Cardiology Flashcards
1
Q
What is Accelerated idioventricular rhythm (AIVR)?
A
Regular broad complex tachycardia due to a ventricular overriding rhythm with rate of 50-110 bpm following re-perfusion
2
Q
Causes of Accelerated idioventricular rhythm (AIVR)?
A
Re-perfusion of ischaemic tissue
Drug toxicity (cocaine, digoxin)
Vagal manoeuvres
Electrolyte abnormalities
3
Q
ECG of Accelerated idioventricular rhythm (AIVR)?
A
P waves not associated with QRS
QRS >120ms
Rate 110-50
4
Q
Treatment of Accelerated idioventricular rhythm (AIVR)?
A
Rarely needs treatment
5
Q
What are the common treatments for all patients with ACS?
A
Aspirin 300mg
Oxygen if sats <94%
Morphine only in severe pain
Nitrates for pain SL
6
Q
STEMI management after 300mg Aspirin?
A
PCI within 120 mins and within 12 hours of symptom onset
Prasugrel (not on anticoag, not high risk of bleeding) OR ticagrelor (high risk of bleeding) OR Clopidogrel (on anticoag)
7
Q
Which access if preferred for PCI in STEMI and what is used during?
A
Radial access
- Drug eluting stents
- Unfractionated heparin +
bailout glycoprotein IIb/IIa inhibitor
8
Q
What to give if femoral access in PCI for STEMI?
A
Bivalirudin + bailout GPI
9
Q
In STEMI if PCI not available within 120 minutes (within 12 hours of symptom onset)?
A
Fibrinolysis
+ antithrombin
Ticagrelor following
ECG 90 mins after if ST elevation remains for PCI
10
Q
Management of NSTEMI following 300mg Aspirin?
A
Fondaparinux (if immediate PCI, creat >265 unfractionated heparin)
GRACE score
<3% Ticagrelor
>3% PCI within 72h + prasugrel/ticagrelor/clopidogrel
11
Q
Pericarditis examination findings?
A
Pericardial rub
Recent viral infection
12
Q
Complication of pericarditis?
A
Cardiac tamponade
13
Q
Triad for cardiac tamponade?
A
Becks triad:
- Muffled heart sounds
- Hypotension
- Raised JVP
14
Q
Common causes of pericarditis?
A
idiopathic
Viral- coxsakie B virus, echo-virus
Bacterial
Malignancy- lung/breast
Early fibrinous pericarditis
Late dresselers
Radiation
SLE/ RA
Drugs
15
Q
What drugs can cause pericarditis?
A
Doxorubicin
Hydralazine
Isoniazid
Methyldopa
16
Q
Most specific ECG finding in pericarditis?
A
PR depression
17
Q
Investigations for pericarditis?
A
ECG
Troponin ? myopericarditis
TTE
18
Q
Management of pericarditis?
A
NSAID + Colchicine
with PPI cover til symptom resolution/ normalised inflammatory markers
Corticosteroids if refractory or cant tolerate
19
Q
When to admit pericarditis?
A
If fever or raised troponin
20
Q
What is the mechanism of action of adenosine?
A
agonist of the A1 receptor in the AVN
(reducing cAMP and hyperpolarization by increasing outward potassium flux)
Which results in transient heart block.
21
Q
Contraindications to adenosine?
A
Asthma
COPD
Compensated HF
Long QT
22
Q
What enhances and what inhibits adenosine?
A
Enhances: dipyridamole (antiplatelet)
Inhibited by theophylline
23
Q
Name examples of Adenosine diphosphate (ADP) Receptor Inhibitors?
A
Clopidogrel
Prasugrel
Ticagrelor
24
Q
What is the mechanism of action of Adenosine diphosphate (ADP) Receptor Inhibitors?
A
Inhibits ADP, a main platelet activation factors medicated by G-coupled receptors P2Y1 and P2Y12
25
What is cardiac amyloidosis?
Extracellular deposition of insoluble amyloid fibrils in the myocardium causing progressive HF, conduction abnormalities and cardiomyopathy
26
Staining for cardiac amyloidosis?
Congo red stain
Green birefringence
27
ECG in cardiac amyloidosis?
Low voltage complexes
Poor R wave progression
28
ECHO of cardiac amyloidosis?
Increased myocardial echogenicity (granular sparking or global speckled appearance)
29
Management of stable angina?
Aspirin 75 + Statin 80mg
GTN
BB or CCB (verapamil)
BB + CCB (amlodipine or MR nifedipine)
BB + CCB (amlodipine or MR nifedipine) + ISMN/ ivabradine/ Nicorandil/ Ranolazine (only when awaiting PCI/ CABG)
Revascularisation
30
When to revascularise in stable angina?
- If 3 agents not effective
- Complex 3 vessel disease - Significant left main stem affected
31
ABPI diagnostic of PAD?
<0.9
32
Normal ABPI?
0.9-1
33
What is secondary prevention for ACS?
DAPT: Aspirin 75mg (lifelong) + clopidogrel 12 months
BB
ACEi
Atorvastatin 80
34
How do you change DAPT if aspirin contraindicated?
Clopidogrel lifelong
35
Management of PAD?
Clopidogrel lifelong
36
What is an aortic dissection?
Tear in the tunica intima creating a false lumen
37
BP variation in aortic dissection?
>20
38
Associations with aortic dissection?
HTN
Trauma
Bicuspid aortic valve
Marfans, EDS
Turners, Noonans
Pregnancy
39
Diagnosis of aortic dissection?
CT angiogram aorta
TOE if unstable
40
Stanford Classification of aortic dissection?
Type A- ascending aorta = surgery
Type B- descending aorta = medical
41
Complications of aortic dissection?
Aortic regurgitation
Inferior MI (RCA involvement)
42
Describe aortic regurgitation murmur?
Early diastolic, louder with expiration, heard best in aortic region
43
Signs of aortic regurgitation?
Wide pulse pressure
Collapsing pulse
De Quincke
De Mussets
Corrigans
44
Management of aortic regurgitation?
Treat HF
Surgery if:
- Symptomatic
- Asymptomatic with LV systolic dysfunction
- IE refractory to medical management
Marfans/ EDS: BB +/- losartan
45
Describe aortic stenosis murmur?
Crescendo-decrescendo ejection systolic murmur, radiates to the carotids, louder with expiration
46
Causes of aortic stenosis?
- Senile calcification
- Bicuspid <65
- Willaim’s syndrome. Supra-valvular aortic stenosis
- Post rheumatic heart disease
- HOCM
47
Additional sounds in AS?
Soft/ absent S2
S4
48
What is Gallvarian phenomena?
Pan-systolic murmur from calcified aortic valve heard at the apex and doesn’t radiate
49
What is Heyde's Syndrome?
Coagulopathy due to depletion of VWF-2a in AS leading to intestinal angiodysplasia and GI blood loss leading to IDA
50
Classification of severe AS?
* Peak gradient >40
* Valve area <1
* Aortic jet velocity >4
* Clinically absent S2 (not official on classification)
51
When is surgical intervention required in AS?
* Symptomatic
* Asymptomatic with LVEF <50
* Asymptomatic with LVEF >50 and have symptoms or fall in BP during exercise testing
52
Surgical choices for AS?
SAVR
TAVI if high operative risk
53
What is Arrthymogenic Right Ventricular Cardiomyopathy (ARVC)?
AD condition where R ventricles myocardium is replaced by fatty fibrous material due to genetic defect of chromosomes
54
Most specific ECG finding of ARVC?
Epsilon wave
55
What is an epsilon wave in ARVC?
Small positive deflection at end of QRS
56
What are the ECHO findings of ARVC?
Enlarged, hypokinetic segments of free wall of R ventricle with thin wall
57
Management of ARVC?
Sotalol
Cardiac ablation
ICD
58
JVP in AF?
Loss of A wave
59
Options for rate control in AF?
BB
Diltiazem
Digoxin
X BB and rate limiting CCB together
60
BB in AF contraindicated in?
Asthma
Hypotension
61
Benefits of digoxin in AF?
Can be used in hypotension and HF
62
Anti-coagulation prior to cardioversion of AF?
3 weeks before
4 weeks after
or TOE to exclude left atrial appendage thrombus
63
Options of pharmacological cardioversion?
Flecanide (structurally normal hearts)
Amiodarone
64
Where do they target in catheter ablation in AF?
Between the pulmonary veins and left atrium
65
How long to anticoagulate prior to catheter ablation of AF?
4 weeks
66
CHA2DS2VASc score
CHF 1
HTN 1
Age 75+ 2
DM 1
Stroke/TIA/VTE 2
Vascular disease 1
Age 65-74 1
Sex female 1
Men 1
Women 2
67
ORBIT score
Sex
Hb <13 M, <12 F 2p
Bleeding hx 2p
Renal eGFR <60
Age >74
Concomitant anti-plt
68
Rate of sawtooth P waves in Atrial flutter?
300/ min
69
Cause of atrial flutter?
Aberrant re-enterent circuit in R atrium
70
Management of atrial flutter?
Rate control
Anti-coagulation
71
Where do you ablate in atrial flutter?
Cavotricuspid isthmus
72
Where are benign cardiac myxoma's seen?
L atrium and commonly attached to the fossa ovalis
73
Signs and symptoms of cardiac myxoma?
PUO
Emboli
Audible plop
Clubbing
Mid-diastolic murmur of MS
74
ECHO findings of atrial myxoma?
pedunculated heterogeneous mass attached to the fossa ovalis
75
What is Carney complex?
AD disorder causing cardiac and cutaneous myxomas, schwannomas, endocrine tumours and skin pigmentation
76
2 forms of ASD?
Ostium primum
Ostium secundum (most common)
77
Sign of ASD?
Ejection systolic murmur
Fixed splitting of S2
78
First degree AV block PR interval?
>200ms
PR >5ss
but every P wave has a QRS
79
Mobitz type 2 heart block?
Consistent PR prolongation with dropping of QRS at set pattern
80
Mobitz type 1 heart block?
AKA Wenckebach
Progressive prolongation til drop of QRS
81
Third degree heart block?
No association between P waves and QRS
Urgent pacemaker due to risk of asystole and VT
82
Mobtiz type 2 management?
Often symptomatic and need pacemaker due to 35% risk of asystole
83
Signs of third degree/ complete heart block on JVP?
Cannon A waves
84
Broad complex tachycardia duration?
>120ms
or 3ss
85
Differentials of broad complex tachycardias?
VT
VF
SVT with aberrancy
Accelerated idioventricular rhythm (AIVR)
86
What features suggest VT rather than SVT with aberrancy?
QRS >160ms
AV dissociation
No RS complexes V1-6
Fusion beats
Capture beats
Positive QRS concordance in chest leads
Marked L axis deviation
87
What are fusion beats?
Sinus and ventricular beats coincide to produce hybrid complex
88
What are capture beats?
QRS of normal duration as the electrical signal is passed to ventricles
89
Inheritance of brugada syndrome?
Autosomal dominant
90
What mutation is most common in Brugada syndrome?
SCN5A gene
91
What is Brugada sydrome?
Inherited Na channelopathy with structurally normal hearts
92
Who is highest risk of Brugada syndrome?
Asian ethnicity
Triggers: alcohol, TCAs, flecanide
93
ECG Brugada sign?
Coved ST elevation of >2mm in >1 V1-3 followed by T wave inversion
94
Investigation for Brugada syndrome?
Flecanide makes ECG changes more apparent
95
Management of Brugada syndrome?
ICD
96
What is Buerger's disease?
Vasculitis of small-medium sized vessels in young smokers
97
Presentation of Buerger's disease?
Acute limb ischaemia
Raynauds
Ulcers
Superficial migratory phlebitis
98
Arterial duplex sign of buergers disease?
Corkscrew collaterals
Mortorelli sign
99
Management of Buerger's disease?
Nifedipine
100
Oxygen sats of R side of the heart?
70%
101
Oxygen sats of L side of heart?
98-100%
102
First cardiac enzyme to rise in ischaemia?
Myoglobin
103
Best cardiac enzyme for recurrence of MI?
CK-MB as returns to normal in 2-3 days
104
Scan of choice for LVF?
MUGA scan
Typically used prior to chemotherapeutic
105
What is Becks triad and what does it indicate?
Muffled heart sounds
Raised JVP
Hypotension
Cardiac tamponade
106
Pulse in cardiac tamponade?
Pulsus paradoxus
- Large drop in BP during inspiration
107
JVP in cardiac tamponade?
Absent Y descent
108
ECG in cardiac tamponade?
Electrical alternans with alternating high and low QRS
109
Cardiac tamponade treatment?
Pericardiocentesis
110
Causes of dilated cardiomyopathy?
Alcohol
Cocaine
Chemo (doxorubicin)
Cocksakie b virus
Haemochromatosis
Wet beri beri
111
Dilated cardiomyopathy HS?
S3 gallop due to rapid ventricular filling
112
What is Loeffler's endocarditis?
Infiltration of WBC causing dilated cardiomyopathy
113
Takotsubo cardiomyopathy seen as?
Transient apical ballooning due to of med and apical segments
114
What causes hypertrophic cardiomyopathy?
AD mutation sarcomeres beta-myosin heavy chains or myosin binding protein C leading to LVH
115
Hypertrophic cardiomyopathy causes what form of dysfunction?
Diastolic with decreased compliance and CO
Only cardiomyopathy with diastolic dysfunction
116
Signs of Hypertrophic cardiomyopathy?
Jerky pulse
Large A waves
Double apex beat
ESM (LVO obstruction)
117
ECG findings of hypertrophic cardiomyopathy?
LVH
T wave inversion
Q waves
118
ECHO findings of hypertrophic cardiomyopathy?
MR SAM ASH
Mitral Regurgitation
Systolic Anterior Motion of mitral valve leaflets
Asymmetrical Septal Hypertrophy
119
Biopsy findings in hypertrophic cardiomyopathy?
myofibrillar hypertrophy with chaotic and disorganized fashion myocytes (disarray) and fibrosis
120
What 2 conditions is hypertrophic cardiomyopathy associated with?
WPW
Fredrich's ataxia
121
Management of hypertrophic cardiomyopathy?
ICD
BB for symptoms
Surgical myectomy in LVOTO
122
Investigations for stable angina?
CT angiography
Stress ECHO
Myocardial perfusion SPECT
123
What are the signs of cholesterol emboli?
Eosinophillia
Renal failure
Livido reticularis
Purpura
124
New York Heart Association (NYHA) Classification of HF:
I- no limitation
II- ordinary activity causes symptoms
III- marked limited physical activity with fatigue
IV- unable to carry of physical activity without discomfort, symptoms at rest
125
NT pro-BNP referrals:
>2,000 = <2 weeks
400-2,000 = <6 weeks
<400 = unlikely
126
Normal ejection fraction?
50-70%
127
Reduced ejection fraction?
<40%
128
Non drug management of HF?
Low salt diet
One of pneumococcal vaccine
Annual influenza vaccine
129
Medial management of HF first and second line management?
ACEi + BB
+ Spironolactone
+ SGLT2
130
Third line management of HF when can you use Ivabradine?
Sinus
>75bpm
LVF <35%
131
Third line management of HF when can you use Sacubitril-valsartan?
LVF <35%, started following ACEi/ARB wash out period
132
Third line management of HF when can you use digoxin?
with AF
133
Third line management of HF when can you use hydralazine + Nitrate?
Afro-Caribbean patients
134
Role of SGLT2 inhibitors e.g., dapagliflozin in HF?
Added with specialist guidance
135
When to use cardiac re-synchronisation in HF?
HF with wide QRS
136
More common cause of constrictive pericarditis?
TB
137
JVP in constrictive pericarditis?
Prominent x and y descent
138
Heart sound in constrictive pericarditis?
S3
139
Kussmaul sign in constrictive pericarditis?
rise in JVP on inspiration
140
CXR of constrictive pericarditis?
Pericardial calcification
141
What coronary artery supplies the SAN and AVN?
RCA
142
Where do the coronary sinuses drain into?
R atrium
143
Most common cardiomyopathy?
Dilated
144
CXR in dilated cardiomyopathy?
Balloon heart
145
Dilated cardiomyopathy is seen with which dysfunction?
Systolic
146
What is wet beri beri?
Thiamine deficiency
147
Cardiac complications in Down's syndrome?
Endocardial cushion defect (most common)
VSD
Secundum ASD
Tertralogy of Fallot
148
Time of driving for MI with angioplasty?
1 week
149
Time of driving for MI no angioplasty?
4 weeks
150
Time of driving for CABG?
4 weeks
151
Time of driving for Pacemaker insertion?
1 week
152
Time of driving for ICD inserted as prophylaxis?
4 weeks
153
Time of driving for ICD due to ventricular arrhythmia?
6 months
154
Time of driving for catheter ablation?
2 days
155
Time of driving for Aortic diameter 6.5cm+?
Banned
156
How is LVH seen in ECG?
Increased voltage of QRS
S wave V1 + R wave of V6 >40mm
157
Causes of LVH?
Aortic stenosis
Hypertrophic cardiomyopathy
HTN
158
What is P mitrale?
L atrial enlargement seen by bifid P waves >120ms
159
What causes L atrial enlargement?
Mitral stenosis
LVH
160
What is P pulmonale?
R atrial enlargement with tall P waves >2.5mm inferior leads or >1.5mm in V1-2
161
Causes of R atrial enlargement?
Cor pulmonale (chronic lung disease)
Tricuspid stenosis
Primary pulmonary HTN
162
Left axis deviation?
+ - -
+90 to +180
163
Causes of left axis deviation?
*Left anterior hemiblock
*LBBB
*Inferior MI
*Wolff-Parkinson-White syndrome- R sided accessory pathway
*HyperK
*Congenital: ostium primum ASD, tricuspid atresia
164
Right axis deviation?
-ve +ve +ve
-30 to -90
165
Causes of R axis deviation?
*RVH
*Left posterior hemiblock
*Lateral MI
*Chronic lung disease → cor pulmonale
*PE
*Ostium secundum ASD
*Wolff-Parkinson-White syndrome- left-sided accessory pathway
166
Options for bifascicular block?
RBBB + L anterior fascicular block (LAD)
RBBB + L posterior fascicular block (RAD)
167
Options for trifascicular block?
3rd degree heart block + RBBB + LAFB (LAD)
3rd degree heart block + RBBB + LPFB (RAD)
168
Signs of digoxin toxicity?
Nausea + vomiting
Blurred yellow vision
169
When to measure digoxin post dose?
6h
170
ECG changes in digoxin toxicity?
Reverse tick sign (down-sloping ST depression)
Inverted T waves
171
Treatment of digoxin toxicity?
Stop digoxin
Correct electrolytes
- Digifab if life threatening
172
How is hypoK seen on ECG?
Prolonged PR
Apparent long QT
St depression
T wave inversion/ absent
U wave
173
How is hypothermia seen on ECG?
Osbourne waves
AKA J waves
- First degree HB
- Long QT
Positive deflections at the J point between QRS and ST
174
Hypothermia definition and severity?
<35
Mild 35-32
Moderate 28-32
Severe <28
175
Diagnosis of ACS in LBBB use what criteria?
Sgarbossa criteria
176
Causes of LBBB?
Always pathological:
ACS
Aortic stenosis
HTN
Cardiomyopathy
HyperK
177
LBBB V1 written as?
rS
178
LBBB V6 written as?
R
179
First degree HB, Mobtiz Type 1 in athlete?
Normal variant
180
Causes of prolonged PR interval?
Idiopathic fibrosis and sclerosis
High vagal tone in athletes
Myotonic dystrophy
Lyme disease
Rheumatic fever
HypoK
Digoxin
Sarcoidosis
IHD
181
V1 of RBBB?
rSR
182
V6 of RBBB?
qRs
183
Causes of RBBB?
Normal variant
RVH/ cor pulmonale
PE
MI
ASD
184
Causes of inverted T waves?
MI
Digoxin toxicity
SAH
ARVC
PE ('S1Q3T3')
Brugada syndrome
185
What is S1Q3T3 for PE?
S wave in I
Q wave in III
T wave inversion in III
186
What is Wellen's syndrome?
Deeply inverted or biphasic T waves in V2-3 due to severe proximal LAD stenosis, high risk of anterior MI
187
Management of Wellen's syndrome?
Angiogram and PCI to LAD
188
What is Eisenmenger's syndrome?
Reversal of a L to R shunt due to congenital heart disease (PDA, VSD, PDA) and pulmonary HTN
189
S4 Heart sound
Atrial contraction agaisnt a stiff ventricle- with P wave
Severe AS
HOCM
HTN
190
S1 heart sound
Ventricular systole- closure of mitral and tricuspid valves
Loud = MS, premature atrial beats
Soft = MR
191
S2 Heart Sound
Diastole - closure of aortic and pulmonary valves
Loud = pulmonary HTN/ HTN
Soft = Severe AS
Fixed split = ASD
Wide Split = deep inspiration, RBBB, PS, MR
Reversed split = LBBB, severe AS, R ventricular pacing, WPW type B, PDA
192
S3 Heart sound
Ventricular filling in diastole
Normal <30
LVF e.g., dilated cardiomyopathy, constrictive pericarditis, MR
193
S2 is broken into?
A2 -> P2
Fixed split doesn't vary with inspiration
194
Hypercalcaemia on ECG?
Shortening of QT interval
195
Aim for <80 with essential hypertension?
135/85
196
Aim for BP >80 with essential hypertension?
145/85
197
Aim for BP in T2DM with essential HTN?
<140/90
198
Aim for BP in T1DM with essential hypertension?
135/85
Unless albuminuria then 130/80
199
Stage 1 hypertension?
Clinic 140/90
HBPM 135/85
200
Stage 2 hypertension?
Clinic 160/100
HBPM 150/95
201
Stage 3 HTN?
Clinic 180 systolic or 120 diastolic
202
HTN 1st line management?
<55 or T2DM/ protienuria = ACEi or ARB
55+ or afro-Caribbean = CCB
203
HTN 2nd line management?
CCB + ACEi / ARB
204
HTN 3rd line management?
CCB + ACEi + thiazide diuretic
205
Fourth line for HTN?
CCB + ACEi + thiazide like diuretic +
K 4.5 or below = spironolactone
K >4.5 = alpha or beta blocker
206
Causes of secondary HTN?
- Primary hyperaldosteronism (Conn’s syndrome) HyperNa, HypoK
- Phaeochromocytoma
- Cushing syndrome
- Liddle syndrome
- Congenital adrenal hyperplasia (11-beta hydroxylase deficiency)
- Acromegaly
- Renal artery stenosis (CT/ MR angiogram)
- Hyperthyroidism
- Coarctation of the aorta
- COCP
- Pregnancy
207
Indications for ICD insertion?
* Long QT syndrome
* HOCM
* previous cardiac arrest due to VT/VF
* previous MI with non-sustained VT on 24 hr monitoring, inducible VT on electrophysiology testing and ejection fraction < 35%
* Brugada syndrome
208
Most important risk factor for infective endocarditis?
Previous IE
209
IE in IVDU patients is more likely to be?
Staph aureus
Tricuspid involvement
210
Most common organism causing IE?
Staph aureus, coagulase +ve
211
Strep viridans IE e.g., mitis or sanguinis due to?
Poor dental hygiene
212
When is coagulase negative staph epidermis IE seen?
Prosthetic valves
Lines
213
Strep bovis e.g., strep gallolyticus IE seen in?
Colorectal Ca- colonoscopy
214
Culture negative causes of IE?
HACEK
Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella
215
Non infective causes of IE?
Malignancy
Lupus
216
What is SLE IE called?
Libman-Sacks endocarditis
217
What is malignancy associated IE called?
Marantic endocarditis
218
Poor prognostic factors for IE?
- Staph aureus
- Prosthetic valves
- Culture negative endocarditis
- Low complement levels
219
ECG in IE requiring surgery?
PR prolongation due to aortic root abscess
220
Pneumonic for Dukes Criteria for IE?
BE
FIVE PM
221
Major Dukes criteria for IE?
X2 blood cultures +ve
ECHO signs
222
Minor Dukes criteria for IE?
FIVE PM
Fever
Immunological phenomena (roth spots, splinter haemorrhages, oslers nodes)
Vascular phenomenon (janeway lesions)
ECHO minor
Predisposing factors
Micro evidence
223
Management of IE?
Prolonged abx for 6 weeks needing midline
224
Blind therapy for IE with native valves?
Amoxicillin (+ gent)
Pen allergy/ MRSA = vancomycin (+ gent)
225
Blind therapy for prosthetic valve IE?
Vancomycin + rifampicin + gentamicin
226
Native valve S. aureus IE treatment?
Flucloxacillin
Allergy/ MRSA: vancomycin + rifampicin
227
Treatment of Prosthetic Valve S. aureus IE?
- 1st line: flucloxacillin + rifampicin + gentamicin
- 2nd line: vancomycin + rifampicin + gentamicin
228
Treatment of Strep viridans IE?
- 1st line: benzylpenicillin
- 2nd line: vancomycin + gentamicin
229
Indications for surgery in IE?
- severe valvular incompetence
- aortic abscess (often indicated by a lengthening PR interval)
- infections resistant to antibiotics/fungal infections
- cardiac failure refractory to standard medical treatment
- recurrent emboli after antibiotic therapy
230
Absent JVP entirely?
SVC obstruction
231
What is Kussmaul sign in JVP?
JVP rising with inspiration seen in constrictive pericarditis
232
What is the A wave of the JVP and abnormalities?
Atrial contraction
Large= pulmonary HTN, PS, TS
Absent= AF
Cannon A waves= VT, ectopics, complete HB
233
What is the C wave of JVP?
Closure of tricuspid valve
234
What is the x descent of JVP?
Ventricular systole
Prominent in constrictive pericarditis
235
What is the V wave of JVP?
Passive filling of atrium
Large in TR
236
What is the Y descent of the JVP?
Opening of the tricuspid valve
Deep/ slow in constrictive pericarditis
237
Long QT values for men and women?
Men >440
Women >460
238
Risk of long QT?
VT
TdP
239
Most common cause of long QT syndrome?
Defect in alpha subunit in the slow delayed rectifier potassium channel
240
Causes of long QT syndrome?
Congenital
- Romano-Ward
- Jervell- Lange- Nielson
TIMES
- Toxins
- Ischaemia
- Myocarditis/ Mitral prolapse
- Electrolyte disturbance
- SAH
Hypothermia
241
How to tell apart Congenital causes of Long QT syndrome?
Jervell-Lange-Nielson = deafness
Romano ward- no deafness
242
Toxins causing long QT syndrome?
amiodarone, sotalol, TCAs, SSRIs (citalopram), methadone, chloroquine, terfenadine, erythromycin, haloperidol, ondansetron
243
What is Lown-Ganong-Levine Syndrome?
Accessory pathway - Bundle of James leading to pre excitation and predisposition to SVT for AVRT
Short PR, normal QRS
244
Mitral regurgitation murmur?
MR PAN
Pansystolic blowing murmur, radiates to the axilla
Heard best at apex
S1 quiet
S2 widely split
245
Causes of MR?
CAD/MI posterior-inferior causing damage to chordae tendinae or papillary muscles
IE
Rheumatic fever
Mitral valve prolapse
246
ECG in MR?
P mitrale
247
CXR sign of MR?
Double heart border due to L atrial hypertrophy
248
Surgical intervention of choice for MR?
Mitral valve repair with valvuloplasty- better survival
249
What is mitral valve prolapse?
Defect of valve causing prolapse but not regurgitation of blood
250
Conditions associated with mitral valve prolapse?
MVP PROLAPSE:
M. Marfan
V. Volf PWS (wolf)
P. Pseudoxanthoma
P. PDA
R. Regurgitation (mitral)
O. Osteogenesis Imp
L. Long QT
A. ASD
P. PCKD
S. (Severe)cardiomyopathy
E. Ehlor DS
251
Signs of mitral valve prolapse?
Mid systolic click (occurs later if squatting)
Late systolic murmur (longer if patient standing)
252
Murmur of MS?
Mid diastolic murmur
Loud S1
Opening snap
253
Cause of MS?
Rheumatic fever
254
Presentation of MS?
Fatigue
Dyspnoea
Haemoptysis (pulmonary HTN)
Hoarsness (Ortner's syndrome)
255
What is Ortner's syndrome?
L atrial enlargement compressing recurrent laryngeal nerve causing hoarseness in MS
256
Signs of MS?
Malar flush
Low volume pulse
Prominent A wave
Loud S1
257
CXR in MS?
Double heart border due to L atrial enlargement
258
Complication of MS?
AF, pulmonary HTN
259
Symptomatic management of MS?
balloon valvuloplasty, percutaneous mitral valvotomy, open valve repair/ replacement if severe disease
260
Which murmurs are louder on inspiration vs expiration?
RILES
Right sided inspiration: P/T
Left sided expiration: A/M
261
Ejection systolic murmurs loudest on inspiration?
PS
ASD
262
Ejection systolic murmurs loudest on expiration?
AS
HOCM
263
Ejection systolic murmur not changing with inspiration/expiration?
Tetralogy of fallot
264
Pansystolic murmurs:
Loudest with inspiration: TR
MR
VSD = harsh
265
Late systolic murmurs?
MVP with mid systolic click
Coarctation of the aorta
266
Early diastolic blowing murmurs?
AR
PR - graham steel murmur
267
What is the Graham-Steel murmur?
PR
268
Name the mid diastolic to late rumbling murmurs?
MS
Severe AR (austin-flint)
269
What is the Austin-Flint Murmur?
Severe AR
270
What gives a continous machinery murmur?
PDA
271
Secondary prevention of MI?
DAPT: Aspirin + ticagrelor/clopidogrel 12 months
ACEi
BB
80mg Statin
If HF and LVF dysfucntion eplerenone (aldosterone antagonist)
272
Post MI complications:
DARTH VADER
Death
Arrhythmia
Rupture of the ventricular free wall
Tamponade
HF/ Heart block
Valve disease - acute MR
Aneurysm of ventricle
Dressler's syndrome
Embolism
Recurrence
273
What arrythmias are common after MI?
VF or VT
274
Heart block post MI is common after what territory is affected?
Inferior infarcts- RCA
275
Left ventricular aneurysm post MI seen as and due to?
Persistent ST elevation
Anterior MI
276
How is ventricular free wall rupture seen post MI?
tamponade and sudden death treat with pericardiocentesis/ thoracotomy
277
Acute mitral regurgitation is more common after what MI?
Inferior-posterior MI due to papillary muscle rupture
278
VSD can happen post which MI?
Anterior or inferior MI within first week
279
When is dressler's syndrome seen?
2-6 weeks post MI with pericarditis (pleuritic chest pain, fever, high ESR)
280
How do you treat Dresslers syndrome?
NSAIDS
281
Early pericarditis in first 48 hours post MI due to?
Transmural MI
282
Most common cause of myocarditis in UK?
Coxsackie B virus
283
Most common cause of myocarditis in developing world?
Chagas disease
284
What is chagas disease?
trypanosoma cruzi
285
Drug causing myocarditis?
Doxorubicin
286
Investigations for myocarditis?
raised troponin
287
Gold standard for myocarditis?
Endomycoardial biopsy
288
Rare complication of myocarditis?
Dilated cardiomyopathy
289
Indications for temporary pacemaker:
- haemodynamically unstable bradycardia not responsive to atropine
- T2 or complete heart block secondary to Posterior-Anterior MI
- Trifasicular block prior to surgery
290
Management of complete heart block following posterior-inferior MI?
Conservative if asymptomatic and stable
291
R ventricular pacing seen as?
LBBB
292
L ventricular pacing seen as?
RBBB
293
Indications for permanent pacemaker insertion?
* persistent symptomatic bradycardia e.g. sick sinus syndrome
* complete heart block
* Mobitz type II AV block
* persistent AV block after MI
294
Naming of pacemakers:
PS RRA
Paced
Sensed
Response
Rate
Anti tachy
295
First and second position pacemaker options?
- V - Ventricle
- A - Atrium
- D - Dual (both atrium and ventricle)
- O - None (no sensing)
296
Options for third space pacemaker- Response to sensing?
- I - Inhibited (pacemaker is prevented from pacing if it senses intrinsic cardiac activity)
- T - Triggered (pacemaker will release a pulse if it senses intrinsic activity, usually used in combination therapies)
- D - Dual (both inhibited and triggered)
- O - None (no response to sensing)
297
Pacemaker wires generally in the?
R atria/ ventricle
298
Which single chamber pacemakers are used and for what?
VVI - AF, AV block
AAI - sinus node dysfunction without AV block
299
When are dual chamber pacemakers used?
Sinus node dysfunction and AV block
300
When are Biventricular pacemakers AKA Cardiac Resynchronization Therapy (CRT) devices used?
In HF with ventricular desynchrony with leads in R atrium, R ventricle and L ventricle
301
Where does blood flow between in Patent Ductus Arteriosus (PDA)?
aorta to pulmonary artery
302
PDA murmur?
Continuous machinery murmur with L subclavian thrill, bounding pulse
303
Management of PDA in preterm infants?
Indomethacin/ ibuprofen for closure if haemodynamically significant or ventilator for >1 week
304
Management of PDA in term infants?
Only is moderate to large, prior endocarditis, small audible PDA using transcatheter closure
305
When do you keep PDA open and with what?
Other congenital heart disease needing surgery keep open with prostaglandin E
306
Shock definition for algorithms?
BP sys <90
307
First line management of bradycardia with shock (BP <90), HF, myocardial ischaemia, syncope?
Atropine 500 micrograms IV repeat in 3-5 mins up to 3mg
308
Management of bradycardia with adverse features (shock, HF, syncope, myocardial ischaemia) if atropine 3mg ineffective?
Transcutaneous pacing
OR
Isoprenaline 5mcg
Adrenaline 2-10 mcg
If ineffective transvenous pacing
309
Bradycardias with high risk of asystole?
* Recent asystole
* Mobitz type 2
* Complete heart block with broad QRS
* Ventricular pause >3s
310
Management of bradycardia with no adverse features but high risk of asystole?
Atropine
and transvenous pacing
311
Reversal agent for BB or CCB causing bradycardia?
Glucagon
312
How to treat tachycardia with adverse features?
Up to 3 Synchronised DC cardioversion
Amiodarone loading 300mg 10-20 mins
Repeat shock
Amiodarone 900mg IV over 24 hours
313
Broad complex regular tachycardia with no adverse features can be?
VT or SVT with aberrancy
VT load with amiodarone and 24h infusion
SVT with aberrancy treat as regular narrow complex with vagal manoeuvres then adenosine
314
Management of broad complex irregular tachycardia without adverse features?
AF with BBB- tx as narrow complex irregular
AF with ventricular preexcitation- amiodarone
TdP
315
Management of regular narrow complex tachycardia without adverse features?
Vagal maneourves
Adenosine- 6, 12, 18
If effective SVT
If ineffective ? Atrial flutter
316
Contraindications for adenosine?
Asthma
Long QT syndrome
Decompensated HF
317
If adenosine contraindicated use?
Verapamil or BB
318
Management of narrow complex irregular tachycardia without adverse features?
AF
give BB or diltiazem
In HF give digoxin
319
What is pre-eclampsia?
HTN >140/90 after 20 weeks of pregnancy with proteinuria and oedema
320
Risk factors for pre-eclampsia?
HTN in previous pregnancy, CKD, autoimmune diseases, diabetes, first pregnancy, >40 years, high BMI, family history, multiple pregnancies.
321
Prevention of pre-eclampsia if multiple risk factors present?
Aspirin form 12 weeks til birth
322
Management of pre-eclampsia?
Labetalol
Nifedipine
Hydralazine
323
Issues of CTPA in pregnancy for ? PE?
Increased maternal breast cancer risk to 13.5%
324
Issues of V/Q scan in pregnancy for PE?
Increased risk of childhood cancers to 1/50,000 vs 1/million
325
In pregnancy can D-dimer to trusted?
No, raised in pregnancy
326
Pulmonary HTN is?
Mean pulmonary arterial pressure 25
327
Causes of pulmonary HTN?
COPD
ILD
Bronchiectasis
Idiopathic
PE
MS/ R
Inherited
328
Investigation to determine treatment in pulmonary HTN?
Acute vasodilator testing with IV epoprostenol or inhaled NO
329
If fall with acute vasodilator testing in pulmonary HTN treat with?
CCB
Nifidipine
330
If no response to acute vasodilator testing in pulmonary HTN treat with?
Treprostinil
Iloprost
Bosentan
Ambrisentan
Sildenafil
331
Rule out PE with?
PERC rules
332
Wells score for PE 4 and above?
Interim DOAC- apixaban or rivaroxaban
CTPA
333
Wells score in PE <4?
D-dimer, age adjusted if >50 years
Positive CTPA and interim anticoagulation
334
PE in cancer patients use?
DOAC
335
PE with eGFR <15?
Warfarin
336
PE in antiphospholipid syndrome?
Warfarin
337
Score to help decide if PE can be managed as OP?
- Pulmonary Embolism Severity Index (PESI)
338
Provoked PE treat for?
3 months
339
Unprovoked PE treat for?
6 months
340
PE with haemodynamic instability?
Thrombolysis
341
What is pulsus paradoxus and what causes it?
Drop of >10 in BP on inspiration seen in severe asthma and cardiac tamponade
342
Slow rising pulse seen in?
AS
343
Collapsing pulse seen in?
AR
PDA
Hyperkinetic states
344
What is pulsus alternans and what is it seen in?
Alternating force of pulses seen in severe LVF
345
What is bisfreriens pulse and what causes it?
Double pulse with two systolic peaks in mixed aortic valve disease
346
Jerky pulse seen in?
HOCM
347
Investigations for cardiomyopathy?
ECHO
then cardiac MRI
348
Restrictive cardiomyopathy causes what kind of dysfunction?
Systolic
349
Causes of restrictive cardiomyopathy?
Inherited
Infiltrative- amyloidosis, sarcoidosis
Post radiotherapy
Loeffler's endocarditis- eosinophillic infiltration
350
What bacteria causes rheumatic fever?
Strep pyogenes
Group A beta-haemolytic strep
351
What is rheumatic fever?
Pharyngitis with strep pyogenes 2-4 weeks post infection developing antibodies against valves
352
What type of hypersensitivity reaction in rheumatic fever?
Type II with autoantibodies M protein cross reacting with myosin
353
What are the granulomatous nodules in rheumatic fever called?
Aschoff bodies
354
Diagnosis of rheumatic fever based on?
Jones criteria
Recent evidence of strep infection
+ 2 major
+ 1 major 2 minor
355
What is evidence of recent strep infection for rheumatic fever?
Throat swab
Rising ASOT >200
DNase B titre
356
Major Jones criteria for rheumatic fever?
Polyarthritis
Sydenham's chorea
Erythema marginatum
SC nodules
Carditis
357
What does erythema marginatum look like in rheumatic fever?
Geographical rash with clear centre
358
What is in the minor criteria for Jones Rheumatic fever?
High ESR/CRP
Pyrexia
Arthralgia
Prolonged PR
359
Management of rheumatic fever?
IV benpen, then 10 days phenoxymethylpenicillin
NSAID
360
Rheumatic fever causes which valve disease most commonly?
MR
361
When do you suspect Takosubo cardiomyopathy?
Troponin +ve chest pain with ST elevation and normal angiogram
362
Why does tetralogy of fallot occur?
Anterior malalignment of the aorticopulmonary septum
363
4 parts of tetralogy of fallot?
VSD
RVH
PS
Overriding aorta
364
Presentation of tetralogy of fallot?
1-2 months tet spells with cyanosis during crying
Ejection systolic murmur of PS
365
CXR in tetralogy of fallot?
Boot shaped heart
366
TdP is?
Polymorphic VT due to QT prolongation
367
What can TdP lead to?
VF and cardiac arrest
368
Management of TdP?
Haemodynamically unstable- DC cardioversion
Stable 2mg IV Mg sulphate over 1-2 minutes
369
Causes of tricuspid regurgitation?
R ventricular infarction
Pulmonary HTN
Rheumatic heart disease
IE (IVDU)
Ebsteins anomaly
Carcinoid
370
What is ebstein's anomaly?
Structurally abnormal tricuspid valve causing regurgitation, young person with R sided HF
371
Turners syndrome is associated with?
Bicuspid aortic valve
Coarctation of the aorta
372
WPW is associated with?
HOCM
MVP
Ebstein's anomaly
Thyrotoxicosis
secundum ASD
373
ECG findings in WPW?
Short PR
Delta wave
Broad QRS
LAD - right sided pathway (Type B)
RAD- left sided pathway (Type A)
374
Which axis deviation is most common in WPW?
LAD in Type B more common
375
Management of paroxysmal SVT in WPW?
Amiodarone
Flecanide
Sotalol (never in AF risk of VF)
Radiofrequency ablation
376
What not to give in WPW?
Anything that blocks AVN
Digoxin
Verapamil
Diltiazem
377
Multifocal atrial tachycardia seen in and cause?
Autonomous atrial cells causing irregular narrow complex tachycardia associated with COPD
378
L sided HF?
Pulmonary congestion
379
R sided HF?
peripheral oedema
380
Indications for CABG?
- Symptoms not controlled by optimal medical management
- Complex 3 vessel disease and/or significant left main stem in CTCA
381
Complications of cardiac catheterisation?
1. Bleeding- more common in femoral access
2. Arterial thrombus
3. Arrhythmia
4. Perforation of great vessels causing tamponade
5. Allergic reaction
6. Atheroemboli (cholesterol emboli) causing renal failure, eosinophilia, livido rectularis, purpura
382
Mother with SLE infant at risk of?
Complete heart block in anti Ro and anti la
383
Order of investigations if PE suspicion in pregnancy?
CXR
USS dopplers
If both negative CTPA/ V/Q scan
384
If on warfarin and going for PCI?
Continue warfarin and DAPT
385
When do you consider PCI in stable angina?
Ischaemia L ventricle >10%
386
Contraindication to ivabradine?
Bradycardia
387
Signs of posterior MI?
Horizontal St depression in V1-3
Tall R waves in V1-3
388
Inverted P wave in lead 1, RAD and loss of R wave progression ECG means?
Dextrocardia
389
Monitoring of U+E after commencing ACEi?
Tolerate up to 30% increase in creatinine
and repeat 1-2 weeks
>30% rise stop ACEi
390
Complication of Kawasaki disease?
Coronary artery aneurysm
391
Management of Kawasaki disease?
High dose aspirin
IV immunoglobulins
392
What cant you give in heart transplant?
Atropine
393
What to give instead of atropine in heart transplant?
Theophylline IV
394
Causes of pericardial calcification?
Repeated pericarditis e.g., by uraemia
395
What is prinzmental angina?
Coronary artery spasms with transient ST elevation, pain and resolves
396
Management of prinzmental angina?
CCB, nitrate, nicrorandil
397
What is an amniotic air embolus?
Fetal cells or amniotic fluid in maternal circulation causing hypotension, bronchospasm, MI and DIC
398
Thrombolysis regimen for STEMI unable to get PCI within time frame?
Ticagrelor + fondaparinux + tenecteplase
399
Drugs to avoid in WPW?
ABCD
Adenosine
BB
CCB
Digoxin
400
Lown-Ganong-Levine syndrome ECG?
Short PR and Normal QRS
401
When can you use the BB pill in the pocket approach?
No Hx of LV dysfunction, valve disease, IHD
Infrequent episodes
BP sys >100, HR >70
Understands when to take
402
When do you intervene with Mitral valve disease?
LV dysfunction
Pulmonary HTN
New AF
Dilated L ventricle
403
Gram +ve cocci in clusters?
Staph aureus
404
Management of pulmonary oedema not responding to diuretics?
CPAP
405
Treatment of refractory VT if not responsive to amiodarone loading and maintenance?
IV lidocaine
406
Resistant HTN with hypoK and high bicarbonate?
Conn's syndrome
407
How to work of MS from capillary wedge pressure and BP L venticle?
CWP - diastolic LV pressure >5 = MS
408
Imaging for myocarditis?
Cardiac MRI
409
Pacemaker for sick sinus syndrome?
AAIR
410
Signs of severe MS?
Pulmonary HTN
R sided HF
Soft S1
