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Cardiology Flashcards

1
Q

What is the anticoagulant regime for PE?

A

Provoked:

  • LMWH/fondaparinux for at least 5 days or until INR 2.0 (longer)
  • Give Warfarin at the same time, for 3 months

Unprovoked/ those with active cancer:

  • As above
  • Extend Warfarin to 6 months
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2
Q

What would you suspect if there is ST elevation in AvR?

A

Either 3 vessel disease (RCA, LAD, Cirfumflex) or left main stem disease

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3
Q

What would a mid-late diastolic murmur suggest?
When would this murmur be heard best?
What is the gold-standard investigation?

A 
Mitral stenosis (may also hear a loud S1 and opening snap)
Best heard in expiration

Echo

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4
Q

Give 5 causes of AS?

Which is the most common in >65 and <65s?

A 
> 65: Degenerative calcification
< 65: Bicuspid aortic valve
- William's syndrome (supravalvular stenosis)
- Post-rheumatic disease
- Subvalvular: HOCM
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5
Q

What is the Mx of AS?

A

If asymptomatic then normally observe, unless valvular gradient > 40 mmHg and features such as left ventricular systolic dysfunction, then consider surgery.

If symptomatic then valve replacement
If not fit for valve replacement then balloon valvuloplasty

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6
Q

What are the side effects of warfarin?

A
  • Haemorrhage
  • Tetratogenic (although okay if breastfeeding)
  • Skin necrosis (rare, due to temporary procoagulant state (reduced protein C synth) when first started, especially common in patients with protein C or S deficiency) = why heparin given at same time)
  • Purple toes
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7
Q

What is the Mx of a regular broad-complex tachycardia?

A

Assume ventricular tachycardia.

Assess if unstable:

  • Shock: hypotension, pallor, sweating, confusion
  • Syncope
  • Myocardial ischaemia
  • Heart failure

If stable, give loading dose amiodarone followed by 24 hour infusion.

If not, then synchronised DC shocks should be given.

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8
Q

What is the Mx of irregular broad-complex tachycardias?

A

Assess if unstable:

  • Shock: hypotension, pallor, sweating, confusion
  • Syncope
  • Myocardial ischaemia
  • Heart failure

If unstable, then synchronised DC shocks should be given.

If stable:

1: AF with BBB: vagal manoeuvres followed by IV adenosine. If unsuccessful consider diagnosis of atrial flutter and control rate (e.g. Beta-blockers)
2: Polymorphic VT (Torsades) - IV magnesium

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9
Q

What is the management of regular narrow-complex tachycardias?

A

Assess if unstable:

  • Shock: hypotension, pallor, sweating, confusion
  • Syncope
  • Myocardial ischaemia
  • Heart failure

If unstable, then synchronised DC shocks should be given.

If stable:
Vagal manoeuvres followed by IV adenosine. If unsuccessful consider diagnosis of atrial flutter and control rate (e.g. Beta-blockers)

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10
Q

What is the Mx of irregular narrow-complex tachycardia?

A

Assess if unstable:

  • Shock: hypotension, pallor, sweating, confusion
  • Syncope
  • Myocardial ischaemia
  • Heart failure

If unstable, then synchronised DC shocks should be given.

If stable:

  • Probable AF
  • If onset <48 hours then consider electrical or chemical cardioversion
  • Rate control (BB or digoxin) and anticoagulation
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11
Q

What advice should be given regarding driving following PCI?

A

For a private vehicle: Don’t need to tell DVLA, may resume driving after 4 weeks.

For a Bus or Lorry: Patients must notify the DVLA themselves and may not drive for at least 6 week, after which they will be assessed by the DVLA.

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12
Q

What advice should be given regarding with HTN?

A 
Can drive unless treatment causes unacceptable SE. 
Group 2 (Bus/lorry), resting BP 180+ systolic or 100+ diastolic would disqualify
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13
Q

What advice should be given regarding driving following elective angioplasty?

A

1 week off driving

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14
Q

What advice should be given regarding driving following CABG?

A

4 weeks off driving

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15
Q

What advice should be given regarding driving following ACS?

A

4 weeks off driving, unless successfully treated by angioplasty- then 1 week

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16
Q

What advice should be given regarding driving and angina?

A

Must not drive if symptoms occur at rest/whilst driving

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17
Q

What advice should be given regarding driving following pacemaker insertion?

A

1 week off

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18
Q

What advice should be given regarding driving following ICD insertion?

A

If for sustained ventricular arrhythmia: cease driving for 6 months.

If implanted prophylatically then cease driving for 1 month.

Having an ICD results in a permanent bar for Group 2 drivers

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19
Q

What advice should be given regarding driving following successful catheter ablation for an arrhythmia?

A

2 days off

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20
Q

What advice should be given regarding driving following aortic aneurysm of 6cm or more?

A

Notify DVLA.
Licensing will be permitted, subject to annual review.
Aortic diameter or 6.5cm or more = disqualify

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21
Q

What advice should be given regarding driving following heart transplant?

A

Can drive as normal. DVLA do not need to be notified

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22
Q

What is Kussmaul sign? What condition is this seen in?

A

A rise in JVP on inspiration (normally: falls - venous BF to heart increases)
Pericarditis (heart fails to relax)

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23
Q

What are the features constrictive pericarditis?

A

= thickened, fibrotic pericardium. (rare, but more common after TB, cardiac surgery, radiation)

  • Dyspnoea
  • Right heart failure: elevated JVP, ascites, oedema, hepatomegaly
  • JVP shows prominent x and y descent
  • Pericardial knock (loud S3)
  • Kassmaul’s sign
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24
Q

How would you differentiate between constrictive pericarditis and cardiac tamponade?

A

Constrictive:

  • Pericardial calcification on CXR
  • Kussmaul’s sign
  • JVP: X + Y present

Tamponade:

  • No Y descent on JVP (TAMponade = TAMpaX)
  • Pulsus paradoxus (abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration)
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25
Q

What are the associations of coarctation of the aorta?

A
  • Turner’s syndrome
  • Bicuspid aortic valve
  • Berry aneurysms
  • Neurofibromatosis
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26
Q

What is coarctation of the aorta?

Features?

A

Congenital narrowing of the descending aorta, more common in males.

  • Infancy: HF
  • Adult: HTN
  • Radio-femoral delay
  • Mid-systolic murmur, maximal over back
  • Apicial click from aortic valve
  • Notching of the inferior border of the ribs (collateral vessels) - not seen in young children.
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27
Q

What would be the most likely cause of ST elevation in leads V1-V4 with reciprocal changes in inferior leads?

A

100% occlusion of the LAD

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28
Q

What is Prinzmetal angina?

A

Non-exertional chest pain, typically cyclical with most episodes occurring the in the early hours. Normal exercise tolerance.
Due to coronary artery spasm.

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29
Q

What are the 9 absolute CI to thrombolysis?

A
  • Active internal bleeding
  • Recent haemorrhage, trauma or surgery (inc dental extraction)
  • Coagulation and bleeding disorders
  • Intracranial neoplasm
  • Stroke <3 months
  • Aortic dissection
  • Recent head injury
  • Pregnancy
  • Severe HTN
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30
Q

What are the side-effects of thrombolysis? Which drug causes these more commonly?

A
  • Haemorrhage
  • Hypotension (more common with streptokinase)
    Allergic reactions may occur with streptokinase
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31
Q

What are the side effects of B blockers?

A
  • Bronchospasm
  • Cold peripheries
  • Fatigue
  • Sleep disturbances inc nightmares
  • Erectile dysfunction
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32
Q

Why wouldn’t you prescribe B blockers to someone also taking verapamil?

A

May precipitate severe bradycardia

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33
Q

CI to B blockers?

A

Uncontrolled HF
Asthma
Sick sinus syndrome
Verapamil use

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34
Q

What doses of simvastatin are used in primary and secondary prevention?

A

Primary: Atorvastatins 20mg OD

Secondary: Atorvastatin 80mg OD

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35
Q

When during the day should statins be taken?

A

At night, as this is when the majority of cholesterol synthesis occurs. (Esp for simvastatin as this has a short HL)

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36
Q

What blood test monitoring should be undertaken with statins?

A

LFTs at baseline, 3 months and 12 months (discontinue if transaminase conc rise to and persist at 3x upper limit)

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37
Q

What are the side effects of statins?

A

Myopathy: myalgia, myositis, rhabdomyolysis and asymptomatic raised CK.
(additional RF: advanced age, female sex, low BMI, DM)

Liver impairment

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38
Q

What are the two non-shockable rhythms?

What would you do instead?

A

Pulseless electrical activity and asystole

Give 1mg of intravenous adrenaline + CPR
Identify and treat cause.
Further 1mg IV adrenaline every 3-5 min

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39
Q

What ECG changes would you expect in pericarditis?

A 
Widespread 'saddle-shaped' ST elevation
PR depression (most specific)
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40
Q

In which patients would you start anti-HTN treatment if one ABPM reading 135/85 or over (but under 160/100)?

A 
This is stage 1 HTN. Treat if:
Aged less than 80 with 1+ of:
- Target organ damage
- Established CVD
- Renal disease
- DM
- 10 year cardiovascular risk of 20% or more
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41
Q

Why should amiodarone be given into central veins?

A

It causes thrombophlebitis

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42
Q

What is the monitoring of patients taking amiodarone?

A

TFT, LFT, U&E, CXR prior to treatment

TFT, LFT every 6 months

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43
Q

What territory and coronary artery is V1-V4?

A

Anteroseptal

LAD

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44
Q

What territory and coronary artery is II, III, aVF?

A

Inferior

RC

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45
Q

What territory and coronary artery is V4-6, I, aVL?

A

Anterolateral

LAD or Left circumflex

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46
Q

What territory and coronary artery is I, aVP, +/- V5-6?

A

Lateral

Left circumflex

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47
Q

What territory and coronary artery would tall R waves in V1-2 suggest?

A

Posterior

Usually left circumflex (also right coronary)

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48
Q

What are the common causative organisms in bacterial endocarditis?

A

Gram positives:

  • Strep viridans
  • Staph aureus (IVDU or prosthetic valves)
  • Staph epidermis (prosthetic valves)
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49
Q

What is the empirical abx therapy in:

  • Native valve endocarditis
  • NVE with severe sepsis, penicillin allergy or MRSA
  • NVE with severe sepsis and RF for gram negative infection
  • Prosthetic valve endocarditis
A
  • Native valve endocarditis: Amox + Gent
  • NVE with severe sepsis, penicillin allergy or MRSA: Vanc + Gent
  • NVE with severe sepsis and RF for gram negative infection: Vanc + meropenem
  • Prosthetic valve endocarditis: Vanc, gent + rifampacin

Can alter once culture results available.
Courses are normally 4-6 weeks.

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50
Q

What are the adverse effects of loop diuretics?

A
  • Hypotension
  • Hyponatraemia
  • Hypokalaemia
  • Hypochloraemic alkalosis
  • Ototoxicity
  • Hypocalcaemia
  • Renal impairment (dehydration and direct toxic effect)
  • Hyperglycaemia (less common than with thiazides)
  • Gout
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51
Q

What are the 2 pansystolic murmurs?

Difference?

A

Mitral regurg - high-pitched and ‘blowing’

VSD - ‘harsh’

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52
Q

What factors would favour rate control in AF?

A

Older than 65

Hx IDH

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53
Q

What factors would favour rhythm control in AF?

A 
<65
Symptomatic
First presentation
Lone AF or AF secondary to corrected precipitant (e.g. alcohol)
CHF
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54
Q

What would be first line for rate control in AF?

What if they also have heart failure?

A

B-blocker or CCB (RATE limiting, not amlodipine)

If HF: Digoxin

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55
Q

What are the most common 3 agents used in rhythm control in AF?

A

Sotalol
Amiodarone
Flecainide

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56
Q

How does subclavian steal syndrome characteristically present?
Mx?

A

Posterior circ symptoms, such as dizziness and vertigo during exertion of an arm. (subclavian A steno-occlusive disease proximal to the origin of the vertebral artery -> flow reversal in the vertebral artery.)

Mx: percutaneous transluminal angioplasty or a stent.

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57
Q

What is the Mx of stable angina?

A

All should receive aspirin and a statin in the absence of CIs

  • Sublingual GTN
  • BB or CCB first line
  • If ineffective then increase dose, then swap/add in the other one.
  • If on monotherapy and cant tolerate addition of BB or CCB then add a long-acting nitrate, ivabradine, nicorandil or ranolazine.
  • If on BB and CCB only add 3rd drug while awaiting assessment for PCI or CABG.

Avoid Verapamil in patients with known HF.

NB. CCB choice:

  • If mono therapy then use verapamil or diltiazem
  • In combo with a BB use MR nifedipine
58
Q

What is the Mx of bradycardia?

A

Only treat if haemodynamic compromise (shock, syncope, MI, HF)

1: Atropine, if this fails or pt risk of aystole then
2: TransCUTANEOUS pacing

59
Q

What factors would indicate a potential risk of asystole and therefore CI atropine in bradycardia?
What would you therefore do?

A
  • complete heart block with broad complex QRS
  • recent asystole
  • Mobitz type II AV block
  • ventricular pause > 3 seconds

TransVENOUS pacing

60
Q

What are the 3 drugs used in the emergency treatment of anaphylaxis?

A

Adrenaline, hydrocortisone, chlorphenamine

61
Q

What is the step-wise treatment of HF?

A

1: BOTH ACE-i and BB
2: Aldosterone antagonist (or angiotensin II receptor blocker or hydralazine + a nitrate)
3: Cardiac resynch, digoxin or ivabradine

Also give diuretics for fluid overload

62
Q

What are the criteria for giving ivabradine in HF?

A

Must already be taking suitable therapy - i.e. a BB, CCB and aldosterone antagonist.

  • HR >75
  • LVEF <35%
63
Q

What vaccines should be offered in HF?

A

Annual flu

One-off pneumococcal vaccine (unless asplenia, splenic dysfunction or CKD - give booster every 5 years)

64
Q

What BBs are licensed to treat HF?

A
  • Bisoprolol
  • Carvedilol
  • Nebivolol
65
Q

When might you give digoxin to a patient with HF?

A

If there is also AF.

66
Q

What type of murmur is associated with collagen disorders, such as Marfans; and Ehlers-Danlos?

A

Mitral regurgitation

Pan-systolic. Soft S1, split S2

67
Q

What anti-anginal would you avoid in a patient with known HF?

A

Verapamil

68
Q

What anti-anginal would be CI in a patient already prescribed atenolol?

A

Verapamil - risk of complete heart block

69
Q

What is the step-wise treatment of HTN?

A

1: If under 55 or diabetic: ACE-i
If over 55 or afro-Caribbean: CCB
2: ACE-i and CCB
3: ACE-I and CCB and Thiazide-LIKE diuretic (chlortalidone or indapamide)
4: If K+ <4.5 add spironolactone
If K+ >4.5 add higher dose thiazide-like treatment
5: See specialist. Consider alpha/beta-blocker

70
Q

What is bifascicular block?

A

RBBB with left anterior or posterior hemiblock (e.g. RBBB with left axis deviation)

71
Q

What is trifascicular block?

A

Bifascicular block + 1st degree heart block.

72
Q

What are the drug causes of long-QT -> Polymorphic ventricular tachycardia?

A
  • Antiarrhythmics (e.g. amiodarone, sotalol)
  • Antibiotics (e.g. erythromycin, clarithromycin, ciprofloxacin)
  • Psychotropic drugs (e.g. serotonin reuptake inhibitors, tricyclic antidepressants, neuroleptic agents)
73
Q

Would you treat stage 1 HTN in a diabetic?

What would be the BP target?

A

Yes!
If end-organ damage then <130/80
Otherwise <140/80

74
Q

What class of drugs may cause angiodema?

A

= swelling due to fluid build up in the deep layers of the skin. Typically in the face, also in the genital , hands or feet.

ACE-i (e.g. ramipril)

75
Q

What are the adult doses of adrenaline, hydrocortisone and chlorphenamine in anaphylaxis?

A

Adrenaline:
500mcg i.e. 0.5ml of 1 in 1000

Hydrocortisone: 200mg

Chlorph’ten’amine: 10mg

Remember: rule of 20!
0.5mg, 10mg, 200mg

76
Q

What is the mode of inheritance of hypertrophic cardiomyopathy?
What is the most common cause of sudden death?

A

AD

Ventricular arrhythmias

77
Q

What would you see on Echo in HOCM?

A

MR SAM ASH

  • Mitral regurgitation (MR)
  • Systolic anterior motion (SAM) of the anterior mitral valve leaflet
  • Asymmetric hypertrophy (ASH)
78
Q

What would you see on ECG in HOCM?

A

LVH (tall R waves in L leads: I, aVL and V4-6) + (deep S in R leads: III, aVR, V1-3)
Progressive T wave inversion
Deep Q waves
(+AF occasionally)

79
Q

What is the most common cause of death following an MI?

A

Ventricular fibrillation

80
Q

What is Takayasu’s arteritis?

Mx?

A

Large vessel vasculitis, typically causing occlusion of the aorta - questions commons refer to an absent pulse. More common in females and Asian people.

Mx: Steroids

81
Q

What is the Mx of long-QT?

A 
Avoid drugs prolonging QT
B blockers (not sotalol)
Implantable cardioverter defibrillator in high risk (previous cardiac arrest, or QTc >500ms)
82
Q 
What are the doses of adrenaline for anaphylaxis in:
<6 months
6 months - 6 years
6 - 12 years
>12 and adults
A

<6 months: 150mcg (0.15ml 1 in 1000)

6 months - 6 years: 150mcg (0.15ml 1 in 1000)

6 - 12 years: 300mcg (0.3ml 1 in 1000)

> 12 and adults: 500mcg (0.5ml 1 in 1000)

83
Q

What coronary artery would have been affected if a patient developed complete heart block following an MI?

A

Right coronary (branch supplies AVN)

84
Q

What ECG changes might you see in hypothermia?

A
  • Bradycardia
  • J wave (hump at end of QRS)
  • 1st degree HB
  • Long QTc
  • Atrial and ventricular arrhythmias
85
Q

Where do furosemide and bumetanide act within the kidney?

A

Ascending loop of Henle. (inhibit the Na-K-Cl cotransporter)

86
Q

When would you offer a statin as primary prevention in T1DM?

A
  • Older than 40
  • Have had diabetes for more than 10 years
  • Established nephropathy
  • Other CVD RF (HTN, obesity etc)

NB. 20mg OD atorvastatin

87
Q

What can you test to establish if a reaction is anaphylaxis?

A

Serum tryptase (elevated for up to 12 hours)

88
Q

What is a common reason ACE-i are not tolerated?

What would you give for HTN instead in someone <55?

A

Dry, persistent cough.

Give angiotensin receptor blocker (ARB) e.g. candesartan.

89
Q

What would you do if a patient had a Wells score 4+, but there was a delay in waiting for CTPA or V/Q?

A

Treat as if PE confirmed - LMWH

90
Q

What would you do if a patient had a Wells score <4 but you still suspected a PE?

A

D-dimer. If this is positive -> immediate CTPA.

91
Q

What is the gold standard for investigating PE? Why is this not done normally?

A

Pulmonary angiography

High complication rate

92
Q

What are the two shockable rhythms?

A

VF

Pulseless VT

93
Q

When do you give adrenaline/amiodarone in cardiac arrest?

A

Give adrenaline 1 mg IV and amiodarone 300 mg IV once chest compressions have restarted after the 3rd shock, then repeat adrenaline every 3-5 mins during alternate cycles of CPR

94
Q

When would you give stacked shocks?

A

If the cardiac arrest is witnessed in a monitored patient, e.g in CCU. Give up to 3 quick, successive shocks rather than 1 shock followed by CPR.

95
Q

What is Dressler’s syndrome?
Features?
Mx?

A

An autoimmune reaction against antigenic proteins formed as myocardium recovers following an MI.
Occurs 2-6 weeks following MI.

  • Fever
  • Pleuritic pain
  • Pericardial effusion
  • Raised ESR

Mx: NSAIDs

96
Q

How common is left ventricular free wall rupture following an MI?
Features?

A

3% MIs, occurs around 1-2 weeks after.

Acute HF - secondary to cardiac tamponade:
- Raised JVP
- Pulsus paradoxus
- Diminished heart sounds
Sudden onset.
97
Q

What type of MI would commonly lead to bradycardia? Why?

A

Inferior (Right coronary)

AVN supplied by branch

98
Q

Why might you get a left ventricular aneurysm following an MI?
What would you see on ECG?
Mx?

A

Ischaemia weakens the myocardium -> aneurysm

Persistant ST elevation and LVF. Thrombus -> increased stroke risk.

Mx: Anticoagulation

99
Q

How often does a VSD occur following an MI?

What would be the clinical features?

A

1-2%
Usually occurs in the first week.

Acute HF, pan-systolic murmur (Echo to exclude acute MR)

100
Q

What is the first-line treatment for HF with reduced ejection fraction?
What is normal LVEF?

A

BB (bisoprolol, carvedilol or nebivolol) and ACE-i (ramipril)

Normal LVEF: 45-60%

101
Q

What would a QRisk score over 10 mean?

Mx?

A

> 10% risk of CVD event over the next ten years,

Give primary prevention- i.e. statin. (Atorvastatin 20mg OD)

102
Q

What are the classic ECG changes in Wolff-Parkinson White?

A
  • Short PR
  • Wide QRS complexes with a slurred upstroke
  • Left axis deviation if right-sided accessory pathway (majority)
  • Right axis deviation if left-sided accessory pathway*
103
Q

How often can you repeat adrenaline in anaphylaxis?

A

Every 5 minutes

104
Q

What ECG changes might you see in hypokalaemia?

A
  • U waves
  • Small/absent T waves
  • Prolonged PR
  • Long QT
  • ST depression
105
Q

What are the 4 NHYA classifications of HF?

A

1: None. No exercise limitations
2: Mild. Comfortable at rest, ordinary activity results in fatigue.
3: Moderate. Comfortable at rest. Less than ordinary activity results in symptoms.
4: Severe. Present at rest. Increased discomfort with any physical activity.

106
Q

Why is BNP measured?

What is the physiology underlying this?

A

To rule out a diagnosis of HF in a acutely dyspneic patient (<100), or for prognosis in patients with CHF (if they haven’t had a previous MI)

pro-BNP released in response to LV strain.
BNP actions: Vasodilator, diuretic and natriuretic. Supresses symp tone and RAAS.

107
Q

What might give a falsely low and falsely high BNP level in a patient?

A

Falsely low: ACE-i, ARB, BB, diuretics, obesity.

High: Myocardial ischaemia, valvular disease, diabetes, COPD, CKD (reduced excretion)

108
Q

What would you do if a patient had a BNP level >400?

A

2-week wait referral for urgent Echo.

109
Q

Give 4 common and 3 rare causes of LBBB?

A
  • IHD
  • HTN
  • Aortic stenosis
  • Cardiomyopathy

Rare:

  • Idiopathic fibrosis
  • Digoxin toxicity
  • Hyperkalaemia
110
Q

How long before surgery should you discontinue clopidogrel if necessary?

A

7 days.

111
Q

What two drugs are used in cardioversion of AF?

A 
Amiodarone
Flecainide (if no structural HD)
112
Q

What is the Mx if someone on warfarin has an INR of 5-8 with no bleeding?

A

Withhold 1-2 doses of warfarin and reduce maintenance doses.

113
Q

What is the Mx of major bleeding in someone on warfarin?

A

Stop warfarin
Give IV vitamin k 5mg
Prothrombin complex conc (Beriplex) or FFP if not available.

114
Q

What is the Mx of minus bleeding with INR >8 in someone on warfarin?

A

Stop warfarin
Give IV vit K 1-3mg
Repeat dose vit K if INR still raised after 24 hours.
Restart warfarin when INR <5

115
Q

What is the Mx INR>8 with NO bleeding in someone on warfarin?

A

Stop warfarin
Give vit K 1-5mg orally (use IV prep orally)
Repeat dose vit K if INR still raised after 24 hours.
Restart warfarin when INR <5

116
Q

What is the Mx of minor bleeding in someone on warfarin with INR 5-8?

A

Stop warfarin.
IV vit K 1-3mg
Restart when INR <5

117
Q

What treatment would you give initially in a afro-carribean diabetic?

A

ACE-i plus either:

  • Thiazide diuretic or
  • CCB
118
Q

What would be the specific ECG ST changes for urgent thrombosis or PCI?

A

ST elevation of >2mm (2 small squares) in 2 or more consecutive anterior leads (V1-V6)

or

ST elevation of >1mm (1 small square) in >2 consecutive inferior leads (II, III, avF, all)

or

New LBBB

119
Q

What drugs should all patients be given as secondary prevention following an MI?

A
  • Dual anti platelet i.e. aspirin plus clopidogrel
  • ACE-i
  • BB
  • Statin
120
Q

What is the gold standard treatment of STEMI?

What drugs should they be given?

A

Primary PCI

  • Aspirin
  • P2Y12-R antag (1: Ticagrelor, 2: Clopidogrel)
  • Unfractionated heparin/LMWH
121
Q

What is the physiological cause of an S3 and S4?

A

S3 = sudden tensing of the chordae tendinae - when there is increased volume in the ventricle (e.g. dilated cardiomyopathy)

S4 = atria contracting against a stiff ventricle (LVH or HOCM)

122
Q

What baseline Ix would you do before starting amiodarone?

A

TFT, LFT, U&E + CXR

Risk of pulmonary fibrosis/pneumonitis

123
Q

The addition of which 2 drugs may precipitate statin-induced myopathy?

A

Erythromycin or clarithromycin

124
Q

Outline the scoring used in CHA2DS2Vs?

A 
CHD: 1
HTN/Treated :1
A2: >74: 2, 65-74: 1
Diabetes: 1
S2: Prev stroke or TIA: 2
Vascular disease (IHD or peripheral): 1
Sex: F: 1
125
Q

How do you decide between giving a bioprosthetic or mechanical valve?

A

Prosthetic:
Older patients (deterioration and calcification)
>65 for aortic
>70 for mitral
NB. Don’t normally need LT anti-coag. Aspirin LT.

Mechanical:
Low failure rate.
Need LT anticoag. (Target INR 3 for aortic, 3.5 for mitral).
Only give aspirin if additional indication.

126
Q

Name one drug that enhances and one drug that reduces the effect of adenosine?

A

Enhances: Dipyridamole
Reduces: Aminophylline

127
Q

What is the Jones criteria used for?

How can you use this to remember the major criteria?

A

Diagnosing rheumatic fever. (Need evidence of recent strep infection + 2 major criteria or 1 major + 2 minor criteria)

J oints (migrating polyarthritis)
O bviously heart involved
N odules (subcutaneous)
E rythema marginatum
S ydenham's chorea
128
Q

What is the mechanism of action of Aspirin?

A

Antiplatelet - inhibits the production of thromboxane A2

129
Q

What is the mechanism of action of clopidogrel?

A

Antiplatelet - inhibits ADP binding to its platelet receptor

130
Q

What is the mechanism of action of enoxaparin?

A

Activates antithrombin III - which potentiates inhibition of Xa

131
Q

What is the mechanism of action of fondaparinux?

A

Activates antithrombin III - which potentiates inhibition of Xa

132
Q

What is the mechanism of action of bivalirudin?

A

Reversible direct thrombin inhibitor

133
Q

What is the mechanism of action of abciximab, eptifibatide and tirofiban?

A

Glycoprotein IIb/IIIa receptor antagonists

134
Q

What type of murmur is mitral regurgitation?

Where is it best heard?

A

Pansystolic

Best heard at the apex in left lateral decubitus position. (APTM)

135
Q

What type of murmur is common in IDVU?

A

Tricuspid regurgitation (2 to infective endocarditis)

136
Q

What is the mechanism of action of alteplase?

A

Activates plasminogen to form plasmin.

137
Q

What is the mechanism of action of dipyridamole?

A

Phosphodiesterase inhibitor

138
Q

What is the most common side effect caused by ivabradine?

A

Transient luminous phenomenon (up to 15%)

139
Q

What is the step-wise mx of HF?

A

1: ACE-i AND BB (carvediol or bisoprolol)
2: Add: Aldosterone antagonist (= spironolactone or eplerenone, esp if MI 1/12) or ARB (NOT in combo with ACE-I) or hydrazine + nitrate (esp if afro-caribbean)
3: Cardiac resynch, digoxin or ivabradine

Give diuretics for relief of congestions.

140
Q

What is pulses alternans?

In that patients is it seen?

A

When the upstroke of the pulse alternates between strong and weak.
Indicates systolic dysfunction, seen in patients with heart failure.

141
Q

If an ACE-i is not tolerated in HTN what would you do?

A

Switch to ARB (-sartan)

142
Q

What three antibiotics can cause long QT?

A

Erythro
Clarithro
Cipro

Specialities (12 decks)

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