambulatory or home readings

Answer 30

essential/primary - no cause (95% of the time) secondary - R – Renal disease. This is the most common cause of secondary hypertension. If the blood pressure is very high or does not respond to treatment consider renal artery stenosis. O – Obesity P – Pregnancy induced hypertension / pre-eclampsia E – Endocrine. Most endocrine conditions can cause hypertension but primarily consider hyperaldosteronism (“Conns syndrome”) as this may represent 2.5% of new hypertension. A simple test for this is a renin:aldosterone ratio blood test.

Answer 31

Ischaemic heart disease Cerebrovascular accident (i.e. stroke or haemorrhage) Hypertensive retinopathy Hypertensive nephropathy Heart failure

Answer 32

measure every 5 yrs to screen more often if borderline for diagnosis every year if have type 2 DM clinic blood pressure between 140/90 mmHg and 180/120 mmHg should have 24 hour ambulatory blood pressure or home readings to confirm the diagnosis measuring blood pressure in both arms, and if the difference is more than 15 mmHg using the reading from the arm with the higher pressure.

Answer 33

Having your blood pressure taken by a doctor or nurse often results in a higher reading. This is commonly called “white coat syndrome”. The white coat effect is defined as more than a 20/10 mmHg difference in blood pressure between clinic and ambulatory or home readings.

Answer 34

Stage Clinic Reading Ambulatory / Home Readings Stage 1 Hypertension >140/90 >135/85 Stage 2 Hypertension >160/100 >150/95 Stage 3 Hypertension >180/120

Answer 35

Urine albumin:creatinine ratio for proteinuria and dipstick for microscopic haematuria to assess for kidney damage Bloods for HbA1c, renal function and lipids Fundus examination for hypertensive retinopathy ECG for cardiac abnormalities

Answer 36

A – ACE inhibitor (e.g. ramipril 1.25mg up to 10mg once daily) B – Beta blocker (e.g. bisoprolol 5mg up to 20mg once daily) C – Calcium channel blocker (e.g. amlodipine 5mg up to 10mg once daily) D – Thiazide-like diuretic (e.g. indapamide 2.5mg once daily) ARB – Angiotensin II receptor blocker (e.g. candesartan 8mg to up 32mg once daily) Angiotensin receptor blockers are used in place of an ACE inhibitor if the person does not tolerate ACE inhibitors (commonly due to a dry cough) or the patient is black of African or African-Caribbean descent

Answer 37

diagnose investigate causes and organ damge advice on lifestyle - diet, smoking, alcohol, caffeine, salt, exercise

Answer 38

All patients with stage 2 hypertension All patients under 80 years old with stage 1 hypertension that also have a Q-risk score of 10% or more, diabetes, renal disease, cardiovascular disease or end organ damage. There are slightly different guidelines for younger patients and those aged over 55 or black: Step 1: Aged less than 55 and non-black use A. Aged over 55 or black of African or African-Caribbean descent use C. Step 2: A + C. Alternatively A + D or C + D. If black then use an ARB instead of A. Step 3: A + C + D Step 4: A + C + D + additional (see below) For step 4, if the serum potassium is less than or equal to 4.5 mmol/l consider a potassium sparing diuretic such as spironolactone. If the serum potassium is more than 4.5 mmol/l consider an alpha blocker (e.g. doxazosin) or a beta blocker (e.g. atenolol). Seek specialist advice if the blood pressure remains uncontrolled despite treatment at step 4.

Answer 39

U and E for hyperkalaemia - ACEi and spirinolactone

Answer 40

Age Systolic Target Diastolic Target < 80 years < 140 < 90 > 80 years < 150 < 90

Answer 41

the closing of AV valves - tricuspid and mitral

Answer 42

closing of semilunar valves - pulmonary and aortic

Answer 43

heard 0.1 seconds after s2 rapid ventricular filling causing the chordae tendineae to pull their full length normal if young (15-40 yrs) - as ventricles easily allow rapid filling older patients - heart failure as ventricles and chordae are stiff and weak so reach limit mcuh faster than normal

Answer 44

heard directly before S1 abnormal and rare indicates stiff or hypertrophic ventricle caused by tubulent flow

Answer 45

bell - low pitched diaphragm - high pitched

Answer 46

Pulmonary: 2nd I.C.S left sternal border Aortic: 2nd I.C.S right sternal border Tricuspid: 5th I.C.S left sternal border Mitral: 5th I.C.S mid clavicular line (apex area) “Erb’s point”. This is in the third intercostal space on the left sternal border and is the best area for listening to heart sounds (S1 and S2).

Answer 47

mitral stenosis

Answer 48

aortic regurg

Answer 49

S – Site: where is the murmur loudest? C – Character: soft / blowing / crescendo (getting louder) / decrescendo (getting quieter) / crescendo-decrescendo (louder then quieter) R – Radiation: can you hear the murmur over the carotids (AS) or left axilla (MR)? I – Intensity: what grade is the murmur? P – Pitch: is it high pitched or low and grumbling? Pitch indicates velocity. T – Timing: is it systolic or diastolic?

Answer 50

Difficult to hear Quiet Easy to hear Easy to hear with a palpable thrill Can hear with stethoscope barely touching chest Can hear with stethoscope off the chest - usually grade 2 or 3

Answer 51

“This patient has a harsh / soft / blowing, Grade …, systolic / diastolic murmur, heard loudest in the aortic / mitral / tricuspid / pulmonary area, that does not / radiates to the carotids / left axilla. It is high / low pitched and has a crescendo / decrescendo / crescendo-decrescendo shape. This is suggestive of a diagnosis of mitral stenosis / aortic stenosis”

Answer 52

left atrial hypertrophy

Answer 53

left ventricular hypertrophy

Answer 54

left atrial dilation

Answer 55

left ventricular dilation

Answer 56

leaky valve allows blood flow back in causing stretching of the muscle

Answer 57

pushing against a stenotic valve, muscle tries harder

Answer 58

Rheumatic Heart Disease Infective Endocarditis

Answer 59

mid diastolic low pitched rumbling due to low velocity of blood flow loud S1 due to thick valves - will be able to palpate it

Answer 60

malar flush - back pressure of blood into pulmonary system so increased CO2 and vasodilation afib - left atrium struggles to pish through stenotic valve causing electrical disruption

Answer 61

congestive cardiac failure because the leaking valve causes a reduced ejection fraction and a backlog of blood

Answer 62

pan-systolic, high pitched “whistling” murmur due to high velocity blood flow through the leaky valve. The murmur radiates to left axilla. You may hear a third heart sound.

Answer 63

Idiopathic weakening of the valve with age Ischaemic heart disease Infective Endocarditis Rheumatic Heart Disease Connective tissue disorders such as Ehlers Danlos syndrome or Marfan syndrome

Answer 64

ejection-systolic, high pitched murmur (high velocity of systole). This has a crescendo-decrescendo character due to the speed of blood flow across the value during the different periods of systole. Flow during systole is slowest at the very start and end and fastest in the middle

Answer 65

murmur radiates to cartoid as turbulence comes to neck slow rising pulse and narrow pulse pressure exertional syncope

Answer 66

Idiopathic age related calcification Rheumatic Heart Disease

Answer 67

early diastolic, soft murmur t can also cause an “Austin-Flint” murmur. This is heard at the apex and is an early diastolic “rumbling” murmur. This is caused by blood flowing back through the aortic valve and over the mitral valve causing it to vibrate

Answer 68

corrigan's pulse - collapsing pulse and is a rapidly appearing and disappearing pulse at carotid as the blood is pumped out by the ventricles and then immediately flows back through the aortic valve back into the ventricles

Answer 69

bioprosthetic - can come from a pig, life of 10 yrs mechanical - life of 20 yrs but require warfarin and INR of 2.5-3.5

Answer 70

starr-edwards tiliting disc valve st jude valve

Answer 71

thrombus infective endocarditis haemolysis causing anaemia

Answer 72

transcatheter aortic valve implantation catheter into femoral artery, feeding under x ray guidance to aortic valve inflate balloon and implant a bioprosthetic valve Long term outcomes for TAVI are still not clear as it is a relatively new procedure. Therefore in younger, fitter patients open surgery is still the first line option. Patient that have a TAVI do not typically require warfarin as the valve is bioprosthetic.

Answer 73

Staphylococcus Streptococcus Enterococcus

Answer 74

where the contraction of the atria is uncoordinated, rapid and irregularly. This due to disorganised electrical activity that overrides the normal, organised activity from the sinoatrial node

Answer 75

absent p waves Narrow QRS Complex Tachycardia Irregularly irregular ventricular rhythm

Answer 76

Irregularly irregular ventricular contractions Tachycardia Heart failure due to poor filling of the ventricles during diastole Risk of stroke

Answer 77

Palpitations Shortness of breath Syncope (dizziness or fainting) Symptoms of associated conditions (e.g. stroke, sepsis or thyrotoxicosis)

Answer 78

afib ventricular ectopics - disappear when HR gets over certain threshold

Answer 79

Valvular AF is defined as patients with AF who also have moderate or severe mitral stenosis or a mechanical heart valve. The assumption is that the valvular pathology itself has lead to the atrial fibrillation

Answer 80

Sepsis Mitral Valve Pathology (stenosis or regurgitation) Ischemic Heart Disease Thyrotoxicosis Hypertension

Answer 81

Rate control- Beta blocker is first line (e.g. atenolol 50-100mg once daily) Calcium-channel blocker (e.g. diltiazem) (not preferable in heart failure) Digoxin (only in sedentary people, needs monitoring and risk of toxicity) rhythm control- cardioversion or long term control

Answer 82

There is reversible cause for their AF Their AF is of new onset (within the last 48 hours) Their AF is causing heart failure They remain symptomatic despite being effectively rate controlled

Answer 83

There is a reversible cause for their AF Their AF is of new onset (<48 hours) Their AF is causing heart failure They remain symptomatic despite being effectively rate controlled

Answer 84

Immediate cardioversion if the AF has been present for less than 48 hours or they are severely haemodynamically unstable. Delayed cardioversion if the AF has been present for more than 48 hours and they are stable (should be anticaoged min of 3 weeks before)

Answer 85

pharmacological - flecanide, amiodarone electrical - sedation or a general anaesthetic and using a defib long term - beta blocker, dronedrone, amidarone

Answer 86

when af comes and goes in episodes not more than 48 hrs anti coagulated based on CHADSVASc score. They may be appropriate for a “pill in the pocket” approach. This is where they take a pill to terminate their atrial fibrillation only when they feel the symptoms of AF starting - only if no stricutal heart disease, usually flecanide used

Answer 87

WITHOUT anticoagulation, patients with AF have around a 5% risk of stroke each year (depending on CHADSVASc score). WITH anticoagulation, patients with AF have around a 1-2% risk of stroke each year (depending on CHADSVASc score). Anticoagulation reduces the risk of stroke by about 2/3.

Answer 88

HAS-BLED score - 3%

Answer 89

vitamin K antagonist. Vitamin K is essential for the functioning of several clotting factors and warfarin blocks vitamin K. It prolongs the prothrombin time, which is the time it takes for blood to clot.

Answer 90

INR - 1 is normal if 2 - twice as long to form a clot target for afib - 2-3

Answer 91

Warfarin is affected by the cytochrome P450 system in the liver. This system is involved in the metabolism of warfarin. The INR will be affected by other drugs that influence the activity of the P450 system. This includes many antibiotics. INR is also affected by many foods such those that contain vitamin K such as leafy green vegetables and those that affect P450 such as cranberry juice and alcohol

Answer 92

Andexanet alfa (apixaban and rivaroxaban) Idarucizumab (a monoclonal antibody against dabigatran)

Answer 93

No monitoring is required No major interaction problems Equal or slightly better than warfarin at preventing strokes in AF Equal or slightly less risk of bleeding than warfarin

Answer 94

higher score - higher risk, if one risk - consider, if more than 1 - offer anticoag CHA2DS2-VASc C – Congestive heart failure H – Hypertension A2 – Age >75 (Scores 2) D – Diabetes S2 – Stroke or TIA previously (Scores 2) V – Vascular disease A – Age 65-74 S – Sex (female)

Answer 95

ORBIT Low haemoglobin or haematocrit Age (75 or above) Previous bleeding (gastrointestinal or intracranial) Renal function (GFR less than 60) Antiplatelet medications or HAS-BLED

Answer 96

Shockable rhythms: Ventricular tachycardia Ventricular fibrillation Non-shockable rhythms: Pulseless electrical activity (all electrical activity except VF/VT, including sinus rhythm without a pulse) Asystole (no significant electrical activity)

Answer 97

Unstable patient: Consider up to 3 synchronised shocks Consider an amiodarone infusion In a stable patient: Narrow complex (QRS < 0.12s) Atrial fibrillation – rate control with a beta blocker or diltiazem (calcium channel blocker) Atrial flutter – control rate with a beta blocker Supraventricular tachycardias – treat with vagal manoeuvres and adenosine Broad complex (QRS > 0.12s) Ventricular tachycardia or unclear – amiodarone infusion If known SVT with bundle branch block treat as normal SVT If irregular may be AF variation – seek expert help

Answer 98

aused by a “re-entrant rhythm” in either atrium. This is where the electrical signal re-circulates in a self-perpetuating loop due to an extra electrical pathway. The signal goes round and round the atrium without interruption. This stimulates atrial contraction at 300 bpm. The signal makes its way into the ventricles every second lap due to the long refractory period to the AV node, causing 150 bpm ventricular contraction

Answer 99

“sawtooth appearance” on ECG with P wave after P wave.

Answer 100

Hypertension Ischaemic heart disease Cardiomyopathy Thyrotoxicosis

Answer 101

Rate/rhythm control with beta blockers or cardioversion Treat the reversible underlying condition (e.g. hypertension or thyrotoxicosis) Radiofrequency ablation of the re-entrant rhythm Anticoagulation based on CHA2DS2VASc score

Answer 102

caused by the electrical signal re-entering the atria from the ventricles. Once the signal is back in the atria it travels back through the AV node and causes another ventricular contraction. This causes a self-perpetuating electrical loop without an end point

Answer 103

fast narrow complex tachycardia (QRS < 0.12). It looks like a QRS complex followed immediately by a T wave, QRS complex, T wave and so on.

Answer 104

“Atrioventricular nodal re-entrant tachycardia” is when the re-entry point is back through the AV node. “Atrioventricular re-entrant tachycardia” is when the re-entry point is an accessory pathway (Wolff-Parkinson-White syndrome). “Atrial tachycardia” is where the electrical signal originates in the atria somewhere other than the sinoatrial node. This is not caused by a signal re-entering from the ventricles but instead from abnormally generated electrical activity in the atria. This ectopic electrical activity causes an atrial rate of >100bpm.

Answer 105

continuous ECG Valsalva manoeuvre. Ask the patient to blow hard against resistance, for example into a plastic syringe. Carotid sinus massage. Massage the carotid on one side gently with two fingers. Adenosine (see below) An alternative to adenosine is verapamil (calcium channel blocker) Direct current cardioversion may be required if the above treatment fails

Answer 106

works by slowing cardiac conduction primarily though the AV node. It interrupts the AV node / accessory pathway during SVT and “resets” it back to sinus rhythm. It needs to be given as a rapid bolus to ensure it reaches the heart with enough impact to interrupt the pathway. It will often cause a brief period of asystole or bradycardia

Answer 107

Avoid if patient has asthma / COPD / heart failure / heart block / severe hypotension Warn patient about the scary feeling of dying / impending doom when injected Give as a fast IV bolus into a large proximal cannula (e.g. grey cannula in the antecubital fossa) Initially 6mg, then 12mg and further 12mg if no improvement between doses

Answer 108

Medication (beta blockers, calcium channel blockers or amiodarone) Radiofrequency ablation

Answer 109

an extra electrical pathway connecting the atria and ventricles. Normally there is only one pathway connecting the atria and ventricles called the atrio-ventricular node. The extra pathway that is present in Wolff-Parkinson White Syndrome is often called the Bundle of Kent.

Answer 110

radiofrequency ablation of accessory pathway

Answer 111

Short PR interval (< 0.12 seconds) Wide QRS complex (> 0.12 seconds) “Delta wave” which is a slurred upstroke on the QRS complex

Answer 112

insert catheter into femoral veins into venous system under x ray, when in heart placed against different areas to test electrical signals The operator may try to induce the arrhythmia to make the abnormal pathways easier to find. Once identified, radiofrequency ablation (heat) is applied to burn the abnormal area of electrical activit - leaving scar tissue which can not conduct

Answer 113

type of polymorphic (multiple shape) ventricular tachycardia. It translates from French as “twisting of the tips”

Answer 114

normal ventricular tachycardia on an ECG however there is an appearance that the QRS complex is twisting around the baseline. The height of the QRS complexes progressively get smaller, then larger then smaller and so on. It occurs in patients with a prolonged QT interval.

Answer 115

When a patient develops Torsades de pointes it will either terminate spontaneously and revert back to sinus rhythm or progress in to ventricular tachycardia. Usually they are self limiting but if they progress to VT it can lead to a cardiac arrest.

Answer 116

Long QT Syndrome (inherited) Medications (antipsychotics, citalopram, flecainide, sotalol, amiodarone, macrolide antibiotics) Electrolyte Disturbance (hypokalaemia, hypomagnesaemia, hypocalcaemia)

Answer 117

Correct the cause (electrolyte disturbances or medications) Magnesium infusion (even if they have a normal serum magnesium) Defibrillation if VT occurs

Answer 118

Avoid medications that prolong the QT interval Correct electrolyte disturbances Beta blockers (not sotalol) Pacemaker or implantable defibrillator

Answer 119

premature ventricular beats caused by random electrical discharges from outside the atria. Patients often present complaining of random, brief palpitations (“an abnormal beat”). They are relatively common at all ages and in healthy patients however they are more common in patients with pre-existing heart conditions (e.g. ischaemic heart disease or heart failure). They can be diagnosed by ECG and appear as individual random, abnormal, broad QRS complexes on a background of a normal ECG.

Answer 120

the ventricular ectopics are occurring so frequently that they happen after every sinus beat. The ECG looks like a normal sinus beat followed immediately by an ectopic, then a normal beat, then ectopic and so on.

Answer 121

Check bloods for anaemia, electrolyte disturbance and thyroid abnormalities Reassurance and no treatment in otherwise healthy people Seek expert advice in patients with background heart conditions or other concerning features or findings (e.g. chest pain, syncope, murmur, family history of sudden death)

Answer 122

type 1 - increased PR until absent QRS type2 -miss QRS but PR normal, risk of asystole 2:1 - 2 P waves for each QRS complex. Every second p wave is not a strong enough atrial impulse to stimulate a QRS complex. It can be caused by Mobitz Type 1 or Mobitz Type 2 and it is difficult to tell which.

Answer 123

NO relationship between P and QRS sig risk of asystole

Answer 124

Stable: Observe Unstable or risk of asystole (i.e. Mobitz Type 2, complete heart block or previous asystole): First line: Atropine 500mcg IV No improvement: Atropine 500mcg IV repeated (up to 6 doses for a total to 3mg) Other inotropes (such as noradrenalin) Transcutaneous cardiac pacing (using a defibrillator) In patients with high risk of asystole (i.e. Mobitz Type 2, complete heart block or previous asystole): Temporary transvenous cardiac pacing using an electrode on the end of a wire that is inserted into a vein and fed through the venous system to the right atrium or ventricle to stimulate them directly Pacemaker

Answer 125

deliver controlled electrical impulses to specific areas of the heart to restore the normal electrical activity and improve the heart function. They consist of a pulse generator (the little pacemaker box) and pacing leads that carry electrical impulses to the relevant part of the heart. The box is implanted under the skin (most commonly in the left anterior chest wall or axilla) and the wires are implanted into the relevant chambers of the heart

Answer 126

Symptomatic bradycardias Mobitz Type 2 AV block Third degree heart block Severe heart failure (biventricular pacemakers) Hypertrophic obstructive cardiomyopathy (ICDs)

Answer 127

single chamber - RA or RV dual chamber - RA and RV triple chamber/CRT - RA, RV, LV

Answer 128

continually monitor the heart and apply a defibrillator shock to cardiovert the patient back in to sinus rhythm if they identify a shockable arrhythmia.

Answer 129

A sharp vertical line in all leads before either the P or QRS but not the other indicates a single-chamber pacemaker A line before both the P and QRS indicates a dual-chamber pacemaker

Answer 130

white lines on ribs

Answer 131

cardiomegaly

Answer 132

In aortic dissection, a pulse deficit may be seen: weak or absent carotid, brachial, or femoral pulse variation in arm BP

Answer 133

most common ECG finding in patients with pulmonary embolism is sinus tachycardia

Answer 134

After starting an ACE inhibitor, significant renal impairment may occur if the patient has undiagnosed bilateral renal artery stenosis

Answer 135

When heart failure becomes severe enough to cause symptoms requiring immediate medical treatment, it is called decompensated heart failure

Answer 136

Prosthetic - vanc, gent, rifampicin

Answer 137

Flutter - saw tooth appearance of baseline, give flecainide Fibrillation - more wavy baseline

Answer 138

Palpitations should first be investigated with a Holter monitor after initial bloods/ECG

Answer 139

Bumetanide is a loop diuretic that is known to cause hypokalaemia

Answer 140

1st line - beta blocker and acei 2nd - add spirinolactone 3rd - add ivabradine or digoxin

Answer 141

There is widespread ST elevation without reciprocal changes and marked PR depression

Answer 142

echocardiogram is the investigation of choice for the diagnosis of heart failure and measurement of left ventricular ejection fractio

Answer 143

IV adenosine is used to manage cases of supraventricular tachycardia. The pulse of these patients is fast and regular

Answer 144

The most commonly affected valve overall is the mitral valve, and the most commonly affected valve in patients who inject drugs intravenously is the tricuspid valve.

Answer 145

not serious - normal in atheletes

Answer 146

Thiazide diuretics work by inhibiting sodium reabsorption at the beginning of the distal convoluted tubule (DCT) by blocking the thiazide-sensitive Na+-Cl− symporter. - hypokalaemia, hyponatraemia

Answer 147

shortening of the QT interval

Answer 148

. In a stable but symptomatic adult patient with aortic stenosis, valve replacement would be the most appropriate treatment.

Answer 149

AF is a kind of type of supraventricular tachycardia But af is irregularly irregular, wheras SVT is regular SVT is very different on ecg on how it looks and also has p wave inversion in II, III avF Both can be treated with flecanide

Answer 150

A period of fast heart rates is often followed by very slow heart rates. When there are periods of both slow and fast heart rates (rhythms) the condition often will be called tachy-brady syndrome With pacemaker

Answer 151

V1 - negative Q (looks like M) V6 - very prominent W in Q wave

Answer 152

Shortness of breath Cough Palpitations

Answer 153

Ivabradine is a class of anti-anginal drug which works by reducing the heart rate. It acts on the If ('funny') ion current which is highly expressed in the sinoatrial node, reducing cardiac pacemaker activity. Adverse effects visual effects, particular luminous phenomena, are common headache bradycardia, heart block There is no evidence currently of superiority over existing treatments of stable angina.

Answer 154

Nicorandil is a vasodilatory drug used to treat angina. It is a potassium-channel activator with vasodilation is through activation of guanylyl cyclase which results in increase cGMP. Adverse effects headache flushing skin, mucosal and eye ulceration gastrointestinal ulcers including anal ulceration

Answer 155

If fibrinolysis is given for an ACS, an ECG should be repeated after 60-90 minutes - then urgent PPCI if not resolved

Answer 156

Orthostatic hypotension can be diagnosed when there is a drop in SBP of at least 20 mmHg and/or a drop in DBP of at least 10 mmHg after 3 minutes of standing

Answer 157

Transoesophageal echocardiography (TOE) may be a useful investigation in clinically unstable patients with a suspected aortic dissection

Answer 158

Rivaroxaban would be offered for haemodynamically stable PE, as DOACs are now increasingly used in PE. However she is hypotensive and tachycardic so this would not be suitable in her case.

Answer 159

if 2-level PE Wells score is ≤ 4 and D-dimer is negative then stop anticoagulation and consider alternative diagnosis

Answer 160

leads 1 and 111 - if reaching for each other - R side devation, if leaving each other - left sided

Answer 161

Long QT syndrome (LQTS) is an inherited condition associated with delayed repolarization of the ventricles. It is important to recognise as it may lead to ventricular tachycardia/torsade de pointes and can therefore cause collapse/sudden death - drugs - amiodarone, haloperidol - acute MI - electrolyte imbalances - hypocalcaemia

Answer 162

Complete heart block is a risk factor for asystole and therefore needs prompt treatment. The most appropriate treatment for this patient is transvenous pacing w

Answer 163

Transoesophageal echocardiography (TOE) may be a useful investigation in clinically unstable patients with a suspected aortic dissection

Answer 164

IV amiodarone is the first-line treatment for regular broad complex tachycardias without adverse features

Answer 165

Antipsychotic medications have a higher probability of causing a prolonged QT interval

Answer 166

ST depression and tall R waves in the anterior leads

Answer 167

staph aureus unless - Staphylococcus epidermidis if < 2 months post valve surgery

Answer 168

New LBBB is always pathological and never normal Important for meLess important This patient is experiencing an ST-elevation myocardial infarction evidenced by the new left bundle branch block on the ECG.

Answer 169

vabradine should be considered 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

Answer 170

NSTEMI management is determined by a risk assessment score such as GRACE - >3%

Answer 171

broad complex - This patient presents with a regular broad complex tachycardia with a palpable pulse and the adverse feature of shock (systolic blood pressure <90mmHg), therefore a synchronised DC cardioversion is indicated. If this patient had no adverse features an intravenous amiodarone infusion would be indicated. narrow complex - Intravenous adenosine and vagal manoeuvres (e.g carotid massage, Valsalva manoeuvre) are indicated for the termination of a regular narrow complex tachycardias.

Answer 172

Takayasu's arteritis is a vasculitic disorder generally affecting young Asian women. It affects the aorta and its branches and causes both systemic features and those specific to which vessels coming off of the aorta are affected. It is associated with renal artery stenosis and so this is the correct answer.

Answer 173

Electrical alternans is a relatively specific but non-sensitive ECG sign of cardiac tamponade. Electrical alternans is characterised by beat to beat variation in QRS amplitude and morphology. This variability is due to the heart 'swinging' in the pericardial fluid.

Answer 174

auto dominant Features often asymptomatic exertional dyspnoea angina syncope typically following exercise due to subaortic hypertrophy of the ventricular septum, resulting in functional aortic stenosis sudden death (most commonly due to ventricular arrhythmias), arrhythmias, heart failure jerky pulse, large 'a' waves, double apex beat

Answer 175

Beta-blockers and calcium channel blockers are first line for rate control in patients with atrial fibrillation. Diltiazem would be the most appropriate drug for rate control in this case because the patient has a background of asthma and beta-blockers are contraindicated.

Answer 176

louder on inspiration v expiration

Answer 177

Beta-blockers combined with verapamil can potentially cause profound bradycardia and asystole.

Answer 178

AV block can occur following an inferior MI

Answer 179

NSTEMI management: patients with a GRACE score > 3% should have coronary angiography within 72 hours of admission

Answer 180

Fludrocortisone increases renal sodium reabsorption and increases the plasma volume. This helps to counteract the physiological orthostatic vasovagal reflex.

Answer 181

Intracranial haemorrhage on warfarin → give IV vitamin K 5mg + prothrombin complex concentrate

Answer 182

no shock - IV loading dose of amiodarone shock - 1 synchronised DC shock

Answer 183

lower left sternal edge louder on inspiration pansysttolic

Answer 184

An inferior myocardial infarction and AR murmur should raise suspicions of an ascending aorta dissection rather than an inferior myocardial infarction alon

Answer 185

mitral aortic

Answer 186

pulmonary tricuspid

Answer 187

short PR intervals

Answer 188

Rivaroxaban for 3 months is correct as the first-line option for treating a provoked PE is a DOAC (such as rivaroxaban) for 3 months.

Answer 189

add amlodipine or nifedipine

Answer 190

horners syndrome cna also cocur

Answer 191

For a patient with hypertension who is already taking an ACE inhibitor, a history of gout would favour a calcium channel blocker over a thiazide as the next step

Answer 192

HOCM may present with ejection systolic murmur, louder on performing Valsalva and quieter on squatting

Answer 193

If shock - hypotension

Answer 194

St elevation

Answer 195

If 48 hrs Or haemodynamically unstable

Answer 196

Widened mediastinum

Answer 197

If k lower than 4.5 - spironooavtone If higher - arb or beta blocker After 4 drugs and not controlled - specialist review

Answer 198

all patients should receive aspirin and a statin in the absence of any contraindication sublingual glyceryl trinitrate to abort angina attacks NICE recommend using either a beta-blocker or a calcium channel blocker first-line based on 'comorbidities, contraindications and the person's preference'

Answer 199

Moderate ro severe aortic stenosis

Answer 200

Widespread ST elevation

Answer 201

Right sided heart failure