Cardiology Flashcards
1
Q
In what condition are a waves absent from the JVP waveform?
A
Atrial Fibrillation
2
Q
What conditions cause large a waves in the JVP waveform?
A
Tricuspid stenosis
Right heart failure
Pulmonary hypertension
3
Q
What conditions cause a cannon a wave in the JVP waveform?
A
Dissociation between atria and ventricles:
Atrial flutter
Atrial tachycardias
3rd degree heart block
Ventricular tachycardia/ectopics
4
Q
What condition causes giant V waves in the JVP waveform?
A
Tricuspid regurgitation
5
Q
What conditions cause a steep descent of x wave in JVP waveform?
A
Tamponade
Cardiac constriction
6
Q
What conditions cause a steep descent of y wave in JVP waveform?
A
Cardiac constriction
Tricuspid stenosis
7
Q
What is Kussmaul’s sign?
A
Raised JVP upon inspiration and drops with expiration (opposite of health).
Implies R heart chambers cannot increase in size to accommodate increased venous return - pericardial disease/effusion/tamponade.
8
Q
What are the causes ion raised JVP with normal waveform?
A
Heart failure
Fluid overload
Severe bradycardia
9
Q
What are some causes of an absent radial pulse?
A
Iatrogenic - post catheter/art line
Blalock-Taussig shunt for congenital heart disease
Aortic dissection with subclavian involvement
Trauma
Takayasu’s arteritis
Peripheral arterial embolus
10
Q
Collapsing arterial pulse can be a sign of?
A
Aortic regurgitation
Arteriovenous fistula
PDA
Extracardiac shunt
11
Q
A slow rising pulse is a sign of which condition?
A
Aortic stenosis
12
Q
What is Bisferiens pulse (double shudder) is a sign of?
A
Mixed aortic valve disease with significant regurgitation.
13
Q
A jerky pulse is a sign of?
A
Hypertrophic obstructive cardiomyopathy
14
Q
When does an alternates pulse occur?
A
Severe left ventricular dysfunction.
15
Q
When can pulses paradoxus (excessive reduction in pulse with inspiration) occur?
A
Ventricular compression
Tamponade
Constrictive pericarditis
Severe asthma
16
Q
A heaving apex beat may indicate?
A
Left ventricular hypertrophy
17
Q
Thrusting/hyperdynamic apex beat indicates?
A
High left ventricular volume:
Mitral regurgitation
Aortic regurgitation
PDA
Ventricular septal defect
18
Q
A tapping apex beat indicates?
A
Palpable first heart sound in mitral stenosis
19
Q
A displaced/dyskinetic apex beat indicates?
A
Left ventricular impairment and dilatation.
20
Q
A double impulse apex beat indicates?
A
Left ventricular aneurysm (with dyskinesia)
Hypertrophic cardiomyopathy (without dyskinesia)
21
Q
A pericardial knock indicates?
A
Constrictive pericarditis
22
Q
A parasternal heave indicates?
A
Right ventricular hypertrophy:
- ASD
- pulmonary hypertension
- COPD
-pulmonary stenosis
23
Q
A palpable third heart sound indicates?
A
Heart failure
Severe mitral regurgitation
24
Q
What valves close during the first heart sound?
A
Mitral and tricuspid
25
What are causes of a loud first heart sound?
Mobile mitral stenosis
Hyperdynamic states
Tachycardia
Left to right shunts
Short PR interval
26
What are causes of a soft first heart sound?
Immobile mitral stenosis
Hypodynamic states
Mitral regurgitation
Poor ventricular function
Long PR interval
27
What causes a spilt first heart sound?
RBBB
LBBB
VT
Inspiration
Ebstein's anomaly
28
What causes a variable first heart sound?
Atrial fibrillation
Complete heart block
29
What valves close during the second heart sound?
Aortic then pulmonary
30
What causes a loud second heart sound?
Systemic hypertension
Pulmonary hypertension
Tachycardia
ASD
31
What causes a soft or absent second heart sound?
Severe aortic stenosis
32
What causes a fixed splitting of the second heart sound?
ASD
33
What causes a widely split second heart sound?
RBBB
Pulmonary stenosis
Deep inspiration
Mitral regurgitation
34
What causes a third heart sound?
Passive filling of ventricles on opening of AV valves.
35
What are pathological causes of a third heart sound?
Rapid ventricular filling:
Mitral regurgitation
VSD
Congestive cardiac failure
Constrictive pericarditis
36
What causes a fourth heart sound?
Atrial contraction that fills a stiff left ventricle
37
What are some causes of a 4th heart sound?
LVH
Amyloid
HCM
Left ventricular ischaemia
38
What is the mechanism of action of clopidogrel?
Inhibits ADP binding to platelet receptors
39
What investigation is used to aid management strategy decisions in patients with pulmonary hypertension?
Acute vasodilator testing
If positive, it indicates that the patient may respond well to calcium channel blockers as a treatment option.
40
What are some indications for a temporary pacemaker?
- symptomatic/haemodynamically unstable bradycardia, not responding to atropine
- post-ANTERIOR MI: type 2 or complete heart block
- trifascicular block prior to surgery
41
What is an early sign of Left ventricular failure?
Gallop rhythm (S3 heart sound)
42
When is verapamil contraindicated?
ventricular tachycardia
43
What are some drug treatment options of ventricular tachycardia?
- Amiodarone: ideally administered through a central line
- lidocaine: use with caution in severe left ventricular impairment
- Procainamide
44
What murmur indicates aortic regurgitation?
Early diastolic murmur
( soft, high pitched)
45
What are some chronic conditions that cause aortic regurgitation?
- rheumatic fever (the most common cause in the developing world)
- calcific valve disease
- connective tissue diseases (e.g. rheumatoid arthritis/SLE)
- bicuspid aortic valve (affects both the valves and the aortic root)
- spondylarthropathies (e.g. ankylosing spondylitis)
- hypertension
- syphilis
- Marfan's, Ehler-Danlos syndrome
46
What are some acute causes of aortic regurgitation?
Aortic dissection
Infective endocarditis
47
What should be monitored during treatment with magnesium sulphate?
- urine output
- reflexes
- respiratory rate
- oxygen saturations
48
Which artery supplies the atrioventricular node in 90% of people?
Right coronary artery.
49
What are some causes of aortic stenosis?
- degenerative calcification (most common cause in older patients > 65 years)
- bicuspid aortic valve (most common cause in younger patients < 65 years)
- William's syndrome (supravalvular aortic stenosis)
- post-rheumatic disease
- subvalvular: HOCM
50
What are the features of severe aortic stenosis?
- narrow pulse pressure
- slow rising pulse
- delayed ESM
- soft/absent S2
- S4
- thrill
- duration of murmur
- left ventricular hypertrophy or failure (displaced apex beat)
51
Which antibiotics are used to treat prosthetic valve endocarditis that grows staphylococci?
Flucloxacillin + rifampicin + low-dose gentamicin
52
What is the 1st line investigation for those with likely stable angina?
CT coronary angiography
53
How long should anticoagulation be continued followed DC cardio version for AF?
4 weeks post DC
Then CHA2DS2-VASc recalculated and reviewed
54
What are the actions of BNP?
- vasodilator: can decrease cardiac afterload
- diuretic and natriuretic
- suppresses both sympathetic tone and the renin-angiotensin-aldosterone system
55
What are some common adverse effects of thiazide diuretics?
- dehydration
- postural hypotension
- hypokalaemia
(due to increased delivery of sodium to the distal part of the distal convoluted tubule → increased sodium reabsorption in exchange for potassium and hydrogen ions)
- hyponatraemia
- hypercalcaemia
- gout
- impaired glucose tolerance
- impotence
56
What is the most common primary cardiac tumour?
Atrial myxoma
57
What is the most common site of a cardiac myxoma?
Left atrium
58
What are the features of atrial myxoma?
- systemic: dyspnoea, fatigue, weight loss, pyrexia of unknown origin, clubbing
- emboli
- atrial fibrillation
- mid-diastolic murmur, 'tumour plop'
- echo: pedunculated heterogeneous mass typically attached to the fossa ovalis region of the interatrial septum
59
What congenital heart defect is associated with biscupid aortic valve?
Coarctation of the aorta
60
What bacteria commonly cause infective endocarditis?
- Staphylococcus aureus
- Staphylococcus epidermidis if < 2 months post valve surgery
61
What features in broad complex tachycardia suggest VT rather than SVT?
- AV dissociation
- fusion or capture beats
- positive QRS concordance in chest leads
- marked left axis deviation
history of IHD
- lack of response to adenosine or carotid sinus massage
- QRS > 160 ms
62
What is the most specific ECG finding for pericarditis?
PR depression
63
What are causes of regular cannon waves on JVP?
- ventricular tachycardia (with 1:1 ventricular-atrial conduction)
- atrio-ventricular nodal re-entry tachycardia (AVNRT)
64
What is a cause of intermittent cannon waves on JVP?
complete heart block
65
What effect does sotalol have on the cardiac membrane?
Blockage of potassium channels
66
Which anti-anginal medication causes GI ulceration?
Nicorandil
67
What is the most common cause of death following MI?
Ventricular fibrillation
68
What are some causes of myocarditis?
- viral: coxsackie B, HIV
- bacteria: diphtheria, clostridia
- spirochaetes: Lyme disease
- protozoa: Chagas' disease
- toxoplasmosis
- autoimmune
- drugs: doxorubicin
69
What is the mechanism of action of ACE inhibitors?
Inhibits the conversion angiotensin I to angiotensin II
→ decrease in angiotensin II levels → to vasodilation and reduced blood pressure
→ decrease in angiotensin II levels → reduced stimulation for aldosterone release → decrease in sodium and water retention by the kidneys.
Renoproctective:
- dilation of the efferent arterioles → reduced glomerular capillary pressure → decreased mechanical stress on the delicate filtration barriers of the glomeruli
70
What is the mechanism of action of adenosine?
- agonist of the A1 receptor in the AV node, which inhibits adenylyl cyclase thus reducing cAMP and causing hyperpolarization by increasing outward potassium flux
- causes transient heart block in the AV node
- used to stop SVT
71
What are the adverse effects of adenosine?
- chest pain
- bronchospasm
- transient flushing
- can enhance conduction down accessory pathways, resulting in increased ventricular rate (e.g. WPW syndrome)
72
What are some examples of adenosine diphosphate (ADP) receptor inhibitors?
Clopidogrel
Prasugrel
Ticagrelor
Ticlopidine
73
What is the mechanism of action of ADP receptor inhibitors?
- adenosine diphosphate (ADP) is one of the main platelet activation factors, mediated by G-coupled receptors P2Y1 and P2Y12.
- The main target of ADP receptor inhibition is the P2Y12 receptor, as it is the one which leads to sustained platelet aggregation and stabilisation of the platelet plaque.
74
What is the definitive management for severe mitral stenosis?
Percutaneous mitral commissurotomy
75
What are the clinical features of mitral stenosis?
- dyspnoea
↑ left atrial pressure → pulmonary venous hypertension
- haemoptysis
due to pulmonary pressures and vascular congestion
- mid-late diastolic murmur (best heard in expiration)
- loud S1
- opening snap
(indicates mitral valve leaflets are still mobile)
- low volume pulse
- malar flush
- atrial fibrillation
(secondary to ↑ left atrial pressure → left atrial enlargement)
76
What anticoagulation is recommended for those with AF and mitral stenosis?
Warfarin
77
What is the mechanism of action of dipyridamole?
phosphodiesterase inhibitor
78
What factors may give a falsely low BNP?
ACE inhibitors
Diuretics
ARBS
Obesity
79
What is syndrome X?
Microvascular angina
- angina-like chest pain on exertion
- ST depression on exercise stress test (downsloping)
- normal coronary arteries on angiography
80
What does a double pulse in systole indicate (Bisferiens pulse)?
Mixed aortic valve disease
81
What are the congenital causes of long QT syndrome?
- Jervell-Lange-Nielsen syndrome (includes deafness and is due to an abnormal potassium channel)
- Romano-Ward syndrome (no deafness)
82
What drugs cause prolonged QT?
- amiodarone, sotalol, class 1a anti-arrhythmic drugs
- tricyclic antidepressants, selective serotonin re-uptake inhibitors (especially citalopram)
- methadone
- chloroquine
- terfenadine
- erythromycin
- haloperidol
- ondansetron
83
What are some other causes of prolonged QT?
- electrolyte: hypocalcaemia, hypokalaemia, hypomagnesaemia
- acute myocardial infarction
- myocarditis
- hypothermia
- subarachnoid haemorrhage
84
What causes a reversed split S2?
- LBBB
- Severe aortic stenosis
- right ventricular pacing
- WPW type B (causes early P2)
- patent ductus arteriosus
85
What causes a fixed split S2?
Atrial septal defect
86
Where does the coronary sinus drain into?
Right atrium
87
What is the use and mechanism of action of Naftidrofuryl?
5-HT2 receptor antagonist which can be used for peripheral vascular disease
88
What is Beck's triad?
Hypotension
Muffled heart sounds
Raised JVP
Suggests cardiac tamponade
89
What are the features of ostium secundum atrial septal defects?
Most common ASD
- associated with Holt-Oram syndrome (tri-phalangeal thumbs)
- ECG: RBBB with RAD
- ejection systolic murmur, fixed splitting of S2
- embolism may pass from venous system to left side of heart causing a stroke
90
What are the features of osmium primum atrial septal defects?
- present earlier than ostium secundum defects
- associated with abnormal AV valves
- ECG: RBBB with LAD, prolonged PR interval
- ejection systolic murmur, fixed splitting of S2
- embolism may pass from venous system to left side of heart causing a stroke
91
What is given to preterm infants with haemodynamically significant patent ductus arteriosus?
give ibuprofen/indomethacin to promote duct closure 1 week after birth
92
What murmur is characteristic of a patent ductus arteriosus?
continuous machine like murmur
93
What does troponin T bind to?
Tropomyosin
94
What are some drug causes of secondary hypertension?
steroids
monoamine oxidase inhibitors
the combined oral contraceptive pill
NSAIDs
leflunomide
95
How is infective endocarditis diagnosed?
Modified Duke's criteria
Infective endocarditis diagnosed if
pathological criteria positive, or
2 major criteria, or
1 major and 3 minor criteria, or
5 minor criteria
96
What is the management of Hypertrophic obstructive cardiomyopathy?
- Amiodarone
- Beta-blockers or verapamil for symptoms
- Cardioverter defibrillator
- Dual chamber pacemaker
- Endocarditis prophylaxis
97
Which drugs should be avoided in HOCM?
nitrates
ACE-inhibitors
inotropes
98
Accumulation of which protein causes a cough after starting ACEis?
Bradykinin
99
What are the adverse effects of ivabradine?
- visual effects, particular luminous phenomena are common (bright spots on vision)
- headache
- bradycardia, heart block
100
What are contraindications to an ETT?
- MI < 7 days ago
- unstable angina
- uncontrolled hypertension (systolic BP > 180 mmHg) or hypotension (systolic BP < 90 mmHg)
- aortic stenosis
- LBBB: this would make the ECG very difficult to interpret
101
For what reasons should an ETT be stopped?
- exhaustion / patient request
- 'severe', 'limiting' chest pain
- > 3mm ST depression
- > 2mm ST elevation.Stop if rapid ST elevation and pain
- systolic blood pressure > 230 mmHg
- systolic blood pressure falling > 20 mmHg
- attainment of maximum predicted heart rate
- heart rate falling > 20% of starting rate
- arrhythmia develops
102
What condition may a prolonged PR interval indicate when being treated for infective endocarditis?
Aortic root abscess
103
What are the 4 characteristic features of Tetraology of Fallot?
ventricular septal defect (VSD)
right ventricular hypertrophy
right ventricular outflow tract obstruction, pulmonary stenosis
overriding aorta
104
What are some other features of tetralogy of fallot?
- cyanosis
- right-to-left shunt
- ejection systolic murmur due to pulmonary stenosis (the VSD doesn't usually cause a murmur)
- a right-sided aortic arch is seen in 25% of patients
- 'boot-shaped' heart on CXR
- ECG shows right ventricular hypertrophy
105
What are the features of cholesterol emboli?
eosinophilia
purpura
renal failure
livedo reticularis
106
What often causes cholesterol emboli?
- Post vascular surgery or angiography
- severe atherosclerosis, particularly in large arteries such as the aorta
107
What is Brugada Syndrome?
- Autosomal dominant cardiovascular disease
- may result in sudden death
- more common in Asian population
- mutation in the SCN5A gene which encodes the myocardial sodium ion channel protein
108
What ECG changes are indicative of Brugada Syndrome?
- convex ST segment elevation > 2mm in > 1 of V1-V3 followed by a negative T wave
- partial right bundle branch block
109
What is the investigation of choice for Brugada syndrome?
Administration of flecainide or ajmaline - makes ECG more pronounced.
110
What is the management for Brugada syndrome?
implantable cardioverter-defibrillator
111
What is the mechanism of action of warfarin?
- Inhibits epoxide reductase preventing the reduction of vitamin K to its active hydroquinone form
- this in turn acts as a cofactor in the carboxylation of clotting factor II, VII, IX and X (mnemonic = 1972) and protein C.
112
What are some factors that may potentiate warfarin?
- P450 enzyme inhibitors
- Cranberry juice
- Liver disease
- drugs which displace warfarin from plasma albumin, e.g. NSAIDs
- inhibit platelet function: NSAIDs
113
What are some side effects of warfarin?
- haemorrhage
- teratogenic, although can be used in breastfeeding mothers
- skin necrosis
when warfarin is first started biosynthesis of protein C is reduced
this results in a temporary procoagulant state after initially starting warfarin, normally avoided by concurrent heparin administration
thrombosis may occur in venules leading to skin necrosis
- purple toes
114
What are some ECGs changes indicative of 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 1st line management for chronic heart failure?
ACE Inhibitor and Beta Blocker
116
What is the 2nd line management for chronic heart failure?
- Aldosterone antagonist e.g spironolactone
- SGLT-2 inhibitors
117
What is the 3rd line management of chronic heart failure?
- Ivabradine
- Salcubitril/Valsartan
- Digoxin
- hydralazine in combination with nitrate
- cardiac resynchronisation therapy
118
What is the mechanism of action of amiodarone?
Blocks voltage gated potassium channels
119
What are poor prognostic factors in hypertrophic cardiomyopathy?
- syncope
- family history of sudden death
- young age at presentation
- non-sustained ventricular tachycardia on 24 or 48-hour Holter monitoring
- abnormal blood pressure changes on exercise
increased septal wall thickness
120
What is the mechanism of hypokalaemia in thiazide use?
increased delivery of sodium to the distal part of the distal convoluted tubule
121
What is the mechanism of action of loop diuretics?
inhibiting the Na+/K+/2Cl- cotransporter in the thick ascending limb of the loop of Henle. This causes loss of water along with sodium chloride, potassium, calcium, and hydrogen ions.
122
What is the mechanism of action of ticagrelor?
Inhibits ADP binding to platelet receptors
123
What is Eisemenger's syndrome?
reversal of a left-to-right shunt in a congenital heart defect due to pulmonary hypertension.
Associated with ventricular septal defect, atrial septal defect, patent ductus arteriosus.
124
What are the features of Eisenmenger's Syndrome?
- original murmur may disappear
- cyanosis
- clubbing
- right ventricular failure
- haemoptysis, embolism
125
What is the management for Eisenmenger's syndrome?
Heart-lung transplant
126
ECG changes associated with 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
127
What is the treatment for Torsades de Pointes?
IV magnesium sulphate
128
What should be given to warfarinised patients who require emergency surgery?
give four-factor prothrombin complex concentrate 25-50 units/kg if emergency.
If surgery can wait 6-8hours given 5mg IV vitamin K
129
Which congenital heart defect is most associated with tricuspid regurgitation?
Ebstein's anomaly
130
What are the signs of tricuspid regurgitation?
- pan-systolic murmur
- prominent/giant V waves in JVP
- pulsatile hepatomegaly
- left parasternal heave
131
What are some causes of tricuspid regurgitation?
- right ventricular infarction
- pulmonary hypertension e.g. COPD
- rheumatic heart disease
- infective endocarditis (especially intravenous drug users)
- Ebstein's anomaly
- carcinoid syndrome
132
What are some causes of a loud S2?
Pulmonary or systemic hypertension
ASD
Hyperdynamic states
133
What is the mechanism of action of ARBs?
block the effects of angiotensin 2 at the AT1 receptor
134
How are aortic dissections classified?
Stanford classification
- type A - ascending aorta, 2/3 of cases
- type B - descending aorta, distal to left subclavian origin, 1/3 of cases
DeBakey classification
- type I - originates in ascending aorta, propagates to at least the aortic arch and possibly beyond it distally
- type II - originates in and is confined to the ascending aorta
- type III - originates in descending aorta, rarely extends proximally but will extend distally
135
What conditions are associated with aortic dissection?
- hypertension: the most important risk factor
- trauma
- bicuspid aortic valve
- collagens: Marfan's syndrome, Ehlers-Danlos syndrome
- Turner's and Noonan's syndrome
- pregnancy
- syphilis
136
What are the 2 main proteins involved in HOCM?
mutation in the gene encoding β-myosin heavy chain protein or myosin binding protein C
137
What are some causes of eruptive xanthoma?
- familial hypertriglyceridaemia
- lipoprotein lipase deficiency
138
What are some causes of tendon xanthoma, tuberous xanthoma and xanthelasma?
- familial hypercholesterolaemia
- remnant hyperlipidaemia
139
What heart defect is associated with migraine?
Patent foramen ovale
140
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
141
What are the features of Arrhythmogenic right ventricular cardiomyopathy?
- palpitations
- syncope
- sudden cardiac death (2nd most common cause after HOCM)
- ECG abnormalities in V1-3, typically T wave inversion
- epsilon wave is found in about 50% of those with ARV - this is best described as a terminal notch in the QRS complex
142
What is transposition of the great arteries?
Cyanotic congenital heart condition caused by the failure of the aorticopulmonary septum to spiral during septation. Children of diabetic mothers are at an increased risk of TGA.
143
What are the features of transposition of the great arteries?
cyanosis
tachypnoea
loud single S2
prominent right ventricular impulse
'egg-on-side' appearance on chest x-ray
144
What is the management for transposition of the great arteries?
- maintenance of the ductus arteriosus with prostaglandins
- surgical correction is the definite treatment.
145
What is multifocal atrial tachycardia?
an irregular cardiac rhythm caused by at least three different sites in the atria.
3 different p wave morphologies seen
Common in elderly patients with lung disease
146
What is the management of multifocal atrial tachycardia?
- correction of hypoxia and electrolyte disturbances
- rate-limiting calcium channel blockers are often used first-line
- cardioversion and digoxin are not useful in the management of MAT
147
What is the most accurate way of measuring left ventricular ejection fraction?
MUGA (multigated acquisition) scan
148
What is Wolff Parkinson White syndrome?
congenital accessory conducting pathway between the atria and ventricles leading to atrioventricular re-entry tachycardia (AVRT).
AF can degenerate rapidly to VF
149
What are the ECG changes present in WPW?
- short PR interval
- wide QRS complexes with a slurred upstroke - 'delta wave'
- left axis deviation if right-sided accessory pathway
(in the majority of cases, or in a question without qualification, Wolff-Parkinson-White syndrome is associated with left axis deviation)
- right axis deviation if left-sided accessory pathway
150
What conditions are associated with Wolff Parkinson White syndrome?
- HOCM
- mitral valve prolapse
- Ebstein's anomaly
- thyrotoxicosis
- secundum ASD
151
What is the management for Wolff Parkinson White syndrome?
- definitive treatment: radiofrequency ablation of the accessory pathway
- medical therapy: sotalol***, amiodarone, flecainide
sotalol should be avoided if there is coexistent atrial fibrillation as prolonging the refractory period at the AV node may increase the rate of transmission through the accessory pathway, increasing the ventricular rate and potentially deteriorating into ventricular fibrillation
152
What chamber of the heart does pulmonary capillary wedge pressure generally equate to?
Left atrium
(normally 6-12 mmHg)
153
What are some ECG changes that can be normal variants ini athletes?
- sinus bradycardia
- junctional rhythm
- first degree heart block
- Mobitz type 1 (Wenckebach phenomenon)
154
What does the x descent indicate on a JVP waveform?
fall in atrial pressure during ventricular systole
155
What does the a wave indicate on a JVP waveform?
atrial contraction
- large if atrial pressure e.g. tricuspid stenosis, pulmonary stenosis, pulmonary hypertension
- absent if in AF
156
What does a c wave indicate on a JVP waveform?
closure of tricuspid valve
(not normally visible)
157
What does a v wave indicate on a JVP waveform?
due to passive filling of blood into the atrium against a closed tricuspid valve
- giant v waves in tricuspid regurgitation
158
What does the y descent on a JVP waveform indicate?
opening of tricuspid valve
159
What is the 1st line treatment for pregnancy induced hypertension?
Labetolol
160
Infective endocarditis secondary to poor dental hygiene is most likely to be caused by which organism?
Streptococcus viridans
Streptococcus mitis
161
What anticoagulation is given following bio prosthetic valve replacement?
Aspirin (lose dose)
162
What are some indications for surgery in infective endocarditis?
- severe valvular incompetence
- aortic abscess (often indicated by a lengthening PR interval)
- infections resistant to antibiotics/fungal infections
- cardiac failure refractory to standard medical treatment
- recurrent emboli after antibiotic therapy
163
What is Ebstein's anomaly?
congenital heart defect characterised by low insertion of the tricuspid valve resulting in a large atrium and small ventricle.
164
What heart conditions are associated with Ebstein's anomaly?
- patent foramen ovale (PFO) or atrial septal defect (ASD) is seen in at least 80% of patients, resulting in a shunt between the right and left atria
- Wolff-Parkinson White syndrome
165
What are the clinical features of Ebstein's anomaly?
- cyanosis
- prominent 'a' wave in the distended jugular venous pulse,
- hepatomegaly
- tricuspid regurgitation
(pansystolic murmur, worse on inspiration)
- right bundle branch block → widely split S1 and S2
166
How soon can a person drive following insertion of permanent pacemaker?
1 week
167
What is the aim of endothelin receptor antagonists in the treatment of pulmonary hypertension?
to reduce pulmonary vascular resistance and hence reduce the strain on the right ventricle.
168
What pulse is typically felt in severe LVF?
Pulsus alternans
169
What is the renoprotective effect of ACE inhibitors/
dilation of the glomerular efferent arteriole thereby reducing glomerular capillary pressure
170
What are the features of aortic regurgitation?
- early diastolic murmur: intensity of the murmur is increased by the handgrip manoeuvre
- collapsing pulse
- wide pulse pressure
- Quincke's sign (nailbed pulsation)
- De Musset's sign (head bobbing)
- mid-diastolic Austin-Flint murmur in severe AR - due to partial closure of the anterior mitral valve cusps caused by the regurgitation streams
171
Which bradycardic conditions are at increased risk of asystole?
- complete heart block with broad complex QRS
- recent asystole
- Mobitz type II AV block
- ventricular pause > 3 seconds
172
What chromosomal disorders are associated with congenital VSD?
- Down's syndrome
- Edward's syndrome
- Patau syndrome
- cri-du-chat syndrome
173
What are the features of VSD post-nataly?
- failure to thrive
- features of heart failure:
hepatomegaly
tachypnoea
tachycardia
pallor
- classically a pan-systolic murmur which is louder in smaller defects
174
What are the management options for VSDs?
- small VSDs that are asymptomatic often close spontaneously and simply require monitoring
- moderate to large VSDs usually result in a degree of heart failure in the first few months
nutritional support
medication for heart failure e.g. diuretics
surgical closure of the defect
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What are some complications of VSDs?
- aortic regurgitation
(aortic regurgitation is due to a poorly supported right coronary cusp resulting in cusp prolapse)
- infective endocarditis
- Eisenmenger's complex
(due to prolonged pulmonary hypertension from the left-to-right shunt, results in right ventricular hypertrophy and increased right ventricular pressure. This eventually exceeds the left ventricular pressure resulting in a reversal of blood flow, this in turn results in cyanosis and clubbing. Eisenmenger's complex is an indication for a heart-lung transplant).
- right heart failure
- pulmonary hypertension (pregnancy is contraindicated in women with pulmonary hypertension as it carries a 30-50% risk of mortality)
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How is hypertrophic obstructive cardiomyopathy characterised on biopsy?
myofibrillar hypertrophy with chaotic and disorganized fashion myocytes ('disarray') and fibrosis
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What are the stages of a Valsalva manoeuvre?
Forced expiration against a closed glottis leads to ...
1. Increased intrathoracic pressure
2. Resultant increase in venous and right atrial pressure reduces venous return
3. The reduced preload leads to a fall in the cardiac output (Frank-Starling mechanism)
4. When the pressure is released there is a further slight fall in cardiac output due to increased aortic volume
5. Return of normal cardiac output
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When is the Valsalva manoeuvre used?
- to terminate an episode of supraventricular tachycardia
- normalizing middle-ear pressures
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What happens to BP during pregnancy?
Falls in first half of pregnancy before rising to pre-pregnancy levels before term. Falls due to systemic vasodilation and increased blood volume.
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What physiological changes occur during exercise?
Blood pressure:
- systolic increases, diastolic decreases
- leads to increased pulse pressure
Cardiac output:
- increase in cardiac output may be 3-5 fold
- results from venous constriction, vasodilation and increased myocardial contractibility, as well as from the maintenance of right atrial pressure by an increase in venous return
- heart rate up to 3-fold increase
- stroke volume up to 1.5-fold increase
Systemic vascular resistance falls in exercise due to vasodilatation in active skeletal muscles.
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What is the mechanism of action of fondaparinux?
Activates antithrombin III
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What is catecholaminergic polymorphic ventricular tachycardia?
- inherited cardiac disease associated with sudden cardiac death.
- autosomal dominant
- defect in the ryanodine receptor (RYR2) which is found in the myocardial sarcoplasmic reticulum
- sx generally develop before the age of 20yrs
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What is the management of catecholaminergic polymorphic ventricular tachycardia?
- Beta blockers
- implantable cardioverter-defibrillator
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What are the ECG features of hypokalaemia?
- U waves
- small or absent T waves (occasionally inversion)
- prolong PR interval
- ST depression
- long QT
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What is the mechanism of action of statins?
inhibit HMG-CoA reductase, the rate-limiting enzyme in hepatic cholesterol synthesis, therefore hepatic cholesterol synthesis decreases
186
What finding on bloods testing may indicate cholesterol embolisation?
Eosinophilia
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What are some causes of restrictive cardiomyopathy?
- amyloidosis (e.g. secondary to myeloma) - most common cause in UK
- haemochromatosis
- post-radiation fibrosis
- Loffler's syndrome: endomyocardial fibrosis with a prominent eosinophilic infiltrate
- endocardial fibroelastosis: thick fibroelastic tissue forms in the endocardium; most commonly seen in young children
- sarcoidosis
- scleroderma
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When are glycoprotein inhibitors started in the management of NSTEMIs?
if GRACE score greater than intermediate risk (>3%) then given prior to angiography within 96 hours
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What are some examples of glycoprotein inhibitors?
Eptifibatide, Tirofiban and Abciximab.
190
What are some causes for dilated cardiomyopathy?
- idiopathic: the most common cause
- myocarditis: e.g. Coxsackie B, HIV, diphtheria, Chagas disease, Keshan disease (selenium deficiency)
- ischaemic heart disease
- peripartum
- hypertension
- iatrogenic: e.g. doxorubicin
- substance abuse: e.g. alcohol, cocaine
- inherited: either a familial genetic predisposition to DCM or a specific syndrome e.g. Duchenne muscular dystrophy
- infiltrative e.g. haemochromatosis, sarcoidosis
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What is the pathophysiology of dilated cardiomyopathy?
- dilated heart leading to predominately systolic dysfunction
- all 4 chambers are dilated, but the left ventricle more so than right ventricle
- eccentric hypertrophy (sarcomeres added in series) is seen
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What are the features of dilated cardiomyopathy?
- classic findings of heart failure
- systolic murmur: stretching of the valves may result in mitral and tricuspid regurgitation
- S3
- 'balloon' appearance of the heart on the chest x-ray
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What are the high risk factors for pre- eclampsia?
- hypertensive disease in a previous pregnancy
- chronic kidney disease
- autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
- type 1 or type 2 diabetes
- chronic hypertension
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What are the moderate risk factors for pre-eclampsia?
- first pregnancy
- age 40 years or older
pregnancy interval of more than 10 years
- body mass index (BMI) of 35 kg/m² or more at first visit
- family history of pre-eclampsia
- multiple pregnancy
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How is the risk of pre-eclampsia reduced?
Women with ≥ 1 high risk factors or ≥ 2 moderate factors should take 75 - 150mg aspirin from 12 weeks gestation
196
What is Prinzmetal angina?
Variant or vasospastic angina - coronary artery vasospasm leading to chest pain.
Treated with dihydropyridine calcium channel blockers
197
What are some risk factors for statin induced myopathy?
- advanced age
- female sex
- low body mass index
- presence of multisystem disease such as diabetes mellitus.
198
What is the mechanism of action of hydralazine?
increases cGMP leading to smooth muscle relaxation.
This happens to a greater extent in the arterioles than the veins.
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What are some contraindications to hydralazine?
- systemic lupus erythematous
- ischaemic heart disease/cerebrovascular disease
200
What are some adverse effects of hydralazine?
- tachycardia
- palpitations
- flushing
- fluid retention
- headache
- drug-induced lupus
201
What is the mechanism of action of entresto (sacubitril/valsartan) in heart failure?
Prevents the degradation of natriuretic peptides such as ANP and BNP
202
What are some examples of centrally acting antihypertensives?
- methyldopa: used in the management of hypertension during pregnancy
- moxonidine: used in the management of essential hypertension when conventional antihypertensives have failed to control blood pressure
- clonidine: the antihypertensive effect is mediated through stimulating alpha-2 adrenoceptors in the vasomotor centre
203
What finding differentiates cardiac tamponade from constrictive pericarditis?
no Y descent on the JVP in cardiac tamponade
204
What is rheumatic fever?
an immunological reaction to a recent (2-4 weeks ago) Streptococcus pyogenes infection.
205
What histological finding in the heart is expected in rheumatic fever?
Aschoff bodies are granulomatous nodules and Anitschkow cells (enlarged macrophages with ovoid, wavy, rod-like nucleus).
206
What are the major criteria for diagnosing rheumatic fever?
- erythema marginatum
- Sydenham's chorea: this is often a late feature
- polyarthritis
- carditis and valvulitis (eg, pancarditis)
The latest iteration of the Jones criteria (published in 2015) state that rheumatic carditis cannot be based on pericarditis or myocarditis alone and that there must be evidence of endocarditis (the clinical correlate of which is valvulitis which manifests as a regurgitant murmur)
- subcutaneous nodules
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What are the minor criteria for diagnosing rheumatic fever?
- raised ESR or CRP
- pyrexia
- arthralgia (not if arthritis a major criteria)
- prolonged PR interval
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What is the management for rheumatic fever?
- antibiotics: oral penicillin V
- anti-inflammatories: NSAIDs are first-line
- treatment of any complications that develop e.g. heart failure
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