Cardiology Flashcards
Name 3 ECG features seen in hypokalaemia?
U waves
Small/ absent/ inverted T waves
ST depression
What is the screening recommendation for AAA?
M >65 should all have one time screening
M > 55 with FHx should have one time screening
You suspect a patient has a leaking AAA, what is your first investigation?
Abdominal US
A patient has an abdominal US for a suspected leaking AAA, this is inconclusive, which is the next investigation to try?
CT
MRI aortography for surgical planning if CT unavailable
How would you manage an AAA which was 3.6cm?
3-4.4cm: Do annual ultrasound to monitor
4.5-5.4cm: Do 3 monthly ultrasound to monitor
>5.5cm: Consider surgery (and continue 3 monthly US until that time)
How would you manage an AAA which was 4.9cm?
3-4.4cm: Do annual ultrasound to monitor
4.5-5.4cm: Do 3 monthly ultrasound to monitor
>5.5cm: Consider surgery (and continue 3 monthly US until that time)
How would you manage an AAA which was 5.7cm?
3-4.4cm: Do annual ultrasound to monitor
4.5-5.4cm: Do 3 monthly ultrasound to monitor
>5.5cm: Consider surgery (and continue 3 monthly US until that time)
What are the two options for surgical management of AAA and when would each be used?
EVAR - If >1.2cm below renal arteries (65%)
Otherwise open surgery
A 62 year old woman is admitted to the medical ward with a 3 week history of fevers and lethargy. On examination you note a few splinter haemorrhages in the finger nails and a loud systolic murmur at the apex. Your consultant instructs you to take 3 sets of blood cultures and to arrange an ECHO.
Which organism (and type) is most likely to have grown?
Infective endocarditis
- staph aureus followed by strep viridans
What is the most common organism responsible for infective endocarditis for those with prosthetic valves?
Staph epidermidis
What is the most common organism responsible for infective endocarditis for IVD users?
Staph aureus
You are doing a medication review on a 79-year-old man. His current medications include aspirin, verapamil, allopurinol and co-codamol. Which one of the following is it most important to avoid prescribing concurrently?
Colchicine Digoxin Simvastatin Tramadol Atenolol
Atenolol
Beta-blockers combined with verapamil can potentially cause profound bradycardia and asystole.
A 58year old male is one month post STEMI. Which drugs should he be taking?
All post MI patients - CRABS (5)
Clopidegrel (or ticagrelor) Ramipril Aspirin B-blocker (Metoprolol/ biso/carvedi) Statins (Atorvastatin 80mg)
Following a stroke treated only with aspirin, what medication should a 59 year old gentlemen take following his discharge on D14?
All stroke patients should take Clopidogrel (lifelong) and a Statin (lifelong) as secondary prophylaxis
If allergic to Clopi, can take aspirin plus dipyridamole
A 52-year-old male attends the stroke unit with dizziness and vertigo while playing tennis. He is known to have hypertension and a previous myocardial infarct. He now complains of right arm pain. What is the most likely diagnosis?
Subclavian steal syndrome characteristically presents with posterior circulation symptoms, such as dizziness and vertigo, during exertion of an arm.
An 85 year old gentlemen has ambulatory blood pressure monitoring. At what cut off would he be given antihypertensive medication?
Stage 2 (Clinic >160/100) (ABPM > 150/95)
Only treat stage one if under 80
An 65 year old gentlemen has ambulatory blood pressure monitoring. At what cut off would he be given antihypertensive medication?
Stage 1 (Clinic > 140/90) (ABPM > 135/85)
What is first line antihypertensive for:
a) White 50 yo F
b) Black 48 yo F
c) White 70 yo M
d) Black 64 yo M
a) ACEI
b) CCB
c) CCB
d) CCB
A 69-year-old man presents to his GP with progressively worsening breathlessness over a two month period. It is associated with a cough productive of white sputum which is worse at night. He has recently had some flu-like symptoms which lasted around two weeks and are now mostly resolving. When asked about night symptoms he says he is finding it harder to sleep lying down due to coughing and breathlessness and has been sleeping in his chair. He has a past medical history of chronic kidney disease, hypertension and angina as well as a 30-pack-year smoking history.
O/E pulse 71 bpm, BP 146/81 mmHg, temperature 36.7ºC and sats 93% on air. His chest expands equally and he has crackles audible at both bases and a widespread quiet wheeze. MLD?
Pulmonary oedema
- Orthopnea
- Clear sputum
- Hypoxia
- Bi-basal crackles
Pulmonary odema can also cause wheeze
During a cardiac arrest, whilst the defibrillator is charging, what should be done regarding chest compression’s?
Keep doing chest compression’s whilst defib is charging
During a VT/VF cardiac arrest, when should adrenaline and amiodarone been given?
1mg adrenaline and 300mg amiodarone IV once chest compressions have restarted after the THIRD shock.
Then every 3-5mins
During a pulseless/ asystole cardiac arrest what treatment should be initiated?
Asystole/pulseless-electrical activity should be treated with 2 minutes of CPR prior to reassessment of the rhythm
(Don’t shock)
A 25-year-old man with a history of Marfan’s disease presents with sudden onset shortness of breath and pleuritic chest pain. MLD?
Pneumothorax
A 67-year-old female with a history of chronic lymphocytic leukaemia presents with a 3 day history of burning pain in the right lower chest wall. Clinical examination is unremarkable. MLD?
Shingles
Pain and paraesthesia often proceeds the rash.
What are the first three steps in acute management of a narrow complex tachycardia?
1) Vasovagal manouvres
2) IV adenosine 6-12mg
3) Electrical cardioversion
Which two rhythms are shockable, when should a defibrilator be used?
VF or pulseless VT
Used defib as soon as possible
What advice should pregnant asthmatics be given regarding use of SABA’s and ICS’s?
Use as normal during pregnancy
A 29-year-old man presents complaining of central chest pain that occurs in the mornings upon waking up. Sometimes it comes on while playing computer games. He doesn’t seem to experience this pain while working out even though he describes his workouts as ‘intense and sweaty’. He does not have any risk factors for cardiovascular disease. His heart sounds are normal. MLD and explanation of disease?
Prinzmetal angina
Coronary artery vasospam - most episodes occur in the easy morning
A baby is delivered on the ward and on the neonatal examination a systolic heart murmur is heard. An echocardiogram shows right atrial hypertrophy and the septal and posterior leaflet of the tricuspid valve attached to the right ventricle. What is this condition most commonly known as?
Ebstein’s anomaly
Low tricuspid valve giving a large atrium and small ventricle
What clotting result is used to distinguish between haemophillia and von Willibrands?
Haemophillia = Normal bleed time vWD = Increased bleed time
Both have raised APTT and normal prothrombin time
What test should be used to monitor heparin levels?
APTT
What test should be used to monitor LMWH levels?
Anti-factor Xa (although routine monitoring not required)
What agent can be used to reverse heparin overdose?
Protamine sulphate
What is first line treatment for torsades de pointes? (3)
IV Magnesium Sulphate
- Also stop all QT prolonging drugs
- May need resus and defib if they go into VT
Note most torsades de pointes is fairly brief, however often reoccurs and can put px into VT
A patient with a tachycardia is unstable, what is the first line treatment?
Syncronised DC shocks
(AF, broad-complex and narrow complex tachycardias now all treated as above if unstable - i.e. hypotensive, MI, syncope, heart failure)
What is first line treatment for a regular broad complex tachycardia in a stable patient?
IV amiodarone (loading dose followed by 24-hr infusion)
- Could then consider lidnocaine or procainamide
What is first line treatment for an irregular broad complex tachycardia in a stable patient?
(Possible AF with bundle branch block)
- If onset <48hrs consider cardioversion
- Otherwise rate control (beta blocker or digoxin)
Don’t forget anticoagulation
What is the treatment for a regular narrow complex tachycardia in a stable patient?
1st: Vagal manoeuvres (sinus massage)
2nd: IV adenosine (6mg > 12mg)
3rd: Beta blockers to control rate
NB: 12mg adenosine CI in asthmatics
What is first line treatment for a irregular narrow complex tachycardia in a stable patient?
- If onset <48hrs consider cardioversion
- Otherwise rate control (beta blocker or digoxin)
Don’t forget anticoagulation
What are the conditions to provide drug treatment to someone with stage 1 hypertension?
Any of: < 80 End organ damage Diabetic/ renal/ CV disease QRisk2 > 20%
If none lifestyle advice only
What are the appropriate blood pressure targets for a patient with T2DM?
- If end-organ damage (e.g. renal disease, retinopathy) < 130/80 mmHg
- Otherwise < 140/80 mmHg
A 53-year-old man presents as he is worried about palpitations. These are described as fast and irregular and typically occur twice a day. They seem to be more common after drinking alcohol. There is no history of chest pain or syncope. Examination of his cardiovascular symptoms is normal with a pulse of 72/min and a blood pressure of 116/78 mmHg. Blood tests and a 12-lead ECG are unremarkable. What is the most appropriate next step in management?
Arrange a Holter monitor (24-hr ECG)
A 72-year-old female presents with irregular palpitations and feelings of light headedness for one month. Her pulse is regular at 84 beats per minute and her ECG is not indicative of any specific pathophysiology. On examination, you note a grade 3 diastolic murmur and when measuring her pulse you notice that her head nods subtly in time with her heart beat. MLD?
Aortic regurgitation
What are the three most common causes of an Ejection systolic murmur?
Aortic sclerosis Aortic stenosis (murmur radiates to carotids + narrow pulse pressure)
- Pulmonary stenosis
- ASD
- HOCM
What are the two most common causes of a pan systolic murmur?
Mitral regurgitation
VSD
What is the most common cause of an early diastolic murmur, what other characteristics are associated?
Aortic regurg
Louder on expiration and when leaning forward
Associated with collapsing pulse
What are the causes of a mid/ late diastolic murmur?
Mitral stenosis
Mitral valve prolapse
Coarctation of the aorta
What is the most common cause of a continuous murmur?
Patent ductus arteriosus
A 77-year-old woman is admitted to the ED with a three day history of lethargy and shortness-of-breath. She is confused and unable to give much useful history. On examination she is noted to be pale, pulse is irregular and around 160/min with a blood pressure of 80/56 mmHg. Her oxygen saturations are 96% on room air. An intravenous cannula is placed and bloods taken showing Hb 8.6. An ECG shows ST elevation. What’s your immediate management?
DC cardioversion
This patient is clearly unwell and hence we should following basic ALS - in this case the peri-arrest protocols. In simple terms if a patient has an arrhythmia and is showing signs of decompensation (hypotension, heart failure etc) then they should be immediately cardioverted. Whilst it is possible that an acute coronary syndrome has triggered everything both thrombolysis and percutaneous coronary intervention cannot be attempted given the tachycardia.
A 70-year-old man with an existing diagnosis of 5.0 cm abdominal aortic aneurysm and atrial fibrillation presents with acute onset abdominal pain radiating to his back. He is still actively bleeding and his observations show the following:
Blood pressure 90/40 mmHg
Heart rate 140 beats per minute
The decision is made to proceed with emergency surgery within the next thirty minutes What is the most appropriate management of his warfarin therapy?
Patients on warfarin undergoing emergency surgery - give four-factor prothrombin complex concentrate
A 7-year-old girl is brought to her GP by her mother. She is conscious but clearly struggling to breathe and has an urticarial rash on her body. The mother states that she saw another GP at the practice that morning and was prescribed a course of antibiotics for impetigo. The GP suspects she is having an anaphylactic reaction to the antibiotic. What dose of IM adrenaline should she administer?
300mcg
Children < 6 = 150mcg
Children 6-12 = 300mcg
Adults = 500mcg (1:1000)
(Always also give hydrocortisone and chloramphenimine)
What is a normal ejection fraction? (LVEF). In what common cardiomyopathies is the EF preserved and reduced?
Normal = >55%
Preserved: Hypertrophic
Reduced: Dilated
A 35-year-old Singaporean female attends a varicose vein pre operative clinic. On auscultation a mid diastolic murmur is noted at the apex. The murmur is enhanced when the patient lies in the left lateral position. MLD?
Mitral stenosis
Classically rumbling mid-late diastolic murmur
You hear an ejection systolic murmur, what is the main way to differentiate between Aortic Stenosis and Aortic Sclerosis?
Aortic stenosis = Carotid radiation and LVH on ECG (big QRS’)
Aortic sclerosis = No carotid radiation, no ECG changes
How do you manage a major bleed in a patient on Warfarin?
(regardless of INR with major bleed)
1) Stop Warfarin
2) Give 5mg of IV vitamin K
3) Give prothrombin complex concentrate or FFP
How do you manage a minor bleed in a patient on Warfarin?
Stop warfarin
Give IV vitamin K 1-3mg (dose can be repeated after 24hrs if still over INR of 5)
Restart when INR < 5.0
How do you manage an INR of >8? (assuming no known bleeding)
Stop warfarin
Vit K orally 1-5mg
How do you manage an INR of 5-8? (assuming no known bleeding)
Withold 1-2 doses and recheck INR
A 75-year-old woman has suffered recurrent falls due to orthostatic hypotension. She has tried conservative measures such as taking in more fluid and salt. Her medications have been reviewed and some of her medications have been stopped. She has also tried wearing compression stockings. Nevertheless, she still suffers dizziness on standing up.
What is a possible medication option to reduce her symptoms?
Fludrocortisone and midodrine
What are the two most characteristic side effects of ACEI?
Cough
Hyperkalaemia
Renal disfunction
Angioedema
A 65-year-old man comes to see you as he has noticed that he has become increasingly short of breath and has to sleep with 3 or 4 pillows to help him breathe at night. He also reports feeling more breathless after climbing 1 flight of stairs. His past medical history includes high cholesterol and myocardial infarction.
On examination, you auscultate bibasal crepitations and note that his ankles appear swollen. Most appropriate investigation?
This patient has had a myocardial infarction in the past, therefore suspected heart failure should be investigated further with an echocardiogram within 2 weeks.
If the person has not had a previous myocardial infarction then, suspected heart failure should be investigated further with a B-type natriuretic peptide (BNP) blood test.
Also all should have an ECG
You suspect someone is having an event of ACS, what management is indicated prior to investigation?
GTN and 300mg aspirin
What is mortality of ACS at 6 months (if treated)?
15%
Anterior MI’s show most in which leads? Which artery is affected?
V1-V4
Left anterior decending
Inferior MI’s show most in which leads? Which artery is affected?
II, III, aVF
Right coronary
How do posterior MI’s present on an ECG?
Tall R waves in V1-V2
Possible ST depression in V1-V4 (reciprocal change)
What are the criteria for PCI in suspected ACS? (3 things on ECG and time criteria)
- ST elevation (2mm in anterior leads, 1mm in I,II,III,avF)
- Any new LBBB
- Posterior changes (ST depression + big R waves in V1-V3)
- Must be within 12 hours of symptom onset
You are seeing a patient in GP. They had cardiac sounding chest pain in the last (X) hours, what action do you take when X is:
a) Last 12 hours
b) 12-72 hours
c) >72 hours
a) Emergency hospital for same day assessment
b) Refer to medics for same day assessment
c) Perform ECG and trops before deciding further action
What is the most common complication of an MI within the first 48hours?
Pericarditis
Within 48 hours of an MI a patient presents with signs of LVF, dropping BP and a new murmur, what is most likely diagnosis?
Papillary muscle rupture
or ventricular septal rupture
What are the conditions for the Framingham criteria to diagnose heart failure? Name 4 of each criteria?
2 major or 2 maj + 1min
Major: PND, bilateral creps, neck vein distension, S3 gallop, cardiomegaly
Minor: Bilateral ankle odema, dyspnoea on exertion, HR > 120, nocturnal cough
How do you investigate a patient who meets the framingham criteria?
If previous MI: Echo in 2 weeks If no MI - do BNP - BNP < 100 (alternative diagnosis) - 100-400 = Echo in 6 weeks >400 = Echo in 2 weeks
Name the New York Heart Failure Classification
Stage I - No symptoms
Stage 2 - Slight limit of physical activity
Stage 3 - Exertion leads to symptoms
Stage 4 - Unable to undertake normal activity due to symptoms
Name the first four lines of heart failure management?
(Fursemide added for symptoms relief)
1) ACEI and BB
2) + Spironolactone
3) Add digoxin
4) Add hydralazine or isosorbide dinitrate
If symptoms require may need to consider CPAP
Which 2 BB’s can be used in heart failure?
Carvedilol or bisoprolol
Name 5 common features of cardiac tamponade?
SOB
Chest pain
Pulsus paradoxus (exaggerated decrease in BP on inspiration)
Features of pericarditis
Beck’s triad (muffled heart sounds, raised JVP, falling BP)
What is the classic presentation of pericarditis? (3)
Chest pain (dull or sharp or burning) - Worse on inspiration/ coughing - Better leaning forward and sitting up Pericardial friction rub (pathognomonic) Tachycardia, tachypnoea and fever
What is first line management for pericarditis?
Naproxen or other NSAID (14days)
- If lasting over one week do blood cultures and consider AB’s
Use Colchicine for 3 months to reduce risk of return
How do you manage cardiac tamponade (1)?
Pericardiocentesis (usually under echo guidance)
How is aortic stenosis managed? (3 points)
Asymptomatic = Monitor
Symptomatic = Valve replacement
Asymptomatic but valvular gradient >40mmHg = Consider replacement
Name 4 common side effects of beta blockers
Bronchospasm
Cold peripheries
Fatigue
Sleep disturbances, including nightmares
Name three containdications for use of beta blockers
Asthma
Concurrent verapamil use
Uncontrolled heart failure
A 56 year old male patient is diagnosed with angina. What is the first line treatment? (5)
LIFESTYLE ADVICE
+ Aspirin (75mg)
+ Atorvastatin (10-20mg)
Plus rescue GTN spray (PRN, use upto 3x in one go)
1st: Beta blocker or calcium channel blocker
In terms of anti-anginal therapy, what are the first three lines of treatment for stable angina?
1st: BB or CCB (verapamil or diltiazem)
2nd: BB and CCB (amlodipine/ nifedipine)
- Put to max dose before moving to (3)
3rd: Isosorbide mononitrate OR ivabradine OR nicorandil OR ranolazine
NB: Consider revascularisation before 3rd drug (i.e. CABG)
What advice should a patient with angina be given about sexual activity? (2)
If the patient can climb up and down two flights of stairs briskly without any symptoms of angina, sexual activity is unlikely to precipitate an episode of angina.
(if it does take GTN before intercourse)
- DO NOT combine GTN and viagra within a 24 hour period ever
How is HOCM inherited?
Autosomal dominant
You are working in a GP practice. Your next patient is a 27-year-old female who has just found out she is 6 weeks pregnant. She has a past medical history of familial hypercholesterolaemia, type 1 diabetes and asthma. She uses salbutamol and beclometason inhalers, regular insulin and takes atorvastatin. What should your next step in management be?
Stop statin
Pregnancy is a contraindication to statin therapy
Where do loop diuretics act?
Ascending loop of Henle
You are called to see a 74-year-old patient who is complaining that her heart is racing. On examination, her heart rate is 209bpm and she appears breathless. She states that she is now experiencing chest pain. What is the most appropriate management step?
Synchronised DC cardioversion
Patients with tachycardia and signs of shock, syncope, myocardial ischaemia or heart failure should receive up to 3 synchronised DC shocks
What is first line treatment for the management of bradycardia?
Atropine
Name three symptoms of aortic stenosis and 2 associated signs?
SAD (syncope, angina, dyspnoea on exertion)
Ejection systolic murmur
Narrow pulse pressure and slow rising pulse
A VSD would present with what kind of murmur?
Pansystolic
First three lines of management for a 66 year old patient in AF?
1) Bisoprolol
2) CCB
3) Digoxin (still first line if also heart failure)
A young patient presents with paroxysmal AF. They have no structural heart disease. First line management?
Flecanide
A young patient presents with paroxysmal AF. They are known to have HOCM. First line management?
Amiodarone
Flecanide only used if no structural heart disease
What is the definition of stage 1 hypertension?
Over 140/90 in clinic
Over 135/85 for HBPM
What is the definition of stage 2 hypertension?
Over 160/100 in clinic
Over 150/95 for HBPM
What is the definition of stage 3 hypertension?
Systolic over 180
OR
Diastolic over 110
What is 3rd, 4th and 5th line treatment for hypertension?
3) ACEI + CCB + Thiazide (Chlorthalidone or indapamide)
4) If K+ <4.5 then add spironolactone
If K+ >4.5 add higher dose thiazide diuretic
5) Add alpha or beta-blocker (doxazosin or bisoprolol)
What are the first three lines of management for pre-eclampsia?
Labetolol > nifidipine > hydralazine
What considerations must be taken when starting a patient on ACEI? (2)
Check renal function in 7-10 days
Advise risk of first dose hypotension
Name 3 side effects of alpha blockers (doxazosin or prazosin)
Headache
Drowsiness
Weakness
Blurred vision
What is first line hypertension medication for diabetics who are a) over 55 and b) under 55
Both should be ACEI first line
Only exception in afro-carribean always use ARB before ACEI
A 12-year-old female from Bulgaria presents to the surgery. She reports being unwell for the past 2 weeks. Initially she had a sore throat but she is now experiencing joint pains intermittently in her knees, hips and ankles. On examination there are some pink, ring shaped lesions on the trunk and occasional jerking movements of the face and hands. What is the most likely diagnosis?
Rheumatic fever develops following an immunological reaction to recent (2-6 weeks ago) Streptococcus pyogenes infection. Diagnosis is based on evidence of recent streptococcal infection accompanied by:
- erythema marginatum
- Sydenham’s chorea
- polyarthritis
- carditis (endo-, myo- or peri-)
- subcutaneous nodules
Name 3 features of co-arctation of the aorta?
Systolic murmur - loudest at back or L sternal edge
Hypertension (HF in kids)
Weak femoral pulses and radio-femoral delay
Name 5 drugs/ classes which cause long-QT
Tricyclic's Antipyschotics (typical - clozapine, olanzapine, haloperidol) Erythro/clarithromycin Ketoconazole/ fluconazole Citalopram Amiodarone Flecanide
Name 4 non drug causes of long-QT
Hypo’s
- Hypothermia
- Hypocalcaemia
- Hypokalaemia
- Hypomagnesaemia
A patient is in complete heart block following an MI, which coronary artery is likely to be affected?
Right coronary artery
How long should a patient be anticoagulated for before attempting cardioversion if new onset AF presenting for >48hrs?
Bisoprolol/ oral anticoag 3 weeks > electrical cardioversion
A 71-year-old woman presents with palpitations and ‘lightheadedness’. An ECG shows that she is in atrial fibrillation with a rate of 130 / min. Her blood pressure is normal and examination of her cardiorespiratory system is otherwise unremarkable. Her past medical history includes well controlled asthma (salbutamol & beclomethasone) and depression (citalopram). Her symptoms have been present for around three days. What is the most appropriate medication to use for rate control?
Diltiazem
BB are CI due to asthma
A 64-year-old man with a history of type 2 diabetes mellitus is admitted with chest pain to the Emergency Department. An ECG shows ST elevation in the anterior leads and he is thrombolysed and transferred to the Coronary Care Unit (CCU). His usual medication includes simvastatin, gliclazide and metformin. How should his diabetes be managed whilst in CCU?
Stop Metformin and Gliclazide - start IV insulin infusion
The nurse calls you to review a patient because she is worried about him. The patient is awake and alert. He has heart rate of 179 beats/minute, his respiratory rate is 18 breaths/minute and his blood pressure is 78/54 mmHg. The nurse shows you the patient’s ECG which she had done just before you arrived.
The ECG shows a ventricular tachycardia.
What should be the initial management?
A synchronised cardioversion is the treatment for a unstable patient in VT
How do you manage a patient with pulseless electrical activity?
Continue CPR for 2mins then reassess rhythm
Give 1mg of IV adrenaline
(non-shockable)
Plus standard:
- Give adrenaline every 3-5mins
- Give amiodarone after 3 shocks
What murmur is associated with tricuspid regurgitation, what are the 2 most common causes of TR?
Pansystolic murmur
- Pulmonary hypertension and rheumatic fever
What is the main treatment of tricuspid regurg?
Often leads to R heart failure
- Focus on good fluid balance
- Rarely do valve replacement
How does a pulmonary stenosis murmur sound? What is the cause and consequence?
Also ejection systolic
- Often congenital (i.e ToF) or just stress over time
Consequence = RV hypertrophy and R heart failure (distended neck veins, swollen ankles, hepatosplenomegaly, cyanosis, SOB etc.)
What is the main treatment of pulmonary stenosis?
Ballon valvoplasty
What are the main 4 valvular systolic murmurs?
Aortic stenosis (Ejection) Mitral regurg (pan) Pulmonary stenosis (Ejection) Triscupid regurg (pan)
What are the 4 main valvular diastolic murmurs?
Aortic regurg (blowing) Mitral stenosis (rumbling) Pulmonary regurg (blowing) Tricuspid stenosis
How should angiography be explained to a patient?
Angiography is a type of X-ray used to check the blood vessels.
Blood vessels don’t show up clearly on a normal X-ray, so a special dye needs to be injected into your blood first.
Done under LA, catheter go through groin or wrist, 30mins- 2hrs
Common risks of angiography?
Days-weeks (bruising, soreness, lump near entry site
Small risk of allergic reaction to dye or MI
What is a classic presentation of aortic dissection?
Abrupt onset ripping, sharp pain, maximal at onset, migrates as dissection progresses. Either retrosternal or in the back.
50-70yoM with multiple CVS risk factors
How do you manage aortic dissection?
Stanford TypeA (ascending aorta-2/3) = Surgery Stanford TypeB (descending aorta-1/3)= Conservative
Both manage hypertension (aim syst < 120), IV beta blockers and morphine
What is the most common cardiomyopathy?
Dilated cardiomyopathy
Name 3 causes of a dilated cardiomyopathy?
Ischemia Alcohol Idopathic Genetic (Autosomal dominant) Thyrotoxicosis
(many others)
How is dilated cardiomyopathy managed?
As heart failure
What is the main cause of hypertrophic cardiomyopathy?
Genetic (autosomal dominant)
1 in 500
Name 2 examination findings in HOCM?
Forceful apex beat
Late ejection systolic murmur (worse on standing or valsalva, diminished on squatting)
Name 3 management points for someone with HOCM?
Anticoagulation
Appropriate anti-arrythmic drugs
ICD as sudden cardiac death is big risk
Name 5 presenting symptoms of infective endocarditis?
Fever Fatigue Arthralgia/ myalgia SOB New murmur
(Classically fever + new murmur = IE)
What are your first investigations in suspected IE?
Blood cultures (at least 3) FBC ECG (immediately) Echo (within 24 hrs) Urinalysis U+E
How should infective endocarditis be managed?
Start IV AB’s whilst awaiting culture results
If acutely ill may need surgery to repair damaged valves
When should INR target not be 2-3 for a patient on Warfarin?
Aim 3-4 if:
- Recurrent DVT/PE
- Mechanical heart valves
Name one key antibiotic which is commonly used but interacts with Warfarin?
Clarithromycin
How long should a patient be anticoagulated with warfarin/ NOAC if:
a) distal DVT
b) provoked proximal DVT or PE
c) Idiopathic DVT or PE
a) 6 weeks
b) 3 months
c) 6 months
Which common blood pressure medication causes hyperkalaemia?
ACEI
Which common blood pressure medications cause hypokalaemia?
Thiazide diuretics (indapamide and bendroflumethiazide)
Loop diuretics (bumetanide or frusemide)
Staph aureus is what type of bacterium?
Gram positive cocci
Name 5 common side effects of loop diuretics?
Hypotension Hyponatremia Hypokalaemia Hypocalcemia Ototoxicity Gout Renal impairement
Name the 8 reversible causes of a cardiac arrest?
Hypoxia
Hypovolemia
Hypothermia
Hypo/hyperkalaemia
Tension pneumothroax
Tamponade
Thrombosis
Toxins
What 4 things should be checked before starting a patient on amiodarone?
TFT (can cause dysfunction)
LFT (can cause fibrosis)
U+E (can cause hypokalaemia)
CXR (pulmonary fibrosis)
A 61-year-old man with peripheral arterial disease is prescribed simvastatin. What is the most appropriate blood test monitoring?
LFT at baseline, 3 months, 12 months
Then annually
What are the characteristic 2 features of pericarditis on ECG?
Widespread ST elevation
PR depression
What are the BP targets for a) T1 diabetics and b) T2 diabetics?
Type 1 = < 135/85
Type 2= < 140/90
If any retinopathy, nephropathy or previous stroke = < 130/80
Which electrolyte imbalance is most frequently responsible for causing VT?
Hypokalaemia
Followed by hypomagenesia
You review a 24-year-old woman with a history of asthma in the Emergency Department. She has been admitted with acute shortness of breath associated with tongue tingling and an urticarial rash after eating a meal containing shellfish. Her symptoms settle with nebulised salbutamol and intravenous hydrocortisone. What is the most useful test to establish whether this episode was due to anaphylaxis?
Anaphylaxis - serum tryptase levels rise following an acute episode
What are the recommendations around stopping warfarin before elective surgery?
Stop 5 days before
Surgery can go ahead once INR < 1.5
Resume warfarin on evening of surgery or next day
A 58-year-old man, Wayne, presents to the emergency department complaining of a cough, high fever, fatigue and palpitations. Wayne informs you that his palpitations started 12 hours ago. His temperature is 38ºC, his heart rate is 110bpm and his ECG shows an irregularly irregular rhythm with the absence of P waves. His blood pressure is 120/70 mmHg and his respiratory rate is 17/minute. His X-ray shows right lower-lobe consolidation. He is otherwise well, with no comorbidities. He is started on treatment for his underlying pneumonia. Which of the following management options should be considered for this patient’s AF
Rhythm control
- Use rhythm control to treat AF if there is coexistent heart failure, first onset AF or an obvious reversible cause
(Flecanide or amiodarone)
When considering cardioversion in patients with AF, what should be considered in relation to stroke risk?
The moment a patient switches from AF to sinus rhythm presents the highest risk for embolism leading to stroke. Therefore cardiovert if:
> Symptoms under 48 hours
OR
> If over 48hrs anticoagulated for minimum 3 weeks whilst offering rate control before cardioversion
A 65-year-old male presents with left sided hemiparesis, and decreased level of consciousness. On examination he has a blood pressure of 145/75 mmHg and pulse 110 beats per minute (regular). On auscultation he has crepitations to the mid zones and mild ankle oedema. He has a past medical history of a myocardial infarction 4 months previously. An ECG confirms persistent ST elevation in leads V1-V4.
What is the most likely cause of the stroke?
Left ventricular thromboembolism (formed around an aneurysm)
Persistent ST elevation after previous MI, is very suggestive of a left ventricle aneurysm. Blood stagnates around a left ventricle aneurysm, thereby promoting platelet adherence and thrombus formation. Embolisation of left ventricular thrombi can lead to embolic stroke or other systemic embolisms.
A 76-year-old man is reviewed. He was recently admitted after being found to be in atrial fibrillation. This was his second episode of atrial fibrillation. He also takes ramipril for hypertension but has no other history of note. During admission he was warfarinised and discharged with planned follow-up in the cardiology clinic. However, on review today he is found to be in sinus rhythm. What should happen regarding anticoagulation?
Still continue lifelong
- Second episode of AF so shows he’s still at risk of getting future episodes
What is the first line investigation if the clinical history suggests a typical angina picture?
1st line: CT coronary angiography
2nd line: non-invasive functional imaging (looking for reversible myocardial ischaemia)
3rd line: invasive coronary angiography
If a CTPA is going to be delayed by 90 mins how should patient be managed?
Give treatment dose tinzaparin
Don’t just thrombolyse
When taking statins what is the cutoff for the ALT rise which would prompt you to stop the statin?
Treatment with statins should be discontinued if serum transaminase concentrations rise to and persist at 3 times the upper limit of the reference range.
Using a beta-blocker has not controlled the rate of a patient in AF, what do you add as second line?
Diltiazem or Digoxin
A 28-year-old who is 10 weeks pregnant is noted to be hypertensive on her booking visit. Blood show a potassium of 2.9 mmol/l. Clinical examination is unremarkable. MLD?
Primary hyperaldosteronism (Conn’s is a subtype)
How does coarctation of the aorta present in newborns?
Acute heart failure at 2 days of age (as duct closes).
Murmur under L clavicle and over L scapula on back
What statin and dose should be given following a cardiovascular event for secondary prevention?
Atorvastatin 80mg
U waves on an ECG are most likely to be caused by?
Hypokalaemia
A 55-year-old lady presents to the GP as she is about to travel to Australia for her daughter’s wedding. She is due to fly next week and is starting to worry that she may develop a blood clot while she flies. She has previously had a DVT after a surgery when she was 45 and her mother and auntie both died of a pulmonary embolism after a DVT.
What is the most appropriate prophylaxis required in this patient?
Anti-embolism stockings
In anaphylaxis, how soon after the first dose of adrenaline can a second dose be given?
5mins
A 45-year-old man presents to the emergency department with chest pain that radiates to his back. On questioning he says in the last couple of days the chest pain has started, and it is much worse on inspiration. On examination you notice that when the patient breaths in, his jugular venous pulse (JVP) rises. MLD?
Constrictive pericarditis
In constrictive pericarditis, the JVP will rise on inspiration; this is known as Kussmaul’s sign
Lateral MIs show ST elevation in which leads? Which artery is affected?
I, aVL +/- V5/V6
Left circumflex
Posterior MIs affect which artery?
Usually left circumflex
Thiazide diuretics cause which electrolyte abnormalities?
Hypokalaemia, hyponatremia, hypercalacemia
Which electrolyte abnormality is common with ACEI?
Hyperkalaemia
A 66-year-old woman suddenly develops dyspnoea 10 days after having an anterior myocardial infarction. Her blood pressure is 78/50 mmHg, JVP is elevated and the heart sounds are muffled. There are widespread crackles on her chest and the oxygen saturations are 84% on room air.
MLD?
Left ventricular free wall rupture
1-2 weeks after MI
Acute heart failure secondary to cardiac tamponade
After being admitted to the coronary care unit a middle aged man develops a regular, broad complex tachycardia. His blood pressure drops to 88/50 mmHg. He was admitted 6 hours previously following an anterolateral myocardial infarction.
MLD?
VT
Broad complex tachycardia following MI is almost always VT
Name two classic signs of constrictive pericarditis?
Kussmauls sign - JVP doesn’t fall with inspiration
Pericardial knock
A 52-year-old male presents with tearing central chest pain. On examination he has an aortic regurgitation murmur. An ECG shows ST elevation in leads II, III and aVF. MLD?
Proximal aortic dissection
An inferior myocardial infarction and AR murmur should raise suspicions of an ascending aorta dissection rather than an inferior myocardial infarction alone. Also the history is more suggestive of a dissection. Other features may include pericardial effusion, carotid dissection and absent subclavian pulse.
What is a Q wave on ECG, when is it pathological and what pathology does it suggest?
Any negative deflection which preceeds and R wave
Pathological if > 2mm deep or >1mm wide
1mm = 1 small square = 40ms
Pathological Q waves indicate current or previous MI
How does the drug alteplase work?
It is a tissue plasminogen activater used for
thrombolysis
In a suspected PE what investigation should happen before a CTPA?
CXR
It is essential to organise a chest xray, to rule out other pathologies causing chest pain, such as a pneumothorax. The NICE guidance is clear this should happen prior to a CTPA or V/Q in suspected PE’s.
Following an MI a patient is in heart block, you suspect the AV node has been affected - which leads would see changes on an ECG and which artery is affected?
Right coronary Inferior leads (II, III, aVF)
What is the QRisk2 cut off score for starting treatment with a statin?
10%
Name 3 Hx questions for syncope and dizziness?
When:
Postural (BP)
Exertional (Arrythmia)
Random
Mallor flush is a sign of?
Mitral Stenosis
Clubbing in a cardiac exam is a sign of?
Cyanotic heart disease/ infective endocarditis
Name 2 peripheral signs of infective endocarditis?
Jayneway lesions (non painful) Oslers nodes (painful - pulps of fingers)
Name 4 things which should be commented on when reporting about a pulse?
Rate, rhythm, character
Radio-radio delay
What is a collapsing pulse and how is it done?
Suggest Aortic Regurg
Check pain in shoulder
Check for pulse
Hold bulk of muscle (feeling for beats in the muscle)
Raise arm very quickly
What vein is observed when looking at the JVP?
Internal jugular vein (between to heads of SCM)
Note external jugular is easier to visualise but it’s further up
The diaphragm vs. bell are best for which kind of sounds?
Diaphragm = High (Aortic Stenosis) Bell = Low pitch (Mitral stenosis)
How do you exagerate aortic murmurs, where do they radiate?
Lean patient forward
Radiate to carotids
How do you exagerate mitral murmurs, where do they radiate?
Lie on L hand side
Radiate to axilla
Why are L sided murmurs easier to hear on expiration?
Increases thoracic pressure so most blood heading to L side of heart
How should you report your findings when you have found a murmur?
I heard a murmur:
- Loudest over
- Radiating to
- Louder with inspiration/ expiration
Like to follow up with an echo
What order should an ECG be interpreted in? (7)
Identifiers Rate Rhythm Axis Waves (P, QRS, T) Intervals Final summary
Name 6 cardiovascular risk factors? (10)
GAFE SADD HF Gender Age Fhx/ Genetrics Ethnicity Smoking Activity Diabetes Diet Hypertension Cholesterol
How long can ST elevation take to show an MI, what other signs could you look for?
Can take over an hour
May see tented T waves (in multiple consistent leads)
Pathalogical Q waves (>1mm wide or >2mm deep), from dead muscle so takes longer to depolarise
In a GP clinic a 48yoM of Caucasian ethnicity is has just been diagnosed with hypertension. He has a family history of hypertension, had his appendix removed and also has renal stenosis, what is the first drug he is prescribed?
First line for Caucasian under 55yrs is ACEI
BUT ace inhibitors are CI in patients with renal stenosis, so give ARB as an alternative
A nurse approaches you to ask about an acutely unwell patient who following and MI yesterday, now has a pulse of 40bpm. What is the first treatment you give to raise the HR?
Atropine (0.6-1.2mg IV)
Troponin levels following an MI peak when?
24-48hrs
How does an NSTEMI present on an ECG?
ST depression
T wave inversion
Or most commonly nothing
(Note changes are often widespread and not localised to specific leads like STEMI)
(Wait for trops to come back)
What risk stratification score is used in NSTEMI?
GRACE/TIMI
How do you manage NSTEMI?
Based on GRACE/ TIMI
Low risk = Medical manage (Aspirin, fondaparineux/ LMWH, ticagralor,
Intermed/ High risk = Angiography +/- PCI in 96hrs
A patient with heart failure is still symptomatic despite taking furosemide, ramipril and carevdilol. What drug do you consider putting him on and what must you consider before you do this?
Spironolactone (25mg OD)
Check potassium level and that no other potassium sparing diuretics are present
High potassium is a CI
A patient has a 2:1 AV block on an ECG which you think is atrial flutter. Their ventricular rate is 150bpm. How do you manage?
Flutter treatment similar to fibrilation:
Rate control- BB, CCB (diltiazem, verapamil)
Rhythm control- Amiodarone, sotolol
A 64yoM Px presents in the GP with a history that is diagnosed as stable angina. What is the initial management?
Council on CVS RF's and severity Aspirin (75-150mg OD) Atorvastatin (40mg OD) GTN Spray (PRN)- With councilling ONE OF EITHER (BB or CCB)
What are the types of heart block?
First: Prolonger PR (rarely treat)
Second M1 (Wenkyback): Progressive PR > dropped beat (treat only if symptomatic)
Second M2: Intermittent non conducted P waves but PR stays the same
Third: No association between P and QRS
Are RBBB and LBBB pathaological?
RBBB can be
- Second R wave in V1-V3
LBBB is ALWAYS pathological
- No Q waves in V5 and V6
How do you classify AF?
Paroxysmal < 7 days
Persistent > 7 days, not self-terminating
Permenant
A patient with angina presents in GP as they feel their symptoms are not fully controlled. They currently take atenolol (100mg OD), aspirin (150mg OD), atorvastatin (40mg OD), isosrobite mononitrate (40mg BD) and their GTN spray for periodic relief. What is the next step in management?
Referral for coronary revascularisation
PCI or CABG
When is thrombolysis CI?
Later than 24hrs from onset
Previous significant bleed (Stoke as could be haemorragic)
Pregnancy
Use streptokinase as thrombolysis agent
During a check up a patient with heart failure asks you what class of heart failure she has as she has heard a friend talk about it. She gets shortness of breath when trying to do daily activities but can sit comfortably at rest. What do you advise?
New York classification of heart failure:
I) Disease present but no undue dyspnoea on ordinary activity
II) Comfortable at rest, dyspnoea on ordinary activity
III) Less than ordinary activity causes dyspnoea which is limiting
IV) Dyspnoea present at rest, all activity causes discomfort
SO CLASS TWO
A patient presents with chest pain. From the history you suspect it is stable angina, what tests do you do?
12 Lead ECG (could be normal or possible ischemia)
FBC/ U+E/ TFT/ LFT/ Troponins/ Blood Glucose
(LFT are to give baseline for when statins started)
START TREATMENT
You have newly diagnosed a 70yoF with heart failure. What lifestyle changes do you recommend?
Stop smoking/ eat less salt
Optimize weight and nutrition
Avoid exacerbating drugs (NSAID/ verapamil)
A patient in A+E has a pulse of 179 and a BP of 119/87. They are in AF. How do you treat the AF?
1) beta blocker (or CCB diltiazem/ verapamill)- NOT TOGETHER
2) Digoxin
3) Amiodarone
Don’t forget to give LMWH to keep options option for cardioversion later on.
How long after chest pain onset can troponins rule out MI? How long do they remain raised for?
6 hours (after this time with no raise, risk = 0.3%)
Can remain raised for up to 2 weeks
What drugs most commonly cause torsades de points?
Antipyschotics
What are the three most common side effects of amlodipine?
Palpitations, leg swelling, tachycardia
What are the most common SE of amiodarone?
Lung fibrosis
Hypo or hyperthyroid
Impaired liver function
Name 5 common side effects of ACEI:
Dry cough, hypotension, hyperkalaemia, renal dysfunction, angioedema
Name 4 CI for ACEI
Pregnancy (or woman of child bearing age)
Bilateral renal artery stenosis
Mod/severe aortic stenosis
Hx of angioedema
Name 6 common side effects of beta blockers
Fatigue (normally when starting and resolves in 6 weeks) Impotence Cold extremities Sleep disturbance Bradycardia/ broncospasm Can develop diabetes
What are some of the common CCB side effects?
Flushing, headaches, ankle swelling
With Rate Limiting can also get constipation (diltiazem etc)
How long after administration do loop diuretics initiate diuresis?
Less than 1 hour
Give two side effects of regular oral nitrates?
Headaches
Low BP
You suspect aortic dissection, what investigations should be done?
Obs B- Bloods B- Bedside (ECG) I- Imagine (CT) S- Special test (none)
What is dresslers syndrome and when does it occur?
2-3 weeks post MI
Autoimmune pericarditis post MI
What does of atorvastatin is used for primary and secondary prevention?
Primary = 20mg Secondary = 80mg
