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MRCP Revision > Cardiology > Flashcards

Cardiology Flashcards

1
Q

Cause of non-pulsatile JVP waveform

A

SVC obstruction

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2
Q

Kussmaul’s sign

A

JVP rise during inspiration - Constrictive pericarditis

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3
Q

JVP a waves signify what?

A

atrial contraction

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4
Q

Causes of cannon a waves (regular, irregular)

A

Regular: AVNRT, VT
Irregular: complete Heart block

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5
Q

Causes of large A waves

A

Tricuspid stenosis
Pulmonary stenosis
Pulmonary hypertension

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6
Q

Causes of absent A waves

A

Atrial fibrillation

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7
Q

What does a JVP C wave signify

A

Closure of tricuspid valve, start of systole (not seen normally)

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8
Q

What does the X descent of JVP signify

A

fall of atrial pressure during systole

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9
Q

What does the JVP V wave signify?

A

Passive atrial filling against closed tricuspid valve

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10
Q

What does the JVP Y descent signify?

A

Fall of atrial pressure as tricuspid valve opens

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11
Q

Cause of Giant V wave?

A

Tricuspid regurgitation

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12
Q

Beck’s Triad?

A

Cardiac tamponade:
Low BP, raised JVP, muffled heart sounds

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13
Q

What do you see in Tamponade?

A

Beck’s triad (low BP, raised JVP, muffled HS)
Absent Y (limited RV filling) TAMPAX
Pulsus paradoxus
Rarely Kussmaul’s sign (more for constrictive pericarditis)
Electrical Alternans

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14
Q

What do you see in constrictive pericarditis

A

X and Y descents are present (as opposed to absent Y in tamponade)
Kussmaul’s sign

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15
Q

What causes variable intensity of S1?

A

Complete heart block

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16
Q

What causes loud S2?

A

Hypertension (atrial or pulmonary)
Hyperdynamic states
Atrial septal defect without pulmonary hypertension

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17
Q

What causes soft S2?

A

Severe Aortic Stenosis

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18
Q

What causes a fixed split S2?

A

Atrial Septal defect

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19
Q

What causes a widely split S2?

A

Deep inspiration
RBBB
Pulmonary stenosis
Severe mitral regurgitation

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20
Q

What causes a reversed split S2?

A

LBBB
Severe aortic stenosis
Right ventricular pacing
WPW type B
Patent Ductus Arteriosus

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21
Q

Causes of S3

A

Caused by diastolic filling of ventricle:
LVF
DCM
Constrictive pericarditis (pericardial knock)
MR

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22
Q

Causes of S4

A

Caused by atrial contraction vs stiff ventricle, coincides with p wave
Aortic stenosis
HOCM (double apical beat in HOCM due to palpable S4)
HTN

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23
Q

Explain the physiological mechanism behind Valsava in lowering cardiac output

A

Increased intrathoracic pressure –> reduced venous return –> reduced cardiac output

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24
Q

What is the normal range of left atrial pressure?

A

6-12mmHg

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25
Q

Causes of high left atrial pressure

A

LVF
MS
MR
AS
age>20

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26
Q

How do you measure pulmonary capillary wedge pressure?

A

Via Swan-Ganz catheter to estimate pulmonary pressure, by inflating balloon in pulmonary artery.

Useful for working out if HF or ARDS is cause of pulmonary oedema and can titrate dose of diuretic drugs

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27
Q

What pressure counts as pulmonary hypertension?

A

> 20mmHg

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28
Q

How do you officially diagnose pulmonary HTN?

A

Cardiac catheterisation

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29
Q

Risk factors for developing pulm HTN

A

COPD
HIV
Cocaine
Anorexigens (eg fenfluramine)

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30
Q

Genetics predisposition of idiopathic pulmonary hypertension

A

10% autosomal dominant

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31
Q

Signs of pulmonary HTN?

A

Right ventricular heave
Loud P2
Prominent A waves
Tricuspid Regurgitation

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32
Q

How to manage pulmonary HTN?

A

Vasodilator testing with nitric oxide:

If positive (pressure drop):
- calcium channel blocker

If negative (no pressure drop):
- prostacycline analogues
- Endothelin receptor antagonists
- Phosphodiesterase inhibitors

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33
Q

Cause of pulsus alternans

A

Severe LVF

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34
Q

Causes of prolonged PR

A

Idiopathic
IHD
Digoxin
Hypokalaemia
Rheumatic fever
Aortic root abscess
Lyme disease
Sarcoidosis
Myotonic dystrophy

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35
Q

LBBB Causes

A

My CHAD FucKs Prime

MI
CDM
HTN
AS
Digoxin
Fibrosis
HyperKalaemia
ASD Primum

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36
Q

ECG changes with hypothermia

A

Bradycardia
J Waves (Osborne)
1st degree HB
Long QTc
Arrhythmias

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37
Q

Causes of aortic stenosis

A

Calcification commonest >65 yrs
Bicuspid Aortic valve commonest <65 yrs
William’s syndrome (supravalvular)
post-rheumatic fever
HOCM (subvalvular)

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38
Q

Features of severe Aortic stenosis

A

Slow rising pulse
Soft/absent S2
narrow pulse pressure
Delayed ESM
S4
Thrill
Displaced apex beat
LV hypertrophy/failure

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39
Q

What pressure counts as severe AS?

A

> 40mmHg

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40
Q

Treatment of AS

A

Surgical AVR in low surgical risk
TAVR in high surgical risk
Balloon valvuloplasty in children with no calcification and adults with critical AS not fit for AVR

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41
Q

Causes of aortic regurgitation?

A

Causes due to valve disease:
- Rheumatic fever (commonest in developing world)
- Calcific valve disease
- Connective tissue disease
- Bicuspid aortic valve
(Acute - infective endocarditis)

Causes due to aortic root disease:
- Bicuspid aortic valve (afffects both valves and aortic root)
- Spondylarthropathies (ankylosing spondylitis)
- HTN
- Syphilis
- Marfan’s
- Ehler-Danlos
(Acute: aortic dissection)

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42
Q

What is an Austin-Flint murmur?

A

mid-diastolic murmur in sevvere aortic regurgitation, due to partial closure of anterior mitral valve cusps

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43
Q

Causes of mitral stenosis

A

Rheumatic fever
Mucopolysaccharidoses
Carcinoid
Endocardial fibroelastosis

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44
Q

Features of Mitral stenosis

A

Loud S1
Opening snap (indicates MV leaflets are still mobile)
Low volume pulse
Malar flush
Atrial fibrillation (LA enlargement)

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45
Q

Features of severe MS

A

Increased length of murmur
Opening snap closer to S2

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46
Q

Normal area of mitral valve

A

4-6cm2. Tight is <1cm2

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47
Q

What is recommended for anticoagulation in MS with Atrial fib

A

Warfarin

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48
Q

Treatment of mitral stenosis

A

Percutaneous mitral balloon valvotomy
Mitral valve surgery - commissurotomy/valve replacement

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49
Q

Contraindications to mitral balloon valvotomy?

A

Area>1.5cm2
Left atrial thrombus
Moderate/severe MR
Severe calcification
Severe aortic/tricuspid disease
Severe coronary disease requiring CABG

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50
Q

Features of tricuspid regurgitation

A

Giant V waves
Tall C waves
Pulsatile hepatomegaly
Left parasternal heave (due to RVH)

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51
Q

Causes of TR?

A

RV infarct
Pulm HTN
Rheumatic heart disease
Infective Endocarditis
Ebstein’s anomaly
Carcinoid

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52
Q

What is Ebstein’s anomaly?

A

Tricuspid valve displaced towards RV, atrialising the RV (low insertion of tricuspid alve)

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53
Q

What causes Ebstein’s anomaly?

A

Exposure to lithium in-utero

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54
Q

Associations with Ebstein’s anomaly?

A

PFO
ASD (80%)
WPW

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55
Q

Features of Ebstein’s anomaly

A

Prominent A waves
Hepatomegaly
Giant V waves + TR
RBBB (widely split S1, S2)

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56
Q

Causes of dilated CDM

A

Idiopathic
Ischaemic
Myocarditis (Coxsackie B, HIV, Diptheria, Chagas)
Peripartum
HTN
Iatrogenic (doxorubicin)
Substance (ETOH, Cocaine)
Inherited (autosomal dominant)
Duchenne Muscular Dystrophy
Infiltrative (Haemochromatosis, sarcoidosis)
Selenium deficiency (Keshan disease)
Beri-Beri (wet)

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57
Q

Causes of restrictive cardiomyopathy

A

Amyloidosis (e.g. secondary to myeloma, most commonly)
Haemochromatosis
Post-radiation fibrosis
Loffler’s syndrome
Endocardial fibroelastosis
Sarcoidosis
Scleroderma
Beri beri (wet)

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58
Q

Inheritance/genetics for HOCM

A

Autosomal dominant
MHC beta (15-25%)
MYH7 (70%)
MYBPC3 (cardiac myosin binding protein C) (15-25%)

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59
Q

Does HOCM cause predominantly systolic or diastolic dysfunction?

A

Diastolic

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60
Q

Treatment for HOCM

A

ABCDE
Amiodarone
Beta blocker
Cardioverter
Dual chamber pacemaker
Endocarditis prophylaxis

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61
Q

What drugs do you avoid in HOCM

A

ACE inhibitors
Nitrates
Ionotropes

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62
Q

Factors for poor prognosis in HOCM

A

Syncope
FHx of sudden death
Young age at presentation
Non-sustained VT 24-48hrs
Septal wall thickening
BP changes on exercise

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63
Q

Inheritance pattern of arrhythmogenic right ventricular cardiomyopathy

A

Autosomal dominant

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64
Q

ECG features in ARVC

A

T inversion in V1-3
Epsilon wave

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65
Q

Treatment for ARVC

A

Sotalol
Catheter ablation
ICD

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66
Q

What is Naxos disease

A

Autosomal recessive ARVC
with palmoplantar keratosis, woolly hair

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67
Q

What defect is there in longQT syndrome (receptors)

A

K channel alpha subunit defect, in Chromosome 11

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68
Q

Types of long QT

A

1: exertional syncope (swimming)
2: emotional stress/exercise/auditory stimuli
3: at night/rest

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69
Q

Drug causes of long QT

A

THEM CO SATS 1a
TCAs
Haloperidol
Erythromycin
Methadone
Chloroquine
Ondansetron
Sotalol
Amiodarone
Terfenadine
SSRI/SNRI
1a anti-arrhythmics

70
Q

Electrolyte causes of long QT

A

Low K, Ca, Mg

71
Q

Some causes of long QT

A

Drugs (THEM CO SATS 1a)
Electrolytes
Genetic
Hypothermia
MI
Myocarditis
SAH

72
Q

Inherited causes of long QT

A

Jervell-Lange-Nielson: Autosomal recessive, deaf, KCNQ1 mutation

Romano-Ward: Autosomal dominant

73
Q

Types of Wolff-Parkinson White Syndrome

A

Type A: left sided accessory pathway, dominant R in V1
Type B: right sided accessory pathway

74
Q

Associations of WPW

A

HOCM
Mitral Valve Prolapse
Ebstein’s
Thyrotoxicosis
ASD secundum

75
Q

Gene mutation for WPW

A

PRKAG2

76
Q

Treatment for WPW

A

Sotalol
Amiodarone
Flecainide
Avoide AV blocking nodes in AFib

77
Q

DVLA restrictions for PCIs and PPMs

A

1 week

78
Q

DVLA retrictions for CABG, ACS

A

4 wks

79
Q

DVLA restrictions for ICDs

A

6 months
1 month if prophylactically

permanent ban for Group 2 vehicles

80
Q

DVLA restrictions for heart transplant

A

6 wks

81
Q

DVLA restrictions for arrhythmia - catheter ablations

A

2 days

82
Q

DVLA restrictions for aortic aneurysms 6.5cm

A

ban

83
Q

Features of complete heart block

A

wide pulse pressure
cannon a wave
variable intensity s1

84
Q

Factors for increased risk of asystole in bradycardia

A

Complete Heart block + broad QRS (if narrow QRS, AV junctional pacemaker still providing haemodynamically stable heart rates)
Recent asystole
Mobitz Type II
Ventricular pause >3s

85
Q

Brugada genetics

A

SCN5A (Na channel) mutations 20-40%
CACNB2 (Ca channel) less common
KCNE3 (K channel) less common

86
Q

What can you give in Brugada to make the diagnosis more obvious?

A

Flecainide/ajmaline

87
Q

ECG features in Brugada

A

Convex ST elevation in V1-3 with T inversions

88
Q

Treatment for Brugada

A

ICD

89
Q

Which cardiac enzyme rises first?

A

myoglobin

90
Q

Which cardiac enzyme is useful to look for reinfarction?

A

CK-MB (returns to normal after 2-3 days)

91
Q

What does Troponin-T bind to?

A

Binds to tropomyosin, to form torponin-tropomyosin complex, which regulates actin

92
Q

When does troponin-T rise, peak and return to normal?

A

rises 4-6hrs
peaks 12-24hrs,
returns to normal 7-10 days

93
Q

What composes of the cardiomyocyte’s thin filament?

A

Actin, Tropomyosin, Troponin-T

94
Q

What does troponin-C bind to?

A

Ca

95
Q

What does Troponin I bind to?

A

Actin, holds troponin-tropomyosin complex in place

96
Q

LDH rise, peak, return to normal time in an MI?

A

rises 24-48hrs, peaks 72hrs, returns to normal 8-10 days

97
Q

Where is BNP from?

A

Left ventricular myocardium, in response to strain

98
Q

What factors/conditions increase BNP

A

LVH
Ischaemia
Tachycardia
RV overload
Hypoxaemia
GFR<60
Sepsis
COPD
Diabetes
Age>70
Cirrhosis

99
Q

What factors/conditions reduce BNP?

A

Obesity
Diuretics
ACE inhibitors
Beta blockers
ARBs
Aldosterone antagonists

100
Q

Effects of BNP

A

Vasodilation
Diuresis
Natriuresis
Supression of sympathetic nervous system, RAAS

101
Q

Where is ANP from?

A

Right and left (right>left) atrial myocytes, in responseto blood volume

102
Q

What is ANP degraded by?

A

Endopeptidases

103
Q

Effects of ANP

A

Natriuresis
Lowers BP
Antagonises Angiotensin II and aldosterone

104
Q

Features of cholesterol embolisation

A

Eosinophilia
purpura
renal failure
livedo reticularis

105
Q

Causes/risk factors for cholesterol embolisation

A

Renal disease
Post vascular surgery/angiography
severe atherosclerosis in large arteries

106
Q

Causes of myocarditis

A

Coxsackie B
HIV
Diptheria
Clostridia
Lyme disease
Chagas
Toxoplasmosis
Autoimmune
Doxorubicin

107
Q

Time period post-PCI for restenosis

A

3-6 months

108
Q

Time period post-PCI for stent thrombosis

A

1 month

109
Q

Drug-eluting stents risks for restenosis and stent thrombosis?

A

Reduces restenosis rates
Increases stent thrombosis (need to give clopidogrel for longer- at least 6 months)

110
Q

Down’s syndrome cardiac associations

A

Endocardial cushion defects
VSD
ASD Secundum
Tetralogy of Fallot
Isolated PDA

111
Q

Large vessel arteritis in 10-40yr old Asian women

A

Takayasu’s arteritis

112
Q

Features of Takayasu’s arteritis

A

Aortic regurgitation 20%
Carotid bruit
Claudication
Association with renal artery stenosis

113
Q

How to investigate/diagnose Takayasu’s arteritis?

A

Vascular imaging (MR/CTA)

114
Q

How to treat Takayasu’s

A

steroids

115
Q

Associations of aortic dissection

A

HTN
Trauma
Bicuspid Aortic valve
Marfan’s
Ehlers-Danlos
Turner’s
Noonan’s
Pregnancy
Syphilis

116
Q

Major criteria for Rheumatic fever

A

CASES
carditis
polyarthritis
sydenham’s chorea
erythema marginatum
subcutaneous nodules

117
Q

When does rheumatic fever present?

A

2-4 wks post strep pyogenes infection (Type 2 hypersensitivity)

118
Q

What can you see histologically in rheumatic fever?

A

Aschoff bodies (granuloma with giant cells)
Anitschkow cells (enlarged macrophages with ovoid, wavy, rod-like nucleus)

119
Q

Poor prognosis in ACS

A

Age
HF
PVD
reduced SBP
Killip class (crackles, S3, pulm oedema, cardiogenic shock)
Initial serum creatinine,
high cardiac markers,
cardiac arrest on admission
ST segment deviation

120
Q

Cyanotic heart disease:

A

Tetralogy of Fallot
Transposition of great arteries
Tricuspid atresia

121
Q

Tetralogy of Fallot

A

VSD
RVH
Right ventricular outflow tract obstruction, pulmonary stenosis
Overriding aorta

122
Q

When does tetralogy of Fallot present?

A

1-2 months

123
Q

What causes tetralogy of Fallot?

A

Anterosuperior displacement of infundibular septum

124
Q

What XR feature can you see for Tetralogy of Fallot?

A

boot shaped heart

125
Q

What causes transposition of the great arteries?

A

Failure of aorticopulmonary septum to spiral

126
Q

What increases risk of getting TGA

A

diabetic mothers

127
Q

What sign do you get (heart sounds) for TGA

A

Loud S2

128
Q

CXR of TGA

A

Egg-on-side appearance

129
Q

Treatment for TGA

A

Prostaglandins to maintain PDA + surgery

130
Q

What is tricuspid atresia?

A

Absent Tricuspid valve and hypoplastic RV

131
Q

Causes of VSD

A

Down’s
Edward’s
Patau
cri-du-chat
congenital infections
post-MI

132
Q

Complications of VSD

A

Aortic regurgitation
Infective endocarditis
Eisenmenger’s
RHF
Pulm HTN

133
Q

Heart sound in ASD

A

Fixed splitting of S2

134
Q

ECG features for ASD primum

A

RBBB + LAD
Prolonged PR

135
Q

ECG features for ASD Secundum

A

RBBB+RAD

136
Q

Which is more common: ASD primum or secundum?

A

Secundum (70%)

137
Q

ASD Primum

A

RBBB+LAD, prolonged PR, abnormal AV valves, earlier than secundum

138
Q

ASD secundum

A

70%) Holt-Oram syndrome (tri-phalangeal thumbs), RBBB+RAD

139
Q

Patent ductus arteriosus causes

A

premature babies
high altitude
maternal rubella in 1st trimester

140
Q

Features of PDA

A

Left subclavicular thrill
cont mach murm
wide pp
collapsing pulse
heaving apex

141
Q

PDA treatment

A

indomethacin/NSAID (inhibits prostaglandin synthesis)

Give prostaglandin E1 if there is another congenital heart disease (cyanotic) to keep duct open pre-surgery

142
Q

Coarctation of aorta associations

A

males
Turner’s
bicuspid AV
berry aneurysms
neurofibromatosis

143
Q

Features of coarctation of aorta

A

Mid systolic murmur loudest over back
apical click from aortic valve
notching of inferior border of ribs (collateral vessels - not seen children)

144
Q

Neuro-vascular associations with patent foramen ovale

A

Migraines
Strokes

145
Q

Multifocal atrial tachycardia

A

pacemaker origin at least 3 sites in atria, distinctive p waves, chronic lung disease association

Rx: correct hypoxia, electrolytes, rate-limiting Ca channel blocker

146
Q

Xanthomas in familial hyper-triglyceridaemia

A

eruptive xanthoma

147
Q

Xanthomas in familial hyper-hypercholesterolaemia

A

tendon xanthoma

148
Q

Pre-eclampsia risk factors

A

HTN
CKD
SLE
antiphospholipid
DM
nulliparity
age>40
BMI>35
Fhx
multiple pregnancy

149
Q

BP fluctuation in pregnancy

A

falls in 1st half (vasodilation, increased volume) by 5-10 systolic, 10-15 diastolic → gradually rises in 2nd half.

150
Q

What do you give for mothers at high risk of pre-eclampsia and when?

A

Give 75mg aspirin from 12wks

151
Q

What investigation measures LVEF most accurately?

A

MUGA scan

152
Q

MIBI scan

A

technetium 99 + methoxyisobutyl isonitrile, with SPECT - stress + rest, to assess for reversible or fixed ischaemia

153
Q

Duke’s criteria for IE

A

path criteria +ve or 2 major or 1 maj + 3 minor or 5 minor

Major:
echo findings
new regurg
2 or more cultures
serology or gene target assays

Minor:
past heart condition
IVDU
fever
vascular or immunological phenomena

154
Q

Culture negative causes of IE

A

Coxiella burnetii, Bartonella, Brucella, HACEK (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella)

155
Q

Valves commonly effected in IE

A

MR commonest. TR commonest in IVDU

156
Q

Treatment for native valve blind IE

A

amoxicillin

157
Q

Treatment for prosthetic valve blind IE

A

vanc + rifampicin + low dose gent

158
Q

Poor prognosis for IE

A

S aureus
Prosthetic valve
Culture negative
Low complement

159
Q

Indications for surgery in IE

A

Severe valve incompetence
Aortic abscess
Abx resistance
Fungal
HF refractory to medical treatment
Recurrent emboli after abx

160
Q

Syndrome X (cardiac)

A

angina-like pain on exertion, ST depression on exercise stress test (downsloping), normal angiography.

Rx: nitrates

161
Q

Catecholaminergic polymorphic ventricular tachycardia

A

Inherited, aut dom, 1:10,000. RYR2 receptor defect in myocardial sarcoplasmic reticulum, dysfunctional Ca regulation, thus excessive AP with adrenaline. VT on exercise/emotion, syncope, cardiac death before 20yrs.

Rx: beta blockers, CRT

162
Q

Beta blocker usage in HTN

A

declined sharply due to ASCOT-BPLA study demonstrating it’s less likely to prevent stroke + potential impairment of glucose tolerance

163
Q

HF NYHA classification

A

I- no symptoms/limitations
II - mild symptoms with ordinary activity
III - marked limitation of physical activity but comfortable at rest
IV - symptoms present at rest.

164
Q

Rx for chronic HF

A

1st line ACEi + b-blocker (bisop, carvedilol, nebivolol) in HFrEF
2nd line: spiro or eplerenone, SGLT-2 inh
3rd line: ivabradine, sacubitril-valsartan, digoxin, hydralazine + nitrates or CRT.
Offer annual flu vaccine + one-off pneumococcal vaccine (every 5 yrs if splenic dysfunction or CKD)

165
Q

Atrial myxoma:

A

75% left atrium. females. Clubbing
A fib, mid-diastolic murmur

Echo - pedunculated heterogeneous mass attached to fossa ovalis of interatrial septum

166
Q

Factors suggesting VT rather than SVT

A

AV dissociation, fusion/capture, +ve QRS concordance in chest leads, marked LAD, IHD hx

167
Q

How to prevent SVT

A

beta blockers, radio-frequency ablation

168
Q

Atrial flutter location of re-entry circuit

A

right atrium

169
Q

Where to ablate in atrial flutter?

A

radiofrequency ablation of tricuspid valve isthmus (critical part of circuit)

170
Q

Atrial fibrillation cardioversion rules

A

Can cardiovert if <48hrs with heparinisation. Amiodarone if structural heart disease, flecainide/amiodarone without structural heart disease

If >48hrs 3 wk anticoagulation then cardioversion or TOE then heparinisation + cardioversion. Then anticoagulant 4 weeks

If high risk of failure, give 4 wks amiodarone or sotalol pre-cardioversion

MRCP Revision (10 decks)

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