Cardiology 🫀 Flashcards
Abdominal aortic aneurysm screening. When, how, who
Abdominal ultrasound is used to screen for abdominal aortic aneurysm (AAA) in men age 65-
75 with a smoking history.
, patients age <45 with AUB who have failed medical management require what
an endometrial biopsy.
Why is a hystersalpkngogram and ablation CI in AUB, when not identified cause
Could be CA, and therefore CA can be spread
Why do patients with AUB refractory to COCP need biopsy
In such patients, the endometrial lining is likely too thick for the progestin to completely shed the endometrium during menstruation; as a result, the unshed endometrium continues to undergo dysregulated proliferation, which leads to an increased risk of endometrial hyperplasia/cancer.
Three main indications to biopsy endometrium in AUB <45 yo
indications for endometrial biopsy in women age <45 include persistent (>6 months) AUB, obesity, or
tamoxifen therapy, all of which increase the amount of unopposed endometrial estrogen exposure. Also if there is failed medical therapy
Main risks of vecicular vaginal fistula
due to young maternal age (ie, small pelvis) and limited or no prenatal care, which results in delayed diagnosis and labor intervention. Obstructed labor is the most common cause.
continuous vaginal discharge with an abnormally elevated pH (ie, >4.5) due to urine,
which may be malodorous due to surrounding necrotic tissue. Pelvic examination typically shows vaginal
pooling of urine, a visible defect, or an area of raised, red granulation tissue on the anterior vaginal wall.
Bladder dye testing is performed to confirm the diagnosis,
Echo finding for MS
Increased transmittal flow velocity
Run through Dukes criteria for endocarditis
BE FIVOR
Bacteraemia, endocardial signs (mama), fever, immune phenomena, vascular phenomena, organism culture, risk factors.
B and E are the major criteria. The rest are minor. Diagnose i.e. if two major, or one major and three minor, or five minor
If CHADVAS says so… how do we prevent thromboemb in AF
NOACs are best. Not anti PLT for sure
HTN and Low dose diuretic causing significantly low K+…. Cause?
Primary hyperaldo
An early peaking systolic murmur is seen in mild or severe AS
Mild AS
A loud S1 is seen in which murmur
M.S.
Some differences between athletes heart and hypertrophic cardiomyopathy
Hypertrophic cardiomyopathy will have focal areas of enlargement (IV septum).
Cavity of the left ventricle will be decreased in HCM (it is usually increased in athletes). The thickness is usually above 15 mm in HCM. Diastolic function is compromised in HCM. The left atria can be enlarged in HCN.
What is masked hypertension
Hypertension fluctuates throughout the day, making it hard to establish a diagnosis.
Which cardiovascular issues are a contraindication for pregnancy
Symptomatic mitral stenosis, aortic stenosis. Heart failure with a ejection fraction of less than 30. Pulmonary artery hypertension. Should try and address these things and then do pregnancy
Why is pregnancy a contraindication for patients with severe symptomatic M.S.and A.S.
In pregnancy we have an increase total volume, which will exacerbate the stretching of the heart, which could predisposed to emboli, AF, pulmonary oedema
Mitral valve replacement surgery
Balloon mitral Valvulotomy. If you can’t do that you can do open mitral repair or replacement
What medication can be given to help mitral stenosis in pregnancy
If a symptomatic, can give a beta blocker. This will decrease the heart rate, increase the left ventricle filling time, lowering the pressure in the left atrium. If symptomatic must do surgery before pregnancy
What is the cornerstone for medical management 4NSTEMI
Dual antiplatelet therapy. P2Y 12 inhibitor and aspirin
Do we give NOAC in acute coronary syndrome
No. Increases the risk of bleeding. So we do dual antiplatelet, and a bit of low molecular weight heparin
Murmur of both papillary muscle rupture, and interventricular wall rupture
Papillary muscle rupture will cause a soft mitral regurgitation. Interventricular will rupture will cause a half pan systolic murmur had left sternal border plus a thrill.
In a cute mitral regurgitation, do we see enlargement of the atria and ventricles
No, there is not enough time for eccentric hypertrophy. Therefore we don’t get accommodation of high-volume, so we get acute pulmonary oedema
Indications for aortic valve replacement. Otherwise do what?
Severe AS & >=1 of the following:
• Onset of symptoms (eg, angina, syncope)
• Left ventricular ejection fraction <50%
• Undergoing other cardiac surgery (eg, CABG)
Severe AS see on another FC
Otherwise do serial monitoring with echo
Criteria for severe AS
Jet velocity of….
Mean Transvaal u,at pressure gradient of….
Valve area of……
Aortic jet velocity 24.0 m/sec, or
• Mean transvalvular pressure gradient 240 mm Hg
• Valve area usually $1.0 cm? but not required
What is secondary mitral regurgitation
Mitral regurgitation, but nothing wrong with the valve itself. Usually due to ventricular movement issues, or ventricular dilation
Which is the only shock type that has elevated SVO2 and cardiac output
Distributive shock
Describe the potential radiation of pericarditis
Pleuritic chest pain that can radiate posteriorly To the bilateral trapezius ridges
Describe the potential radiation of pericarditis
Pleuritic chest pain that can radiate posteriorly To the bilateral trapezius ridges
We all know pericarditis can cause diffuse ST elevation. Eventually what else can we see on the ECG
T-wave inversion
Patient contraindicated for NSAID in pericarditis. What can be given
Corticosteroid
Two ways to definitively diagnose aortic dissection. One of them is for stable, the other is for unstable patient
Unstable, do transoesophageal echocardiogram. Stable patients can have a CTA
Medical management of acute aortic dissection
Pain control, Ivy beta blockers, nitroprusside if the systolic blood pressure is above 120.
Why might a Peri operative MI be painless
Because the patient is probably on morphine for pain control
What kind of shock does adrenal crisis cause
Both distributive and hypovolaemic shock
When does infective endocarditis cases require surgical intervention
If there is heart failure from valve dysfunction, if there is localised extension of infection (abscess, fistula, heart block). Difficult to treat pathogens like fungi or multidrug resistant. Vegetation is more than 1 cm which are high risk of embolisation
What is a pericardial window, and when is it used
It’s a removal of part of the pericardium, to allow pericardial fluid drain into either the flora or peritoneum. Used when there is continuous tamponade after days, or is recurrent.
How to manage malignant pericardial effusion
Acute drainage to relieve symptoms and do psychology. To prevent accumulation either do pericardial window or catheter drainage
A couple of things to manage a tit spell
Knee chest positioning, and inhale oxygen
what size aortic stenosis can usually cause a final symptoms
<1cm and increased pulse pressure. Otherwise the cause is likely CAD
Signs of purulent pericardial effusion
Acute, fever and illness. Chest pain and chills. Fatal. Usually pericarditis ECG and maybe low QRS amp. Need to do centesis
Risk factors for purulent pericardial effusion
Immunosupressed, dialysis, recent thoracic surgery
Patient with Taki arrhythmia who is haemodynamically unstable. Patient has a pulse. What do we do
Direct current cardioversion (i.e. synchronised cardioversion). This could be in a fib or a flutter or other arrhythmia which is unstable. If the patient has pulseless VT or VF, THEN of course we do defib
What is transcutaneous pacing used for
Heart block. Usually complete heart block, or symptomatic bradycardia
Are plural effusions common after coronary artery bypass surgery
Yes
Name me three elements to a Plural effusion, post coronary artery bypass graft surgery, That would make you want to investigate it further
If it’s large in size, it’s enlarging, it’s late onset (many days after surgery), is associated with significant respiratory symptoms. If none of these exist can just observe
Name some complications for acute aortic dissection
Stroke, aortic regurgitation, Horners syndrome, myo infarction, Tamponade, haemothorax, renal injury, abdominal injury, paraplegia
How can an aortic dissection cause MI
Dissection can affect the coronary Ostei
Which different symptoms can you see in aortic regurgitation
Water hammer pulse, pistol shot femoral pulse, crescendo diastolic murmur, widened pulse pressure, Palpitations, head bobbing, quincke pulse
Persistent pulmonary HTN of newborn.
Pathogenesis?
RF?
Exam?
Tx?
High pulmonary BP, usually due to low O2 states (potters, meconium aspiration, neonatal pneumonia, CDH). Get high PVR and this PDA remain open with Right to left shunt. This causes low o2 in the legs but normal in upper body. Give O2 and NO
Pulses bisferiens can be seen in which diseases
Aortic regurgitation and HCM and large PDA. It’s essentially a biphasic pulse
What are the lifestyle interventions to decrease hypertension. And roughly rank them in order
Dash diet. Weight loss (SBP decrease by six per 10 kg weight loss). Aerobic exercise. Reduce dietary sodium. Alcohol limitation
What is the single biggest risk factor for hypertension
Visceral/central obesity
Talk about cholesterol embolise syndrome
Usually after fracture or stent/Angio. Can cause Davido reticularis, hypocomplementaemia, eosinophilia, renal damage, GI issues
Causes of high output heart failure
Obesity, AV fistula, hypothyroidism, anaemia, cirrhosis, Paget disease, thiamine deficiency beriberi
 Strongest risk factor for aortic dissection
Hypertension history
List as many complications as you can from aortic dissection
Stroke, Acute aortic regurgitation, Horner syndrome, MI, Tamponade, haemothorax, renal injury, abdominal pain, paraplegia of lower limbs
Symptoms of sudden aortic regurgitation
Chest pain, low blood pressure, pulmonary oedema
Does Tamponade
Affect the left or right side of the heart
The right side. Therefore there should not be pulmonary oedema, but rather peripheral oedema
A risk carotid pulse is indicative of aortic stenosis or hypertrophic cardiomyopathy
Hypertrophic cardiomyopathy
Left atria Increase size, is a sign of chronic or acute mitral regurgitation
Chronic only
Why is the Chad Vaz score done, what does it indicate
Patients with low Chad virus unlikely to have recurrent AF. So younger patients, non-comob patients, generally have one episode of AF. Therefore do not need anticoagulant
Causes of constrictive pericarditis
Radiation therapy, previous cardiac surgery, recurrent viral pericarditis, Tb in endemic areas
ECG and venous tracing findings of constrictive pericarditis
 Low voltage QRS. Venus tracing shows prominent X and Y descent
Recap on the A CV an XY descent On Venus tracing
 A wave is for atrial contraction, Seawave is for ventricular contraction closing the tricuspid, the wave is for right atrial filling.
Canon a wave on Venus tracing is seen in which pathology
Atrioventricular dissociation
What pathology causes prominent V wave on Venus tracing
Tricuspid regurgitation
Which arrhythmia causes an absent a wave on Venus tracing
Atrial fibrillation
Which pathology causes flattened Y decent
Cardiac tamponade
Pregnant woman has high blood pressure, urine has 0/1+ protein. Management to do
24 hour urine collection. Needed since protein in urine dipstick has high false negative
The mum heard in a cute interventricular wall septum perforation
Harsh holo systolic murmur, with palpable thrill
t Contrast the murmur between papillary muscle rupture and interventricular wall rupture.
Acute mitral regurgitation is soft, and there is no palpable thrill.
 If patient who has M I is not revascularised in until up to 24 hours, what does this mean clinically for the future
Highlights of complications, like IV septum rupture, freewheel rupture et cetera
A cute limb ischaemia management
Anticoagulation at 1st (heparin). Then thrombolyses or surgery
Ventricular aneurysm and three wall rupture, both show what ECG finding which is interesting
Persistent ST elevation is in correspondence to the MI preceding 
Three times you hear S4
 Concentric hypertrophy, restrictive cardiomyopathy, myocardial infarcti
Thyro toxicosis can cause what heart sound
S3
Where is S3 and S4 heard best
Apex, with the bell stethoscope
 Why do patients who have acute on chronic limb ischaemia, have slower onset
Because chronic plaques in the legs will cause collaterals to form
AAA screening
Ultrasound in 65 to 70-year-old man who have any history of smoking
Went to do surgical repair for AAA
If above 5.5 cm, if symptomatic, or on
SAD of aortic stenosis
Syncope, angina, dyspnoea
What is an Austin Flint Mumma
Apical diastolic rumbling, seen in aortic regurgitation
Thrill/Mama over femoral arteries is a sign of which valvular disease
Aortic regurgitation
Associated conditions with Mitral valve prolapse
Polycystic kidney disease, ehrlos Danlos syndrome, Marfan syndrome, fragile X
Aside from mitral regurg/prolapse what are the pathology can cause a systolic click
Myxoma
Greatest risk factor for aortic dissection, and aneurysm respectively
Hypertension and smoking respectively
Leriche syndrome
Area occluded
Aortoiliac obstruction
If a woman who is on oestrogen for her hot flushes, and end up getting a DVT. What medication change you to make
Swap to SSRI Or SNRI
Distended veins above and below the ankle. Significance?
Hello the ankle is normal. Above the ankle is a sign of venous insufficiency
If thrombosed vein is palpable in superficial. Is it more DVT or superficial thrombophlebitis
Superficial thrombophlebitis
What is lemierre disease 
A complication of pharyngitis/tonsillitis/peritonsillar abscess. Where we get septic thrombophlebitis of internal jugular vein
Went to give statins in primary prevention and secondary prevention
Primary prevention, after ACS angina CABG/TIA PAD
Secondary prevention, LDL above 190, about 40 years old and diabetes
Can prostaglandin be given after the ductus arteriosus is closed
Yes, it can reopen
What kind of check should turner syndrome patients have the cardiac problems
They need screening with for extremity blood pressure measurements, an echocardiogram. This can diagnose coartcion or bicuspid aortic valve
 How to differentiate between pleural friction rub and pericardial friction rub
Ask the patient to hold their breath, if the rub remains it’s pericardial
 Syncope with exertion, what are your thoughts
Either ventricular arrhythmia secondary to ischaemia, or an outflow obstruction like aortic stenosis
And when diagnosing coronary artery disease (angina), when is an exercise ECG test done
With intermediate pretest probability. In patients who can do exercising, and reach a target heart rate. ECG at baseline is normal. Not allowed if the patient has left bundle branch block, a pacemaker, patient unable to reach target heart rate
And when diagnosing coronary artery disease (angina), when is an exercise Donumatime stress test done
Of course when there is an intermediate pretest probability. I done when a patient is unable to meet the target heart rate, or has reactive airway disease. This is not allowed if somebody has a tachyarrhythmia
And when diagnosing coronary artery disease (angina), when is a Coronary steel stress test done
Of course done when there is intermediate pretest probability. Good if the patient has left bundle branch block, a pacemaker, unable to reach target heart rate. Not allowed if the patient has reactive Airway disease, or is on dipyridamole or theophylline
How does COPD, or severe asthma cause pulsus paradoxus
It creates negative pressure in the thorax, which when breathing in causes big drop in intrathoracic pressure. The pressure causes blood to pool in the pulmonary vasculature, leading to less ventricular preload
How can an aortic regurgitation even prevent pulses paradoxus in patients with Tamponade
Severe regurgitation will cause higher left ventricle and diastolic pressure, that would preclude the IV septum from shifting into the left ventricular cavity
Mamma heard in co-arched aorta
Systolic heard at the left infraclavicular area anteriorly and left interscapular area posteriorly
Clues for syncope being cardiac origin
Sudden onset, no prodromal, heart structural issues, occurs at rest or excretion, ECG clues
Discuss the murmur heard in atrial myxoma
Because the mass is typically mobile, obstructive symptoms may be transient and influenced by position (ie, mitral obstruction is exacerbated by upright posture but is alleviated by lying down); tumor movement occasionally causes a characteristic “tumor plop” sound at the end of diastole on auscultation.
Discuss the murmur heard in atrial myxoma
Because the mass is typically mobile, obstructive symptoms may be transient and influenced by position (ie, mitral obstruction is exacerbated by upright posture but is alleviated by lying down); tumor movement occasionally causes a characteristic “tumor plop” sound at the end of diastole on auscultation.
Regular wide-complex tachycardia with 2 fusion beats, Dx?
Sustained monomorphic ventricular tachycardia (SMVT).
In hypertensive emergencies… how much can we lower BP by in 1st hour, then in next 23 hours.
mean arterial pressure should be lowered by 10%-20% in the 1st hour and by
another 5%-15% over the next 23 hours.
Pacemaker insertion causes risk for which valve disease
TC regurg
QT prolongation stuff
Hypocalcemia
Hypokalemia
.
Hypomagnesemia
Antibiotics (eg, macrolides,
fluoroquinolones)
• Psychotropics (eg, antipsychotics, TCAs,
SSRIs)
Opioids (eg, methadone, oxycodone)
Antiemetics (eg, ondansetron, granisetron)
Antiarrhythmics (eg, quinidine,
procainamide, flecainide, amiodarone,
sotalol)
And our channelipathies (K channels)
Can cor pulmonale be secondary to left side HF
No
Someone with subacute symptoms of fever, aortic regurgitate, heart block
Peri valvular abcess
Perivalvular abcess sus, invx?
TEE echo
Eccentric hypetrophy. Compensation to decomp story
Increase LV VOL. increase stretch and thus SV (frank starling). More vol means eccentric hypertrophic over time. Keeps SV, but wall stress increases. Eventuallly stress is too much and we decompensate.
What is the passive and active cause for pulmonary artery BP to increase in MS/left HF
The passive (or postcapillary) component of pulmonary hypertension is most prominent and results from transmission of elevated pressure backward from the left atrium to the pulmonary veins, pulmonary capillaries, and pulmonary arteries. Clinically, this process is typically evidenced by pulmonary edema and its associated symptoms (eg, orthopnea,
paroxysmal nocturnal dyspnea, hemoptysis), as well as peripheral edema.
• The reactive (or precapillary) component of pulmonary hypertension is only sometimes present and occurs independent of left atrial pressure. In this process, MS triggers endothelin-mediated pulmonary arteriolar vasoconstriction and pathologic vascular remodeling through a poorly understood mechanism.
PAH vs other pulmonary HTN Mx approach
PAH, use endothelium antag, prostenoids, PDE inhib etc.
Other pulmonary HTN, focus on cause
Flags to suggest psychigeninc psuedosyncope….. aka conversion disorder
Prolonged LOC (eg, 20 min): PPS episodes typically last many minutes to hours versus approximately 1-2 minutes in
syncope.
• Absence of objective findings during the episode: As in this patient, typical objective findings accompanying syncope
(eg, abnormal vital signs, pallor, sweating) are usually absent on examination.
• Patient’s reports of symptoms/events that occurred during the episode (eg, “I felt my head throbbing after it hit the
floor”): This awareness rules out true LOC. Symptoms are often reported in a detached or disassociated manner (la
belle indifférence).
Discuss the retroperitoneal hematoma from cardiac catheterisation
If the arterial puncture site is
above the inguinal ligament, the hematoma can extend into the retroperitoneal space, even with minimal visible localized
hematoma, and present with sudden hemodynamic instability and ipsilateral flank or back pain.
 Seizure versus syncope
Consider preceding symptoms, patient position, tongue biting, convulsive movement, urine incontinence, post episode recovery
Seizures have auras, syncopating may have a prodrome (vasovagal). Seizure can happen in any position, syncope can happen when standing in vasovagal only. Tongue biting is very indicative of seizure. Convulsive movements can be seen in both (is usually before or with the consciousness loss in seizure, and after the LOC in syncope). Your incontinence is seen more in seizure. Post-episode recovery is usually longer in seizure
Which symptom in seizures has the highest specificity against Syncope
Tongue biting
A patient newly diagnosed with hypertension. What other investigations do we need to do in a normal primary hypertension patient
Consider renal function test, lipids, glucose/haemoglobin A1 C, ECG, full blood count
 Patient with recurrent palpitations, potential arrhythmia. Do ECG a normal. Might we have to do to identify this problem
24 hour ambulatory monitoring
What is the most common cause for foci in atrial fibrillation
Usually left atrial enlargement. Most of the time it’s hypertension, causing left ventricle hypertrophy, decreasing diastolic volume, transferring the pressure back to the left atria, causing it to enlarge. This can create an atrial substrate for a fib
Changes in right ventricular preload, left on curricular preload, SVr in right-sided is STEMI
Right ventricular preload increase, left entrepreneur decrease, SVR increase
ALS guidelines for treatment of:
A fib or a flutter
Superventricular tachycardia
A fib with aberrant conduction
Monomorphic VT
Rate control
Vago manoeuvre, Than adenosine
Rhythm control
Pharmacological cardioversion (amiodarone, procainamide, lidocaine, sotalol
Amiodarone is a good rhythm control drug. How does it also have some rate control elements
It’s a potassium channel blocker, but also blocks some calcium channels in the AV node, thus having rate control properties
Does decrease aortic compliance increase systolic or diastolic blood pressure
It increases the systolic blood pressure, and thus the pulse pressure
How does a mild aortic regurgitation sound compared to a severe
Mild AR is heard only at early diastole, where as severe AR is heard throughout diastole
How does restrictive cardiomyopathy appear on an echo
Usually concentric hypertrophy, and atria enlargement.
Recall the presentation of restrictive cardiomyopathy
Predominantly right sided heart issue. JVD, ascites, hepato-megaly, pitting oedema. Concentric ventricular hypertrophy, with dilated atria. Diastolic dysfunction
Patient has aortic dissection, vitals are okay. History of kidney problems. Investigation of choice
Transoesophageal echocardiogram UF***Retard. Anyone with contrast allergy or renal problems must have for TEE instead of CTA
How might elevated systemic venous pressure is caused a protein losing enteropathy
Patients can get intestinal lymphangiectasia secondary to protein loss in the GI system.
What is the pericardial knock
A mid diastolic sound, that is indicative
Multifocal atrial, tachycardia management
 usually don’t have to treat. But definitely treat any underlying cause (pulmonary, septic, metabolic et cetera). If patient has ischaemia or heart failure signs due to this, we can give rate control therapy
Anterolateral MI can cause which deviation in axis
Right
Inferior MI can cause which deviation in axis
Left
PR interval
QRS interval
<5 small square
< 3 small squares
Comprehensive list of causes of drugs causing long QT
Class 1A, Class III, ondensetron, macrolides, quinolones, opioids,
General electrolytes causing long QT
Low Mg, low Ca, low K
After days of an MI what ECG signs remain
T inversion (go within months) and patho Q waves
Do my NSTEMI have Q waves
No
Lft and Rt atrial enlargement mneumonic
Pulmonale causes peaked P wave
Mitrale causes M shaped P wave
More than ?cm is increased JVP
3cm
Increase preload with increase most murmurs except ??
HOCM and MVP
Other causes of collapsing pulse
Aortic incompetence of course, then also, AV malf, thyrotox, severe anemia, (like high output HF)
Other than tamponade and severe asthma/COPD. What else can cause pulses paradox
Tension pneumothorax, foreign airway obs
Pulsus alternans and causes
Alternating string and weak pulse. Cardiomyopathy’s (like a poor LV stroke vol). Poor Px
Jerky pulse seen where
HCOM
Bifid pulse
Twice beating in systole. Aortic regurg. Or AR AND AS together. HOCM
Third-degree block. What is the RR and pee pee intervals
The R&R intervals will be regular. The PP intervals will also be regular. But they are just not in Synkro
Most common indication for pacemaker placement
Sick sinus syndrome (because of increased risk of AF or other superventricular tachyarrhythmias)
Why do patients with sick sinus syndrome get junctional escape
Because the P-wave has dropped, there is a long paws, so the ventricle generates its own rhythm.
List me the contraindications to do carotid sinus massage
Three months past history of MI, TIA, stroke, carotid stenosis, carotid atheroma, ventricle fibrillation, ventricular tachycardia
What is a retrograde P-wave
Essentially where the P-wave comes before the T-wave. And is often seen in AVNRT or AVRT
If an AVRT is secondary to wolf Parkinson white, how do we treat
Observation if no symptoms. Procainamide or amiodarone. The whole vagal maneuvres or adenosine is for AVRT not due to WPW. Can put on procainamide if has Hx of syncope/palpitations
Main cause of multifocal atrial tachycardia
Anything that causes cardiac remodelling. For example COPD, heart failure et cetera
 General management for multifocal atrial tachycardia
IV beta blocker or CCB (normal rate control
What is an atrial tachycardia, and what do I give to try and uncover the underlying ectopia
It is an ectopic foci but within the atria. Give adenosine Musk underlying activity
Monomorphic VT recap of management
If stable can just give rhythm control (amiodarone, lidocaine, procainamide). If haemodynamically unstable do synchronised cardioversion. If pulseless VT do defib
Review of torsade de pointes management
If stable give magnesium. If unstable to synchronised cardioversion. If pulseless do defibrillation. And correct electrolytes or remove offending medication
Should hyperthyroidism always be considered in A fibrillation work up
Yes
If a wolf Parkinson white patient develops recurrent AF. What should I give
Procainamide. Remember never give adenosine, beta blocker, non-dihydropyridine CCB in wolf Parkinson white. Even if AVRT or AF occurs
