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Mrcp > Cardiology > Flashcards

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!

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2
Q

ECG territories: vessel and area for V1-V4

A

anteroseptal, Left anterior descending

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3
Q

ECG territories: vessel and area for V4-6, I, aVL

A

Anterolateral, left anterior descending or left circumflex

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4
Q

ECG territories: vessel and area for I, aVL +/- V5-6

A

Lateral, left circumflex

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5
Q

ECG territories: vessel and area for Tall R waves V1-2

A

posterior, left circumflex/right coronary

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6
Q

ECG changes for posterior MI

A

Tall R waves in V1-2

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7
Q

where is B-type natriuretic peptide produced

A

cardiomyocytes mainly left ventricular myocardium in response to strain

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8
Q

effects of BNP

A 
similar to ANP
vasodilator
decreases sodium resorption 
diuretic and natriuretic
suppresses renin-angiotensin system
supprsesses sympathetic tone
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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

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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

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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

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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%

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13
Q

Which vessel supplies AV node

A

Posterior interventricular artery, branch of Right coronary

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14
Q

Complete heart block following MI, causative vessel

A

Right coronary

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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
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16
Q

Echo of hypertrophic obstructive cardiomyopathy

A

MR SAM ASH
mitral regurgitation
Systolic anterior motion of anterior mitral valve
Asymmetric hypertrophy

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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)

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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

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19
Q

Electrolyte causes of VT

A

hypokalemia and hypomag, hypocalcemia

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20
Q

specific ECG changes for Acute pericarditis

A

PR depression is most specific.

Also ST saddle ST elevation

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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

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22
Q

What is role of troponin in cardiac muscle

A

Component of the thin filaments

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23
Q

Most important drug in stable angina for best long term prognosis

A

Aspirin

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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

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25
Q

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?

A

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 dosesbefore adding ISMN

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26
Q

Young patient with AF for more than 48hr, stable rate, what’s the plan

A

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

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27
Q

Stop exercise tolerance test if…

A

3 mm ST depression , 2 mm ST elevation, SBP more than 230 mmHg , SBP falling more than 20mmHg , HR falling more than 20%.

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28
Q

U waves on ecg

A

Hypokalemia (severe)

Also bradycardia according to LITFL

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29
Q

J waves on ECG

A

hypothermia

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30
Q

Delta waves on ECG

A

Wolff Parkinson white

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31
Q

Management for VT during angiogram

A

Secondary to irritation of myocardium so withdraw catheter. If this resolves it then can be discharged with no extra mx

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32
Q

Epsilon waves on ECG - a notch at the end of QRS complex

DIAGNOSIS

A

Arrythmogenic right ventricular cardiomyopathy

Second most common inherited cause of sudden death
May present as syncope

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33
Q

Most common cause of restrictive cardiomyopathy

A

Amyloidosis

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33
Q

Difference between constrictive pericarditis and restrictive cardiomyopathy

A

Similar features
Low voltage ECG

Cardiomyopathy has prominent apical pulse
Enlarged heart
BBB , q waves
Absent pericardial calcification

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34
Q

The most important factor predicting outcomes post-STEMI is…

A

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

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35
Q

Broad complex tachy… Management if adverse features Vs nil

A

Electrocardioversion if adverse features (syst <90)

Amiodarone if no signs of shock

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36
Q

What is esseinmengers syndrome

A

Reversal of left to right shunt in congenital heart defect due to pulmonary hypertension…
E.g. In downs

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37
Q

Talk through valsalvae physiology

A

Increased intra thoracic pressure
Increased venous pressures so decreased venous return
Fall in cardiac output

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38
Q

What type of valve would someone who’s 75 probably get Vs 55yr

A

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)

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39
Q

Indications for a temporary pacemaker

A

Post anterior mi complete heart block (contrastingly, post inf this is common so managed conservatively)

Haemodynamically Unstable/symptomatic bradycardia

Trifasicular block pre surgery

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40
Q

Effect of squatting on heart murmurs

A

Squatting increases M + A stenosis
But decreases HOCM + mitral valve prolapse
Opposite is true in valsalvae

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41
Q

Aortic stenosis marker of severity on examination

A

Fourth heart sound
Narrow pulse pressure
Slow rising

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42
Q

Contraindication of exercise tolerance test

A

exercise tolerance test would be contraindicated in a patient with suspected aortic stenosis.

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43
Q

most accurate method to determine his left ventricular function?

A

MUGA scan

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45
Q

Patient with infection causing heart block

A

Diphtheria, chagas, Rocky Mountain

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46
Q

blood test to demonstrate re-infarction within a week of another MI ?

A

CK-MB

this cardiac enzyme returns to normal with 2-3 days, unlike trop T which is 10d

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47
Q

Drugs to avoid in HOCM

A 
DANI has HOCM
Diuretics and digoxin
ACEi
Nitrates 
Inotropes
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48
Q

Management of HOCM

A 
Amiodarone
Beta blocker
Cardioverter defib (could be first line!)
Dual chamber pacemaker
Endocarditis prophylaxis
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49
Q

Prosthetic heart valves - antithrombotic therapy:

A

bioprosthetic: aspirin

mechanical: warfarin + aspirin
aortic: 3.0
mitral: 3.5

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50
Q

Cardiac complication in Lyme’s disease

A

Myocarditis / heart block are late features

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51
Q

where is Atrial Natriuretic Peptide (ANP) produced

A

myocytes in right atrium and ventricle (a bit in left too) in response to increased volume

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52
Q

what does Atrial Natriuretic Peptide (ANP) do

A

Similar to BNP

promotes Na excretion,
decreases BP
antagonises angiotensin II and aldosterone
vasodilator

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53
Q

causes of raised b-type natriuretic pepetide BNP

A 
anything that causes LV dysfunction...
 Heart failure
MI
valvular disease
CKD due to decreased excretion
Age >70yr
Hypoxia - COPD, PE
sepsis
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54
Q

causes of reduced b-type natruiretic peptide (BNP)

A

BMI >35
HF drugs - ACEi, A2RB, Diuretics
African-carribbean origin

55
Q

Management for BNP levels

A

CKS say >2000 then refer and echo in 2/52

400-2000 then echo in 6/52 and refer

56
Q

What scoring system can classify risk post MI?

A 
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
Q

first cardiac enzyme to rise post MI

A

Myoglobin

58
Q

what do Troponin T, C and I bind to?

A

T binds to tropomyosin (another component of thin filament )
C binds to Calcium
I binds to actin

59
Q

which heart sound is normal under 30 yr ?

A

Third heart sound can be normal in under 30yr, and can persist in women up to 50yr

60
Q

what anatomy and ECG do S1 and S2 heart sounds correlate with
what ecg do S3 and S4 heart sounds correlate with.

A

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
Q

PR depression on ECG…diagnosis?

A

specific marker for pericarditis

62
Q

what is Kussmaul’s sign?

A

a paradoxical rise in JVP on inspiration, found in constrictive pericarditis and restrictive cardiomyopathy

63
Q

patient presents in community with chest pain three days ago…what’s management?

A

trop and ecg before referral if longer than 72hr ago

if 12-72hr then same-day hosp assessment

64
Q

timeline of Dressler’s syndrome and pericarditis post MI

A

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
Q

Causes of heart failure post MI

A

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
Q

what is management post thrombolysis?

A

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
Q

management of diabetic post MI

A

Metformin may cause lactic acidosis if taken during time of tissue hypoxia
so stop and start insulin IV infusion

68
Q

management of Dressler’s

A

NSAIDs - Colchicine

remember: usually 2-6weeks post MI

69
Q

management of Prinzmetal angina

A

dihydropyridine calcium channel blocker like felodipine/amlodipine

(rare vasospasm pain at rest)

70
Q

angina not controlled by atenolol 100mg, what is next step?

A

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
Q

angina and sexual dysfunction…

A

Nitrates or nicorandil and phosphodiesterase inhibitors (Sildenafil etc) are contraindicated
Don’t take Sildenafil within 24hr of Nitrates

72
Q

Anticoagulation management before and after catheter ablation for AF

A

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
Q

how successful is catheter ablation for AF?

A

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
Q

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?

A

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
Q

what drug should not be given in VT

A

Verapamil - can precipitate VF

treat with Amiodarone (ideally through central line) or immediately cardiovert if there are any adverse signs

76
Q

how do you differentiate between the type A and type B wolff-parkinson White?

A 
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
Q

causes of dilated cardiomyopathy

A

Alcohol
Beriberi wet - thiamine deficiency
Coxsackie B
Doxorubicin

78
Q

poor prognostic genetic mutations in HOCM

A

myosin binding protein C
troponin T

USUALLY caused by Myocin heavy chain-beta (15-25%) and myosin binding protein C (15-25%).

79
Q

What wall thickness is poor prognostically for HOCM?

A

wall thickness > 30mm

80
Q

triad of Arrhythmogenic right ventricular cardiomyopathy, palmoplantar keratosis, and woolly hair

A

Naxos disease

- autosomal recessive variant of ARVC

81
Q

patient with fatigue and SOB on exertion. He has pulsing nailbed…what is this sign called?

A

Quinke’s sign - in Aortic Regurge, so early Diastolic murmur

82
Q

patient has a mid-systolic click that moves later as she squats. Diagnosis?

A

Mitral valve prolapse.

Also should move earlier with valsalvae

83
Q

Patient with Mitral Valve prolapse. What heart sounds would you expect?

A

Mid-systolic click which moves later with squat and earlier wiht valsal
Late systolic murmur

84
Q

long-term management of atrial flutter

A

radioablation of tricuspid valve isthmus is curative in most

medication is less effective than with AF
It is sensitive to cardioversion though

85
Q

most common heart defect in Marfans

A

dilatation of aortic sinuses

86
Q

Most common heart defect in Turners

A

Bicuspid aortic valve (15%)

but also get coarctation of the aorta (5-10%)

87
Q

patient presents with ejection systolic murmur over carotid area… what is the most like cause, if he is 55yr or 75yr ?

A

aortic stenosis…caused by:

<65yr , most likely bicuspid aortic valve
>65yr calcification

88
Q

What value of pulmonary artery pressure is considered diagnostic of pulmonary arterial hypertension?

A

> 25mmHg at rest

—-measured by cardiac catheterisation

89
Q

how do you determine management for patient with pulmonary hypertension?

A

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
Q

which congenital defect is more common: ventricular septal defects or atrial septal defects?

A

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
Q

important thing to warn woman with pulmonary hypertension…………..

A

pregnancy is contraindicated in women with pulmonary hypertension as it carries a 30-50% risk of mortality

92
Q

how common is patent foramen ovale?

A

20% of population!

93
Q

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?

A

ticagrelor can cause dyspnoea, due to the impaired clearance of adenosine

Heart failure unlikely due to normal Echo

94
Q

74yr old with T2DM, and BP 146/88 mmHg. what would yuo use to treat her blood pressure?

A

Hypertension in diabetics - ACE-inhibitors are first-line regardless of age

95
Q

patient has AAA and needs immediate surgery. His last INR was taken 2 weeks ago and was 2.5. How should you proceed?

A

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
Q

ECG signs of hypokalaemia

A

U waves
PR lengthening
Small / absent T waves (occasionally inversion)
ST depression

97
Q

Afrocaribbean patient on amlodopine 10mg with persistent hypertension, what do you add?

A

an angiotensin receptor blocker in preference to an ACE inhibitor

98
Q

Which occurs sooner post PCI stent - stent thrombosis or restenosis?

A

Stent thrombosis = first month

Restenosis = 3 to 6 months

99
Q

First line investigation for stable chest pain in suspected coronary artery disease

A

contrast-enhanced CT coronary angiogram

100
Q

What is the most specific sign for left ventricular failure?

A

Gallop rhythm… Also an early sign.

S3 and/or S4
Considered normal if under 30yr, or sometimes up to 50y in women

101
Q

Management of malignant hypertension with papilloedema

A

PO atenolol

But if severe/ encephalopathy:
IV lebetalol or nitroprusside
“Push down pressure”

102
Q

What are Aschoff bodies the histological sign of

A

granulomatous nodules found in rheumatic heart fever

103
Q

What is cardiac syndrome X

A

Aka microvascular angina
Normal ECG at rest, normal angiogram, but st depression on exercise stress test

Can treat with nitrates

104
Q

Factors that increase and decrease BNP falsely

A

Obesity and HF drugs decrease it

Everything else increases .. eg copd, lvh diabetes ischaemia age >70

105
Q

Distinguish between constrictive pericarditis and cardiac tamponade

A

PaY TaX

X and Y descent on the JVP for pericarditis
Absent Y in tamponade

Pulsus paradoxus present in tamponade absent in peri

106
Q

Signs of severe AS

A

Slow-rising pulse and a S4 heart sound are signs of severe aortic stenosis.

107
Q

Patient has inferior mi… Severe hypotension after starting nitrate. Cause

A

Right ventricular infarct (occurs in 30-50% of inf MI)… Nitrates would reduce V filling and systemic circ

108
Q

most common cause of restrictive cardiomyopathy in the Uk

A

Amyloidosis (e.g. secondary to myeloma) - most common cause in UK

109
Q

Prevention of svt

A

beta-blockers

radio-frequency ablation

110
Q

Infective endocarditis - strongest risk factor

A

Previous inf endocarditis

111
Q

Heart sound in dilated cardiomyopathy and in HOCM

A

DCM & LVF has three letters - S3

HOCM has four letters - S4

112
Q

SCN5A gene mutation

A

Brugada

113
Q

KCNQ1 mutation

A

Romano ward LQT

114
Q

Mx of atrial flutter

A

Similar to AF but meds are less successful

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

115
Q

Pulsus alternans -

A

seen in left ventricular failure

116
Q

Where does furosemide act

A

thick ascending limb of the loop of Henle

inhibits the Na-K-Cl cotransporter

117
Q

General mechanism of drug induced LQT

A

blocking cardiac potassium channels

  • excessive lengthening of cardiac re-polarisation
118
Q

Persistent Vs paroxysmal AF

A

last greater than 7 days then persistent

119
Q

Right ventricular enlargement with estimated PASP (pulmonary arterial systolic pressure) of 44mmHg

Heart sounds

A

Loud S2 in pulmonary hypertension

120
Q

Drugs that affect adenosine

A

DE-AR Adenosine

Dipyridamole - enhances
Aminophylline - reduces

121
Q

Adenosine MOA

A

transient heart block in the AV node

By A1 R agonist on AVnode

122
Q

Drugs to avoid in WPW

A

Verapamil and digoxin —may precipitate VT or VF

123
Q

Which vessel is affected in Takayasu’s

A

Aorta

124
Q

Vessels affected in Buerger’s disease

A

Small/medium vasculitis - arteries of hands/feet

Assx with smoking

125
Q

Osium primium vs ostium secondum BBB?

A 
Primary LBBB (left by your parents in primary school)
Secondum RBBB
126
Q

Risk factors for aortic dissection

A 
Hypertension (most important)
Trauma?
Bicuspid aortic valve (increases risk X6)
Collagens
Syndromes
Preg
Syphilis
127
Q

AF pharmacological cardioversion… No structural heart disease Vs structural heart disease

A

Flecainide if nil

Amiodarone if structural HD

128
Q

Risk factors for stent restenosis

A

Diabetes, renal impairment..

Usually Presents with angina symp 3-6m later

129
Q

WPW associations

A 
HoT As ME
HOCM
Thyroxicosis
ASD secondum
Mitral valve prolapse
Ebsteins ab
130
Q

Signs of severity in AS

A

S for Severity

Slow rising pulse
Soft S2
S4

131
Q

ECG sign on hyperkal that precedes arrest

A

QRS longation

132
Q

Where does S4 correlate with on ECG

A

After p wave

133
Q

Unwell, AF, collapse, k 2.6, management

A

Correct potassium first

134
Q

Where has the wire touched if you cause VF arrest

A

Coronary sinus

Mrcp (21 decks)

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