Cardiology Flashcards
1
Q
What are signs of right-sided heart failure?
A
Raised JVP
Ankle oedema
Hepatomegaly
2
Q
Which coronary artery will be affected if there is complete heart block following a MI?
A
Right coronary artery - it supplies the AV node in 90% of people
3
Q
In resistant hypertension (stage 4 of NICE guidelines), you give different drugs depending on potassium levels (above or below 4.5mmol/L) - what do you give?
A
Potassium levels below 4.5mmol/L: add spironolactone (potassium-sparing diuretic)
Potassium levels above 4.5mmol/L: add alpha- or beta-blocker
4
Q
How should you manage an acute presentation of atrial fibrillation with haemodynamic instability (i.e. heart failure, hypotension)?
A
Synchronised electrical cardioversion
5
Q
How do you manage haemodynamically stable atrial fibrillation patients?
A
< 48 hours: rate or rhythm control
≥ 48 hours or uncertain (e.g. patient not sure when symptoms started): rate control. If considered for long‑term rhythm control, delay cardioversion until they have been maintained on therapeutic anticoagulation for a minimum of 3 weeks
6
Q
What medications can you use for rate control in AF?
A
Beta blockers
Rate-limiting CCBs (i.e. verapamil)
Digoxin
7
Q
What do you do for rhythm control in AF?
A
If presenting within 48hrs:
* DC cardioversion
* Chemical cardioversion with flecainide or amiodarone
If presenting after 48hrs:
* Anticoagulate for 3-4 weeks before attempting cardioversion
* Also claculate CHADVASC
8
Q
What are long-term rhythm controlling drugs that can be used?
A
Beta blockers
Dronedarone
Amiodarone
9
Q
What cause falsely low BNP levels?
A
Aldosterone antagonists
ACE inhibitors
Angiotensin-II receptor antagonists
Beta-blockers
Diuretics
Obesity
10
Q
What murmur are Marfan’s Syndrome and Ehlers-Danlos syndrome associated with?
A
Mitral regurgitation (pansystolic murmur)
11
Q
What should you do if Well’s score is above 4?
A
CTPA as pulmonary embolism is likely
If there is a delay in getting the CTPA then interim therapeutic anticoagulation should be given until the scan is performed.
12
Q
What should you do if Well’s score is below 4?
A
D-dimer
13
Q
What causes persistent ST elevation following recent MI, no chest pain?
A
Left ventricular aneurysm
Patients usually present with tiredness and breathlessness
14
Q
How does papillary muscle rupture present?
A
Severe complication of an inferior MI. It causes incompetence of the mitral valve and results in pulmonary oedema. Peak incidence is about 3-5 days following an MI.
15
Q
What are contraindications to GTN administration?
A
Hypotensive conditions
Aortic or mitral stenosis
Cardiac tamponade
Constrictive pericarditis
Hypertrophic cardiomyopathy
Raised ICP
16
Q
State if the following is a shockable or non-shockable rhythm:
* Ventricular fibrillation
* Pulseless ventricular tachycardia
* Asystole
* Pulseless-electrical activity
A
- Ventricular fibrillation - shockable
- Pulseless ventricular tachycardia - shockable
- Asystole - non-shockable
- Pulseless-electrical activity - non-shockable
17
Q
When should you administer adrenaline in cardiac arrest?
A
1mg adrenaline as soon as possible in non-shockable rhythms
1mg adrenaline once chest compressions have restarted after the third shock in VT/VF cardiac arrest
*Repeat adrenaline 1mg every 3-5 minutes whilst ALS continues
18
Q
When do you administer amiodarone in a cardiac arrest?
A
Amiodarone 300 mg should be given to patients who are in VF/pulseless VT after 3 shocks have been administered.
A further dose of amiodarone 150 mg should be given to patients who are in VF/pulseless VT after 5 shocks have been administered
19
Q
What are the reversible causes of cardiac arrest?
A
4Hs:
* Hypoxia
* Hypovolaemia
* Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia and other metabolic disorders
* Hypothermia
4Ts:
* Thrombosis (coronary or pulmonary)
* Tension pneumothorax
* Tamponade – cardiac
* Toxins
20
Q
What organisms cause infective endocarditis?
A
- Staphylococcus aureus - acute presentation and IVDU
- Streptococcus viridans - poor dental hygiene, dental procedures
- Staphylococcus epidermidis (coagulase-negative Staphylococci) - prosthetic valves
- Streptococcus bovis - associated with colorectal cancer
21
Q
What are causes of non-infective endocarditis?
A
SLE, ALP
Marantic endocarditis (malignancy) - metastatic carcinomas
22
Q
What is the mechanism of flash pulmonary oedema in myocardial infraction?
A
Acute mitral valve regurgitation (with new pansystolic murmur)
23
Q
What investigations should you order in suspected pericarditis?
A
- ECG: widespread, global changes + saddle-shaped ST elevation + PR depression
- Transthoracic echocardiography
- Bloods: modest rise in troponin
24
Q
How should you manage a patient on warfarin with a major bleed?
A
Stop warfarin
Give intravenous vitamin K 5mg
Prothrombin complex concentrate - if not available then FFP (FFP takes time to defrost)
25
What ECG changes can be considered normal varient in atheletes?
* Sinus bradycardia
* Junctional rhythm
* First degree heart block
* Mobitz type 1 (Wenckebach phenomenon)
26
What ECG changes are seen in hypokalaemia?
U waves
Small or absent T waves (occasionally inversion)
Prolong PR interval
ST depression
Long QT
27
What ECG changes are seen in hyperkalaemia?
Peaked or 'tall-tented' T waves (occurs first)
Loss of P waves
Broad QRS complexes
Sinusoidal wave pattern
Ventricular fibrillation
28
When would you perform an immediate coronary angiography in an NSTEMI patient?
If they are clinically unstable
If patients have a GRACE score>3%
29
What is the management of NSTEMI/unstable angina?
1. Aspirin 300mg
2. Fondaparinux if no immediate PCI planned or not high risk of bleeding
3. Unfractionated heparin if PCI or creatinine level <265
For antiplatelet choice, if patient has high bleeding risk give clopidogrel, otherwise give ticagrelor
30
When do you consider PCI in a STEMI?
If the presentation is within 12 hours of the onset of symptoms AND PCI can be delivered within 120 minutes (otherwise consider fibrinolysis if there is a significant delay in being able to provide PCI)
If patients present after 12 hours and still have evidence of ongoing ischaemia then PCI should still be considered
*Need to be on dual antiplatelet therapy before PCI: aspirin + prasugrel (if patient not taking oral anticoagulants) or clopidogrel (if patient on oral anticoagulants)
31
What is the management of angina pectoris?
* All patients should receive aspirin and a statin in the absence of any contraindication
* Sublingual glyceryl trinitrate to abort angina attacks
* 1st step: Beta-blocker or rate-limiting CCB (verapamil or diltiazem).
* 2nd step: Beta-blocker + longer-acting dihydropyridine CCB (amlodipine, modified-release nifedipine). Do not use verapamil with beta-blocker as it can cause heart block
32
What murmur is atrial fibrillilation associated with?
Mitral stenosis: mid-diastolic murmur best heard on expiration.
This is secondary to ↑ left atrial pressure → left atrial enlargement → AF.
33
What are causes of LBBB?
* Myocardial infarction
* Hypertension
* Aortic stenosis
* Cardiomyopathy
34
Name side effects of loop diuretics (i.e. furosemide)
* Electrolyte imbalances - hyponatraemia, hypokalaemia, hypochloraemia, hypomagnesaemia, hypocalcaemia
* Hypotension
* Ototoxicity
* Renal impairment (dehydration + toxic effect)
* Hyperglycaemia
* Gout
35
What can be used to differentiate constrictive pericarditis and cardiac tamponade?
Kussmaul's sign (raised JVP that doesn't fall on inspiration) is seen in constrictive pericarditis
36
What are absolute contraindication to thrombolysis?
* Active internal bleeding
* Recent haemorrhage, trauma or surgery (including dental extraction)
* Coagulation and bleeding disorders
* Intracranial neoplasm
* Stroke < 3 months
* Aortic dissection
* Recent head injury
* Severe hypertension
37
If there is ST elevation in leads II, III and aVF, which coronary artery is affected?
Right coronary artery
38
Which ECG leads are affected in a right coronary artery MI?
II, III and aVF
39
Which ECG lead changes suggests and MI in the left anterior descending coronary artery territory?
V1 to V4 (anteroseptal)
40
Which ECG leads do you see changes in an MI in the proximal left anterior descending coronary artery territory?
V1-6, I, aVL
41
Which class of anticoagulants are indicated in AF for reducing stroke risk?
DOACs i.e. rivaroxaban
42
In AF, what should you do if CHADSVASc score suggests no need for anticoagulation?
Transthoracic echocardiogram has been done to exclude valvular heart disease, which in combination with AF is an absolute indication for anticoagulation.
43
What CHADSVASc score would suggest need for anticoagulants?
1 if male. If 1 and female, no need. 2 or over
44
What needs to be monitored when starting on statins?
LFTs at baseline, 3 months and 13 months
*Treatment should be discontinued if serum transaminase concentrations rise to and persist at 3 times the upper limit of the reference range
HbA1c at baseline and 3 months if patient is at risk of diabetes
45
What skin change can amiodarone cause?
Jaundice + grey skin discolouration
46
How does NICE define anginal pain?
1. Constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms
2. Precipitated by physical exertion
3. Relieved by rest or GTN in about 5 minutes
Patients with all 3 features have typical angina
Patients with 2 of the above features have atypical angina
Patients with 1 or none of the above features have non-anginal chest pain
47
What are side effects of beta blockers?
* Bronchospasm
* Cold peripheries
* Fatigue
* Sleep disturbances, including nightmares
* Erectile dysfunction
48
What are the different aortic dissections according to the Stanford classification?
Type A - ascending aorta, 2/3 of cases
Type B - descending aorta, distal to left subclavian origin, 1/3 of cases
49
What is the management of aortic dissection?
Type A: surgical management, but blood pressure should be controlled to a target systolic of 100-120 mmHg whilst awaiting intervention
Type B: conservative management + bed rest + reduce blood pressure IV labetalol to prevent progression
50
Which cardiac enzyme is the first to rise after infarction?
Myoglobin (rises at 1-2 hours and peaks at 6-8 hours)
51
Which cardiac enzyme is most useful for identifying re-infarction?
CK-MB (it returns to normal after 2-3 days)
*Troponin T remains elevated for up to 10 days
52
How does a posterior MI present on a 12-lead ECG?
ST depression and not elevation
Tall, broad R waves, dominant R wave in V2
Upright T waves
*Specific changes are really only seen in V1-V3
53
What is dabigatran and what can be given to reverse its effects?
Oral anticoagulant that works by being a direct thrombin inhibitor
Idarucizumab is a monoclonal antibody used to reverse the effects of dabigatran
54
You are considering prescribing an antibiotic to a 28-year-old man who tells you he has Long QT syndrome. Which antibiotic is it most important to avoid?
* Doxycycline
* Trimethoprim
* Erythromycin
* Rifampicin
* Co-amoxiclav
Erythromycin
It is associated with cardiotoxicity, specifically QT interval prolongation and ventricular arrhythmias such as torsades de pointes
55
A 25-year-old female is found to have a left hemiparesis following a deep vein thrombosis. An ECG shows RBBB with right axis deviation. What is the most likely underlying diagnosis?
* Ventricular septal defect
* Patent ductus arteriosus
* Coarctation of the aorta
* Ostium secundum atrial septal defect
* Tetralogy of Fallot
Ostium secundum atrial septal defect
Clots are more commonly passed from venous to arterial circulation through atrial defects as opposed to ventricular defects.
Paradoxical stroke is much more likely in an ASD as the pressure gradient between the two atrial chambers is much smaller, so blood (and clots) can flow from right to left occasionally. The left ventricular pressure is usually much greater than the right, so blood flow across a VSD is usually only left to right, so paradoxical embolism is much rarer (but can still happen). Eisenmenger's syndrome in large VSDs can cause reversal of flow (also RBBB/right axis deviation) but you would expect more features of right heart failure.
56
In ALS, patients who are in VF/pulseless VT after 5 shocks have been administered should be given what medication?
2nd dose of amiodarone at 150mg
*1st dose is at 300mg
57
If a patient presents >48hours after the start of AF symptoms, how long should they be anticoagulated for before cardioversion?
At least 3 weeks before attempting **electrical cardioversion**
In the meanwhile patients should also be started on rate-controlling drugs such as bisoprolol
58
In what type of MI can you see heartblock?
Inferior MI
Right coronary artery supplies the AV node in 80% of people (in the remaining 20% this is supplied by the circumflex artery)
59
Which statin is commonly used 1st line for prevention of cardiovascular disease?
Atorvastatin
*Simvastatin is not as potent at reducing cholesterol
60
What investigations do you do for patients suspected of stable angina?
1st line: CT coronary angiography
2nd line: non-invasive functional imaging (looking for reversible myocardial ischaemia)
3rd line: invasive coronary angiography
61
Which valve pathology is usually associated with early diastolic murmur?
Aortic regurgitation
62
What are causes of chronic presentation of aortic regurgitation?
Valve disease:
* Rheumatic fever: the most common cause in the developing world
* Calcific valve disease
* Connective tissue diseases e.g. rheumatoid arthritis/SLE
* Bicuspid aortic valve
Aortic root disease:
* Bicuspid aortic valve
* Spondylarthropathies
* Hypertension
* Syphilis
* Marfan's, Ehler-Danlos syndrome
63
What are causes of acute presentation of aortic regurgitation?
Valve disease:
* Infective endocarditis
Aortic root disease:
* Aortic dissection
64
Causes of dilated cardiomyopathy
* Idiopathic (the most common cause)
* Myocarditis: e.g. Coxsackie B, HIV, diphtheria, Chagas disease
* Ischaemic heart disease
* Peripartum
* Hypertension
* Iatrogenic: doxorubicin (abx)
* Substance abuse: alcohol, cocaine
* Inherited: Duchenne muscular dystrophy
* Infiltrative: haemochromatosis, sarcoidosis
65
What ECG changes are associated with Wolff-Parkinson White?
* Short PR interval
* Wide QRS complexes with a slurred upstroke - 'delta wave'
* Left axis deviation if right-sided accessory pathway (in majority of cases)
* Right axis deviation if left-sided accessory pathway
66
What is Wolff-Parkinson White?
Congenital accessory conducting pathway between the atria and ventricles leading to atrioventricular re-entry tachycardia (AVRT).
As the accessory pathway does not slow conduction AF can degenerate rapidly to VF.
67
What conditions are associated with Wolff-Parkinson White?
* HOCM
* Mitral valve prolapse
* Ebstein's anomaly
* Thyrotoxicosis
* Secundum ASD
68
What is the definitive management of AVRT?
Radiofrequency ablation of the accessory pathway
69
What are the different types of AVNRT?
Typical (slow-fast) where the current travels anterograde through the alpha (slow) pathway and then up the beta (fast) pathway
Atypical (fast-slow) which is the opposite of typical
70
What is Beck's triad?
Classical features of cardiac tamponade:
* hypotension
* muffled heart sounds
* elevated JVP
71
What are features of constrictive pericarditis?
JVP: X + Y wave present
Pulsus paradoxus: absent
Kussmal's sign: present
Characteristic features: Pericardial calcification on CXR
72
What is the mechanism of action of furosemide?
Inhibits the Na-K-Cl cotransporter in the thick ascending limb of the loop of Henle
It affects the apical membranes of epithelial cells, reducing absorption of NaCl and thereafter increased urine output and decreased fluid volume in the body
73
How does left ventricular free wall rupture present following a MI?
Seen in around 3% of MIs and occurs around 1-2 weeks afterwards.
Patients present with acute heart failure secondary to cardiac tamponade (raised JVP, pulsus paradoxus, diminished heart sounds).
Urgent pericardiocentesis and thoracotomy are required.
74
What is a S3 heart sound associated with and caused by?
Caused by diastolic filling of the ventricle
Considered normal if < 30 years old (may persist in women up to 50 years old)
Heard in left ventricular failure (e.g. dilated cardiomyopathy), constrictive pericarditis (called a pericardial knock) and mitral regurgitation
75
What is a S4 heart sound caused by and associated with?
May be heard in aortic stenosis, HOCM, hypertension
Caused by atrial contraction against a stiff ventricles —> coincides with the P wave on ECG
In HOCM a double apical impulse may be felt as a result of a palpable S4
76
What is the management of torsades de pointes?
IV magnesium sulphate
77
What ECG abnormality is subarachnoid haemorrhages associated with?
Torsades de pointes
78
In aortic dissection, what is seen on the following imaging modalities?
CXR
CT
CXR - widened mediastinum
CT - false lumen
79
How much atropine can be given in bradycardia?
IV bolus of 500 micrograms of atropine
This can be repeated up to 5 more times (making 6 boluses in total and a total dose of 3 mg given)
80
What can you do if atropine does not resolve acute bradycardia?
Transcutaneous pacing
or
Isoprenaline/adrenaline infusion titrated to response
81
What is the preferred imaging modality for suspected aortic dissection?
CT angiography (depending on stability of patient)
TOE tends to be used to confirm the diagnosis if still unclear after CT angiography, or if the patient is unstable and is likely to deteriorate before getting to the CT scanner.
82
What are common ECG findings in patients with pulmonary embolism?
Sinus tachycardia (most common)
Right bundle branch block and right axis deviation
S1Q3T3 - large S wave in lead I, a large Q wave in lead III and an inverted T wave in lead III
83
A patient is on warfarin, how do you treat the following situations?
* Major bleeding
* Minor bleeding, INR > 8.0
* Minor bleeding, 5.0-8.0
* No bleeding, INR > 8.0
* No bleeding, 5.0-8.0
* Major bleeding: Stop warfarin, IV vitamin K, IV Prothrombin Complex Concentrate (or FPP if previous unavailable)
* Minor bleeding, INR > 8.0: Stop warfarin, IV vitamin K, restart warfarin when INR < 5.0
* Minor bleeding, 5.0-8.0: Stop warfarin, IV vitamin K, restart warfarin when INR < 5.0
* No bleeding, INR > 8.0: Stop warfarin, oral vitamin K, restart warfarin when INR < 5.0
* No bleeding, 5.0-8.0: Withhold 1 or 2 doses of warfarin, reduce subsequent maintenance dose
84
What anti-thrombotic therapy is given for prosthetic heart valves?
* Bioprosthetic
* Mechanical
* Bioprosthetic: aspirin
* Mechanical: aspirin + warfarin
85
What is the target INR for a mechanical aortic valve?
3.0
86
What is the target INR for a mechanical mitral valve?
3.5
87
What rib pathology can be seen in coarctation of the aorta?
Notching of the inferior border of the ribs (due to collateral vessels) - generally seen in 70% of adults and not seen in children
88
What are features of cor pulmonale?
Peripheral oedema
Raised jugular venous pressure
Systolic parasternal heave
Loud P2
89
What is first-line therapy for chronic heart failure?
ACE-inhibitor and beta-blocker
90
What is second-line therapy for chronic heart failure?
Aldosterone antagonists
*There is also an increasing role for SGLT2 inhibitors
91
What is the most specific ECG marker for pericarditis?
PR depression
92
What are 4 aetiologies of ST depression?
* Normal variant
* Ischaemia
* Hypokalaemia
* Digoxin
93
What ECG changes are seen in digoxin use?
* Down-sloping ST depression ('reverse tick', 'scooped out')
* Flattened/inverted T waves
* Short QT interval
* Arrhythmias e.g. AV block, bradycardia
94
What are causes of S3 heart sounds?
aka ventricular gallop - rapid ventricular filling
"Ken-tuc-ky" - occurs in early diastole (during passive ventricular filling)
* Dilated cardiomyopathy
* Valvular heart disease (mitral regurgitation and aortic regurgitation) --> ventricular volume overload
* Congenital heart disease
* Heart failure
* Constrictive pericarditis
It can also be a normal finding in children, well-trained athletes and pregnant women
95
What are causes of S4 heart sounds?
aka atrial gallop - atrial contraction against stiff ventricle
"Ten-nes-see" - occurs in late diastole (during active ventricular filling)
* HOCM
* Stenotic valves - especially aortic stenosis
* Hypertension
* Severe LVH
* Ischaemic heart disease
96
What is a bisfierens pulse and in which condition do you see it?
'double pulse' - two systolic peaks
Seen in mixed aortic valve disease
97
What should also be administered in a NSTEMI patients with high GRACE score undergoing PCI?
IV glycoprotein IIb/IIIa receptor antagonist
98
What ECG changes are seen in hypothermia?
* bradycardia
* 'J' wave (Osborne waves) - small hump at the end of the QRS complex
* first degree heart block
* long QT interval
* atrial and ventricular arrhythmias
99
What is Wellen's syndrome?
Particularly deeply inverted or biphasic T waves in leads V2-V3, that is highly specific for critical, proximal stenosis of the left anterior descending (LAD) coronary artery - cardiac ischaemia in the setting of unstable angina and is a high-risk trace warranting further investigation
100
What monitoring do patients on amiodarone require?
TFT, LFT, U&E (due to risk of hypokalaemia), CXR (due to risk of pulmonary fibrosis) prior to treatment
TFT, LFT every 6 months
101
What are causes of non-infective endocarditis?
SLE
Malignancy - marantic endocarditis
102
What is arrhythmogenic right ventricular cardiomyopathy?
Form of inherited cardiovascular disease which may present with syncope or sudden cardiac death - second most common cause of sudden cardiac death in the young after HOCM
103
What is the pathophysiology of arrhythmogenic right ventricular cardiomyopathy?
* inherited in an autosomal dominant pattern with variable expression
* the right ventricular myocardium is replaced by fatty and fibrofatty tissue
* around 50% of patients have a mutation of one of the several genes which encode components of desmosome
104
What are the features and what do you see on investigations in arrhythmogenic right ventricular cardiomyopathy?
Features:
* palpitations
* syncope
* sudden cardiac death
Investigations:
* ECG abnormalities in V1-3, typically T wave inversion. An epsilon wave found in 50% of those with ARV (described as a terminal notch in the QRS complex)
* echo changes are often subtle in the early stages but may show an enlarged, hypokinetic right ventricle with a thin free wall
* magnetic resonance imaging is useful to show fibrofatty tissue
105
How do you prevent nitrate tolerance?
NICE advises that patients who take standard-release isosorbide mononitrate should use an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimise the development of nitrate tolerance
This effect is not seen in patients who take once-daily modified-release isosorbide mononitrate
106
What are two common causes of an absent radial pulse?
Grafting - arterial grafts tend to last longer than venous grafts
AV fistula for dialysis
107
What causes an apex beat displacement?
Dilatation of the heart
NOT HYPERTROPHY
108
Name causes of heart dilatation
This is caused by volume overload (CXR diagnosis):
* aortic regurgitation
* mitral regurgitation
* ASD/VSD
109
Name causes of heart hypertrophy
This is caused by pressure overload (ECG diagnosis):
* aortic stenosis
* hypertension
* coarctation of the aorta
110
What can you give in cardiogenic shock to help with perfusion?
Dobutamine - cardiac stimulant through beta 1 agonists.
Dopamine can also be used but less preferred.
111
What can you give in septic shock to help with perfusion?
Noradrenaline - stimulates alpha and beta-1 receptors.
Main effect is vasoconstruction to shut off non-essential organs, and thereby maintaining BP
112
What imaging is done in the assessment of stable angina?
1st line: CT coronary angiography
2nd line: non-invasive functional imaging (looking for reversible myocardial ischaemia)
3rd line: invasive coronary angiography
113
What is Brugada syndrome?
Inherited disorder of the cardiac sodium channel that predisposes to the development of fatal arrhythmia and sudden cardiac death.
The ECG changes are divided into several types but the classic Brugada sign is ST elevation in V1-V3 with deep T wave inversion
114
What ECG changes are seen in HOCM?
* Left ventricular hypertrophy
* Non-specific ST segment and T-wave abnormalities, progressive T wave inversion may be seen
* Deep Q waves
* Atrial fibrillation may occasionally be seen
115
What is the mechanism of sudden death in HOCM?
Ventricular arrythmias
116
In AF do you withhold anticoagulation based on age or risk falls?
No
But it is still important to consider ORBIT scores
117
What condition should you be suspicious of if there is an inferior MI with AR murmur
Proximal aortic dissection
118
What should you do after performing fibrinolysis in ACS?
Repear ECG at 60-90 minutes post-fibrinolysis
If ST elevation persists, send patient for PCI
119
What are the indication of the following 3rd-line heart failure therapies:
* Ivabradine
* Sacubitril-valsartan
* Digoxin
* Hydralazine with nitrate
* Cardiac resynchornisation therapy
* Ivabradine: sinus rhythm >75/min and LVEF <35%
* Sacubitril-valsartan: LVEF <35% and ACEi/ARB not working
* Digoxin: coexisting AF
* Hydralazine with nitrate: Afro-Caribbean patients
* Cardiac resynchornisation therapy: widened QRS complex on ECG
120
What is the aim in cholesterol reduction following use of a statin?
Reduction in non-HDL cholesterol of >40%
121
What should you do if a patient presents with BP >= 180/120 mmHg?
If signs of retinal haemorrhage or papilloedema - same day specialist referral
Otherwise arrange investigations for end-organ damage (e.g. bloods, urine ACR, ECG).
* If present, start anti-hypertensives without ABPM/HBPM
* If none, repeat BP in 7 days
122
What does ambulatory blood pressure monitoring involve?
* at least 2 measurements per hour during the person's usual waking hours (for example, between 08:00 and 22:00)
* use the average value of at least 14 measurements
123
What does home blood pressure monitoring involve?
* for each BP recording, two consecutive measurements need to be taken, at least 1 minute apart and with the person seated
* BP should be recorded twice daily, ideally in the morning and evening
* BP should be recorded for at least 4 days, ideally for 7 days
* discard the measurements taken on the first day and use the average value of all the remaining measurements
124
What is coarctation of the aorta associated with?
Turner's syndrome
Bicuspid aortic valve
Berry aneurysms
Neurofibromatosis
125
What murmur is heard in HOCM and how is it affected in the following situations:
* when performing valsava manouvre
* squatting
Ejection systolic murmur
* when performing valsava manouvre - louder
* squatting - quieter
126
What is the target INR for mechanical valves?
Aortic - 3.0
Mitral 3.5 (due to increased risk of thromboembolism)
127
How long should CPR be continued for when given thrombolytics dugs (e.g. alteplase) for a suspicion of PE-induced cardiac arrest?
60-90 minutes
