Cardiology Flashcards
Causes of a 3rd heart sound?
Diastollic filling of the ventricle
Normal variant <30 yrs
LV failure - dilated cardiomyopathy
Constrictive pericarditis
Mitral regurgitation
Causes of a 4th heart sound?
Atrial contraction against a stiff ventricle
Aortic stenosis
HOCM
Hypertension
Mechanism of action of adenosine?
Transient block at the AV node
When to check LFTs after starting a statin?
3 months, 6 months then 12 months
Side effects and contra-indications of b-blockers?
SE:
Bronchospasm
Erectile dysfunction
Contraindications:
Asthma
Uncontrolled heart failure
Heart block
Concurrent verapamil use
1st line anti-hypertensive if <55 years or T2DM?
ACE.I
1st line anti-hypertensive if >55 yrs or afrocarribean? (and not diabetic)
CCB
Following ACS which medications should all patients be offered?
Dual antiplatelet therapy (aspirin + another)
ACE.I
B-blocker
Statin
How does beurger’s disease present? aka thromoangitis obliterans
Progressive inflammation and thrombosis of the small and medium arteries in the hands and feet. It can present as acute ischaemia or chronic progressive ischaemic changes to the skin/tissues. Ultimately it may result in gangrene of the affected area, often needing amputation. It is strongly associated with an extensive smoking history. The exact pathophysiology is not fully understood.
Which anti-hypertensive agent is contra-indicated in patients with renal artery stenosis?
ACE inhibitors
Who should be prescribed a statin?
Established cardiovascular disease (stroke, TIA, ischaemic heart disease, peripheral arterial disease)
10-year cardiovascular risk >= 10%
Type 1 diabetics who were diagnosed more than 10 years ago OR are aged over 40 OR have established nephropathy
Which medications are used for angina in what order?
B-blocker or CCB
Then use both
Then add isosorbide mononitrate as a 3rd agent whilst patient is awaiting assessment for PCI or CABG
Which medication is used for chemical cardioversion and which is the option if there is structural heart disease (eg valve disorder)?
Amiodarone or Flecainide
Amiodarone if there is structural heart disease
What tests are needed prior to starting amiodarone?
TFT, LFT, U&E, CXR
What is the criteria for stopping an ACE. I when U&Es are checked after initiation?
> 30% rise in creatinine or 25% decrease in eGFR
What causes a pansystolic murmur?
Mitral regurgitation
What causes a late diastolic murmur?
Mitral stenosis
What causes a continuous machinery murmur?
Patent ductus arteriosus
What causes an ejection systolic murmur?
Aortic stenosis
When to consider using digoxin?
Heart failure + AF
What are the treatment options for heart failure?
1st line - ACE.I + b-blocker - start one at a time. ACE.I if they have diabetes, bisoprolol if they have angina.
2nd line - aldosterone antagonists eg spironolactone, eplerenone
+
SGLT2 inhibitors may also have a role. Can add after spiro.
3rd line - ivabradine/ digoxin etc on specialist advice
Which antiplatelet for stable coronary heart disease?
Aspirin longterm
Mechanism of action of the anti-platelets?
Aspirin - inhibits cyclo-oxygenase + blocks production of thromboxane
Clopidogrel, prasugrel and ticagrelor - blocks platelet P2Y12 receptors > blocks platelet aggregation
Dipyridamole - phosphodiesterase III inhibitor and suppresses cAMP degradation
Which antiplatelet for stable cerebrovascular disease?
Clopidogrel longterm
Which antiplatelet for symptomatic PAD?
Clopidogrel longterm
What is the antiplatelet regime after an acute coronary event?
Aspirin lifelong
2nd antiplatelet for up to 12 months: clopidogrel/ prasugrel or ticagrelor
What is the antiplatelet regime following planned PCI?
aspirin + clopidogrel for 6 months
Which PPI/ antiplatelet combination to avoid?
Avoid omeprazole and esomeprazole with clopidogrel
Which antiplatelets have a higher bleeding risk?
Prasugrel and ticagrelor are more effective, and have a faster onset of action, but higher bleeding risk.
How long is the treatment for a provoked PE?
3 months
How long is the treatment for an unprovoked PE without other other risk factors?
6 months
Which heart valve is most likely affected in IVDU endocarditis?
Tricuspid
What is the target BP in diabetics?
<140/90
What is the DVLA guidance following an acute coronary event?
Successful PIC > don’t drive for 1 week, don’t need to tell the DVLA
As long as no other procedure planned within 4 weeks and LV ejection fraction is at least 40%
If not successfully treated by coronary angioplasty, driving may recommence after 4 weeks.
If bus/ taxi / lorry driver then must not drive for 6 weeks and must inform the DVLA
What is a contra-indication to statins?
Pregnancy
What is coarctation of the aorta?
congenital narrowing of the descending aorta
you can get notching of the inferior border of the ribs due to devleoplm
Presents with: heart failure in children, radio-femoral delay, resistant hypertension, mid systolic murmur and an ‘apical click’ from the aortic valve
Do patients who have had a catheter ablation for AF require anticoagulation longterm?
Yes - after catheter ablation you still need anticoagulated even if in sinus rhythm if you have a high CHADVAS score
How long after an MI can you prescribe a PDE5 inhibitor (eg sildenafil) for erectile dysfunction?
Need to wait at least 6 months
What are the ECG changes in a posterior STEMI?
ST depression in V1-3
St elevation in V7-9 (posterior leads)
What is Dressler’s syndrome?
Occurs around 2-6 weeks following an MI. The underlying pathophysiology is thought to be an autoimmune reaction against antigenic proteins formed as the myocardium recovers. It is characterised by a combination of fever, pleuritic pain, pericardial effusion and a raised ESR. It is treated with NSAIDs.
What’s in the CHADSVS score?
C- congestive heart failure =1
H - Hypertension =1
A - Age
- >70 =2
- 65-74 =1
D - Diabetes =1
S - Stroke (previous stroke/ TIA/ emobolism) =2
V - vascular disease(IHD/ PAD)= 1
D - sex - female = 1
What ECG change might you see in mitral stenosis?
P mitrale > bifid p wave
When do ACE.I and b-blockers decrease mortality in HF patients?
Only if there is impaired ejection fraction. Otherwise no effect on mortality.
new LBBB + chest pain = MI. What territory is most likely to be affected?
Anterior
Which class of antibiotics can cause VT/ torsades?
Macrolide antibiotics (e.g. erythromycin, clarithromycin, ciprofloxacin)
What is the PESI score?
Helps determine which PE patients could be managed as outpatients
How do you manage major bleeding in a warfarin patient?
Stop warfarin
IV vitamin K 5mg
PCC or FFP
How do you manage minor bleeding in a warfarin patient?
Stop warfarin
IV vitamin K 1-3mg
If INR > 8 - repeat dose at 24 hours if still high
How do you manage INR > 8 no bleeding in a warfarin patient?
Stop warfarin
Vitamin K 1-5mg PO
How do you manage INR 5-8 no bleeding?
Omit warfarin for 1-2 doses and reduce maintenance dose
Treatment for a NSTEMI?
Apirin, fondaparinux
Ticagrelor if not a bleeding risk
Clopidogrel if high bleeding risk
You would perform an immediate coronary angiography in an NSTEMI patient if they were clinically unstable. You would also offer one in 72 hours in patients with a GRACE score>3%.
Fondaparinux should be offered to patients who are not at a high risk of bleeding and who are not having angiography immediately.
What is electrical alternans?
ECG finding where the QRS complexes vary from tall to short in alternating beats - pathognomic of tamponade
ECG changes in hypokalaemia
U waves
Small / absent T waves
Long PR
ST depression
Long QT
How long after a stroke can you start an anticoagulant for AF?
2 weeks due to risk of haemorrhagic transformation
Which valve disorder is associated with polycystic kidney disease?
Mitral valve prolapse
How do you manage AF >48 hrs in a patient that would be suitable for cardioversion?
Rate-control in the first instance (e.g. beta-blockers) and commenced on anticoagulation. After a period of 3 weeks on anticoagulation, these patients are brought back for an elective DC cardioversion followed by the continuation of anticoagulation for at least a further 4 weeks.
An alternative to anticoagulation is to get an immediate bedside echo to rule out the presence of an atrial thrombus followed by proceeding to cardioversion. However, this is not always routinely done in most hospitals.
What is the likely diagnosis when there is persistent ST elevation following an MI but no chest pain?
left ventricular aneurysm
Typically presents with tiredness and breathlessness
What medication must be avoided in patients with HOCM?
ACE. Inhibitors
Due to left ventricular outflow obstruction
Because ACE. I can reduce afterload
Complete heart block following an MI - which territory likely to be affected?
RCA - supplies the AV node
What are the stages of hypertension?
Stage 1: >140/90 or >135/85 on ABPM
Stage 2: >160/100 or >150/95 on ABPM
Stage 3: >180 systolic or >120 diastolic
What drug must you NOT give in VT?
Verapamil
> blocks the AV node so can lead to VF
What drug used in angina has the potential side effect of anal ulceration?
Nicorandil
What are some of the features of aortic regurgitation?
Early diastolic murmur
Collapsing pulse
Wide pulse pressure
Nailbed pulsation
