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Cardiology Flashcards

1
Q

What is unstable angina?

A

Chest pain which occurs at rest and is >10 mins duration
Severe and new onset
Crescendo pattern: episodes are worse than those previously

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2
Q

What is hypertrophic cardiomyopathy?

A

Due to mutations (inherited or spontaneous) in genes encoding myocyte contractile filament proteins
Ventricular hyper trophy with systolic dysfunction
Cause of sudden death in young people

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3
Q

What is rheumatic heart disease?

A

Results from acute rheumatic fever often precipitated by strep pyogenes
Streptococcal antigens cross react with myocardial antigens, resulting in an autoimmune response against heart valves, most often mitral and aortic valves

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4
Q

What is dilated cardiomyopathy?

A

Dilation of all 4 chambers of the heart and thinning of ventricle wall
Caused by: viral infections, endocrine disease, chronic alcohol use, severe protein malnutrition

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5
Q

What is pancarditis?

A

Triad of endocarditis, myocarditis and pericarditis

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6
Q

A 24 year old man has been admitted to a surgical ward for treatment of an abscess on his back. He is due to for theatre tomorrow and his pre operative ECG shows ST elevation. What is the most appropriate management of this patient?

A

Organise ECHO as an outpatient

Changes are that of an athletic heart with mild ST elevation and prominent T waves

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7
Q

What is Wolff Parkinson white syndrome?

A

Abnormal accessory electrical conduction pathway between atria and ventricles called bundle of Kent
This may stimulate ventricles to contract prematurely, resulting in supraventricular tachycardia

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8
Q

What prophylaxis should be given for DVT?

A

Once daily low molecular weight heparin

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9
Q

How is DVT most reliably diagnosed?

A

Venography

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10
Q

In what proportion of patients is DVT clinically apparent?

A

70% of cases

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11
Q

Which organs can cause central chest pain?

A 
Heart
Lungs 
Thoracic wall
Great vessels
Stomach
Pancreas
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12
Q

What are the cardiac causes of central chest pain?

A 
Acute coronary syndrome
Myocardial infarction 
Pericarditis 
Arrhythmias 
Cardiac failure 
Dissection
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13
Q

What features of a history would support a theory of a cardiac cause for central chest pain?

A

Central / L-sided
Sudden, on exertion
Crushing, heaviness, sharp
Classically into L arm/neck, may be none
Sweating, SOB, fever, palpitations, associated risk factors
Constant, worsening, periodic on exertion or at rest
Exacerbating: exertion (MI), inspiration/lying flat (Pericarditis)
Alleviating: GTN (MI), leaning forward (Pericarditis)
Severity – 0 -10

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14
Q

For cardiac causes of central chest pain, what would you look for on examination?

A

Around the bed: GTN spray
End of the bed: comfortable/uncomfortable, sweating
Pulse: regular/irregular, character, rate
BP: may be high if in pain, worrying if low
JVP: may be raised if constrictive pericarditis or cardiac
tamponade
Cardiac examination: may be normal (MI, ACS); pericardial friction rub (Pericarditis); Evidence of valvular disease (Arrhythmias)
Peripheral oedema

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15
Q

What would expect in history/examination of a patient with aortic dissection?

A

History: very acute, sharp, tearing, radiating into the back, associated with hemiplegia/paraplegia or acute limb ischaemia as dissection progresses
Examination: Unequal pulses/BP between arms, may be hemiplegia / paraplegia

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16
Q

What are the respiratory causes of central chest pain?

A

Pneumonia
Pneumothorax
PE

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17
Q

What factors in the history would make you suspect a respiratory cause of central chest pain?

A

Central or L/R sided
Sudden (PE/Pneumothorax), gradual (Pneumonia)
Sharp
SOB, fever, cough (productive/non-productive), haemoptysis, associated risk factors
Constant (PE/Pneumothorax) or intermittent
Exacerbating: inspiration, coughing
Severity – 0 -10

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18
Q

What might you expect to find on examination for a respiratory cause of central chest pain?

A

Around the bed: sputum pot, inhalers
End of the bed: comfortable/ uncomfortable, visibly short of breath
Hands: cyanosis
BP: worrying if low
Mouth: cyanosis
Chest: Pneumonia – bronchial breathing, creps, dull percussion note (assoc effusion), use of accessory muscles
- Pneumothorax – deviated trachea, absent breath sounds,
hyperresonant percussion note
- PE – may be normal apart from raised respiratory rate

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19
Q

What are thoracic wall causes for central chest pain?

A

Costochondritis
Rib fractures
Herpes zoster

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20
Q

What features in a history and examination would make you suspect Costochondritis as a cause of chest pain?

A

Usually L or R sided, sharp, worse on inspiration, may have recently had cough/pneumonia
Evidence of pneumonia, chest pain is reproducible on palpation, usually at costosternal junction

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21
Q

What features in the history and examination would make you suspect rib fractures as a cause of chest pain?

A

Usually L or R sided, sharp, worse on inspiration, history of trauma
Evidence of trauma elsewhere, overlying bruising or visible flail segment, localised tenderness, significant shortness of breath

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22
Q

What features in the history and examination would make you suspect herpes zoster as a cause for chest pain?

A

Dermatomal pattern, vesicular lesions visible within a single dermatome, may be normal examination

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23
Q

What are some abdominal causes of central chest pain?

A

Perforated peptic ulcer
Pancreatitis
GORD
Cholecystitis

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24
Q

What features from a history and examination would make you think of a ruptured peptic ulcer as a cause of chest pain?

A

Sudden onset, sharp, associated with vomiting/abdominal pain/sweating, risk factors (alcohol excess,previous GORD or ulcer) will look uncomfortable, may be tachycardic and hypotensive, cold peripheries, chest examination may well be normal apart from raised RR, abdominal examination – epigastric tenderness, guarding, rebound

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25
What features in the history and examination would make you suspect pancreatitis as a cause for central chest pain?
Gradual but worsening, dull, radiation to back, associated with vomiting/abdominal pain, risk factors (alcohol excess,previous gallstones or pancreatitis) Look uncomfortable, tachycardic and hypotensive, cold peripheries, chest examination may well be normal apart from raised RR, abdominal examination – epigastric tenderness, guarding, rebound Grey-Turner’s sign or Cullen’s sign
26
What features in the history and examination would make you suspect GORD as a cause for central chest pain?
Intermittent, burning, radiation into throat, associated with certain foods, may be worse on lying flat Examination will be largely normal
27
What is buergers test?
Assesses arterial circulation of lower limb Raise patients leg and observe angle at which there is blanching. After one minute, lower legs so dependent with feet on floor If reactive hyperaemia is observed - arterial insufficiency present
28
How do you differentiate between an anterior MI and pericarditis on an ECG?
Anterior MI: convex, upwards, gravestone sign ST elevation in leads V1-5 Pericarditis: concave, downwards ST elevation
29
What would a posterior MI look like on an ECG?
Dominant R wave in lead V1 and posterior leads V5-8 revealing ST elevation
30
What does a PE look like on an ECG?
SI QIII TIII acute cor pulmonale, right heart strain
31
A 55 year old male presents with weight gain and shortness of breath, he has a long history of chronic airway disease. On examination he has a raised JVP with prominent v waves and auscultation of the heart reveals a soft systolic murmur. What is the likely cardiological defect?
Tricuspid regurgitation | Elevated right sided pressures following pulmonary hypertension
32
A 22 year old female presents with a six month history of deteriorating shortness of breath. She has turners syndrome. On examination she has a blood pressure of 162/88 and has a harsh ejection systolic murmur over the aortic and pulmonary areas. What is the likely cardiological defect?
Coarctation of the aorta | Hypertension and ejection systolic murmur
33
A man in his 30s presents with cadiac type chest pain and has had an MI. On further investigation he is found to have familial Hypercholesterolaemia but normal triglycerides. Biochemically what is the underlying abnormality?
Defective LDL receptors
34
What is Flecainide?
Class 1c sodium channel blocker that is used for paroxysmal atrial fibrillation
35
What class of anti arrhythmic is atenolol?
Class II
36
What is Amiodarone?
Class III anti arrhythmic drug that prolongs the action potential by blocking K channels
37
What is digoxin? What is it used for as an anti arrhythmic?
Positive Inotrope that increases vagal activity | Used in atrial fib and flutter
38
What is the mechanism of adenosine as an anti arrhythmic drug?
Causes hyperpolarisation when bound to its receptor therefore decreases the pacemaker potential slope
39
In which patients might a silent MI occur?
Elderly Hypertensive Diabetes
40
What dose of aspirin should be given in an acute MI?
300mg PO immediately reduces mortality
41
What condition typically has a pericardial rub on auscultation?
Pericarditis
42
What could result from inappropriate thrombolysis of pericarditis?
Haemopericardium
43
What are some absolute contraindications for thrombolysis?
Active internal bleeding Suspected aortic dissection Recent head trauma/intracranial neoplasm Previous haemorrhagic stroke at any time Previous ischaemic stroke in the past year Previous allergic reaction to fibrinolytic agent Trauma/surgery within 2 weeks at risk of bleeding
44
What is a gallop rhythm?
Presence of S3 and S4 at a rate making it impossible to accurately distinguish the two
45
What is the acute management for an MI?
``` High flow oxygen 300mg aspirin chewed 5mg IV morphine 300mg clopidogrel GTN spray ```
46
What is the acute management for left ventricular heart failure?
High flow oxygen 2.5-5mg diamorphine IV 40mg furosemide IV Two puffs GTN spray
47
What are the risk factors assessed for in the CHA2DS2 VASc
``` C: congestive heart failure H: hypertension A: age >75 (2) D: diabetes S: stroke or Tia history (2) V: vascular disease history A: age 65-74 S: female ```
48
What are the Ts and Hs which are major contributing factors to pulseless arrest?
``` Hypovolaemia Hypoxia Hydrogen ions (acidosis) Hyper/hypokalaemia Hypoglycaemia Hypothermia Toxins Tamponade Tension pneumothorax Thrombosis Trauma ```
49
What 4 things should be done in the acute management of an MI?
Morphine Oxygen Nitrates Aspirin
50
What is PCI?
Percutaneous coronary intervention Revascularisation technique Non surgical widening of the coronary artery using a balloon catheter. A stent is placed after dilation
51
What is the target door to balloon time in a STEMI patient needing PCI?
90 minutes
52
What drugs are required post PCI procedure?
Dual anti platelet therapy: aspirin and clopidogrel
53
What are possible complications of PCI?
Stent thrombosis: acute MI with high mortality | Restenosis: excessive healing of vessel wall, angina symptoms
54
What are the main contraindications to thrombolysis?
``` Bleeding disorder History of recent haemorrhage Trauma Surgery Acute cerebrovascular event ```
55
What should be given to patients presenting with ACS 12 hours after onset of symptoms where reperfusion therapy is not possible?
Aspirin Clopidogrel Anti thrombin agent: heparin, enoxaparin or fondaparinux
56
What factors determine whether PCI or CABG is used in an MI patient?
PCI: Short, non calcified lesion on straight unbranched artery. Single or 2 vessel disease CABG: longer, calcified lesions in tortuous vessels, involving major bifurcations, chronic occlusions, left anterior descending involvement, patients with diabetes, LV dysfunction or strongly positive exercise test
57
What are possible complications of CABG?
``` MI AKI Ventricular arrhythmia Stroke Low output state requiring supportive measures ```
58
What long term medications should a patient be on after an MI?
Antiplatelet: low dose aspirin, clopidogrel Beta blocker ACE inhibitor Cholesterol lowering agent
59
What are common and rare causes of atrial fibrillation?
``` Mitral valve disease Hypertension Myocardial ischaemia Hyperthyroidism Alcohol Rarer: Endocarditis Constrictive pericarditis Pneumonia ```
60
What investigations are useful for AF?
``` ECG FBC: anaemia can complicate TFTs Echo 24 hour ECG tape U&Es ```
61
If an apex beat is described as heaving, what is the underlying mumur?
Aortic stenosis | Left ventricular hypertrophy
62
If an apex beat is in the sixth intercostal space and is thrusting in nature. What is the underlying murmur?
Aortic regurgitation | Volume overload
63
If an apex beat is described as tapping in nature, what is the underlying murmur?
Mitral stenosis | Opening snap
64
Which drug is considered first line to treat AF with rate control?
B blocker
65
What is the embryological origin of the diaphragm?
Mesoderm of second pharyngeal arch
66
What is the embryological origin of the cardiac muscle?
Splanchnic mesoderm
67
A 35 year old man diagnosed with HTN. He has visible pulsation a suprasternal notch, heaving apex beat and a continuous bruit best heard over back. What pulse abnormality would you expect to feel?
Radio femoral delay | HTN in young with abnormal pulse think of coarctation of aorta
68
A 65 year old female with a tapping apex best, loud first heart sound, opening snap and rumbling mid diastolic murmur best heard medial to apex beat. No pre systolic accentuation of the murmur. What pulse abnormality would you expect to feel?
Irregular pulse she has mitral stenosis Patient is likely to develop AF
69
A 68 year old man with a heaving apex beat, soft single second heart sound and harsh ejection systolic murmur radiating to neck, what pulse abnormality would you expect to find?
Anacrotic He has systolic overload - aortic stenosis or severe systemic HTN. Soft second heart sound and neck radiation suggests AS Character of pulse is small volume and slow rising - anacrotic
70
When does pulsus paradoxus occur?
Severe obstructive airway disease | Decreased venous return to left atrium that normally occurs is exaggerated
71
When does pulsus alternans occur?
Left ventricular failure
72
When do you hear a soft first heart sound?
Mitral regurgitation | Poor apposition of mitral valves prior to systole
73
When would you expect to hear a gallop rhythm with a third heart sound?
Congestive cardiac failure | Stretching of the ventricles during diastolic filling, restriction to the stretch causes a jarring noise
74
What is corrigans sign?
Rapid upstroke and collapse of the carotid pulse associated with a decrescendo diastolic murmur Associated with aortic regurgitation, water hammer pulse best felt in the carotids
75
What is kussmauls sign?
Elevated jvp which rises on inspiration and has a knock on auscultation of the heart Constrictive pericarditis/ pericardial effusion
76
What are some risk factors for atrial fibrillation?
``` COPD IHD/MI Thyrotoxicosis Mitral stenosis Pneumonia PE Sepsis ```
77
What causes an s3 gallop?
Heart failure
78
What are causes of complete heart block?
MI Cardiac operations Rheumatic disease Drugs
79
50 year old female with worsening SOB on exertion and orthopnoea. On examination, tapping apex, loud first heart sound and apical rumbling mid diastolic murmur. What is it?
Mitral stenosis
80
What are common causes of mitral stenosis?
Rheumatic fever Congenital SLE/RA
81
What are some complications of mitral stenosis?
Atrial fibrillation Embolism Infective endocarditis
82
30 year old female with palpitations, SOB on exertion. On examination she has a high arched palate, arm span greater than her height. Soft first heart sound, mid systolic click and apical blowing late systolic murmur radiating to axilla. What is it? And what does she have?
Mitral valve prolapse | Marfans syndrome
83
Name some causes of mitral valve prolapse
``` Connective tissue disorders: Marfans, ehlers danlos DMD Fragile X syndrome Congenital heart disease Ebstein anomaly Ischaemic heart disease ```
84
80 year old man presents with exertional syncope. On examination he has slow rising carotid pulse and loud ejection systolic murmur at the upper right sternal edge, radiating to carotids. What is it?
Aortic stenosis
85
What are some causes of aortic stenosis?
Congenital bicuspid valve Rheumatic fever Senile calcification
86
What is the classical triad of symptoms for aortic stenosis?
Chest pain Heart failure Syncope
87
55 year oral female presets with ankle swelling. On examination, early diastolic murmur at aortic area. Loudest with the patient sitting forward in expiration. What is it?
Aortic regurgitation
88
What are some causes for aortic regurgitation?
``` Rheumatic fever Infective endocarditis Trauma Aortic dissection Marfans Ankylosing spondylitis RA SLE HTN ```
89
An otherwise healthy female of 6 months is found to have a continuous machinery murmur at the upper left apex during routine examination at baby clinic. What is it?
Patent ductus arteriosus
90
What might a child with patent ductus arteriosus have a history of?
``` Premature birth Perinatal distress Born at extreme altitude Failure to thrive Low birth weight ```
91
What can be used to close a patent ductus arteriosus if there are no other heart abnormalities?
Indomethacin
92
On auscultation there is a soft first heart sound, what is this?
Mitral regurgitation: poor apposition of mitral valves prior to systole
93
On auscultation there is a gallop rhythm with a third heart sound. What is this?
Congestive cadiac failure: stretching of the ventricles during diastolic filling being restricted, creating a jarring noise
94
On auscultation there is a loud first heart sound and an opening snap heard in diastole, what is it?
Mitral stenosis: close proximity of tethered valves, high velocity closure of leaflets - loud first heart sound Opening snap - rapid opening of a pliable valve, as it becomes more calcified this may disappear
95
List some causes of atrial fibrillation
``` Thyrotoxicosis Mitral valve disease Congenital heart disease Cardiac surgery Pericarditis Ischaemic heart disease Pulmonary embolism Pneumonia Sepsis Alcohol Excess caffeine Cardiomyopathy Sleep apnoea ```
96
What are the 3 main modifiable risk factors for cardiovascular disease?
Hyperlipidaemia Smoking Hypertension
97
An 84 year old patient is incidentally found to have an ejection systolic murmur loudest over the second right intercostal space. The patient is asymptomatic and an echo reported no pressure gradient across the valve. What is the most likely diagnosis?
Aortic sclerosis
98
An 84 year old patient is incidentally found to have an ejection systolic murmur loudest over the second right intercostal space. The patient is asymptomatic and an echo reported no pressure gradient across the valve. What is the most likely diagnosis?
Aortic sclerosis
99
In a patient newly diagnosed with HTN who is 50 and Caucasian, what is the first line therapy?
ACE inhibitor | Under 55 and Caucasian
100
Name some drugs which may cause Hyperkalaemia as a side effect?
``` ACE inhibitors Heparin Ciclosporin Amiloride Spironolactone Angiotensin II receptor blockers ```
101
Where does the right coronary artery originate?
Right aortic sinus
102
Where does the diagonal artery originate?
Anterior descending artery
103
Where does the right atrioventricular nodal artery originate?
Right coronary artery near its termination
104
Where does the left marginal artery originate?
Circumflex artery
105
Describe the branches of the right coronary artery
60% individuals SA nodal artery Right marginal Posterior descending AV nodal
106
Describe the branches of the left coronary artery
40% individuals SA nodal Left anterior descending, branches to give diagonal Circumflex, branches to give left marginal
107
A 56 year old male with a five year history of HTN attends ED complaining of severe chest pain which radiates to the back. He describes it as tearing in nature. He is tachycardic and hypertensive with a BP of 185/95 and a soft early diastolic murmur. The ECG shows st elevation of 2mm in inferior leads and there is a small left sided pleural effusion on chest X-ray. What is the likely diagnosis?
Aortic dissection | Murmur is aortic regurgitation
108
What examination findings might there be in a patient with pericardial constriction or effusion?
``` Dyspnoea Raised JVP Pulsus paradoxus Pericardial knock Pericardial rub Kussmauls sign ```
109
What is the definition of orthostatic hypotension?
Fall in systolic BP of at least 20mmHg (30 in HTN), or diastolic of 10mmHg within 3 mins of standing
110
How is perfusion rhythm maintained in complete heart block? What happens if this doesn't occur?
Junctional or ventricular escape rhythm | Or ventricular standstill leading to syncope or sudden cardiac death
111
What causes orthopnoea?
Left heart can't cope with increased venous return when recumbent
112
What causes PND?
Inability to cope with increased volume return when recumbent along with interstitial pulmonary oedema leading to increased airway resistance
113
What are the categories of the chads2 VASc score?
``` Congestive heart failure Hypertension Age over 75 Diabetes Stroke Vascular disease Age 65-74 Sex ```
114
How do you manage a haemodynamically stable patient with SMVT? What if they are pulseless?
IV arrhythmic: amiodarone, procaineamide, lidocaine | DC cardio version and CPR
115
What are causes of aortic stenosis?
Bicuspid aortic valve Age related calcification Rheumatic fever
116
What are signs and symptoms of aortic stenosis?
``` Syncope Angina Dyspnoea Slow rising pulse Left ventricular hypertrophy Micro angiopathic haemolytic anaemia Systolic ejection murmur ```
117
What are some causes of aortic regurgitation?
Tertiary syphilis Connective tissue disorders Endocarditis Rheumatic fever
118
What are signs and symptoms of aortic regurgitation?
``` Fatigue Syncope SOB Palpitations Widened pulse pressure Left ventricle dilation S3 heart sound Displaced apex beat Early diastolic murmur ```
119
What are 3 mechanisms for arrythmogenesis?
Accelerated automaticity Triggered activity Re entry
120
What is sick sinus syndrome and what can cause it?
``` Fibrosis of sinus node Idiopathic Ischaemic heart disease Cardiomyopathy Myocarditis ```
121
What are potential side effects of IV adenosine?
``` Bronchospasm Flushing Chest pain Heaviness of limbs Sense of impending doom ```
122
A 68 year old male presents with breathlessness and weight loss. He is a smoker of 10 cigarettes a day. On examination he has a raised JVP, two finger breadth pulsatile hepatomegaly and ankle oedema. What is the likely diagnosis?
Congestive heart failure | Secondary to COPD
123
What heart abnormality is pulsatile hepatomegaly a sign of?
Tricuspid regurgitation
124
A 55 year old male presents with weight gain and SOB. He has a long hx of chronic airway disease. On examination he has a raised jvp with prominent v waves. Auscultation of the heart reveals a soft systolic murmur. What is the likely diagnosis?
Tricuspid regurgitation
125
60 year old man with chest pain, NSTEMI changes on ecg, pulse 66, BP 130/82 and sats 98%. What is the most appropriate immediate management?
``` Aspirin Nitrates Morphine Clopidogrel Calculate GRACE score ```
126
70 year old man with chest pain, STEMI changes on ECG, pulse 102, BP 160/90, sats 93%. What is the most appropriate immediate management?
``` Aspirin Nitrates Morphine Oxygen Prasugrel Arrange immediate percutaneous coronary intervention ```
127
What are absolute contraindications for thrombolysis?
Active internal bleeding Suspected aortic dissection Recent head trauma or intracranial neoplasm Previous haemorrhagic stroke at any point Previous ishchaemic stroke in past year Previous allergic reaction to fibrinolytic agent Trauma or surgery in past 2 weeks at risk of bleeding
128
What are causes of a collapsing pulse?
Aortic regurgitation | Patent ductus arteriosus
129
What can cause an ejection systolic mumur?
``` Aortic stenosis Pulmonary stenosis Hypertrophic obstructive cardiomyopathy Tetralogy of fallot Atrial septal defect ```

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