Cardiology Flashcards
Fast irregular Narrow Complex tachycardia
How do you treat
IV Flecanide ( if not heart structural abnormality)
IV Amiodarone ( If structural abnormality present)
DIrect Synchronised Dc conversion
( If Hemodynamically unstable) - Syncope, CP, Hypotension , pulm oedema
Systolic murmur in Tricuspid region
T wave inversion in V3,V4,V5
( anterior leads)
What should you think of
HOCM
when do you se amdioarone for fast Af and when do you use digoxin for fast AF
✔ Amiodarone → Unstable AF, WPW, refractory cases.
✔ Digoxin → AF with heart failure, hypotension, or sedentary patients.
What type of tachycardia is A-V nodal re-enerant tachycardia
type of SVT
(seen in cocain/ amphetamine abuse)
mx: same as SVT
Pt. with HOCM and
Non sustained VT;
what is the Mx
ICD
when do you use single chamber Pacemaker vs Double chamber
✔ Single-chamber (VVI) → Permanent AF with bradycardia
✔ Dual-chamber (DDD) → AV block, sinus node disease with AV block (preserves synchrony)
Which drug should be stopped prior to coronary angiography
Metfromin (as angiography can worsen renal function)
- Can restart metformin 48 hrs post angiography if renal functions are stable
Romano- Ward syndrome
Long Qtc syndrome
Sudden collapses after physical activity
Family history
LQT1-6 mutation ( LQT1 and LQT2) most common
Jervell-Lange-Nielson Syndrome
Prolonged Qtc
Deafness
JLN1 and JLN2 mutations
Low voltage -Small Complex ECG
Signs LVH on ECG
Physical signs of Right heart Failure and Postural Drops
Echo :
Dilatation fo atria ;
Concentric Left Ventricular thickening
Diastolic dysfunction
What is your Dx
Cardiac Amylodosis
Note: Sparkling Granular Appearance of Myocardium
What kind of cardiomyopathy do you see in Cardiac Amylodosis
Restrictive Cardiomyopathy
What is the difference between Obstructive and Restrictive Cardiomyopathy
Key Takeaways:
✔ Obstructive (HOCM) → LVOT obstruction, systolic murmur, risk of SCD
✔ Restrictive → Severe diastolic dysfunction, bi-atrial dilation, right heart failure
What is the 1st line Mx of HOCM
Beta Blockers
Post Valve Replacement
Pt, is dyspneic and SOB
Bloods show Anemia;
Low Iron
Increase Fibrin Degraion product
Coombs :- ve
What is the Dx
Valve Hemloysis
( Fragmentation of erythrocytes on prosthetic Valve)
What is the target LDL in Pt. with peripheral arterial disease
LDL cholesterol goal < 1.8 mmol/l
( as Pt.;s with PAD have increased risk of CVD)
Classification of severity of AS
Parameter
Mild AS Moderate AS Severe AS Critical AS
Aortic Valve Area (AVA)
>1.5 cm² ; 1.0–1.5 cm² ;<1.0 cm² <0.6 cm²
Mean Pressure Gradient
<20 mmHg ; 20–40 mmHg ;
>40 mmHg ; >50 mmHg
Peak Aortic Jet Velocity
<2.5 m/s 2.5–4.0 m/s >4.0 m/s >5.0 m/s
Symptoms
None May be asymptomatic Symptomatic (angina, syncope, dyspnoea) Severe HF symptoms
Key Takeaways:
✔ Severe AS → AVA <1 cm², Gradient >40 mmHg, Velocity >4 m/s
✔ Symptoms in Severe AS → SAD (Syncope, Angina, Dyspnoea)
✔ Critical AS → AVA <0.6 cm², High risk of cardiogenic shock
Cardio-inhibitory Carotid Sinus Hypersensitivity ;
What kind of pacemaker would you use
Dual Chamber Pacemaker
Representaion 1-8 weeks after MI
Fever, Malaise, Pericardial Pain
Raised ESR
Negative trops
Possible pleurites / pneumonitis
What is your Dx and Mx
Dressler syndrome
Aspirin x 650mg x QDS
Note: Sydrome due to release of cardiac antigen which stimulate antibody production. The immune complexes are deposited in Pleura, Lung, heart
Prominent a waves in JVP
Soft Systolic murmur in left sternal border
Pulm Stenosis
( seen in Noonan Syndrome)
What is the definitive mx for Post MI ; ventricle Septal Rupture
Surgery
What are the key ECG changes in HOCM
Bundle branch block
T wave inversions ( in anterior leads)
Right/Left Axis deviation
Prolonged PR
What murmur do you hear in HOCM
Displaced Apex beat and Ejection systolic murmur
What do you see in familial hypertriglycerdimeia
Eruptive Xanthomata
Branch retinal vein occlusion
MX: Fenofibrate
Late systolic murmur loudest over thoracic Spine
Coarctation of aorta
Note:
We also see radiofemoral delays
Scalloping of posterior ribs on car can also be seen
Acute Mitral regurgitation post MI
( median onset time 13 hrs after)
What is the cause
Papillary muscle Rupture
What is the criteria for valve replacement in AR
If symptomatic
if EF <55%
If LVESD > 50mm
Out of hospital, cardiac arrest , now having eneurology
What is suggested
Therapeutic Hypothermia
( aim 36 degrees)
What gene is associated with Marfans Syndrome
FBN1 Gene
Where do you see pacts escavatum and thoracolumbar striae
Marfans Syndrome
What is Hyede Syndrome
Angiodysplasia with severe AS
Microcytic anemia due to loss of VWF that goes through narrow AS
What is the criteria for Cardiac Resynchronisation Therapy
Pt. already on optimised medical therapy
EF < 35% + Conduction delays in ECG;s
LBBB
QRS >120
How do you treat palpitations with long Congenital Long QtC
1st line - Metoprolol
2nd Line - ICD ( if above fails)
What is the definitive Ix for Coarctation of Aorta
Echo !
What is the criteria for anticoagulant in HF
If Pt.has HF and low EF and any of the following, anticoagulation is recommended ;
> prev thrombotic event
> Intracardiac thrombus
> Left Ventricular Aneurysm
What is the Mx of NSTEMI in someone with an eGFR of <20
Aspirin, Ticagrelor , Unfractioned Heparin /LMWH
What is the Mx of primary pulm HTN
( >25mmhg)
Acute Vasoreactive test :
If positive ;
Choose CCB ( amodipine/ Diltiazem)
If signs of relative bradycardia ;
Choose Amlodipine ( Non rate limiting)
Acute Vasoreactive test :
If Negative ;
-> Bosentan ( Endotheline receptor antagonist)
-> Iloprost ( Prostacycline Anologue)
-> Sildenafil ( Phosphodiesterase 5 inhibitor)
What are the key feature of Familial Hypercholestrolemia
> raised Cholesterol and LDL
Normal Triglcerides
Tendon Xanthomata ; Corneal Arcus , XAnthelasma
Mx:
Atorvastatin Statin x 80mg x OD
Ezetimibe
Evolocumab ( PCSK9 inhibitor)
What drugs are uses in Hypertensive Emergency.
Sodium Nitroprusside/ Labetolol x IV
Note :
Do NOT use Nifedipine x S/L it an rapidly reduce the BP and cause stroke
What are the indication for a PPM after a holter monitoring
3rd degree HB
Symptomatic 2nd degree HB
Asymptomatic 2nd Degree HB (type2)
Pauses > 3 seconds
Q waves in ECG post few weeks of MI
VT/VF few weeks after PCI
What is the Mx
ICD insertion
Q wave indicates full thickness infarct
What are the key takeaways of
p-mitrale
Bifid P Waves (P Mitrale) – Meaning & Clinical Significance
✔ Definition: A bifid (notched) P wave seen on ECG, classically associated with left atrial enlargement (LAE).
✔ ECG Features:
Lead II → Broad, notched ‘M-shaped’ P wave (>120 ms).
V1 → Biphasic P wave with a deep, broad negative terminal component.
✔ Clinical Causes of P Mitrale:
Left Atrial Enlargement (LAE) → Due to increased left atrial pressure or volume overload.
Mitral Valve Disease (e.g., Mitral stenosis, Mitral regurgitation).
Left Ventricular Hypertrophy (LVH) (e.g., Hypertension, Aortic stenosis).
✔ Key Takeaway:
Bifid P waves = P mitrale → Suggests left atrial enlargement.
ST elevation in precordial leads
With “ J notches’
What is your Dx
Early Repolarisation
What are the key features of Early Repolarisation
Key Characteristics of Early Repolarization (Benign Early Repolarization - BER)
✔ Definition: A benign ECG pattern seen in young, healthy individuals, often mistaken for myocardial ischemia.
✔ ECG Features:
Concave (“smiley face”) ST elevation (most prominent in precordial leads, V2–V5).
J-point elevation (typically ≥0.1 mV) with a notched or slurred appearance.
No reciprocal ST depression (helps differentiate from ischemia).
Prominent T waves (tall and symmetrical, especially in anterior leads).
Stable over time (does not progress to infarction).
✔ Clinical Significance:
Typically benign and seen in young, athletic individuals.
No chest pain or ischemic symptoms.
Must be differentiated from pericarditis and STEMI.
What is the common cause of IE post bowel resection
Bacteriodes
Although S. Bovis can also be seen
What is a key difference between Beckers Muscular Dystrophy (BMD) and Duschens Muscular Dystrophy (DMD)
BMD has cardiomyopathy and HF and milder Proximal Myopathy
Pt. may present with HF and then the proximal myopathy will be found
In DMD
Proximal myopathy is severe and will present in much earlier age
What are the key MRCP features of rheumatic fever
Key MRCP Features of Rheumatic Fever (Jones Criteria - Revised)
✔ Cause: Post-streptococcal autoimmune reaction (Group A Streptococcus).
✔ Diagnosis: Based on the modified Jones criteria (evidence of recent streptococcal infection + 2 major OR 1 major + 2 minor criteria).
Major Criteria (“J♥NES”)
Joint involvement (migratory polyarthritis) – large joints, asymmetrical.
♥ Carditis (pancarditis) – new murmur, pericarditis, heart failure.
Nodules (subcutaneous, painless, firm).
Erythema marginatum – pink rings on trunk, non-itchy.
Sydenham’s chorea – involuntary movements, emotional lability.
Minor Criteria
Fever
Arthralgia
Raised inflammatory markers (ESR, CRP)
Prolonged PR interval on ECG
✔ Investigations
ASO (Anti-Streptolysin O) titre → evidence of prior Strep infection.
Throat culture or rapid Strep test.
✔ Management
Penicillin V (eradication of Strep infection).
NSAIDs for arthritis.
Corticosteroids for severe carditis.
Long-term prophylaxis: Penicillin IM (monthly) for years.
What are the septal leads
V1, V2
What are the Anterior leads
V3, V4
What are the lateral leads
V5, V5, I
What do you use to treat VT In digoxin toxicity in someone ho is hemodynamically stable
IV lidocaine / IV phenytoin
When do you choose mitral valve replacement over Mitral vagotomy
Mod to serve MR
Left atrial thrombus
Severe calcified Mitral Valve
Concomitant coronary artery or other valve defect needing sx
What is the definitive Mx for WPW
Radiofrequency Ablation
SVT in asthmatics who have failed carotid sinus massage.
What is the Mx
IV x Verapamil
What are some normal findings in cardiac monitoring post PCI for MI
Bradycardia
Type 1 HB
Morbitz Type 1 HB
Ventricular ectopics
Accelerated idioventricular rhythm
Pt. hs HF, on ACE and Diuretics. Has not tolerated beta blocker.
ha edema and crackles.
if HR >75
What can you add next to improve prognosis
Ivabradine
Which medication can help prognostic value in those affected by mild to moderate AR
ACE int
Pt. already on CCB and Beta blocker
Angina symptoms persist
HR >70
What is the next step
Ivabradine
Note:
Never use Verpamail ( CCB) and BTea blocker together; risk of severe bradycardia
CXR shows calcifications over cardiac sillouhette
What is your Dx
AS
What drug should be used with caution in cardiac amylodosis
Digoxin
As it can bind with the amyloid fibrils and worsen digoxin tocxicity
When do you use dioxin in HF
If they have associated AF with it.
What re some key differences between In-stent thrombosis vs in-stent restenosis
Both can be seen where bare metal stents are used
Both can be seen in diabetics
In stent-restenosis ; presents with Angina like symptoms
Mx:
Use Coated/drug eluting stents
In stent thrombosis occurs with ACS/STEMI
( usually occurs with/coincides with cessation of Antiplateltes)
Pt. is an athlete
Complains of periods of palpitations
Feeling dizzy
ECG and CXR normal
Bradycardia seen
Wat is your Dx
Paroxysmal AF
Note in Atrial and ventricular topics; they feel like their heart is skipping abet.
there is no period of palpitations and no dizzines
What is the time period of peripartum Cardiomyopathy
Last month of pregnancy to upto 5 month post delivery
What is the 3 criteria to dx peripartum Cardiomyopathy
1) Absence of heart disease prior to last mont of pregnancy
2) No other cause of HF
3) Confirmed systolic dysfcution
How do you manage Staph Endocarditis
IV Fluclox
How do you manage Empirical Endocarditis in native valve where organism is not confirmed yet
Benzylpencillin + Gent
How do you treat IE with MRSA +ve
Vanc
What is the mx of IE for staph if pt is alergryc to penicillin
Clarithromycin
Symptomatic Wencheback phenomenon ( type 1 morbitz)
what is the definitve Mx
PPM
Note:
If asymptomatic, no indication
NOte:
But if Type 2 Morbitz, irrespective of symptoms o symptoms -> PPM is indicated
How long do tissue valves last
10 years
What is a good peri-operative measurement of Cardiac function
Stress Echo ( dobutamine stress test)
What is the normal response to BP n stress test
SBP should gradually increase
DBP will remain same/slightly decrease
Abnorma findings;
Drop In SBP
SBP >250
Choosing Between Thallium Cardiac Scanning & Dobutamine Stress Echo (DSE)
How do you do it?
Flowchart for Choosing Between Thallium Cardiac Scanning & Dobutamine Stress Echo (DSE)
Step 1: Can the patient exercise?
➡ Yes → Do Exercise Stress Test (ECG, Echo, or Perfusion Scan).
➡ No → Move to Step 2.
Step 2: What do you need to assess?
✅ Myocardial Perfusion & Viability? → Thallium Perfusion Scan
✅ Wall Motion & Ischemia-Induced Dysfunction? → Dobutamine Stress Echo (DSE)
Step 3: Special Considerations
🔹 Thallium Scan → Use if the patient has LBBB, pacemaker, or if you need to check viability before revascularization.
🔹 DSE → Use if assessing valvular disease (AS, MR) or ischemia-related wall motion changes.
📌 Quick Rule of Thumb:
“Thallium = Think Perfusion” (Blood flow & viability).
“Dobutamine = Think Motion” (Wall motion & ischemia).
How do you Mx peripartum cardiomyopathy
Fluid restriction
Diuretics
Digoxin
VTE prophylaxis - with heparin ( as at risk of thromboembolism)
Pt. on tx for IE
But continues have fever , stagnant inf. markers and pronged PR interval
What are you thinking >
Possible aortic root abscess
Ix:
ECho
Mx: Will need debridement and valve repalcement
What is the dukes criteria for IE
Duke’s Criteria for Infective Endocarditis (IE) – MRCP Key Points
1. Major Criteria
✅ Positive Blood Cultures (one of the following):
Typical organism (Strep viridans, Staph aureus, Enterococcus, HACEK) in two separate cultures
Persistently positive cultures (≥2 positive cultures >12 hrs apart)
Single Coxiella burnetii culture or IgG titre >1:800
✅ Endocardial Involvement (one of the following):
Echo findings: Vegetation, abscess, new partial dehiscence of prosthetic valve
New valvular regurgitation (not just worsening of pre-existing murmur)
- Minor Criteria
🔹 Predisposition (e.g., prosthetic valve, IVDU, structural heart disease)
🔹 Fever ≥38°C
🔹 Vascular phenomena: Janeway lesions, arterial emboli, mycotic aneurysm, intracranial hemorrhage
🔹 Immunological phenomena: Osler nodes, Roth spots, glomerulonephritis, RF+
🔹 Microbiological evidence: Positive cultures not meeting major criteria
Diagnosis
Definite IE = 2 Major, or 1 Major + 3 Minor, or 5 Minor
Possible IE = 1 Major + 1 Minor, or 3 Minor
Pt. is hypertensive and in CCF
What is the Mx
IV diuresis
Where do you see palmar Xanthomas
Disbetalipopreotenaemia
If a pt. has severe impaired LVD and shows possibly severe AS
what do you do
Repeat Echo ( dobutamine) stress test
As , in Pt. withs severe HF or LVF/dysfcumtion, AS can be false +ve
What is the 1st line Mx of Prolonged Qtc
Atenolol
IF no benefit, the ICD ( esepceilly in high risk, family, etc)
But note; always start with atenolol or in conjunction
What is a very poor marker of prognosis of CCF
Hyponatremia
What is the 1st line for symptomatic severe Mitral Stenosis
Baloon Valvuloplasty
In Pt. who need Pacemaker and have AF, how do you know if they need single chamber or double chamber PPM
1) if paroxysmal AF, then double chamber PPM
2) If AF, is longstanding, permanent , persistent, then single chamber
What are the features of Mg toxicity in Eclampsia
Depressed Deep tendon reflexes
Oliguira
Hypoventialtion
Mx: Calcium Chloride/ Calcium Gluconate
What is Lutembaker Syndrome
Booth MS and ASD are present
What is Eisenmenger Syndrome
Reversal of Left to right Shunt to Right to Left Shunt
What are the features of severe MS
Prolonged duration of murmur
Soft S1
Presence of parasternal Heave
Decreased interval between A2-OS
Loud P2
Where do you see petechial hemorrgahes in conductive and membranes
IE
How do you create unstable angina or NSTEMI in someone with significant renal impairement
Use unfractioned heparin over Fondaparinux
( if creat >265)
POST PCI/ MI;
Pt. becomes hemodynamically unsatable and dies in few moments
What is the complication
Ventricular Free Wall Rupture
