Cardiology

Question 1

S1 HS ??

Answer 1

MV & TV closure
Causes of Loud S1
- MS
- Left to Right shunt
- Short PR interval, Atrial Premature beat
- Hyperdynamic states
Causes of Quiet S1
- Long PR
- MR

Question 2

S2 HS

Answer 2

Closure of AV (A2) very closely followed by PV (P2)
Causes of Loud S2
- HTN: Systemic (A2) or Pulm. (P2)
- Hyperdynamic states
- ASD without Pulm. HTN
Causes of Soft S2 : AS
Causes of FIXED Split : ASD

Question 3

Causes of-
- Widely split S2 ??
- Reverse Split or Paradoxical Split S2 (P2 before A2) ??

Answer 3

Deep Inspiration
RBBB
Pulmonary Stenosis
Severe MR

LBBB
Severe AS
RV Pacing
WPW Type B (causes early P2)
PDA

Question 4

S3 HS

Answer 4

Diastolic filling of Ventricles
- Normal if < 30 yr (may persist in women in upto 50 yrs)
Heard in Left Ventricular Failure
- CDM
- Constrictive Pericarditid
- MR

Question 5

S4 HS

Answer 5

Atrial Contraction against stiff ventricles
- Coincides with P wave
- Occurs just before S1
Causes
- AS, HOCM, HTN

Question 6

Causes of
- Ejection Systolic Murmur ??
- Late Systolic Murmur

Answer 6

“RILE”
Ejection Systolic Murmur
Louder on Inspiration
- PS, - ASD, - ToF
Louder on Expiration
- AS, - HOCM
Late Systolic
- MVP
- Coarctation of Aorta

Question 7

Causes of
- Holosystolic murmur ??

Answer 7

TR (becomes louder during Inspiration)
MR (louder on Expiration)
MR/TR: High pitched & blowing in character
VSD : Harsh in character

Question 8

Causes of
- Mid-late Diastolic murmur ??
- Early Diastolic ??
- Continuous Machinery murmur ??

Answer 8

MS & Austin-Flint (Severe AR)
- Rumbling in character

AR & Graham-Steel (PR)
- High pitched & Blowing character

PDA

Question 9

What is Pulsus paradoxus ??

Answer 9

Greater than the normal (10 mmHg) fall in SBP during Inspiration => Faint or absent pulse on Inspiration
-Severe Asthma
- Cardiac Tamponade

Question 10

Causes of
- Slow rising/ Plateau pulse ??
- Collapsing Pulse ??

Answer 10

• AS
• AR, - PDA
• Hyperkinetic states (Anaemia, Thyrotoxic, Fever, Exercise/Pregnancy)

Question 11

Causes of
- Pulsus alternans ??
- Bisferiens pulse ??
- Jerky pulse ??

Answer 11

Regular alternation of the force of the arterial pulse
- Severe LVF

Double pulse- 2 systolic peaks
Mixed Aortic Valve disease

HOCM
- Bisferiens pulse may be seen

Question 12

Bisfereins pulse ??

Answer 12

MIXED AV Disease
2 distinct peaks during Systole, involves Both Stenosis & Regurgitation of AV. The double peak occurs because of
- Initial upstroke (V ejection)
- 2nd Peak: regurgitant flow when V relaxes

Question 13

1st line investigations of Palpitations ??

Answer 13

12-Lead ECG
TFT
U&E
FBC

Question 14

How to Ix. Episodic Arrhythmias ??

Answer 14

Holter Monitoring
- Battery operated
- Continuously records ECG from 2- 3 leads
- Done for >= 24 hrs
- Pt. is asked to keep a dairy to record any symptomatic episodes
If Holter Monitor is (-)ve
- External loop recorder
- Implantable loop recorder

Question 15

Reasons for Inaccurate BP values ??

Answer 15

Wrong Cuff size
- Bladder too small: Overestimation
- Bladder too large: Underestimation
The arm should be Horizontal at the level of Heart
- Below Heart level: Overestimation
- Above Heart level: Underestimation
Sitting Posture is considered std.
Arm Support
- If unsupported, may raise DBP (as arm will be performing Isometric exercise)

Question 16

Valsalva Maneuver Stages ??

Answer 16

Forced expiation against a closed glottis
- Leads to increased Intrathoracic pressure
STAGES:
- Increased Intrathoracic pressure
- Resultant increase in Venous & RA pressure, reduces venous return
- Reduced Preload => fall in CO (Frank-Starling mechanism)
- When pressure released, there is a further slight fall in CO due to increased Aortic volume
- Return to normal CO

Question 17

Coronary Circulation ??

Answer 17

LCA or Left Main
- LCX
- Obtuse Marginal Artery
- LAD (supplies Ante. 2/3rd of IV Septum, Anterolateral Papillary muscle & Ante. surface of LV
RIGHT CORONARY Artery
- PDA (supplies Posterior 1/3rd of IV septum, Poste. 2/3rd wall of ventricle & Posteromedial Papillary Muscle
- Acute Marginal Artery (supplies RV)
RCA supplies AVN (in 90%) & SAN (in 60%)

Question 18

How is Dominance in the Coronary Artery decided ??

Answer 18

Right Dominant Circulation (MC)
- PDA arises from RCA
Left Dominant Circulation
- PDA arises from LCX
CoDominant Circulation
- PDA arises from both LCX & RCA

Question 19

Venous drainage of Heart ??

Answer 19

Coronary Sinus runs in the Left AV groove & drains into RA

Coronary Blood flow to LV & IV Septum peaks at
- EARLY Diastole

Question 20

Pericardial layers ??

Answer 20

Out => In
- Fibrous P
- Parietal P
Pericardial Space
- Epicardium (Visceral P)
Coronary vessels lies here
- Myocardium
Pericardium is innervated by PHRENIC Nerve

Question 21

ECG localization

Answer 21

Anteroseptal (LAD)
- V1- V2
Antero-apical (Distal LAD)
- V3- V4
Antero-lataral (LAD or LCX)
- V5- V6, aVL
Lateral (LCX)
- I, aVL +/- V5, V6
Inferior (RCA)
- II, III, aVF
Posterior (PDA)- LCX & also RCA
- V7- V8,
- ST depression in V1-V2 + Tall R waves

Question 22

Posterior Territory ECG changes ??

Answer 22

Changes seen in V1- V3
Reciprocal changes of STEMI are typically seen:
- Horizontal ST depression
- Tall, Broad R wave
- Upright T wave
- Dominant R wave in V2
Posterior Infarction is confirmed by
- ST Elevation &
- Q wave in posterior leads (V7- V9)

Question 23

New onset LBBB ??

Answer 23

can be ACS

Question 24

Normal variants of ECG ??

Answer 24

The following are considered normal in an Athlete
- Sinus Bradycardia
- Junctional Rhythm
- 1st degree heart block
- Mobitz type-1 (Wenckebach phenomenon)

Question 25

Causes of LAD ??

Answer 25

Left Anterior Hemiblock LBBB IWMI Hyperkalaemia Congenital: Ostium primum ASD, Tricuspid atresia Minor LAD in OBESE people

Question 26

Causes of RAD ??

Answer 26

Right Ventricular Hypertrophy Left Posterior HEmiblock Lateral MI Chr. Lung disease => Cor Pulmonale Pulm. Embolism Ostium Secundum ASD Normal in infants < 1 yr old Minor RAD in Tall people

Question 27

Axis deviation seen in WPW syndrome ??

Answer 27

LAD - RIGHT Sided Accessory Pathway - More common RAD - LEFT Sided Accessory Pathway - Less common

Question 28

Dextrocardia ECG changes ??

Answer 28

Inverted P wave in Lead 1 RAD Loss of R wave progression

Question 29

P wave changes ??

Answer 29

Increased P wave amplitude - Cor Pulmonale Broad, notched (Bifid) P wave - Sign of LA enlargement classically seen in MS - Often most pronounced in Lead 2 Absent P wave - AF

Question 30

PR interval Changes ??

Answer 30

Start of P wave to start of QRS - 0.12 to 0.20 sec Causes of Prolonged PR interval - Idiopathic - IHD, - Rheumatic Fever - Digoxin toxicity - Aortic Root pathology eg.- Abscess secondary to Endocarditis - Lyme's disease - Sarcoidosis, - Myotonic Dystrophy - Hypo[K+] - Hyper[K+] (very Rare) - Normal in Athletes SHORT PR Interval - WPW syndrome

Question 31

T wave changes

Answer 31

Peaked T waves - Hyper[K+] - Myocardial Ischaemia Inverted P wave - Myocardial Ischaemia - Digoxin Toxicity - SAH - Arrhythmogenic RV Cardiomyopathy - Pulmonary Embolism [S1Q3T3] - Brugada syndrome

Question 32

ST Depression causes ??

Answer 32

ST Depression - Secondary to abnormal QRS (LVH, LBBB, RBBB) - Ischaemia - Digoxin - Hypo[K+] - Syndrome X

Question 33

ST Elevation changes ??

Answer 33

Myocardial Infarction Pericarditis/ Myocarditis Normal variant- 'High Take-off' LV Aneurysm Prinzmetal Angina (CA Spasm) Takotsubo Cardiomyopathy Rare: SAH

Question 34

Hypo[K+] ECG features ??

Answer 34

U wave Small or Absent T waves (Occasional inversion) Prolong PR Interval ST depression Long QT "U have no Pot. & no T, but a long PR & a long QT"

Question 35

Hypothermia ECG changes ??

Answer 35

Bradycardia J wave (Osborne waves)- Small hump at the end of QRS complex 1st degree Heart Block Long QT interval Atrial & Ventricular Arrhythmias

Question 36

What are the features suggesting VT rather than SVT with aberrant conduction ??

Answer 36

- AV Dissociation - Fusion or Capture beat - (+)ve QRS concordance in Chest leads - Marked LAD - H/o IHD - Lack of response to Adenosine or Carotid sinus massage - QRS > 160 ms

Question 37

AV Blocks ??

Answer 37

FIRST Degree HB - PR interval > 0.2 ms - Asymptomatic HB: NO Rx. SECOND Degree HB Mobitz-1, Wenckebach - Progressive prolongation of PR interval until a dropped beat occurs Mobitz-2 - PT interval is constant - P wave is often NOT followed by QRS complex 2nd degree AV block (2:1 block) THIRD Degree HB - No association b/w P wave & QRS complex

Question 38

Complete HB features ??

Answer 38

Syncope Heart Failure Regular Bradycardia (30- 50 bpm) Wide Pulse Pressure JVP: Cannon wave in neck Variable Intensity of S1

Question 39

LBBB & RBBB ECG features ??

Answer 39

"WiLLiaM MaRRoW" LBBB - 'W' in V1 & a 'M' in V6 RBBB - 'M' in V1 & a 'W' in V6

Question 40

Causes of LBBB ??

Answer 40

New LBBB is ALWAYS Pathological - M Infarction - HTN - AS - Cardiomyopathy - Rare: Idiopathic Fibrosis, Digoxin toxicity, Hyper[K+]

Question 41

Original Sgarbossa Criteria ??

Answer 41

Used to Dx. Infarction in pts. with LBBB - Concordant ST elevation >= 1 mm in >= 1 leads with a (+)ve QRS complex (score 5) - Concordant ST depression >= 1 mm in >= 1 lead of V1- V3 (Score 3) - Excessively discordant ST elevation > 5 mm in leads with (-)ve QRS complex (Score 2) These criteria are SPECIFIC but not Sensitive (36%)

Question 42

Smith-Modified Sgarbossa Criteria ??

Answer 42

Concordant ST elevation >= 1 mm in >= 1 lead Concordant ST depression >= 1 mm in >= 1 lead of V1 to V3 Proportionally excessive discordant ST elevation in >= 1 lead anywhere with >= 1 mm STE, as defined by >= 25% of the depth of preceding S wave

Question 43

Causes of RBBB ??

Answer 43

Normal Variant (MC with Aging) RV Hypertrophy Chr. increased RV Pressure - eg.- Cor Pulmonale Pulmonary Embolism Myocardial Infarction ASD (Ostium Secundum) Cadiomyopathy or Myocarditis

Question 44

JVP waves ??

Answer 44

A wave : Atrial Contraction C wave : TV closure (cusps bulging into RA) X descent: RA relaxation (Fall in Atrial pressure during Ventricular Systole) V wave : Passive rapid filling of blood into RA against a closed TV (during late Systole) Y descent: TV opening - Early V filling (during Early diastole)

Question 45

A wave pathology ??

Answer 45

Absent in AF or A Flutter Increase in TS or PS & RV Failure (due to increase resistance to forward flow) Cannon A waves - Junctional Rhythm - VT & Third degree HB - RA contracts against closed TV => Large reflection wave back into RA

Question 46

C wave pathology ??

Answer 46

TR causes fusion of 'C' & 'V' waves with blunting of 'X' descent

Question 47

X wave pathologies ??

Answer 47

Increase in 'X' descent - Constrictive Pericarditis Decrease or Absent 'X' descent - TR (as this jet increase RA pressure) - Suggests RV dysfunction due to decreased apical motion

Question 48

V wave Pathologies ??

Answer 48

Increase 'V' wave - TR (from regurgitation jet => increases RA pressure)

Question 49

Y descent pathologies ??

Answer 49

Increase 'Y' descent - Constrictive Pericardotis - RV Failure Decreased or Absent 'Y' descent - Cardiac Tamponade (Pericardial fluid pressure impairing caval inflow to RA)

Question 50

Non-Pulsatile JVP is seen in ?? What is Kussmaul's Sign ??

Answer 50

- Superior Vena Caval Obstruction - Paradoxical rise in JVP during inspiration seen in Constrictive Pericarditis

Question 51

Cardiac catheterisation & O2 sats. ??

Answer 51

Normal O2 Sats. in Heart - RA & RV & PA : 70% - LA & LV & Aorta : 100% Mixing of Deoxygenated blood with Oxygenated blood : 85%

Question 52

Types of Cannon 'A' waves ??

Answer 52

Caused by Atrial contraction against a closed TV 2 types REGULAR Cannon waves - VT (with 1:1 Ventricular-Atrial conduction) - AV Nodal Re-entry Tachycardia - Single-chamber Ventricular Pacing IRREGULAR Cannon Waves - Complete H B

Question 53

Hallmarks of Cardiac MRI ??

Answer 53

aka CMR is the Gold std. for providing - STRUCTURAL Images of Heart Particularly useful when assessing - Congenital Heart disease - Determining RV & LV masses - Differentiating forms of Cardiomyopathy Myocardial Perfusion can also be assessed following administration of GADOLINIUM

Question 54

Hallmarks of Cardiac CT ??

Answer 54

Useful for assessing suspected IHD using 2 main methods [Ca2+] Score: - There is correlation b/w the amount of Atherosclerotic plaque Ca2+ & risk of future Ischaemic events CECT: - Allows visualization of CA Lumen When these 2 technique when combined, Cardiac CT has a very high (-)ve predictive value for IHD

Question 55

Nuclear Imaging of Heart ??

Answer 55

These technique use Radiotracers which are extracted by normal myocardium; Eg. are - Thallium - Fluorodeoxyglucose (FDG): PET scan - (99m)Tc Sestamibi: A complex of Radioisotope Tc-99m + Methoxyiso-butyl Isonitrile (MIBI) used in 'MIBI' or Cardiac SPECT scans

Question 56

Cardiac Imaging uses ??

Answer 56

1) Cardiac CT : IHD - Atherosclerotic plaque Ca2+ - CA Lumen visualization 2) CMR: - Str. Imaging of heart - Myocardial Perfusion (with Gadolinium use) 3) SPECT : - Myocardial Perfusion & Viability (Ischaemic tissue can be identified) 4) MUGA Scan - Used before & after Cardiotoxic drug usage - Accurately measure LVEF

Question 57

SPECT scan of Heart ??

Answer 57

To assess Myocardial Perfusion & Myocardial Viability Two sets of images are acquired - 1st Myocardium at Rest - 2nd Myocardium during Stress (Exercise or following Adenosine/ Dipyridamole) By comparing the 2 images, site of Ischaemia can be identified & classified as Reversible or Irreversible

Question 58

MUGA scan of Heart ??

Answer 58

Multi Gated Acquisition Scan aka Radionucleotide Angiography - Tc-99m is injected as IV - Then placed under Gamma Camera - Can be performed as Stress test - Can accurately measure LVEF - Typically used Before & After Cardiotoxic drug use

Question 59

Name the murmurs heard at - Aortic area ?? - Pulmonary area ??

Answer 59

Aortic area Systolic Murmurs - AS - AV Sclerosis - Flow Murmur (eg.- Physiological) Pulmonary area Systolic Ejection Murmurs - PS. - ASD - Flow Murmur

Question 60

Name the Murmurs heard at - Mitral area (Apex) ?? - Tricuspid area ??

Answer 60

Mitral area Systolic Murmur - MR - MVP Diastolic Murmur : MS Tricuspid area Holosystolic Murmur - TR - VSD Diastolic Murmur : TS

Question 61

Which murmurs are heard at Left Sternal Border ??

Answer 61

Systolic Murmur - HOCM Diastolic Murmur - AR - PR

Question 62

CVS changes a/w the following - Standing, Valsalva (Strain phase) ?? - Passive Leg raise ?? - Squatting - Hand Grip - Inspiration

Answer 62

- Decrease Preload (decrease LV vol.) - Increase Preload (Increase LV vol.) - Increase Preload, Afterload (Increase LV volume) - Increase Afterload => increase reverse flow across AV (increase LV volume) - Increase Venous return to Rt. Heart, Decrease V return to left heart

Question 63

Name the murmurs that INCREASE with - Standing, Valsalva ?? - Passive Leg raise & Squatting ?? - Hand grip ?? - Inspiration ??

Answer 63

- MVP (decrease LV vol.) with Earlier Midsystolic Click & HCM (decrease LV vol.) - Most murmurs (Increase flow through Stenotic/ Regurgitant valve) - Most other Lt. sided Murmurs (AR, MR, VSD) - Most Rt. sided murmurs

Question 64

Name the murmurs that DECREASE with - Standing, Valsalva ?? - Passive Leg raise & Squatting ?? - Hand grip ?? - Inspiration ??

Answer 64

- Most murmurs (decrease flow through Stenotic/Regurgitant valves) - MVP (increase LV vol.) with later Midsystolic click & HCM (increase LV vol.) - AS (decrease transaortic valve pressure gradient) & HCM (increase LV vol.) - Most Lt. sided murmur

Question 65

Indications of Implantable Cardiac Defibrillators ??

Answer 65

Long QT syndrome HOCM Previous Cardiac arrest due to VT/VF Previous MI with - Non-Sustained VT on 24hr monitoring - Inducible VT on Elecrtrophysiology testing & Ef < 35% Brugada Syndrome

Question 66

Indications of Temporary Pacemaker ??

Answer 66

1) Symptomatic/ Haemodynamically unstable Bradycardia 2) Post- ANTERIOR wall MI induced - Type 2 or Complete HB 3) Post- InFERIOR wall MI Complete HB + Asymptomatic & Stable Haemodynamically 4) Tri-Fascicular Block prior to Sx.

Question 67

Hallmarks of MR ??

Answer 67

aka Mitral Insufficiency (seen when blood leaks back through MV at systole) - As MR becomes more severe, the body's O2 demands may exceed the heart's capacity to pump => Thickened Myocardium RFs - Female, - Age, - Low BMI - Renal dysfunction - Prior MI - Prior MS or MVP - Marfan's or Ehlers-Danlos

Question 68

Causes of Mitral Insufficiency ??

Answer 68

CAD or Post-MI: If Papillary muscle or C tendinae are affected by insult MVP: - MV Leaflets are deformed => valve does't close properly INFECTIVE Endocarditis - Vegetation prevents valve from closing properly RHEUMATIC Fever - Inflammation of valve => MR CONGENITAL

Question 69

Signs & Symptoms of Mitral Insufficiency ??

Answer 69

Asymptomatic (Mild to mederate MR) LV Failure, Arrhythmias or Pulm. HTN - This may present as Fatigue, SoB & Oedema Pansystolic 'Blowing' murmur Best heard: Apex & Radiates to Axilla S1 may be quiet (due to incomplete closure) Severe MR: Widely Split S2

Question 70

Ix. & Rx. of Mitral Insufficiency ??

Answer 70

ECG: Broad P wave (Atria enlarged) CXR: Cardiomegaly (enlarged LA & LV) 2D-Echo: imp. for Dx. & to assess severity Rx.- - Drugs: Nitrates, Diuretics, (+)ve Inotropes & Intra-aortic balloon pump to increase CO - HF: ACEi/ ARBs, Beta Blockers, Spironolactone Acute Severe MR: Surgery - Repair preferred over Replacement - When repair not possible Replacement with an Artificial or Pig valve is considered

Question 71

Why is valve Repair preferred over Replacement ??

Answer 71

Repair has a lower rates of - Degenerative regurgitation - Lower Mortality - Higher Survival rates

Question 72

MR Rx. ??

Answer 72

ACUTE MR - Immediate Sx: Repair preferred over replacement - Replacement is done with Artificial valve or pig valve - Post-Op. after load reduction (Diuretics, Na nitroprusside, &/or Intra-aortic Balloon Counterpulsation CHRONIC MR Primary: Symptomatic/Asymptomatic Secondary - Medical Rx of HF (ACEi/ARBs, Beta B, Spironolactone) => Failed + Low Sx. Risk => Transcath. MV Intervention

Question 73

Rx. of Primary Chronic MR ??

Answer 73

SYMPTOMATIC - If acceptable Sx. Risk: MR Sx. - Inoperable/ High Sx. risk: Transcath. MV Intervention or HF Rx. ASYMPTOMATIC Preserved LVSF - [LVEF > 60% + LVESD < 40 mm] + No other indications for Sx. => TTE 6- 12 monthly MV Sx (if one of the 7 indications)

Question 74

Indications to perform MV Sx. in an Asymptomatic pt. ??

Answer 74

Low LVSF: LVEF< 60% + LVSD> 40mm 2) New onset AF 3) Increase Systolic PAH 4) Left Atrial Dilatation - LA vol. >= 60 ml/m3 or Diameter >= 55 mm 5) Progressive increase in LV size on > 3 serial imaging studies 6) Progressive decrease in LVEF on >= 3 serial imaging studies 7) High likelihood of durable repair + Low risk of Sx.

Question 75

Hallmarks of MS ??

Answer 75

Increases pressure in LA, Pulm. vasculature & Rt. side of Heart Causes: - RHEUMATIC FEVER (most imp.) - Rare : Mucopolysaccharidoses, Carcinoid & Endothelial fibroelastosis

Question 76

Features of MS ??

Answer 76

Dyspnoea - Increase LA pressure => Pulm. Venous HTN. Haemoptysis - Due to pulm. pressures & vascular congestion - Pink frothy to sudden haemorrhage Mid-Late Diastolic murmur Loud S1, Opening Snap Low Vol. Pulse, Malar Flush AF (2ndary to LA enlargement)

Question 77

Features of Severe MS ?? Is the Haemoptysis in MS an arterial or Venous bleed ??

Answer 77

Length of Murmur INCREASES Opening Snap becomes closer to S2 Secondary to rupture of thin-walled & Dilated Bronchial VEIN

Question 78

Dx. & Rx. of MS ??

Answer 78

CXR: LA Enlargement 2D-Echo: Normal area of MV is 4-6 cm2; 'Tight' MS < 1 cm2 Rx.- Pts. a/w AF: require AntiCoagulation - Moderate/Severe MS: Warfarin - Mild AS: DOACs may be suitable Asymptomatic Pts. - Regular 2D-Echo - Percutaneous/ Sx. Rx. NOT advised Symptomatic Pts. - Percutaneous Mitral Balloon Valvotomy - MV Sx. (Commissurotomy or Valve replacement)

Question 79

CXR features of MS ??

Answer 79

LA Enlargement - Splaying of Carina - Elevation of Left Main Bronchus: Double Rt. Heart Border - Cardiomegaly

Question 80

Hallmarks of MVP ??

Answer 80

IDIOPATHIC but may be a/w wide variety of CVS diseases - Congenital HD: PDA, ASD - Cardiomyopathy - Turner's Syndrome - Marfan's, - Fragile X - Osteogenesis imperfecta - Pseudoxanthoma Elasticum - WPW, - Long-QT syndrome - Ehlers-Danlos Syndrome - PCKD

Question 81

Features of MVP ??

Answer 81

- Atypical Chest pain or Palpitations - Mid-Systolic click (occurs later if Squatting) - Late Systolic murmur (longer if pt. Standing) Complications - MR - Arrhythmias (including Long-QT) - Emboli - Sudden Death

Question 82

Hallmarks of TR ??

Answer 82

Signs- - Pan Systolic Murmur - Prominent V wave on JVP - Pulsatile Hepatomegaly -Left Parasternal Heave Enlarged RV Causes - RV Infarction - Pulm. HTH eg.- COPD - RHD - Infective E (specially IVDU) - Ebstein's Anomaly - Carcinoid Syndrome

Question 83

Hallmarks of AR ??

Answer 83

Causes blood to flow in Reverse direction during V Diastole Features - Early Diastolic Murmur (intensity increased by handgrip maneuvre) - Collapsing Pulse - Wide Pulse Pressure - QUINCKE's Sign: Nail Pulsations - DE MUSSET's Sign: Head Bobbing Ix.- 2D-Echo

Question 84

Severe AR features ??

Answer 84

Mid-Diastolic AUSTIN- FLINT murmur - AR: due to partial closure of Anterior MV cusps caused by Regurgitation stream

Question 85

Causes of AR ??

Answer 85

AR due to VALVE Disease - Rheu. F (MCC in developing nations) - Calcific Valve disease - Infective Endocarditis - Connective Tissue disease (RA/ SLE) - Bicuspid Aortic Valve (affects BOTH valve & aortic root) AR due to AORTIC ROOT Disease - Bicuspid Aortic Valve - Aortic Dissection - HTN, - SYPHILIS - Marfan's & Ehlers-Danlos - Spondyloarthropathies (eg- Ank. Spon.)

Question 86

Rx. of AR ??

Answer 86

Ix.- 2D-Echocardiography Rx.- Medical Rx. if a/w HF Surgery: AV indications includes - Symptomatic pts. with Severe AR - Asymptomatic pts. with Severe AR + LV Systolic Dysfunction

Question 87

Hallmarks of AS ??

Answer 87

Causes - Degenerative Calcification - Bicuspid AV, - William Synd. - Post-Rheumatic disease, - HOCM C/F - Chest pain, Dyspnoea - Syncope/ Presyncope (eg.- Exertional dizziness) ESM; radiates to Carotids; decreased following Valsalva

Question 88

Features of Severe AS ??

Answer 88

- Narrow Pulse Pressure - Slow Rising Pulse - Delayed ESM - Soft/ Absent S2 - S4 - Thrill, - Duration of Murmur - LVH or LVF

Question 89

MCC of AS in - Older pts. > 65 yrs - Younger pts. < 65 yrs Supravalvular cause of AS Subvalvular cause of AS

Answer 89

- Degenerative Calcification - Bicuspid AV Supravalvular AS: William Synd. Subvalvular AS: HOCM

Question 90

Rx. of AS ??

Answer 90

1) Asymptomatic: Observe 2) Symptomatic: Valve Replacement 3) Asymptomatic + Valvular gradient > 40 mmHg + LVSD features - Surgery 4) Options for AV replacement (AVR)-- - Sx. AVR: ToC for Young, Low/ Medium operative risk pts. => Do Angiogram prior to Sx. (can be done together) - Transcatheter AVR: High operative risk pts. 5) Balloon Valvuloplasty (Indications) - Children + No AV Calcification - Adults: Critical AS + Not fit for Sx.

Question 91

Which Murmur - Radiates to Axilla ?? - Radiates to Carotids ??

Answer 91

- Mitral Insufficiency (MR) - AS (ESM)

Question 92

Hallmarks of Bicuspid AV ??

Answer 92

Asymptomatic in Childhood - Maj. develop AS or AR A/W - Left Dominant Coronary Circulation (PDA arises from LCX instead of RCA) - Turner's Syndrome 5% pts. have Coarctation of Aorta Complications - AS or AR - High risk of Aortic Dissection & Aneurysm formation of Ascending aorta

Question 93

Which is the MC valve that needs replacement ??

Answer 93

AV & MV

Question 94

What are the 2 main types of Prosthetic Heart Valves ??

Answer 94

Bioprosthetic or Mechanical HV Biological (Bioprosthetic) - Bovine or Porcine in origin - Disadv.- Str. deterioration & Calcification over time - Indications: Older pts.- > 65 yrs for AV & > 70 yrs for MV Long Term AntiCoagulation NOT usually needed - Warfarin given for first 3 months - Low-dose Aspirin: Long term

Question 95

Mechanical HV ??

Answer 95

BiLeaflet valve (MC type now used) Have LOW Failure rate Disadv.- Higher risk of THROMBOSIS - Long Term AntiCoagulation needed - Warfarin preferred to DOACs - Aspirin is only given IF there is additional indication eg.- IHD Target INR - Aortic: 3.0 - Mitral: 3.5

Question 96

ACS Hallmarks ??

Answer 96

Is an umbrella term covering a no. of Acute presentations of IHD Presentations STEMI NSTEMI Unstable Angina: Ischaemic C/F suggestive of ACS + NO elevation in Troponins +/- ECG changes indicative of Ischaemia - Rise in Troponins may take some hrs., it may be indistinguishable for NSTEMI initially & is hence treated the same until Trops. result is known

Question 97

Pathophysiology of IHD ??

Answer 97

1) Initial Endothelial Dysfunction - Smoking, HTN, Hyperglycaemia - Results in Proinflammatory, Pro-oxidant, Proliferative & Reduced Nitric Oxide bioavailability 2) Fatty Infiltration of SubEndothelial space with LDL particles - Monocytes migrate from blood => become Macrophages => These Phagocytose Oxidized LDL => Large Foam Cells - As these Macrophages die => Propagates Inflam. process 3) SMOOTH Muscle Proliferation & Migration from T media into intima - Results in the formation of Fibrous capsule covering Fatty plaque

Question 98

Symptoms & Signs of ACS ??

Answer 98

CHEST Pain - Central/ Left sided - May radiate to Jaw/ Left arm - 'Heavy' or 'Crushing', like an elephant on my chest DM & Elderly may NOT experience any chest pain Dyspnoea, Sweating, N & V Signs: - HR, BP, Temp., O2 sats. are often normal or mildly altered- Tachycardia - ACS Complications: HF - Pale & Clammy

Question 99

Common Rx. of all pts. with ACS ??

Answer 99

Initial: MONA Morphine (Only if in severe pain) O2 (only if sats, < 94% on RA) Nitrates - Sublingually or IV - Useful if ongoing Chest pain or HTN - Used in Caution if pt. Hypotensive Aspirin 300mg Next step is to determine with ECG if its STEMI or NSTEMI/ Unstable Angina

Question 100

STEMI ECG Criteria ??

Answer 100

C/F of ACS (for >= 20 min) + Persistent (> 20 min) ECG features in >= 2 contiguous leads of V2- V3: - Men < 40 yrs: >= 2.5 mm (0.25mV) - Men >= 40yrs: >=2.0 mm (0.2 mV) - Women: >= 1.5 mm (0.15 mV) - In other Leads: >= 1mm (0.1 mV) New LBBB (considered new unless there is evidence otherwise)

Question 101

PCI ??

Answer 101

1) Further Anti-platelet prior to PCI - Aspirin + another drug - If the pt. NOT on Oral AC: Prasugrel - If pt. is on Oral AC: Clopidogrel 2) Drug Therapy during PCI PCI with Radial access - UfH + Bailout GP2b/3a inhibitor PCI with Femoral access - Bivalirudin + Bailout GP2b/3a 3) Other procedure during PCI - Thrombus Aspiration (NOT mechanical thrombus extraction) should be considered - Complete Revascularisation: in pts. with Multi-vessel CAD without Cardiogenic shock

Question 102

Rx. of STEMI ??

Answer 102

STEMI confirmed => MONA => Assess eligibility for Coronary Reperfusion Therapy TWO Types of C Reperfusion T 1) PCI - If pt. presents in < 12hrs of C/F + PCI can be delivered in 120 min - If pt. presents > 12hrs of C/F + still has evidence of ongoing Ischaemia, consider PCI - Drug-Eluting stents are used - RADIAL preferred over Femoral (Give UfH + Bailout GP2b/3a i) - Consider Fibrinolysis IF there is a significant delay in providing PCI 2) FIBRINOLYSIS - Given < 12hrs of C/F + PCI can't be delivered in 120 min. - Give Anti-Thrombin - After procedure give Ticagrelor - If ongoing MIschaemia, consider PCI

Question 103

NSTEMI/ Unstable Angina Criteria ??

Answer 103

1) MONA 2) Anti-Thrombin Rx - FONDAPARINUX offered if pt. not at high risk of bleeding + not having Angiography immediately (OR) - UfH offered if Immediate Angio. planned or Cr. > 265 umol/L 3) Estimate 6 m Mortality (GRACE) Low Risk <= 3% : - Ticagrelor (Not high risk of bleeding) - Clopidogrel if High risk of bleeding Intermediate/High risk > 3% : PCI - Offer asap if clinically unstable OR ELSE offer in <= 72 hrs PCI: UfH given regardless of Fondaparinux is given or not. Aspirin + another drug prior to PCI - If pt. NOT on Oral AC: Prasugrel/Ticagrelor - If on Oral AC: Clopidogrel

Question 104

GRACE scoring components ??

Answer 104

Global Registry of Acute Coronary Event is the most widely used risk assessment tool The following factors are considered - Age - HR, BG - Cardiac (Killip Class) & RFT (S. Cr) - Cardiac arrest on presentation - ECG Findings & - Trops level

Question 105

Risk stratification of GRACE ??

Answer 105

Predicted 6 m Mortality : Risk of further adverse CV Events - <= 1.5% = Lowest - 1.5 to 3.0% = Low - 3.0 to 6.0% = Intermediate - 6.0 to 9.0% = High - > 9.0% = Highest

Question 106

Which pts. with NSTEMI/Unstable Angina should have Coronary Angiogram (with follow-on PCI if necessary) ??

Answer 106

1) Immediate PCI - If clinically unstable (eg. Hypotensive) 2) Within 72 hrs - Pts. with a GRACE score > 3% ie. hose at Intermediate/High or Highest risk 3) Coronary Angiography - Considered for pts. if Ischaemia is subsequently experienced after admission

Question 108

Prognostic Factors of ACS ??

Answer 108

Poor Prognostic Factor - Age - Development (or History) of HF - Peripheral Vascular Disease - Reduced SBP - KILLIP Class: used to stratify risk Post-MI - Initial S Cr. conc. - Elevated initial Cardiac markers - Cardiac arrest on admission - ST segment deviation

Question 109

Killip Class ??

Answer 109

Class-1 : No C/F of HF : 6% (30-day mortality) Class 2 : Lung Crackles, S3 : 17% Class 3 : Frank Pulm. Oedema : 38% Class 4 : Cardiogenic Shock : 81%

Question 110

Secondary Prevention in ACS ??

Answer 110

ACS pts. require Lifelong Drug therapy to help reduce the risk of further events Std. therapy comprises the following - Aspirin - Second Anti-platelet if appropriate - Beta-Blockes - ACE i or ARBs - Statin

Question 111

Hallmark of Acute Pericarditis ??

Answer 111

Causes - Viral infection (Coxsackie) - TB, - Trauma - Uraemia (Fibrinous Pericarditis) - Post- MI, Dressler's - Connective Tissue Disorder - Hypothyroidism, - Malignancy Rx.- - Treat the Underlying cause - 1st line for Acute Idiopathic or Viral pericarditis : NSAIDs + Colchicine

Question 112

Features of Pericarditis ??

Answer 112

Chest pain: may be Pleuritic - Relieved by Siting & Leaning forward Dyspnoea, Flu-like C/F, Non-Productive Cough Peri-cardial Rub Tachyponea & Tachycardia

Question 113

Ix. done in Acute Pericarditis ??

Answer 113

1) ECG changes - Global/ Widespread - PR depression: Most specific - Saddle shaped ST elevation 2) TTE (all pts. must undergo)

Question 114

Most specific ECG marker for Pericarditis ??

Answer 114

PR Depression

Question 115

Rx. of Angina Pectoris or Stable Angina ??

Answer 115

Lifestyle changes, Medications, PCI, Surgery MEDICATIONS 1) Aspirin & Statin (All pts must receive in the absence of CI) 2) Sublingual GTN (for acute attacks) 3) BETA_Blockers or CCBs (based on co-morbidities) 4) If CCBs used as monotherapy - Rate-limiting CCBs (Verapamil or D is used) 5) If CCBs is used in combination with Beta-Blockers - Long-acting Dihydropyridine CCBs are used eg.-Mod. Release Nifedipine 6) If poor response to initial Rx., drug should be increased to max. tolerated dose 7) If still has C/F add a 2nd drug (Beta-blocker or CCBs) 8) 3rd line: Long-acting Nitrates, Ivabradine, Nicorandil or Ranolazine

Question 116

What is Nitrate tolerance ??

Answer 116

When Nitrates are taken for a long time, reduced efficacy is noted Pts. on Std. release Isosorbide Mononitrate should use Asymmetric dosing interval ie. - Maintain a daily Nitrite-free time of 10- 14 hrs This effect is NOT sen if Once daily Mod. Release Isosorbide Mononitrate used

Question 117

Why should Beta-blockers NOT be coprescribed with Rate-limiting or Non-Dihydropyridine CCBs ??

Answer 117

Risk of Complete Heart Block

Question 118

Complications of PCI ??

Answer 118

Stent Thrombosis (1- 2% cases) - Due to Platelet aggregation - MC in FIRST Month after PCI - Presents with Acute MI Restenosis (5- 20% cases) - Due to Excessive Tissue Proliferation around stent - MC in 3- 6 months after PCI - Presents with recurrence of Angina - RFs: DM, Renal impairment & Stents in Venous Bypass grafts

Question 119

Types of Stents ??

Answer 119

Bare-Metal Stents Drug-Eluting Stents - Coated with Paclitaxel or Rapamycin which (-) local tissue growth - This REDUCES Restenosis. - Rates of Stent Thrombosis are INCREASED as process of Stent Endothelization is slowed - S Thrombosis is prevented by Anti-Platelet Therapy - Aspirin continued for Life long

Question 120

Hallmarks of Aortic Dissection ??

Answer 120

Tear in Tunica Intima of Aortic Wall Associations- - HTN (Most imp. RF) - Bicuspid Aortic Valve - Marfan's & Ehlers-Danlos - Turner's & Noonan's - Pregnancy & SYPHILIS

Question 121

Features of Aortic Dissection ??

Answer 121

Chest/ Back pain - Severe & Sharp, Tearing/Ripping - Maximal at onset - Classic C pain is MC in Type-A D - Upper back pain is MC in Type-B D - But there is Overlap PULSE Deficit - Weak or absent Carotid, Brachial ir Femoral pulse - Variation (> 20 mmHg) in SBP b/w Arms AR, HTN ST Elevations in INFERIOR Leads

Question 122

Symptoms specific to the arteries involved in Aortic Dissection ??

Answer 122

Angina if Coronary artery involved Paraplegia: Spinal artery involved Limb Ischaemia: Distal aorta

Question 123

Aortic Dissection Classification ??

Answer 123

Stanford Classification - Type-A: Ascending A [2/3rd cases] - Type-B: Descending A distal to Lt. Subclavian origin [1/3rd cases] DeBackey Classification - Type-1: Originates in Ascending A, propagates to at least aortic arch & possibly beyond it Distally - Type-2: Originates in & is confined to Ascending A - Type-3: Originates in Descending A, rarely extends Proximally but will extend Distally

Question 124

Ix. done in Aortic Dissection ??

Answer 124

Pt. is Haemodynamically stable - CT Angio of Chest, Abd. & Pelvis Pt. is Haemodynamically unstable - TOE CXR: Widened Mediastinum IoC: CT Angio of Chest, Abd. & Pelvis

Question 125

Rx. of Aortic Dissection ??

Answer 125

Type A - Sx. Rx. & BP should be controlled to 100 to 120 mmHg Type B - Conservative Rx. - Bed Rest - Reduce BP: IV Labetelol to prevent progression - Endovascular repair of Type-B A D may have a role in the future

Question 126

Complications of Aortic Dissection ??

Answer 126

Backward Tear Complication - Aortic Incompetence or AR - MI: IWMI (due to RCA involvement) Forward Tear Complications - Unequal Arm pulses & BP - Stroke - Renal Failure

Question 127

Coarctation of Aorta ??

Answer 127

Congenital narrowing of DESCENDING Aorta - MC in MALES (despite a/w Turner's) Features - Infancy: HF - Adult: HTN - Radio-Femoral delay - Mid-Systolic Murmur; Maximal over back - Apical Click from AV - Notching of Inferior Border of Ribs (due to Collateral vessels) is NOT seen in Young children

Question 128

Associations of Co of Aorta ??

Answer 128

Turner's Syndrome Bicuspid AV Berry Aneurysm Neurofibromatosis

Question 129

Hallmark of PAH ??

Answer 129

Mean P A Pressure >= 25 mmHg 10% cases is inherited as A D disease - MC in Females aged 30- 50 yrs old PAH can develop 2ndary to - COPD Increased risk is seen in - HIV - Cocaine, Anorexigen (Fenfluramine)

Question 130

Features of PAH ??

Answer 130

"Progressive Exertional Dysponea" Exertional syncope Exertional Chest pain Peripheral Oedema Cyanosis - RV heave, Loud P2, TR, Raised JVP- Prominent 'A' wave

Question 131

Rx. of PAH ??

Answer 131

1) Acute Vasodilator Testing is done PA pressure is measured after administration of Vasodilator such as IV Epoprostenol/ Inhaled Nitric Oxide - If PA pressure falls significantly (seen only in a minority of pts.) : Oral CCBs can be used to treat - If PA Pressure does't fall significantly (Vast maj. pts.) --- Prostacyclin analogues: Iloprost, Treprostinil --- Endothelin r Antagonist: Bosentan, Ambrisentan --- PDE inhibitor: Sildenafil Progressive C/F despite Rx. consider Heart-Lung Transplant

Question 132

Hallmark of Pulm. Capillary Wedge Pressure ??

Answer 132

PCWP is measured using a balloon tipped Swan-Ganz catheter which is inserted into the Pulm. Artery - Pressure measured is similar to that of the LA (normally 6- 12 mmHg) Uses- - Find out if Pulm. Oedema is caused by HF or ARDS

Question 133

HTN Rx. strategy ??

Answer 133

Clinic BP : >= 140/90 mmHg => Offer ABPM or HBPM If ABPM/HBPM - < 135/85 mmHg : No HTN - >= 135/85 mmHg : Stage 1 HTN (Treat if < 80yrs + any of 5 condition) - >= 150/95 mmHg : Stage 2 HTN (Treat all pts. regardless of age)

Question 134

Conditions to treat Stage 1 HTN in a pt. who is < 80 yrs old ??

Answer 134

TREAT Stage 1 HTN if < 80 yrs + Any one of the following - Target Organ damage - Established CV disease - Renal disease - DM - 10 yrs CV Risk >= 10% (Drug Rx. is considered in addition to lifestyle advice in adults < 60yrs old + Stage 1 HTN + 10 yrs CV Risk < 10%

Question 135

BP Classification ??

Answer 135

Stage 1 HTN - Clinic BP >= 140/90 mmHg - ABPM/ HBPM average BP >=135/85 Stage 2 HTN - Clinic BP >= 160/100 mmHg - ABPM/ HBPM average BP >=150/95 SevereHTN - Clinic SBP/DBP >= 180/120 mmHg

Question 136

How to Dx. HTN ??

Answer 136

Measure BP in BOTH arm - If difference > 20 mmHg, repeat - If still a difference of > 20 mmHg, subsequent BP readings should be recorded from the arm with higher reading Pathological conditions is considered in unequal BP readings eg., SUPREVALVULAR Aortic Stenosis - So, listen to the heart Also take a 2nd reading if 1st reading is > 140/90 mmHg & lower one of the 2 is considered

Question 137

How to manage a pt. with BP >= 180/ 120 mmHg ??

Answer 137

1) ADMIT for Specialist assessment - Retinal Bleed or Papilloedema (or) - Life threatening C/F like- New onset confusion, Chest pain, HF signs or AKI 2) REFER if Phaeochromocytoma is suspected: Headache,Labile/ Postural Hypotension, Palpitations, Pallor, Diaphoresis 3) If NONE of the Above, do Ix. for End-Organ Damage (Bloods, ACR, ECG) - If Present: Start Antihypertensives immediately without waiting for ABPM or HBPM results - If NOT present: Repeat clinic BP within 7 days

Question 138

How to measure ABPM & HBPM ??

Answer 138

Ambulatory BP Monitoring - At least 2 readings/ hr during wake hrs (eg. b/w 08:00 to 22:00) - Use Average of >= 14 readings - If ABPM not tolerated of declined, offer HBPM Home BP Monitoring - For each BP recording, 2 consecutive readings is taken at least 1 min apart with pt. seated - Recorded 2x daily, ideally in the Morning & Evening - Measured for at least 4 days, ideally for 7 days - Discard the readings of 1st day & use the average value of ALL Remaining readings

Question 139

Lifestyle advice given to BP pts. ??

Answer 139

Low Salt: < 6g /day, ideally < 3g /day - [Average adult daily intake: 8- 12g] - Reducing salt intake by 6g/day lower SBP by 10mmHg CAFFEINE intake should be reduced Stop Smoking, Drink less [-OH], Eat a balanced diet rich in Fruits & Vegetables, Exercise more, Lose Wt. If < 40 yrs old consider specialist referral to exclude 2ndary causes

Question 140

Rx. of High BP ??

Answer 140

STEP 1 Rx. < 55 yrs or H/o T2DM: ACEi/ ARBs [A] > 55yrs or Black Africans/ African- Caribbean origin: CCBs [C] - ARBs preferred over ACEi in Black Africans or African-Caribbean due to reduced efficacy STEP 2 Rx. - If on ACEi/ ARBs add a CCBs or Thiazide - If on CCBs add ACEi/ARBs or Thiazide - ARBs preferred over ACEi in Blacks

Question 141

Step 3 & Step 4 Rx. of BP ??

Answer 141

STEP 3 Rx. Add a 3rd drug ie., - If on [ACEi/ARBs + CCBs] add Thiazides - If on [ACEi/ARBs + Thiazides] add CCBs STEP 4 Rx - Step 4 is Resistant HTN & suggests adding a 4th drug or seek Specialist advice - If K+ < 4.5 mmol/L: add Low dose Spironolactone - If K+ > 4.5 mmol/L: add Alpha or Beta Blockers If the BP still remains uncontrolled with optimal or max. tolerated doses of 4 drugs, seek Expert advice if it has not been obtained earlier

Question 142

What is the target BP for a Hypertensive pts. ??

Answer 142

Age < 80 yrs. old - Clinic BP: 140/90 mmHg - ABPM/ HBPM: 135/85 mmHg Age > 80 yrs. old - Clinic BP: 150/90 mmHg - ABPM/ HBPM: 145/85 mmHg

Question 143

Which BP reading is the most accurate predictor of CV Events ??

Answer 143

ABPM

Question 144

Novel Anti-Hypertensives ??

Answer 144

Direct Renin Inhibitors - Aliskiren (branded as Rasilez) - By (-) Renin, blocks conversion of Angiotensinogen ==> AT-1 S/E: Diarrhoea

Question 145

Secondary Causes of HTN ??

Answer 145

RENAL Diseases - GN, - Pyelonephritis - ADPKD, - Renal Artery Stenosis ENDOCRINE Disorders (Other than Primary Hyperaldosteronism) - Phaeaochromocytoma - Cushing's Syndrome - Liddle's, - Acromagaly - CAH (11-Beta Hydroxylase def.) DRUG Causes - Steroids, - NSAIDs - MAOi, - COCPs - Leflunomide OTHER Causes - Pregnancy, - Coarctation of Aorta

Question 146

HTN Rx. in DM ??

Answer 146

BP Target: < 140/90 mmHg T1DM - Rx. if BP > 135/85 mmHg (OR) - Albuminuria or >= 2 Metabolic Synd. features, in which case it should be 130/80 mmHg 1st line Antihypertensives regardless of age: ACEi or ARBs - ARBs preferred over ACEi in Blacks Autonomic Neuropathy may result in more Postural C/F in pts. on BP Rx.

Question 147

Why should Bete-blockers avoided with Thiazides ??

Answer 147

They can cause - Insulin Resistance - Impair Insulin Secretion - Alter Autonomic response to Hypoglycaemia

Question 148

Hallmarks of Isolated Systolic HTN ??

Answer 148

Common in Elderly, affecting 50% of people > 70 yrs old Risk Factors - Aging, - Elastin Calcifications - Increased Vascular Stiffness - Increased Endothelial Dysfunc. - Increased RAAS & Sym. activity - Ventricular-Arterial Uncoupling - Increased Salt sensitivity Rx. is same as the Stepwise strategy used in Std. HTN

Question 149

Hallmarks of Malignant HTN ??

Answer 149

BP > 200/130 mmHg Seen in both Essential & 2ndary types Severe HTN => Exceeding regulation capacity of Arterioles => Capillary Hyperperfusion => Reversible Capillary Leakage - Fibrinoid necrosis of B vessels => Retinal bleeds, Exudates & Proteinuria, Haematuria (Benign Nephrosclerosis)

Question 150

Features & Rx. of Malignant HTN

Answer 150

Severe Headache, N & V, Visual probs Chest pain & Dysponea Papilloedema Severe: Encephalopathy (eg. Seizures) Rx.- - Reduce DBP no lower than 100 mmHg within 12- 24 hrs - Bed Rest - Most pts.- Oral therapy: ATENELOL - Severe/ Encephalopathy: IV Na Nitroprusside or IV Labetelol

Question 151

HTN in Pregnancy ??

Answer 151

Women at high risk of developing Pre-Eclampsia should take - Aspirin 75mg OD from 12 wks POG until delivery High Risk Group include - HTN before pregnancy - CKD, - T1DM & T2DM - SLE or APLS BP usually falls in 1st trimester & continues to fall till 20-24 wks POG after which it returns back to Pre-Pregnancy levels by Term

Question 152

Criteria to Dx. HTN in Pregnancy ??

Answer 152

BP of > 140/90 mmHg (OR) An increase above Booking readings of > 30 mmHg SBP or > 15 mmHg DBP

Question 153

Define the following - Pre-Existing HTN ?? - PIH or Gestational HTN ?? - Pre-Eclampia ??

Answer 153

H/o HTN before Pregnancy (OR) a BP of > 140/90 mmHg before 20wks POG - No Proteinuria, No Oedema BP of > 140/90 mmHg after 20 wks POG - NO Proteinuria & Oedema - Resolves in 1 months after delivery PIH + Proteinuria (> 0.3g/ 24 hrs) - Oedema may occur but now less commonly used as a criteria

Question 154

Hallmarks of Pre-Eclampsia ??

Answer 154

TRIAD: New-onset HTN + Proteinuria + Oedema BP >= 140/90 mmHg after 20 wks POG & >= 1 of the following - Proteinuria - Other Organ involved (Renal Cr. >= 90 umol/L, Liver, CNS, Utero-Placental dysfunction, Haematological

Question 155

Consequences of Pre-Eclampsia ??

Answer 155

1) Eclampsia - Other CNS c/f- Altered mentation, Blindness, Stroke, Clonus, Headaches , Persistent Visual Scotoma 2) Fetal Complications - IUGR, - Prematurity 3) Liver: Elevated Transaminases 4) Haemorrhage: Abruptio Placenta, Intra-Abd., Intra-Cerebral 5) Cardiac Failure

Question 156

Features of Severe Pre-Eclampsia ??

Answer 156

HTN > 160/110 mmHg Proteinuria: Dipstick ++/+++ Headache, Visual disturbance Papilloedema RUQ or Epigastric pain Hyperreflexia Pit. Count < 100, Abnormal Liver enzymes or HELLP syndrome

Question 157

Rx. of Pre-Eclampsia ??

Answer 157

Initial Assessment - Arrange emergency 2ndary care assessment if suspected - BP >=160/110 : Admit & Observed Further Rx. - 1st line: Oral Labetelol - 2nd line: Nifedipine (if Asthmatic) & Hydralazine Definitive Mgt: DELIVERY of Baby

Question 158

Prevention of Pre-Eclampsia ??

Answer 158

HIGH RFs - HTN in previous pregnancy - CKD, - SLE, - APLS - T1DM & T2DM, - Chr. HTN Moderate RFs - 1st Pregnancy, - >= 40 yrs old - Pregnancy interval of > 10 yrs - BMI >= 35 kg.m2 at 1st visit - FHx. of Pre-eclampsia - Multiple Pregnancy ASPIRIN 75- 150 mg daily from 12 wks POG until birth if - >= 1 High risk factors - >= 2 Moderate risk factors

Question 159

Hallmarks of Eclampsia ??

Answer 159

Seizures + Pre-Eclampsia [(PIH + Proteinuria) seen after 20wks POG] - Seen upto 6 wks after delivery Rx.- - MgSO4 (to Prevent & Treat seizures) - Given once a decision of Delivery is made - IV Bolus of 4g over 5-10min followed by an infusion of 1g/hr - Rx must continue for 24 hrs after last seizure or Delivery Urine Output, reflexes, RR & O2 sats. should be monitored MgSO4 induced Resp. Depression can occur: Ca Gluconate Fluid Restriction

Question 160

Hallmark of Pulm. Embolism ??

Answer 160

Pleuritic Chest pain, Dyspoenia & Haemoptysis (Triad seen in 10%) The relative frequency of C/F are- - Tachypnea (RR > 20/min): 96% - Crackles - 58% - Tachycardia (HR > 100/min) - 44% - Fever (> 37.8 C) - 43% [Well's Criteria uses Tachycardia rather than Tachypnoea]

Question 161

What is the use of - Pulm. Embolism Rule-Out Criteria ?? - 2-Level PE Wells Score ??

Answer 161

PECR: Rule out PE in pts. known to have a low Pre-test probability (<15%)

Question 162

What is Pulm. E Rule-out Criteria ??

Answer 162

All criteria must be absent for have a (-)ve PECR result ie. rule out PE Done when we think there is a low pre-test probability (< 15%) BUT want more reassurance that it isn't the Dx. (-)ve PECR reduces PE chances to < 2%

Question 163

Criteria of PERC ??

Answer 163

Age >= 50 yrs HR >= 100 bpm O2 Sats. <= 94% Previous DVT or PE Recent Sx. or Trauma in past 4 wks Haemoptysis U/L Leg swelling Oestrogen use (HRTs, COCPs) If ALL are (-)ve, chances of PE is < 2%

Question 164

2 level PE Wells Score ??

Answer 164

1) Signs & C/F of DVT (Minimum of Leg swelling & Pain on palpation): 3 2) Alternative Dx. less likely : 3 3) HR > 100 bpm : 1.5 4) Immobile for > 3 days or Sx. in the previous 4 wk : 1.5 5) Previous DVT : 1.5 6) Haemoptysis : 1 7) Malignancy (On Rx./ Treated in last 6m/ Palliative) : 1 PE is likely if > 4 points PE less likely if <= 4 points

Question 165

Rx. of PE ??

Answer 165

If Wells Score > 4 Immediate CTPA (or) Interim Therapeutic AC while awaiting CTPA - CTPA (+)ve : PE disgnosed - CTPA (-)ve : Proximal Leg Vein USS if DVT suspected If Wells Score <= 4 points Do D-Dimer with results within 4 hrs (or) Interim Therapeutic AC while waiting for D-Dimer - If D-Dimer (+)ve : Immediate CTPA or Interim T AC (if not given) while awaiting for CTPA) - If D-Dimer (-)ve : Consider alternative Dx. & Stop AC

Question 166

CTPA or V/Q scan ??

Answer 166

Non-Massive PE : CTPA (initial Ix.) V/Q Scan may be used initially if - Facilities available - CXR is normal - No significantC/F concurrent Cardio-Pulmonary disease - IOC in pts. with RENAL Impairment

Question 167

Advantages of CTPA over V/Q scan ??

Answer 167

- Faster, Easier to perform out of hr - Reduced need of further imaging - Can provide an alternative Dx. if PE excluded - If CTPA is (-)ve, no need of further Ix. or Rx. for PE

Question 168

Drawbacks of - D-Dimers ?? - CXR ?? - V/Q scan ?? - CTPA ??

Answer 168

1) Sensitivity: 95-98%; Poor Specificity - If > 50 yrs: Age-adjusted D-Dimers must be used 2) CXR is done in all pts. to exclude other pathology - NORMAL in PE - Wedge-Shaped Opacification 3) Sensitivity: 75%; Specificity: 97% 4) PERIPHERAL Emboli affecting SUB-SEGMENTAL Arteries may be missed

Question 169

Causes of Mismatched V/Q ??

Answer 169

Old PEs AV Malformation Vasculitis Previous RT COPD gives Matched Defect

Question 170

ECG features of PE ??

Answer 170

1) "S1Q3T3" - Lead 1: Large S wave - Lead 3 : Large Q wave & TwI - These changes are seen in <= 20% 2) RBBB & RAD 3) Sinus Tachycardia

Question 171

Rx. of PE ??

Answer 171

1) Anti-Coagulation 2) THROMBOLYSIS : Massive PE + Circulatory Failure 3) IVC Filters: Repeat PE despite on AC - Prevents clots formed in Deep veins of leg from moving to Pulm. Artery

Question 172

AC in PE ??

Answer 172

1st line : DOACs (Apixaban or Rivaroxaban) - Instead of LMWH use until Dx. confirmed, DOAC use is advocated in suspected cases as it can be continued if Dx. is confirmed If DOACs are not suitable, use either- - LMWH followed by Dabigatran or Edoxaban (OR) - LMWH followed by Vit. K antagonist (Warfarin)

Question 173

AC of choice in PE with the following - Active Cancer ?? - Severe Renal Impairment ?? - APLS [Triple (+)ve] ??

Answer 173

- DOACs (unless CI) - LMWH followed by UfH (OR) LMWH followed by Warfarin (VKA) - LMWH followed by Warfarin (Vit.KA)

Question 174

Length of AC in PE ??

Answer 174

All pts. should have AC for at least 3 months Provoked VTE: - Occurs due to an obvious ppt. event - Stop after Initial 3 months - 3- 6 months in Active Ca pts. Unprovoked VTE: - Occurs in the absence of an obvious ppt. event (unknown factor) - Continue for 3 more months (6 m in total)

Question 175

Types of AF ??

Answer 175

FIRST detected episode (irrespective of whether it is symptomatic or self-terminating) RECURRENT Episodes (>= 2 episodes) - Paroxysmal AF: If self terminates (< 7 days but typically < 24hrs) - Persistent AF: If lasts > 7 days 3) PERMANENT AF - Continuous AF which cannot be Cardioverted (OR) if attempts to do so are deemed inappropriate - Rx goals: Rate control & AC

Question 176

Features of AF ??

Answer 176

Palpitations, Dyspnoea, Chest pain Sign: Irregularly irregular Pulse Ix.- ECG Rx.- - Rate or Rhythm Control - Reducing Stroke risk

Question 177

Rate v/s Rhythm Control ??

Answer 177

RATE Control - Accept pulse is irregular & slow the rate to avoid (-)ve effects on Cardiac function RHYTHM Control : Try to get the pt. back into & maintain, normal Sinus rhythm Termed as Cardioversion - Pharmacological CV (Drugs) - Electrical CV (Synchronised DC shocks) RATE Control strategy is used in maj. of pts. Haemodynamically STABLE - If AF onset < 48hrs : Rate or Rhythm control If AF onset > 48 hrs or Uncertain : Start Rate control for long-term rhythm control; delay CV & start AC for 3 wks

Question 178

When is Rhythm Control preferred over Rate control ??

Answer 178

Co-Existent HF 1st onset AF Obvious Reversible cause

Question 179

Rate Control in AF ??

Answer 179

Beta-Blocker or a Rate-limiting CCBs (Diltiazem) is used as 1st line If 1 drug does't control rate adequately, a combination of 2 of the following can be used Beta-Blockers (common CI is asthma CCBs (Diltiazem) Digoxin (NOT 1st line)

Question 180

Rhythm Control in AF ??

Answer 180

Pt. must have had C/F for a short duration < 48 hrs (OR) be AC for a period of time prior to attempting CV - Switch from Rate control to Rhythm control if Symptoms/ HR fails to settle - The moment a pt., switches from AF to Sinus Rhythm, presents the highest risk for Embolism => Stroke

Question 181

How to calculate Stroke risk in AF cases ??

Answer 181

CHA2DS2 VASc score - CHF : 1 - HTN (or HTN on Rx.) : 1 - Age >= 75yrs : 2 - DM : 1 - H/o Stroke, TIA or VTE : 2 - Vascular disease (including IHD & PAD) : 1 - Sex (Female) : 1 Score 0 : NO Rx. Score 1 : - Males: Consider AC - Females: No Rx Score >= 2 : Offer AC

Question 182

How to start AC in pts. with previous H/o maj. bleed ??

Answer 182

Assess risk of Stroke & Bleeding Identify & treat other comorbidities Identify the cause of Bleeding - If Treatable cause : Restart OACs (NOACs: Novel Oral ACs) - If Bleeding cause unknown or Untreatable or Irreversible: No Rx. or Left Atrial Appendage Occlusion

Question 183

How to assess bleeding risk ??

Answer 183

Use ORBIT or HAS-BLED score Haemoglobin or Haematocrit - Males < 130g/L or < 40% : 2 - Females < 120g/L or < 36% : 2 Age > 74 yrs : 1 H/o Bleeding (GI bleed, Intracranial or Haemorrhagic Stroke) : 2 Renal Impairment (GFR < 60ml/min/ 1.73m2 : 1 Rx. with Anti-platelets : 1

Question 184

ORBIT Score Interpretation ??

Answer 184

There is no formal rules on how we act on ORBIT score & individual pts. factors must be takes into account. But the following table acts as guide- ORBIT Score = Risk Group = Bleeds/ 100 pt. yrs. - [0-2] = Low Risk = 2.1 - [3] = Medium = 4.7 - [4-7] = High = 8.1

Question 185

How to decide whether AC is needed or not ??

Answer 185

1) Ask for H/o AF ie. the following group must be assessed - Symptomatic or Asymptomatic Paroxysmal/Persistent/Permanent AF - Atrial Flutter - Continuing risk of Arrhythmia recurrence after CV back to Sinus rhythm or Catheter Ablation 2) CHA2DS2 VASc used to determine the most appropriate AC strategy. 3) Do TTE (If CHADS VASc suggests no need for AC) to exclude Valvular disease, which in combination with AF is an Absolute indication for AC

Question 186

AC of choice in AF ??

Answer 186

The following DOACs are promotes by NICE to reduce Stroke risk in AF - Apixaban - Dabigatran - Edoxaban - Rivaroxaban 2nd line: Warfarin (if DOACs are CI or not tolerated) Aspirin is NOT recommended

Question 187

Indication of Cardioversion in AF ??

Answer 187

Electrical CV if Haemodynamically Unstable Electrical or Pharmacological CV as an Elective procedure where Rhythm control strategy is preferred E-CV is synchronised to R wave (as it should NOT be delivered during Repolarization as VF can be induced)

Question 188

CV as Rx. of AF if Onset < 48 hrs ??

Answer 188

Heparinize Cardioverted using Electrical: DC Cardioversion Pharmacology - Amiodarone [Str. Heart Disease (+)] - Flecainide or Amiodarone (If NO Str. Heart disease After DC-CV if the onset was < 48 hrs, further AC is NOT necessary (Pt. at risk of Ischaemic Stroke should be put on Lifelong AC)

Question 189

CV as Rx. of AF if Onset > 48 hrs ??

Answer 189

1) AC given for 3 wks prior to CV (OR) 2) Do a TOE to exclude a Left Atrial Appendage (LAA) thrombus => If excluded => Heparinize the pt., => Cardiovert immediately - E-CV is preferred over Drug-CV 3) If High risk of CV failure (eg. Previous Failure or AF Recurrence): At least 4 wks of Amiodarone or Sotolol prior to E-CV 4) After E-CV : AC continued for 4 wks

Question 190

Pharmacological CV drugs used ??

Answer 190

Highly Efficacious Drugs - Amiodarone - Flecainide (If NO Str. Heart disease) - Others: Quinidine, Dofetilide, Ibutilide, Propafenone Less Effective agents - Beta-Blocker (including Sotalol) - CCBs, - Digoxin - Disopyramide, - Procainamide

Question 191

Post Stroke Rx. of AF ??

Answer 191

After TIA, AC for AF is started immediately once Imaging excludes bleed - Acute Stroke + No Haemorrhage : AC is started after 2 wks - Anti-platelet Therapy given in the intervening period - If imaging shows a very large infarct : AC initiation should be delayed

Question 192

When should Rate Control NOT be used in AF ??

Answer 192

- AF due to Reversible cause - HF is the primarily caused by AF - New-onset AF (< 48 hrs) - With Atrial Flutter : condition of pt. suitable an Ablation strategy to restore sinus rhythm - For whom Rhythm Control is more suitable based on clinical judgement

Question 193

Indication of Digoxin in AF Rx. ??

Answer 193

NOT a 1st line option for AF - Considered ONLY if the person does NO or Very little Physical exercise (or) other 1st line drugs are CI - May be used in cases of HF

Question 194

Rhythm control drugs used to MAINTAIN Sinus rhythm with H/o AF ??

Answer 194

Beta-Blockers Dronedarone : 2nd line in pts. following CV Amiodarone : particularly if coexisting HF

Question 195

Catheter Ablation in AF ??

Answer 195

Indication - AF who have NOT responded to or wish to AVOID Antiarrhythmic drugs Aim: Ablate faulty electric pathways that are causing AF - Site: Aberrant electrical activity b/w the Pulm. Vein & LA Both Radiofrequency (heat) & Cryotherapy can be used - Percutaneous procedure (via Groin)

Question 196

AC for Catheter Ablation ??

Answer 196

AC used 4 wks before & during the procedure - C Ablation controls rhythm but does NOT reduce Stroke risk (even if the pt. remains in Sinus rhythm) CHA2DS2 VASc - Score 0 : 2 months AC - Score > 1 : Long term AC

Question 197

Outcomes of Catheter Ablation ??

Answer 197

Complications - Cardiac Tamponade - Stroke - Pulm. Vein Stenosis Success Rate - 50% has Early recurrence (in < 3 m) of AF that often resolves spontaneously - After 3 yrs. + Single procedure : 55% remain in Sinus R - After 3 yrs. + Multiple Procedures : 80% remain in Sinus R

Question 198

Hallmark of Atrial Flutter ??

Answer 198

Form of SVT characterised by Rapid Atrial depolarization waves ECG: ('Sawtooth appearance') Atrial rate is around 300/min The Ventricular or HR is dependent on the degree of AV block - 2:1 block = HR is 150/min Flutter waves may be seen after Carotid sinus massage or Adenosine

Question 199

Rx. of Atrial Flutter ??

Answer 199

Cure: RF Ablation of TV Isthmus Drugs: Similar to AF but less effective More sensitive to CARDIOVERSION - Lower energy levels are used [Flutter waves can be seen after Carotid sinus waves or Adenosine]

Question 200

What is Multifocal Atrial Tachycardia ??

Answer 200

Irregular Cardiac Rhythm caused by at least 3 different sites in Atria - Morphologically distinctive P waves MC in Elderly with Chr. Lung disease (COPD) Rx.- - Correct Hypoxia & Electrolyte disturbances - 1st line : Rate-limiting CCBs - CV & Digoxin NOT useful

Question 201

What is Supraventricular Tachycardia ??

Answer 201

Tachycardia that is not Ventricular in origin Sudden onset Narrow complex T - MC is: AVNRT - Other causes AVRT (AV Re-entry T) & Junctional T

Question 202

Rx. of SVT ??

Answer 202

ACUTE Rx. 1) Vagal Maneuvres - Blow into empty plastic syringe - Carotid Massage 2) IV Adenosine - Rapid IV bolus of 6mg => if not successful give 12mg => unsuccessful give further 18mg - CI in Asthma : Give VERAPAMIL 3) Electrical Cardioversion Prevention: - Beta-blocker & RF ablation

Question 203

What is WPW syndrome ??

Answer 203

Congenital accessory conduction pathway b/w A & V leading to AVRT - As accessory pathway does not slow the conduction, AF degenerates rapidly to VF

Question 204

ECG features of WPW Syndrome ??

Answer 204

- Short PR interval - Wide QRS with Delta wave (Slurred upstroke) - LAD if Rt. accessory pathway - RAD if Lt. accessory pathway In maj. of cases or in questions with qualification, WPW is a/w LAD - Non-Specific ST-T changes are common (do not mistake for Ischaemia)

Question 205

Types of WPW syndrome ??

Answer 205

Type A (Lt. sided P): - Dominant R wave in V1 Type B (Rt. sided P): - NO Dominant R wave in V1 Type C (rare) - Delta wave are upright in V1- V4 but (-)ve in V5- V6

Question 206

Rx. of WPW syndrome ??

Answer 206

Cure : RF Ablation of Accessory pathway Drug Rx.- Sotolol, Amiodarone, Flecainide [Sotolol is CI in WPW with AF as prolonging Refractory period at AVN increases rate of transmission through Accessory P => Ventricular Rate Increases => VF]

Question 207

C/F of Bradycardia with Haemodynamic Instability ??

Answer 207

Shock: (SBP < 90mmHg), pallor, sweating, Cold, clammy extremities, Confusion or impaired consciousness Syncope M Ischaemia Heart failure

Question 208

Rx. of Bradycardia with Haemodynamic Compromise ??

Answer 208

1st line: IV Atropine 500mcg Unsatisfactory Response - Atropine upto 3mg - Transcutaneous Pacing - Isoprenaline/ Adrenaline infusion titrated to response

Question 209

RFs for Asystole in Bradycardia ??

Answer 209

- Complete HB with Broad QRS - Recent asystole - Mobitz type 2 AV HB - Ventricular pause > 3 sec. Transvenous Pacing done even if satisfactory response if seen with Atropine

Question 210

Peri-arrest Tachycardias ??

Answer 210

Broad-Complex T Narrow-Complex T AF Unified Rx. algorithm has replaced the Separate Rx. algorithm After basic ABC assessment, pts. are classified as being Stable or Unstable according to the presence of any Adverse Signs- - Shock: SBP <90mmHg, pallor, Sweating, Cold clammy extremeties, confusion, impaired consciousness - Syncope, - M Ischaemia, - HF

Question 211

Rx. of Peri-arrest Tachycardia ??

Answer 211

If ANY of the Adverse signs (+)ve - Synchronised DC-CV given - Upto 3 shocks can be given, after this Expert help should be sought Haemodynamically Stable Rx. id given based on - Narrow QRS or Broad QRS ?? - Regular rhythm or Irregular rhythm

Question 212

Broad Complex T Rx. ??

Answer 212

REGULAR Rhythm - Assume as VT (unless previously confirmed SVT with BBB) - Loading dose of AMIODARONE followed by 24hrs infusion IRREGULAR Rhythm (Expert help) Possibilities include - AF with BBB : most likely cause in a Stable pt. - AF with Ventricular Pre-excitation - Torsade de pointes

Question 213

Narrow Complex T Rx. ??

Answer 213

REGULAR Rhythm - Vagal maneuvres followed by IV Adenosine - If above Rx. unsuccessful, consider Dx. of Atrial Flutter & Control Rate (eg.- Beta blockers) IRREGULAR Rhythm - Probable AF - If onset < 48 hrs consider E-CV or Chemical CV - Rate Control: Beta-blockers (1st line) unless CI

Question 214

What is VT ??

Answer 214

Broad complex Tachycardia originating from a Ventricular Ectopic focus. 2 main types - Monomorphic VT : MC caused by MI - Polymorphic VT : A subtype of this is Torsades de pointes which is ppt. by QT interval Prolongation

Question 215

Causes of Prolonged QT interval ??

Answer 215

Congenital - Jervell-Lange-Nielsen syndrome (SNHL & is due to abnormal K+ channel) - Romano-Ward syndrome (No SNHL) Drugs - Amiodarone, Sotalol, Class-1a - TCAs, Fluoxetine - Chloroquine, - Erythromycin - Terfenadine Other - Hypo[Ca2+], Hypo[K+], Hypo[Mg2+] - Acute MI - Myocarditis - Hypothermia - SAH

Question 216

Rx. of VT ??

Answer 216

Broad complex T can result from SVT with aberrant conduction => assume Peri-arrest situation to be Ventricular in origin Haemodynamically Unstable - Synchronised DC Shock Drug Therapy - Amiodarone: (ideally via central line) - Lidocaine (use with caution in Severe LV impairment) - Procainamide If Drug Therapy FAILS - Electrophysiology Studies (EPS) - ICD (particularly in pts. with significantly impaired LV function

Question 217

Drug CI in VT ??

Answer 217

Verapamil is not used in VT

Question 218

Hallmarks of Torsades de pointes ??

Answer 218

'Twisting of the points' is a form of Polymorphic VT a/w Long QT interval - Can deteriorate into VF => Death Rx.- - IV MgSO4

Question 219

Hallmarks of Cardiac Tamponade ??

Answer 219

Accumulation of Pericardial Fluid under pressure Beck's Triad Hypotension - Raised JVP - Muffled HS Other features - Dysponea, - Tachycardia 1) Absent 'Y' descent on JVP (due to limited RV filling) 2) Pulsus Paradoxus: Abnormally large drop in BP on Inspiration 3) ECG: Electrical alternans (alteration of QRS complex amplitude b/w beats) Rx.- Urgent Pericardiocentesis

Question 220

Key difference b/w C Tamponade & Constrictive Pericarditis ??

Answer 220

C Tamponade - JVP: Absent Y descent - P Paradoxus: Present - Kussmaul's Sign: RARE Constrictive Pericarditis - JVP: Prominent X + Y descent - P Paradoxus: Absent - Pericardial Knock: Loud S3 - Kussmaul's Sign: PRESENT - Pericardial Calcification on CXR

Question 221

Genetic cause of Primary Cardiomyopathy ??

Answer 221

HOCM (A D condition) - Mutation in gene encoding Beta-Myosin Heavy chain protein Arrhythmogenic RV Dysplasia (A D) - RV myocardium is replaced by Fatty & Fibrofatty tissue

Question 222

ECG features of ARVD ??

Answer 222

A D Condition - TwI: V1 to V3 - Epsilon wave (50% cases): Terminal notch in QRS complex

Question 223

Acquired causes of Cardiomyopathy ??

Answer 223

PERIPARTUM CM - Develops b/w Last month of Pregnancy & 5 months post-partum - MC in Older women, Greater parity & Multiple gestations TAKOTSUBO CM - Stress Induced - Transient, apical ballooning of Myocardium - Rx- Supportive

Question 224

Mixed ( 2ndary + Genetic predisposition) causes of Cardiomyopathy ??

Answer 224

DILATED CM - Alcohol, - Beri-Beri (Wet) - Coxasackie B virus, - Doxorubicin RESTRICTIVE CM - Amyloidosis - Post- Radiotherapy - Loeffler's Endocarditis

Question 225

Secondary causes of CM ??

Answer 225

Infective CM - Chagas & Coxsackie B virus Infiltrative CM - Amyloidosis Storage CM - Haemochromatosis Toxicity CM - Doxorubicin & [-OH] CM Inflammatory (Granulomatous) - Sarcoidosis Endocrine CM - DM, Thyrotoxicosis, Acromegaly Neuromuscular CM - Friedreich's Ataxia - Duchenne & Becker's M D - Myotonic Dystrophy Nutritional: Beriberi (thiamine) Autoimmune: SLE

Question 226

Hallmarks of DCM ??

Answer 226

MC form of CM (90% cases) Dilated heart => Systolic Dysfunc. - All 4 chambers are dilated but LV > RV - Eccentric Hypertrophy (sarcomeres added in series) is seen

Question 227

Causes of DCM ??

Answer 227

IDIOPATHIC (MCC) Myocarditis (Coxsackie B, HIV, Diphtheria, Chagas) IHD & HTN Peri-Partum Iatrogenic (Doxorubicin) Substance abuse (-OH, Cocaine) Wet Beriberi (Thiamine deficiency) Infiltrative (Haemochromatosis, Sarcoidosis) : Can lead to Restrictive CM

Question 228

Inherited cause of DCM ??

Answer 228

Familial genetic predisposition or a Specific Synd. (Duchenne M D) - 1/3rd of pts. with DCM are thought to have genetic predisposition - Maj. are inherited in a A D pattern

Question 229

Features of DCM ??

Answer 229

Classic finding: HF Systolic Murmur: MR & TR (Stretching of valves) S3 CXR: Balloon appearance of Heart

Question 230

Hallmarks of HOCM ??

Answer 230

A D condition & is the MCC of SCD in the Young adults Defect in the gene encoding - Beta-Myosin Heavy chain protein or - Myosin-binding protein C DIASTOLIC Dysfunction - LV Hypertrophy => Decreased Compliance => Decreased CO Myofibrillar Hypertrophy with Chaotic & Disorganised fashion myocytes (Disarray) & FIBROSIS of Biopsy

Question 231

Poor prognostic factors of HOCM ??

Answer 231

- Syncope - FHx of Sudden death - Young age at presentation - Non-sustained VT on 24- 48 hrs Holter's - Abnormal BP changes on exercise - Increased Septal wall thickness

Question 232

Features of HOCM ??

Answer 232

Often Asymptomatic Exertional Dysponea; Angina Syncope - Typically after Exercise - Due to SubAortic Hypertrophy of IV Septum => FUNCTIONAL AS 1) SCD: (MC due to V Arrhythmias), HF 2) Jerky pulse, Large 'A' waves 3) Double Apex beat 4) ESM : Increases with Valsalve & decreases with Squatting - MR (MV impaired closure)

Question 233

Echo findings of HOCM ??

Answer 233

MR SAM ASH - MR - Systolic Anterior Motion of anterior MV leaflet - Asymmetric Hypertrophy

Question 234

ECG findings of HOCM ??

Answer 234

- LVH - Non-Specific ST segment - T wave abnormalities; Progressive TwI - Deep Q waves - AF (occasional)

Question 235

Rx. of HOCM ??

Answer 235

ABCDE - Amiodarone - Beta-blockers or Verapamil - Cardioverter Defibrillator - Dual Chamber Pacemaker - Endocarditis Prophylaxis

Question 236

Drugs to avoid in HOCM ??

Answer 236

Nitrates ACEi Ionotropes

Question 237

Associations of HOCM ??

Answer 237

Friedreich's Ataxia WPW Syndrome

Question 238

Hallmarks of Restrictive CM ??

Answer 238

Primarily characterised by decreased Compliance of Ventricular Endo-myocardium - Predominantly DIASTOLIC Dysfunc. Features - Similar to Constrictive Pericarditis - Low voltage ECG Ix.- - Echo - Cardiac MRI

Question 239

What are the features suggesting Restrictive CM over Constrictive Pericarditis ??

Answer 239

Prominent Apical Pulse ABSENCE of Pericardial Calcification on CXR Heart may be Enlarged ECG abnormalities: BBB, Q waves

Question 240

Causes of Restrictive CM ??

Answer 240

- MCC: Amyloidosis (eg. 2ndary to Myeloma) - Haemochromatosis - Post-Radiation Fibrrosis - Loffler's Synd.- EndoMyocardial Fibrosis with a prominent Eosinophillic ifiltrate - Endocardial Fibroelastosis: Thick Fibroelastic tissue forms in Endocardium, MC in CHILDREN - Sarcoidosis - Scleroderma

Question 241

Hallmark of Takotsubo CM ??

Answer 241

Broken Heart Syndrome Non-Ischaemic CM a/w Transient, Apical ballooning of Myocardium - Triggered by STRESS C/F - Chest pain -Features of Heart Failure - ECG: ST elevation - Normal Coronary Angiogram Rx.- Supportive (Maj. improve)

Question 242

ECG feature & Rx. of Myocarditis ??

Answer 242

Tachycardia, Arrhythmias ST/T wave changes including - ST segment elevation - TwI Rx.- - Treat the cause, Abx. if bacterial - Supportive Rx

Question 243

Pathophysiology of Takotsubo CM ??

Answer 243

Takotsubo is a Japanese word that describes an Octopus Trap "Transient Apical Ballooning of the Myocardium Ballooning occurs due to Severe - Mid & Apical segments: Severe Hypokinesis - Basal segments: Activity preserved The bottom (Apex) of the heart does not contract & so appears to balloon out BUT the area closer to the top (Base) continues to contract (Creating the neck of the Octopus trap)

Question 245

Hallmark of Myocarditis ??

Answer 245

Inflammation of Myocardium C/F - Young pt. with an Acute history - Chest pain, - Dysponea - Arrhythmias Ix.- - Increased inflam. markers (99%) - Increased Cardiac enzymes - Increased BNP

Question 247

Causes of Myocarditis ??

Answer 247

Viral: Caosackie B, HIV Bacteria: Diphtheria, Clostridia Spirochetes: Lyme's Protozoa: Chaga's, Toxoplasmosis Autoimmune Druga: Doxorubicin

Question 248

Complications of Myocarditis ??

Answer 248

HF Arrhythmia => Sudden Death DCM: late complication

Question 249

Hallmark of Constrictive Pericarditis ??

Answer 249

Causes: Any cause of Pericarditis; Particularly TB CXR: Pericardial Calcification Features - Dyspnoea - RV Failure: Elevated JVP, Ascites, Oedema, Hepatomegaly - Prominent X & Y descent - Pericardial Knock- Loud S3 - Kussmaul's sign is (+)ve

Question 250

Hallmarks of Atrial Myxoma ??

Answer 250

MC Primary Cardiac Tumour Site: LA (75% cases), MC attached to Fossa ovalis MC in Females Features - Systemic: Dysponea, Fatigue, Wt, loss, Pyrexia of unknown origin, Clubbing - Emboli - AF - Mid-Diastolic murmur, 'Tumour Plop'

Question 251

Echo features of Atrial Myxoma ??

Answer 251

Pedunculated Heterogenous mass typically attached to Fossa Ovalis region of Interatrial Septum

Question 252

Strongest RF foe developing IE ??

Answer 252

Previous episode of Endocarditis

Question 253

Aetiology of Infective Endocarditis ??

Answer 253

The following types of pts. are affected - Previous Normal valve (50%, acute presentation) - Rheumatic V D (30% acses) - Prosthetic Valves - Congenital Heart disease - IVDU (typically TRICUSPID V lesion) - Others: recent piercing

Question 254

Organisms causing Infective Endocarditis ??

Answer 254

1) Staph. Aureus (MCC) - Particularly common in Acute presentation & IVDUs 2) Strepto. Viridans - MCC in Developing Nations - MC found in Mouth & in Dental plaques so, is linked with Poor Oral Hygiene or after Dental procedure - Is a Pseudotaxonomic term & has 2 organism namely-Strep. Mitis & Strep. Sanguinis 3) Staph. Epidermidis-Coagulase (-)ve - Colonize indwelling lines - MCC in pats. after Prosthetic valve Sx. (Perioperative contamination) - After 2 month, it returns back to Stap. aureus 4) Strep. Bovis (a/w Colon Cancer) - Subtype: Strep. Gallolyticus is most linked with Colorectal Ca 5) Non-infective - SLE (Libman-Sacks) - Malignancy: Marantic Endocarditis

Question 255

Causes of Culture (-)ve I Endocarditis ??

Answer 255

- Prior Antibiotic Therapy - Coxiella burnetii - Bartonella - Brucella - HACEK: Haemophilus, Actinobacillus , Cardiobacterium, Eikenella, Kingella

Question 256

Modified Duke's Criteria ??

Answer 256

PATHOLOGICAL Criteria - (+)ve Histology/ Microbiology of autopsy or Cardiac Sx. (Valve tissue, vegetations, embolic fragments or Abscess contents) MAJOR Criteria POSITIVE Blood Culture (BC) - 2 (+)ve BC + shows typical bugs (Strep. Viridans or HACEK) [OR] - Persistent Bacteraemia from 2 B Clutures taken > 12 hrs apart or >= 3 (+)ve BC showing less specific species-Staph. epidermidis or aureus - (+)ve Serology for C Burnetii/ Bartonella spp./ C Psittaci [OR] - (+)ve Molecular assays for specific gene targets Evidence of ENDOCARDIA involved - (+)ve Echo (Oscillating str./abscess formation/ new valvular involvement/ Dehiscence of prosthetic V) OR New Valvular Regurgitation

Question 257

What are the Minor Duke's Criteria ??

Answer 257

1) Predisposing heart condition/ IVDU 2) Microbiological evidence NOT meeting Maj. Criteria 3) Fever > 38 C 4) Vascular Phenomenon - Major Emboli, Splenomegaly, Clubbing, - Sphincter Haemorrhages, Janeway Lesions (Non-tender), Petechiae or Purpura 5) Immunological Phenomenon - Osler's Node (Tender) - Roth Spots - Glomerulonephritis

Question 258

Poor Prognostic factors in IE ??

Answer 258

Staph. Aureus Infection Prosthetic H Valve (especially Early, acquired during Sx.) Culture (-)ve Endocarditis Low Complement Levels

Question 259

Indications for Sx. ??

Answer 259

- Severe Valvular Incompetence - Aortic abscess (indicated by PR interval lengthening) - Infections resistant to Abx./ Antifungals - HF refractory to Std. medical Rx - Recurrent emboli after Abx. Therapy

Question 260

What is the Mortality rate according to Organisms ??

Answer 260

Staphylococci- 30% Bowel Organisms: 15% Streptococci: 5%

Question 261

Dx. based on Duke's Criteria ??

Answer 261

Dx. if - Pathological criteria (+)ve (OR) - 2 maj. criteria (OR) - 1 Maj. + 3 Minor (OR) - 5 Minor

Question 262

C/F of IE ??

Answer 262

Fever + New onset Murmur VASCULAR Phenomenon - Major Emboli - Splenomegaly - Clubbing - Sphincter (Subungual) Haemorrhage (Dark red linear lesions in nail bed) - Janeway L: Non-Tender macules on palms & soles - Petechiae or Purpura IMMUNOLOGICAL Phenomenon - Osler's Node: Tender Subcutaneous nodules in PULPS of finger - Roth Spots: Retinal bleeds with Clear centre - Glomerulonephritis

Question 263

Initial Blind Rx. of IE ??

Answer 263

NATIVE Valve - Amoxicillin + Gentamicin-Low dose If Penicillin Allergic, MRSA or Severe Sepsis - Vancomycin + Gentamicin-Low dose PROSTHETIC Valve - Vancomycin + Rifampicin + Low dose Gentamicin

Question 264

Rx. of Staphylococci infection of - Native Valve IE ?? - Prosthetic Valve IE ??

Answer 264

Flucloxacillin If Penicillin allergic/ MRSA - Vancomycin + Rifampicin Flucloxacillin + Rifampicin + Low dose Gentamicin If Penicillin allergic or MRSA - Vancomycin + Rifampicin + Low dose Gentamicin

Question 265

Rx of Endocarditis caused by - Fully sensitive Strept. (eg. Viridans) - Less sensitive Strept.

Answer 265

Benzylpenicillin If Penicillin allergic - Vancomycin + Low dose Gentamicin Benzylpenicillin + L dose Gentamicin If Penicillin allergic - Vancomicin + L dose Gentamicin

Question 266

Prophylaxis of IE ??

Answer 266

The following procedures do NOT require Prophylaxis - Dental procedures, - Upper or Lower GI procedures - Genitourinary tract (Urological, ObGyn procedures, Childbirth) - URT & LRT (includes ENT procedures & Bronchoscopy)

Question 267

Condition where Prophylaxis is necessary ??

Answer 267

At risk of IE + Taking Antimicrobial Rx. + Undergoing GI or GU procedure at site where infection is suspected - give ABX. that covers the bug causing IE

Question 268

Hallmarks of Rheumatic Fever ??

Answer 268

IMMUNE reaction to recent (2-6 wks ago) Grp. A Strep. (Strept. Pyogenes) infection - S Pyogenes => Innate immunity activated =>Antigen presented to T-cells => B & T cells produce IgG & IgM antibodies => CD4+ T cells activated - Cross-reactive immune response (Type 2 HS) mediated by Molecular Mimicry - Antibodies produced against M protein cross react with Myosin & SM of arteries

Question 269

Dx. of RF (Jones Criteria) ??

Answer 269

MAJOR Criteria ["JONES"] - Joint pain (Polyarthritis) - O Carditis & Valvulitis - Nodules (Subcutaneous) - Erythema Marginatum - Sydenham's Chorea (Late feature) - Carditis & Valvulitis Carditis is NOT based on Peri- or Myo- carditis alone BUT there must be evidence of ENDOCARDITIS (clinically relates to Valvulitis- regurgitant murmur)

Question 270

Minor Jones Criteria ??

Answer 270

Raised ESR or CRP Pyrexia Arthralgia (NOT if arthritis a Maj. criteria) Prolonged PR interval

Question 271

Dx. of RF ??

Answer 271

Evidence of Strept. Infection + - 2 major criteria - 1 major & 2 minor criteria Evidence of Recent Strept. infection - Raised or Rising Strept. antibodies - (+)ve throat swab - (+)ve Rapid Grp. A Strept. antigen test

Question 272

Rx. of Rheumatic Fever ??

Answer 272

Antibiotics: Oral Penicillin V Anti-inflammatories: NSAIDs (1st line) Rx. of any complications that develops eg.- HF ASCHOFF Bodies describe the Granulomatous nodules found in RF

Question 273

What is Heart Failure ??

Answer 273

Heart can't pump enough blood to meet the body's need; arises from Str. or Func. heart issues & is categorised by - EF - Timing - Anatomical involvement

Question 274

Classification of HF ??

Answer 274

1) HFrEF (LVEF < 40%) Systolic Dysfunction + Impaired Myocardial Contraction Causes: IHD, DCM, Myocarditis, Arrhythmias 2) HFpEF (LVEF > 50%) Diastolic Dusfunc. + Impaired Ventricular Filling Causes: HOCM, Restrictive CM, Constrictive Pericarditis, Cardiac Tamponade 3) HFmrEF (Borderline LVEF) - LVEF 40%- 49% - Features overlap b/w HFrEF & HFpEF

Question 275

Classification of HF based on - Timing ??

Answer 275

ACUTE HF (AHF) Sudden worsening of Chr. HF - Features: Pulm. Oedema, Severe dyspnea needing urgent care CHRONIC HF (CHF) Slow onset + Progressive C/F - Leads to Functional decline

Question 276

Classification of HF based on - Anatomical involvement ??

Answer 276

LEFT-Sided HF - Pulm. Edema - Dyspnea, Orthopnea, PND & Fine Bibasal Crackles RIGHT Sided HF - 2ndary to Left-sided or Pulm. HTN - Peripheral Oedema, Raised JVP, Hepatomegaly, Ascites & Wt. gain BI-VENTRICULAR HF - Combination of Left & Right HF

Question 277

Symptoms & Signs of HF ??

Answer 277

Dyspnea, Fatigue, Exercise intolerence Left-sided: Orthopnea, PND Rt.-Sided: Peripheral Swelling SIGNS- - HRrEF: Tachycardia, Displaced apex beat & S3 gallop - Rt.-sided: Raised JVP, Hepatomegaly - Pulm. Crackles & Oedema

Question 278

Ix. done in HF ??

Answer 278

Dx.- BNP or NT-proBNP: Elevated CBC, LFT, RFT TFT to exclude 2ndary causes IMAGING 1) Echo: Check LVEF & Str. 2) CXR: Pulm. Congestion or Cardiomegaly 3) Cardiac MRI: Detects Myocardial Fibrosis or Infiltrative CM ECG

Question 279

Rx. of HFrEF ??

Answer 279

1st Line - ACEi or ARBs - Beta-blockers (Bisprolol, Carvedilol) - Sacubitril-Valsartan: used when ACEi & Beta-blockers are not relieving C/F + LVEF < 35% Add on Therapy - MRAs : Spironolactone - SGLT2i : Dapagliflozin Symptomatic Relief: Diuretics DEVICE Therapy - ICDs to prevent Arrhythmias - C Resynchronization Therapy (CRT) LifeStyle Modifications - Salt & Fluid restriction - Regular Physical activity as tolerated

Question 280

Indications of CRT ?? Importance of ICD ??

Answer 280

LVEF <= 35% Symptomatic despite Medical Rx - NYHA Class 2- 4 QRS duration >=130ms + LBBB Benefits of CRT - Reduces symptom & Mortality - Improves quality of life & Decreases Hospitalizations ICDs prevent SCD

Question 281

Rx. of HFpEF ??

Answer 281

1) Symptomatic Rx. & Comorbidity Rx Diuretics (To relieve Fluid Overload) - Manage Pulm. Congestion & Edema 2) Rx. of Underlying Condition - HTN (ACEi, ARBs, CCBs) - AF (Rate & Rhythm control & use AC based on CHA2DS2 VASc score) - Ischaemia : Optimize CAD Rx. with Anti-anginal Rx. & Revascularization 3) LifeStyle & Supportive - Physical activity & Cardiac Rehabilitation - Na+ restriction & Wt. loss

Question 282

Prognosis in HF ??

Answer 282

HFrEF generally has a worse outlook than HFpEF - Severity, Cause & Co-morbidities impact prognosis

Question 283

What is High Output HF ??

Answer 283

NORMAL Heart is unable to pump enough blood to meet the metbolic needs of body Signs & C/F of HF + CO >= 8L/min or Cardiac Index >= 4L/min/m2

Question 284

Causes of High Output HF ??

Answer 284

Anaemia AV Malformation Paget's disease Pregnancy Thyrotoxicosis Wet Beri-beri (Thiamine deficiency)

Question 285

What id Kawasaki Disease ??

Answer 285

Type of Vasculitis predominantly seen in Children - CA Aneurysm is a serious complication FEATURES - High-grade fever for > 5 days; resistant to Antipyretics - Conjunctival injection (Red eyes) - Bright red, Cracked lips - Strawberry tongue - Widespread Rash - Cervical LNpathy - Red Palms & Soles which later Desquamates

Question 286

Dx. & Rx. of Kawasaki Disease ??

Answer 286

Clinical Dx. [No specific Dx. test] TREATMENT - High-dose Aspirin - IVIGs Initial Screening test for CA Aneurysm - ECHOCARDIOGRAM (rather than Angio)

Question 287

Hallmark of Takayasu's Arteritis ??

Answer 287

Large Vessel Vasculitis - Typically causes occlusion of Aorta - Questions commonly refer to an ABSENT/ WEAK limb pulse - MC in Young Females (10-40 yrs) - MC in Asians Associations: Renal Artery Stenosis

Question 288

Features of Takayasu's ??

Answer 288

Systemic features of Vasculitis - Malaise, Headache UNEQUAL BP in Upper Limbs Carotid Bruit & Tenderness Absent or Weak Peripheral pulses UL & LL Claudication on Exertion AR (20% cases)

Question 289

Ix. & Rx. of Takayasu's ??

Answer 289

Dx.- MRA or CTA - Vascular Imaging of Arterial tree Treatment - Steroids

Question 290

Hallmarks of ACE inhibitors ??

Answer 290

MoA: Angiotensin-1 =(-)=> AT-2 - ACEi are activated by Phase-1 Metabolism of liver S/E - Cough (15% pts.) due to increased Bradykinin levels - Angioedema - HYPER[K+] - 1st dose Hypotension: MC in pts. taking Diuretics

Question 291

Interactions of ACEi ??

Answer 291

High-dose Diuretics (> 80mg of Furosemide a day) - Significantly increases the risk of Hypotension 1st Dose Hypotension - MC in pts. taking Diuretics

Question 292

CI of ACEi ??

Answer 292

Pregnancy & Breastfeeding Renovascular disease- may result in Renal impairment AS : may cause Hypotension Hereditary Idiopathic Angioedema Seek Specialist advice before starting if K+ >= 5mmol/L

Question 293

Monitoring of ACEi ??

Answer 293

U&E checked before starting Rx. & after increasing dose - A rise in Cr. & K+ is expected Acceptable changes - Rise in S Cr. upto 30% from baseline - Rise in S. K+ upto 5.5mmol/L Fall in eGFR of < 20% (SIGN) & < 25% (NICE CKD) is acceptable

Question 294

What is suspected if there is a significant change in U&E after starting ACEi ??

Answer 294

Undiagnosed B/L Renal Artery Stenosis

Question 295

Hallmarks of ARBs ??

Answer 295

Indications - Used when ACEi are not tolerated (Cough) - Afro-Caribbean pts. Should be used with caution in pts. with RenoVascular disease

Question 296

Features of ARBs ??

Answer 296

MoA: Blocks effects of AT-2 at [AT-1r] Candesartan, Losartan, Irbesartan - LOSARTAN reduces CVA & IHD mortality in HTN pts.

Question 297

Centrally Acting Anti-HTN ??

Answer 297

Methyldopa (Rx. of HTN in Pregnancy) Moxonidine - Rx. of Essential HTN when conventional Anti-HTNs have failed Clonidine - (+) Alpha-2 r in Vasomotor centre - Anti-HTNs effects

Question 298

Hydralazine ??

Answer 298

Used in Pregnancy & in Severe HTN MoA: Increase cGMP => SM relaxes CI: SLE, IHD, CerebroVascular D S/E: Tachycardia, Palpitations, Flushing, Fluid retention, Headache, Drug induced Lupus

Question 299

Adenosine ??

Answer 299

MC used to terminate SVTs Adenosine effects are enhanced by - Dipyridamole (Antiplatelets) Adenosine effects are blocked by - Theophylline CI: Asthma (bronchospasm) S/E: Chest pain, Bronchospasm, Transient flushing, Can enhance Conduction down accessory pathway => Increased Ventricle Rate (WPW)

Question 300

MoA of Adenosine ??

Answer 300

Causes TRANSIENT HB in AVN - A1 r agonist in AVN =(-)=> Adenylyl Cyclase ==> Reduces cAMP ==> Hyperpolarisation by Increasing K+ Efflux - 1/2 life: 8- 10 sec - Infused ideally via Large-calibre Cannula due to its Short 1/2 life

Question 301

What are ADP receptor Inhibitors ??

Answer 301

ADP is a main Plt. Activation factor, mediated by G-coupled r P2Y1 & P2Y12 Main target of [ADPr i] is [P2Y12 r], as this leads to - - Sustained Plt. aggregation & stabilisation of Plt. plaque Eg.- Clopidogrel, Prasugrel, Ticagrelor, Ticlopidine

Question 302

Dual Anti-Platelet Therapy ??

Answer 302

[Aspirin + ADP i] work by blocking different Plt. aggregation pathway, which have Synergistic effect Moderate-High Risk ACS pts. - [Prasugrel + Aspirin] causes marked reduction in ischaemic events than [Clopidogrel + A] NICE guideline for 2ndary prevention of ACS - Aspirin 75mg + Ticagrelor 90mg BD

Question 303

DAPT for ACS undergoing PCI ??

Answer 303

Aspirin (75- 100mg) OD + Prasugrel 10mg (OR) Ticagrelor 90mg BD If newer Anti-Plt. are CI - Use Clopidogrel 75mg Given for 12m with Aspirin

Question 304

S/E of Ticagrelor ??

Answer 304

Dyspnoea (due to impaired Adenosine clearance => increased conc. in blood => (+) Adenosine r in lungs => Adenosine (+) sensory nerve fibres => Dysponea)

Question 305

Drug interactions of ADP i (Clopidogrel & Prasugrel) ??

Answer 305

Clopi + PPIs (Ome- & Esmo- prezole) => Reduced Antiplatelet effect CI of Prasugrel - Prior Stroke or TIA + High risk of Bleeding - Prasugrel Hypersensitivity

Question 306

Drug interactions of ADP i - Ticagrelor ??

Answer 306

CI of Ticagrelor - High risk of bleeding, - H/o Intracranial Bleeding - Severe hepatic dysfunction Use Ticagrelor with caution in - Acute Asthma - COPD - Due to higher rates of Dyspnoea

Question 307

Hallmarks of Loop Diuretics ??

Answer 307

Works by (-) Na+/K+/2Cl- in Thick Ascending Limb of L of H - Reduces NaCl There are 2 variants of NKCC; Loop D acts on NKCC2, which is more prevalent in Kidneys - They must be Filtered INTO Tubules by Glomerulus before they can have an effect

Question 308

Indications & S/E of Loop D ??

Answer 308

Heart Failure: Acute (IV) & Chronic (Oral) Resistant HTN, particularly in pts. with Renal Impairment S/E - HYPO: Na+, K+, Mg2+ - HYPOCALCAEMIA - Hypotension - Hyperglycaemia (less common than Thiazides) - Gout - Hypochloraemic Alkalosis - Ototoxicity - Renal Impairment (Dehydration + Direct Toxic efect)

Question 309

Why should we increase the dose of Loop D in Renal Impairment ??

Answer 309

Pt. with poor Renal Func. require escalating doses to ensure sufficient conc. is achieved WITHIN the Tubules - Loop D to work has to get filtered into Tubules via glomerulus before they have their effect

Question 310

Hallmarks of Thiazide D ??

Answer 310

Work by (-) Na+ reabsorption at Early DCT by blocking Na+/Cl- Symporter - K+ is lost as more Na+ reaches the Collecting D - Mainly used in HTN Rx NICE now recommends use of other Thiazide like D: Indapamide & Chlorthalidone

Question 311

S/E of Thiazide D ??

Answer 311

Dehydration, Postural Hypotension HYPO: Na+, K+ Impotence HYPER[Ca2+] leads to Hypocalciuria - Useful in reducing incidence if Renal Stones Hyperuricaemia (Gout) Hyperglycaemia (IGT) Rare S/E - Thrombocytopaenia - Agranulocytosis - Photosensitive Rash - Pancreatitis

Question 312

Hallmarks of Amiodarone ??

Answer 312

Class 3 Anti-arrhythmic agent used in Rx of Atrial, Nodal & Ventricular tachycardias - (-) K+ channels =(-)=> repolarization & hence prolongs AP - Also has Na+ (-) effect (Class1 effect) Monitoring - Before Rx: TFT, LFT, U&E, CXR - TFT & LFT every 6 monthly

Question 313

Factors limiting Amiodarone use ??

Answer 313

Very Long 1/2 life (20- 100 days) - Loading doses are used oftenly Ideally be given via Central veins Pro-arrhythmic effect (Prolong QT) Interacts as P450 inhibitor drugs (decrease metabolism of Warfarin) Numerous S/E

Question 314

S/E of Amiodarone ??

Answer 314

Thyroid Dysfunction (Hyper & Hypo) Corneal deposits Pulm. Fibrosis or Pneumonitis Liver fibrosis/ Hepatitis Peripheral Neuropathy, Myopathy Photosensitivity 'SLATE-GREY' appearance Thrombophlebitis Bradycardia Lengthens QT interval

Question 315

Hallmarks of Dipyridamole ??

Answer 315

Anti-Platelet mainly used in with Aspirin after Ischaemic Stroke or TIA - (-) PDE => Elevates Plt. cAMP levels => in turn Reduces Intracellular Ca2+ - Also reduces Cellular uptake of Adenosine - (-) Thromboxane Synthase

Question 316

Fondaparinux ?? Direct Thrombin Inhibitors ??

Answer 316

- Activates AT-3 => Potentiates (-) of Factor 10a & is given SC Often grouped with DOACs 1) Bivalirudin (given as IV) : Is a Reversible direct thrombin inhibitor used as an AC in Rx. of ACS 2) Dabigatran taken Orally - Used as an alternative to Warfarin - Do NOT require regular monitoring

Question 317

Importance of Dabigatran ??

Answer 317

2 main indications VTE Prophylaxis after Hip/Knee replacement Sx. Non-Valvular AF (Stroke prevention) who have >=1 of the following RFs - H/o:- Stroke/TIA/Systemic Embolism - LVEF < 40% - NYHA Class >=2 (Symptomatic HF) - >= 75 yrs old - >= 65 yrs + one of: DM, CAD or HTN

Question 318

S/E of Dabigatran ??

Answer 318

- Haemorrhage (Maj. S/E) - Dose should be reduced in CKD Higher risk of bleeding & VTE events seen with recent Mechanical HV replacement compared with Warfarin CI if Cr. Clearance < 30 ml/min

Question 319

Dabigatran antidote ??

Answer 319

Idarucizumab (rapid reversal of AC)

Question 320

Hallmarks of Clopidogrel ??

Answer 320

Anti-Platelet Agent & is a 1st line in pts. after Ischaemic Stroke & PAD Belongs to class of drug called THIENOPYRIDINES which have similar MoA. - Eg.- Prasugrel, Ticegrelor, Ticlopidine

Question 321

MoA & Interactions of Thienopyridines ??

Answer 321

Antagonist of P2Y12 ADP r => (-) Plt. activation Interactions - Don't use with Ome- or Esmo- Prazoles - Pantoprazole can be used

Question 322

Secondary prevention of Stable CV disease with an indication for an AC

Answer 322

All must be started on Anti-Platelets If indication for AC exists (eg. AF) - Give Only AC Monotherapy without Anti-Platelet agents

Question 323

How to give a combination of Anti-Platelet & AC in- - Post ACS or PCI ??

Answer 323

Triple Therapy (2 Anti-P + 1 AC) - For 4 wks to 6 months after the event (THEN) Dual Therapy (1 Anti-P + 1 AC) to complete 12 months

Question 324

Pt. on Anti-P agent develops VTE, how to treat this pt. ??

Answer 324

ORBIT score calculated - Low risk bleeders : Continue Anti-P - Intermediate or High risk bleeder : Stop Anti-P & start AC

Question 325

Anti-P of choice in - ACS (medical Rx.) ?? - PCI ??

Answer 325

1st line: Aspirin (life long) + Ticagrelor (12 months) 2nd line: If Aspirin CI, Clopidogrel (LL) 1st line: Aspirin (LL) + Prasugrel or Ticagrelor (12 months) 2nd line: If Aspirin CI, Clopidogrel (LL)

Question 326

Anti-P of Choice in- - TIA ?? - Ischaemic Stroke ?? - PAD ??

Answer 326

TIA & Ischaemic Stroke - 1st line: Clopidogrel (life long) - 2nd line: Aspirin & Dipyridamole (LL) 1st line: Clopidogrel (LL) 2nd line: Aspirin (LL)

Question 327

What are GP 2b/3a r Antagonists ??

Answer 327

Abciximab Eptifibatide Tirofiban

Question 328

Hallmarks of Warfarin ??

Answer 328

Oral AC; used previously in the Rx. of VTE & reducing Stroke risk in AF pts. - Now been superseded by DOACs MoA: (-) Epoxide Reductase => prevents Vit.K reduction to its active Hydroquinone form - This in turn acts as in Carboxylation of Factors 2, 7, 9 & 10 & Protein C

Question 329

Indications of Warfarin ??

Answer 329

Mechanical Heart Valve - Target INR depends on Valve type & its location - MV requires higher INR targets than AV Second line after DOACs - VTE: Target INR= 2.5 & if Recurrent 3.5 - AF: Target INR- 2.5

Question 330

Monitoring of Warfarin ?? What are the Factors that potentiate Warfarin ??

Answer 330

Using INR= PTT of Pt. : Normal PTT - has long 1/2 life & achieving stable INR may take several days Factors that Potentiate Warfarin are - Liver Disease - P450 inhibitors - CRANBERRY Juice - Drugs that displace Warfarin from Albumin- eg.- NSAIDs - Inhibit Plt. func.- NSAIDs

Question 331

S/E of Warfarin ?

Answer 331

- Haemorrhage - Teratogenic, but can be used in Breastfeeding mothers - Purple Toes Skin Necrosis - When Warfarin is 1st started, Protein C synthesis is reduced => Temporary Procoagulant state - Thrombosis may occur in venules leading to necrosis

Question 332

Why is Heparin administered when Warfarin is started ??

Answer 332

When warfarin STARTED => Synthesis of Protein C is reduced => Temp. Procoagulant state => Thrombosis - To AVOID this, Concurrently Heparin is administered

Question 333

Rx. of Warfarin induced High INR ??

Answer 333

1) MAJOR Bleed - Stop W + IV VitK 5mg + PTCC - FFP given IF PT Conc. Complex not available. FFP can take time to defrost - Intracranial Bleed: PTCC 2) INR > 8.0 + Minor Bleed - Stop W + (IV) Vit.K 1- 3mg - Repeat Vit.K if INR still too high after 24hrs - Restart W when INR < 5.0 3) INR > 8.0 + No bleeding

Question 334

Rx. of Warfarin induced High INR ??

Answer 334

3) INR > 8.0 + No Bleeding - Stop W + Vit.K 1- 5mg by mouth, using the IV preparation Orally - Repeat dose of Vit.K if INR still too high after 24hrs - Restart W when INR < 5.0 4) INR 5.0- 8.0 + Minor Bleed - Stop W + (IV) Vit.K 1- 3mg - Restart W when INR < 5.0 5) INR 5.0- 8.0 + No Bleeding - Withhold 1 or 2 doses of W - Reduce Maintenance dose

Question 335

Dentistry in Warfarinised pts. ??

Answer 335

Check INR 72hrs before procedure, proceed if INR < 4.0 If H/o an unstable INR, then it should be checked within 24hrs of Dental procedure

Question 336

What is Thrombolysis ??

Answer 336

Thrombolytic drugs activate plasminogen to form plasmin => this in turn degrades Fibrin & breaks up Thrombi - Used in ST elevation MI Other indication: Acute Ischaemic Stroke & PE Eg.- Alteplase, Tenecteplace, Streptokinase

Question 337

Physiological effect of Atropine ??

Answer 337

- Tachycardia - Mydriasis - Can trigger Acute Angle Closure G in susceptible pts.

Question 338

CI & S/E of Thrombolysis ??

Answer 338

Active internal bleeding Recent Bleed, Trauma or Sx (including Dental extraction) Coagulation & Bleeding disorder Intracranial Neoplasia Stroke < 3m ago Aortic Dissection, Severe Head injury Severe HTN S/E: Bleeding, Hypotension (MC with Streptokinase), Allergic Reaction (can occur with Streptokinase)

Question 339

Hallmark of Atropine ??

Answer 339

Muscuranic ACh r antagonist Uses: - Symptomatic Bradycardia (IV Atropine) - Rx. of OP poisoning - In ALS, it is no longer recommended for routine use in Asystole or Pulseless Electrical Activity (PEA)

Question 340

Hallmark of BNP ??

Answer 340

Source: LV Myocardium in response to Strain Increased Synthesis - Raised in HF (mainly) but also in - M Ischaemia, Valvular HD Reduced Excretion - CKD Drugs that reduce BNP are - ACEi, ARBs, Diuretics

Question 341

Effects of BNP ??

Answer 341

- Vasodilator - Diuretic & Natriuretic - Suppress both Sympathetic tone & RAAS

Question 342

Clinical uses of BNP ??

Answer 342

1) Dx. Pts. with Acute Dyspnoea - Low BNP (< 100pg/ml) has a high (-)ve predictive value; makes the Dx. of HF unlikely - Helps to RULE OUT a dx. of HF 2) PROGNOSIS in pts. with Chr. HF - Very useful marker of prognosis 3) Guiding Rx.- Effective Rx. lowers BNP levels

Question 343

Beta-Blockers ??

Answer 343

Beta-1 : Heart (1 heart) Beta-2 : Lungs (2 lungs) Cardioselective Beta Blockers "MANBABE" - Metoprolol, - Atenelol - Nebivolol, - Bisprolol - Acebutolol, - Betaxolol, - Esmolol

Question 344

Indications of Beta-Blockers ??

Answer 344

- Angina, - Post-MI - HF (improve both symptom & Mortality) - Arrhythmias (has replaced Digoxin as the rate control DoC in AF) - HTN (use here has been diminished) - Thyrotoxicosis - Migraine Prophylaxix - Anxiety

Question 345

Which Beta-blocker crosses BBB ???

Answer 345

Propranolol (1st Beta-B to be developed) - Lipid soluble, hence can cross BBB

Question 346

S/E & CI of Beta blockers ??

Answer 346

- Bronchospasm - Cold Peripheries, - Fatigue - Sleep disturbances including Nightmares - Erectile dysfunction CI - Uncontrolled HF - Asthma - Sick Sinus Syndrome - Concurrent VERAPAMIL use: can ppt. severe bradycardia

Question 347

ECG Features of Digoxin toxicity ??

Answer 347

Down-sloping ST depression - Reverse Tick, Scooped Out Flat/Inverted T wave Short QT interval Arrhythmias (eg.- AV block, Bradycardia)

Question 348

Hallmarks of Ivabradine ??

Answer 348

Anti-Anginal drug which works by reducing HR - Acts on "If"(funny) ion current which are highly expressed in SAN - Reduces Cardiac Pacemaking activity S/E - Visual Effects, LUMINOUS Phenomenon is common - Headache, - Bradycardia, - H Block

Question 349

Nicorandil ??

Answer 349

Vasodilatory drug used to treat Angina - K+ channel activator - Vasodilation occurs via Guanylyl Cyclase activation => Increases cGMP

Question 350

S/E & CI of Nicorandil ??

Answer 350

Headache, Flishing Skin, Mucosal & Eye Ulceration GI ulcers & Anal Ulceration CI : LV Failure

Question 351

Hallmark of Nicotinic Acid ??

Answer 351

Niacin is used in the Rx. of Hyperlipidaemia & also to lower Cholesterol & TGs - Raises HDL levels S/E - Flushing: mediated by PGs - Impaired Glucose Tolerance - Myositis

Question 352

What is Syndrome X ??

Answer 352

Angina like Chest pain on Exertion ST depression on Exercise Stress Test But NORMAL Coronary Arteries on Angiogram Rx- - Nitrates

Question 353

Hallmarks of Nitrates ??

Answer 353

Have Vasodilatory effect Main Indication: - Angina & Acute Rx. of HF Sublingual GTN MC drug used in IHD pts. to relieve Angina attack S/E - Hypotension, - Headache - Tachycardia, - Flushing

Question 354

What is Nitrate Tolerance ??

Answer 354

Pts. on Nitrates develop Tolerance & Experience reduced Efficacy Pts. who develop tolerance should take the 2nd dose of Isosorbide Mononitrate after 8 hrs rather than after 12 hrs - This allows Blood-nitrate levels to fall for 4 hrs & maintain effectiveness This effect is NOT seen in pts. who take modified release Isosorbide Mononitrate

Question 355

Broad Complex T + which is most commonly by SVT with aberrant conduction rather than VT ??

Answer 355

Absent QRS concordance in chest leads - (+)ve QRS concordance in chest leads is a/w VT - AV dissociation suggests VT

Question 356

What is Brugada Algorithm ??

Answer 356

Used to differentiate b/w SVT with aberrant conduction & VT The following suggests VT - Absent RS complex (ie. either monophasic R or S waves) in all precordial leads (OR) - An R to S interval is > 100ms in 1 precordial lead - AV dissociation is also suggestive Following is suggestive of SVT with Aberrant conduction - RS wave in precordial lead + AV association - RSRdash pattern

Question 357

Pre-eclampsia affects what %age of Pregnancy ??

Answer 357

2- 8% of pregnancies worldwide

Question 358

MoA of Nitrates ??

Answer 358

Cause Nitric Oxide release in SM - Activating Guanylate Cyclase which then converts GTP => cGMP => leads to a FALL in Intracellular Ca2+ - They dilate Coronary Arteries & also reduce Venous Return ==> Reduces LV work => Reduce Myocardial O2 Demend

Question 359

Cardiac X syndrome ??

Answer 359

Microvascular Angina Normal Coronary angiogram + ECG changes on Exercise Stress testing (ST depression) ECG normal at rest

Question 360

Prosthetic valve Thrombotic therapy ??

Answer 360

Bioprosthetic: Aspirin Mechanical : Warfarin + Aspirin

Question 361

Statin induced Myopathy ??

Answer 361

Inhibition of Mevalonate pathway => depletion of several metabolites necessary for Muscle function

Question 362

Admitted to hospital for ACS + DM; how to handle DM ??

Answer 362

Keep BG < 11mmol/L (avoid Hyoglycaemia) - Stop OHAs & Start Dose adjusted IV Insulin infusion + regular BG monitoring

Question 363

Variable intensity S1 ?? Loud S1 ?? Soft S1 ?? Loud S2 ?? Soft S2 ?? Variable S1 ??

Answer 363

- MS & TS - MR, Severe HF, LBBB, 1st degree HB - Systemic HTN - Severe AS - Complete HB

Question 364

Rx. of Prinzmetal Angina ??

Answer 364

Dihydropyridine CCBs (Felodipine)

Question 365

Non-Synchronised DC-CV & Synchronised DC-CV ??

Answer 365

N-S DC-CV is Defibrillation & should only be used in Cardiac ARREST cases for Shockable Rhythms (VF & VT) DC-CV is Synchronised to R wave to minimise the risk of inducing VF

Question 366

Witnessed Cardiac arrest while on monitor Rx ??

Answer 366

3 successive (Stacked) shocks before CPR - Start CPR immediately after 3rd shock & continue CPR for 2 min. - 3 quick successive shocks are regarded as FIRST Shock

Question 367

Non-Shockable Rhythm (PEA & Asystole) Rx. ??

Answer 367

Give Adrenaline 1mg 1:10000 asap - Defibrillator will not be able to bring back the pulse

Question 368

The most important factor predicting outcomes Post-STEMI ??

Answer 368

New onset Systolic HF (suggests a large amount of Myocardial damage) - 10x more likely to die

Question 369

Why is Beta blocker not used as an anti Hypertensive ??

Answer 369

Less likely to prevent stroke + Causes Impaired Glucose Tolerance

Question 370

Regurgitation caused by DCM ??

Answer 370

MR (not AR)