Cardiology

Question 1

Who to give endocarditis prophylaxis to?

Answer 1

Unrepaired cyanotic heart disease
Prothetic valves
Previous endocarditis
NEJM 2013

Question 2

Empirical antibiotics for endocarditis? Who to give Vanc

Answer 2

Fluclox/Gent/BenPen

Vanc/Gent for: Hospital acquired, suspected MRSA, prothestic valve, penicillin allergy

Question 3

Indications for surgery for endocarditis

Answer 3

Heart failure
o Regurgitation/obstruction causing cardiogenic shock, pulmonary oedema, signs of pulmonary hypertension, haemodynamic compromise
Embolic events
o Vegetation >10mm after an embolic event
o Vegetation >10mm with complicated course
o Vegetation >15mm to spare native valve
Uncontrolled infection
o Abscess, dehiscence, fistula, false aneurysm, enlarging vegetation
o Persistent fever and blood culture > 5-7 days
o Infection due to fungi or MDR organism

Question 4

Endocarditis risk factors

Answer 4

Previous IE (strongest risk factor)
Prothetic valves
Implantable cardiac devices
Rheumatic heart disease
Unrepaired cyanotic heart disease
Age related degenerative valve disease
IVDU
DM
HIV
MOST INFECTIVE ENDOCARDITIS IS ON NORMAL VALVES

Question 5

stable angina workup

Answer 5

< 10% CAD risk: no Ix
10-29%: coronary CT
30-60% risk: echo stress test
61-90%: angiogram

Question 6

Long qt

Answer 6

LQT1: decreased activity slow potassium channel; worse in exercise; 80% respond to beta blockade
broad tall T waves

LQT2: decreased activity rapid potassium channel; worse in women
late T U

LQT3: increased activity sodium channel; worse in sleep; 50% respond to beta blockers
worse in men; from sleep / startle
late T wave

Question 7

Brugada syndrome

Answer 7

Sodium channels
St elevation in v1-v3
Most in v2
Inferior brugada: early repolarisation syndrome: st elevation 1-3, terminal qrs notching

Question 8

Svt v vt

Answer 8

Negative v5, v6 suggests vt

Question 9

drugs which cause long QT

Answer 9

most anti arrhythmics:
•amiodarone, sotalol, class 1a antiarrhythmic drugs
(almost) all antidepressants
•tricyclic antidepressants, selective serotonin reuptake inhibitors (especially citalopram)

• methadone
• chloroquine
• terfenadine**
• erythromycin
• haloperidol

Question 10

••Long QT3 -

Answer 10

events often occur at night or at rest

Na channels

Question 11

Long QT1 -

Answer 11

usually associated with exertional syncope, often swimming

K+ channels

Question 12

•Long QT2

Answer 12

• often associated with syncope occurring following emotional stress, exercise or auditory stimuli
  K+ channels

Question 13

Inhibitors of the P450 system include

Answer 13

• antibiotics: ciprofloxacin, erythromycin
• isoniazid
• cimetidine, omeprazole
• amiodarone
• allopurinol
• imidazoles: ketoconazole, fluconazole
• SSRIs: fluoxetine, sertraline
• ritonavir
• sodium valproate
• acute alcohol intake
• quinupristin

Question 14

Inducers of the P450 system include

Answer 14

• antiepileptics: phenytoin, carbamazepine
• barbiturates: phenobarbitone
• rifampicin
• St John’s Wort
• chronic alcohol intake
• griseofulvin
• smoking (affects CYP1A2, reason why smokers require more aminophylline)

Question 15

Indications fo Digibind

Answer 15

Life threatening arrhythmia
Signs of end-organ damage
Hyperkalaemia

Question 16

Acute CP - Ix according to risk stratification

Answer 16

Low (10-30%) - Coronary CT
Mod (30-60%) - Non invasive e.g. stress echo)
High (>60%) - Angiogram

Question 17

TIMI Risk Score

Answer 17

To stratify pts with unstable angina or NSTEMI

1. Age 65 years
2. Presence of at least three risk factors for CHD
3. Prior coronary stenosis of 50%
4. At least 2 anginal episodes in prior 24 hrs
5. Use of aspirin in prior 7 days
6. Elevated serum cardiac biomarkers
7. Presence of ST segment deviation

> 3 early invasive strategy
4 use tirofiban

Question 18

DES v BMS

Answer 18

benefit with DES is less restenosis.

dual antiplatelet for 12 months (min 6) v 3 months (min 6 weeks)

Question 19

Congenital heart disease saturations

Answer 19

Eisenmengers - flow reversed - right to left
PDA - aorta to pulmonary artery
A, V, Pul art
therefore ASD - diff at atrial level
VSD - diff at ventricular level
PDA - diff at pul art / aorta level
normal right heart 70%
left heart 100%

Question 20

pulmonary HT

Answer 20

mena PAP > 25mmHg
low nitric oxide; low prostacyclin
increased endothelia 1

Question 21

regurgitant fraction

Answer 21

= regurgitant volume / total volume
regurgitant volume = (LVEDV - LVESV) - SV
LVESV is measured prior to regurgitant blood coming back
what you start with minus what you’re left with; take away what actually stayed out
tells you how much went out then came back in

Question 22

torsades de pointe

Answer 22

form of polymorphic VT with QT prolongation

Rx: IV magnesium

Question 23

apixaban

Answer 23

compared to warfarin in non valvular AF
lower all cause mortality
lower ICH, GI bleeds
lower PE, AMI
Aristotle trial

Question 24

rivaroxaban

Answer 24

post AMI: decreased mortality, more bleeding
interactions: 3A4; p glycoprotein - azoles, ritonavir, rifampicin, carbamazepine, st johns wort
dose reduce if eGFR < 50
contraindicated if eGFR < 30

Question 25

dabigatran

Answer 25

dyspepsia common

reduce in renal failure

Question 26

NOACS

Answer 26

non valvular AF
similar stroke reduction
less ICH

Question 27

ticagrelor

Answer 27

more dyspnoea