Cardiology Flashcards
1
Q
ECG territories: vessel and area for II, III, aVF
A
inferior, right coronary
Can affect AV node so complete heart block
also in 40% RV infarction also occurs…nitrates are contraindicated!
2
Q
ECG territories: vessel and area for V1-V4
A
anteroseptal, Left anterior descending
3
Q
ECG territories: vessel and area for V4-6, I, aVL
A
Anterolateral, left anterior descending or left circumflex
4
Q
ECG territories: vessel and area for I, aVL +/- V5-6
A
Lateral, left circumflex
5
Q
ECG territories: vessel and area for Tall R waves V1-2
A
posterior, left circumflex/right coronary
6
Q
ECG changes for posterior MI
A
Tall R waves in V1-2
7
Q
where is B-type natriuretic peptide produced
A
cardiomyocytes mainly left ventricular myocardium in response to strain
8
Q
effects of BNP
A
similar to ANP vasodilator decreases sodium resorption diuretic and natriuretic suppresses renin-angiotensin system supprsesses sympathetic tone
9
Q
ECG changes of brugada
A
Auto dominant condition, more common in Asians. ST elevation of >2mm on >1 v1-3 leads with inverted t wave and partial RBBB
10
Q
What ECG abnormality do you need to monitor for in endocarditis
A
Prolonged pr… Sign of aortic abscess, which is an indication for surgery
11
Q
When would you consider coronary angiography post NSTEMI
A
consider within 96 hours if predicted 6 month mortality above 3%… So if high risk and comorbid
12
Q
BP is 135/85, who do you treat?
A
If under 80 yr AND organ damage, cardiovascular disease, renal disease, diabetes, 10-yr risk greater than 10%
13
Q
Which vessel supplies AV node
A
Posterior interventricular artery, branch of Right coronary
14
Q
Complete heart block following MI, causative vessel
A
Right coronary
15
Q
Genetics of hypertrophic obstructive cardiomyopathy
A
Auto dominant (1 in 500) Due to disorder in muscle tissue caused by defect in coding for beta myosin heavy chain protein or myosin binding protein c - sarcomere protein
16
Q
Echo of hypertrophic obstructive cardiomyopathy
A
MR SAM ASH
mitral regurgitation
Systolic anterior motion of anterior mitral valve
Asymmetric hypertrophy
17
Q
Purpose of drug eluting stents
A
Coated with paclitaxel or rapamycin rich inhibits local tissue growth. So lower restonosis rate but higher thrombosis rate (so longer clopi)
18
Q
factors favouring rate controlling AF vs rhythm
A
age of 65 and ischaemic heart disease,,,rate
younger symptomatic, reversible causes ,Congestive heart failure… rhythm (sotalol, amiodarone)
but if it’s secondary to infection just give Abx
19
Q
Electrolyte causes of VT
A
hypokalemia and hypomag, hypocalcemia
20
Q
specific ECG changes for Acute pericarditis
A
PR depression is most specific.
Also ST saddle ST elevation
21
Q
What is the time window for primary PCI
A
Presents with STEMI within 12hr and PCI can be reached within 120 minutes, if not then thrombolysis
22
Q
What is role of troponin in cardiac muscle
A
Component of the thin filaments
23
Q
Most important drug in stable angina for best long term prognosis
A
Aspirin
24
Q
most common cardiac defect in Turner’s syndrome
A
Bicuspid valve -soft ejection systolic murmur
Increased risk of developing aortic valve problems- AS, AR and aortic valve infective endocarditis
25
Patient on angina treatment....
aspirin 75mg od, simvastatin 40mg on, atenolol 50mg od and a GTN spray prn
Still requiring regular gtn. What is next step?
When treating angina, if there is a poor response to the first-line drug (e.g. a beta-blocker), the dose should be titrated up before adding another drug...so increase atenolol up to 100mg daily in 1 or 2 doses before adding ISMN
26
Young patient with AF for more than 48hr, stable rate, what's the plan
2, 3, 4
If more than 2 days, then 3 weeks of anticoagulant before electrical cardioversion, then 4 weeks of anticoagulant after. Obv carry on if risk factors
If high risk of failure (i.e. previous failed cardioversion) then 4 weeks amiodarone or sotalol
27
Stop exercise tolerance test if...
3 mm ST depression , 2 mm ST elevation, SBP more than 230 mmHg , SBP falling more than 20mmHg , HR falling more than 20%.
28
U waves on ecg
Hypokalemia (severe)
| Also bradycardia according to LITFL
29
J waves on ECG
hypothermia
30
Delta waves on ECG
Wolff Parkinson white
31
Management for VT during angiogram
Secondary to irritation of myocardium so withdraw catheter. If this resolves it then can be discharged with no extra mx
32
Epsilon waves on ECG - a notch at the end of QRS complex
| DIAGNOSIS
Arrythmogenic right ventricular cardiomyopathy
Second most common inherited cause of sudden death
May present as syncope
33
Most common cause of restrictive cardiomyopathy
Amyloidosis
33
Difference between constrictive pericarditis and restrictive cardiomyopathy
Similar features
Low voltage ECG
Cardiomyopathy has prominent apical pulse
Enlarged heart
BBB , q waves
Absent pericardial calcification
34
The most important factor predicting outcomes post-STEMI is...
the presence of new systolic heart failure. It suggests that a large amount of myocardial damage.10x more likely to die than those without Mi
35
Broad complex tachy... Management if adverse features Vs nil
Electrocardioversion if adverse features (syst <90)
| Amiodarone if no signs of shock
36
What is esseinmengers syndrome
Reversal of left to right shunt in congenital heart defect due to pulmonary hypertension...
E.g. In downs
37
Talk through valsalvae physiology
Increased intra thoracic pressure
Increased venous pressures so decreased venous return
Fall in cardiac output
38
What type of valve would someone who's 75 probably get Vs 55yr
Bioprosthetic biologic valve for older, as they don't need long-term anticoag (except aspirin)
Mechanical for younger, because they last longer.. need warfarin though (aortic: 3.0, mitral: 3.5)
39
Indications for a temporary pacemaker
Post anterior mi complete heart block (contrastingly, post inf this is common so managed conservatively)
Haemodynamically Unstable/symptomatic bradycardia
Trifasicular block pre surgery
40
Effect of squatting on heart murmurs
Squatting increases M + A stenosis
But decreases HOCM + mitral valve prolapse
Opposite is true in valsalvae
41
Aortic stenosis marker of severity on examination
Fourth heart sound
Narrow pulse pressure
Slow rising
42
Contraindication of exercise tolerance test
exercise tolerance test would be contraindicated in a patient with suspected aortic stenosis.
43
most accurate method to determine his left ventricular function?
MUGA scan
45
Patient with infection causing heart block
Diphtheria, chagas, Rocky Mountain
46
blood test to demonstrate re-infarction within a week of another MI ?
CK-MB
this cardiac enzyme returns to normal with 2-3 days, unlike trop T which is 10d
47
Drugs to avoid in HOCM
```
DANI has HOCM
Diuretics and digoxin
ACEi
Nitrates
Inotropes
```
48
Management of HOCM
```
Amiodarone
Beta blocker
Cardioverter defib (could be first line!)
Dual chamber pacemaker
Endocarditis prophylaxis
```
49
Prosthetic heart valves - antithrombotic therapy:
bioprosthetic: aspirin
mechanical: warfarin + aspirin
aortic: 3.0
mitral: 3.5
50
Cardiac complication in Lyme's disease
Myocarditis / heart block are late features
51
where is Atrial Natriuretic Peptide (ANP) produced
myocytes in right atrium and ventricle (a bit in left too) in response to increased volume
52
what does Atrial Natriuretic Peptide (ANP) do
Similar to BNP
promotes Na excretion,
decreases BP
antagonises angiotensin II and aldosterone
vasodilator
53
causes of raised b-type natriuretic pepetide BNP
```
anything that causes LV dysfunction...
Heart failure
MI
valvular disease
CKD due to decreased excretion
Age >70yr
Hypoxia - COPD, PE
sepsis
```
54
causes of reduced b-type natruiretic peptide (BNP)
BMI >35
HF drugs - ACEi, A2RB, Diuretics
African-carribbean origin
55
Management for BNP levels
CKS say >2000 then refer and echo in 2/52
| 400-2000 then echo in 6/52 and refer
56
What scoring system can classify risk post MI?
```
Killip class, ranked 1-4, predicts 30 day mortality
1 no HF , 6%
2 lung crackles, S3, 17%
3 frank pulmonary oedema, 38%
4 cardiogenic shock 80%!
```
57
first cardiac enzyme to rise post MI
Myoglobin
58
what do Troponin T, C and I bind to?
T binds to tropomyosin (another component of thin filament )
C binds to Calcium
I binds to actin
59
which heart sound is normal under 30 yr ?
Third heart sound can be normal in under 30yr, and can persist in women up to 50yr
60
what anatomy and ECG do S1 and S2 heart sounds correlate with
what ecg do S3 and S4 heart sounds correlate with.
s1 closure of Mitral and Tricuspid (QRS wave)
s2 closure of aortic and pulmonary (end of T)
remember M + T and a + p look similar
S3 passive ventricular filling
S4 P wave
61
PR depression on ECG...diagnosis?
specific marker for pericarditis
62
what is Kussmaul's sign?
a paradoxical rise in JVP on inspiration, found in constrictive pericarditis and restrictive cardiomyopathy
63
patient presents in community with chest pain three days ago...what's management?
trop and ecg before referral if longer than 72hr ago
if 12-72hr then same-day hosp assessment
64
timeline of Dressler's syndrome and pericarditis post MI
pericarditis is common in the first 48hr (10% of patients with transmural MI).
Dressler's, which is an autoimmune pericarditis is 2-6weeks
(Dressler's has fever, pleuritic pain, pericardial effusion and a raised ESR. It is treated with NSAIDs
65
Causes of heart failure post MI
1week (1-2%) - intraventricular septum rupture - acute HF w pan sys murmur
1-2 weeks (3%) - LV free wall rupture - acute HF w cardiac tamponade
Acute MR - hypotension/pulmonary oedema - often inferopost infarct
Chronic HF - treat with Eplerenone if LVSD
66
what is management post thrombolysis?
An ECG should be performed 90 minutes following thrombolysis to assess whether there has been a greater than 50% resolution in the ST elevation.
If <50% then rescue PCI
If >50%, PCI has been shown to be beneficial. The optimal timing of this is still under investigation
67
management of diabetic post MI
Metformin may cause lactic acidosis if taken during time of tissue hypoxia
so stop and start insulin IV infusion
68
management of Dressler's
NSAIDs - Colchicine
| remember: usually 2-6weeks post MI
69
management of Prinzmetal angina
dihydropyridine calcium channel blocker like felodipine/amlodipine
(rare vasospasm pain at rest)
70
angina not controlled by atenolol 100mg, what is next step?
As Atenolol is at max dose, add Nifedipine MR
(remember Verapamil contra w beta due to complete heart block)
(diltiazem "used with caution due to the risk of bradycardia)
71
angina and sexual dysfunction...
Nitrates or nicorandil and phosphodiesterase inhibitors (Sildenafil etc) are contraindicated
Don't take Sildenafil within 24hr of Nitrates
72
Anticoagulation management before and after catheter ablation for AF
need to be anticoag for 4 weeks before and 2 months after, then following this it is down to CHA2DS2-VASc score
-counterintuitively, ablation doesn't reduce stroke risk even if sinus rhythm
73
how successful is catheter ablation for AF?
doesn't seem to reduce stroke rate
55% of patient wiht single procedure remain in sinur rhythm at 3yr
80% of patient with multiple procudures
74
70yr old man with persistent atrial fibrillation, type 2 diabetes mellitus and treated for hypertension and on Warfarin comes in with 3 falls in 6 months...what do you do?
If CHADSVASc is 4 risk is 4.8% annually... You would have to have 295 falls a year for the risk to require stopping Warfarin
75
what drug should not be given in VT
Verapamil - can precipitate VF
treat with Amiodarone (ideally through central line) or immediately cardiovert if there are any adverse signs
76
how do you differentiate between the type A and type B wolff-parkinson White?
```
Type A (left sided accessory pathway) has dominant R waves in V1... basically right axis deviation
Type B (right-sided) does not. left axis deviation
```
77
causes of dilated cardiomyopathy
Alcohol
Beriberi wet - thiamine deficiency
Coxsackie B
Doxorubicin
78
poor prognostic genetic mutations in HOCM
myosin binding protein C
troponin T
USUALLY caused by Myocin heavy chain-beta (15-25%) and myosin binding protein C (15-25%).
79
What wall thickness is poor prognostically for HOCM?
wall thickness > 30mm
80
triad of Arrhythmogenic right ventricular cardiomyopathy, palmoplantar keratosis, and woolly hair
Naxos disease
| - autosomal recessive variant of ARVC
81
patient with fatigue and SOB on exertion. He has pulsing nailbed...what is this sign called?
Quinke's sign - in Aortic Regurge, so early Diastolic murmur
82
patient has a mid-systolic click that moves later as she squats. Diagnosis?
Mitral valve prolapse.
| Also should move earlier with valsalvae
83
Patient with Mitral Valve prolapse. What heart sounds would you expect?
Mid-systolic click which moves later with squat and earlier wiht valsal
Late systolic murmur
84
long-term management of atrial flutter
radioablation of tricuspid valve isthmus is curative in most
medication is less effective than with AF
It is sensitive to cardioversion though
85
most common heart defect in Marfans
dilatation of aortic sinuses
86
Most common heart defect in Turners
Bicuspid aortic valve (15%)
but also get coarctation of the aorta (5-10%)
87
patient presents with ejection systolic murmur over carotid area... what is the most like cause, if he is 55yr or 75yr ?
aortic stenosis...caused by:
<65yr , most likely bicuspid aortic valve
>65yr calcification
88
What value of pulmonary artery pressure is considered diagnostic of pulmonary arterial hypertension?
>25mmHg at rest
----measured by cardiac catheterisation
89
how do you determine management for patient with pulmonary hypertension?
Acute vasodilator testing if pt has signif fall in pul pressure
- -> positive response then calcium channel blockers
- -> negative response then prostacyclin analogues, endothelin R antag, or phosphodiesterase inhib
90
which congenital defect is more common: ventricular septal defects or atrial septal defects?
VSDs are more common, and the most common acyanotic defects
| however, ASD are more common as a new diagnosis in adults as they generally present later
91
important thing to warn woman with pulmonary hypertension..............
pregnancy is contraindicated in women with pulmonary hypertension as it carries a 30-50% risk of mortality
92
how common is patent foramen ovale?
20% of population!
93
patient post NSTEMI with normal Echo gets started on aspirin, ticagrelor and fondaparinux.
He develops dyspnoea a few days later, what is the likely cause of this?
ticagrelor can cause dyspnoea, due to the impaired clearance of adenosine
Heart failure unlikely due to normal Echo
94
74yr old with T2DM, and BP 146/88 mmHg. what would yuo use to treat her blood pressure?
Hypertension in diabetics - ACE-inhibitors are first-line regardless of age
95
patient has AAA and needs immediate surgery. His last INR was taken 2 weeks ago and was 2.5. How should you proceed?
As surgery immediate, treat with 25-50units of four-factor prothrombin complex
if it can wait 6hr then can give 5mg Vit K IV
96
ECG signs of hypokalaemia
U waves
PR lengthening
Small / absent T waves (occasionally inversion)
ST depression
97
Afrocaribbean patient on amlodopine 10mg with persistent hypertension, what do you add?
an angiotensin receptor blocker in preference to an ACE inhibitor
98
Which occurs sooner post PCI stent - stent thrombosis or restenosis?
Stent thrombosis = first month
| Restenosis = 3 to 6 months
99
First line investigation for stable chest pain in suspected coronary artery disease
contrast-enhanced CT coronary angiogram
100
What is the most specific sign for left ventricular failure?
Gallop rhythm... Also an early sign.
S3 and/or S4
Considered normal if under 30yr, or sometimes up to 50y in women
101
Management of malignant hypertension with papilloedema
PO atenolol
But if severe/ encephalopathy:
IV lebetalol or nitroprusside
"Push down pressure"
102
What are Aschoff bodies the histological sign of
granulomatous nodules found in rheumatic heart fever
103
What is cardiac syndrome X
Aka microvascular angina
Normal ECG at rest, normal angiogram, but st depression on exercise stress test
Can treat with nitrates
104
Factors that increase and decrease BNP falsely
Obesity and HF drugs decrease it
Everything else increases .. eg copd, lvh diabetes ischaemia age >70
105
Distinguish between constrictive pericarditis and cardiac tamponade
PaY TaX
X and Y descent on the JVP for pericarditis
Absent Y in tamponade
Pulsus paradoxus present in tamponade absent in peri
106
Signs of severe AS
Slow-rising pulse and a S4 heart sound are signs of severe aortic stenosis.
107
Patient has inferior mi... Severe hypotension after starting nitrate. Cause
Right ventricular infarct (occurs in 30-50% of inf MI)... Nitrates would reduce V filling and systemic circ
108
most common cause of restrictive cardiomyopathy in the Uk
Amyloidosis (e.g. secondary to myeloma) - most common cause in UK
109
Prevention of svt
beta-blockers
| radio-frequency ablation
110
Infective endocarditis - strongest risk factor
Previous inf endocarditis
111
Heart sound in dilated cardiomyopathy and in HOCM
DCM & LVF has three letters - S3
| HOCM has four letters - S4
112
SCN5A gene mutation
Brugada
113
KCNQ1 mutation
Romano ward LQT
114
Mx of atrial flutter
Similar to AF but meds are less successful
..radiofrequency ablation of the tricuspid valve isthmus is curative for most patients
115
Pulsus alternans -
seen in left ventricular failure
116
Where does furosemide act
thick ascending limb of the loop of Henle
inhibits the Na-K-Cl cotransporter
117
General mechanism of drug induced LQT
blocking cardiac potassium channels
- excessive lengthening of cardiac re-polarisation
118
Persistent Vs paroxysmal AF
last greater than 7 days then persistent
119
Right ventricular enlargement with estimated PASP (pulmonary arterial systolic pressure) of 44mmHg
Heart sounds
Loud S2 in pulmonary hypertension
120
Drugs that affect adenosine
DE-AR Adenosine
Dipyridamole - enhances
Aminophylline - reduces
121
Adenosine MOA
transient heart block in the AV node
| By A1 R agonist on AVnode
122
Drugs to avoid in WPW
Verapamil and digoxin ---may precipitate VT or VF
123
Which vessel is affected in Takayasu's
Aorta
124
Vessels affected in Buerger's disease
Small/medium vasculitis - arteries of hands/feet
Assx with smoking
125
Osium primium vs ostium secondum BBB?
```
Primary LBBB (left by your parents in primary school)
Secondum RBBB
```
126
Risk factors for aortic dissection
```
Hypertension (most important)
Trauma?
Bicuspid aortic valve (increases risk X6)
Collagens
Syndromes
Preg
Syphilis
```
127
AF pharmacological cardioversion... No structural heart disease Vs structural heart disease
Flecainide if nil
| Amiodarone if structural HD
128
Risk factors for stent restenosis
Diabetes, renal impairment..
Usually Presents with angina symp 3-6m later
129
WPW associations
```
HoT As ME
HOCM
Thyroxicosis
ASD secondum
Mitral valve prolapse
Ebsteins ab
```
130
Signs of severity in AS
S for Severity
Slow rising pulse
Soft S2
S4
131
ECG sign on hyperkal that precedes arrest
QRS longation
132
Where does S4 correlate with on ECG
After p wave
133
Unwell, AF, collapse, k 2.6, management
Correct potassium first
134
Where has the wire touched if you cause VF arrest
Coronary sinus
