Cardiology

Question 1

What ECG changes are found in LV aneurysm?

Answer 1

Persistent ST elevation >2 weeks post-STEMI

Question 2

What causes the 4th heart sound?

Answer 2

Contraction of the atria into a stiff, hypertrophied ventricle.

It is always abnormal: heart failure, MI, cardiomyopathy, HTN (pressure overload)

Le-lub-dub

Question 3

What causes the 3rd heart sound?

Answer 3

Can be physiological in children and young adults.

Cause is rapid ventricular filling in early diastole. Stiff or dilated ventricle reaches elastic limit and decelerates incoming rush of blood.

• HF, MI, Cardiomyopathy, HTN
• Mitral or aortic regurgitation: volume overload
  constrictive pericarditis

lub-de-dub

Question 4

4 stages of clubbing

Answer 4

Stage 1 - increase fluctuancy
Stage 2 - Loss of angle
Stage 3 - Increase curvature
Stage 4 - Expansion of terminal phalanx

Question 5

How can you distinguish AF from multiple ventricular ectopics?

Answer 5

Both cause an irregularly irregular pulse.

Perform an exercise test as exertion causes ectopics to reduce and disappear. Ventricular ectopics occur in diastole, exertion reduces time for diastole thus reducing ventricular ectopic ‘window of opportunity’

Question 6

What is the pulse deficit in AF?

Answer 6

Due to fast ventricular response in AF there can be sometimes insufficient diastolic filling time to create cardiac output.

This results in there being no palpable distal pulse but heart sounds can still heard at the apex.

Question 7

How would you asses whether AF is well controlled?

Answer 7

Time apical rate with a stethoscope.

Question 8

What causes the tapping apex beat in mitral stenosis?

Answer 8

Systole slams shut stenosed mitral valve

LUB-de-Derr = loud S1 + low-pitched, rumbling, mid-diastolic murmur

Question 9

What cardiac abnormality is visible on CXR in mitral stenosis and how is it caused?

Answer 9

Prominent LA.

Mitral stenosis leads to back pressure in the LA. This causes LA dilatation.

This dilatation also is the cause of the increased risk of AF and the development of emboli.

Question 10

What indicates the degree of severity of mitral regurgitation?

Answer 10

Degree of apical displacement

‘burrrr’

Question 11

Bornholme disease

Answer 11

Viral-induced costochondritis

Pain made worse by gently pressing on chest.

Question 12

Commonest murmur in Marfan syndrome?

Answer 12

Mid-systolic click with a late systolic murmur

Mitral valve prolapse occurs in 75%

Question 13

Criteria for diagnosing Rheumatic Fever

Answer 13

Jones criteria:

Evidence of recent Streptococcal infection + 2 major or 1 major & 2 minor criteria

Major: CASES

• Carditis
• Arthritis (migratory)
• Subcutaneous nodules
• Erythema marginatum
• Sydenham’s chorea

Minor:

• Fever
• Raised ESR/CRP
• Arthralgia
• prolonged PR
• previous rheumatic fever

Question 14

Indications for CABG

Answer 14

Multiple complex narrowings

• 3 vessel disease
• LMS stenosis >50%
• proximal LAD or LCx >70%

DM or young patients
- stenting is unsuitable.

Question 15

How do you distinguish between a JVP and a carotid pulse?

Answer 15

JVP:

• double wave form
• impalpable; disappears on compression
• decreased by inspiration
• increased by hepatojugular reflex and lying supine

Question 16

Indication for giving patients with aortic stenosis a valve repair

Answer 16

1) Symptomatic

2) Asymptomatic + valvular gradient >50mmHg with evidence of LVF e.g. EF

Question 17

TAVI = ?

Answer 17

Transcatheter Aortic Valve implantation.

Percutaneous endovascular valve replacement: transfemoral, transapical, transaortic, transcaval.

Question 18

Prognosis of SOB, angina and syncope in AS?

Answer 18

Angina - 50% in 5 years
Syncope - 50% in 3 years
Dyspnoea - 50% in 2 years

Question 19

Causes of mitral regurgitation

Answer 19

Acute

1) Valvular
- bacterial endocarditis
2) Chordae/papillae
- Rupture

Chronic

1) Valvular
- Rheumatic heart disease
- MVP: CTD (Marfan’s, Ehlers-Danlos)

2) Functional
- LV dilatation

3) Chordae/papillae
- Infiltration (Amyloidosis)
- Fibrosis (post-MI//trauma)

Question 20

What is the sign of LV strain found on ECG in patients with aortic regurgitation?

Answer 20

Lateral TWI

Question 21

How do you reduce the afterload in patients with AR or MR

Answer 21

Give ACEi/B blockers + Diuretics

Question 22

Indications for valve replacement in aortic regurgitation?

Answer 22

1) Symptomatic with NYHA >2

2) LV dysfunction
- wide pulse pressure > 100mmHg
- ECG : lateral TWI
- CXR = LV enlargement OR Echo = EF 50mm

Question 23

What is the contraindication for percutaneous balloon valvuloplasty in mitral stenosis?

Answer 23

LA mural thrombus.

Mitral valve must also be pliable and minimally calcified.

Question 24

Mid-systolic click and late systolic murmur =

Answer 24

Mitral valve prolapse

aka Barlow syndrome

Question 25

Low-pitched mid-diastolic rumble at the apex

Answer 25

Austin-Flint murmur

Aortic regurgitation → mitral valve disturbance

Question 26

High pitched early diastolic murmur at ULSE, loudest during inspiration

Answer 26

Graham-Steell murmur, due to pulmonary HTN

Question 27

JVP morphology in AF

Answer 27

absent ‘a waves’

Question 28

JVP morphology in complete heart block

Answer 28

Cannon ‘a waves’

Question 29

3 diagnostic criteria of Prinzmetal angina

Answer 29

Prinzmetal = variable = vasospastic angina

1) Nitrate-responsive angina
2) Transient ischaemic ECG changes
3) Angiographic evidence of coronary artery spasm (>90% on provocation testing)

Question 30

Classic finding of constrictive pericarditis

Answer 30

Kussmaul’s sign

Paradoxical increase in JVP during inspiration