Cardiology

Question 1

ODYSSEY LONG TERM Trial

Answer 1

Demonstrated that alirocumab (a PCSK9 inhibiter) reduced LDL by 61% at 24 weeks (2015)

Question 2

OSLER

Answer 2

Demonstrated that evolocumab (a PCSK9 inhibiter) reduced LDL by 61% at 24 weeks (2015)

Question 3

FOURIER

Answer 3

Evolocumab in stable atherosclerosis resulted in a 15% reduction of composite end points (CV death. MI. stroke etc) but no mortality reduction (2017)

Question 4

ODYSSEY-OUTCOMES

Answer 4

Alirocumab post ACS reduces all cause mortality by 15% (2018)

Question 5

ORION-10

Answer 5

Inclisiran: Small interfering RNA.6 monthly injection Knocks down PCSK9 expression60% reduction in LDL

Question 6

CLEAR Harmony

Answer 6

Bempedoic acid; blocks ATP citrate lyase (prodrug) 16% reduction in LDL but 3% get gout (2019)

Question 7

Acute pericarditis risk factors for hospitalisation

Answer 7

Fever >38CSubacute presentationCardiac tamponade (or haemodynamic compromise) Large pericardial effusion >20mmImmunosuppression AnticoagulationTrauma No improvement after 7d of NSAID Troponin rise

Question 8

Treatment of acute pericarditis

Answer 8

First line: NSAID + colchicine If ACS: aspirin specifically + colchicine If NSAID contraindicated: glucocorticoid + colchicine Activity restriction Treat underlying cause Drainage if: - Large effusion - Malignancy or infection - Tamponade Beta blocker if HR>70 + symptoms despite NSAID

Question 9

Initial treatment of ACS

Answer 9

• Nitrate (ex. RV infarct) - Beta blocker (ex. RV infarct) - Antiplatelets: Aspirin + P2Y12 - Anticoagulation - K>4 Mg>1 - Cease NSAIDs

Question 10

Heritable aortopathy

Answer 10

MELT - Marfan Syndrome FBN1/2 - Ehlers-Danlos Syndrome (EDS) Alpha-1 procollagen type III - Loeys-Dietz TGF-beta receptor - Turner Syndrome (dissection in particular) X deletion (45.X +/- mosaicism)

Question 11

Marfan Syndrome gene mutation

Answer 11

FBN1/2

Question 12

Ehlers-Danlos Syndrome (EDS) gene mutation

Answer 12

Alpha-1 procollagen type III

Question 13

Loeys-Dietz gene mutation

Answer 13

TGF-beta receptor

Question 14

Definition of aortic aneurysm

Answer 14

Aorta >50% of expected diameter involving all three layers

Question 15

Aortic dissection risk factors

Answer 15

• Age. male - Atherosclerosis and its associated risk factors - Bicuspid aortic valve -Aortic coarctation - Instrumentation of AV or aorta - Intense exercise Cocaine use

Question 16

Lenegre Disease

Answer 16

Progressive fibrosis of cardiac skeleton in under 60s resulting in heart block

Question 17

Lev disease

Answer 17

Sclerosis of left heart skeleton in over 70s resulting in heart block

Question 18

Underlying cause of heart block in over 50% of cases

Answer 18

Fibrosis and sclerosis; idiopathic

Question 19

Cause of 40% of cases of AV block

Answer 19

Ischaemia

Question 20

Identify the rhythm

Answer 20

Mobitz I - Wenckebach

Question 21

Initial treatment of unstable Mobitz II heart block

Answer 21

Isoprenaline (or dobutamine/adrenaline/dopamine) + transcutaneous (TV) pacing Not atropine

Question 22

Initial treatment of unstable Mobitz I heart block

Answer 22

Atropine + transcutaneous (TV) pacing

Question 23

Identify the arrhythmia

Answer 23

Mobitz II

Question 24

Identify the arrhytmia

Answer 24

Third degree heartblock

Question 25

Drugs which may cause AV block

Answer 25

Beta blockers Verapamil Adenosine Digoxin

Question 26

LBBB ECG criteria

Answer 26

QRS>120msec Broad/slurred R in I. aVL. V5. V6R wave peak>60msec V5. V6 Absent or narrow q waves in I. V5. V6

Question 27

Name the abnormality

Answer 27

Left posterior fasicular block Right axis deviation rS in I and aVL qR in III and aVF

Question 28

Name the ECG abnormality

Answer 28

Left anterior fasicular block - QRS<120 - Marked left axis deviation - qR in aVL

Question 29

HFpEF risk calculator

Answer 29

H2FPEF score - Heavy - 2 points - HTN - 1 point - atrial Fibrillation - 3 points - Pulmonary HTN (PASP >35) - 1point - Elderly >60 - 1 point - Filling pressure E/e' >9 - 1 point

Question 30

NYHA - II symptoms

Answer 30

Mild symptoms with normal activity

Question 31

NYHA III symptoms

Answer 31

Marked limitation of physical activity due to symptoms

Question 32

NYHA IV symptoms

Answer 32

Symptoms at rest or unable to do any physical activity without symptoms

Question 33

Four cardinal features of acute pericarditis

Answer 33

1. Left retrosternal chest pain (worse supine. better leaning forward) 2. Pericardial friction rub 3. ECG changes (STE widespread) 4. Pericardial effusion

Question 34

Beck's triad

Answer 34

Diagnosis of cardiac tamponade 1. Hypotension 2. Soft heart sounds 3. JVP distention

Question 35

Classes of pulmonary hypertension

Answer 35

Group 1: Pulmonary arterial hypertension Group 2: Left sided heart disease Group 3: Chronic lung disease Group 4: Pulmonary arterial obstruction Group 5: Unidentified

Question 36

Group 1 pulmonary hypertension

Answer 36

Group 1 ? Pulmonary arterial hypertension Idiopathic Heritable - Most commonly due to BMPR2 mutationDrug/toxin related Secondary to non cardiopulmonary disease - World wide schistosomiasis is the most common cause of pulmonary HTN

Question 37

Group 2 pulmonary hypertension

Answer 37

Group 2 ? Left sided heart disease Heart failure (most common cause of PHN accounting for 70% of cases) Valvular disease Congenital disease

Question 38

Physical exam findings of PHTN

Answer 38

#NAME?

Question 39

Group 4 pulmonary hypertension

Answer 39

Group 4 ? Pulmonary arterial obstruction Chronic PE

Question 40

Group 5 PHTN

Answer 40

Group 5 ? Unidentified Haematological disorders Metabolic Renal failure Tumour Fibrosing mediastinitis

Question 41

Targeted therapies for PHTN

Answer 41

- Prostacyclin pathway agonists (e.g. epoprostenol) - Endothelin receptor antagonists (e.g. ambrisentan) - PDE-5 inhibitors (e.g. sildenafil)

Question 42

Jet velocity diagnostic of severe aortic stenosis

Answer 42

4 m/s

Question 43

Mean gradient diagnostic of severe aortic stenosis

Answer 43

40mmHg

Question 44

Valve area diagnostic of severe aortic stenosis

Answer 44

<1cm^2

Question 45

Diagnosis of low-flow. low-gradient aortic stenosis

Answer 45

Echo demonstrating mean pressure gradient <40mmHg. AVA <1cm^2. LVEF <50 AND low-dose dobutamine stress echo - Dobutamine will show if there is contractile reserve and if so increase LVEF. If AVA remains low but MG resolves indicative of true AS

Question 46

Left posterior fasicular block ECG definition

Answer 46

Right axis deviationrS in I and aVLqR in III and aVF

Question 47

Brugada algorithm for diagnosing VT

Answer 47

1. Absence of RS in all precordial leads (YES VT SN=.1; SP1) 2. R to S >100msec in any precordial (YES VT SN=0.66; SP=0.98) 3. AV dissociation (YES VT SN=0.82l SP=0.98) 4. VT morphology in V1-2 AND V6 (YES VT SN=0.99; SP=0.97) - RBBB; V1 R smooth - V6 QS complex NO = SVT

Question 48

CHA2DS2-VASc score

Answer 48

Congestive heart failure Hypertension Age over 75 (2pts) Diabetes Stroke or TIA history (2 pts) Vascular disease including MI Age 65-75 Female sex