Cardiology

Question 1

How to Tx STEMI?

Answer 1

If within 12hrs -> transfer to PCI centre (within 2hrs)
If not, offer alteplase -> if not >50% ECG resolution at 90 mins, transfer for PCI
If >12hrs -> consider angiography first, then PCI

Give all DAPT

Question 2

How to Tx NSTEMI?

Answer 2

Fondaparinux and DAPT, refer for angio
Calculate GRACE score

Question 3

What medications should be prescribed in stable angina?

Answer 3

Aspirin
Statin
GTN spray
Then consider adding:
- B blocker/CCB or both
- then nitrates/nicorandil
(Do not give B blocker with verapamil -> risk of CHB)

Question 4

Investigation of choice in stable angina?

Answer 4

CT coronary angiography, then noninvasive functional imaging if required (MR perfusion etc), then invasive angiogram

Question 5

Complications after ACS?

Answer 5

Acute:
1) Cardiac arrest
2) Cardiogenic shock
3) Brady/tachyarrhthmias

Subacute/chronic:
1) Heart failure
2) Dressler’s syndrome (occurs 2-6 wks after, AI reaction)
3) LV aneurysm
4) LV free wall rupture (occurs 1-2 weeks after)
5) VSD (occurs in first week)
6) Acute MR (pap muscle rupture)

Question 6

Investigations in a patient with suspected Marfan’s, with regards to aortic dissection?

Answer 6

1) Hx (particularly FH) + obs
2) Bloods
3) ECG - check for signs of MI if chest pain
4) CXR - widened mediastinum
5) CT CAP

Question 7

How to manage acute aortic dissections?

Answer 7

Get IV access
Give morphine
Urgent HTN management
IV B-blockers

Stanford A: ASS (systolic Mx + surgery)
Stanford B: BooBs (B-blockers and bed rest)

Question 8

CXR findings in heart failure?

Answer 8

Alveolar oedema
Kerley B lines
Cardiomegaly
Dilated prominent upper lobe vessels
Pleural effusions

Question 9

4 pillars of heart failure management?

Answer 9

ACEi, BB, MRA, SGLT2

Question 10

What is the NY classification for heart failure?

Answer 10

1) No symptoms/limitations
2) Mild symptoms/limitation on daily activities
3) Moderate symptoms/limitations
4) Severe, dyspnoea at rest

Question 11

Adjuvant therapy for heart failure? (devices)

Answer 11

Consider implantation of a CRT-P, CRT-D or ICD based on QRS length, evidence of LBBB and NYHA class

Question 12

Treatment options for PAH?

Answer 12

Acute vasodilator testing
Positive result: CCB
Negative result:
Endothelin receptor antagonists - bosartan
Phosphodiesterase inhibitors - sildenafil
Prostacyclin analogues - iloprost (SEVERE CASES)

Question 13

What is Brugada syndrome? ECG findings?

Answer 13

Rare inherited (AD) sodium or calcium channelopathy
ECG - RBBB, persistent ST elevation in V1-V3
Mx - may require ICD

Question 14

What is included in the ORBIT score?

Answer 14

Haemoglobin/haematocrit levels
Age
Bleeding history
Renal impairment
Treatment with anti-platelet drugs

Question 15

What are common causes of myocarditis?

Answer 15

Idiopathic (~50%)
Infectious:
Viral - coxsackie, HIV
Bacterial - lyme disease

Non-infectious:
Autoimmune - sarcoid, lupus
Drugs - doxorubicin
Radiation

Question 16

What two conditions if HOCM associated with?

Answer 16

Friedrich’s Ataxia
WPW syndrome

Question 17

What is arrhythmogenic right ventricular cardiomyopathy?

Answer 17

AD condition, second most (c) cause of sudden cardiac death in the young
R vent myocardium is replaced with fatty/fibrofatty tissue

Question 18

ECG findings and treatment in arrhythmogenic right ventricular cardiomyopathy?

Answer 18

ECG - TWI in V1-V3, epsilon wave in 50% (extra notch after QRS)
Mx - sotalol, catheter ablation to prevent VT, ICD

Question 19

Investigations for pericarditis?

Answer 19

Usual bloods
Pericarditis screen - includes viral serology, blood cultures, autoAbs, fungal precipitins
CXR
May need echo

Question 20

Management of pericarditis?

Answer 20

Analgesia
Avoid strenuous activity for 3 months
Treat underlying cause
Consider NSAIDs + colchicine
Steroids if relapse/unresolved

Question 21

Why should you avoid strenuous activity in pericarditis?

Answer 21

To reduce the risk of progression to myocarditis, pericardial effusion, cardiac tamponade + constrictive pericarditis

Question 22

What causes constrictive pericarditis?

Answer 22

Often unknown, or after any pericarditis
Can be TB or radiotherapy

Question 23

What is the most common cause of restrictive cardiomyopathy in the UK?

Answer 23

Amyloidosis

Question 24

Diagnostic triad in cardiac tamponade?

Answer 24

Beck’s triad: muffled heart sounds, rising JVP, hypotension

Question 25

Indications for surgery in IE?

Answer 25

Infection resistant to medical therapy
Cardiac failure refractory to medical therapy
Recurrent emboli (esp risk to CNS)

Severe valvular incompetence
Aortic abscess (lengthening PR interval)

Question 26

Poor prognostic factors in IE?

Answer 26

Staph aureus
Prosthetic valve
Culture negative endocarditis
Low complement levels

Question 27

Indications for permanent pacemaker?

Answer 27

Persistent symptomatic bradycardia
Mobitz T2 / CHB
Persistent AV block after MI