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Medicine > Cardiology > Flashcards

Cardiology Flashcards

1
Q

what Leads represent the anterior surface of the heart?

A

V2-V6

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2
Q

what leads represent the posterior surface of the heart?

A

V1-V3

but reciprocal

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3
Q

what Leads represent the inferior surface of the heart?

A

II, III, aVF

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4
Q

what leads represent the anterolateral surface of the heart?

A

I, aVL, V5+ V6

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5
Q

what leads represent the anteroseptal surface of the heart?

A

V2-V4

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6
Q

what vessel supplies the inferior aspect of the heart?

A

Right Coronary Artery

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7
Q

what vessel supplies the anterior aspect of the heart?

A

Left main stem

which splits into LAD + Left Cx

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8
Q

what vessel supplies the posterior aspect of the heart?

A

right coronary artery

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9
Q

what vessel supplies the anterolateral aspect of the heart?

A

Left circumflex

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10
Q

what vessel supplies the anteroseptal aspect of the heart? (V2-V4)

A

Left anterior descending

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11
Q

ECG showing PR interval > 200ms (0.20 s)

what diagnosis?

A

first degree heart block

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12
Q

ECG shows progressive lengthening of the PR interval

diagnosis?

A

2nd degree heart block

mobitz type I

wenckebach

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13
Q

ECG shows complete dissociation of P waves and QRS complexes

A

3rd degree heart block

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14
Q

ECG shows two p waves per QRS complex

w normal consistent PR intervals

A

2nd degree heart block

(2:1 block)

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15
Q

ECG shows constant PR interval, wide QRS complexes, occasional non-conducted p waves

A

2nd degree heart block

mobitz type II

(block usually in bundle branches of Purkinje fibres)

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16
Q

Right BBB

features on ECG?

A

MarroW

Rabbit ears in V1, W in V6

Wide QRS complexes

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17
Q

Causes of RBBB?

A

Infarct - Inferior MI

Normal Variant

Congenital - ASD, VSD, Fallot’s

Hypertrophy - RVH (PE, Cor Pulmonale)

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18
Q

Left BBB

features on ECG?

A

WilliaM

W in V1, rabbit ears in V6

wide QRS

T wave inversion in lateral leads

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19
Q

Causes of LBBB?

A

Fibrosis

LVH - AS, HTN

Infarct - Inf MI

Coronary Heart Disease

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20
Q

Bifasicular Block

involves?

A

RBBB + LAFB

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21
Q

Trifascicular Block

involves?

A

RBBB +

LAFB (left anterior fascicular block)

+ 1st degree heart block

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22
Q

What is Beck’s triad?

A

Hypotension

Raised JVP

muffled heart sounds

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23
Q

Complication of MI due to left ventricular free wall rupture?

A

Cardiac tamponade

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24
Q

Signs of Cardiac Tamponade

A

Becks Triad:

low BP, raised JVP, muffled heart sounds

Pulsus paradoxus

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25
Q

What is pulsus paradoxus?

A

An abnormally large decrease in stroke volume and Systolic Blood pressure and pulse wave amplitude during inspiration.

fall in > 10mmHg

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26
Q

Complication of MI

-> Papillary muscle rupture

what signs?

A

Pan systolic murmur

due to mitral regurgitation

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27
Q

What is the mx of STEMI?

A

after confirmation by 12 lead ECG

  1. O2 2-4L aim for SpO2 94-98%
  2. IV access

Bloods for FBC, U+E, glucose, lipids, Troponin

  1. Aspirin 300mg and Clopidogrel 300mg
  2. Morphine 5-10mg IV and Metoclopramide 10mg IV
  3. GTN spray 2 puffs + BB atenolol
  4. LMWH enoxaparin
  5. Monitor with cardiac monitoring + regular obs
  6. Primary PCI or thrombolysis
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28
Q

what is stable angina?

A

chest pain induced by effort

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29
Q

what is unstable angina?

A

chest pain that occurs at rest/ on minimal exertion

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30
Q

what is angina decubitus?

A

chest pain induced by lying down

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31
Q

what is Syndrome X?

A

angina pain + ST elevation on exercise test

but no evidence of coronary atherosclerosis

probably microvascular disease

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32
Q

what is Prinzmetal’s angina?

A

chest pain at rest

due to coronary spasm

ST elevation during attack: resolves as pain subsides

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33
Q

Angina

management for secondary prevention of cardiovascular events?

A

Aspirin 75mg

ACEi

Statins: simvastatin 40mg

Antihypertensives

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34
Q

anti anginals tx?

A

GTN spray

+ BB Atenolol (or CCB Verapamil)

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35
Q

signs of RVF

A

raised JVP

tender smooth hepatomegaly

pitting oedema

ascites

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36
Q

signs of LVF

A

cold peripheries +/- cyanosis

often in AF

cardiomegaly w displaced apex

S3 + tachycardia = gallop rhythm

wheeze

bibasal creps

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37
Q

CXR signs of HF

A

ABCDE

Alveolar shadowing

Kerley B lines

Cardiomegaly

Upper lobe Diversion

Effusions

Fluid in the fissures

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38
Q

what is the normal ejection fraction?

A

60%

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39
Q

key investigation of heart failure?

A

Echo

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40
Q

what is a biomarker of HF?

A

BNP

(>100)

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41
Q

what mx have shown to reduce mortality in chronic HF?

A

ACEi + BB + Spironolactone

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42
Q

Mx of chronic HF

1st line

A

ACEi

e.g. lisinopril or candesartan

+

BB

e.g. carvedilol or bisoprolol

+

Loop Diuretic

e.g. furosemide or bumetanide

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43
Q

Mx of Chronic HF

2nd line

A

seek specialist advice

spironolactone

ACEi + ARB

Vasodilators: hydralazine + ISDN (isosorbide dinitrate)

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44
Q

Symptoms of Pulmonary Oedema

A

SOB

Orthopnoea and PND

Pink frothy Sputum

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45
Q

Cardioresp signs of pulmonary oedema

A

raised JVP

Gallop rhythm/ S3

Bibasal creps

Wheeze

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46
Q

Causes of supraventricular tachycardias?

A

Sinus tachycardia: may be physiological, e.g. response to illness

Atrial tachyarrhythmias: AF (irregular rhythm), atrial flutter,

Junctional tachycardias: AVRT (e.g. WPW), AVNRT

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47
Q

what electrolyte abnormalities cause prolonged QT interval?

A

low Mg, K, Ca

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48
Q
A

atrial tachycardia

abnormally shaped P waves

normal QRS complexes

rate > 150

may be assoc w AV block

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49
Q

causes of broad complex tachycardias?

A

VT

Torsades de pointes

VF

SVT with BBB or SVT with WPW

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50
Q

Is it a VT or SVT with BBB?

A

VT more likely if:

hx of recent infarction

AV dissociation

broad QRS complexes (> 140ms)

Concordant QRS direction in V1-V6

Fusion and capture beats

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51
Q

Peaked P wave on ECG?

A

P Pulmonale

Causes: generally due to Right atrial hypertrophy from tricuspid stenosis/ pulmonary HTN

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52
Q

a broad bifid P wave on ECG?

A

P mitrale

due to Left atrial hypertrophy e.g. Mitral stenosis

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53
Q

How to diagnose RVH on ECG?

A

Tall R wave in V1 ( > 7mm)

Deep S wave in V6 (>7 mm)

Right Axis deviation

may be T wave inversion in V1-V3

cause: cor pulmonale

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54
Q

How to diagnose LVH on ECG?

A

deep S wave in V1 + Tall R wave in V6

( S + R > 35mm)

may have left axis deviation

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55
Q
A

rhythm regular, rate N, p wave N
PR short

QRS: usually wide

Delta wave: slurred upstroke of QRS

can establish reentrant circuit -> SVT

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56
Q
A

irregularly irregular broad QRS complexes

-> AF + WPW

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57
Q
A

ST segment elevation > 2mm in >1 of V1-V3

followed by negative T wave

brugada syndrome

pseudo RBBB

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58
Q

features of HyperK on ECG?

A

tall tented T waves

widened QRS complexes

Absent P waves

Sine wave appearance

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59
Q

Features of HypoK on ECG?

A

Small T waves

ST depression

Prolonged QT interval

Prominent U waves

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60
Q
A

Digoxin toxicity

Reverse tick sign: down sloping ST depression

Also: flattened, inverted or biphasic T waves, shortened QT interval

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61
Q

Causes Of Bradycardia?

A

Drugs: Amiodarone, BB, CCB (verapamil), Digoxin

Ischaemia/ Infarction: Inf MI (SA node affected)

Vagal hypertonia: Carotid sinus syndrome, athletes

Infection

Sick sinus syndrome: structural damage or fibrosis of SAN, AVN or conducting tissue

Amyloid/ Sarcoid/ Haemochromatosis, Muscular dystrophy

Hypothyroid/ HypoK/ Hypothermia

Raised ICP

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62
Q

Types of bradycardias?

A

sinus bradycardia

First degree heart block: PR > 200 ms

Second Degree Heart Block: Mobitz I and II

Complete Heart Block:

Junctional- narrow QRS @ 50 bpm

Ventricular- broad QRS @ 40bpm

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63
Q

tx of bradycardia?

A

if asymptomatic and rate> 40, no tx needed

If symptomatic/ rate <40:

  1. tx underlying cause e.g. drugs, MI
  2. Medical: atropine 500 mcg (max 3mg) IV

or isoprenaline 5 mcg/min IVI

or transcutaneous pacing

  1. External pacing
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64
Q

what is sick sinus syndrome?

A

structural damage or fibrosis of SAN, AVN or conducting tissue

PC: SVT alternating w sinus bradycardia +/- arrest or SA/ AV block

Mx of bradyarrhythmias: Pacing

Tachyarrhythmias: Amiodarone

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65
Q

what do vagal manouevres accomplish in mx of SVT?

A

transiently increases AV block and may unmask underlying atrial rhythm

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66
Q

Adenosine MOA in mx of SVT?

A
  • > transient AV block, unmasking atrial rhythm
  • > cardioverts junctional tachycardias (AVRT/AVNRT) to sinus rhythm
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67
Q

AF mx?

A
  1. rate control w BB (metoprolol) or digoxin
  2. if onset <48h consider cardioversion w amiodarone or DC shock
  3. consider anticoagulation w LMWH +/- warfarin
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68
Q

if sinus tachycardia requires tx?

(ie not a physiological response to fever/ hypovolaemia)

A

B- blocker rate control

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69
Q

What should be remembered about giving adenosine?

A

Adenosine 6mg IV bolus into a large vein

  • followed by 0.9% saline flush

while recording rhythm strip

if unsuccessful, after 2 min give 12mg, then one further 12mg bolus

warn about SEs! -transient chest tightness, dyspnoea, headache, flushing

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70
Q

what are relative contraindications of adenosine?

A

asthma

2nd/ 3rd degree heart block

or sinoatrial disease

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71
Q

drug interactions of adenosine?

A

potentiated by dipyridamole

antagonized by theophylline

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72
Q

if adenosine fails in SVT mx, what next?

A

Use verapamil 5mg IV over 2-3 min (NOT if on BB)

alternatives: amiodarone, atenolol

if unsuccesful -> DC cardioversion

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73
Q

if Junctional tachycardias are not cardioverted to sinus rhythm with adenosine?

A

Try BBs

if medications are insufficient -> try radiofrequency ablation

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74
Q

Risk of SVT w WPW?

A

degeneration to VF and sudden death

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75
Q

Tx of WPW?

A

flecainide, propafenone, sotalol or amiodarone

refer to cardiologist for electrophysiology and ablation of the accessory pathway

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76
Q

what dose to administer amiodarone?

A

amiodarone 300 mg IVI over 20-60 min

then 900mg over 24h

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77
Q

First thing to ask if pt has broad complex tachy?

A

pulse present?

if no -> CPR

if yes -> gain IV access, ECG and give O2

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78
Q

Mx of broad complex tachycardia?

pulse present

no adverse features

A

correct electrolyte abnormalities esp low K+ and low Mg2+

Then assess rhythm:

if regular: treat as VT

amiodarone 300mg IV over 20 or more mins via central line

if known hx of SVT w BBB: consider adenosine

if irregular:

Torsades de pointes: MgSO4 2g IV over 10 min

pre-excited AF: consider amiodarone

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79
Q

Prevention of recurrent VT?

A

may need antiarrhythmic tx: sotalol (if good LV function) or amiodarone (if poor LV function)

Surgical isolation of arrhythmogenic area or an ICD

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80
Q

pathophysiology of AF?

A

Focal atrial activity usually originates in roots of pulmonary veins, overwhelming normal impulses generated by SA node in RA

-> recurrent, uncoordinated contraction @ 300-600 bpm

AVN responds intermittently -> irregular ventricular rate

atrial contraction responsible for ~25% of CO -> heart failure

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81
Q

causes of AF:

A

cardiac: HTN, ischaemic heart disease, valvular heart problems
endocrine: hyperthyroidism, excess alcohol
resp: PE

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82
Q

symptoms of AF?

A

asymptomatic or

palpitations, dyspnoea, anginal chest pain, presyncope (faintness)

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83
Q

signs of AF?

A

irregularly irregular pulse

or fast AF-> loss of diastolic filling -> no palpable pulse

Signs of LVF

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84
Q

Mx of Acute AF (onset < 48h)?

A

if heamodynamically unstable -> emergency cardioversion

Electrical Cardioversion or pharmacological (IV Amiodarone)

2nd line IV flecainide (if no structural heart disease)

Anticoagulate with LMWH

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85
Q

Mx of acute AF (<48h onset) with stable patient?

A

Control ventricular rate: BB (bisoprolol) OR rate limitning CCB (e.g. verapamil)

Anticoagulate with LMWH

Cardioversion: DC shock or medical amiodarone

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86
Q

what is paroxysmal AF?

A

spontaneous termination within <7d (most often within 48h)

recurring and may degenerate into sustained AF

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87
Q

Mx of paroxysmal AF?

A

Rhythm: “pill in pocket”: flecainide or sotalol PRN

Prevention: BB, sotalol or amiodarone

Anticoagulate: Use CHA2DS2-VAS score

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88
Q

what is persistent AF?

A

> 7d, not self terminating, may recur after cardioversion

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89
Q

Mx of persistent AF?

A

Rhythm Control: elective cardioversion

1st line rhythm control if symptomatic of CCF, <65, presenting first time w lone AF, secondary to treated precipitant

Beforehand: anticoagulate w warfarin for > 3 wks or use TOE to exclude mural thrombus

Pre-treatment >4 wks w sotalol or amiodarone if increased risk of failure

Rate: monotherapy BB (bisoprolol, metoprolol) or rate limiting CCB 1st line

Anticoagulation: use CHA2D2VAS score

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90
Q

What is permanent AF?

A

long stnading > 1yr, not succesfully terminated by cardioversion/ unlikely to succeed

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91
Q

Mx of permanent AF?

A

Rate control: BB or digoxin

Anticoagulate: use CHADVAS score

Rhythm control: Radiofrequency ablation of AV node +/- Pacing, Maze procedure,

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92
Q

What is CHADVAS score?

A

determines neccessity of anticoagulation in AF

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93
Q

what is the CHADSVAS score made of

A

Congestive Cardiac Failure

HTN

Age ≥ 75 (2 points)

DM

Stroke or TIA (2 points)

VAS

Vascular disease

Age 65-74

Sex: female

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94
Q

What CHADSVAS scores mean what?

A

0: dont need anticoagulation

if 1: male -> anticoagulate

≥ 2: Warfarin (INR 2-3)

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95
Q

what is the HASBLED score for?

A

determines bleeding risk in those starting or on anticoagulation

HTN

Abnormal Kidney or liver function (1 each)

Stroke

Bleeding tendency

Labile INR

Elderly

Drug (NSAIDs + alcohol): 1 each

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96
Q

what HASBLED score means what?

A

≥ 3 = high risk

AVOID oral anticoagulation

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97
Q

Modifiable risk factors of Acute coronary syndromes?

A

HTN

DM

Smoking

High cholesterol

Obesity

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98
Q

non modifiable risk factors of acute coronary syndrome?

A

age

male

FH (MI< 55 yrs)

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99
Q

what ECG findings show a STEMI?

A

ST elevation

Q waves: full thickness infarct

T wave inversion

or

New onset LBBB also -> STEMI

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100
Q

ECG findings of NSTEMI?

A

ST depression

T wave inversion

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101
Q

ECG findings of Pericarditis?

A

saddle shaped ST elevation

+/- PR depression

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102
Q

mx of pericarditis?

A

NSAIDs: ibuprofen

Echo to exclude effusion

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103
Q

ECG findings of ventricular aneurysm?

A

persistent ST elevation

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104
Q

Mx of ventricular aneurysm?

A

anticoagulation

consider surgical excision

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105
Q

Ix of angina?

A

Bloods: FBC, U+E, lipids, glucose, ESR, TFTs

ECG: usually normal

May show ST ↓, flat/inverted T waves, past MI

Consider exercise ECG

Stress echo

Perfusion scan

CT coronary Ca2+ score

Angiography (gold standard)

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106
Q

mx of atrial flutter?

A

is similar to that of atrial fibrillation although medication may be less effective

atrial flutter is more sensitive to cardioversion however so lower energy levels may be used

radiofrequency ablation of the tricuspid valve isthmus is curative for most patients

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107
Q

inheritance of Marfans?

A

AD

Spontaneous mutation in 25%

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108
Q

what is the most sensitive ecg marker for pericarditis?

A

PR depression: most specific ECG marker for pericarditis

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109
Q

presentation of Marfans?

A

Cardiac

  • Aortic aneurysm and dissection
  • Aortic root dilatation → regurgitation
  • MV prolapse ± regurgitation

Ocular

Lens dislocation: superotemporal

MSK

High-arched palate

Arachnodactyly

Arm-span > height

Pectus excavatum

Scoliosis

Pes planus

Joint hypermobility

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110
Q

complications assoc w Marfans?

A

Ruptured aortic aneurysm

Spontaneous pneumothorax

Diaphragmatic hernia

Hernias

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111
Q

Mx of Marfans?

A

Refer to ortho, cardio and ophthal

Life-style alteration: ↓ cardiointensive sports

Beta-blockers slow dilatation of the aortic root

Regular cardiac echo

Surgery when aortic root ≥5cm wide

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112
Q

pathogenesis of Ehlers-Danlos?

A 
Rare heterogeneous group of collagen disorders.
6 subtypes w varying severity
Commonest types (1 and 2) are autosomal dominant
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113
Q

presentation of ehlers danlos syndrome?

A

Hyperelastic skin

Hypermobile joints

Cardiac: MVP , AR, MR and aneurysms

Fragile blood vessels → easy bruising, GI bleeds

Poor healing

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114
Q

bicuspid aortic valve assoc w?

A

aortic stenosis +/- regurgitation

pre disposes to IE/ subacute endocarditis

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115
Q

Pathology of Tetralogy of Fallot?

A

VSD

Pulmonary stenosis

RV Hypertrophy

Overriding aorta

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116
Q

Tetralogy of Fallot associated with which congenital syndrome?

A

Di George’s Syndrome

CATCH 22

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117
Q

Ix of Tetralogy of Fallot?

A

ECG: RVH + RBBB

CXR

Echo: anatomy + degree of stenosis

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118
Q

presentation of tetralogy of fallot in adults?

A

often asymptomatic

unoperated: cyanosis, ESM of Pulm Stenosis

Repaired: Dyspnoea, palpitations, RVF

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119
Q

mx of tetralogy of fallot?

A

surgical closure of VSD + correction of the pulmonary stenosis

usually before 1 yo

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120
Q

causes of VSD?

A

congenital

acquired: post MI

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121
Q

Signs of VSD?

A

Smaller holes -> louder murmurs

harsh PSM @ LLSE

Systolic thrill

Left parasternal heave

larger holes -> Pulmonary HTN

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122
Q

complications of VSD?

A

infective endocarditis

Pulmonary HTN

Eisenmengers

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123
Q

Ix of VSD?

A

ECG: if small- normal.

if large: LVH + RVH

CXR: small- mild pulmonary plethora

large - cardiomegaly + marked pulmonary plethora

Echo to visualise

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124
Q

Mx of VSD?

A

surgical closure indicated

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125
Q

what is coarctation of the aorta?

A

Congenital narrowing of the aorta

Usually occurs just distal to origin of left subclavian

M>F

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126
Q

signs of coarctation of the aorta?

A

radio-femoral delay / radial radial delay

weak femoral pulse

HTN

systolic murmur/ bruit heard best over left scapula

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127
Q

complications of coarctation of aorta?

A

heart failure

IE

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128
Q

Ix of coarctation of aorta?

A

CXR: rib notching

ECG: LV strain

CT angiogram

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129
Q

mx of coarctation of aorta?

A

balloon dilatation + stenting

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130
Q

Complications of Atrial septal defect?

A

Paradoxical emboli

Eisenmengers syndrome:

increased RA pressure -> cyanotic R to L shunt

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131
Q

mx of atrial septal defect?

A

transcatheter closure

recommended in adults if high pulmonary to systemic blood flow ratio (≥1.5:1)

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132
Q

signs of atrial septal defect?

A

AF

raised JVP

pulmonary ESM

Pulm HTN -> Tricuspid regurg or Pulm Regurg

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133
Q

Causes of Dilated Cardiomyopathy?

A
  1. Dystrophy: muscular, myotonic
  2. Infection: complication of myocarditis
  3. Late pregnancy: peri-partum
  4. Autoimmune: SLE
  5. Toxins: alcohol, cyclophosphamide, radiotherapy
  6. Endocrine: thyrotoxicosis
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134
Q

presentation of dilated cardiomyopathy?

A

right HF and L HF

Arrhythmias

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135
Q

Signs of Dilated cardiomyopathy

A

Displaced apex beat

S3 gallop

raised JVP

low BP

MR/ TR

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136
Q

Ix of dilated cardiomyopathy?

A

CXR: cardiomegaly, pulmonary oedema

ECG: T inversion, poor progression

Echo: globally dilated, hypokinetic heart + decreased ejection fraction

Catheter + biopsy: myocardial fibre disarray

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137
Q

Mx of dilated cardiomyopathy?

A

Bed rest

medical: Diuretics, ACEi, Digoxin, anticoagulation

Non medical: Biventricular pacing, ICD

Surgical: heart transplant

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138
Q

What is an Atrial myxoma?

A

rare, benign cardiac tumour

may be familial

e.g. Carney Complex: cardiac and cutaneous myxoma, skin pigmentation, endocrinopathy (e.g. Cushings)

90% in L atrium, most commonly attached to fossa ovalis of the interatrial septum

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139
Q

features of cardiac myxoma?

A

Clubbing, fever, weight loss, Raised ESR

Signs similar to Mitral stenosis (Mid diastolic murmur, systemic emboli, AF)

which varies w posture

symptoms typically due to effect of tumour obstructing normal flow of blood (SOBOE, paroxysmal nocturnal dyspnoea, syncope)

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140
Q

diagnosis of cardiac myxoma?

A

echo

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141
Q

tx of cardiac myxoma?

A

excision

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142
Q

Causes of restrictive cardiomyopathy?

A

Sarcoid

Systemic sclerosis

Haemochromatosis

Amyloidosis

Primary: endomyocardial fibrosis

Eosinophilia (Loffler’s eosinophilic endocarditis)

Neoplasia: carcinoid (-> TR and PS)

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143
Q

Pathophysiology of HOCM?

A

LV outflow obstruction from asymmetrical septal hypertrophy

Familial form AD inheritance

B-myosin heavy chain mutation commonest

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144
Q

symptoms of HOCM?

A

Angina

SOB

Palpitations: AF, WPW, VT

exertional syncope or sudden death

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145
Q

signs of HOCM?

A

jerky pulse

double apex beat

harsh ESM @ LLSE w systolic thrill

S4

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146
Q

ix of HOCM

A

ECG: LVH/L axial deviation, ventricular ectopics/ VT

echo

exercise test +/- holter monitor to quantify risk

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147
Q

Mx of HOCM?

A

Medical:

  • ve inotropes: BB (2nd verapamil)
    amiodarone: arrhythmias

anticoagulate if AF or emboli

if severe symptoms: septal myomectomy

consider ICD

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148
Q

causes of acute myocarditis?

A

Idiopathic (50%)

viral: coxsackie B, flu, HIV

Bacterial: S aureus, syphilis

Drugs: Cyclophosphamide

Autoimmune: giant cell myocarditis assoc w SLE

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149
Q

Ix of acute myocarditis?

A

Bloods: +ve troponin, raised CK

ECG: ST elevation or depression

T wave inversion

transient AV block

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150
Q

Mx of acute myocarditis?

A

supportive

tx cause

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151
Q

Causes of Cardiac Tamponade?

A

Accumulation of pericardial fluid -> increased intra pericardial pressure -> poor ventricular filling -> decreased Cardiac output

Any cause of pericarditis

Aortic dissection

Warfarin

Trauma

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152
Q

Signs of cardiac tamponade?

A

Becks triad: Raised JVP, hypotension, muffled heart sounds

Pulsus paradoxus: pulse fades on inspiration

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153
Q

Ix of cardiac tamponade?

A

ECG: low voltage QRS +/- electrical alternans

CXR: large globular heart

Echo: diagnostic, echo- free zone around heart

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154
Q

Mx of cardiac tamponade?

A

urgent pericardiocentesis

  • 20 ml syringe + long 18G cannula
  • generally done under ultrasound guidance
  • subxiphoid appraoch: under the xiphoid process, up and leftwards
  • parasternal approach: between 5th and 6th ICS at L sternal border
  • aspirate continuously and watch ECG

tx cause

send fluid for cytology, ZN stain and culture

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155
Q

Causes of Pericardial Effusion?

A

Acute pericarditis

infection: viral, bacterial, fungal

MI

Dresslers

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156
Q

Ix of pericardial effusion?

A

CXR: enlarged globular heart

ECG: low voltage QRS complexes, Alternating QRS amplitude (electrical alternans)

Echo: echo free zone around heart

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157
Q

Clinical features of pericardial effusion?

A

Dyspnoea

raised JVP (prominent X descent)

Bronchial breathing @ L base

  • Ewart’s sign: large effusion compresion LLL

Signs of cardiac tamp present

158
Q

Mx of pericardial effusion?

A

tx cause

pericardiocentesis may be diagnostic or therapeutic: culture, ZN stain, cytology

159
Q

Clinical features of constrictive pericarditis?

A

Heart encased in a rigid pericardium

RHF w raised JVP

Kussmaul’s sign: raised JVP w inspiration

Quiet HS

S3

Hepatomegaly, ascites, oedema

160
Q

Ix of Constrictive pericarditis?

A

CXR: small heart + pericardial calcification

Echo

Cardiac Catheterisation

161
Q

Mx of constrictive pericarditis?

A

surgical excision

162
Q

clinical features of acute pericarditis?

A

central chest pain: sharp, worse lying down, relieved by sitting forward, radiates to L shoulder, pleuritic

pericardial friction rub

Fever

Signs of effusion/ tamponade

163
Q

ix of acute pericarditis?

A

Bloods: FBC, ESR, Trop (may be raised), cultures, virology

ECG: saddle shaped ST elevation +/- PR depression

164
Q

causes of acute pericarditis?

A

Viral: coxsackie, flu, EBV, HIV

bacterial: rheumatic fever, pneumonia, TB

Fungal

Post MI, Dressler’s syndrome

Drugs: penicillin, isoniazid, procainamide, hydralazine

Other: uraemia, RA, SLE, Sarcoid, radiotx

165
Q

Organism responsible for rheumatic fever?

A

Group A beta-haemolytic strep

e.g. strep pyogenes

166
Q

epidemiology of rheumatic fever?

A

5-15 yrs

rare in West

v common in developing world

167
Q

pathophysiology of rheumatic fever?

A

Antibody cross reactivity following S pyogenes infection -> Molecular mimicry

abs vs myocardium ie. myosin, muscle glycogen and Smooth muscle cells

Pathology: Aschoff bodies and Anitschkow myocytes

168
Q

Revised Jones criteria for rheumatic fever

for diagnosis?

A

Evidence of Group A strep infection

+

2 major criteria

or

1 major + 2 minor

169
Q

Revised Jones criteria

  • what is considered evidence for group a strep infection?
A

Positive ASOT titre or DNase B titre

+ve throat culture

Rapid Strep Ag test

Recent scarlet fever

170
Q

What are the major criteria for the Revised Jones criteria for diagnosis of rheumatic fever?

A

need 2 major

or 1 major + 2 minor

PACES

Pancarditis

Arthritis

subCutaneous nodules

Erythema marginatum

Sydenham’s chorea

171
Q

What are the minor criteria for the revised Jones criteria for diagnosis of Rheumatic fever?

A

need 2 minor criteria if only 1 major present

Arthralgia (not if arthritis is major)

Fever

Raised ESR or CRP

prolonged PR interval (not if carditis is cause)

prev rheumatic fever

172
Q

Features of Rheumatic Fever?

A

Pancarditis:

pericarditis, myocarditis, endocarditis (MR, AR)

Arthritis: migratory polyarthritis of large joints

Subcut nodules: small mobile, painless nodules on extensor surfaces esp elbows

Erythema marginatum

Sydenhams chorea: due to damage of basal ganglia

173
Q

Ix of rheumatic fever?

A

ASOT titre

Strep antigen test

FBC, ESR/ CRP

Echo

ECG

174
Q

Mx of rheumatic fever?

A

bed rest until CRP normal for 2 weeks

Benpen: 0.6- 1.2 mg IM for 10 days

Analgesia: aspirin / NSAIDs

Add oral prednisolone if CCF, cardiomegaly, 3rd degree HB

Chorea: haloperidol

175
Q

Secondary prophylaxis against Rheumatic fever?

A

indicated in those with carditis for 10 yrs after last attack or 25 yrs of age (whichever is longer)

severe valvular disease/ surgery: lifelong

Without proven carditis: for 5 yrs after last attack/ 18 yrs of age

Pen V PO

176
Q

prognosis of valves in rheumatic fever?

A

regurgitation -> stenosis

Mitral (70%)

Atrial (40%)

Tricuspid (10%)

Pulmonary (2%)

177
Q

pathophysiology of infective endocarditis?

A

cardiac valves develop vegetations composed of bacteria and platelet-fibrin thrombus

178
Q

risk factors of infective endocarditis?

A

Faulty valves:

prosthetic valves

prev rheumatic fever

degenerative valvuopathy

Dental caries

IVDU (tricuspid valve)

Immunocompromised (ie DM)

179
Q

Organisms causing Infective endocarditis?

A

Strep viridans - most common if subacute bacterial endocarditis

Strep bovis- assoc w colon cancer

Staph aureus - most common if acute, IVDU

Strep epidermidis - prosthetic valves

HACEK organisms

180
Q

endocarditis assoc w SLE?

A

Libman Sacks endocarditis

non bacterial

mitral valve typically affected

181
Q

General clinical features assoc w infective endocarditis?

A

FLAWS

splenomegaly

clubbing

new/ changing murmur (Mitral regurg: 85%, AR: 55%)

182
Q

what murmurs are most common with infective endocarditis?

A

mitral regurg (PSM)

followed by aortic regurg

183
Q

what embolic phenomena may occur in Infective endocarditis?

A

abscesses in brain, heart, kidney, spleen, gut and lung

Janeway lesions: painless palmar macules

Splinter haemorrhages: due to septic emboli from infected heart valves

184
Q

What signs of immune complex deposition occur in Infective endocarditis?

A

microhaematuria due to GN

Vasculitis

Roth spots: boat shaped retinal haemorrhages w pale centre

Osler’s nodes: painful, purple papules on finger pulps

185
Q

How is diagnosis of infective endocarditis confirmed?

A

Duke Criteria

  • 2 major
  • 1 major + 3 minor
  • All 5 minor
186
Q

What are the Major criteria in Duke Criteria for Infective endocarditis?

A
  1. +ve blood culture
    - typical organism in 2 separate cultures or
    - persistently +ve cultures e.g. 3, >12 h apart
  2. Endocardium involved
    - +ve echo - vegetation, abscess, valve dehiscence
    - new valvular regurgitation
187
Q

What are the minor criteria of Duke criteria for infective endocarditis?

A
  1. Predisposition: Cardiac lesion, IVDU
  2. Fever >38
  3. Emboli: Septic infarcts, splinter haemorrhages, Janeway lesions
  4. Immune phenomenon: GN, Osler nodes, Roth spots
  5. +ve blood culture not meeting major criteria
188
Q

Ix of Infective endocarditis?

A

Bloods:

Anaemia, raised ESR/ CRP, +ve IgG RF, Cultures x 3 >12 h apart, Serology for unusual organisms

urine: microscopic haematuria

ECG: AV block

Echo:

TOE most sensitive, TTE detects vegetations > 2mm

189
Q

mx of infective endocarditis?

staph aureus

A

Flucloxacillin +/- Rifampicin IV

190
Q

Empiric tx of acute severe infective endocarditis?

A

Flucloxacillin + Gentamicin IV

191
Q

Empiric tx of subacute bacterial endocarditis?

A

Benpen + gent IV

192
Q

Causes of tricuspid regurgitation?

A

Functional: RV dilatation

Rheumatic fever

Infective endocarditis

Carcinoid syndrome

193
Q

Pts with rheumatic fever are recommended bed rest until?

A

CRP normal for 2 weeks

194
Q

what antibiotic regimen is used in rheumatic fever?

A

Benzylpenicillin 1.2g STAT IV

then

Penicillin V 250-500mg QDS PO for 10 days

195
Q

symptoms of tricuspid regurgitation?

A

fatigue

hepatic pain on exertion

ascites, oedema

196
Q

signs of tricuspid regurgitation?

A

raised JVP w giant V waves

RV heave

PSM loudest @ LLSE on inspiration (carvallo’s sign)

Pulsatile hepatomegaly

Ascites, oedema

197
Q

Ix of tricuspid regurgitation?

A

LFTs

Echo

198
Q

mx of tricuspid regurgitation?

A

Tx cause

Medical: diuretics, ACEi, digoxin

Surgical: valve replacement

199
Q

causes of tricuspid stenosis?

A

rheumatic fever w Mitral valve and aortic valve disease

200
Q

Symptoms of tricuspid stenosis?

A

fatigue

ascites

oedema

201
Q

signs of tricuspid stenosis?

A

Large A waves

opening snap

EDM loudest at LLSE on inspiration

202
Q

mx of tricuspid stenosis?

A

medical: diuretics

Surgical: repair, replacement

203
Q

causes of pulmonary regurgitation?

A

any cause of pulmonary HTN

PR secondary to pulmonary HTN from mitral stenosis = Graham-Steell murmur

204
Q

murmur of pulmonary regurgitation?

A

Decrescendo EDM @ ULSE

205
Q

causes of pulmonary stenosis?

A

usually congenital: e.g. Turner’s, Fallots

rheumatic fever

carcinoid syndrome

206
Q

features of pulmonary stenosis?

A

dyspnoea, fatigue

dysmorphia

large A wave

RV heave

ejection click, soft P2

ascites, oedema

ESM loudest at ULSE, radiating to L shoulder

207
Q

Ix of pulmonary stenosis?

A

ECG: P pulmonale, Right Axis deviation, RBBB

CXR: prominent pulmonary arteries: post stenotic dilatation

Cardiac Catheterisation: diagnostic

208
Q

Causes of mitral regurgitation?

A

mitral valve prolapse

LV dilatation: AR, AS, HTN

rheumatic fever

Annular calcification -> contraction (elderly)

post MI: papillary muscle dysfunction/ rupture

connective tissue: Marfans, Ehlers-Danlos

209
Q

symptoms of mitral regurgitation?

A

dyspnoea, fatigue

AF -> palpitations + emboli

Pulmonary congestion -> HTN + oedema

210
Q

signs of Mitral Regurgitation?

A

AF

Left parasternal heave (RVH

Apex: displaced

-> LV hypertrophy

Heart Sounds: soft S1

Murmur: Blowing PSM best heard at apex, radiates to axilla, louder in left lateral position in end expiration

211
Q

clinical indicators of severe Mitral regurg?

A

Lagrer Left ventricle

Decompensation: LVF

AF

212
Q

ix of mitral regurgitation?

A

Bloods: FBC, U+E, glucose, lipids

ECG: AF, P mitrale, LVH

CXR: LA and LV hypertrophy, Mitral valve calcification, pulmonary oedema

Echo: assess MR severity

Cardiac catheterisation: confirm Dx, assess coronary artery disease

213
Q

Mx of Mitral Regurgitation?

A

Medical:

Refer to cardiologist for regular follow up w echo

Optimise RFs: Statins, antihypertensives, DM

AF: rate control and anticoagulate

drugs to decrease afterload can help decrease symptoms:

ACEi or BB (esp carvedilol)

Diuretics

Surgical: Valve replacement or repair

214
Q

indications for surgical repair of mitral regurgitant valve?

A

severe symptomatic MR

or

severe asymptomatic MR w diastolic dysfunction: reduced ejection fraction

215
Q

causes of Barlow Syndrome?

ie. mitral valve prolapse

A

commonest valve problem ~ 5%

primary: myxomatous degeneration

MI

marfans, ehlers danlos

Turners

216
Q

Features of MV prolapse/ Barlow Syndrome?

A

usually asymptomatic

autonomic dysfunction: atypical chest pain, palpitations, anxiety, panic attack

MR: fatigue, SOB

Murmur

217
Q

complications of Barlow Syndrome?

A

mitral regurgitation

Cerebral emboli

arrhythmias -> sudden death

218
Q

mx of Barlow Syndrome?

A

BB may relieve palpitations and chest pain

Surgery if severe MR

219
Q

Causes of mitral stenosis?

A

rheumatic fever

prosthetic valve

congenital (rare)

220
Q

what medications are recommended for secondary prevention following an MI?

A

dual antiplatelet therapy:

Aspirin 75 mg + Clopidogrel 75 mg

angiotensin-converting enzyme (ACE) inhibitor: e.g. lisinopril 2.5mg

beta-blocker e.g. bisoprolol 1.25 mg OD

statin e.g. atorvastatin 80mg

221
Q

Causes of mitral regurg?

A

Mitral valve prolapse

LV dilatation: AR, AS, HTN

Annular calcification -> contraction (elderly)

post-MI: papillary muscle dysfunction/ rupture

rheumatic fever

connective tissue: marfans, Ehlers -Danlos

222
Q

symptoms of mitral regurgitation?

A

SOB, fatigue

AF -> palpitations + emboli

Pulmonary congestion -> HTN + oedema

223
Q

signs of mitral regurg?

A

AF

left parasternal heave (RVH)

apex: displaced

(volume overload as ventricle has to pump forward SV and regurgitant volume)

heart sounds: soft S1 + Blowing PSM at the apex, accentuated in Left lateral position in end expiration + radiates to the axilla

224
Q

differentials of PSM loudest at mitral region?

A

Tricuspid regurg

aortic stenosis

VSD

225
Q

clinical indicators of severe mitral regurg?

A

larger LV

decompensation: LVF

AF

226
Q

ix of mitral regurgitation?

A

Bloods: FBC, U+E, glucose, lipids

ECG: AF, P mitrale, LVH

CXR: LA + LV hypertrophy, mitral valve calcification, pulmonary oedema

Echo: Doppler echo to assess MR severity, TOE to assess severity and suitability of repair

Cardiac Catheterisation: confirm Dx, assess coronary artery disease

227
Q

What criteria is used to assess severity of MR on echo?

A

jet width >0.6cm

Systolic pulmonary flow reversal

regurgitant flow volune > 60ml

228
Q

Mx of Mitral Regurg?

A

Conservative: monitor w regular follow up and echo

medical:

Optimised RFs: statins, anti-hypertensives, DM

AF: rate control and anticoagulate

Drugs to decrease afterload can help symptoms: ACEi or BB (esp Carvedilol), Diuretics

Surgical:

valve replacement or repair

229
Q

indications for surgical mx of mitral regurgitation?

A

severe symptomatic MR

severe asymptomatic MR w diastolic dysfunction: decreased ejection fraction

230
Q

commonest valve problem?

A

mitral valve prolapse

231
Q

causes of mitral valve prolapse?

A

primary: myxomatous degeneration

Post-MI: papillary muscle rupture

Marfans, Ehlers Danlos

Turner’s

232
Q

symptoms of mitral valve prolapse?

A

usually asymptomatic

autonomic dysfunction: atypical chest pain, palpitations, anxiety, panic attack

MR: SOB, fatigue

233
Q

mitral valve prolapse signs?

A

mid systolic click + late systolic murmur

234
Q

complications of mitral valve prolapse?

A

MR

cerebral emboli

arrhythmias -> sudden death

235
Q

mx of mitral valve prolapse?

A

BB may relieve palpitations and chest pain

surgery if severe

236
Q

pathophysiology of mitral stenosis?

A

valve narrowing -> ↑ left atrial pressure -> loud S1 and atrial hypertrophy -> AF

pulmonary oedema and pulmonary HTN

-> RVH, TR, R heart failure

237
Q

symptoms of mitral stenosis?

A

SOB, fatigue

chest pain

AF -> palpitations + emboli

haemoptysis: rupture of bronchial veins

238
Q

signs of mitral stenosis?

A

AF

Malar flush (back pressure)

JVP raised

Left parasternal heave (RVH 2º to Pulm HTN)

tapping apex (palpable S1)

HS: Loud S1, Loud P2 (if PHT), early diastolic opening snap + rumbling mid diastolic murmur in apex louder in Left lateral position in end expiration, radiates to the axilla

239
Q

complications of Mitral stenosis?

A

pulmonary HTN

emboli: TIA, CVA, PVD, ischaemic colitis

Hoarseness: recurrent laryngeal n palsy

dysphagia (oesophageal compression)

bronchial obstruction

240
Q

Ix of mitral stenosis?

A

Bloods: FBC, U+E, glucose, lipids

ECG: AF, P mitrale, RVH w strain

CXR: LA enlagement, pulmonary oedema (ABCDE), mitral valve calcification

Echo: to assess severity, use TOE to look for left atrial thrombus if intervention considered

Cardiac catheterisation: assess coronary arteries

241
Q

what criteria would determine severe mitral stenosis on echo?

A

valve orifice < 1cm2

pressure gradient > 10 mmHg

Pulmonary artery systolic pressure > 50 mmHg

242
Q

Mx of mitral stenosis?

A

Medical:

optimise RFs: statins, anti-hypertensives, DM

Regular followup w echo

AF: anticoagulation and rate control

Consider prophylaxis vs RF: Pen V

diuretics provide symptomatic relief

Surgical:

indicated in mod-severe MS

percutaneous balloon valvuloplasty

valve repair

valve replacement if repair not possible

243
Q

what is the surgical tx of choice in Mitral stenosis?

A

Percutaneous mitral balloon Valvotomy (commissurotomy)

244
Q

causes of aortic regurgitation?

A

Acute

Infective endocarditis

Type A aortic dissection

Chronic

Congenital: bicuspid aortic valve

Rheumatic heart disease

Connective tissue: Marfan’s, Ehler’s Danlos

Autoimmune: Ank spond, RA

245
Q

symptoms of aortic regurgitation?

A

LVF:

246
Q

signs of aortic regurgitation?

A

collapsing pulse (corrigans pulse)

wide pulse pressure

Apex: displaced (volume overloaded)

Heart sounds: soft/ absent S2 +/- S3

+ Early diastolic murmur at URSE, sitting forward in end expiration

+/- Ejection systolic flow murmur

Underlying cause:

high-arched palate

spondyloarthropathy

embolic phenomena

Corrigans sign: Carotid pulsation

de mussets: head nodding

Quinckes: capillary pulsation in nail bed

Traubes: pistol shot sound over femorals

Austin Flint murmur: rumbling MDM @ apex due to regurgitant jet fluttering ant mitral valve cusp = severe AR

Duroziez’s: systolic murmur over the femoral artery w proximal compression, diastolic murmur w distal compression

247
Q

clinical indicators of severe AR?

A

wide PP and collapsing pulse

S3

long murmur

austin flint murmur

decompensation: LVF

248
Q

Ix of aortic regurgitation?

A

Bloods: FBC, U+E, Lipids, glucose

ECG: LVH (S1 + R6 >35mm)

CXR: cardiomegaly, dilated ascending aorta, pulmonary oedema

Echo: assess severity of aortic regurg, aortic valve structure and morphology (e.g. bicuspid), evidence of Infective endocarditis (vegetations), LV function: ejection fraction

Cardiac catheterization: coronary artery disease

249
Q

what are the criteria to assess severity of aortic regurg on echo?

A

Jet width (>65% outflow tract = severe)

Regurgitant jet volume

premature closure of mitral valve

250
Q

mx of aortic regurgitation?

A

Medical:

optimise Risk factors: anti-hypertensives, statins, DM

monitor w regular follow up + echo

decrease systolic HTN: ACEi, CCB (decrease afterload -> decrease regurg)

Surgery: aortic valve replacement

251
Q

when is aortic valve replacement indicated?

A

in severe AR

if symptoms of HF

asymptomatic w LV dysfunction: low ejection fraction

252
Q

e.g.s of thrombolytics?

A

alteplase

tenecteplase

streptokinase

253
Q

how do thrombolytics work?

A

Thrombolytic drugs activate plasminogen -> plasmin. This in turn degrades fibrin and help breaks up thrombi. They in primarily used in patients who present with a STEMI. Other indications include acute ischaemic stroke and pulmonary embolism, although strict inclusion criteria apply.

254
Q

contraindications to thrombolysis?

A

active internal bleeding

recent haemorrhage, trauma or surgery (including dental extraction)

coagulation and bleeding disorders

intracranial neoplasm

stroke < 3 months

aortic dissection

recent head injury

pregnancy

severe hypertension

255
Q

side effects of thrombolysis?

A

haemorrhage

hypotension - more common with streptokinase

allergic reactions may occur with streptokinase

256
Q

Ix to confirm diagnosis of HTN?

A

both ambulatory blood pressure monitoring (ABPM) and

home blood pressure monitoring (HBPM)

measure BP in both arms:

If the difference in readings between arms is > 20 -> measurements should be repeated. If difference remains > 20 then subsequent blood pressures should be recorded from the arm with the higher reading.

257
Q

classification of HTN?

A

Stage 1:

Clinic BP >= 140/90 and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg

Stage 2:

Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg

Severe HTN:

Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 110 mmHg

Malignant:

BP > 180/110 + papilloedema and/or retinal haemorrhage

258
Q

what is isolated systolic HTN?

A

SBP ≥140, DBP <90

259
Q

what is

Ambulatory blood pressure monitoring (ABPM)?

A

at least 2 measurements per hour during the person’s usual waking hours (for example, between 08:00 and 22:00)

use the average value of at least 14 measurements

260
Q

what is

Home blood pressure monitoring (HBPM)?

A

for each BP recording, two consecutive measurements need to be taken, at least 1 minute apart and with the person seated

BP should be recorded twice daily, ideally in the morning and evening

BP should be recorded for at least 4 days, ideally for 7 days

discard the measurements taken on the first day and use the average value of all the remaining measurements

261
Q

mx if BP >180/110 in clinic?

A

immediate treatment should be considered

if there are signs of papilloedema or retinal haemorrhages -> same day assessment by a specialist

NICE also recommend referral if a phaeochromocytoma is suspected (labile or postural hypotension, headache, palpitations, pallor and diaphoresis)

262
Q

causes of aortic stenosis?

A

degenerative calcification (most common cause in older patients > 65 years)

bicuspid aortic valve (most common cause in younger patients < 65 years)

William’s syndrome (supravalvular aortic stenosis)

post-rheumatic disease

subvalvular: HOCM

263
Q

Clinical features of symptomatic disease
of aortic stenosis?

A

chest pain

dyspnoea

syncope

264
Q

Features of severe aortic stenosis?

A

narrow pulse pressure

slow rising pulse

delayed ESM

soft/absent S2

S4

thrill

duration of murmur

left ventricular hypertrophy or failure

265
Q

signs of aortic stenosis?

A

slow rising pulse w narrow Pulse pressure

aortic thrill

apex: forceful, non-displaced (pressure overload)

heart sounds: Quiet A2, early syst ejection click if pliable (young) valve +/- S4

Murmur: ESM @ right 2nd ICS,

sitting forward in end expiration, radiates to carotids

266
Q

aortic stenosis vs aortic sclerosis?

A

aortic stenosis:

valve narrowing due to fusion of the commissures

narrow PP, slow rising pulse

forceful apex

ESM radiating -> carotids

ECG: LVF

aortic sclerosis:

valve thickening

ESM w no radiation

267
Q

differential for aortic stenosis?

A

Mitral regurg

coronary artery disease

aortic sclerosis

HOCM: ESM murmur which increases in intensity w valsalva

268
Q

Ix of Aortic Stenosis?

A

Bloods: FBC, u+E, glucose, lipids

ECG: LVH, LV strain, LBBB or complete AV block (septal calcification) -> may need pacing

CXR: LVH, calcified Aortic valve, evidence of heart failure, post-stenotic aortic dilatation

Echo + doppler: diagnostic

  • thickened, calcified, immobile valve cusps
  • assess severity of AS

Cardiac catheterisation + angiography:

can assess LV function, valve gradient

assess coronaries in all pts planned for surgery

Exercise stress test:

contraindicated if symptomatic

may be useful to assess exercise capacity in asympto pts

269
Q

what is the criteria to assess severity of aortic stenosis on echo?

A

pressure gradient > 40 mmHg

jet velocity >4m/s

Valve area <1 cm2

270
Q

Mx of aortic stenosis?

A

medical:

regular follow ups w echo

optimise risk factors: statins, anti-hypertensives, DM

Angina: BB

Heart failure: ACEi, diuretics

Avoid nitrates

Surgical:

Valve replacement

Options for unfit pts: TAVI - transcatheter aortic valve implantation,

balloon valvuloplasty

271
Q

indications for valve replacement in aortic stenosis?

A

severe asymptomatic AS

severe asymptomatic AS w decreased ejection fraction (<50%)

severe AS undergoing CABG or other valve op

*poor prognosis if symptomatic:

  • angina/ syncope: 2-3 yrs
  • LVF: 1-2 yrs
272
Q

what are the differences between prosthetic and mechanical valves?

A

mechanical last longer but need anticoagulation:

younger pts

prosthetic valves do not require anticoagulation but fail sooner

273
Q

when is a TAVI indicated?

A

used in aortic stenosis

  • for unfit patients not suitable for valve replacement

folded valve deployed in aortic root

274
Q

adverse effects of statins?

A

myopathy: includes myalgia, myositis, rhabdomyolysis and asymptomatic raised creatine kinase.

liver impairment: the 2014 NICE guidelines recommend checking LFTs at baseline, 3 months and 12 months. Treatment should be discontinued if serum transaminase concentrations rise to and persist at 3 times the upper limit of the reference range

some evidence that statins may increase the risk of intracerebral haemorrhage in patients who’ve previously had a stroke

275
Q

causes of HTN?

A

Primary: 95%

Renal: RAS, GN, APKD

Endo: Cushings, phaeo, acromegaly, Conns, thyrotoxicosis

Drugs: cocaine, NSAIDs, OCP

Coarctation of aorta

276
Q

end organ damage due to HTN?

A

CANER

Cardiac: Ischaemic heart disease, LVH -> CCF, AR, MR

Aortic: dissection, aneurysm

Neuro: CVA: ischaemic, haemorrhagic, encephalopathy (malignant HTN)

Eyes: hypertensive retinopathy

renal: proteinuira, chronic renal failure

277
Q

ix of HTN?

A

24h ABPM (for dx)

urine: haematuria, Alb:Cr ratio
bloods: FBC, U+Es, eGFR, glucose, lipids

12 lead ECG: LVH, old infarct

calculate 10 yr CV risk

278
Q

treatment ladder for antihypertensives?

A

<55: start with ACEi (or ARB)

e.g. lisinopril (or candesartan)

>55 or afrocarribean: start with CCB (e.g. nifedipine/ amlodipine)

step 2:

ACEi + CCB

step 3:

add thiazide diuretic (e.g. chlorthalidone or indapamide)

step 4:

  • consider further diuretic treatment
  • if potassium < 4.5 mmol/l add spironolactone 25mg od
  • if potassium > 4.5 mmol/l add higher-dose thiazide-like diuretic treatment
  • if further diuretic therapy is not tolerated, or is contraindicated or ineffective, consider an alpha- or beta-blocker

Patients who fail to respond to step 4 measures should be referred to a specialist.

279
Q

Blood pressure targets in clinic?

A

Age >80: 150/90

age <80: 140/90

280
Q

blood pressure targets for ABPM/ HBPM?

A

age >80: 145/85

age <80: 135/85

281
Q

options for pts who are intolerant of established antihypertensive drugs?

A

direct renin inhibitors

e.g. Aliskiren

by inhibiting renin blocks the conversion of angiotensinogen to angiotensin I

-> reduces BP

282
Q

CTPA vs V/Q scan?

A

CTPA is imaging of choice

if CTPA -ve -> pts do not need further ix or tx for PE

V/Q scan may be used instead if pt has allergy to contrast media or renal impairment. and may be used initially if CXR is normal, and no significant symptomatic concurrent cardiopulmonary disease

283
Q
A

Large saddle embolus straddling the main pulmonary artery bifurcation

CT pulmonary angiogram

-> PE

284
Q

e.g. of thiazide like diuretic used in step 3 of HTN?

A

chlortalidone 25-50mg OD

indapamide

285
Q

what is the gold standard ix for PE?

A

Pulmonary angiography CT

286
Q

Indications for pharmacological tx of HTN?

A

<80 yo: Stage I HTN +

  • target organ damage
  • 10yr CV risk >20%
  • established CVD
  • DM
  • renal disease

anyone w stage 2 HTN (>160/100)

severe/ malignant HTN (specialist referral)

consider specialist opinion if <40 yrs w stage I HTN and no end organ damage

287
Q

Mx of HTN?

A

Conservative:

lifestyle interventions- exercise, decrease smoking/ alcohol/ salt/ caffeine

Medical:

ACEi / CCB (if >55 or afrocarribean)

Statins for pirmary prevention of CVD

aspirin may be indicated: evaluate risk of bleeding

288
Q

mx of malignant HTN?

A

controlled decrease in BP over days to avoid stroke

atenolol or long acting CCB PO

encephalopathy/ CCF: frusemide + nitroprusside / labetalol IV

  • aim to decrease BP to 110 diastolic over 4 h
  • nitroprusside requires intral arterial BP monitoring
289
Q

definition of cardiogenic shock??

A

inadequate tissue perfusion primarily due to pump failure

290
Q

causes of cardiogenic shock?

A

Infarction: MI

Electrolytes: HyperK

Infection: endocarditis

arrhythmias

aortic dissection

Obstructive: tension pneumo, massive PE

291
Q

mx of cardiogenic shock?

A

A-> E approach

Oxygen: 15L via non rebreather mask

IV access + monitor ECG (bloods for U+E, troponin, ABG)

Diamorphine 2.5-5mg IV + metoclopramide 10mg IV

Correct any electrolyte disturbance, arrhythmias, acid-base abnormalities

Ix: CXR, Echo, CT thorax (PE/ dissection)

consider need for dobutamine

tx underlying cause

292
Q

causes of pulmonary oedema?

A

cardiogenic:

MI

arrhythmia

fluid overload: renal, iatrogenic

non-cardiogenic:

ARDS: sepsis, post op, trauma

Upper airway obstruction

neurogenic: head injury

293
Q

Mx of severe pulmonary oedema?

A

A-> E approach

sit pt up

O2 via 15L nonrebreather mask
IV access + monitor ECG (bloods for U+E, troponin, BNP, ABG)

-> tx any arrhythmias

Morphine 5mg IV + metoclopramide 10mg IV

Frusemide 40-80mg IV

GTN tabs sublingual or nitrate IVI (unless SBP < 90)

if worsening, consider:

CPAP

more frusemide or increase nitrate infusion

haemofiltration/ dialysis

if SBP <100: tx as cardiogenic shock

consider inotropes (dobutamine)

294
Q

role of morphine in pulmonary oedema?

A

make pt more comfortable

pulmonary venodilators -> decrease pre load -> optimise position on starling curve

295
Q

continuing therapy for pts w severe pulmonary oedema after acute mx

A

daily weights

DVT prophylaxis

repeat CXR

change to oral frusemide/ bumetanide

ACEi + BB if HF

consider spironolactone

consider digoxin +/- warfarin (esp if in AF)

296
Q

how long should pts be anticoagulated for after a PE?

A

LMWH or fondaparinux initially (unless thrombolysed)

Warfarin within 24h of diagnosis and continued for at least 3 months

  • if unprovoked PE: 6 months or longer
  • if pt w active cancer: LMWH for 6 months
297
Q

mx of stable angina?

A

conservative: lifestyle changes
medical: optimise RFs, antihypertensives, statins, aspirin

Sublingual GTN to abort angina attacks

1st line- BB or CCB (rate limiting one e.g. verapamil or diltiazem)

2nd: BB + CCB (then use long acting CCB e.g. modified release nifedipine)

Interventional: Percutaneous coronary intervention

Surgery: CABG

298
Q

can BB be prescribed w verapamil?

A

no.

risk of complete heart block!!

verapamil - rate limiting CCB

If giving BB + CCB in angina -> use long acting dihydropyridine CCB e.g. modified release nifedipine

299
Q

Which one of the following types of anti-anginal medication do patients commonly develop tolerance to?

A

standard release isosorbibe mononitrate

(not seen in modified release)

  • develop tolerance and reduced efficacy

the BNF advises that patients who develop tolerance should take the second dose of isosorbide mononitrate after 8 hours, rather than after 12 hours. This allows blood-nitrate levels to fall for 4 hours and maintains effectiveness

300
Q

pt who requires anticoagulation but do not want regular monitoring?

A

consider NOACs

e.g. rivaroxaban

301
Q

What mutation leads to hypertrophic obstructive cardiomyopathy?

A

usually due to mutation of gene encoding B-myosin heavy chain protein

common cause of sudden death

302
Q

echo findings of HOCM?

A

mitral regurg

systolic anterior motion of the anterior mitral valve

asymmetric septal hypertrophy

303
Q

what is arrhythmogenic right ventricular dysplasia?

A

R ventricular myocardium is replaced by fatty and fibrofatty tissue

~50% of pts have mutation of one the genes that encode desmosome

ECG abnormalities in V1-3, typically T wave inversion.

An epsilon wave is found in about 50% of those with ARV - this is best described as a terminal notch in the QRS complex

304
Q

types of cardiomyopathies?

A

genetic: both auto dom
- implantable cardioverter-defibrillator often inserted to reduce incidence of sudden cardiac death
1. HOCM
2. Arrhythmogenic right ventricular dysplasia
mixed: genetic predisposition which is triggered by a secondary process
1. dilated cardiomyopathy
2. restrictive cardiomyopathy

acquired:

  1. peripartum cardiomyopathy
  2. Takotsubo cardiomyopathy

Secondary - pathological myocardial involvement as part of generalized systemic disorder

infective, infiltrative, inflammatory, neuromuscular, autoimmune, storage etc

305
Q

causes of dilated cardiomyopathy?

A

genetic predisposition to cardiomyopathy which is then triggered by the secondary process

Classically:

  • alcohol
  • Coxsackie B virus
  • wet beri beri
  • doxorubicin
306
Q

causes of restrictive cardiomyopathy?

A

genetic predisposition to cardiomyopathy which is then triggered by the secondary process

classically:

amyloidosis

post-radiotx

Loeffler’s endocarditis

307
Q

what is peripartum cardiomyopathy?

A

typically during last month of pregnancy - 5 months post partum

308
Q

what is Takotsubo cardiomyopathy?

A

‘Stress’-induced cardiomyopathy e.g. patient just found out family member dies then develops chest pain and features of heart failure

Transient, apical ballooning of the myocardium

(Takotsubo = jap for octopus trap)

ST elevation + normal coronary angiogram

Treatment is supportive

309
Q

E.g.s of secondary cardiomyopathies?

A

infective: coxsackie B virus, Chagas disease
infiltrative: amyloidosis
storage: haemochromatosis
toxicity: doxorubicin, alcoholic cardiomyopathy
inflammatory: sarcoidosis
endocrine: DM, thyrotoxicosis, acromegaly
neuromuscular: Friedreichs ataxia, duchenne muscular dystrophy, myotonic dystrophy

Nutritional deficiencies: beriberi (thiamine)

autoimmune; SLE

310
Q

if drug therapy fails in managing ventricular tachycardia?

A

electrophysiological study

implantable cardioverter-defibrillator (ICD) - particularly indicated in pts w significantly impaired LV fn

311
Q

when is adrenaline given during a VF/VT cardiac arrest?

A

adrenaline 1 mg given once chest compressions have restarted after the third shock and then every 3-5 mins

312
Q

scale for determining intensity of murmur?

A

The Levine Scale:

Grade 1 - Very faint murmur, frequently overlooked

Grade 2 - Slight murmur

Grade 3 - Moderate murmur without palpable thrill

Grade 4 - Loud murmur with palpable thrill

Grade 5 - Very loud murmur with extremely palpable thrill. Can be heard with stethoscope edge

Grade 6 - Extremely loud murmur - can be heard without stethoscope touching the chest wall

313
Q

what causes a late systolic murmur?

A

mitral valve prolapse

coarctation of aorta

314
Q

early diastolic murmur?

A

aortic regurg (high pitched and blowing in character)

Graham-Steel murmur (pulm regurg)

315
Q

mid late diastolic murmur?

A

mitral stenosis

austin-flint murmur- severe aortic regurg

316
Q

continuous machine like murmur?

A

patent ductus arteriosus

317
Q

Monitoring of pts taking amiodarone prior to starting treatment?

A

TFTs: risk of thyrotoxicosis

LFTs

U+Es: low K+

CXR: risk of pulmonary fibrosis/ pneumonitis

318
Q

long term monitoring of pts taking amiodarone?

A

TFT, LFT every 6 months

319
Q

how does amiodarone work?

A

blocks K+ channels which inhibits repolarisation and hence prolongs Action potential

  • long half life
  • should be given into central veins (causes thrombophlebitis)
  • proarrhythmic effects due to lengthening of QT interval
320
Q

adverse effects of amiodarone use?

A

thyroid dysfunction: hypo + hyperthyroid

eyes: corneal deposits, photosensitivity

pulm fibrosis/ pneumonitis

liver fibrosis/ hepatitis

peripheral neuropathy, myopathy

slate grey appearance

lengthens QT interval, bradycardia

321
Q

cardioversion of paroxysmal AF?

A

if haemodynamically unstable: electrical cardioversion

pharmacological: amiodarone, flecainide (if no structural heart disease)

322
Q

can adenosine be administered through small peripheral vein?

A

no

Adenosine half-life is less than 10 seconds and therefore, a central route or large-calibre vein is required to administer adenosine effectively.

BNF:

For rapid intravenous injection give over 2s into central or large peripheral vein followed by rapid Sodium Chloride 0.9% flush; injection solution may be diluted with Sodium Chloride 0.9% if required.

323
Q

what is adenosine enhanced/ blocked by?

A

enhanced by dipyridamole (anti-platelet)

blocked by theophyllines

avoided in asthmatics due to possible bronchospasm

324
Q

complete heart block after MI - which artery is affected?

A

Right coronary artery

AV node is supplied by the posterior interventricular artery, which in the majority of patients is a branch of the right coronary artery.

325
Q

common side effects of thiazide diuretics?

A

dehydration

postural hypotension

hypoNa, hypoK, hyperCa*

gout

impaired glucose tolerance

impotence

326
Q

A 65-year-old patient with a known history of stable angina is presented to his GP with poor control of his symptoms. He is taking atenolol for the angina. The patient’s allergy notes indicate that he had developed ankle oedema when tried on nifedipine in the past for hypertension. According to NICE guidelines, which of the following drugs can be added to help control his symptoms?

A

if a patient is on monotherapy and cannot tolerate the addition of a CCB or a BB then consider one of the following drugs: a long-acting nitrate, ivabradine, nicorandil or ranolazine

327
Q

1st line tx in bradycardia w signs of haemodynamic compromise?

A

Atropine

If this fails to work, or there is the potential risk of asystole then transvenous pacing is indicated

328
Q

causes of prolonged QT interval?

A

Congenital:

Jervell-Lange-Nielsen syndrome

Romano-Ward Syndrome

Drugs:

amiodarone, sotalol, class 1a antiarrhythmic drugs

TCAs

chloroquine

erythromycin

Electrolytes: hypoCa, hypoK, hypoMg

acute MI, myocarditis

hypothermia

subarachnoid haemorrhage

329
Q
A

Type B dissection, seen in descending aorta

mx:

conservative management

bed rest

reduce blood pressure IV labetalol to prevent progression

330
Q
A

Type A Aortic Dissection

seen in ascending aorta

mx:

surgical management, but BP should be controlled to a target systolic of 100-120 mmHg whilst awaiting intervention

331
Q

Mx of Type 1 HTN?

A

only treat medically if: diabetic, renal disease, QRISK2 >20%, established coronary vascular disease, or end organ damage

lifestyle advice: low salt diet, decrease caffeine intake, stop smoking, drink less, exercise more, lose weight

if QRISK2 10-20% -> offer statin therapy

332
Q

Causes of RBBB?

A

normal variant - more common with increasing age

right ventricular hypertrophy

chronically increased right ventricular pressure - e.g. cor pulmonale

pulmonary embolism

myocardial infarction

atrial septal defect (ostium secundum)

cardiomyopathy or myocarditis

333
Q

most common cause of death following an MI?

A

VF ->cardiac arrest/ arrhythmias

334
Q

complications of MI?

A

immediate:

cardiac arrest (VF)

cardiogenic shock

bradyarrhythmias (AV block)

early:

pericarditis

rupture of interventricular seputm -> VSD

acute mitral regurg due to papillary muscle rupture

late:

Dressler’s syndrome (2-6 wks)

chronic heart failure

L ventricular aneurysm

L ventricular free wall rupture

335
Q

mx of acute mitral regurg due to papillary muscle rupture after MI?

A

vasodilator therapy

often require emergency surgical repair

336
Q

Mx of rupture of interventricular septum following MI?

A

rupture -> VSD

features: acute HF w pan systolic murmur

echo is diagnostic

urgen surgical correction needed

337
Q

mx of left ventricular aneurysm following MI?

A

ischaemic damage sustained may weaken the myocardium resulting in aneurysm formation

-> persistent ST elevation and LV failure

thrombus may form in the aneurysm and increase risk of stroke

Pts should be anticoagulated

338
Q

mx of Dressler’s syndrome?

A

NSAIDs

or

prolonged course of colchicine or steroids

339
Q

mx of chronic heart failure following MI?

A

Loop diuretics such as furosemide decrease fluid overload

ACEi and BBs improve long term prognosis

340
Q

mx of left ventricular free wall rupture following MI?

A

Patients present with acute heart failure secondary to cardiac tamponade (raised JVP, pulsus paradoxus, diminished heart sounds)

urgent pericardiocentesis and thoracotomy needed

341
Q

mx of pt w chest pain in last 12 hrs (now settled) w an abnormal ECG?

A

emergency admission

342
Q

mx of pt w chest pain 12-72h ago?

A

refer to hospital for same day assessment

343
Q

features of Atrial septal defect?

A

ejection systolic murmur, fixed splitting of S2

embolism may pass from venous system to left side of heart causing a stroke

ostium secundum ECG: RBBB w RAD

344
Q

what statin dose is used for secondary prevention?

prev IHD/ CVD/ PAD

A

Atorvastatin 80mg OD

345
Q

what dose of statin is used for primary prevention?

ie chronic kidney disease, T1DM, 10yr CV risk >10%

A

Atorvastatin 20mg OD

(can titrate up after)

346
Q

what protein is affected in Marfans?

A

fibrillin-1

auto dom connective tissue disorder

defect in the FBN1 gene

347
Q

SEs of Beta blockers?

A

bronchospasm

cold peripheries

fatigue

sleep disturbances, including nightmares

erectile dysfunction

348
Q

Contraindications of beta blockers?

A

uncontrolled heart failure

asthma

sick sinus syndrome

concurrent verapamil use: may precipitate severe bradycardia

349
Q

ECG changes seen in hypothermia?

A

bradycardia

‘J’ wave - small hump at the end of the QRS complex

first degree heart block

long QT interval

atrial and ventricular arrhythmias

350
Q

Why are AF patients only cardioverted when its new onset <48h or anticoagulated for 3 wks beforehand?

A

the moment a patient switches from AF to sinus rhythm presents the highest risk for embolism leading to stroke. Imagine the thrombus formed in the fibrillating atrium suddenly being pushed out when sinus rhythm is restored.

For this reason patients must either have had a short duration of symptoms (less than 48 hours) or be anticoagulated for a period of time prior to attempting cardioversion.

351
Q

what scenarios would u choose to rhythm control AF instead of rate control?

A

Use rhythm control to treat AF if there is coexistent heart failure, first onset AF or an obvious reversible cause

e.g. amiodarone

Immediate DC cardioversion is only recommended when there is life-threatening haemodynamic instability caused by new-onset atrial fibrillation.

352
Q

which valve is most commonly affected by IE in IVDU?

A

Tricuspid

353
Q

most common organism causing infective endocarditis?

A

staph aureus

354
Q

coarctation of aorta assoc w?

A

Turner’s syndrome

bicuspid aortic valve

berry aneurysms

neurofibromatosis

355
Q

causes of postural hypotension?

A

hypovolaemia

autonomic dysfunction: diabetes, Parkinson’s

drugs: diuretics, antihypertensives, L-dopa, phenothiazines, antidepressants, sedatives

alcohol

356
Q

long term antiplatelets after Peripheral arterial disease?

A

1st line: lifelong clopidogrel

2nd: lifelong aspirin

357
Q

long term antiplatelets after ischaemic stroke?

A

1st line: lifelong clopidogrel

2nd line: lifelong aspirin + dipyridamole

358
Q

long term antiplatelet therapy after TIA?

A

1st line: lifelong clopidogrel

2nd line: lifelong aspirin + dipyridamole

359
Q

long term antiplatelet therapy after Percutaneous coronary intervention?

A

1st line: Aspirin (lifelong) & prasurgrel or ticagrelor (12 months)

2nd line: lifelong clopidogrel

360
Q

long term antiplatelets after acute coronary syndrome (medically treated)?

A

1st line: Aspirin (lifelong) & ticagrelor (12 months)

2nd line: lifelong clopidogrel

361
Q

Patients on warfarin undergoing emergency surgery?

A

give four-factor prothrombin complex concentrate

If surgery can wait for 6-8 hours - give 5 mg vitamin K IV

362
Q

causes of cardiac syncope?

A

arrhythmias: bradycardias (sinus node dysfunction, AV conduction disorders) or tachycardias (supraventricular, ventricular)
structural: valvular, MI, HOCM
others: PE

363
Q

causes of orthostatic syncope?

A

primary autonomic failure: Parkinson’s, Lewy body dementia

secondary autonomic failure: e.g. Diabetic neuropathy, amyloidosis, uraemia

drug-induced: diuretics, alcohol, vasodilators

volume depletion: haemorrhage, diarrhoea

364
Q

causes of reflex syncope?

A

vasovagal: triggered by emotion, pain or stress. Often referred to as ‘fainting’
situational: cough, micturition, gastrointestinal

carotid sinus syncope

365
Q

evaluation of pt with syncope?

A

cardiovascular examination

postural blood pressure readings: a symptomatic fall in systolic BP > 20 mmHg or diastolic BP > 10 mmHg or decrease in systolic BP < 90 mmHg is considered diagnostic

ECG

carotid sinus massage

tilt table test

24 hour ECG

366
Q

What is the pulse like in Severe Left HF?

A

Pulsus alternans:

regular alternation of the force of the arterial pulse

(strong-weak-strong-weak)

367
Q

diagnostic test of choice for cardiac tamponade?

A

echocardiogram

368
Q

Mx of chronic limb ischaemia?

A

Non-surgical:

  • CV risk factor control
  • Antiplatelet agents
  • Analgesia
  • Graded exercise programs: walk through pain

Interventional:
Angioplasty ± stenting

  • *Surgical:**
  • Reconstruction
  • Endarterectomy
  • Amputation
369
Q

Mx of acute limb ischaemia?

A

Resus: NBM, hydration, analgesia

UH IVI: prevent thrombus extension

Angiography: only if incomplete occlusion

Surgery

  • Embolectomy w Fogarty catheter
  • Emergency reconstruction

Treat cause

  • e.g. warfarinise
  • Mx CV risk
370
Q

SEs of GTN?

A

hypotension

tachycardia

headaches

flushing

371
Q

Statins + erythromycin/clarithromycin -??

A

statin-induced myopathy

372
Q

Mx of Long QT syndrome?

A

beta-blockers***

implantable cardioverter defibrillators in high risk cases

***not sotalol

373
Q

when should a gpIIb./IIIa receptor antagonist be used in STEMI?

A

e.g. eptifibatide or tirofiban

should be given to patients who have an intermediate - high risk of adverse CV events, and who are scheduled to undergo angiography within 96 hours of hospital admission.
(ie. PCI)

374
Q

What dose of adrenaline should be given during a cardiac arrest?

A

1mg

375
Q

what are Ticagrelor and prasugrel?

A

now the preferred second antiplatelet instead of clopidogrel

376
Q

What is the dose of hydrocortisone administered in anaphylaxis?

A

200mg

377
Q

What is the dose of adrenaline administered in anaphylaxis?

A

0.5 ml 1:1000 or 500 mcg

378
Q

What is the dose of chlorphenamine administered in anaphylaxis?

A

10mg

379
Q

If unsure of anaphylaxis, what ix can be used to confirm?

A

Serum tryptase levels

remain elevated for up to 12h following an acute episode of anaphylaxis.

380
Q

Mx of Aortic stenosis general rules?

A

if asymptomatic -> conservative

if symptomatic -> valve replacement

if asymptomatic but valve gradient >40mmHg and features of LV systolic dysfn -> consider surgery

Critical AS not fit for valve replacement -> balloon valvuloplasty

381
Q

An elderly man with aortic stenosis is assessed. Which one of the following would make the ejection systolic murmur quieter?

A

Left ventricular systolic dysfunction will result in a decreased flow-rate across the aortic valve and hence a quieter murmur.

382
Q

Apart from clopidogrel, what other antiplatelets can be added to aspirin post-MI?

A

ticagrelor and prasugrel (also ADP-receptor inhibitors)

stop the second antiplatelet after 12 months

383
Q

What mx for patients who have had an acute MI and who have symptoms and/or signs of heart failure and left ventricular systolic dysfunction?

A

treatment with an aldosterone antagonist licensed for post-MI treatment (e.g. eplerenone) should be initiated within 3-14 days of the MI, preferably after ACE inhibitor therapy

384
Q

what diuretic increases risk of gout?

A

Thiazide diuretics reduce uric acid excretion from the kidneys

385
Q

ECG finding of hyperCa?

A

Shortening of QT interval

386
Q

Heart failure medical mx?

A

1st: ACEi + BB
2nd: aldosterone antagonist, ARB or hydralazine + nitrate
3rd: cardiac resynchronisation therapy or digoxin or ivabradine

**diuretics should be given for fluid overload

387
Q

normal corrected QT interval?

A

< 430 ms in males and 450 ms in females.

388
Q

congenital causes of a prolonged QT interval?

A

Jervell-Lange-Nielsen syndrome (includes deafness)

Romano-Ward syndrome (no deafness)

389
Q

Drugs that cause Long QT syndrome?

A

amiodarone, sotalol

TCAs, SSRIs (esp citalopram)

erythromycin

haloperidol

390
Q

causes of long QT syndrome?

A

electrolyte: hypoCa, hypoK, hypoMg
MI
myocarditis
hypothermia
subarachnoid haemorrhage

391
Q

Mx of Long QT syndrome?

A

avoid drugs which prolong the QT interval and other precipitants if appropriate (e.g. Strenuous exercise)

BBs

ICD in high risk cases

392
Q

monitoring of pts taking amiodarone?

A

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

TFT, LFT every 6 months

Medicine (16 decks)

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