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Cardiology Flashcards

1
Q

Initial management of all ACS patients

A

MONA
Morphine (only if in severe pain)
Oxygen (if less than 94 sats
Nitrates (caution if hypotensive)
Aspirin 300mg

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2
Q

What is STEMI criteria

A

Symptoms of ACS for over 20mins
AND
ST elevation in 2 or more leads

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3
Q

Which leads are ST elevation in mm different in

A

V2 and V3

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4
Q

What is ST elevation criteria in leads V2 and V3 for men

A

Men under 40
- >2.5mm
Men over 40
- >2mm

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5
Q

What is ST elevation criteria in leads V2 and V3 in women

A

> 1.5mm

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6
Q

What is ST elevation criteria in all leads

A

Above 1mm

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7
Q

What is criteria for being eligible for percutaneous coronary intervention

A

Within 12 hours of onset of symptoms
Able to be delivered within 120 minutes

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8
Q

Where is access gained in PCI

A

Radial access

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9
Q

If present after 12 hours from onset of symptoms, what can do for STEMI

A

If ongoing ischaemia or HF- do PCI

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10
Q

What is given alongside PCI if radial access

A

Unfractionated heparin
Bailout Glycoprotein IIb/IIIa inhibitor ( tirofiban and eptifibatide)
Another antiplatelet- prasugrel etc

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11
Q

What antiplatelet is used alongisde PCI

A

Prasugrel- 60mg
If high risk bleeding then ticagrelor- 180mg
If on anticoagulant- clopidogrel

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12
Q

What give alongisde aspirin prior to PCI if patient already on an anticoagulant

A

Clopidogrel

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13
Q

What can be used as antiplatelet alongside aspirin prior to PCI if high risk of bleeding

A

Ticagrelor

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14
Q

What is counted as postural drop in BP

A

Sys- drop in 20
Dias- drop in 10
Systolic going under 90

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15
Q

How evaluate all patients with syncope

A

Cardiac examination
ECG
Postural BP measurement
Any other investigations depend on features of history etc

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16
Q

Causes of collapse

A

Cardiac causes
Neuro
- seizure
Reflex
- vasovagal
Orthostatic

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17
Q

What can cause an orthostatic syncope

A

Primary autonomic dysfunction
- parkinsons
- LBD
Secondary autonomic
- DM
- amyloid
- uraemia
Drug induced
- diuretics
Volume depleted
- haemorrhage
- dehydration

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18
Q

What is first line antiplatelet alongside aspirin prior to PCI

A

Prasugrel

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19
Q

Type A aortic dissection on CT angio

A

See flap in the ascending aorta

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20
Q

Type B aortic dissection on CT angio

A

See flap in descending aorta

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21
Q

What is gold standard investigation for aortic dissection

A

CT angio

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22
Q

What investigation do for aortic dissection

A

CT angio if stable
If unstable then do transoesophageal echo if needs be

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23
Q

Management of aortic dissection

A

Type A- control BP to systolic 100-120 then surgical management
Type B- conservative bed rest and IV labetalol

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24
Q

Complications of aortic dissection

A

If tear goes towards heart
- MI
- aortic regurgitation
If tear goes forward
- stroke
- renal failure
- unequal BP in arms

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25
Q

What happens to BP in aortic dissection

A

Rises due to catecholamine surge

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26
Q

Assesment of aortic dissection

A

Obs- hypertension
ECG- may show inferior MI
CXR- widened mediastinum
Next choice depends on stability of patient
- CT angio preferable
- TOE if unstable

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27
Q

When refer if presenting with GP >180/110

A

Signs of end organ damage
- papilloedema
- retinal haemorrhages
- confusion
- chest pain

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28
Q

What is pulsus paradoxus

A

A large drop in BP on inspiration
Seen in cardiac tamponade

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29
Q

What is cardiac tamponade vs pericardial effusion

A

Pericardial effusion is fluid within the pericardial space
Tamponade is when there is pressure on the heart and the output is reduced

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30
Q

Features of cardiac tamponade

A

Becks triad
Pulsus paradoxus
Electrical alternans
May see kussmauls sign

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31
Q

What is in becks triad

A

Elevated JVP
Hypotension
Muffled heart sounds

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32
Q

What is kussmauls sign

A

JVP rises on inspiration

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33
Q

MOA of dabigatran

A

Direct thrombin inhibitor

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34
Q

Management of NSTEMI

A

MONA
Assess if stable
- if severely unwell (eg hypotensive) then immediate PCI
If stable then establish GRACE risk
- if >3% then PCI within 72 hours
- if <3% then fondaparinux and ticagrelor

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35
Q

If doing PCI in NSTEMI/unstable angina, what give alongside

A

Unfractionated heparin
Prasugrel or ticagrelor

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36
Q

When give fondaparinux in NSTEMI/UAP

A

Every time unless doing PCI immediately

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37
Q

What are causes of dilated cardiomyopathy

A

Idiopathic most commonly
Drugs- doxorubicin, cocaine, alcohol
IHD
Post myocarditis
Duchenne muscular dystrophy
Infiltrative- haemochromatosis, sarcoid

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38
Q

What impact can have thiamine deficiency have on heart

A

Restrictive and obstructive cardiomyopathy

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39
Q

Features on examination of dilated cardiomyopathy

A

HF findings
S3

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40
Q

CXR finding of dilated cardiomyopathy

A

Balloon appearance

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41
Q

Viral causes of myocarditis

A

Cocksackie B
HIV

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42
Q

Bacterial causes of myocarditis

A

Diphtheria
Clostridia
Lyme disease

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43
Q

Causes of myocarditis

A

viral: coxsackie B, HIV
bacteria: diphtheria, clostridia, lyme
protozoa: Chagas’ disease, toxoplasmosis
autoimmune- SLE, RA and sarcoid
doxorubicin

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44
Q

Presentation of myocarditis

A

Recent viral illness
Chest pain
HF features
Cause of 10% of sudden cardiac death

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45
Q

Blood findings of myocarditis

A

BNP up
Inflammatory markers up
Cardiac enzymes up

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46
Q

Complications of myocarditis

A

HF
Arrythmias
May progress to dilated cardiomyopathy

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47
Q

Management of myocarditis

A

Supportive- manage arrythmias and HF
May require transplant
Treat underlying cause

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48
Q

What is risk of left ventricular aneurysm

A

Thrombus formation
Patients are anticoagulated as a result

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49
Q

When do ventricular wall ruptures occur

A

1-2 weeks after

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50
Q

Presentation of ventricular free wall rupture

A

1-2 weeks post MI
HF presentation
Raised JVP
Pulsus paradoxus
Reduced HS

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51
Q

Management of dresslers syndrome

A

Oral NSAIDS

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52
Q

How does ventricular septal defect present post MI

A

HF with pansystolic murmur

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53
Q

Management of ventricular septal defect post MI

A

Urgent surgical correction

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54
Q

Ejection systolic murmurs

A

Aortic stenosis
HOCM
Pulmonary stenosis
Atrial septal defect
Tetralogy of fallot

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55
Q

How differentiate ejection systolic murmurs

A

Louder on expiration
- aortic stenosis
- HOCM
Louder on inspiration
- pulmonary stenosis
- atrial septal defect

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56
Q

Causes of pansystolic murmurs

A

Mitral and tricuspid regurgitation
Ventricular septal defect

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57
Q

Differentiating the pansystolic murmurs

A

Regurgitation murmurs high pitched and blowing
VSD very harsh sounding

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58
Q

Late systolic murmur

A

Mitral valve prolapse
Aortic coarctation

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59
Q

Early diastolic murmurs

A

Aortic regurgitation
Pulmonary regurgitation

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60
Q

What is the graham steel murmur

A

Pulmonary regurgitation which is very high pitched and blowing

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61
Q

What is the austin flint murmur

A

Seen in severe aortic regurgitation
Rumbling mid late diastolic

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62
Q

What is continuous machine murmur seen in

A

Patent ductus arteriosus

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63
Q

What are the mid late diastolic murmurs

A

Mitral stenosis
Austin flint murmur (severe aortic regurgitation)

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64
Q

Electroltye causes of prolonged QT

A

Hypocalcaemia
Hypokalaemia
Hypomagnaesaemia

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65
Q

What is difference between monomorphic and polymorphic VT

A

Monomorphic is all 1 shape
Polymorphic is multiple shapes

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66
Q

What is most common cause of monomorphic VT

A

MI

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67
Q

What does prolonged QT lead to

A

Torsades des pointes- a subtype of polymorphic VT

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68
Q

Which MIs are mitral regurg seen in

A

Infero-posterior

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69
Q

What antithrombotic therapy is given with bioprosthetic valves

A

Warfarin initially then aspirin

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70
Q

What antithrombotic therapy is given with mechanical heart valves

A

Warfarin + aspirin

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71
Q

What is kussmauls sign most likely to be seen in

A

Constrictive pericarditis

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72
Q

What is constrictive pericarditis

A

When the pericardial sac becomes granulomatous and non-elastic

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73
Q

Causes of constrictive pericarditis

A

Any pericarditis may progress to it
Mainly TB

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74
Q

Presentation of mitral stenosis

A

SOB
Haemoptysis- pulmonary congestion
AF- from left atrial enlargement

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75
Q

Features of MS murmur

A

Mid late diastolic heard best on expiration
Loud S1
Opening snap

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76
Q

Signs on examination of mitral stenosis

A

Low volume pulse
Malar flush
Loud S1 and opening snap
Mid diastolic murmur

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77
Q

What is management of mitral stenosis

A

Asymptomatic= regular echos
Symptomatic= balloon valvotomy or surgery
If in AF anticoagulate

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78
Q

What is arrythmogenic right ventricular cardiomyopathy

A

Autosomal dominant cardiac disease where right ventricle replaced by fibrofatty tissue

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79
Q

What are epsilon waves seen in

A

arrythmogenic right ventricular cardiomyopathy

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80
Q

Management of arrythmogenic right ventricular cardiomyopathy

A

Anti-arrythmics- sotalol
Catheter ablation of tissue
ICD implanted

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81
Q

How manage patient who has just had fibrinolysis for STEMI

A

Repeat ECG in 60 minutes
If still ST elevation then transfer to centre for PCI

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82
Q

Which valve most commonly affected in IE

A

Mitral except for in IVDU where is tricuspid

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83
Q

What is quinckes sign

A

Pulsating nailbed seen in aortic regurgitation

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84
Q

What is de mussets sign

A

Head bobbing- seen in aortic regurgitation

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85
Q

Signs on examination of aortic regurgitation

A

early diastolic murmur: intensity of the murmur is increased by the handgrip manoeuvre
collapsing pulse
wide pulse pressure
Quincke’s sign
De Musset’s sign

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86
Q

Management of aortic regurg

A

medical management of any associated heart failure
surgery: aortic valve indications include
- symptomatic patients with severe AR
- asymptomatic patients with severe AR who have LV systolic dysfunction

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87
Q

Causes of AR

A

Infections- rheumatic fever, syphillis, endocarditis
Calcified valve
Connective tissue diseases- RA, SLE, ank spond
Genetic conditions- marfans, ehlers-danlos
Aortic dissection

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88
Q

Which drugs should patients take following an MI long term

A

Dual antiplatelet therapy- aspirin 75 mg plus ticagrelor, prasugrel or clopidogrel for a year
Beta-blocker
ACEi
Aldosterone antagonist if reduced LVEF
Statin

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89
Q

Lifestyle advice post MI

A

Mediterranean diet
20-30 mins exercise to become slightly SOB
Sex 4 weeks after

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90
Q

What is best choice of drug for reduced LVF post MI

A

Aldosterone antagonist- epleronone

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91
Q

Causes of ST elevation (non-ACS)

A

pericarditis/myocarditis
normal variant
left ventricular aneurysm
Prinzmetal’s angina
Takotsubo cardiomyopathy
rare: subarachnoid haemorrhage

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92
Q

What is prinzmetal angina

A

Coronary artery spasm

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93
Q

Which arteries may aortic dissection involve

A

Coronary- MI
Spinal- paraplegia
Distal aorta- limb ischaemia

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94
Q

SVT management

A

Haem stable= Valsava first line
IV adenosine 6mg
Then 12mg
Then 18mg
Then verapamil if fails
Haem unstable, MI signs or HF= synchronised DC cardioversion

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95
Q

What is used for SVT if asthmatic

A

Verapamil

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96
Q

Long term prevention of SVT

A

B blockers
Radio frequency ablation

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97
Q

Causes of high output HF

A

anaemia
Pregnancy
thyrotoxicosis
arteriovenous malformation
Paget’s disease
thiamine deficiency

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98
Q

ECG findings of hyperkalaemia

A

Tented T waves
Widened QRS
Small p waves
If over 9 then get sinusoid/sine wave

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99
Q

When stop beta blockers in HF

A

HR<50
Second or third degree HB
Shock

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100
Q

What do if patient presents with bradycardia

A

A-E
In particular looking at BP and ECG
Look for
- shock signs
- syncope
- MI
- HF
Blood gas to identify electrolyte causes

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101
Q

Management of bradycardia

A

If signs of shock, MI, HF or syncope
- atropine 500mcg first line
If no response to this consider
- atropine doses up to 3mg
- transcutaneous pacing
- adrenaline injection
If no response to these then specialist help for transvenous pacing

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102
Q

What are options if atropine 500mcg does not work for bradycardia

A

Atropine 3mg
Transcutaenous pacing
Adrenaline injection

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103
Q

What do if second line options for bradycardia do not work

A

Seek specialist help for transvenous pacing

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104
Q

Even if satisfactory response to atropine 500mcg what still need to do

A

Check for risk of asystole
- recent asystole
- Mobitz II AV block
- complete HB
- ventricular pause >3s

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105
Q

Even if no signs of life threatening bradycardia what need to do

A

Check for risk of asystole
- recent asystole
- Mobitz II AV block
- complete HB
- ventricular pause >3s

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106
Q

Side effects of adenosine

A

Chest pain
Bronchospasm
Flushing

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107
Q

Indications for surgery in IE

A

Severe incompetence
Abscess
Antibiotic resistant infections
Cardiac failure
Persistent tachycardia

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108
Q

What is moa of alteplase

A

Activates plasminogen to plasmin

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109
Q

What is drug of choice for thrombolysis in STEMI

A

Tissue plasminogen activator- alteplase or tenectoplase

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110
Q

What is MOA of ticagrelor and prasugrel

A

P2Y12-receptor antagonist same as clopidogrel

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111
Q

What can be normal physiological findings on ECG in athletes

A

Sinus bradycardia
1st degree AV block
Mobitz type 1

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112
Q

What needs to always be given alongside thrombolysis

A

Antithrombin drug like fondaparinux

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113
Q

What are causes of preserved ejection fraction HF

A

HOCM
Restrictive cardiomyopathy
Cardiac tamponade
Constrictive pericarditis

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114
Q

Causes of reduced ejection fraction HF

A

Ischaemic heart disease
Dilated cardiomyopathy
Myocarditis
Arrhythmias

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115
Q

Who does ACS present atypically in

A

Women
Elderly

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116
Q

What causes deep pointed t wave inversion

A

Unstable angina or NSTEMI

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117
Q

What valve disease is associated with a loud opening snap

A

Mitral stenosis

118
Q

What does S3 heart sound suggest

A

HF

119
Q

Torsades des pointes management

A

IV mag sulph

120
Q

Causes of torsades des pointes

A

Causes of long QT interval
congenital
Jervell-Lange-Nielsen syndrome
Romano-Ward syndrome
antiarrhythmics: amiodarone, sotalol, class 1a antiarrhythmic drugs
tricyclic antidepressants
antipsychotics
chloroquine
terfenadine
erythromycin
electrolyte: hypocalcaemia, hypokalaemia, hypomagnesaemia
myocarditis
hypothermia
subarachnoid haemorrhage

121
Q

Poor prognostic markers in ACS

A

Cardiogenic shock
Cardiac arrest
Raised serum creatine
Hypotension
Age
Elevated cardiac markers
Peripheral vascular disease

122
Q

What must do for ALL patients with acute HF

A

IV furosemide

123
Q

When give oxygen in HF

A

Sats under 94%

124
Q

What give for resp failure in HF

A

CPAP

125
Q

If in cardiogenic shock in HF what do

A

Dobutamine first line
If this fails or is continuing circulatory failure use vasopressors
If these fals use mechanical circulatory assistance

126
Q

If someone comes in with HF, what consider in all patients

A

IV furosemide in all patients
Oxygen- only if less than 94% sats
Vasodilators- avoid if hypotensive

127
Q

When mainly want to use nitrates in HF

A

concomitant myocardial ischaemia
severe hypertension
regurgitant aortic or mitral valve disease

128
Q

Management of HOCM

A

Beta blockers 1st line or CCB
ICD
Surgical or catheter based reduction of atrial septa
May need heart transplant

129
Q

Which drugs cant give in HOCM

A

Nitrates
ACEi
Inotropes

130
Q

Causes of tricuspid regurgitation

A

right ventricular infarction
pulmonary hypertension e.g. COPD
rheumatic heart disease
infective endocarditis
Ebstein’s anomaly
carcinoid syndrome

131
Q

Signs on examination of tricuspid atresia

A

pan-systolic murmur
prominent/giant V waves in JVP
pulsatile hepatomegaly
left parasternal heave

132
Q

What can cause a raised troponin

A

ACS
High demand for cardiac muscle
- sepsis
- anaemia
- HF
- arrythmias

133
Q

What measure for a reinfarction

A

CK-MB

134
Q

Which heart enzyme is first to rise

A

Myoglobin

135
Q

MOA of fondaparinux

A

Activates anti-thrombin III

136
Q

Typical vs atypical angina

A

Typical has 3 of the following
Atypical has 2 of;
- pain described as constricting in chest, shoulders or arms
- brought on by exercise
- relieved by GTN within 5 mins

137
Q

First line investigation for angina if diagnosis uncertain

A

CT coronary angio

138
Q

What is best investigation for dresslers syndrome

A

ESR

139
Q

Causes of acute pericarditis

A

Cocksuckie
TB
Uraemia
Malignancy
Post MI
Radiotherapy
SLE, RA
Hypothyroidism

140
Q

Presentation of pericarditis

A

Pleuritic chest pain
Relieved on sitting forward
SOB
Flu like

141
Q

ECG changes for pericarditis

A

Saddle ST elevation
PR depression

142
Q

What investigation must always do for pericarditis

A

Transthoracic echo

143
Q

Investigations for pericarditis

A

ECG
- saddle shaped ST elevation
- PR depression
Bloods
- troponin may be up
- inflam markers up

144
Q

What does troponin being up in pericarditis suggest

A

Indicates myopericarditis

145
Q

What troponin measure nowadays

A

Troponin I/T

146
Q

Management of pericarditis

A

NSAIDs short term and colchicine for 3 months
Minimal exercise
Inpatient if raised trop or fever over 38

147
Q

Do pericarditis patients need to be treated as inpatient

A

Not necessarily, do if:
- fever 38>
- elevated troponin

148
Q

What is point of furosemide long term in HF

A

Only symptomatic support
No help for mortality

149
Q

First line for HF long term with reduced ejection fraction

A

ACEi or ARB
Beta blocker

150
Q

Which beta blockers are licensed for HF in UK

A

Bisoprolol
Carvedilol

151
Q

Second line treatment for reduced ejection fraction HF

A

Aldosterone antagonist
- spironolactone
- epleronome
Can add SGLT2s

152
Q

Extra non-cardiac treatments for HF

A

SGLT2
Annual flu
One off pneumococcal

153
Q

Management options for orthostatic hypotension

A

Conservative
- more fluid
- more salt in diet
- wean medications
Medical
- fludrocortisone

154
Q

What is collapsing pulse seen in

A

Aortic regurg
Hyperkinetic state- anaemia, sepsis, thyrotoxic etc

155
Q

What is jerky pulse seen in

A

HOCM

156
Q

Presentation of rheumatic fever

A

J- arthralgia
O- carditis
N- subcut nodules
E- erythema marginatum
S- sydenams chorea

157
Q

Management of rheumatic fever

A

If current infection- phenoxymethicillin
NSAIDS first line anti-inflammatory

158
Q

What is presentation of VSD post MI

A

Acute HF
Pan systolic murmur
Seen in first week post MI

159
Q

If have colorectal cancer, what organism is associated with endocarditis

A

Strep bovis

160
Q

Who should be considered for anticoagulation in AF

A

Anyone with even paroxysmal, asymptomatic AF or atrial flutter

161
Q

How interpret chadvasc scores

A

0= No anticoagulation
1= in men consider but not in women as 1 due to their sex
2= offer anticoagulation

162
Q

What do if chadvasc=0

A

No anticoagulation
Need to do TTO however to exclude valvular disease

163
Q

What is an absolute indication for anticoagulation in AF regardless of CHADVASC

A

Valvular disease

164
Q

What is second line anticoagulation post DOAC for AF

A

Warfarin

165
Q

What use in all patients with stable angina

A

Aspirin
Atorvastatin 80mg
Nitrates PRN

166
Q

First line for stable angina

A

1 of CCB or beta blocker
On top of aspirin and atorvastatin

167
Q

Stepped approach to stable angina

A

(whilst aspirin + atorvastatin already given)
1 of beta blocker or CCB
Increase dose
Add the other
If dual therapy does not work
Refer for PCI or CABG
While waiting add 1 of
- a long-acting nitrate
- ivabradine
- nicorandil
- ranolazine

168
Q

If waiting for PCI or CABG in stable angina- what do in meantime

A

Add 1 of
- a long-acting nitrate
- ivabradine
- nicorandil
- ranolazine

169
Q

What is problem of using nitrates long term in angina treatment

A

Tolerance and reduced efficacy

170
Q

When electrically cardiovert AF patients

A

Haem instability
HF signs

171
Q

Management of AF haemodynamically stable

A

Under 48 hours
- rhythm or rate control
Over 48 hours
- can rate control
- wait 3 weeks to cardiovert electrically
- anticoagulate for 3 weeks

172
Q

What medications use for rate control in AF

A

1st line: Beta blockers
- atenolol
- bisoprolol
2nd line: CCB
- verapamil
- diltiazem
3rd: Digoxin

173
Q

If asthmatic what use for rate control in AF

A

Verapamil (CCB)

174
Q

What is best person to use digoxin in for rate control

A

Sedentary lifestyle
HF

175
Q

What use for rate control if reduced LVF

A

Digoxin

176
Q

If going to medically cardiovert someone, what drug use

A

Flecainide if no structural or ischaemic heart disease
Amiodarone if so

177
Q

What do if AF unresponsive to anti-arrythmics or patient wishes to avoid antiarrythmics

A

Consider catheter ablation

178
Q

If having catheter ablation for AF, what need to do before it

A

Anticoagulate for 4 weeks

179
Q

What effect does ablation have on AF stroke risk

A

None so still need to be anticoagulated for life

180
Q

ECG of hypokalaemia

A

Small or absent T waves
u waves
Long PR
Long QT

181
Q

When refer chest pain in the GP

A

In last 12 hours= if ECG changes then ambulance
12-72 hours ago= refer for same day assessment
Over 72 hours= ECG and troponin measurement

182
Q

If management for SVT is unsuccessful after treatment with drugs then what is most likely cause

A

Atrial flutter

183
Q

What are the different NYHA classfications of HF

A

1- no symptoms even after normal exercise
2- fine at rest but ordinary activity results in symptoms
3- fine at rest but minimal activity results in symptoms
4- severe symptoms even at rest

184
Q

How are stanford B dissections managed

A

Uncomplicated- analgesia and HTN control
Complicated- surgery

185
Q

First line investigation for HF

A

NT-proBNP

186
Q

If have one episode of paroxysmal AF, what do

A

Calculate CHADVASC and consider starting DOAC

187
Q

Signs and symptoms of malignant HTN

A

Papilloedema
Retinal bleeding
Increased cranial pressure causing headache and nausea
Chest pain due to increased workload on the heart
Haematuria due to kidney failure
Nosebleeds which are difficult to stop

188
Q

Rhythm controlling beta blockers

A

Flecainide
Sotalol

189
Q

What is a double/bisferens pulse

A

Where feel 2 systolic peaks

190
Q

What is bisferens pulse seen in

A

Mixed aortic disease
HOCM

191
Q

What ECG changes are seen in hypothermia

A

J waves
ST elevation
Long QT
Bradycardia

192
Q

RFs for mitral regurg

A

Collagen disorders- ehlers danlos, marfans
Female sex
Recent MI
Mitral stenosis

193
Q

Management of broad complex tachycardia

A

Adverse signs- DC conversion
Regular= IV amiodarone
Irregular= cardio input

194
Q

Which drugs can cause long QT

A

amiodarone, sotalol
SSRI
TCA
methadone
chloroquine
erythromycin
haloperidol
ondanestron

195
Q

When take statins in day

A

Last thing in evening

196
Q

Causes of aortic stenosis

A

Calcification
Bicuspid valve
Williams syndrome
HOCM
Rheumatic fever

197
Q

Most common cause of aortic stenosis in young vs old

A

Old= calcfication
Young= biscupsid valve

198
Q

Antibiotics chosen for IE

A

Native valve- IV amox initially
Prosthetic valve- rifampicin, gentamicin and vancomycin
Severely ill or pen allergic- vancomycin and low dose gentamicin

199
Q

Which valve replacements are preferred

A

Mechanical valves as last longer

200
Q

What can raise BNP falsely

A

CKD

201
Q

What can falsely lower BNP

A

Diuretics
ACEi
ARB

202
Q

MOA of furosemide

A

Inhibits Na-K-Cl transporter in ascendiging loop of henle

203
Q

What are pericardial friction rubs associated with

A

Pericarditis

204
Q

What is wolf parkinson white syndrome

A

Congenital syndrome caused by accessory pathway from ventricles back to atria- AV re-entry tachycardia

205
Q

ECG findings of WPW

A

Short PR
Wide QRS with slurred upstroke- delta wave
Axid deviation depending on the location of the accessory pathway- most commonly left

206
Q

What is a delta wave

A

Slurred upstroke on QRS

207
Q

Management of WPW

A

Definitive management= radiofrequency ablation of accessory pathway
Long term medical tx- amiodarone and flecainide

208
Q

What are the surgery options for mitral stenosis

A

Commissurotomy or valve replacement
Balloon valvulotomy

209
Q

What do if patient has AF but chest pain

A

DC cardioversion
As do this in case of not only haem unstable but ACS signs too

210
Q

What can cause irregular broad complex tachycardia

A

AF with bundle branch block

211
Q

What causes a loud S2

A

Pulmonary HTN

212
Q

What is p mitrale indicative of

A

Left atrial enlargement often due to mitral stenosis

213
Q

How does p mitrale appear on ECG

A

Bifid p wave

214
Q

What can be side effects of nitrates

A

Hypotension
Tachycardia
Flushing
Headache

215
Q

If have AV block post MI, what is likely artery

A

Right

216
Q

When assessing orthostatic drops- how long wait

A

3 minutes

217
Q

What injection give if allergic to atropine in bradycardia

A

Adrenaline

218
Q

Target INR for mitral vs aortic valve replacement

A

Aortic- 3
Mitral- 3.5

219
Q

Management of brugada syndrome

A

Implantable cardioverter-defibrillator

220
Q

Pathophysiology of brugada syndrome

A

Inherited defect in cardiac sodium ion channel

221
Q

ECG changes which change after being given flecainide

A

Brugada syndrome

222
Q

ECG changes in brugada

A

Convex ST elevation in V1-3 followed by a negative T wave

223
Q

What ECG changes see in a posterior MI

A

Changes seen in V1-V3:
- ST depression
- dominant tall R waves
- upright T waves

224
Q

What is ECG territory is covered by LAD

A

V1-V4

225
Q

What is ECG territory of left circumflex

A

V5-V6
I
aVL

226
Q

What is ECG territory of right coronary

A

Inferior part of heart
aVF
II
III

227
Q

What artery occlusion causes a anteroseptal MI

A

Left anterior descending

228
Q

What artery occlusion causes an anterolateral MI

A

Proximal anterior descending

229
Q

What artery occlusion causes a lateral MI

A

Left circumflex

230
Q

What artery occlusion causes an inferior MI

A

Right coronary

231
Q

What artery occlusion causes a posterior MI

A

Typically left circumflex but can be right coronary

232
Q

How confirm a posterior MI

A

Repeat ECG with leads V7-V9 which will show ST elevation and Q waves

233
Q

What are U waves

A

Where get an upwards deflection following the T wave

234
Q

Which site of ablation is most likely to be effective for atrial flutter

A

Tricuspid valve isthmus

235
Q

How do you describe atrial flutter rate

A

Describe the degree of block present
Atrial rate is calculated as the number of flutters
Ventricular rate is the number of R waves
The degree of block is the atrial flutters: r waves

236
Q

What accentuates atrial flutter seen

A

Giving adenosine or carotid sinus massage

237
Q

What can do at the bedside to further identify atrial flutter

A

Give adenosine or carotid sinus massage

238
Q

4 causes of ST depression

A

Ischaemia
Hypokalaemia
Digoxin
Normal variant

239
Q

Pathognomic finding for digoxin therapy on ECG

A

Scooped ST depression in leads aVF, II, III and V5-6

240
Q

ECG findings in digoxin therapy

A

down-sloping ST depression (‘reverse tick’, ‘scooped out’)
flattened/inverted T waves
short QT interval

241
Q

What MI is most likely to cause bradyarrythmias due to AV block

A

Inferior

242
Q

What is murmur in HOCM

A

ESM louder on valsalva and quieter when squatting

243
Q

What foods should people on warfarin avoid

A

Those high in vitamin K
- spinach
- kale
- sprouts

244
Q

What are stages to hypertension

A

1= clinic BP>140/90 or ABPM>135/85
2= clinic BP >160/100 or ABPM> 150/95
3= clinic BP >180/110

245
Q

What are 3rd line options chronically for HF

A

Ivabradine
Hydralazine in combination with nitrate
Sacubitril-valsartan
Digoxin
Cardiac resynchronisation therapy

246
Q

What is cardiac resynchronisation therapy

A

biventricular (triple chamber) pacemakers, with leads in the right atrium, right ventricle and left ventricle. The objective is to synchronise the contractions in these chambers to optimise heart function.

247
Q

When start cardiac resynchronisation therapy for HF

A

Widened QRS from LBBB
Always add ICD at same time

248
Q

Who is hydralazine with nitrates considered in 3rd line for HF

A

Black people

249
Q

Best management of AF in HF

A

Digoxin

250
Q

When give digoxin for HF

A

No specific criteria but can help symptoms
Certainly give if coexistent AF

251
Q

When give ivabradine for HF

A

Sinus rhythm rate above 75
LVEF under 35

252
Q

When give sacubitril-valsartan (entresto)

A

LVEF under 35
Symptomatic on ACEi or ARB

253
Q

What need to do before giving sacubitril-valsartan

A

ACEi/ARB washout period

254
Q

What is sacubitril-valsartan

A

Valsartan (ARB) in combination with sacubitril a drug which inhibits neprilysin which breaks down naturietic proteins

255
Q

Ivabradine MOA

A

Slows HR allowing for more efficient pump

256
Q

If femoral access in PCI for ACS what give alongside angiography

A

Bivalirudin with bailout GPI

257
Q

If someone having STEMI what is first thing must assess

A

If eligible for PCI
If not then just give dual antiplatelet with cardio review

258
Q

Which antithrombin drug give in NSTEMI

A

Fondaparinux
UFH if creatinine over severe renal impairment

259
Q

What 3 things form main part of post MI management

A

Echo
Cardiac rehab
Dugs- BASH

260
Q

What give if beta blockers CI post MI

A

Verapamil or diltiazem unless reduced LVF

261
Q

What would consider as high risk for bleeding when deciding which antiplatelet post ACS

A

If over 75

262
Q

How long give antiplatelets for post ACS

A

Aspirin- indefinetely
Others- 12 months

263
Q

How long give beta blocker for post MI

A

12 months unless if reduced LVF

264
Q

When give second antiplatelet if doing thrombolysis

A

Post giving drug

265
Q

MI complications

A

muscle damage: HF, free wall rupture, ventricular aneurysm, VSD
inflammation: pericarditis or dresslers
valvular failure: MR
arrhythmia: VF/VT

266
Q

Which second antiplatelet give if fibrinolysis

A

Ticagrelor or clopidogrel if high bleeding risk/on anti coag
Give after administration

267
Q

If NSTEMI which second antiplatelet give

A

If not having PCI then ticagrelor or clopi (think high risk bleeding from antithrombin drug so avoid prasugrel)
If having PCI soon offer prasugrel, ticagrelor or clopi

268
Q

Do you refer from GP if angina

A

Only refer to chest pain clinic if unsure about diagnosis or murmur, previous MI, HF, AF

269
Q

What do if stable angina diagnosis certain in GP

A

Investigate potential precipitating causes- lipids, HbA1c, anaemia
Give aspirin 75mg
1 of CCB or B blocker
GTN spray

270
Q

How explain GTN therapy to a patient

A

Stop exercise when comes on and take medication
If not relieved in 5 mins take again, if after second dose no effect then call ambulance

271
Q

2nd and 3rd line investigations for angina

A

2nd line- non invasive functional imaging- MR angio, single photon emission uptake, stress echo
3rd line- angiography

272
Q

What vagal manouevers are recommended for SVT

A

Valsalva method of blowing into syringe
Cold stimulus to face
Carotid sinus massage- CI in history of IHD or HF

273
Q

What do if adenosine fails for SVT

A

Verapamil- given as slower bolus over 2 minutes

274
Q

Classification of SVT

A

AVNRT- re-entry pathway via av node
AVRT- re-entry pathway from atria to ventricles
Atrial tachycardia

275
Q

What types of SVT is WPW

A

AVRT

276
Q

Most common classification of SVT

A

AVNRT

277
Q

Most common cardiac arrythmia

A

AF

278
Q

What is first line for AF assuming stable

A

Rate control is first line unless
- onset within last 48 hours
- is causing HF
- reversible cause

279
Q

If medical cardioversion is contraindicated for a patient with new onset AF starting in last 48 hours what do

A

Electrical cardioversion

280
Q

Presentation of sick sinus syndrome

A

Bradycardia with episodes of arrythmias

281
Q

Which chronic HF drug use with caution in valvular disease

A

ACEi

282
Q

When use steroids for pericarditis

A

2nd line or NSAIDs CI
Underlying RA

283
Q

Cardiomyopathy causes

A

Restrictive
- amyloid
- post radiation
- sarcoid
Dilated
- haemochromatosis
- alcohol
- chemo
- post myocarditis
Genetic
- HOCM
-arrythmogenic right ventricle
Takotsobu

284
Q

Indications for ICD

A

HOCM/arrythmogenic right ventricular cardiomyopathy
Long QT
Previous VT or VF

285
Q

Pacemaker vs ICD

A

ICD there if go into cardiac arrest
Pacemaker to initiate contractions for heart

286
Q

What are the different types of pacemaker

A

Single chamber in either RV or RA
Dual chamber in RA and RV
Biventricular in LV, RV and RA

287
Q

Indications for pacemaker

A

Mobitz T2
3rd degree HB
Symptomatic bradycardia
Ablation at AVN
Severe HF
Sick sinus syndrome

288
Q

What is pacemaker used in severe HF

A

Biventricular in RA, LV and RV which synchronises contractions to maximise LVF

289
Q

How to tell if dual chamber pacemaker

A

On ECG will see lines before p wave and r wave

290
Q

Single chamber pacemaker in RA

A

On ECG will see line before p wave

291
Q

Single chamber pacemaker in RV

A

On ECG will see line before R wave

Finals (29 decks)

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