Cardiology 3

Question 1

When treating a diabetic patient with hypertension, which combinations of anti-hypertensives should be avoided if possible?

Answer 1

thiazides and BB as can cause insulin resistance

Question 2

Thiazides can cause which electrolyte abnormalities (3)
Adverse effects (3)

Answer 2

low K and Na
High calcium

gout, impaired glucose intolerance, impotence

Question 3

Heart failure with reduced ejection fraction is defined as an ejection fraction below?

Answer 3

40%

Question 4

Which PPI interacts with clopi?
Clopi MOA

Answer 4

Omeprazole - makes it less effective
Anti-platelet

Question 5

Bioprosthetic versus mechanical valves
Anticoagulation for prosthetic
How is each option chosen?
Anticoagulation for mechanical aortic and mitral

Answer 5

Prosthetic - warfarin for first three months, otherwise aspirin long term
Given in >65yo aortic or >70 for mitral
Mechanical - warfarin aortic 3, mitral 3.5

Question 6

Heart block
1st degree
Mobitz type 1
Mobitz type 2
Third degree

Answer 6

1st degree - prolonged PR >0.2
Mobitz type 1 increasingly prolonged PR then a dropped QRS
Mobitz type 2 PR interval is constant but the P wave is often not followed by a QRS complex
Third degree no association between P and QRS

Question 7

Major bleeding
Minor bleeding + INR >8
No bleeding INR >8
Minor bleeding INR 5-8
No bleeding INR 5-8

Answer 7

Stop warfarin, IV vit K 5mg
Prothrombin complex concentrate - if not available then FFP*

Stop warfarin
Give IV vit K 1-3mg
Repeat dose of IV vit K if INR still too high after 24 hrs
Restart warfarin when INR < 5.0

Stop warfarin
Give PO vit K 1-5mg by mouth
Repeat dose of vitamin K if INR still too high after 24hrs Restart when INR < 5.0

Stop warfarin
Give IV vit K 1-3mg
Restart when INR < 5.0

Withhold 1 or 2 doses of warfarin
Reduce subsequent maintenance dose

Question 8

What are the below scoring systems used for?
ABCD2
DAS28
Child Pugh
SCOFF
Epworth
IPSS
Waterlow
FRAX
Ranson
MUST

Answer 8

TIA
RA severity
Liver cirrhosis
Eating disorders
Sleep apnoea
Prostate symptoms score
Pressure sores
10 year risk of developing osteoporotic fracture
Acute pancreatitis
Malnutrition

Question 9

Brugada syndrome
AD/AR
Common in which demographic?
Mutation in which gene?
ECG changes (3)

Ix of choice

Mx

Answer 9

Autosomal dominant
Asians
SCN5A gene

Convex ST segment elevation
Negative T waves V1-V3
RBB

Administration of flecainide or ajmaline - more apparent ECG changes following this

Mx ICD

Question 10

What is Buerger’s diease?
Strongly associated with?

Features (5)

Answer 10

Small to medium vessel vasculitis
Smoking

Extremity ischaemia
Intermittent claudication
Ischaemic ulcers
Superficial thrombophlebitis
Raynaud’s phenomenon

Question 11

Beck’s triad (3)
Found in which condition?

Answer 11

hypotension
raised JVP
muffled heart sounds

cardiac tamponade

Question 12

Cardiac tamponade
ECG findings

Mx

Answer 12

ECG: electrical alternans

Mx urgent pericardiocentesis

Question 13

When can one use dabigatran?

Answer 13

Non valvular AF with at least one of:
prev stroke/ TIA/ systemic embolism
LVEF <40% or NYHA class 2 or above
75yo >=
65yo >= with DM, CAD, HTN

VTE prophylaxis post knee or hip replacement surgery

Question 14

Normal variants ECG in an athlete (4)

Answer 14

sinus bradycardia
junctional rhythm
first degree heart block
Mobitz type 1 (Wenckebach phenomenon)

Question 15

multiple red/yellow vesicles on the extensor surfaces

Answer 15

Eruptive xanthoma

Question 16

Ix for palpitations

1st line (4) (including three sets of bloods)
2nd line (1)
3rd line (2)

Answer 16

ECG
TFT
FBC
U+E

2nd line 24 hour Holter

3rd line external loop recorder
implantable loop recorder

Question 17

MI secondary prevention meds (4)

Answer 17

dual antiplatelet therapy (aspirin plus ticagrelor OR prasugrel)
ACE inhibitor
beta-blocker
statin

Question 18

Pts who have sx of acute heart failure following an MI should be treated with?
How many days post MI should this treatment be started?

Answer 18

aldosterone antagonist - eplerenone should be initiated within 3-14 days of the MI

Question 19

Coarctation associations (4)

Answer 19

Turner’s syndrome
Bicuspid aortic valve
Berry aneurysms
Neurofibromatosis

Question 20

Coarctation signs
Infancy:
Adults: (2)
Pulse
Murmur
Sound

Answer 20

infancy: heart failure
adult: hypertension, notching of the inferior border of the ribs
radio-femoral delay
mid systolic murmur, maximal over back
apical click from the aortic valve

Question 21

HOCM
Features - can give hint

Answer 21

MR SAM ASH
mitral regurg, systolic anterior motion, asymmetric hypertrophy

Question 22

HOCM
ECG findings (3)

Answer 22

left ventricular hypertrophy
deep q waves
+/- AF

Question 23

HOCM
Murmur type
Increases with?
Decreases with?

Answer 23

Ejection systolic murmur
Increases with Valsalva manoeuvre
Decreases on squatting

Question 24

jerky pulse, large ‘a’ waves, double apex beat = ?

Answer 24

HOCM

Question 25

SVT management (3) CI for 2nd line tx, alternative choice Prevention (2)

Answer 25

1. vagal manoeuvres e.g valsalva and carotid sinus massage 2. adenosine 6mg, then 12mg, then 18mg 3. electrical cardioversion asthmatics - verapamil BB or ablation

Question 26

WPW ECG (3) right sided accessory pathway gives left sided accessory pathways gives

Answer 26

short PR interval wide QRS complexes slurred upstroke - 'delta wave' left axis deviation if right-sided accessory pathway* right axis deviation if left-sided accessory pathway*

Question 27

Type A WPW Type B WPW Most common type?

Answer 27

Left sided pathway i.e RAD - dominant R wave Right sided pathway i.e LAD - no dominant R wave LAD (type B)

Question 28

WPW associations (3)

Answer 28

HOCM mitral valve prolapse thyrotoxicosis

Question 29

WPW mx (2)

Answer 29

ablation of accessory pathway or medical mx with sotalol, amiodarone or flecainide

Question 30

Sharp pain relieved by sitting forwards, can be pleuritic?

Answer 30

Pericarditis

Question 31

What is Boerhaaves syndrome? Diagnostic Ix Mx

Answer 31

Spontaneous rupture of the oesophagus that occurs as a result of repeated episodes of vomiting. CT contrast swallow Thoracotomy and lavage if <12 hours

Question 32

Advice given to those who develop tolerance to ISMN?

Answer 32

Take the second dose after 8 hours instead of 12

Question 33

Warfarin INR target VTE recurrent VTE AF SE (4)

Answer 33

2.5 3.5 2.5 SE purple toes, skin necrosis, teratogenic, bleeding

Question 34

Examples of thrombolytic drugs (2) CI (8)

Answer 34

alteplase, streptokinase Active bleeding Recent haemorrhage or surgery Bleeding disorders Intracranial neoplasm Stroke <3 months prior Aortic dissection Recent head injury Severe HTN

Question 35

What is Takayasu's arteritis?

Answer 35

Large vessel vasculitis

Question 36

Name some features of Takayasu's arteritis (6) Hints: Age, gender, ethnicity x2 non specific Impact on BP Pulse Murmur Associated with which condition? Mx

Answer 36

Young female Asians - malaise, headache - unequal BP in upper limbs - carotid bruit and tenderness - weak peripheral pulses - upper and lower limb claudication on exertion - AR RAS Steroids

Question 37

When would you consider treating a patient with stage 1 hypertension?

Answer 37

aged under 60

Question 38

ORBIT score (5) Use Risk group

Answer 38

Use instead of HASBLED Hb <130 M <120 F 2 Age >74 1 eGFR <60 1 Prev hx of bleeding 2 On antiplatelets 1 2 or less low risk 3 medium risk 4 or more high risk