Cardiology Flashcards
1
Q
Which valvular disorder is most strongly associated with atrial fibrillation?
A
Mitral stenosis
2/3 of patients develop AF
2
Q
What are the two treatment approaches to AF?
A
Rate and rhythm control
3
Q
When and why is rhythm control used to treat AF?
A
Young patients
Restoration of sinus rhythm prevents atrial remodelling
4
Q
What are the 1st, 2nd and 3rd line rate control drugs for AF?
A
- Beta blockers, non-dihydropyridine calcium channel blockers
- Digoxin
- Amiodarone
5
Q
When is percutaneous coronary intervention (PCI) vs fibrinolytic therapy used for STEMI?
A
PCI within 90 minutes of symptom onset
6
Q
How are unstable angina and NSTEMI differentiated?
A
No troponin elevation in unstable angina
8
Q
What causes unstable angina?
A
Rupture of an unstable plaque → thrombus → partial occlusion of a coronary vessel
The interaction between thrombus formation and endogenous thrombolysis prevents complete vessel occlusion
9
Q
How does blood vessel occlusion differ in a NSTEMI vs a STEMI?
A
NSTEMI - complete occlusion of small branches
STEMI - complete occlusion of a main coronary artery
10
Q
What are 3 late complications of an MI?
A
- Rupture (LV wall, ventricular septal, papillary muscle)
- Atrial and ventricular aneurysms
- Arterial thromboembolism (due to venous stasis → stroke risk)
- Reinfarction
- Pericarditis
- Congestive heart failure
11
Q
What are the complications of atrial/ventricular aneurysms following MI?
A
Arrhythmias (VF)
Rupture → tamponade
Thrombus formation
12
Q
MI affecting which artery is most associated with mitral regurgitation?
A
Posterior descending artery → rupture of posteromedial papillary muscle
13
Q
What is Dressler syndrome?
A
Pericarditis 2-10 weeks following MI without an infective cause
Autoimmune aetiology
15
Q
Name two GPIIb/IIIa receptor inhibitors
A
Eptifibatide
Tirofiban
16
Q
When is aspirin given in patients with symptoms of ACS?
A
All patients with possible ACS and without contraindications
300mg orally, as soon as possible after presentations
17
Q
How long following STEMI is reperfusion therapy (PCI or fibrinolytic therapy) no longer indicated?
A
12 hours
18
Q
Which medications are given to all patients with confirmed ACS?
A
Aspirin 300mg orally
P2Y12 inhibitor (ticagrelor, prasugrel, clopidogrel)
Double anti-platelet therapy
25
Q
Which ECG leads show an inferior view of the heart?
A
II, III, aVF (right coronary/marginal artery)
26
Q
Which ECG leads show the lateral side of the heart?
A
I, aVL, V5, V6 (left circumflex artery)
27
Q
Which ECG leads show an anteroseptal view of the heart?
A
V1, V2 (LAD)
28
Q
What is a normal ejection fraction?
A
>55%
29
Q
Which drug prevents remodelling of the heart following an AMI?
A
ACEi
30
Q
When is a bubble study used?
A
Patent foramen ovale
Atrial septal defect
31
Q
Which congenital heart disease has a pansystolic murmur?
A
VSD
Pansystolic murmur over the left lower sternal border
32
Q
What is the HAS-BLED score?
A
Way of assessing 1 year risk of major bleeding in patients taking anticoagulants for atrial fibrillation
33
What is the CHA2DS2-VASc score?
Predictor of stroke risk in patients with atrial fibrillation
Used to determine whether anticoagulant/antiplatelet therapy is required
34
What are the 5 types of MI?
1. Primary coronary event e.g. plaque erosion, rupture, fissuring or dissection
2. Supply-demand mismatch
3. Sudden unexpected cardiac death
4. Associated with PCI or stent thrombosis
5. Associated with cardiac surgery
35
Which beta blockers can be used for heart failure?
Bisoprolol
Carvedilol
Metoprolol XR
36
What are the potential side effects of amiodarone?
Amiodarone is a BITCH
B - bradycardia/blue man
I - interstitial lung disease
T - thyroid (hyper and hypo)
C - corneal microdeposits (visual haloes and photophobia)/cutaneous
H - hepatic/hypotension
37
What are the potential side effects of amiodarone?
Amiodarone is a BITCH
B - bradycardia/blue man
I - interstitial lung disease
T - thyroid (hyper and hypo)
C - corneal microdeposits (visual haloes and photophobia)/cutaneous
H - hepatic/hypotension
38
Which condition is Watson's water hammer pulse/collapsing pulse associated with?
Aortic regurgitation
39
Which condition is pulsus alternans associated with?
Advanced LV failure, aortic valve disease
## Footnote
*Regular pulse with alternating strong and weak beats*
40
What anticoagulation is given to patients with atherosclerosis?
Aspirin
41
What anticoagulation is given to patients with acute coronary syndromes?
Aspirin PLUS clopidogrel/prasugrel/ticagrelor
42
What is the mechanism of hydralazine?
Arteriolar vasodilation
Antihypertensive
43
What are the two most significant side effects of hydralazine?
Tachycardia
Fluid retention
*Give with a beta blocker and a diuretic*
44
What is the most common electrolyte abnormality with ACEi used? Why does this occur?
Hyperkalaemia
## Footnote
*ACEi → reduced angiotensin II → reduced aldosterone → reduced urinary potassium excretion*
45
Why do ACEis reduce proteinura?
Angiotensin II usually increases GFR
+ afferent arteriole constriction
++ efferent constriction
ACEis reduce glomerular pressure
46
Why do patients with bilateral renal artery stenosis have a reduction in GFR with ACEi use?
When renal perfusion is significantly impaired, angiotensin II induces efferent constriction, helping maintain GFR
ACEis block this effect
Because angiotensin II is not used to maintain renal perfusion in healthy patients, they do not have impaired renal function with ACEis
47
What constitutes a long QT on ECG?
QTc \> 440ms
11 small squares or T wave after half the R-R distance
48
Which drugs are most strongly associated with long QT syndrome?
Amiodarine
TCAs
Haloperidol
Antibiotics e.g. macrolides, fluoroquinolones
Ondansetron
49
How is blood pressure calculated?
Cardiac output x systemic vascular resistance
50
What is a measurement of pulmonary capillary wedge pressure used for?
Estimate left atrial pressure
Evaluating the severity of LV failure and quantifying the degree of mitral valve stenosis
*Normally 8-10 mmHg*
51
What is an anacrotic pulse (pulsus tardus) and when is it felt?
Low amplitude with slow rise and fall
Prolonged pulse duration
Seen in aortic stenosis
52
What is bumetanide?
Loop diuretic
53
What is the mechanism of rivaroxaban/apixaban? What does factor X do?
Factor Xa inhibitor
Factor X cleaves prothrombin, forming thrombin
Thrombin stimulates the conversion of fibrinogen to fibrin
54
Why is bridging therapy often used with warfarin?
Warfarin inhibits both factor II, VII, IX and X
AND anticoagulants protein C and S
Protein C and S are inhibited immediately but inhibition of clotting factors requires a couple of days
Patients initially have a hypercoagulable state
*Why warfarin is not used for acute PE/DVT therapy*
55
From which value is an INR derived?
Prothrombin time
(measure of the extrinsic and common pathways)
56
Which coagulation pathway does warfarin predominantly act on?
Extrinsic
(prothrombin time/INR measures the extrinsic + common pathways)
Warfarin has a greatest inhibitory effect on factor VII
57
What are the 4 Hs and 4 Ts of pulseless electrical activity (PEA)?
Hypoxia
Hypovolemia
Hypothermia
Hypo/hyperkalaemia
Thrombosis - coronary or pulmonary
Tamponade - cardiac
Toxins
Tension pneumothorax
58
What does the breadth of the QRS complex tell you about pulseless electical activity?
Broad: metabolic/ischaemia/LV failure
Narrow: mechanic (poor RV inflow or outflow obstruction)
59
What is the most common cause of sudden cardiac death in young people, especially elite athletes?
Hypertrophic cardiomyopathy (HOCM)
60
Systolic anterior motion of the mitral valve is characteristic of which disease?
HOCM
Obstruction → high flow rate during systole → mitral valve is sucked into the ventricle by negative pressure
61
Pain that is worse when lying flat and better when sitting up is characteristic of what?
Pericarditis
62
What murmur is heard in mitral stenosis?
Decreascendo diastolic murmur with an opening snap
63
How are murmurs graded?
64
What is afterload?
The force or load against which the heart has to contract to eject blood (aortic pressure and systemic vascular resistance)
65
What is preload?
Stretcing of the myocytes prior to contraction
66
How do ACE inhibitors help hypertension and heart failure?
1. Vasodilation
2. Decreased sympathetic activity
3. Diuresis
4. Inhibits remodelling
67
What are the actions of angiotensin II?
Vasoconstriction
Increased ADH
Thirst → fluid retention
Stimulates aldosterone
68
How is blood pressure calculated?
CO x SVR
69
What is Beck's triad of cardiac tamponade?
1. Hypotension
2. Distended neck veins
3. Muffled heart sounds
70
What complications can occur in the first 24 hours following an AMI?
Suddent cardiac death (VF/VT)
Arrhythmias
Acute left heart failure
Cardiogenic shock
71
What is the most common complication 1-3 days post AMI?
Early infarct-associated pericarditis
72
What complications occur 3-14 days post AMI?
Papillary muscle rupture
Ventricular septal rupture
Left ventricular free wall rupture
73
What complications occur 2 weeks to months post AMI?
Atrial and ventricular aneurysms
Dressler syndrome (autoimmune pericarditis)
Arrhythmias
Congestive heart failure
Reinfarction
74
For how long is dual antiplatelet therapy continued following an ACS?
12 months, then reassess risk of bleeding and risk of discontinuation
75
Following AMI, which patients should be given beta blockers?
Reduced LV systolic function (ejection fraction \< 40%)
76
Following an ACS, which patients should be given an ACEi/ARB?
Heart failure
LV systolic dysfunction
Diabetes
Anterior MI
Co-existent hypertension
77
What are indications for revascularisation in patients with stable coronary artery disease?
Activity-limiting symptoms despite optimal medical therapy
Active patients who prefer PCI for improved quality of life compared to medical therapy
78
Which patients are at a very high risk of further thrombotic events following an ACS?
Haemodynamic instability
Heart failure
Cardiogenic shock
Mechanical complications of MI
Recurrent or ongoing ischaemia
79
Which patients are at a high risk of further thrombotic events following an ACS?
Rise and/or fall in troponin level consistent with MI
Dynamic ST-segment and/or T wave changes with or without symptoms
GRACE score \> 140
80
Which patients are at an intermediate risk of further thrombotic events following an ACS?
Diabetes mellitus
Renal insufficiency (GFR \< 60)
LVEF \< 40%
Prior revascularisation
GRACE score 109-140
81
What PaO2 is an indication for oxygen therapy in ACS?
\< 93%
82
Which P2Y12 inhibitors are preferred in dual antiplatelet therapy?
Ticagrelor and prasugrel
83
What are the indications for long-term ACEi use following an ACS?
Heart failure
LV systolic dysfunction
Diabetes
Anterior MI
Co-existent hypertension
84
What are the indications for long-term anticoagulation following an ACS?
Mechanical heart valves
LV thrombus
Chronic AF
CHA2DS2VASC score 2 or more
85
What are the indications for long-term beta blockers in patients with an ACS?
LVEF \< 40%
86
For how long is dual antiplatelet therapy continued following an ACS?
12 months
87
Within what timeframe should invasive therapies (PCI/CABG) be commenced in patients with NSTEMI/UA?
Very high risk - 2 hours
High risk - 24 hours
Intermediate risk - 72 hours
88
What anticoagulation is given to patients with non-valvular AF based on their CHA2DS2-VASc score?
0 = no anticoagulation
1 = no anticoagulation OR treatment with oral anticoagulants
2+ = oral anticoagulation with either warfarin or NOACs
89
What anticoagulation is given to patients with valvular AF based on their CHA2DS2-VASc score?
Warfarin regardless of score
## Footnote
*Valvular AF = patients with mitral stenosis, artificial heart valves and/or repaired mitral valves*
90
What ECG changes are seen in hyperkalaemia?
Tall, peaked T waves
Lengthening of the QRS interval
P wave flattening
Lengthening of PR interval
Shortening of the QT interval
91
What causes a notched P wave?
Left atrial enlargement
"P mitrale" - enlargement is commonly due to mitral disease
*P pulmonale - RA enlargement due to pulmonic disease*
92
Inverted T waves are normal in which leads?
aVR and V1
93
What are hyperacute T waves?
Broad, asymmetrically peaked T waves
Seen in the early stages of a STEMI, often preceding ST elevation
94
What are the causes of biphasic T waves?
Myocardial ischaemia - up then down *(pictured)*
Hypokalaemia - down then up
95
What is Wellens syndrome?
A pattern of inverted or biphasic T waves in V2-3 that is highly specific for critical stenosis of the LAD
96
What do the a and v JVP waves reflect?
a wave = atrial contraction
v wave = atrial filling (ventricular contraction)
