Cardiology Flashcards
Monitoring required when using Mg sulfate?
Urine output
RR
O2 sat
What to do if respiratory depression when giving Mg Sulfate?
Calcium gluconate
Cardiac CP + Bradycardia + Low BP is suggestive of what? which structure is affected?
Suggestive of MI with complete heart block
RCA occlusion - as this supplies SA and AV nodes
Effect of thiazide diuretics on bones?
Reduced renal excretion of calcium
-> increased osseous matter + reduced risk of fractures
Contraindications to statins?
Macrolides - -mycin abx (stop until course is complete)
Pregnancy (stop 3 months before) - cholesterol cruical for foetal development + teratogenic risk
Main ECG change for hypercalcaemia?
Short QT
Main cause of infective endocarditis in colorectal ca?
Streptococcus bovis most commonly:
->Streptococcus gallolyticus
Pathogenesis of arrhytmogenic RV cardiomyopathy?
Right ventricular myocardium is replaced by fatty and fibrofatty tissue
Pathophysiology of long QT?
Loss of function of K+ channel / blocked K+ channel
ECG changes in Brugada syndrome? How can these changes be made apparent?
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
Mutation in Brugada syndrome?
SCN5A gene - encodes myocardial Na channel protein
What examination sign is an early sign of LVF?
Gallop rhythm - S3 sound
Pathophysiology of HOCM?
Mutation to gene encoding B-myosin heavy chain protein or myosin-binding protein C
Which factors are affected by Warfarin?
10, 9, 7, 2
Warfarin was invented in 1972
Which medication used for HTN can impact HbA1c?
Thiazide diuretics - impaired glucose tolerance
Heart murmur in ebstein’s anomaly?
Tricuspid regurg - pansytolic murmur worse on inspiration
VSD murmur?
pansystolic murmur worse on expiration
Which cause of endocarditis is associated with poor dental hygiene? examples?
Streptococcus viridans - examples:
- Streptococcus mitis
- Streptococcus sanguinis
ECG changes for 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
What are aschoff bodies?
These are the ganulomatous nodules found in rheumatic heart fever
Which part of ECG wave is electrical cardioversion sync’d to?
The R wave
How to reduce risk of developing pre-eclampsia?
Low dose aspirin (75-150mg)
Given 12 weeks gestation until the birth if
≥ 1 high risk factors
≥ 2 moderate factors
Causes of loud S2?
- HTN (systemic or pulmonary)
- Hyperdynamic states
- Atrial septal defect w/out pulmonary HTN
Heart sounds in complete heart block?
Variable intensity of S1
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)
Which patients with DVT / PE should be considered for IVC filters?
Recurrent PE / DVT
Strongest indication for thrombolysis in PE?
Hypotension
Antithrombotic therapy in prosthetic valves?
Aspirin only
HTN in diabetics? change in age?
ARB / ACEi regardless of age
What can increase BNP levels? (not hf)
CKD egfr <60
What can decrease BNP levels?
ACEi
ARB
Diuretics
Effects of BNP?
Vasodilation
Diuretic + Natriuretic
Suppresses sympathetic tone + RAAS
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
BNP below what level makes HF highly unlikely?
<100
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
Ix of choice for HOCM?
TT Echo
Takayasu’s arteritis is an obliterative arteritis affecting the ….
Aorta
Rate limiting CCBs in AF, when to be avoided?
Avoid in patients with AF and HFrEF
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
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
What does persistent ST elevation follow recent MI not associated with CP mean?
L Ventricular aneurysm
1st line ix for stable chest pain of suspected CAD?
CT cornary angio w/ contrast
What drug is CI in VT?
Verapamil
What are the main medications used for pharmacological cardioversion in AF?
Amiodarone
Flecainide - if not structural heart disease
When for valve replacement in AS?
If assymptomatic generally observe
If symptomatic
OR
If valvular gradient >40 w/ features like LV systolic dysfunc
-> surgery
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
Strongest RF for Infective endocarditis?
Prev episode of infective endocarditis
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
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
What to do in mx of STEMI if can’t PCI in 120 mins?
Fibrinolysis within 12 hours of onset of symptoms
Which medications should be avoidede in WPW cause they can percipitate VT / VF?
Verapamil
Digoxin
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
Features of cholesterol embolisation?
eosinophilia
purpura
renal failure
livedo reticularis
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
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
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)
Causes of loud / soft S2?
Loud - HTN
Soft - AS
Causes of fixed split and reverse split S2?
Fixed split - ASD
Reveresed split - LBBB
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
Most common cause of IE if < 2 months post valve surgery?
Stpah epidermis
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
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
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
Mx of HOCM?
Amiodarone
Beta-blockers or verapamil for symptoms
Cardioverter defibrillator
Dual chamber pacemaker
Endocarditis prophylaxis*
What drugs to avoid in HOCM?
nitrates
ACE-inhibitors
inotropes
What happens to BP in pregnancy?
Falls in first half of pregnancy before rising to pre-pregnancy levels before term
Most common cause of death after MI?
VF
How to measure QT interval?
QT interval: Time between the start of the Q wave and the end of the T wave
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
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
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)
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)
MoA of hypokalaemia in thiazaide diuretics?
increased delivery of sodium to the distal part of the distal convoluted tubule
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
When is mitral valve repair used?
Mitral regurg / prolapse
Cause of soft S1?
Caused by closure of MV and TV valves
- Long PR
- MR
Cause of loud S1?
Caused by closure of MV and TV valves
- MS
Cause of soft S2?
Caused by closure of AV and PV valves
- Soft in AS
What can happen to S2 during inspiration?
Physiological splitting of S2
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
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
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
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)
Which infective endocarditis has a good prognosis?
Streptococci infection
Poor prognostic factors in infective endocarditis?
Staphylococcus aureus infection
prosthetic valve (especially ‘early’, acquired during surgery)
culture negative endocarditis
low complement levels
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
Adverse reactions associated with Ivabradine
visual effects, particular luminous phenomena, are common
headache
bradycardia, heart block
Nicorandil MoA?
K+ channel activator + nitrate
Driving advice - angioplasty (elective)
1 week off
Driving advice - CABG
4 weeks off (4 letters)
Driving advice - ACS
4 weeks
(1 week if treated successfully with angioplasty)
Pacemaker insertion - Driving advice
1 week
ICD - Driving advice?
If for sustained ventricular arrhytmia - 6 months
Prophylactic - 1 month
Permanent bar for Group 2 vehicles
Ablation for arrhythmia - advice re driving?
2 days off
Aortic aneurysm - driving advice
If >6cm notify and annual review
If >6.5cm disqualified
Heart transplant - driving advice
Don’t drive for 6 weeks no need to notfiy
HTN - Driving advice
Drive unless side-effects
Group 2 vehicles - if resting >180/100 can’t drive
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
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
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
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
Causes of low BNP?
Obesity
Flash pulmonary oedema
Pericardial constriction
Use of ARBs, ACEi and Diuretics
How to reduce frequency of SVTs?
BBs
Radio-frequency ablation
DVLA advice in HF?
Symptomatic HF rules you out from Group 2 licence
Need to become assymptomatic and also LVEF >40%
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
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)
What is WPW associated with?
HOCM
mitral valve prolapse
Ebstein’s anomaly
thyrotoxicosis
secundum ASD
What are some causes of myocarditis?
viral: coxsackie B, HIV
bacteria: diphtheria, clostridia
spirochaetes: Lyme disease
protozoa: Chagas’ disease, toxoplasmosis
autoimmune
drugs: doxorubicin
Prosthetic valve endocarditis caused by staphylococci mx?
Flucloxacillin + rifampicin + low-dose gentamicin
If penicillin allergic or MRSA
vancomycin + rifampicin + low-dose gentamicin
Native valve endocarditis caused by staphylococci mx?
ucloxacillin
If penicillin allergic or MRSA = vancomycin + rifampicin
Actions of BNP?
vasodilator: can decrease cardiac afterload
diuretic and natriuretic
suppresses both sympathetic tone and the renin-angiotensin-aldosterone system
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
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
Is verapamil used in HTN?
No
Can you give verapamil with BBs?
No as both reduce conduction at the AV node and this could lead to complete heart block.
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
bivalirudin moa and when is it used?
Reversible direct thrombin inhibitor
Used as parenteral anticoagulation
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
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
Mx of uraemic pericarditis?
Haemodialysis
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
collapsing pulse
wide pulse pressure
Freatures of?
Aortic regurg
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
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
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
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
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
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
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
Physiological response to valsalva?
- Increased intrathoracic pressure
- Resultant increase in venous and right atrial pressure reduces venous return
- The reduced preload leads to a fall in the cardiac output (Frank-Starling mechanism)
- When the pressure is released there is a further slight fall in cardiac output due to increased aortic volume
- Return of normal cardiac output
ticagrelor common side effect?
Dyspnoea can be switched to clopidogrel
Hydralazine Moa?
Increases cGMP leading to smooth muscle relaxation - more in arterioles than veins
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
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
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
Clinical features of PDA?
left subclavicular thrill
continuous ‘machinery’ murmur
large volume, bounding, collapsing pulse
wide pulse pressure
heaving apex beat
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
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)
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
HOCM echo findings?
mnemonic - MR SAM ASH
mitral regurgitation (MR)
systolic anterior motion (SAM) of the anterior mitral valve leaflet
asymmetric hypertrophy (ASH)
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.
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
RFs for statin induced myopathy?
thin old diabetic lady
Inheritance and who is Brugada more common in?
AD and more common in asians
radiotracer for PET?
Flurodeoxyglucose - PET looks at glucose uptake
Atrial myxoma - commonest site?
Left atria @ fossa ovalis border
1st cardiac enzyme to rise after MI?
Myoglobin
Dentistry in warfarinised patients?
Dentistry in warfarinised patients - check INR 72 hours before procedure, proceed if INR < 4.0
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.
What is the role of troponin in cardiac muscle?
Components of thin filaments -> blocking actin binding to myosin during the relaxed phase.
TropoTHIN
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
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
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
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
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
Signs of TR?
Pan-systolic murmur
prominent/giant V waves in JVP
pulsatile hepatomegaly
left parasternal heave
When is cut off for pregnancy induced HTN / pre-eclampsia?
after 20 weeks
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)
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
Ix for Pulmon HTN?
all patients need to have right heart pressures measured.
Cardiac catheterisation is therefore the single most important investigation
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
Why check U+Es before amiodarone?
Hypokalaemic risk
TOF features?
P Pulmonary Stenosis
R RVH
O Overriding Aorta
V VSD
Causes of long PR?
Myotica dystrophica
IHD
Lyme
Digoxin toxicity
Rheumatic fever
Aortic abscess
Sarcoidosis
Hypokalemia
Causes of restrictive cardiomyopathy?
SLASHER(restrictive cardiomyopathy causes):
sarcoidosis
lofflers
amyloid (most common in UK)
scleroderma
haemochromatosis
endocardial fibroelastosis
post-Radiation fibrosis
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
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
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
What is pulsus alternans? when is it seen?
regular alternation of the force of the arterial pulse
severe LVF
What type of valve is HOCM associated with?
Jerky pulse
or occasionaly bisferiens pulse
Causes of collapsing pulse?
aortic regurgitation
patent ductus arteriosus
hyperkinetic states (anaemia, thyrotoxic, fever, exercise/pregnancy)
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.
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)
Adenosine effect in WPW?
can enhance conduction down accessory pathways, resulting in increased ventricular rate (e.g. WPW syndrome)
What can happen after inferior MI?
AV block - AV nodal artery is branch of RCA
What are the features of papillary muscle rupture following MI?
acute mitral regurgitation → widespread systolic murmur, hypotension, pulmonary oedema (1-7d after MI)
pansystolic murmur heard lowest over the left lower sternal edge? JVP finding?
Tricuspid regurg associated with prominent V waves on JVP
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
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
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
Mx of trosades de pointes?
polymorphic ventricular tachycardia associated with a long QT interval
Mx = IV MgSO4
Why are BB used less in HTN these days?
Less likely to prevent stroke + potential glucose tolerance impairment
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
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)
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.
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
Dipyridamole MoA?
non-specific phosphodiesterase inhibitor and decreases cellular uptake of adenosine
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
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
TIA + AF when to start DOAC?
ASAP
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
Can acromegaly cause mitral valve prolapse?
Not really
Does williams syndrome cause AS? wb HOCM?
Yes Williams causes supravalvular AS
In contast HOCM causes subvalvular AS
Coarctation of the aorta is associated with which conditions?
Turner’s syndrome
bicuspid aortic valve
berry aneurysms
neurofibromatosis
When to avoid sotalol in WPW?
If coexistent AF
What to use for SVT in asthmatics?
Verapamil / rate limiting CCB
Can you get the following with bendroflumethiazide:
Photosensitivity rash
Agranulocytosis
Hypokalaemia
Pancreatitis
Hirsutism
Photosensitivity rash - Yes
Agranulocytosis - Yes
Hypokalaemia - Yes
Pancreatitis - Yes
Hirsutism - NOOOOOOO
Causes of LBBB
myocardial infarction
hypertension
aortic stenosis
cardiomyopathy
rare: idiopathic fibrosis, digoxin toxicity, hyperkalaemia
What is the main mechanism causing hypokalaemia in patients taking bendroflumethiazide?
Increased sodium reaching the collecting ducts
ECG changes in cardiac syndrome X? mx?
Downsloping ST depression esp on exercise testing with normal coronary angio despite anginaly pain
Mx = nitrates?
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
early diastolic murmur + wide pulse pressure is what?
Aortic regurg
Antiembolic therapy with valve replacement?
mechanical : warfarin
bioprosthetic: aspirin
bioprosthetic + CAD/CABG - aspirin
mechanical + CAD/CABG - warfarin and aspirin
Where to thiazides work?
inhibits sodium reabsorption by blocking the Na+-Clˆ’ symporter at the beginning of the distal convoluted tubule
Why do you need assymetric dosing with IR nitrates?
Prevent nitrate tolerance
Which CCB is the only one licenced for use in HF?
Amlodipine
ECG change in PAH?
RAD
