Cardiology Flashcards

1
Q

Monitoring required when using Mg sulfate?

A

Urine output

RR

O2 sat

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2
Q

What to do if respiratory depression when giving Mg Sulfate?

A

Calcium gluconate

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3
Q

Cardiac CP + Bradycardia + Low BP is suggestive of what? which structure is affected?

A

Suggestive of MI with complete heart block

RCA occlusion - as this supplies SA and AV nodes

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4
Q

Effect of thiazide diuretics on bones?

A

Reduced renal excretion of calcium

-> increased osseous matter + reduced risk of fractures

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5
Q

Contraindications to statins?

A

Macrolides - -mycin abx (stop until course is complete)

Pregnancy (stop 3 months before) - cholesterol cruical for foetal development + teratogenic risk

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6
Q

Main ECG change for hypercalcaemia?

A

Short QT

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7
Q

Main cause of infective endocarditis in colorectal ca?

A

Streptococcus bovis most commonly:

->Streptococcus gallolyticus

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8
Q

Pathogenesis of arrhytmogenic RV cardiomyopathy?

A

Right ventricular myocardium is replaced by fatty and fibrofatty tissue

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9
Q

Pathophysiology of long QT?

A

Loss of function of K+ channel / blocked K+ channel

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10
Q

ECG changes in Brugada syndrome? How can these changes be made apparent?

A

Convex ST segment elevation > 2mm in > 1 of V1-V3 followed by a negative T wave

Partial right bundle branch block

Exaggerate this by administering flecainide or ajmaline

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11
Q

Mutation in Brugada syndrome?

A

SCN5A gene - encodes myocardial Na channel protein

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12
Q

What examination sign is an early sign of LVF?

A

Gallop rhythm - S3 sound

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13
Q

Pathophysiology of HOCM?

A

Mutation to gene encoding B-myosin heavy chain protein or myosin-binding protein C

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14
Q

Which factors are affected by Warfarin?

A

10, 9, 7, 2

Warfarin was invented in 1972

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15
Q

Which medication used for HTN can impact HbA1c?

A

Thiazide diuretics - impaired glucose tolerance

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16
Q

Heart murmur in ebstein’s anomaly?

A

Tricuspid regurg - pansytolic murmur worse on inspiration

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17
Q

VSD murmur?

A

pansystolic murmur worse on expiration

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18
Q

Which cause of endocarditis is associated with poor dental hygiene? examples?

A

Streptococcus viridans - examples:

  • Streptococcus mitis
  • Streptococcus sanguinis
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19
Q

ECG changes for hypothermia?

A

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

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20
Q

What are aschoff bodies?

A

These are the ganulomatous nodules found in rheumatic heart fever

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21
Q

Which part of ECG wave is electrical cardioversion sync’d to?

A

The R wave

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22
Q

How to reduce risk of developing pre-eclampsia?

A

Low dose aspirin (75-150mg)

Given 12 weeks gestation until the birth if
≥ 1 high risk factors
≥ 2 moderate factors

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23
Q

Causes of loud S2?

A
  • HTN (systemic or pulmonary)
  • Hyperdynamic states
  • Atrial septal defect w/out pulmonary HTN
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24
Q

Heart sounds in complete heart block?

A

Variable intensity of S1

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25
ECG changes for WPW?
Short PR interval Wide QRS compled w/ slurred upstroke (delta wave) LAD (if r-sided accessory pathway) or RAD (if l-sided accessory pathway)
26
Which patients with DVT / PE should be considered for IVC filters?
Recurrent PE / DVT
27
Strongest indication for thrombolysis in PE?
Hypotension
28
Antithrombotic therapy in prosthetic valves?
Aspirin only
29
HTN in diabetics? change in age?
ARB / ACEi regardless of age
30
What can increase BNP levels? (not hf)
CKD egfr <60
31
What can decrease BNP levels?
ACEi ARB Diuretics
32
Effects of BNP?
Vasodilation Diuretic + Natriuretic Suppresses sympathetic tone + RAAS
33
What is a bisferiens pulse? When is it seen?
This is a double pulse caused by 2 systolic peaks Seen in mixed aortic valve disease
34
BNP below what level makes HF highly unlikely?
<100
35
GRACE MI scoring markers:
age heart rate, blood pressure cardiac (Killip class) and renal function (serum creatinine) cardiac arrest on presentation ECG findings troponin levels
36
Ix of choice for HOCM?
TT Echo
37
Takayasu's arteritis is an obliterative arteritis affecting the ....
Aorta
38
Rate limiting CCBs in AF, when to be avoided?
Avoid in patients with AF and HFrEF
39
Indications for urgent valvular replacement in endocarditis?
Severe congestive cardiac failure refractory to standard medcical tx Severe valvular incompetence Overwhelming sepsis despite antibiotic therapy (+/- perivalvular abscess, fistulae, perforation) Recurrent embolic episodes despite antibiotic therapy Pregnancy Aortic abscess (can see lengthening of PR interval) infections resistant to antibiotics/fungal infections
40
Which type of MI may you need a temporary pacemaker with?
Post-anterior MI when there is type 2 or complete heart block Complete heart block is common after inferior MI and can be managed conservatively if haemodynamically stable
41
What does persistent ST elevation follow recent MI not associated with CP mean?
L Ventricular aneurysm
42
1st line ix for stable chest pain of suspected CAD?
CT cornary angio w/ contrast
43
What drug is CI in VT?
Verapamil
44
What are the main medications used for pharmacological cardioversion in AF?
Amiodarone Flecainide - if not structural heart disease
45
When for valve replacement in AS?
If assymptomatic generally observe If symptomatic OR If valvular gradient >40 w/ features like LV systolic dysfunc -> surgery
46
Angina mx?
1st BB or CCB (If CCB on its own rate-limiting one if not other type) 2nd Dual therapy If can't tolerate dual add one of: - Long acting nitrate - Ivabradine - Nicorandil - Ranolazine 3rd If on dual therapy only add 3rd whilst awaiting PCI / CABG
47
Strongest RF for Infective endocarditis?
Prev episode of infective endocarditis
48
Features that suggest VT instead of SVT with abberant conduction
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
49
What medication should be avoided in RV infarct? Why?
In RV infarct - RV dysfunction -> hypotension and peripheral blood increase (eg raised JVP) Nitrates reduce preload and can worsen this
49
What to do in mx of STEMI if can't PCI in 120 mins?
Fibrinolysis within 12 hours of onset of symptoms
50
Which medications should be avoidede in WPW cause they can percipitate VT / VF?
Verapamil Digoxin
51
Initial blind abx therapy for infective endocarditis?
Native valve: -> Amox +- low-dose gent -> Vanc + low-dose gent (pen-allergic) Prosthetic valve: -> Vanc + Rifampicin + low-dose gent
52
Features of cholesterol embolisation?
eosinophilia purpura renal failure livedo reticularis
53
Describe the NYHA classes of HF?
Class I - No sx + limitation Class II - Mild sx + fatigue with ordinary activity Class III - Moderate sx + fatigue with less than ordinary activity Class IV - Severe + unable to exert / present at rest
53
When is 3rd heart sound normal? When is it heard otherwise?
Caused by diastolic filling of ventricle Normal if <30 - can be upto 50 in women Heard in LVF (dilated cardiomyopathy), constrictive pericarditis and mitral regurg
54
Target INR for mechanical valves
Anticoagulate with Warfarin Aortic - 3.0 Mitral - 3.5 Mechanical valve anticoagulation is 1st thing in the AM (A then M)
55
Causes of loud / soft S2?
Loud - HTN Soft - AS
56
Causes of fixed split and reverse split S2?
Fixed split - ASD Reveresed split - LBBB
57
ECG changes in hypokalaemia?
U waves small or absent T waves (occasionally inversion) prolong PR interval ST depression long QT In Hypokalaemia, U have no Pot and no T, but a long PR and a long QT
58
Most common cause of IE if < 2 months post valve surgery?
Stpah epidermis
59
How do the following drugs work? Heparin Clopidogrel Abciximab Dabigatran Rivaroxaban
Heparin - Activates anti-thrombin III Clopidogrel - P2Y12 inhibitor Abciximab - Glp IIb/IIIa inhibitor Dabigatran - direct thrombin inhibitor Rivaroxaban - Direct factor X inhibitor
60
What are features of severe AS?
narrow pulse pressure slow rising pulse delayed ESM soft/absent S2 S4 thrill duration of murmur left ventricular hypertrophy or failure
61
What are the features of cardiac syndrome x? how is managed?
Angina like CP upon exertion ST depression on stress test NORMAL CORONARIES Nitrates may be beneficial
62
Mx of HOCM?
Amiodarone Beta-blockers or verapamil for symptoms Cardioverter defibrillator Dual chamber pacemaker Endocarditis prophylaxis*
63
What drugs to avoid in HOCM?
nitrates ACE-inhibitors inotropes
64
What happens to BP in pregnancy?
Falls in first half of pregnancy before rising to pre-pregnancy levels before term
65
Most common cause of death after MI?
VF
66
How to measure QT interval?
QT interval: Time between the start of the Q wave and the end of the T wave
67
What is Jervell-Lange-Nielsen syndrome and Romano-Ward syndromes? How do they differ?
JLN + RW syndromes are inherited syndromes of long QT intervals JLN - sensorineural hearing loss RW - no hearing loss
68
Causes of cannon a waves - regular and irregular?
Regular cannon waves -> ventricular tachycardia (with 1:1 ventricular-atrial conduction) -> atrio-ventricular nodal re-entry tachycardia (AVNRT) Irregular cannon waves -> complete heart block
69
When is CK-MB better than Troponin?
CK-MB is useful to look for reinfarction as it returns to normal after 2-3 days (troponin T remains elevated for up to 10 days)
70
When to stop ACEi in CKD?
A potassium above 6mmol/L should prompt cessation of ACE inhibitors in a patient with CKD (once other agents that promote hyperkalemia have been stopped)
71
MoA of hypokalaemia in thiazaide diuretics?
increased delivery of sodium to the distal part of the distal convoluted tubule
72
What is normal MV area - what is it in severe MS? What is the intervention of choice for severe MS?
Normal area 4-6cm2 -> Severe MS <1cm2 Intervention: - MV commussurotomy -> if this fails then valve replacement
73
When is mitral valve repair used?
Mitral regurg / prolapse
74
Cause of soft S1?
Caused by closure of MV and TV valves - Long PR - MR
75
Cause of loud S1?
Caused by closure of MV and TV valves - MS
76
Cause of soft S2?
Caused by closure of AV and PV valves - Soft in AS
77
What can happen to S2 during inspiration?
Physiological splitting of S2
78
What is S3 caused by? when is this normal when is it abnormal?
caused by diastolic filling of the ventricle -> considered normal if < 30 years old (may persist in women up to 50 years old) -> heard in left ventricular failure (e.g. dilated cardiomyopathy), constrictive pericarditis (called a pericardial knock) and mitral regurgitation
79
When can you get S4? What causes it?
S4 caused by atrial contraction against stiff ventricle hence coincides with P wave on ECG Can be in AS, HOCM or HTN -> In HOCM double apical impulse maybe felt due to palpable S4
80
What is Sacubitril? How does it work?
Sacubitril is a neprilysin inhibitor -> prevents degradation of BNP and ANP ANP and BNP work similarly -> natriuresis and vasodilation
81
Management of VF / pulseless VT when identified?
1 shock ASAP -> 2 minutes of CPR (If monitored patient eg in CCU upto 3 successive shocks -> CPR)
82
Which infective endocarditis has a good prognosis?
Streptococci infection
83
Poor prognostic factors in infective endocarditis?
Staphylococcus aureus infection prosthetic valve (especially 'early', acquired during surgery) culture negative endocarditis low complement levels
84
How can you remember causes of different parts of JVP wave?
A= Atrial contraction C= Closure of triCuspid x descent= Vent cont V= passiVe filling of atrium Y descent= Tricuspid opening
85
Adverse reactions associated with Ivabradine
visual effects, particular luminous phenomena, are common headache bradycardia, heart block
86
Nicorandil MoA?
K+ channel activator + nitrate
87
Driving advice - angioplasty (elective)
1 week off
88
Driving advice - CABG
4 weeks off (4 letters)
89
Driving advice - ACS
4 weeks (1 week if treated successfully with angioplasty)
90
Pacemaker insertion - Driving advice
1 week
91
ICD - Driving advice?
If for sustained ventricular arrhytmia - 6 months Prophylactic - 1 month Permanent bar for Group 2 vehicles
92
Ablation for arrhythmia - advice re driving?
2 days off
93
Aortic aneurysm - driving advice
If >6cm notify and annual review If >6.5cm disqualified
94
Heart transplant - driving advice
Don't drive for 6 weeks no need to notfiy
95
HTN - Driving advice
Drive unless side-effects Group 2 vehicles - if resting >180/100 can't drive
96
Causes of LAD?
left anterior hemiblock left bundle branch block inferior myocardial infarction Wolff-Parkinson-White syndrome* - right-sided accessory pathway hyperkalaemia congenital: ostium primum ASD, tricuspid atresia minor LAD in obese people
97
Causes of RAD?
right ventricular hypertrophy left posterior hemiblock lateral myocardial infarction chronic lung disease → cor pulmonale pulmonary embolism ostium secundum ASD Wolff-Parkinson-White syndrome* - left-sided accessory pathway normal in infant < 1 years old minor RAD in tall people
98
What to do re-Warfarin if patient is having emergency surgery?
If surgery can wait 6-8 hours - 5mg Vit K IV If surgery can't wait - 25-50 U/kg 4 factor prothrombin complex
99
Causes of raised BNP?
Lung issues - COPD / Pneumonia Sepsis Cardiac causes - AF, valve disease Older age Chemo Female sex HTN Reduced excretion - renal issues eg CKD
100
Causes of low BNP?
Obesity Flash pulmonary oedema Pericardial constriction Use of ARBs, ACEi and Diuretics
101
How to reduce frequency of SVTs?
BBs Radio-frequency ablation
102
DVLA advice in HF?
Symptomatic HF rules you out from Group 2 licence Need to become assymptomatic and also LVEF >40%
103
Which factor is most associated with sudden death within first 6m after MI?
Low LVEF Those with systolic heart failure post MI can be up to 10x more likely to die than those that do not have an MI
104
Causes of eruptive xanthomas? What are these?
Causes of eruptive xanthoma: -> familial hypertriglyceridaemia -> lipoprotein lipase deficiency Eruptive xanthoma are due to high triglyceride levels and present as multiple red/yellow vesicles on the extensor surfaces (e.g. elbows, knees)
105
What is WPW associated with?
HOCM mitral valve prolapse Ebstein's anomaly thyrotoxicosis secundum ASD
106
What are some causes of myocarditis?
viral: coxsackie B, HIV bacteria: diphtheria, clostridia spirochaetes: Lyme disease protozoa: Chagas' disease, toxoplasmosis autoimmune drugs: doxorubicin
107
Prosthetic valve endocarditis caused by staphylococci mx?
Flucloxacillin + rifampicin + low-dose gentamicin If penicillin allergic or MRSA vancomycin + rifampicin + low-dose gentamicin
108
Native valve endocarditis caused by staphylococci mx?
ucloxacillin If penicillin allergic or MRSA = vancomycin + rifampicin
109
Actions of BNP?
vasodilator: can decrease cardiac afterload diuretic and natriuretic suppresses both sympathetic tone and the renin-angiotensin-aldosterone system
110
How do cholesterol emboli present? What can precipitate this?
the majority of cases are secondary to vascular surgery or angiography. Other causes include severe atherosclerosis, particularly in large arteries such as the aorta Features: eosinophilia purpura renal failure livedo reticularis
111
Mx of angina?
1st BB / CCB 2nd Add the other one, cant tolerate CCB add nitrate 3rd If taking both only add 3rd whilst awaiting PCI / CABG
112
Is verapamil used in HTN?
No
113
Can you give verapamil with BBs?
No as both reduce conduction at the AV node and this could lead to complete heart block.
114
Why is prolonged loading regime required with Amiodarone?
Amiodarone has a long half-life (20-100 days) - it is highly lipophilic and widely absorbed by tissue, which reduces its bioavailability in serum Longer loading regimen helps achieve stable therapeutic levels
115
bivalirudin moa and when is it used?
Reversible direct thrombin inhibitor Used as parenteral anticoagulation
116
Poor prognostic features in HOCM?
Syncope FHD of sudden death young age at presentation nonsustained VT on 24/48h holter abnormal BP on excercise Septal thickness >3cm
117
How long should the warfarin be continued after successful cardioversion?
At least 4w If echo = structural abnormalities / AF likely to recurr then long term anticoagulation
118
Mx of uraemic pericarditis?
Haemodialysis
119
ECG features of digoxin use?
down-sloping ST depression ('reverse tick', 'scooped out') flattened/inverted T waves short QT interval arrhythmias e.g. AV block, bradycardia
120
collapsing pulse wide pulse pressure Freatures of?
Aortic regurg
121
AR causes?
Causes of AR due to valve disease: - Rheum fever - most common developing - Calcified valve - Connective tissues - RA, SLE - Bicuspid aortic valve - IE Causes of AR due to aortic root disease - Bicuspid aortic valve - Spondyloarthropathies eg ank spond - HTN - Syphilis - Marfans and EDS - Aortic dissection
122
Dukes criteria for IE?
Modified Duke's Criteria for Infective Endocarditis : Mnemonic 1.B lood culture positive for IE 2.E ndocardial involvement 3.F ever 4.I mmunologic phenomena 5.V ascular phenomena 6. D rug abuse (or with Previous Heart conditions) ''FIVE BD
123
When are a waves in JVP: large? absent? cannon?
large - if raised atrial pressure eg TS, PS and Pulmon HTN absent - AF cannon - atrial contraction v closed TV - complete heart block, VT/ V ectopics, nodal rhythm, single chamber ventricular pacing
124
Features of severe pre-eclapsia?
hypertension: typically > 160/110 mmHg and proteinuria as above proteinuria: dipstick ++/+++ headache visual disturbance papilloedema RUQ/epigastric pain hyperreflexia platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome
125
High RFs for pre-eclampsia?
High risk factors 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
126
Moderate RFs 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
127
Mx of fully sensitive and less sensitive strep?
Fully: Benpen or if allergic vanc + low dose gent less Benpen + low dose gent or if allergic vanc + low dose gent
128
Physiological response to valsalva?
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
129
ticagrelor common side effect?
Dyspnoea can be switched to clopidogrel
130
Hydralazine Moa?
Increases cGMP leading to smooth muscle relaxation - more in arterioles than veins
131
marker of severity in AS?
S4 = S4vere Soft / absent S2 narrow pulse pressure slow rising pulse delayed ESM thrill duration of murmur left ventricular hypertrophy or failure
132
Causes of dilated cardiomyopathy?
idiopathic: the most common cause myocarditis: e.g. Coxsackie B, HIV, diphtheria, Chagas disease 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 THIAMINS Thiamine deficiency (wet beri-beri) Hypertension Ischaemic heart disease Alcohol (and cocaine) Myocarditis Infiltrative (haemochromatosis and sarcoidosis) No cause (idiopathic) Selenium deficiency
133
Drugs used for PAD and their MoA?
naftidrofuryl oxalate: vasodilator, sometimes used for patients with a poor quality of life cilostazol: phosphodiesterase III inhibitor with both antiplatelet and vasodilator effects - not recommended by NICE
134
Clinical features of PDA?
left subclavicular thrill continuous 'machinery' murmur large volume, bounding, collapsing pulse wide pulse pressure heaving apex beat
135
What are the different coronary territories and what are the supplied by?
Anterolateral - V1-4 - LAD Inferior - II, III and aVF - RCA Anterolateral - V1-6, I and aVL - proximal LAD Lateral - I, aVL, +- V5-6 - Left circumflex Posterior - V1-3 - Usually left circumflex + RCA
136
Wellens' syndrome ECG changes?
ECG manifestation of critical proximal left anterior descending (LAD) coronary artery stenosis in patients with unstable angina symmetrical often deep >2mm T wave inversions in anterior precordial leads (V1-4)
137
When is Warfarin used after for anticoagulation?
Mechanical heart valves + 2nd line after DOACs in below: venous thromboembolism: target INR = 2.5, if recurrent 3.5 atrial fibrillation, target INR = 2.5
138
HOCM echo findings?
mnemonic - MR SAM ASH mitral regurgitation (MR) systolic anterior motion (SAM) of the anterior mitral valve leaflet asymmetric hypertrophy (ASH)
139
Changes to murmurs with squatting / leg raise (increased venous return) v standing /valsava (decreased venous return)
Mitral & Aortic stenosis and regurgitation increase intensity of murmurs in squatting or leg raising and decrease in valsalva or standing. whilst in HOCM & MVP increase intensity of murmurs in valsalva or standing and decrease in squatting or leg raising.
140
What are the types of ASDs?
Ostium secundum (70% of ASDs) - associated w tripharyngeal thumbs (Holt-Oram synd) ECG - RBBB w RAD Ostium primum - present earlier associated with abnormal AV valve ECG - RBB w LAD + prolonged PR
141
RFs for statin induced myopathy?
thin old diabetic lady
142
Inheritance and who is Brugada more common in?
AD and more common in asians
143
radiotracer for PET?
Flurodeoxyglucose - PET looks at glucose uptake
144
Atrial myxoma - commonest site?
Left atria @ fossa ovalis border
145
1st cardiac enzyme to rise after MI?
Myoglobin
146
Dentistry in warfarinised patients?
Dentistry in warfarinised patients - check INR 72 hours before procedure, proceed if INR < 4.0
147
Bloods monitoring in Statins?
LFTs at baseline, 3 months and 12 months A fasting lipid profile may also be checked during monitoring to assess response to treatment.
148
What is the role of troponin in cardiac muscle?
Components of thin filaments -> blocking actin binding to myosin during the relaxed phase. TropoTHIN
149
Associations of 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
150
Endo causes of HTN?
Endocrine disorders (other than primary hyperaldosteronism) may also result in increased blood pressure: phaeochromocytoma Cushing's syndrome Liddle's syndrome congenital adrenal hyperplasia (11-beta hydroxylase deficiency) acromegaly
151
Drug and other (non-renal / endo) causes of HTN?
Drug causes: steroids monoamine oxidase inhibitors the combined oral contraceptive pill NSAIDs leflunomide Other causes include: pregnancy coarctation of the aorta
152
Indications for ICDs?
long QT syndrome HOCM previous cardiac arrest due to VT/VF previous myocardial infarction with non-sustained VT on 24 hr monitoring, inducible VT on electrophysiology testing and ejection fraction < 35% Brugada syndrome
153
Mx of AF with percipitating cause?
A stable patient presenting in AF with an obvious precipitating cause may revert to sinus rhythm without specific antiarrhythmic treatment
154
Signs of TR?
Pan-systolic murmur prominent/giant V waves in JVP pulsatile hepatomegaly left parasternal heave
155
When is cut off for pregnancy induced HTN / pre-eclampsia?
after 20 weeks
156
What investigation is most useful in predicting symptomatic response to cardiac resynchronisation therapy?
ECG & TTE - LVEF <35% and a LBBB (QRS duration greater than 120 ms) on ECG are excellent candidates for CRT (biventricular pacing)
157
MUGA Multi Gated Acquisition Scan, also known as radionuclide angiography radionuclide (technetium-99m) is injected intravenously When is it used and what does it measure?
Used before and after cardiotoxic drug use Accurately measures LVEF mre than echo
158
Ix for Pulmon HTN?
all patients need to have right heart pressures measured. Cardiac catheterisation is therefore the single most important investigation
159
Medical Mx of WPW?
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
160
Why check U+Es before amiodarone?
Hypokalaemic risk
161
TOF features?
P Pulmonary Stenosis R RVH O Overriding Aorta V VSD
162
Causes of long PR?
Myotica dystrophica IHD Lyme Digoxin toxicity Rheumatic fever Aortic abscess Sarcoidosis Hypokalemia
163
Causes of restrictive cardiomyopathy?
SLASHER(restrictive cardiomyopathy causes): sarcoidosis lofflers amyloid (most common in UK) scleroderma haemochromatosis endocardial fibroelastosis post-Radiation fibrosis
164
Warfarin what to do in - Major bleeding - INR >8 + Minor bleeding - INR >8 + No bleeding - INR 5-8 + Minor bleeding - INR 5-8 + No bleeding
- Major bleeding Stop warfarin Give intravenous vitamin K 5mg Prothrombin complex concentrate - if not available then FFP* - INR >8 + Minor bleeding Stop warfarin Give intravenous vitamin K 1-3mg Repeat dose of vitamin K if INR still too high after 24 hours Restart warfarin when INR < 5.0 - INR >8 + No bleeding Stop warfarin Give vitamin K 1-5mg by mouth, using the intravenous preparation orally Repeat dose of vitamin K if INR still too high after 24 hours Restart when INR < 5.0 - INR 5-8 + Minor bleeding Stop warfarin Give intravenous vitamin K 1-3mg Restart when INR < 5.0 - INR 5-8 + No bleeding Withhold 1 or 2 doses of warfarin Reduce subsequent maintenance dose *as FFP can take time to defrost prothrombin complex concentrate should be considered in cases of intracranial haemorrhage
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What is Prinzmetal angina? how is it mx?
Prinsmetal (vasospastic) angina = rare angina where pain is at rest instead of on activity Caused by narrowing / occlusion of proximal coronary arteries due to vasospasm due to spasms Not dx by coronary angio Mx = avoid BB as they can worsen coronary spasm, use dihydropyridine derivative CCB eg amlodipine / felodipine
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What is pulsus paradoxus and when is it seen?
greater than the normal (10 mmHg) fall in systolic blood pressure during inspiration → faint or absent pulse in inspiration severe asthma, cardiac tamponade
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What is pulsus alternans? when is it seen?
regular alternation of the force of the arterial pulse severe LVF
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What type of valve is HOCM associated with?
Jerky pulse or occasionaly bisferiens pulse
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Causes of collapsing pulse?
aortic regurgitation patent ductus arteriosus hyperkinetic states (anaemia, thyrotoxic, fever, exercise/pregnancy)
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What can enhance / block effects of adenosine? when to avoid adenosine?
The effects of adenosine are enhanced by dipyridamole (antiplatelet agent) and blocked by theophyllines. It should be avoided in asthmatics due to possible bronchospasm.
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MoA of adenosine?
Transient heart block in AV node - agonism of A1 receptor in AV node - inhibiting adenylyl cyclase -> reduced cAMP -> hyperpolarisation (increased outward K flux)
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Adenosine effect in WPW?
can enhance conduction down accessory pathways, resulting in increased ventricular rate (e.g. WPW syndrome)
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What can happen after inferior MI?
AV block - AV nodal artery is branch of RCA
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What are the features of papillary muscle rupture following MI?
acute mitral regurgitation → widespread systolic murmur, hypotension, pulmonary oedema (1-7d after MI)
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pansystolic murmur heard lowest over the left lower sternal edge? JVP finding?
Tricuspid regurg associated with prominent V waves on JVP
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What causes TGA in neonates? CXR finding?
TGA is caused by failure of the aorticopulmonary septum to spiral during septation 'egg-on-side' appearance on chest x-ray
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What is multifocal atrial tachycardia and how is it mx?
Multifocal atrial tachycardia (MAT) may be defined as a irregular cardiac rhythm caused by at least three different sites in the atria Seen in elderly w chronic lung disease Mx = rate limiting CCBs + correction of hypoxia and electrolyte abnormalities
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What drugs can percipitate Torsades de pointes?
Those that can cause long QT Causes: (ABCDEF-H) anti-Arrhytmics'-mainly K-channel blocker-as they increase repolarization time-hence QT prolongation anti-Biotics'flouroquonolones and macrolides (also they are p450 inh) anti-Cychotics anti-Depressants'SSRI and TCA anti-Emetics'>ondansetron anti-Fungals'>Azoles group mainly Anti-Histamine Decreased K,Ca,Mg'-also causes Long QT so torsades de pointes
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Mx of trosades de pointes?
polymorphic ventricular tachycardia associated with a long QT interval Mx = IV MgSO4
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Why are BB used less in HTN these days?
Less likely to prevent stroke + potential glucose tolerance impairment
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How is pulmonary capillary wedge pressure measured and what is this used for?
balloon tipped Swan-Ganz catheter which is inserted into the pulmonary artery / left atrium (similar pressures 6-12) Used to determine whether pulmonary oedema is due to HF or ARDS
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Chadsvasc scoring?
C H A2 D S2 V S C Congestive heart failure 1 H Hypertension (or treated hypertension) 1 A2 Age >= 75 years 2, Age 65-74 years 1 D Diabetes 1 S2 Prior Stroke, TIA or thromboembolism 2 V Vascular disease (including ischaemic heart disease and peripheral arterial disease) 1 S Sex (female)
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Physiological changes to exercise?
BP - systolic rise and diastolic drop hence increased pulse pressure, in healthy young MABP is slight Cardiac output - increase by 3-5x due to venous constriction, vasodilation, increased contractility + maintained RA pressure by increased venous return, HR upto 3x and SV 1.5x Systemic vascular resistance falls in exercise due to vasodilatation in active skeletal muscles.
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VT during coronary angio?
An uncommon complication of a coronary angiogram is a ventricular arrhythmia secondary to irritation of the myocardium. When present, the offending catheter must be pulled back immediately to restore normal sinus rhythm. Then if all cardiac ix are normal can be safely discharged
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Dipyridamole MoA?
non-specific phosphodiesterase inhibitor and decreases cellular uptake of adenosine
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Which drug directly blocks P2Y12-receptors, which are important in the activation of platelets? Is this reversible or irreversibly done?
Ticagrelor - Reversibly Clopidogrel and prasugrel IRREVERSIBLY inhibits
187
What are the different classifications of AF?
Paroxysmal AF - 2 or more episodes of AF that terminate spontaneously Persistent AF - 2 or more episodes of AF that DO NOT terminate spontaneously Permanent AF - continuous atrial fibrillation which cannot be cardioverted or if attempts to do so are deemed inappropriate. Treatment goals are therefore rate control and anticoagulation if appropriate
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TIA + AF when to start DOAC?
ASAP
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Examples of centrally acting anti-HTNs?
Methyldopa - used in pregnancy Moxonidine - Used in essential HTN when conventional meds have failed Clonidine - Anti-HTN effect via stimulation of alpha-2 adrenoceptors in the vasomotor centre
190
Can acromegaly cause mitral valve prolapse?
Not really
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Does williams syndrome cause AS? wb HOCM?
Yes Williams causes supravalvular AS In contast HOCM causes subvalvular AS
192
Coarctation of the aorta is associated with which conditions?
Turner's syndrome bicuspid aortic valve berry aneurysms neurofibromatosis
193
When to avoid sotalol in WPW?
If coexistent AF
194
What to use for SVT in asthmatics?
Verapamil / rate limiting CCB
195
Can you get the following with bendroflumethiazide: Photosensitivity rash Agranulocytosis Hypokalaemia Pancreatitis Hirsutism
Photosensitivity rash - Yes Agranulocytosis - Yes Hypokalaemia - Yes Pancreatitis - Yes Hirsutism - NOOOOOOO
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Causes of LBBB
myocardial infarction hypertension aortic stenosis cardiomyopathy rare: idiopathic fibrosis, digoxin toxicity, hyperkalaemia
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What is the main mechanism causing hypokalaemia in patients taking bendroflumethiazide?
Increased sodium reaching the collecting ducts
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ECG changes in cardiac syndrome X? mx?
Downsloping ST depression esp on exercise testing with normal coronary angio despite anginaly pain Mx = nitrates?
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Her 12-lead ECG at rest shows sinus rhythm with T wave inversion in V1-3, with a small positive deflection at the end of the QRS complexes in V1-3. A 24-hour Holter monitor shows evidence of frequent premature ventricular complexes and runs of non-sustained ventricular tachycardia. Suggestive of what dx? pathphys?
Arrhythmogenic right ventricular cardiomyopathy due to RV myocardial replacement w fatty + fibrofatty tissue
200
early diastolic murmur + wide pulse pressure is what?
Aortic regurg
201
Antiembolic therapy with valve replacement?
mechanical : warfarin bioprosthetic: aspirin bioprosthetic + CAD/CABG - aspirin mechanical + CAD/CABG - warfarin and aspirin
202
Where to thiazides work?
inhibits sodium reabsorption by blocking the Na+-Clˆ’ symporter at the beginning of the distal convoluted tubule
203
Why do you need assymetric dosing with IR nitrates?
Prevent nitrate tolerance
204
Which CCB is the only one licenced for use in HF?
Amlodipine
205
ECG change in PAH?
RAD