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Cardiology Flashcards

1
Q

Malar flush

A

Pulmonary hypertension with low
cardiac output, typically in mitral stenosis

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2
Q

Slate grey rash in sun-exposed areas

A

Adverse effect of amiodarone

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3
Q

Uvula bobbing up and down

A

Muller’s sign in severe AR

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4
Q

Head bobbing up and down

A

de Musset’s sign in severe AR

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5
Q

Plucked chicken skin

A

Pseudoxanthoma elasticum = classic cause of coronary artery disease in young

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6
Q

Thrill in apex

A

Severe MR

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7
Q

Thrill at left sternal edge

A

VSD

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8
Q

Thrill in aortic area

A

AS

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9
Q

Loud 2nd heart sound

A

Pulmonary HTN

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10
Q

3rd heart sound (lub dub dub)

A

Rapid ventricular filling of dilated LV = Heart failure (MR, post-MI)

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11
Q

4th heart sound (la-lub dub)

A

Atria contract against stiff ventricles = (e.g. HOCM, HTN)

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12
Q

Quiet 2nd heart sound

A

Severe AS

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13
Q

Features of aortic stenosis

A
  • Heaving apex beat (LVH)
  • Slow rising pulse
  • Quiet 2nd heart sound
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14
Q

Features of aortic regurtitation

A
  • Collapsing pulse
  • Wide pulse pressure.
  • Cardiac dilatation.
  • Early diastolic murmur, usually maximal at lower left sternal edge
  • Corrigan’s pulse.
  • De musset’s: bobbing of head with pulse
  • Quincke’s: nail bed pulsations
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15
Q

Features of mitral stenosis

A
  • Old patient as likely rheumatic
  • Mid-diastolic murmur (best heart left lateral on expiration using the bell)– sounds like thunder rumbling in distance
  • AF
  • Tapping apex beat (palpable first heart sound)
  • Loud S1 = closing snap (important clue for mixed mitral valve disease when there is also pansystolic murmur)
  • Malar flush
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16
Q

Features of mitral regurgitation

A
  • Soft S1 and widely-split S2 (severe MR)
  • Pansystolic murmur loudest at apex and radiating to axilla and loudest on expiration
  • Displaced apex beat laterally +/- apical systolic thrill
  • Marfan’s = arm span to height ratio >1.05
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17
Q

Causes of aortic stenosis

A
  • Calcific degenerative is the most common.
  • Congenital, usually associated with a bicuspid valve.
  • Rheumatic (now quite rare).
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18
Q

Severity of aortic stenosis based on

A
  • Quiet 2nd heart sound
  • Narrow pulse pressure
  • Presence of heart failure
  • Syncope is poorest prognostic symptom
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19
Q

Differential for aortic stenosis

A
  • Aortic sclerosis: can overlap with AS
  • PS: normal pulse character, 2nd heart sound normal, although pulmonary component may be reduced. Murmur louder on inspiration.
  • VSD: very loud murmur, heard all over the praecordium. Maximal at sternal edge. More likely to be associated with a thrill (Maladie de Roger).
  • HOCM: jerky pulse, murmur gets quieter if crouches down (increased afterload and consequent splinting open of the outflow tract). No ejection click, normal 2nd heart sound. Younger patient.
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20
Q

Investigations for aortic stenosis

A
  • Echo: severe if valve area <1cm2, mean valve gradient >40mmHg (gradient is difference in pressure before and after valve), peak velocity >4m/sec
  • Stress echo: to see if heart failure due to the AS or because of issue with myocardium
  • Coronary angiography before any valve surgery!
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21
Q

Criteria for surgery in aortic stenosis

A

Symptomatic severe AS

Asymptomatic severe AS and:
- EF <50% without other cause or
- Symptomatic or 20mmHg fall in BP on exercising or
- Very severe AS (mean gradient >60mmHg) or BNP x3 normal without other explanation

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22
Q

What are the common complications of AS?

A
  • Endocarditis
  • Heart failure
  • AV block due to invasion of calcium from the valve ring into the His–Purkinje system
  • Embolic events.
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23
Q

How would you differentiate sclerosis from stenosis?

A

Normal pulse character, normal 2nd heart sound, frequently in an elderly person. Note this overlaps with mild AS.

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24
Q

Causes of aortic regurgitation

A

Split into acute AR and chronic AR!

Acute AR:
* Infective endocarditis
* Aortic dissection
* Prosthetic valve failure
* Acute rheumatic fever (rare in the West, but not elsewhere)

Chronic AR:
* Bicuspid aortic valve
* Marfan’s syndrome
* Rheumatic heart disease
* Endocarditis
* Seronegative arthritides (ank spond!)

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25
Q

Differential for aortic regurgitation

A

Pulmonary regurgitation = not maximal at the lower left sternal border, and none of the other signs are present.

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26
Q

Criteria for surgery in aortic regurgitation

A

Symptomatic

Asymptomatic and
- EF <50% or
- LV end-systolic diameter >50mm (>25mm/m2 per BSA if low BSA) or
- Aortic enlargement (>55mm or >45mm if Marfan’s)

Medical for the rest (ACEi, diuretics)

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27
Q

Signs suggesting severe aortic regurgitation

A
  • Clinically dilated heart
  • Left-sided heart failure
  • Very wide pulse pressure
  • Short murmur (more severe flow of blood back into the LV, causing ever more rapid rise in the LV diastolic pressure. This results in the regurgitant flow diminishing much earlier in diastole as the gradient between aorta and LV diminishes.)
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28
Q

Severe mitral stenosis shown by

A
  • AF.
  • Pulmonary hypertension.
  • A short gap between S2 and the opening snap
  • A long mid-diastolic murmur
  • Pulmonary congestion and right heart failure
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29
Q

Causes of mitral stenosis

A
  • Rheumatic fever (>90 %).
  • Degenerative: severe calcification.
  • Endocarditis with large thrombus
  • Congenital (carcinoid)
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30
Q

Investigations for mitral stenosis

A
  • 12-lead ECG– p mitrale (broad p wave due to LA enlargement)
  • CXR: LA size (splaying of subcarinal angle, loss of pulmonary bay).
  • Transthoracic echocardiogram (TTE) to assess severity – mean gradient and mitral valve area (MVA)
  • Transoesophageal echocardiogram (TOE) for detailed assessment of valvular and subvalvular anatomy and to assess LA appendage for thrombus prior to PBMV.
  • Right and left heart catheterization to assess coronary anatomy and right heart pressure
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31
Q

Indications for surgery in mitral stenosis (or percutaneous mitral commissurotomy)

A

Symptomatic

Asymptomatic
- High VTE risk (AF, previous VTE)
- High-risk for haemodynamic decompensation (systolic pulmonary pressure >50mmHg, need for major surgery/pregnancy)

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32
Q

Aortic stenosis symptoms

A
  • Breathless
  • Angina
  • Syncope = worst prognosis
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33
Q

Aortic regurgitation symptoms

A
  • Breathless
  • Heart failure
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34
Q

Mitral stenosis symptoms

A
  • Heart failure
  • AF (palpitations, breathless)
  • Endocarditis symptoms (unexplained fever)
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35
Q

Mitral regurgitation symptoms

A
  • Heart failure
  • AF (palpitations, breathless)
  • Endocarditis symptoms (unexplained fever)
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36
Q

Severe mitral regurgitation shown by

A
  • AF (develops as LA enlarges),
  • Displaced thrusting apex beat
  • Signs of pulmonary hypertension (parasternal heave, palpable P2, evidence of TR)
  • Cardiac failure
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37
Q

Causes of mitral regurgitation

A
  • Degenerative
  • Functional (secondary to LV dilatation and causes thereof)
  • Ischaemic
  • MV prolapse (affects 1–2.5 % of population)– includes connective tissue deases
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38
Q

Criteria for surgery in mitral regurgitation

A

Symptomatic

Asymptomatic and
- LV end-systolic diameter >40mm
- LVEF <60%
- Preserved LV function but AF or pulmonary systolic pressures >50mmHg

Medical management has no effect on MR!

Always do mitral valve repair rather than replacement (replacement can lead to LV function reduction)

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39
Q

Tricuspid regurgitation symptoms

A
  • Usually asymptomatic
  • Symptoms of pulmonary hypertension which is main cause of TR (breathless, ankle oedema)
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40
Q

Features of tricuspid regurgitation

A
  • Pansystolic murmur loudest at left sternal edge and on inspiration
  • Very high JVP (large CV waves) without other bad heart failure signs
  • Parasternal heave (severe TR)
  • Pulsatile hepatomegaly
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41
Q

Causes of tricuspid regurgitation

A

Acute
- Endocarditis always

Chronic
- Pulmonary hypertension = main cause
- Endocarditis
- Carcinoid (flushing, diarrhoea, bronchoconstriction)
- Ebstein’s anomaly (apical displacement of TV)

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42
Q

Management of tricuspid regurgitation

A

Medical
- Diuretics
- Manage condition causing pulmonary hypertension

Surgical = rarely used
- Early in symptomatic patients
- Consider when doing left-sided cardiac surgery (helps RV remodelling)

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43
Q

Metallic valve click before vs after carotid pulse

A
  • Before carotid pulse (S1): mitral valve
  • After carotid pulse: aortic valve
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44
Q

Cause of regurgitation in prosthetic valve

A

Valvular leak

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45
Q

Cause of systolic murmur in prosthetic valve

A
  • Soft systolic murmur in AV = normal
  • Any systolic murmur in MV = abnormal (paravalvular leak)
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46
Q

Mixed mitral valve disease discriminating factors

A

Apex beat:
- MR: thrusting laterally displaced
- MS: tapping undisplaced

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47
Q

Mixed aortic valve disease discriminating factors

A

Pulse character:
- AS: slow rising
- AR: collapsing

BP:
- AS: low SBP
- AR: high SBP

Apex beat:
- AS: heaving undisplaced
- AR: thrusting laterally displaced

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48
Q

Biological vs mechanical heart valves

A

Biological = over 70s (or anyone younger with 10-15yr prognosis)
- ADV: No long-term anticoagulation, less prone to endocarditis
- DISADV: quicker to fail

Mechanical:
- Opposite to above

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49
Q

NYHA Classification for Heart Failure

A

Class I No effect on normal daily activities
Class II Able to walk ~100m on the flat, breathless with greater levels of exertion
Class III Breathless on walking around the house, comfortable at rest
Class IV Breathless at rest or on minimal exertion.

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50
Q

Heart failure treatment

A
  • ACEi = ramipril 1.25mg (do salcubritil/valsartan if ACEi not tolerated)
  • Beta-blocker = bisoprolol 1.25mg
  • Aldosterone antagonist = spironolactone 12.5mg (if eGFR >30 as causes high K)
  • SGLT2 inhibitors in HFrEF = dapagliflozin 10mg

Add on
- Digoxin 62.5mg if AF
- Diuretics

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51
Q

Indications for CRT-D/P in heart failure

A

Prognosis >1year AND
- LVEF <30% and NYHA class I/<35% and class II-III
- QRS >130ms
- Despite optimal medical management

(Because heart loses synchronous contraction when it is severe HF)

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52
Q

Indications for ICD in heart failure

A

Prognosis >1year AND
- LVEF <35%
- QRS 120-150ms (though CRT if LBBB)
- Despite optimal medical management

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53
Q

Signs of constrictive pericarditis

A
  • Cachexia/leuconychia (low albumin)
  • Pulsus parodoxus (BP drops 20mmHg during inspiration – because RV fills so bulges into LV as cannot expand due to pericarditis –> reduced LV filling and LV output!)
  • Ventricular interdependence (filling of one ventricle reduces the size and filling of the other – see fluctuating LV/RV pressure)
  • Very raised JVP
  • Auscultation: early loud S3 = “pericardial knock” (RV) and pansystolic murmur due to TR
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54
Q

Management of constrictive pericarditis

A
  • High-dose NSAID reducing regiment (e.g. ibuprofen 600mg TDS for 2 weeks and then reduce)
  • Colchicine
  • Steroids in TB pericarditis
  • Pericardiectomy
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55
Q

How many Duke’s criteria needed for endocarditis?

A
  • 2 major
  • 1 major and 3 minor
  • 5 minor
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56
Q

Major and Minor Duke’s criteria for endocarditis

A

Major
- 2 separate +ve blood cultures with typical organism
- Vegetation on echo

Minor
- 1 +ve blood culture
- Fever
- IV drug use/predisposing heart condition
- Embolic phenomena (septic emboli, Janeway lesions = palm, splinter haemorrhages)
- Immune phenomena (Roth spots, Osler nodes = TENDER nodules finger tips)
- Echo finding suggestive but not confirm

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57
Q

Common bugs causing endocarditis

A

Strep. viridans, Strep. bovis or a HACEK organism
Staph aureus
Enterococcus

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58
Q

Relevance of lengthening PR in endocarditis

A

Aortic root abscess- would need urgent surgery

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59
Q

Indications for surgery in endocarditis

A
  • Progressive heart block (aortic root abscess)
  • Uncontrolled infection
  • Haemodynamic failure due to valve insufficiency

Also strongly consider in prosthetic valve endocarditis

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60
Q

Symptoms of VSD

A
  • Most asymptomatic (incidental finding)
  • Big VSD = heart failure as infant
  • High output cardiac failure in adults
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61
Q

Signs of VSD

A
  • Pansystolic murmur left sternal edge
  • Thrill left sternal edge
  • RV overload if shunt severe (parasternal heave)
  • Right heart failure signs–> Eisenmenger’s (clubbing, cyanosis)
  • Small VSD = loud pansystolic murmur without other signs (Maladie de Roger VSD)
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62
Q

Treatment for VSD

A
  • Incidental: no treatment
  • Right heart failure/increasing right-sided pressures: surgical or percutaneous catheter-based closure
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63
Q

VSD associated with?

A
  • Tetralogy of Fallot
  • Coarctation of aorta
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64
Q

Symptoms of atrial septal defect

A
  • Present in 30s
  • Dyspnoea (pulmonary HTN/AF)
  • Stroke (paradoxical embolism)
  • Pulmonary oedema (right heart failure)
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65
Q

4 features of Tetralogy of Fallot

A

PROV
- Pulmonary stenosis
- Right ventricular hypertrophy
- Over-riding aorta (lies above VSD = takes deoxy blood from RV)
- VSD

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66
Q

Signs of atrial septal defect

A
  • Soft ESM over pulmonary area (due to increased turbulent flow through the pulmonary valve)
  • Widely split S2 (P2 is much after A2 because of increased pulmonary flow)
  • Raised JVP if right heart failure
  • Signs of Downs’ (low-set ears, flat nasal bridge, prominent epicanthic folds, glossoptosis)
  • Signs of Holt-Oram Syndrome (hypolastic thumb, radial hypoplasia, phocomelia, bradycardia)
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67
Q

Signs of Patent Ductus Ateriosus (connection between descending aorta and pulmonary artery)

A
  • Toes cyanotic/clubbed + fingers normal (shunt causes Eisenmenger’s)
  • Palpable thrill left infraclavicular area
  • Continue “machinery” murmur in S1 and S2- heard over left scapular
  • Collapsing pulse and wide pulse pressure (blood goes from aorta to pulmonary artery in diastole)
  • Parasternal heave and loud P2 (pulmonary HTN)
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68
Q

Causes of Patent Ductus Ateriosus

A
  • Congenital
  • Neonatal Rubella Syndrome
  • Birth at high-altitude
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69
Q

Treatment of Patent Ductus Arteriosus

A
  • Percutaneous duct closure device (do for all PDA except if shunt has reversed or irreversible pulmonary HTN)
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70
Q

Symptoms for coarctation of aorta (narrowing of aorta)

A
  • Intermittent claudication of legs
  • Uncontrolled HTN (epistaxis, vision changes, headache)
  • Heart failure
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71
Q

Associations with Coarctation of Aorta

A
  • Bicuspid aortic valve (85% of coarcation)
  • VSD
  • Turner Syndrome
  • Marfan’s
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72
Q

Signs of Coarctation of Aorta

A
  • Radio-femoral delay (radio-radio delay if coarctation before left subclavian)
  • Femoral BP less than brachial BP
  • Loud S1 with systolic murmur loudest over thoracic spine
  • ESM due to bicuspid aortic valve
  • Left lateral thoracotomy = surgical repair
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73
Q

Indications for surgery in Coarctation of Aorta

A
  • Symptomatic and gradient across coarcation >30mmHg
  • Asymptomatic with gradient >30mmHg and HTN
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74
Q

Signs of HOCM

A
  • Pacemaker scar (dual chamber PPM decreases LVOT gradient/ICD prevents sudden death)
  • Bifid jerky pulse (terminates when outflow tract temporarily obstructed, then resumes when becomes unobstructed)
  • ESM loudest at left sternal edge, or MR murmur (systolic anterior movement of the anterior leaflet of the MV and asymmetrical septal hypertrophy)
  • Murmur loudest on valsava, but wait 3 cardiac cycles! (increases LVOT gradient)
  • Double apical impulse (feel atria and ventricles contract)
  • S4
75
Q

Cause of HOCM

A
  • Autosomal dominant in 50% patients
76
Q

ECG features of HOCM

A
  • P mitrale
  • Tall QRS complexes
  • Lateral T wave inversion
  • Deep Q waves V3-4
77
Q

Causes of raised JVP

A
  • Increased blood in SVC (pulsatile = CCF, non-pulsatile = SVCO)
  • TR
  • Constrictive pericarditis
78
Q

Inferior leads of ECG

A

II, III, aVF

79
Q

Inferior heart supplied by which vessel

A

Right coronary artery

80
Q

Lateral leads of ECG

A

I, aVL, V5 + V6

81
Q

Lateral heart supplied by which vessel

A

Left circumflex

82
Q

Anterior leads of ECG

A

V2-V6

83
Q

Anterior heart supplied by which vessel

A

Left mainstem

84
Q

Posterior leads of ECG

A

V7-V9 (below left scapula)

85
Q

Treatment for HOCM

A
  • Beta-blockers (reduce myocardial consumption)
  • ICD if risk of sudden death (syncope, BP not rising with exercise, FH of sudden death)
  • Surgical myectomy/alcohol septal ablation (inject ethanol into LAD –> controlled MI–> death of hypertrophic tissue)
86
Q

Cause of Marfan’s Syndrome

A
  • Autosomal dominant in chromosome 15
  • Defect of fibrillin-1
87
Q

Features of Marfan’s Syndrome

A
  • Arm span: height ratio >1.05
  • Can circle wrist with thumb and little finger (arachnodactyly and joint hypermobility)
  • Thumb touches forearm on wrist flexion
  • Ascending aorta dilation–> dissection (ask about FH of sudden death)
  • Mitral/aortic regurgitation
  • Pneumothorax
  • High arched palate
  • Displaced lens upwards/blue sclera
  • Pectus carinatum/excavatum
88
Q

Management of Marfan’s Syndrome

A
  • Family screening for aortic dilation (annual echo monitoring of aortic root size)
  • Beta-blockers in anyone with dilated aorta (reduces rate of dilation)
  • Genetic screening
  • Podiatrist for pes planus
89
Q

Indications for aortic root replacement in Marfan’s

A
  • Meets surgical criteria for aortic regurgitation (e.g. symptomatic)
  • Aortic root >45mm (operate if >55mm in normal people)
  • Aorta grows >1cm in 1yr
90
Q

Conditions associated with Tetralogy of Fallot

A
  • DiGeorge Syndrome (long face, low-set ears, cleft palate)
  • Poland’s Syndrome (one pec smaller than other)
91
Q

Signs of Tetralogy of Fallot

A

All patients need surgical correction in childhood so will never see active Tetralogy in the exam! Look for signs of

Surgical repair:
- Sternotomy

Blalock-Taussig shunt (redirects one of the subclavians to pulmonary artery = temporary measure to increase blood flow to lungs)
- Weaker radial pulse ipsilateral to shunt
- Left lateral thoracotomy
- Undeveloped arm ipsilateral to shunt

Complications:
- Regurgitation of any valve
- Left sternal thrill and loud ESM: residual VSD
- PPM due to refractory arrhythmias (scarred RVOT)

Associated conditions:
- DiGeorge syndrome: cleft palate/repaired, long face & low set ears)
- Polands Syndrome: Unilateral pectoral hypoplasia

92
Q

ECG features of Tetralogy of Fallot

A
  • Right axis deviation
  • RBBB
  • Right ventricular hypertrophy
93
Q

CXR findings of Tetralogy of Fallot

A
  • Boot-shaped heart (upturned cardiac apex due to RVH)
  • Dilated aorta
94
Q

Signs of dextrocardia

A
  • Apex beat on right
  • Situs inversus may occur (liver on left)
  • ASD (soft pulmonary ESM, widely split S2, raised JVP)
  • Bronchiectasis signs!
95
Q

Features of Scarlet Fever

A
  • Erythema marginatum
  • Chorea
  • Subcutaneous nodules
  • Polyarthritis
  • Carditis
96
Q

Mitral valve prolapse caused by

A

Primary
- Myxomatous degeneration

Secondary:
- Marfan’s/Ehlers Danlos
- Polycystic Kidney Disease
- Osteogenesis imperfecta

97
Q

How to accentual mitral valve prolapse mid-systolic ejection click/pansystolic murmur

A
  • Standing from squatting
  • Valsalva
    (reduce blood flow through heart)
98
Q

Signs of pulmonary stenosis

A
  • ESM loudest in pulmonary area and on inspiration
  • Widely split S2 (delayed RV emptying)
  • Raised JVP with giant A waves
  • Thrill in pulmonary area
  • RV failure
99
Q

Pulmonary stenosis associated with

A
  • Tetralogy of Fallot (VSD, overriding aorta, RVH)
  • Noonan Syndrome (Turner Syndrome in men)
  • Carcinoid (also associated with TR)
100
Q

Treatment of Carcinoid Syndrome

A
  • Octreotide
  • Surgical resection
101
Q

Indications for ICD

A
  • LVEF <35% and QRS 120-150ms (tho CRT if LBBB)
  • At risk of sudden cardiac death (HOCM, Brugada, Long QT)
  • Cardiac arrest due to VT/VF
  • VT with LVEF <35% (not NYHA IV)
102
Q

Indications for CRT

A
  • LVEF >35%
  • Sinus and QRS >150ms (or LBBB and QRS >120ms)
  • NYHA II-IV
103
Q

Absent a waves in JVP

A
  • AF
104
Q

Large a waves in JVP

A
  • Pulmonary HTN
  • Pulmonary stenosis
105
Q

Canon a waves in JVP (very tall a waves = like a canon)

A
  • Complete heart block
  • Ventricular ectopic/arrhythmia
    (because RA and RV contract at same time, so blood from RA rebounds off a closed tricuspid valve into the IJV!)
106
Q

Large CV waves in JVP

A
  • Tricuspid regurgitation
107
Q

Rise in JVP during inspiration (Kussmaul’s Sign)

A
  • Constrictive pericarditis
108
Q

Causes of constrictive pericarditis

A

All the T’s
- TB
- Tumour/therapy (radio)- check radiotherapy tattoos
- Tissue disease connective

109
Q

Classic sign of constrictive pericarditis

A
  • Ventricular interdependence (filling of one ventricle reduces the size and filling of the other – see fluctuating LV/RV pressure)
110
Q

Echo features of HOCM

A
  • Asymmetrical septal hypertrophy
  • LV thickness >15mm in absence of other causes
  • Systolic anterior motion of mitral valve
111
Q

Different types of apex beat

A
  • Tapping = sudden brief: mitral stenosis
  • Heaving = forceful sustained localised: pressure overload (AS)
  • Thrusting = less forceful, non-sustained non-localised: volume overloaded (MR/AR)
112
Q

Sustained vs non-sustained VT

A
  • Sustained >30secs or <30secs with haemodynamic instability
113
Q

T waves inverted is normal in which leads

A
  • aVR
  • V1
114
Q

Bifascicular block ECG criteria

A
  • RBBB
  • LAD
115
Q

Trifascicular block ECG criteria

A
  • RBBB
  • LAD
  • 1st degree heart block
116
Q

Non-AF causes of irregularly irregular

A
  • Atrial flutter with variable block
  • Ventricular ectopics
117
Q

Cause of peaked p wave

A
  • Right atrial hypertrophy (pulmonary HTN, tricuspid stenosis)
118
Q

Cause of broad bifid p wave

A
  • Left atrial hypertrophy (mitral stenosis)
119
Q

ECG signs of right ventricular hypertrophy

A
  • Tall R wave V1
  • Deep S wave V6
  • Right axis deviation
  • T wave inversion V1-3
120
Q

ECG signs of left ventricular hypertrophy

A
  • Deep S wave in V1
  • Tall R wave in V6
  • Left axis deviation
  • T wave inversion II, aVL, V5-6
121
Q

Cardiac causes of syncope

A
  • Aortic stenosis
  • Fast arrhythmia (SVT or VT)
  • Slow arrhythmia (complete heart block)
122
Q

Risk scores before anticoagulating for AF

A
  • CHADVASC for clot risk (consider if 1, offer if 2)
  • ORBIT for bleeding risk (4+ is high risk)
123
Q

When do rhythm control in AF

A
  • Reversible cause
  • Heart failure due to AF
  • New-onset (<48hrs)
  • Failed rate-control (or still symptomatic despite rate controlled)
124
Q

When do ablation for AF

A
  • Symptomatic despite medical therapy
125
Q

First-line rate-control for AF

A
  • Beta-blocker
  • Non-dihydropyridine CCB: diltiazem 60mg TDS
  • Digoxin monotherapy if inactive (62.5mcg)
126
Q

Contraindications for digoxin

A
  • Supraventricular arrhythmia (WPW)
  • Conduction block
  • HOCM (except if heart failure and AF)
127
Q

Contraindications for beta-blockers

A
  • Bronchospasm (can use cardioselective with caution e.g. bisoprolol)
  • Severe peripheral vascular disease (rest pain)
  • 2nd or 3rd degree heart block
  • Diabetes with frequent hypos
128
Q

Which calcium channel blocker must never be prescribed with beta-blocker

A
  • Non-dihydropyridine (verapamil, diltiazem) - bradycardia, asystole, severe hypotension
129
Q

Contraindications for verapamil/diltiazem

A
  • Heart failure with reduced ejection fraction
  • WPW
  • Women of child-bearing potential/pregnant
  • Severe aortic stenosis
  • 2nd or 3rd degree heart block
130
Q

Contraindications for DOAC

A
  • Liver failure with coagulopathy
  • Creatinine clearance <15
  • Current GI ulcer
  • Oesophageal varices
  • Brain tumour with high bleeding risk
131
Q

Tests needed before stating regular amiodarone

A
  • Thyroid function tests.
  • Liver function tests.
  • U&Es
  • CXR
132
Q

Monitoring needed if on regular amiodarone

A
  • TFTs every 6 months and for 12 months afters stopping
  • LFTs every 6 months.
  • U&Es every 6 months.
  • ECG every 12 months.
133
Q

Which AF rate control is contraindicated in structural heart disease

A
  • Flecainide
  • Propafenone
134
Q

Rhythm control in AF

A
  • Anticoagulate for 3weeks first (or TOE to exclude left atrial appendage thrombus)
  • DC cardioversion is favoured
  • Chemical cardioversion: amiodarone if structural heart disease (can give flecainide if no structural disease)
135
Q

Alternative to anticoagulation in AF

A
  • Left atrial appendage occlusion (e.g. Watchman device)
136
Q

Liver enzyme inducers (decrease drug’s effect)

A

SCARS
- Smoking
- Chronic alcohol
- Anti-epileptics (phenytoin, carbamazepine)
- Rifampicin
- St John’s wort

137
Q

Liver enzyme inhibitors (increase drug’s effect)

A

ASS-ZOLES
- Antibiotics (cipro, erythromycin, isoniazid)
- SSRIs
- Sodium valproate
- ZOLES (fluconazole, omeprazole)

138
Q

Beck’s Triad for tamponade

A
  • Decreased BP
  • Increased JVP
  • Muffled heart sounds
139
Q

Treatment for mitral valve prolapse

A
  • Most: reassurance
  • Beta-blockers help palpitations
  • Surgery if severe (esp if regurgitation)
140
Q

Causes of infective endocarditis

A
  • IVDU = staph aureus
  • Prosthetic valve = staph epidermidis
  • Dental = strep viridans
141
Q

Features of Takayasu Disease

A

Inflammation –> scarring/stenosis of big arteries
- Absent pulses
- Bruit (carotid, subclavian, abdominal)
- Aortic regurgitation (ascending aorta dilated)
- HTN (renal artery stenosis)

142
Q

Definition of valvular AF

A
  • Moderate/severe mitral stenosis
  • Prosthetic valve
143
Q

Paroxysmal vs persistent AF

A
  • Paroxysmal <7days
  • Persistent >7days
144
Q

Causes of radial-radial delay

A
  • Coarctation of aorta before left subclavian (left arm delayed)
  • Subclavian stenosis
  • Takayasu’s Disease
145
Q

Causes of radial-femoral delay

A
  • Coarctation of aorta after left subclavian (no radial-radial delay)
  • Atherosclerosis of aorta
146
Q

Echo features of severe aortic stenosis

A
  • Valve area <1cm2
  • Mean valve gradient >40mmHg
  • Peak velocity >4m/sec
147
Q

Echo features of severe mitral stenosis

A
  • Valve area <1cm2
  • Mean gradient >10mmHg
148
Q

Important cause of pulmonary regurgitation murmur

A
  • Graham-Steele murmur: mitral stenosis –> pulmonary HTN–> functional pulmonary regurgitation
149
Q

Complications of valve insertion

A
  • Valve failure
  • Valve thrombosis
  • Acute valvular dehiscence
  • Acute endocarditis (post-op)
  • CVA/TIA (Embolic phenomena)
150
Q

What is Eisenmenger’s Syndrome

A
  • VSD –> worsening pulmonary HTN until RV pressure excess LV, so reversal of VSD shunt –> right-to-left shunt –> cyanosis/clubbing
151
Q

Types of atrial septal defect

A

Primum = 15%
- Most inferior ASD (just above AV valves)
- Causes RBBB + left axis deviation

Secundum = 70%
- Causes RBBB+ right axis deviation

Sinus venous = 15%
- Connection between SVC and both atria

152
Q

Conditions associated with atrial septal defect

A
  • Down’s
  • Holt-Oram
153
Q

Indications for surgery in atrial septal defect

A
  • Right heart failure
  • Paradoxical emboli
  • Pulmonary pressure >2/3 systolic pressure which improves with vasodilators
154
Q

Causes of diastolic murmur

A
  • Early: aortic/pulmonary regurgitation
  • Mid: mitral/tricuspid stenosis
155
Q

How to use GTN spray and when to call 999

A
  • 1-2 sprays –> another 1-2 sprays 5 mins later if necessary
  • If still chest pain after second dose, call 999
156
Q
  • Mode of inheritance of pseudoxanthoma elasticum
  • Pathogenesis
A
  • Autosomal recessive (chromosome 16)
  • Mineralisation of elastic fibres (calcium and other minerals)
157
Q

Features of pseudoxanthoma elasticum

A
  • Plucked chicken skin
  • Angioid streaks (cracks in Bruch’s membrane)
  • Mitral valve prolapse (pansystolic with ejection click)
  • Early atherosclerosis
158
Q

Causes of displaced apex beat

A
  • AR
  • MR
  • Cardiomyopathy
159
Q

Quiet S1 causes

A
  • Mitral regurgitation
  • Calcified mitral valve
  • LV failure (severe)
160
Q

Quiet S2 causes

A
  • AS
  • AR (if valve not closing properly)
161
Q

Echo finding for severe aortic regurgitation

A
  • Pressure half-time <200ms (time taken for peak pressure gradient to half)
162
Q

Causes of loud/palpable P2 (louder than A2) with RV heave

A
  • Pulmonary HTN
  • ASD
163
Q

Causes of loud/palpable P2 without RV heave

A
  • Bioprosthetic pulmonary valve
164
Q

Palpable device in infraclavicular area

A
  • Likely ICD as PPM is size of 50p coin!
165
Q

Other imaging investigation in HOCM (apart from echo)

A
  • Cardiac MRI with late gadolinium enhancement (shows fibrosis = prognostic)
166
Q

Young patient with midline sternotomy but no radial grafts

A

Valve replacement
- Marfan’s – look for other signs!
- Congenital including bicuspid aortic valve and Tetralogy (PV replacement)

167
Q

Wide splitting of S2 (splitting louder on inspiration)

A
  • Delayed conduction down RV (RBBB, premature LV beats)
  • Pulmonary stenosis
168
Q

Fixed splitting of S2 (not louder on inspiration)

A
  • Pulmonary HTN
  • Right heart failure
  • ASD (blood flow left to right –> lengthened cardiac cycle on right)
169
Q

Single S2 (cannot hear separate A2 and P2)

A
  • Severe AS
  • Severe AR
170
Q

Midline sternotomy without graft sites- could it be IHD?

A
  • Yes: CABG using the LIMA!
171
Q

Non-medical option for mitral valve disease in patients who cannot have open heart surgery

A
  • MitraClip (inserted percutaneously)
172
Q

Signs of cardiac syncope

A
  • No warning
  • Quick recovery
  • Exertional
173
Q

Drugs contraindicated in aortic stenosis

A

Vasodilators which increase gradient across the valve
- ACEi!
- Nitrates
- Sildenafil

174
Q

Cardiac complications of Noonan’s

A
  • Pulmonary stenosis
  • HOCM
  • ASD/VSD
175
Q

Why right-sided murmurs louder on inspiration

A
  • Increased venous return to right heart –> increased flow across valve
176
Q

Why left-sided murmurs louder on expiration

A
  • Increased venous return from pulmonary veins to left heart –> increased flow across valve
177
Q

Causes of Eisenmenger’s

A
  • VSD
  • ASD
  • PDA
178
Q

Indications for surgery in VSD

A
  • Significant left-to-right shunt (pulmonary: systemic flow ratio >2)
  • LV failure
  • Endocarditis
179
Q

Complications of Eisenmenger’s

A
  • RV failure
  • Paradoxical embolus
  • Hypoxaemia
180
Q

Posterior thoracotomy scar in young patient

A
  • Pulmonary artery banding in VSD (reduces pulmonary blood flow to prevent pulmonary HTN) = old procedure, not used anymore
181
Q

Complications of Tetralogy of Fallot

A
  • Pulmonary regurgitation (due to pulmonary stenosis/RVOT surgeries)
  • Arrhythmias
  • Paradoxical emboli
182
Q

Causes of restrictive cardiomyopathy

A

Primary
- Endomyocardium fibrosis

Secondary
- Sarcoid
- Scleroderma
- Haemochromatosis
- Malignancy
- Radiotherapy

183
Q

Other murmur heard in aortic regurgitation (not diastolic)

A
  • Austin-Flint (mid-diastolic heard at apex, due to regurgitant jet hitting mitral valve anterior leaflet)
184
Q

Types of Cardio-Renal Syndrome

A
  • 1: acute cardiorenal (sudden heart failure)
  • 2: chronic cardiorenal (chronic heart failure)
  • 3: acute renocardiac (AKI)
  • 4: chronic renocardiac (CKD)
  • 5: secondary cardiorenal (systemic condition –> both cardiac and renal failure)

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