Cardiology

Question 1

Target of blood pressure

Answer 1

People with proteinuria >1 g/day, (with or without diabetes) < 125/75mmHg People with associated condition/s: 130/80 mmHg or end-organ damage:* • Coronary heart disease • Diabetes • Chronic kidney disease • Proteinuria (> 300 mg/day) • Stroke/TIA People with none of the following: 140/90 mmHg or lower if tolerated • Coronary heart disease • Diabetes • Chronic kidney disease • Proteinuria (> 300 mg/day) • Stroke/TIA

Question 2

Pansystolic murmur

Answer 2

mitral regurgitation, tricuspid regurgitation, ventricular septal defect,

Question 3

Midsystolic murmur

Answer 3

Aortic stenosis, pulmonary stenosis, hypertrophic cardiomyopathy, pulmonary flow murmur of an atrial septal defect

Question 4

Late systolic

Answer 4

mitral valve prolapse, Papillary muscle dysfunction

Question 5

early diastolic

Answer 5

aortic regurgitaiton, pulmonary regurgitation

Question 6

Mid diastolic

Answer 6

mitral stenosis, tricuspid stenosis, atrial myxoma, austin flint murmur of aortic regurgitaion

Question 7

presystolic

Answer 7

Mitral stenosis, tricuspid stenosis, atrial myxoma

Question 8

differenciation of ulcers

Answer 8

Venous ulcer:around malleoli,associated with pigmentation, stasis eczema, an irregular margin, pale surrounding neo-epithelium, and a pink base of granulation tissue, skin is warm and oedema is often present Arterial ulcer: a regular margin and ‘punched out’ appearance. the surrounding skin is cold. the peripheral pulses are absent in large artery disease, samll vessel disease (eg. leucocytoclastic vasculitis, palpable purpura) Diabetic ( neuropathic) ulcer: are painless penetrating ulcer on sole of foot, and are associated with reduced sensation in the surrounding skin underling systemic disease: diabetes mellitus: vascular disease, neuropathy or necrobiosis lipoidica(front of leg), pyoderma gangrenosum, rheumatoid arthritis, lymphoma, haemolytic anaemia (samll ulcers over malleoli, e.g. sicle cell anaemia)

Question 9

Collapsing pulse

Answer 9

aortic regurgitaiton, hyperdynamic circulation, arteriosclerotic aorta, peripheral arteriovenous fistula, patent ductus arteriosus

Question 10

indications for surgery for aortic regurgitation

Answer 10

1. Symptoms - dyspnoea on exertion 2. Worseing left ventricular function, such as low ejection fraction, 3. progressive left ventricular dilatation on serial echocardiograms: left ventricular end-systolic dimension of 5.5 cm

Question 11

indications for surgery for mitral regurgitation

Answer 11

1. NYHA class III and IV 2. left ventricular dysfunction, LVEF 45mm .4 in acute mitral regurgitation, operate if there is haemodynamic collapse 5. repair of a prolapsing posterior and often anterior leaflet is now undertaken earlier than valve replacement

Question 12

Cholesterol target guidelines

Answer 12

LDL < 4.0 HDL > 1.0 Triglycrides <1.5

Question 13

Treatment of aortic regurgitation

Answer 13

Valve replacement • 55 rule – before LVEDD > 55mm or LVEF <55% • Acute AR • Symptomatic with chronic severe AR Vasodilator therapy (nifedipine) delays need for AVR (if no LVF) Beta blockers contraindicated as prolong diastole and increase regurg fraction

Question 14

common causes and association of AF:

Answer 14

advanced age (3% of 65 years old, >6% of people in their 80s hypertension mitral valve diseae ischaemic heart disease and myocardial infarction recent thoracic or abdominal surgery atrial septal defect wolff- Parkinson-white syndrome recent alcoholic binge pulmonary embolism thyrotoxicosis

Question 15

findings suggestive of VT

Answer 15

QRS > 0.14secnds (if RBBB) or >0.16 seconds(if a LBBB) left axis deviation Atroventricular dissociation change from the pre-existing QRS morphology in pre-existing bundle branch block capture/fusion beats, BROAD COMPLEX TACHYCARDIA in a patient with ischemic heart disease is usually VT (95%)

Question 16

Drugs that cause QT Prolongation

Answer 16

•clarithromycin •erythromycin •metaclopramide •haloperidol •TCA •methadone •droperidol

Question 17

what electrolytes disturbance cause VT

Answer 17

•hypokalaemia •hyperkalaemia •hypomagnesaemia •hypocalcaemia

Question 18

Diagnostic Criteria for LAFB

Answer 18

•Small Q waves with tall R waves (= ‘qR complexes’) in leads I and aVL •Small R waves with deep S waves (= ‘rS complexes’) in leads II, III, aVF left axis deviation

Question 19

Diagnostic Criteria for LPFB

Answer 19

Right axis deviation (> +90 degrees)
Small R waves with deep S waves (= ‘rS complexes’) in leads I and aVL
Small Q waves with tall R waves (= ‘qR complexes’) in leads II, III and aVF

Question 20

indication for Dual-chamber pacemakers

Answer 20

treat symptomatic bradycardia in people with sick sinus syndrome, atrioventricular block, or both

sick sinus syndrome + flow of electrical impulses between the upper and lower chambers of the patient’s heart is normal = use a single-chamber pacemaker,should be attached to the upper chamber of the heart

atrioventricular block + atrial fibrillation=should use a single-chamber pacemaker and attached to the lower chamber of the heart

Question 21

indications for permanent pacemaker insertion

Answer 21

1. intermittent or permanent complete heart block, with
   a. symptomatic bradycardia
   b. cardiac failure
   c. arrythmias that require treatment with drugs that slow conduction
   d. documented asystole of more than 3 seconds or escape rhythm with a rate <40 beats/min
   e. confusional states that improve with temporary pacing
2. intermittent second degree AV block with symptomatic bradycardia
3. sinus node dysfunction with symptomatic bradycardia

less certain indicaitons:

1. asymptomatic complete heart block with HR >40 beats
2. symptomatic type 2 second degree heart block
3. bifascicular or trifascicular block with syncope of unknown aetiology

Question 22

indications for cardiac resynch therapy

Question 23

indication for implantable cardiac defibrillator?

Question 24

Causes of secondary hypercholesteroleami

Answer 24

Nephrotic syndrome

obstructive jaundice

hypothyroidism

cushing syndorme

Thiazide diuretics

cyclosporin

anorexia nervosa

Question 25

modified cardiovascular risk factors?

Answer 25

**_Inactivity:_** Raise HDL and may slightly lower LDL in proportion to the duration spent exercising – Improve glycaemic control (and prevent development of diabetes) – Lower blood pressure (as much an ACEi) – Treat moderate depression (as well as an SSRI) – Reduce Falls – Assist weight loss **_• Elevated cholesterol_** High Cholesterol – Testing • ATP-III (by NCEP)Guidelines: – Test Every 5 years in individuals aged 20 & over – Test more often in those with 1 or more other risk factors for CVD NHF Guidelines (2005) post ACS: – Total Chol \< 4.0 – LDL \< 2.0 – Triglycerides \< 1.5 Lipid Targets – No IHD • Every 1.0 mmol reduction in LDL = 22% reduction in mortality • A 10% reduction in total cholesterol confers an 11% relative reduction in all cause mortality **_• Smoking_** • Poor glycaemic control (diabetes) • Obesity **_• Hypertension_** Salt restriction to \< 4g/day will produce a BP drop of: – 4 – 5 mmHg in hypertensive patients – 2mmHg in normotensive patients Increased dietary potassium intake – Can lower BP by 4 – 8mmHg in hypertensive – Can lower BP by 2mmHg in normotensive – Obviously not in renal impaired HTN – Dietary Measures • Reduce alcohol intake • Reduce caffeine intake • Stop smoking HTN –Weight loss • Every 1% Reduction in weight results in a 1mmHg drop in BP HTN - Exercise • Aerobic exercise will reduce BP – By ~6.9mmHg in hypertensive people – By 1.9mmHg in normotensive people Choice of Antihypertensive • In absence of other comborbities: – If under 55: ACEi or ARB – If over 55: Calcium Channel Blocker Exclude secondary cause if resistant

Question 26

If has HTN & Orthostatic Hypotension •

Answer 26

Consider role of: – Alpha-blockers – Autonomic neuropathy – Dehydration – Nocturnal hypertension (often with nocturia) • Less likely with beta-blockers • Less likely with ACEi

Question 27

No Driving Periods:

Answer 27

After AMI – 2 weeks private vehicle – 4 weeks commercial vehicle • After (elective) PCI – 2 days private vehicle – 4 weeks commercial vehicle • After CABG – 4 weeks private vehicle – 3 months commercial vehicle Cardiac Arrest: – 6 months • ICD 􀃆 Cannot hold commercial licence – 2 weeks after Generator change – 4 weeks after AICD therapy required for symptoms • PPM – 2 weeks for private licence – 4 weeks for commercial licence Heart / Lung Transplant – 6 weeks private licence – 3 months commercial licence • PE – 6 weeks whatever the licence • Cardiovascular Syncope (not triggered vasovagal) – 4 weeks private licence – 3 months commercial licence Undiagnosed syncope – If one or more episode in 24 hours – 6 months • 5 years for commercial – If 2 or more episodes more than 24 hours apart – 12 months • 10 years for commercial