Cardiology Flashcards

Question

When can a PCI be given in a STEMI ?

Answer 1

within 12 hours of the onset of pain and are less than 2 hours since first medical contact

Answer 2

A diagnosis needs two of the following. 1. Cardiac chest pain 2. Newly abnormal ECG with non ST elevation 3. Raised troponin.

Answer 3

O - Targeted o2 therapy A - Loading dose PO of aspirin 300mg and fondaparinux N - Sublingual GTN M - IV morphine A - Antithrombin therapy like LMWH or fondaparinux (If immediate angiogram).

Answer 4

Prasugrel or ticagrelor

Answer 5

PO clopidogrel 300mg

Answer 6

Aspirin. Fondaparinux in patients where they are due to undergo angiography.

Answer 7

1. A - Aspirin 75mg OM 2. A - Antiplatelet clopidogrel 75mg OD or ticagrelor 90mg OD. 3. A - Ace inhibitor (Ramipril) 4. B - BB like bisoprolol 5. S - Statin (Atorvastatin 80mg ON) ECO and cardiac rehabilitation

Answer 8

Post MI pericarditis. Patients present with a persistent fever and pleuritic chest pain 2-3 weeks post MI and symptoms generally resolve within a couple of days.

Answer 9

High dose aspirin.

Answer 10

If a patient presents with chest pain less than 10 days post MI, the most useful blood test is CK-MB. This remains elevated only up to 4 days post MI.

Answer 11

Acute mesenteric ischemia

Answer 12

CT abdomen

Answer 13

Lactate (plasma): 0.5 – 2.2 mmol/L

Answer 14

- Constriction like pain in the chest/neck/arm/jaw - Brought on by physical activity - Alleviated by rest or GTN within minutes 2/3 can indicate atypical angina pain.

Answer 15

CT coronary angio

Answer 16

Renal impairment as the contrast can cause contrast induced nephropathy. In this case, myocardial perfusion imaging would be used.

Answer 17

- Conservative management, modification of RF for CV disease - GTN - BB OR - Rate limiting CA channel blocker like Diltiazem or veramapril.

Answer 18

CA channel blocker as BB is CI

Answer 19

When starting GTN, patients should be informed of the side effects (headaches, flushing, dizziness) and to take another dose if the pain has not subsided after 5 minutes. Importantly, emergency help should be sought if the pain has not subsided after 2 doses of GTN as this may indicate acute coronary syndrome.

Answer 20

- BB AND long acting dihydropyridine Ca channel blocker (Amlodipine or felodipine)

Answer 21

- Their symptoms are not satisfactorily controlled on optimal medical treatment AND - There is complex 3 vessel disease or - There is significant left main stem stenosis

Answer 22

Respiratory disease. Pulmonary hypertension causes the right ventricle being unable to efficiently pump blood.

Answer 23

- COPD - PE - ILD - Cystic fibrosis - Primary pulmonary hypertension

Answer 24

- Often patients in early stages are asymptomatic. - Most common is SOB - Peripheral edema - Increased SOB on exertion - Syncope - Chest pain

Answer 25

- Hypoxia - Cyanosis - Raised JVP - Peripheral odema - Pan systolic murmur ( tricuspid regurgitation) - Hepatomegaly

Answer 26

Pan systolic (Tricuspid regurgitation)

Answer 27

- Management of the underlying cause. - Most patients are on long term oxygen therapy.

Answer 28

Myocarditis - Inflammatory disease of the myocardium. Myopericarditis if the pericardium is also inflamed

Answer 29

- Cardiac type chest pain - Fatigue - Symptoms of heart failure

Answer 30

- Signs of heart failure - S3 and S4 gallops - Pericardial rub if pericarditis is associated.

Answer 31

Non specific ST segment and T wave changes. Ectopic beats and arrhythmias can also be present.

Answer 32

- ECHO can reveal ventricular dysfunction if present. - Troponin enzymes can be markedly elevated

Answer 33

endomyocardial biopsy via cardiac catheterization however carries its own risks as an invasive procedure

Answer 34

- Addressing the underlying cause and supportive management - Patients may need vasopressors (used to increase BP) need ICU monitoring. - Viral - Corticosteroids - Advice after recovery is that patients should be advised to limit activity for a few months

Answer 35

In Myocarditis, ST changes are likely to be widespread throughout the leads, whereas in a stemi, they are more likely to be isolated to certain leads.

Answer 36

Clots can become emboli and can cause ischemic stroke.

Answer 37

- Palpitations - SOB - Syncope

Answer 38

Irregularly irregular

Answer 39

- AF and ventricular ectopic ANYONE with this pulse should have an Ecg. In ventricular ectopics, they disappear before the HR gets over a certain threshold.

Answer 40

- Absent P waves - Narrow complex QRS tachycardia - Irregularly irregular ventricular rhythm

Answer 41

Patients with AF that have moderate or severe mitral stenosis or a mechanical heart valve, and that itself has lead to the AF.

Answer 42

**AF effects mrs SMITH** - Sepsis - Mitral valve pathology - Ischemic heart disease - Thyrotoxicosis - Hypertension

Answer 43

Rate and rhythm control

Answer 44

- 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 45

- **First line is BB (Atenolol 50-100mg OD)** - CA channel blocker like Diltiazem (not used in HF) - Digoxin is used in sedentary patients as it needs monitoring and there is a risk of toxicity.

Answer 46

Single cardioversion

Answer 47

if AF has been present for less than 48 hours and severely hemodynamically unstable

Answer 48

if the AF has been present for more than 48 hours and the patient is stable. The patient should be anticoagulated for at least 3 weeks before. The patient should have rate control whilst waiting for cardioversion.

Answer 49

Anticoagulation at least three weeks before.

Answer 50

Flecainide or amiodarone (structural heart disease)

Answer 51

Rapidly shock the heart back into sinus rhythm. The patient is usually sedated/GA and a defib is used

Answer 52

- BB first line - Dronedarone - Maintaining normal rhythm where patients have successful cardioversion - Amiodarone is used in patients with heart failure or LVD.

Answer 53

CHA2DS2-VASc

Answer 54

More than 1

Answer 55

- **C** – **C**ongestive heart failure - **H** – **H**ypertension - **A2** – **A**ge >75 (Scores **2**) - **D** – **D**iabetes - **S2** – **S**troke or TIA previously (Scores **2**) - **V** – **V**ascular disease - **A** – **A**ge 65-74 - **S** – **S**ex (female)

Answer 56

Vitamin K antagonist and prolongs PT time

Answer 57

INR is used to assess how anticoagulated a patient is. It measures how the PT time of the patient compares with that of the PT time in a normal healthy adult.

Answer 58

- INR 1 = Normal PT time - INR 2 = PT time 2x that of healthy adult (2x as long to form a blood clot.

Answer 59

- Warfarin requires close monitoring of patients INR and dose adjustments to keep within range. - Target INR for AF = 2-3 - INR of warfarin is effected by foods that contain vitamin K like green veg, and those that affect p450 like cranberry juice, alcohol and antibiotics.

Answer 60

- Apixaban (2D), dabigatran (2D) Rivaroxaban (OD) - Short half lives - Advantages include - No monitoring is needed, no major interactions.

Answer 61

orbit tool or HAS - BLED.

Answer 62

- **H** – **Hypertension - **A** – **Abnormal renal and liver function - **S** – **Stroke - **B** – **Bleeding - **L** – **Labile INRs (whilst on warfarin) - **E** – **Elderly - **D** – **Drugs or alcohol

Answer 63

- Increased risk of morbidity and mortality from all causes - Heart failure - Renal failure -CAD - Stroke - Peripheral vascular disease.

Answer 64

Also assess for end organ damage including urine dip, blood glucose, RFT, fundoscopy and ECG for LVH.

Answer 65

Over stage 2 hypertension (140> syst AND 90> DIA) Or Stage 1 hypertensive patients who are <80 years old with end organ damage, CVS disease, renal disease, diabetes or 10-year CVS risk >10%

Answer 66

- Weight loss - Healthy diet (reduce salt and saturated fats) - Reduce alcohol and caffeine - Reduce stress - Stop smoking

Answer 67

ACE inhibitor like Ramipril. If unable to tolerate ARB like candesartan

Answer 68

It causes a DRY cough

Answer 69

CA channel blocker like amlodipine

Answer 70

Add in the opposing drug

Answer 71

Add thiazide-like diuretic (e.g. Indapamide)

Answer 72

- If blood potassium <4.5mmol/L then add **Spironolactone** - If >4.5mmol/L **increase thiazide-like diuretic dose**

Answer 73

Peripheral edema. If cannot be tolerated, take an ACE inhibitor instead.

Answer 74

PR interval > 200ms (5MM)

Answer 75

- High vagal tone (Athletes) - Acute inferior MI - Hyperkaliemia - Drugs - BB, Digoxin, cholinesterase inhibitors. - Prolonged PR - RCAD Caused by prolongation of electrical activity through the AV node.

Answer 76

- Does not need managed as benign - Any underlying pathological findings should be reversed

Answer 77

- Lengthening PR intervals that eventually results in a dropped beat where the P wave fails to conduct QRS.

Answer 78

- Inferior MI - Drugs like BB/Ca channel blockers and digocin - Professional athletes - Myocarditis - Cardiac surgery

Answer 79

- Constant PR interval - Intermittent unconducted P waves. - Usually a conduction system failure - usually in a pattern 2:1/3:1 ect

Answer 80

- Usually does not require treatment if asymptomatic. - If symptomatic - ECG monitoring, exclusion of any drugs and atropine if bradycardia

Answer 81

Permanent pacemaker

Answer 82

- Anterior MI - Surgery (Mitral valve repair) - Inflammatory/autoimmune - RHD, SLE, SSM - Fibrosis - Sarcoidosis, haemochromatosis - BB, CA channel blockers, amiodarone, digoxin.

Answer 83

Permanent pacemaker

Answer 84

ECG shows dissociation between the P waves and the QRS complexes.

Answer 85

Can be caused by a combination of BB and Ca channel blockers. In conjunction can cause AV block. Donepezil used in Alzheimer's can cause complete heart block. Can be caused by Lyme disease

Answer 86

- Syncope or cardiac arrest - Severe Bradycardia

Answer 87

- Ventricular tachycardia (Without a pulse) - Ventricular fibrillation Make sure look over structures on notion

Answer 88

- Randomized waveform. - Hill like structure

Answer 89

- Pulseless electrical activity (Apart from VF/VT) - Asystole

Answer 90

- CPR - Adrenaline 1mg IV - Adrenaline 1mg IV every 3-5 mins during 2 alternate loops of CPR - NO SHOCK

Answer 91

- Narrow QRS - Sawtooth pattern

Answer 92

- COPD - Obstructive sleep apnoea - PE - Pulmonary hypertension - IHD - Valvular heart disease (Mitral stenosis) - Sepsis - Alcohol - Cardiomyopathy - Thyrotoxicosis

Answer 93

- Can be asymptomatic - Palpitations - Dizziness - Chest pain

Answer 94

- Rate control with BB and Ca channel blockers Direct current synchronized cardioversion

Answer 95

managed with direct current synchronised cardioversion

Answer 96

shock syncope chest pain pulmonary odema

Answer 97

- shortened pr interval - delta waves - widened qrs

Answer 98

- can be asymptomatic - palpitations - dizziness - SOB - tachycardia

Answer 99

radiofrequency ablation of the accessory pathway - vagal moves can be trialled - amiodarone can be trialled for rate and rhythm control

Answer 100

- Digoxin and Veramapril.

Answer 101

urgent DC cardioversion.

Answer 102

polymorphic ventricular tachycardia

Answer 103

- twisting isoelectric line - prolonged QTc interval

Answer 104

- Toxins - Clarithromycin/mycin suffix (Antibiotic) , anti arrhythmic TCAs ect - Anti psychotics like haloperidol. Patients will have a PMH of schizophrenia and often new commencement of a drug. - Inherited - Congenital long QT syndromes - Ischemia - Myocarditis - Mitral valve prolapse - Electrolyte abnormalities (Hypokalaemia and hypocalcaemia like in acute pancreatitis ) - SAH

Answer 105

- IV magnesium sulphate 2g over 10 minutes

Answer 106

DC cardioversion

Answer 107

Ventricular ectopic are premature ventricular beats that are often caused by random electrical discharges from outside the atria. Patients often complain of random and brief palpitations

Answer 108

They present as abnormal QRS complexes on a background of a normal ECG. In normal healthy patients, treatment is not needed.

Answer 109

- Hypothyroidism - Electrolyte abnormalities - BB overdose - Ca channel overdose - Sinus/AV node abnormalities

Answer 110

- Iv atropine (500 mcg) after assessment via ABCDE and can be given up to 3mg in boluses.

Answer 111

If a patient presents with symptomatic bradycardia (adverse effects e.g syncope)

Answer 112

- Glucagon before transcutaneous pacing

Answer 113

HIGH VIS Hypertension Infection/immune states Genetic Heart attack Volume overload Infiltration Structural

Answer 114

- Dyspnoea on exertion - Fatigue - Orthopnoea (pillows to reduce symptoms) - PND - attacks of severe SOB in the night relieved by sitting up. - Nocturnal cough with or without characteristic - Pink frothy sputum - Reduced appetite - Pre syncope/syncope - PMH - HTN - CAD - valvular heart disease (common causes) - FHX - Cardiomyopathy or CAD - CHF - RF like smoking, excess alcohol and rec drug use - DHX - Ca antagonists, antiarrhythmics, cytotoxic medication and BB.

Answer 115

- Orthopnoea (pillows at night) - PND - attacks of SOB in the night relieved by sitting up - Pink frothy sputum

Answer 116

- Raised JVP - Hypotension - LVH - displaced apex beat - Tachycardia at rest - Gallop rhythm on auscultation (pathognomic in CHF) - Pedal and ankle odema - Narrow pulse pressure - Murmurs associated with valvular heart disease - Ejection systolic murmur in aortic stenosis. P pulmonary - Tall, peaked P waves on ECG trace and reflects right atrial enlargement in right sided heart failure.

Answer 117

- Gallop rhythm

Answer 118

ejection systolic murmur

Answer 119

- Tachypnoea - Bibasal end inspiratory crackles and wheeze on auscultation of the lung fields - pul odema - Reduced air entry and stony dullness to percussion (pleural effusion)

Answer 120

reduced air entry Stony dullness to percussion

Answer 121

- Tachycardia - AF - LAD - LVH - Lead 1 is +, lead 2 and 3 and avf is negative - Prolonged PR due to AV block -Q waves due to previous MI

Answer 122

+ in L1 _ in L 2,3 and avf

Answer 123

Should be measured in all patients presenting with symptoms and clinical signs of heart failure to inform the type and urgency of ECHO.

Answer 124

NT-proBNP level >2000 ng/L – refer urgently for specialist assessment and transthoracic echocardiography within 2 weeks NT-proBNP level 400-2000ng/L – refer routinely for specialist assessment and transthoracic echocardiography within 6 weeks

Answer 125

Hyponatraemia due to fluid overload

Answer 126

ECHO Cardiac MRI is the gold standard investigations when assessing ventricular mass, volume and wall motion. It is typically used when ECHO has provided inadequate views. CXR

Answer 127

- Alveolar oedema (bat wing opacification) - Kerley B lines - Cardiomegaly - Dilated upper lobe vessels - Effusions Fluids in the horizontal fissure

Answer 128

LVEF is the percentage of blood that enters the left ventricle in diastole that is subsequently pumped out in systole. measured using ECHO

Answer 129

Lifestyle management - Fluid and salt restriction - Regular excersise - Smoking cessation - Reduced alcohol intake - Vaccination for influenza and pneumococcal disease - Medication review for medications that can make HF worse, Ca channel blockers, TCA, lithium, NSAIDS, cox-2 inhib ect - Monitoring - Management of co-morbidities - CAD - may be prescribed statins and aspirin. - AF

Answer 130

Below 55 percent

Answer 131

Furosemide - increase NA excretion and reduce cardiac afterload (note, monitor renal function)

Answer 132

- All patients with CHF and a reduced ejection fraction (≤40%) should be commenced on an ACE inhibitor unless contraindicated (pril) - ACE inhibitors have been shown to improve ventricular function and reduce mortality.

Answer 133

ARB like candesartan should be prescribed as an alternate to ACE inhib if not tolerated due to cough ect

Answer 134

Contraindications include a history of angioedema, bilateral renal artery stenosis, hyperkalaemia (>5 mmol/L), severe renal impairment (serum creatinine >220 μmol/L) and severe aortic stenosis.

Answer 135

BB should be prescribed in all patients with LVEF less than 40 and symptomatic heart failure. Bisproprolol.

Answer 136

include asthma, 2nd or 3rd degree AV block, sick sinus syndrome and sinus bradycardia.

Answer 137

- Arrhythmia - AF and ventricular arrhythmia. - Depression and impaired quality of life - Loss of muscle mass - Sudden cardiac death.

Answer 138

- Syncope - Angina - Dyspnoea Also associated with heart failure, excertional dyspnoea and decreased excersise tolerance.

Answer 139

Ejection systolic murmur that is heard loudest over the aortic area (over the 2nd intercostal space) and radiates to the carotid arteries.

Answer 140

-Ejection systolic murmur heart loudest over the aortic valve and radiates to the carotid artery. - s2 may be quiet or absent due to radiation to the carotid - Pulse is slow rising and narrow pulse pressure - heaving apex beat that is non displaced (LVH) - Murmur is loudest on expiration and when the patient is sitting forward

Answer 141

CT angio Cardiac MRI ECG - to look for LVH.

Answer 142

LVH is a common sign of aortic stenosis. It is commonly diagnosed by the S wave depth in V1 + tallest R wave height in V5-V6 > 35 mm

Answer 143

- All patients with symptomatic aortic stenosis - Asymptomatic patients with LVEF < 50 - Asymptomatic patients with an LVEF > 50% who are physically active, and who have symptoms or a fall in blood pressure during exercise testing - Asymptomatic patients with an LVEF > 50% who have the following risk factors - Aortic valve peak velocity > 5.5m/s - Markedly elevated BNP levels without other explanation - Severe pulmonary hypertension (pulmonary artery systolic pressure > 60mmHg)

Answer 144

SAVR and TAVR

Answer 145

Mechanical - ADV lasts longer and is unlikley to be rejected however patients need warfarin which requires INR monitoring.

Answer 146

Biologics - No anticoagulation is needed but cant be used in the immunosuppressed and is less sustainable.

Answer 147

A TAVI can be used in patients that are not fit for surgery. Usually patients older than 75, previous heart surgery, frailty, restricted mobility, severe comorbidities ect.

Answer 148

Patients that are not fit for surgery, should have regular follow up. Severe every 6 months, every onve 1 year if moderate

Answer 149

Aortic sclerosis is an asymptomatic condition that can be incidentally revealed through physical examination or ECHO. It is caused by age related senile degeneration of the valve.

Answer 150

Classic examination findings are an ejection systolic murmur that does not radiate to the carotids. Cardiovascular examination is normal.

Answer 151

- IVDU - Valve replacement - Pacemakers

Answer 152

Can be classified as left sided which is more common (aortic/mitral) or right sided (pulmonary/tricuspid). - Can be prostetic valve, which is more serious with worse prognosis and native valve endocarditis.

Answer 153

- Transient bacteraemia - Damage to valvular tissue - formation of vegetations Bacteria often enters the bloodstream, often by things like dental infections, IV drug use ect.

Answer 154

Endocarditis in patients with prosthetic valves, acute endocarditis and intravenous drug use.

Answer 155

No causative organism is found from standard blood culture methods. This is often due to patients having antibiotic therapy prior to blood cultures being taken. You may need serology to identify them.

Answer 156

- HACEK organisms - *Coxiella burnetti* (Q fever) - Chlamydia spp - Bartonella spp (trench fever and cat-scratch disease) - Legionella

Answer 157

- IVDU - Invasive procedures like central lines - Poor oral hygiene/infections _ valvular stenosis or regurgitation - Hypertrophic cardiomyopathy - Previous infection causing structural damage

Answer 158

- Systemic features of infection (fever, malaise, night sweats, weight loss) - Anaemia symptoms ( fatigue and SOB) - Other symptoms associated with symptoms like emboli and mesenteric ischaemia

Answer 159

- - Fever and tachycardia - New or changing heart murmur - Splinter haemorrhages - Oslers nodes - Tender subcutaneous nodules in the fingers - Janeway lesions - Painless erythematous macules on the palms. - roth spots - Clubbing (late sign) - Mild splenomegaly - Bi basal lung crepitations (HF in severe cases)

Answer 160

May have first degree heart block, which is a finding of aortic root abscesses, a rare complication of IE ( 5 small boxes = 20s). This measurement should be 0.12-0.20 seconds, or 3-5 small squares in duration

Answer 161

This measurement should be 0.12-0.20 seconds, or 3-5 small squares in duration

Answer 162

Blood cultures - Should be done ideally prior to starting antibiotic therapy. Three sets of blood cultures at least 30 mins apart from three separate sites.

Answer 163

- Basic obs - Look for signs of infection like fever or tachycardia. - Urine dipstick to look for microscopic haematuria. - FBC - WCC and HB monitoring - CRP and ESR - Urea and electrolytes - baseline as well as needed if the patient is going to be starting gentamycin as it is nephrotoxic.

Answer 164

Trans thoracic echo which should be performed as soon as suspected to look for vegetation.

Answer 165

If ECHO is clear, a transoeophageal ECHO can be arranged. Patients can also undergo CXR and CT abdomen.

Answer 166

- **Direct** **evidence** of infective endocarditis by **histology** or **culture** of organisms (e.g. from a vegetation) - **TWO** major criteria - **ONE** major + **THREE** minor criteria - **FIVE** minor criteria

Answer 167

- **ONE** major and **ONE** minor criterion - **THREE** minor criteria

Answer 168

Positive for typical organisms (Strep bovis, Staph aureus, community aquired enterococci) Persistently positive cultures Single positive culture for coxiella burnetti Evidence of endocardial involvement like intra cardiac vegitation, abscess, new valvular regurgitation or new partial dehiscence of prostetic valve.

Answer 169

Risk factors for infective endocarditis (see risk factors section) Fever > 38oC Vascular phenomena: septic emboli, Janeway lesions, conjunctival haemorrhage, intracranial haemorrhage Immunological phenomena: glomerulonephritis, Osler’s nodes, Roth spots, positive rheumatoid factor Microbiological evidence: positive blood cultures which do not meet the major criteria

Answer 170

Mainstay - prolonged course of IV antibiotics for at least two weeks before switching to oral preparations

Answer 171

at least 6 weeks

Answer 172

Start of antibiotic course is taken from the first day a negative set of blood cultures are taken. regardless of if antibiotics have been started before

Answer 173

Start of antibiotic course is taken from the first day a negative set of blood cultures are taken. regardless of if antibiotics have been started before

Answer 174

- Heart failure - Uncontrolled infection - PE and large vegitations - Increased PR interval and aortic root abscesses

Answer 175

Mesenteric ischaemia - complication of septic emboli. Gold standard is CT angio

Answer 176

Mesenteric ischaemia - complication of septic emboli. Gold standard is CT angio

Answer 177

- Emboli (e.g. stroke, splenic infarction) - Immune complex deposition (e.g. glomerulonephritis) - Septicaemia - Death

Answer 178

- Valve destruction - Heart failure (secondary to valve regurgitation) - Arrhythmias and conduction disorders (e.g. AV block) - Myocardial infarction - [Pericarditis](https://geekymedics.com/pericarditis/) - Aortic root abscess - Mesenteric ischaemia - complication of septic emboli. Gold standard is CT angio

Answer 179

Failure of the heart to generate sufficient CO to meet the metabolic demands of the body. Heart output is normal, but there is an increase in peripheral metabolic demands. Seen in pregnancy, thiamine deficiency, anaemia, AVN malformation and pagets.

Answer 180

- Raised JVP - Ascities - Fatigue - Pitting ankle odema and sacral odema - Bilateral pleural effusions - Weight gain - usually secondary to chronic pulmonary problems like COPD as they cause pulmonary hypo perfusion.

Answer 181

New york heart association classification of heart failure. - Class I - no limitation in physical activity, and activity does not cause undue fatigue, palpitation or dyspnoea. - Class II - slight limitation of physical activity, and comfort at rest. Ordinary physical activity causes fatigue, palpitation and/or dyspnoea. - Class III - marked limitation in physical activity, but comfort at rest. Minimal physical activity causes fatigue (less than ordinary). - Class IV - inability to carry on any physical activity without discomfort, with symptoms occurring at rest. If any activity takes place, discomfort increases.

Answer 182

Cardiac MRI

Answer 183

- <40% = heart failure is reduced ejection fraction - Greater than 40% but raised BNP = Heart failure with preserved ejection fraction

Answer 184

Furosemide for symptom relief and conservative management of risk factors.

Answer 185

- Furosmide - BB - ACE (ARB) if not tolerated due to cough.

Answer 186

If a patient has persistent symptoms and is new york classification 3/4, consider an alternate like aldosterone agonists (spirnolactone) or ivadarabrine if already on enadebrine

Answer 187

- Sit upright - O2 therapy - IV furosemide (40mg or more) and fluid balance. - SC morphine

Answer 188

Spirnolactone

Answer 189

ICD should be considered in all patients with a reasonable quality of life and poor LVEF despite optimum medical therapy. Also should be considered in patients with previous episodes of VF or VT

Answer 190

Iron storage disorder that results in excessive total body iron and the deposition of iron in tissues

Answer 191

Usually due to mutation in HFE gene on chromosome 6. Autosomal recessive.

Answer 192

- Chronic fatigue - Joint pain - Bronze/slate grey pigmentation. - Hair loss - Erectile dysfunction - Amenorrhoea - Cognitive symptoms

Answer 193

- Main : serum ferritin. - Transferrin saturation is helpful in distinguishing between a high ferritin caused by iron overload (high) or due to other causes like inflammation or NAFL. - Liver biopsy with perls stain - iron conc in parechymal cells - CT abdo and MRI for liver deposits of iron.

Answer 194

High serum ferritin and high Transferrin saturation with no other reason = genetic testing

Answer 195

- T1D - Liver cirrhosis - Iron deposits in the pituitary and gonads - Cardiomyopathy - Hepatocellular carcinoma - Hypothyroidism - Chondrocalcinosis/pseudogout

Answer 196

- Venesection - removal of blood to decrease total body iron - Serum ferritin monitoring - Alcohol avoidance - Genetic counselling - Monitoring and treatment of complications.

Answer 197

Massive PE when thrombolysis is CI

Answer 198

DOAC like apixaban

Answer 199

used in patients with renal failure in preference to DOAC. This is due to poor renal clearance. Also preferred in patients with a history of cancer

Answer 200

IV ateplase (thrombolysis)

Answer 201

History of stroke

Answer 202

2-3 increased to 3-4

Answer 203

Diagnostic imaging is required. LMWH should be administered if clinical suspicion is high. PE is very likley

Answer 204

D dimer should be carried out. PE is less likely

Answer 205

Wells score

Answer 206

Pregnancy Renal impairment Allergies

Answer 207

This is typically normal in PE but possible findings include Fleischner sign (an enlarged pulmonary artery), Hampton's hump (a peripheral wedge shaped opacity), and Westermark's sign (regional oligaemia). The chest x-ray is helpful in ruling out differentials (e.g. pneumonia, pneumothorax).

Answer 208

This is typically normal in PE but possible findings include Fleischner sign (an enlarged pulmonary artery), Hampton's hump (a peripheral wedge shaped opacity), and Westermark's sign (regional oligaemia). The chest x-ray is helpful in ruling out differentials (e.g. pneumonia, pneumothorax).

Answer 209

T1RF and or resp alkalosis

Answer 210

Important if the patient is started on LMWH or Warfarin

Answer 211

Classic Q3S1T3 sign is only present in 20 percent of presentations. May also be signs of right sided heart strain Lg S wave in L1 Inverted T wave in L3 Q wave in Lead 3 or can be sinus tachycardia

Answer 212

- Tachypnoea - Tachycardia (sometimes the only presenting symp) - Hypoxia - Low grade pyrexia - Small - Asymptomatic - Large - Hypotension, cyanosis, signs or RSHS - Calves - Tenderness that may indicate a DVT

Answer 213

- Sudden onset SOB - Pleuritic chest pain - Haemoptysis

Answer 214

Aspirin Atorvastatin Bisopolol Ramipril Clopidogrel

Answer 215

Due to the risk of emboli dislodging and causing a stroke.

Answer 216

AF or ventricular ectopics.

Answer 217

- Often incidental - SOB -Syncope - Symptoms of complications - stroke, sepsis or thyrotoxicosis.

Answer 218

- Absent P waves - Narrow QRS complex tachycardia - Irregularly irregular ventricular rhythm.

Answer 219

S - sepsis M - Mitral valve pathology I - IHD T - Thyrotoxicosis H - Hypertension

Answer 220

First line (rate control - BB like atenolol 50/100mg OD) Ca channel blocker (not in HF) Digoxin - Only in sedentary patients.

Answer 221

Immediate - If AF has been present for less than 48 hours or very haemodynamically unstable. Delayed - If the AF has been present for more than 48 hours and they are stable. The patient should be anti-coagulated for at least 3 weeks prior to the cardio-version - 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 222

Cardiac tamponade is where a pericardial effusion is large enough to raise the intra pericardial pressure. This leads to reduced filling during diastole.

Answer 223

- Transudative effusion - CHF or pulmonary hypertension - Exudative effusions - (inflammatory ) like in infection, autoimmune and inflammatory conditions, injury to the pericardium (after an MI), uraemia, cancer and certain medications like methotrexate. Rupture of the heart of the aorta can cause rapid onset cardiac tamponade like MI, type A aortic dissection and trauma.

Answer 224

A rapidly collecting effusion with cardiac tamponade can quickly cause haemodynamic compromise and collapse. Slowly developing, chronic effusions, may initially be asymptomatic. As the pressure rises, symptoms can develop which may include - Chest pain - SOB - Feeling of fullness in the chest - Orthopnoea

Answer 225

- Phrenic nerves compression may cause hiccups. - Oesophageal nerve may cause dysphagia. - Recurrent laryngeal nerve compression - Hoarse voice.

Answer 226

- Quiet heart sounds - Fall in BP on inspiration - HYPOTENSION - Raised JVP - Fever with pericarditis and pericardial rub

Answer 227

Gold standard investigation (ECHO) Fluid analysis to determine the underlying cause

Answer 228

Symptoms of a stroke that resolve within 24 hours. Ischaemia without infarction. Often precede a full stroke.

Answer 229

Two or more TIAs in a week. This carries a risk of developing into a stroke.

Answer 230

- Aspirin 300mg daily. - Secondary prevention for CVD. - 24 hours to see stroke specialist.

Answer 231

- Sudden weakness of limbs - Sudden facial weakness - Sudden onset dysphasia (speech disturbance) - Sudden onset visual or sensory loss

Answer 232

ROSIER TOOL (stroke is likely in patients with a score over 0 )

Answer 233

- CVD like angina, PVD or MI - Previous stroke or TIA - AF - CAD - Hypertension - Smoking and diabeties - Vasculitis - Combined contraceptive pill

Answer 234

- Admit to a specialist stroke centre - Exclude hypoglycaemia - CT brain - Aspirin 300mg STAT and continue for 2 weeks.

Answer 235

- Thrombolysis with **ateplase** can be used after CT brain has excluded intracranial haemorrhage. - Thombectomy can be offered if an occlusion is confirmed on imaging. Not used after 24 hours of the symptoms starting. - Diffusion weighted MRI - Carotid USS for carotid stenosis - Endarterectomy to remove plaques or carotid stenting.

Answer 236

- Clopidogrel 75mg OD - Atorvastatin 80 mg (not straight away) - Carotid endererectomy or stenting in patients with CAD - Treat modifiable RF like hypertension and diabeties. - Stroke rehabilitation if needed.

Answer 237

Pulmonary hypertension is increased resistance and pressure of the blood in the pulmonary arteries.

Answer 238

Causes right sided heart strain and right ventricular hypertrophy.

Answer 239

- LSHF COPD PVD sarcoidosis, SLE Can be primary

Answer 240

- SOB is the main presenting symptoms - Syncope - Tachycardia - Hepatomegaly - peripheral odema. - Raised JVP.

Answer 241

Shows right sided heart strain ( seen as larger R waves on the right sided chest leads (V1-3) and S waves on the left sided chest leads (V4-6), RAD and RBBB.

Answer 242

CXR will show right ventricular hypertrophy and dilated pulmonary arteries. Raised NT-proBNP and ECHO will show raised pulmonary artery pressure

Answer 243

- IV prostanoids like epoprostenol - Endothelin receptor antagonists like macitentan - Phosphodiesterase 5 inhib like sidenafil

Answer 244

managing the underlying cause like PE or SLE.

Answer 245

- - Infective causes - Viruses (HIV, coxsackie ect) - Bacteria - Staphylococcus, pneumococcus, streptococcus, TB ect - Malignant causes (lung, breast and hodgkin lymphoma) - Cardiac causes (HF), dresslers syndrome. - Drugs and toxin causes - Radiation - Rheumatological disease like SLE, RA ect - Renal failure - IBD ect

Answer 246

- Pleuritic chest pain - worse on lying flat - Fever - Pericardial friction rub - ECG changes (saddle shaped ST elevation, PR depression) - Raised troponin

Answer 247

- 1-3 weeks: normalisation of ST changes, T wave flattening - 3-8 weeks: flattened T waves become inverted - 8+ weeks: ECG returns to normal Saddle shaped ST elevation and PR depression

Answer 248

- ECG - Troponin - ECHO - Angiogram - Normal coronary arteries that excludes an MI

Answer 249

Exercise restriction and NSAIDS. Colchicine in patients with hepatic or renal impairment.

Answer 250

Corticosteroids

Answer 251

Bacterial causes are treated with intravenous antibiotics and pericardiocentesis if purulent exudate present.

Answer 252

Although rare, cardiac tamponade and pericardial effusion. Long term, patients may develop constrictive pericarditis.

Answer 253

Due to fibrosis and constriction of the tissues surrounding the heart

Answer 254

- Raised JVP - Kussmaul's sign (paradoxical rise in JVP with inspiration), - Pulsus paradoxus (drop in cardiac output on inspiration) - Heart sounds may also be quiet (if pericardial effusion also present) - Third heart sound (S3) may be present (due to rapid early diastolic ventricular filling).

Answer 255

Saddle ST changes - Widespread ST elevation and PR depression

Answer 256

IV heparin. DOAC inidcated in a small PE

Answer 257

Amiodarone

Answer 258

Asthmatics veramapril 2.5mg-5mg

Answer 259

In bradycardia

Answer 260

Abdo pain Nausea and vomiting Arrhythmia Yellow green visual disturbance

Answer 261

Tachycardia (>100 beats per minute), plus Absent P waves, plus Monomorphic regular broad QRS complexes (>120 ms).

Answer 262

Leads 2,3 and aVF

Answer 263

New onset Af where there is a heart rate 120 or over ?

Answer 264

Pericardial effusion

Answer 265

RCA infarct. Inferior

Answer 266

Tumour of the cardiac atria usually in the left atria Patients with a history of AF, dyspoea and high cholesterol make this more likley

Answer 267

Iv heparin. This is because of its short half life and reversibility. Alteplase/DOACs are usually used in a PE. Heparins features if also why patients are often changed to heparin before surgery, as it can be turned on and off in theory.

Answer 268

IV atropine sulfate.

Answer 269

Three symptoms that can indicate oesophageal rupture. These include - Neck emphysema - Vomiting - Severe chest pain.

Answer 270

Mitral regurgition

Answer 271

Due to rupture of the papillary muscles.

Answer 272

Vagal menouvures

Answer 273

Make sure to look for any other potential causes

Answer 274

Depression, consipation and lethargy

Answer 275

J waves/osbourne waves

Answer 276

Macrolide antibiotics like arithromycin as well as ondansetron and some antidpressants/antipsychotics.

Answer 277

Coxsackie B virus

Answer 278

Chadsvasc score and anti-coagulating with DOAC. If patients heart rate is under 80, there is no need for rate control with BB or CA channel blocker

Answer 279

- Mechanical heart valves - Stage 4/5 CKD.

Answer 280

Structural or functional abnormality of the myocardium without CAD, hypertension, valvular or congenital heart disease.

Answer 281

Dilation and poor contraction of either the left ventricle or both of the ventricles (EF less than 40 percent). Most common

Answer 282

- Post MI (ischaemic heart disease) - Haemochromatosis - Hypertension - Congenital/ genetic/congenital - Thyrotoxicosis

Answer 283

- Exertional dyspnoea - Orthopnoea - PND - Peripheral odema - Arrhythmias - SCD - Conduction disturbances Symptoms of heart failure

Answer 284

- Displaced apex beat - S3 gallop rhythm - Murmur (mitral regurgitation) - systolic murmur - Signs of HF (odema/hepatomegaly/ascites/raised JVP)

Answer 285

Diagnostic - ECHO

Answer 286

ACE inhib as they narrow blood vessels and increase blood pressure. Decrease risk of heart failure

Answer 287

Genetic condition characterised by left ventricular hypertrophy. Arises as a result of a mutation in one of the myocyte sarcomere genes like myosin and troponin. Most inheritance develops during childhood and adolescent period, however genetic variation means some late onset disease does occur.

Answer 288

Hypertrophic cardiomyopathy

Answer 289

- Most are asymptomatic - First presentation - Presyncope/syncope or sudden death - Some may experience excertional dyspnoea, fatigue or chest pain

Answer 290

- Left ventricular outflow tract obstruction - Diastolic dysfunction - Ischaemia - Mitral regurgitation

Answer 291

- Jerky pulse - Double apex beat - Harsh Ejection systolic murmur - Apical thrill.

Answer 292

- Abnormal Q waves - Deep inverted T waves - LVH - V1-V3 have a large downwards deflection due to the direction of the depolarisation. Further to travel due to the increased thickness of the ventricular wall.

Answer 293

Non dilated, non hypertrophied ventricles with impaired ventricular filling

Answer 294

- Familial AMyloidosis Diabetic cardiomyopathy Radiotherapy/chemotherapy

Answer 295

- Heart failure - Similar to constrictive pericarditis - 75 percent of patients have associated atrial fibrillation

Answer 296

Results in amyloid protein deposition in tissues in the body. Can lead to restrictive cardiomyopathy that appears sparkling on ECHO. Also causes arrhythmia's and conduction disturbances. Heart failure symptoms.

Answer 297

LV pathology. Impaired function results in chronic backlog of blood waiting to flow into the heart. Vasculature begins to leak fluid.

Answer 298

Percentage of blood in the left ventricle that is squeezed out with each ventricular contraction.

Answer 299

a patient has the clinical features of heart failure, but EF is more than 50 percent. Usually due to an issue with diastolic dysfunction.

Answer 300

HF symtpoms where the EF is less than 50 percent

Answer 301

- IHD - Valvular heart disease like in AS - Hypertension - Arrhythmias like AF - Cardiomyopathy.

Answer 302

- Breathlessness worse on excertion - Cough - may produce frothy white/pink sputum - Orthopnoea - Breathless when lying flat. Patients will often lie with multiple pillows. - PND - Peripheral odema - Fatigue.

Answer 303

- Tachycardia - Tachypnoea - Hypertension - Murmurs - As - Third heart sound - Bilateral bibasal crackles (wet sounding on auscultation) indicating pulmonary odema. - Raised JVP - Peripheral odema.

Answer 304

Ejection systolic in AS

Answer 305

- New york association classification -Class 1 - No limitation on activity - Class 2 - Comfortable at rest, symptomatic ordinary with activity - Class 3 - Comfortable at rest but symptomatic with any activity - Class 4 - Symptomatic at rest.

Answer 306

- ***From 400 – 2000 ng/litre*** should be seen and have an echocardiogram ***within 6 weeks*** - ***Above 2000 ng/litre*** should be seen and have an echocardiogram ***within 2 weeks***

Answer 307

- ACE inhib like ramipril. ARB can be given if not tolerated. (ARB not given to patients with valvular heart disease) - BB like bisoprolol

Answer 308

when symptom are not controlled with A/B like spirinolactone. Used when there is reduced EF and symptoms not controlled by the above.

Answer 309

ACE inhib and aldosterone antagonists can derange U and Es hence should be monitored. Renal function should be monitored. Hyperkalaemia risk.

Answer 310

ACE inhib and aldosterone antagonists can derange U and Es hence should be monitored. Renal function should be monitored. Hyperkalaemia risk.

Answer 311

Hyperkalaemia.

Answer 312

- Lifestyle interventions like management of CVD, smoking, diet ect.

Answer 313

- TAVI in underlying heart disease - Implantable cardioverter defib in patients with ventricular tachycardia/VF - Heart transplants in patients with severe disease

Answer 314

Used in HF with an EF of less than 35 percent. Synchronises the contractions in the chambers to optomise heart function.

Answer 315

Riveroxaban

Answer 316

Transferrin sats and serum ferittin measured

Answer 317

Ventricular arrhythmia

Answer 318

WPWS Friedchrichs ataxia

Answer 319

- Palpitations - Chest pain - SOB - Syncope.

Answer 320

Syndrome caused by congenital accessory conducting pathway between the atria and ventricles, causing AV re entry tachycardia.

Answer 321

- Short PR interval (normal PR interval 0.12-0.2 seconds), one large square = 0.2 seconds - Wide QRS complex with a delta wave - LAD (most of the time if a problem with the right sided accessory pathway) - RAD (most of the time if a problem with left sided pathway)

Answer 322

- HOCM (hypertrophic obstructive cardiomyopathy) - Mitral valve prolapse - Ebsteins anomaly - Thyrotoxicosis - Secundum ASD

Answer 323

Type A (left sided pathway) - RAD and dominant R wave in V1

Answer 324

Type B (right sided pathway) - LAD no dominant R wave in V1

Answer 325

Radio-frequency ablation of the accessory pathway

Answer 326

Radio-frequency ablation of the accessory pathway

Answer 327

Sotalol, amiodarone, flecainide

Answer 328

not used if there is co-existing AF, as may cause VF

Answer 329

VF and pulseless VT

Answer 330

Asystole and PEA

Answer 331

Start CPR and get IV access Single shock, followed by 2 mins of CPR/if known patient, up to three shocks. 1mg adrenaline after third shock Give adrenaline 1mg every 3-5 mins Amiodarone 300mg after the third shock. Further 150mg of amiodarone should be give after 5 shocks have been administered.

Answer 332

Start CPR and get IV access. Adrenaline 1mg as soon as possible Give adrenaline 1mg every 3-5 mins

Answer 333

Thrombolytic can be given if a PE is suspected. CPR should be continued for 60/90 mins.

Answer 334

Pericardial effusion - Excess of fluid accumulates around the pericardial sac.

Answer 335

- Transudate (low protein content) - Exudates (high protein content) - Blood - Pus - Gas (bacterial infections)

Answer 336

- Transudate (low protein content) - Exudates (high protein content) - Blood - Pus - Gas (bacterial infections)

Answer 337

- pericardial effusions is large enough to raise the Intra pericardial pressure. This increased pressure squeezes on the heart and affects its ability to function. This means there is decreased filling of the heart in diastole and decreased CO in systole. Emergency requiring draining.

Answer 338

Increased venous pressure can reduce drainage from the pericardial cavity - (congestive heart failure and pulmonary hypertension)

Answer 339

Increased venous pressure can reduce drainage from the pericardial cavity - (congestive heart failure and pulmonary hypertension)

Answer 340

Inflammatory - (pericarditis) like in infection (TB, HIV, Coxsackievirus, epstein barr virus), SLE/RA, injury to the pericardium like MI, open heart surgery or trauma, uraemia secondary to renal impairment, cancer and some medications like methotrexate.

Answer 341

(MI/Trauma/Aortic dissection type A) can cause bleeding into the pericardial cavity resulting in a rapid onset cardiac tamponade.

Answer 342

haemodynamic compromise and collapse.

Answer 343

- Chest pain - SOB - A feeling of fullness in the chest - Orthopnoea - **Compression of phrenic nerve - Hiccups** - **Oesophageal compression - dysphagia** - **Recurrent laryngeal - hoarse voice.**

Answer 344

- Quiet heart sounds - Pulsus paradoxux - abnormally large fall in BP on inspiration, when palpating the pulse - Hypotension - Raised JVP - Fever/pericardial rub in pericarditis.

Answer 345

protein, bacterial culture, viral PCR, cytology and tumour markers.

Answer 346

Treatment of the underlying cause and drainage of the effusion where required Inflammatory causes ( like pericarditis) - aspirin, NSAIDs, colchicine and steroids. Drainage - Needle pericardiocentesis (echo guided) and surgical drainage.

Answer 347

globular appearance, flattening of the upper heart borders.

Answer 348

Pericardial window - Surgical procedure where a portion of the pericardium is removed creating a window or a fistula, this allows fluid to drain from the pericardial cavity into the into the pleural/peritoneal cavity. In recurrent cases, a pericardiectomy can be performed (surgical removal of the pericardium).

Answer 349

BP over 180/120 with retinal haemorrhages or papilloedema (swelling of the optic disc due to raised ICP)

Answer 350

- Same day referral - Fundocopy examination - Monitor for any side effects. Confusion, HF, suspected ACS or AKI - End organ damage.

Answer 351

- Sodium nitroprusside - Labelatol - GTN - Nicardipine.

Answer 352

Acute event results in the left ventricle being unable to move blood efficiently through the left side of the heart and into the systemic circulation. **Pulmonary odema** occurs due to backlog of blood in the pulmonary vascularure, leading to SOB and reduced oxygen saturation.

Answer 353

Decompensated CHF

Answer 354

- Iatarogenic (agressive IV fluid in frail elderly patient) - MI - Arrhythmias - Sepsis - Hypertensive emergency.

Answer 355

Acute left ventricular failure and pulmonary oedema are common in the acute hospital setting. When a nurse asks you to review a breathless and desaturating patient, ask yourself how much fluid that patient has been given and whether they will be able to cope with that amount. For example, an 85 year old patient with chronic kidney disease and aortic stenosis is prescribed 2 litres of fluid over 4 hours and then starts to drop her oxygen saturation. This is a common scenario, and a dose of IV furosemide can work like magic to clear the excess fluid and resolve the symptoms.

Answer 356

Type 1 respiratory failure

Answer 357

- Acute SOB made worse by lying flat and improves on sitting up - T1 RF - Cough with frothy white or pink sputum - Looking and feeling unwell.

Answer 358

- Raised RR - Tachycardia - Reduced o2 sats - 3rd HS - Bilateral basal crackles (wet) - Hypotension in severe cases. There all may also be signs of the precipitating cause, chest pain in an MI, fever in sepsis and palpitations with arrhythmia's. Patients may also have RSHF - raised JVP and peripheral odema.

Answer 359

- BNP will be raised - ECHO - EF can measure LVF. Below 50 is abnormal

Answer 360

Cardiomegaly, upper lobe diversion (increased prominence and diameter of the upper lobe vessels), bilateral pleural effusions, fluid in the interlobular fissures and fluid in the septal lines (kerley lines)

Answer 361

- **S** – **S**it up - **O** – **O**xygen - **D** – **D**iuretics - **I** – **I**ntravenous fluids should be **stopped** - **U** – **U**nderlying causes need to be identified and treated (e.g., myocardial infarction) - **M** – **M**onitor fluid balance

Answer 362

Tricuspid valve

Answer 363

Cool peripheries (atenolol not as it is a cardioselective BB). Propanolol can be used in things like anxiety management

Answer 364

vagal manoeuvres IV adenosine 6mg --> 12mg --> 18mg Electrical cardioversion PREVENTIVES (BB and radiofrequency ablation)

Answer 365

SAVAR in patients that are a good candidate for surgery i.e no co-morbidities like no and fit and healthy. TAVAR - More co-morbidities/frail and elderly.

Answer 366

BB and ACE inhib

Answer 367

Stop the Warfarin, IV vitamin K 5mg and PT complex concentrate

Answer 368

20 mg OD T1DM, QRISK score > 10 or CKD > egfr 60

Answer 369

80 Mg OD IHD, CVD or PAD.

Answer 370

Long QT syndrome (an inherited condition) Medications, such as antipsychotics, citalopram, flecainide, sotalol, amiodarone and macrolide antibiotics Electrolyte imbalances, such as hypokalaemia, hypomagnesaemia and hypocalcaemia

Answer 371

New pan systolic murmur and new AHF.

Answer 372

more than 450 ms (more than 2 large squares)

Answer 373

- Drugs - Amiodarone (slow down the heart), TCAs, antiotics like flucanazole, erythromycin ect. Hypo (electrolyte abnormalities) - Myocardial disease

Answer 374

- Electrocardiogram +/- 24 hour tape. - ECHO for structural heart disease - Genetic testing if required

Answer 375

- BB - Cardiac pacing - Manage the underlying cause - Implantation of ICD.

Answer 376

Complication of streptococcus infection (typically laryngitis) and patients present 2-4 weeks post infection

Answer 377

- STAT dose of IV benzylpenicillin with a 10 day course of phenoxymethylpenicillin to follow - Analgesia for arthritic symptoms like arthritis - Glucocorticoids if carditis is suspected.

Answer 378