Cardiology Flashcards

1
Q

Aortic stenosis

A
Features :
Narrow PP 
ESM 
Soft absent S2
S4 
Thrill 
LVH 

Causes: age seven/calc

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2
Q

Aortic stenosis

A

Aortic stenosis:
Features: Narrow PP, Slow rising pulse, Thrill, ESM, Absent/soft S2, S4, LVH.

Causes: >65 – Age related/calc. <65 – Bicuspid valve, Williams syndrome (supravalvular AS) Post rheumatic dx, HOCM (subvalv)

Mx
– if Symptomatic, Gradient <40  Replace – Do angio for co-existent CVD
- Asx – observe

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3
Q

Lipid management

A

Lipids:

- Fibrates increase HDL: - Activate PPAR receptor  Lipoprotein lipase activity increase.  rduces TG + increase HDL

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4
Q

WPW

A

Accessory pathway

Don’t give adenosine OR Verapamil as will Block AVN -
increase accessory pathway

Use flecainide sotalol or amiodarone and DC cardioversion

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5
Q

Atrial naturetic peptiode:

A

Secreted by Right atrium – in response to High BP
Works by antagoinising AT2 + aldosterone – promotes NA excrtetion and BP lowering.
Broken down by Andopeptidase.

BNP – Vasodialtor _ diuretic – suppresses sympathetic tone + RAAS

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6
Q

I.E.

A

following procedures do not require prophylaxis:
•dental procedures
•upper and lower gastrointestinal tract procedures
•genitourinary tract; this includes urological, gynaecological and obstetric procedures and childbirth
•upper and lower respiratory tract; this includes ear, nose and throat procedures and bronchoscopy

The guidelines do however suggest:

  • any episodes of infection in people at risk of infective endocarditis should be investigated and treated promptly to reduce the risk of endocarditis developing
  • if a person at risk of infective endocarditis is receiving antimicrobial therapy because they are undergoing a gastrointestinal or genitourinary procedure at a site where there is a suspected infection they should be given an antibiotic that covers organisms that cause infective endocarditis

Causes:
1) Staph A,

2) Steph epidermis if <2/12 post valve surgery or in dwelling lines .
3) streptococcus viridens = sanguinis - dental check
4) strep bovis - associate with colorectal Ca

Culture negative causes:

  • prior abx therapy
  • coxiella burnetti
  • bartonella
  • Brucella
  • HÁČEK

NOTE STREP INFECTIONS - good prognosis

Strongest R.F - Previous I.E.

Other RF - Rheumatic valve dx, Prosthetic valves, congenital heart defect, IVDU,

Indications for surgery:

  • sev valvular incompetence
  • aortic abscess - lengthened PR
  • cardiac fx refractory to standard medical therapy
  • recurrent emboli after abx is
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7
Q

HTN targets:

A
  • Syss inc 20 and dias increase 90 for grades.

- Target: <80 – 140/90 >80 150/90

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8
Q

Exercise tolerance test:

A

CI – MI <1/52, unstable angine, uncontrolled HTN or hypotension, A.S>, LBBB

Terminate if:

  • Exhaustion
  • Chest pain
  • Drop of Sys BP <20 or Sys BP >230
  • STEMI >2mm ST depression >3mm
  • Arryhtmia
  • HR decrease >20%
  • Max HR attained – 220 – age
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9
Q

Cholesterol embolization:

A

Recognised folling coronary angipography + vascular surgery:

  • Eosinophilia
  • Purpura
  • Renal Fx
  • Liverdo reticularis
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10
Q

Hypothermia – ECG changes:

A
  • J waves on QRS - hump
  • first degree HB, - long QT
  • Arrythmia
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11
Q

DVLA + CVDx

A

HTN – no unless side effecrs

Angioplasty 1 week

CABG 4/52

ACS – 4/52

ICD – prophylactic 1/12 or ventric arrhythmia 6/12 – PERMANT FOR GROUP 2

Cath ablation - 2/7

AA - notify and annuyal review

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12
Q

Heart failure Management:

A
  • ACEI + Betablocker
  • 2nd = spiro/eplerenone, or ARB or hydralazine + nitrate
  • 3rd CRT or Dig
  • Features of overload - diuretics.
  • Annual influenza vax and one off pneumococcal
  • Mortality benefits: ACEI, Betablockers, spironolactone, hydralazine + nitrates.
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13
Q

1) pulsus paradoxus
2) slow rising
3) collapsing
4) pulsus alternans
5) Bisferiens Pulse
6) Jerky pulse

A

1) greater than 10mmHg fall in says BP on insp - sev asthma, tamponade
2) AS
3) AR, PDA, hyperkinetic states
4) Sev LVF - alt of of force of arterial pulse

5) mixed AV disease - double
Pulse

6) HOCM

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14
Q

Tetralogy of

Fallout

A

Pulmonary valve stenosis
VSD
Overriding aorta
rVH

Get a BOOT shaped heart

Ft in infants/children –> cyanotic attacks
- Tuck legs to chest if baby or ask child to squat –> increase Systemic vas resistance and decrease venour return. (H+ causes infundibular spasm)

Mx:

  • two part surgical repair
  • Beta-blocker prophylaxis vs cyanotic attacks –> decreadse infundibular spasm.
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15
Q

Canon A Waves

A

Caused by RA contacting against closed Tricuspid Valve.

Regular:

VT
AVNRT

Irregular:
Complete heart block

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16
Q

Warfarin

A

ODEVICES:

Omeprazole
Disulifram 
Erythromycin 
Valproate 
Isoniazid 
Cipro + cimetidine 
Ethanol - acute 
Sulphonamides 

PCBRAS - stop warfarin - inducers

Phenytoin 
Carbamazepine 
Barbiturates 
Rifampicin 
Alcohol - chronic 
Sulphonylureas 

Others:

St. John’s wort - inducer - decrease warf
Cranberry juice - increase warf

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17
Q

Heart sounds

A

S1 - closure of MV + TV- prolonged in MR or PR - loud in MS

S2 - closure of AV + PV - soft in AS - splitting during inso is Normal

S3 - caused by diatomic filling of Ventricle - normal if <30. - causes LVF, MR, constrictive pericarditis

S4 - caused by atrial contraction against stiff ventricle - AS, HTN, HOCM - P wave

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18
Q

Causes of LBBB

A
Acute MI 
Aortic stenosis 
cardiomyopathy 
HTN 
Rare: idiopathic fibrosis, digoxin toxicity, hyperkalaemia
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19
Q

Stable angina and assessing CVD

A

Probability for CAD:

<30% - CT Ca Score

30-60% - myocardial perfusion scintigraphy

> 60% - invasive coronary angiography

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20
Q

pulmonary artery hypertension management

A

Definition: PA pressure >= 25mmHg

Causes: COPD/CLD, drugs, idiopathic - AD

Ft: progressive exertional dyskinesia, exertional syncope/vest pain and peripheral oedema. Cyanosisz

Findings: RV heave , loud P2, raises JVP with a waves, tricuspid regurg.

Management:

Acute vasodilator test —> aims to show a sig fall in pulm Artery pressure following admin of vasodilator m.

+ve response to acute vasodilator testing: PO ca channel blocker

-ve response:
Prostacyclin - illoprost and treprostrinil
Endothelin receptor antagonists - bosentan, ambrosentan
PDE-V - sildenafil

Progressive sx —> heart/lung transplant

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21
Q

Hyperlipidsemia - primary prevention

A

Use QRISK2 if <85 - >=10% give atorvastatin 20mg

QRISK2 not used if:
DB1
eGFR <60 and/or albuminuria
Hx of familial hyperlipidaemia

QRISK underestimates if:
Treated for HIV 
Serious mental health 
Antipsychotics, corticosteroids or immunosuppressant drugs —> dyslipidaemia 
AI DX or systemic inflamm dx (SLE) 

Aim for a reducing of non-HDL cholesterol of >40% in 3 months
If don’t meet target —> concordance and lifestyle advice —> increased dose

Measuring lipids:

Total chol >7.5 & famil hx of prem CVD —> consider familial

Total chol >9 or non-HDL >7.5 —> refer

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22
Q

Hyperlipidaemi - secondary prevention

A

Give atorvastatin 80

To all CVD

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23
Q

Hyperlipidaemia special situations

A

DB1:

Consider in all adults with type 1
Give atorvastatin 20 if:
- >40 yes or dB >10 years or nephropathy or other CVD Rf

CKD:

Give atorvastatin 20mg

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24
Q

Warfarin targets

A

AF: 2-3

Venous thromboembolism: 2.5 or 3.5 if recurrent. If unprovoked—> lifelong

Prosthetic valve: 2.5

Metallic valve: 3 if AVR. If recurrent DVT 3.5. 3.5 if MVR.

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25
Q

HOCM

A

A.D

Mutations in beta myosin heavy chain protein, Troponin T
Septal hypertrophy —> LV outflow obstruction

Poor prognostic factors:
Syncope 
FHx of suddenly death 
Young age of px 
Non-sustained Ventricular tachy 
Abnormal BP change on ex 

Septal wall thickness increase >3cm
On Evho - BAD

Mx:
A - Amiodarone 
B - beta block/CCB
C - cardioverter defib
D - dual chamber pacer
E - Endocarditis prophylaxis

Drugs to avoid:

  • Nitrates
  • Inotropes
  • ACEI
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26
Q

Fabry disease

A

X-linked recessive
Deficiency of alpha-galactosidase A

Px:

F - fever 
A - angiomeratomas - bathing suit 
B - burning pain
R - renal - proteinuri 
YX - Xlinked recessive 
S - stroke/CV disease 

Corneal Whirls on slit lamp

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27
Q

Rheumatic fever

A

Recent strep pyogenes infection

aInnate immune system —> Ag presenting T cells —> aB and T cells —> prod IgG, and IgM and CD4 T cells —> X tactics immune with myosin.

Aschoff bodies

Diagnosis: 1
Major or 2
Minor

Major - JONES criteria:
J - joints - polyarthritis 
O - think heart - carditis + valvulitis
N - nodules- subcutaneous 
E - erythema marginatum
S - Sydenham chorea 
Minor criteria: 
Raised ESR
Pyrecia 
Arthralgia 
Prolonged PR

Indications for surgery:

  • lengthx ened PR - aortic root abscess
  • severe valvular incompetence
  • refractory infection
  • refractory CHF
  • recurrent emboli post abx
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28
Q

Cardiac markers

A

Trops are most common - components of thin filaments

Others:
Myoglobin increasesfirst

CK-mb is goo to look at reinfarction as it returns to normal after 2-3 days (whereas trop takes up to 10days)

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29
Q

RIght ventricular MI

A

Px:

ECG features of MI with triad of:

  • Clear lung field
  • raised JVP
  • hypotension

Don’t give nitrates as will decrease preload and worsen

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30
Q

HOCM VS PAH

A

Both cause syncope / suddenly death in young adults with family history

Murmur: HOCM - Y. PAH - N

Heart sounds: HOCM-N PAH - loud S2

Increased SOB: HOCM - N PAH - Yes

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31
Q

Restrictive Cardiomyopathy

A

Ft: Prominent apical size , Increased heart size , ECG abnormalities = Q waves or BBB

Causes:

  • UK most common - Amyloidosis following Myeloma
  • haemochromatosis
  • loffler’s syndrome
  • sarcoidosis
  • scleroderma
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32
Q

Atrial Myxoma

A

features:

Clubbing 
Pre-sys murmur - normally mid diastolic 
AF
Anaemia 
Fever
Atrial Plop
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33
Q

Warfarin Mx of High INR

A

Major bleed:

  • Stop Warfarin
  • IV Vit K 1-5mg - rpt INR @ 24hr if INR still high –>rpt dose
  • Prothrombin complex

INR >8.0 with minor bleed:

  • Stop Warfarin
  • IV Vit K 1-3mg - rpt INR @ 24hr if INR still high –>rpt dose
  • restart warfarin once INR <5.0

INR>8.0 with no bleed:

  • Stop Warfarin
  • Vitk K 1-5mg (PO) - rpt INR @ 24hr if INR still high –>rpt dose
  • restart Warfarin once INR<5.0

INR 5.0 - 8.0 w/ minor bleed:
- Stop Warfarin
A - IV Vit K 1-3mg - rpt INR @ 24hr if INR still high –>rpt dose
- Restart Warfarin when INR <5.0

INR 5.0 - 8.0:

  • Stop Warfarin
  • Reduce subsequent maintenance dose

In emergent surgery:

  • can’t wait give PTCC 25-50units/Kg
  • can wait give IV Vit K 5mg and wait 6-8hrs
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34
Q

Brugada syndrome

A

Inherited - A.D.

Young asian px with syncope or sudden death, often due to arrythmias

PrMutation in gene coding for Na channels. Therefore furing cardiac cycle, don’t get theapid influx of Na for dep. As a result get slow conduction –> “short circuiting” –> reverse in direction of depolarisation –> cycling –> re-entrant tachy

ECG Changes:

  • Convex ST elevation with assoc. neg Trop
  • RBBB (partial)

Mx: ICD

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35
Q

Thrombolysis in STEMI

A

Remember contraidicated if risk of bleed.

Post-Thrombolysis

  • rpt ECG @ 90min
  • Aim is reduction of >50%
  • If <50% –> PCI
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36
Q

I.E - dukes criteria

A
Diagnosis:
Pathological criteria +ve 
2 major 
1 major and 3 minor 
5 minor 

Pathological criteria:
- + histology or micro from
Cardiac tissue directly - autopsy or surgery

Major:

Positive blood cultures:

  • 2 + BCs of typical ( strep viridans and HÁČEK) or
  • persistent bachatas is from 2 BCs taken >12 he apart or >= 3 In less specific orgabsisms (staph A or staph Ep)
    • serology - coxiella burnetii, bartonella or chlamidyia psittaci or
    • molecular assay for specific gene targets

Evidence of Endocardial involvement:

    • echo or
  • new valvular regurg (murmur)

Minor criteria:

  • predisposing heart condition or IVdU
  • micro that doesn’t meet major
  • fever >38
  • vascular phenomena
  • immunological phenomena - Glomerularnephritis, oslers nodes, Roth spots
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37
Q

Angina management

A

1) aspirin + statin + GTN
2) beta blocker or CCB

  • if ccb - mono then use verapamil Or diltiazrm
  • if with beta blocker - nifdedipine as risk of heart block with verapamil

3) if poor intiial response —> increase dose
4) use combo of advice

  • if any tolerate addition of one or the other, use long acting nitrate, ivabradine,
    Nicorandil or ranolazine

5) only add 3rd drug if awaiting assessment for PPI or CABG

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38
Q

Central acting anti-HTN

A

Methyldopa - mx of htn in preg

Moxonidine - mx of essential
Htn when normal therapy fails

Colonidine - stimulate alpha-2 adrenoreceptors in vasomotor centre

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39
Q

Dilated cardiomyopathy

  • Causes:
    idiop[athic + ABCCCD
A

All4 chambers LV>RV.

Ft - arrhythmia, MR, emboli

Causes:

  • Idiopathic
  • EtOH
  • Postpartum
  • HTN

ABCCCD:
- Alcohol/beriberi (Wet)/Chagas/coxsackie/cocaine/doxurubicin

Others:

  • inherited
  • infective
  • endocrine - hypothyroid
  • infiltrative- haneochromatosus, sarcoidosis
  • DMd
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40
Q

MI Secondary prevention

A

All patients: ACEI, Beta-Blocker, statin, aspirin, clopidogrel/ticagrelor/pasugrel

Diet + lifestyle:

  • Mediterranean diet
  • 20-40 mins of ex - slight breathlessness
  • can resume sexual activity at 4 weeks. Doesn’t increase risk of MI, can use viagra at 6/12

Post MI:
Ticafrelor and aspirin preferred
Stop ticagrelor at 12montgs

Post PCI:
Stop 2nd antiplatelet at 12 months

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41
Q

Malignant HTN

A

Basics:

Severe htn >200/130
Fibrinoud necrosis of blood vessels —-> retinal haemorrhages, exudates, proteinuria, haematuria

Can lead to cerebral oedema—> encephalopathy

Ft:

  • sev headache. n/v. Visual symptoms
  • chest pains + dyspnoea
  • papilloedena
  • encephalopathy —> seizure

Mx:

  • reduce Dias no more than 100mmHg in 24hr
  • oral use atenolol
  • of severe —> IV sodium nitroprusside/labetolol
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42
Q

Familial hypercholesterolaemi

A

Autosomal Dominant —> high LDL

Simon broome criteria:

  • adults: TC > 7.5. And. LDL >4.9
  • children: TC >6.7. And LDL >4
  • for definite: tendon Xanthoma in pt with 1st or 2nd degree relative with DNA evidence of FH
  • possible: FHx of MI <50 in 2nd degree relative or <60 in 1st defeee.

Management:

Do not use QRISK
Referral to special lipid clinic
High dose station first line
Screen 1st degree relatives

Statin should be discontinued 3/12 before conception

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43
Q

Stent thrombosis vs restonosis

A

Thrombosis:

  • within first month
  • often get ACS

Restonosis:

  • 3 to 6 months
  • worsening angina
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44
Q

Adenosine

A

Enhanced by anti-platelets and dipyridamole

Reduced by - aminophylline

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45
Q

Cyanotic vs acyanotic heart defects

A

Cyanotic:

At birth most common - Transposition of great arteries

  • > 1-2months - tetarology
  • tricuspid atresia

Acyanotic:

VSD - most common 
ASD 
PDA 
Coarctation 
AV stenosis
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46
Q

Arrythmogenic RV cardiomyopathy

A

Autosomal doninant

Replacement of RIGHT myocardium with fatty and fibrofatty tissue.

Features:

Present with palpitations and syncopal episodes.

ECG - inverse T waves in V1-V3.
- epsilon wave = notch on QRS

Echo - hypokinetic thin free wall of RV

MRI is diagnostic

Mx:
Sotalol

Catheter ablation

ICD

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47
Q

Pericarditis

A

Causes:

Viral (coxsackie), TB, Uraemia, Trauma, post Mi, CT dx,hypothyroid, malignancy

ECG features:

Widespread ST elevation

PR DEPRESSION- most specific

Mx: NSAIDs and tx underlying cause

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48
Q

Raised JVP causes

A

Normal Waveform

  • HFx
  • Fluid overload

Kusmails sign

  • Raised on insp and decreased on exp
  • Sign of RV inability to expand
  • Tamponade/effusion/constrictive

Loss of normal pulsatation
-SVC syndrome - obstruction due to medialstinal malignancy

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49
Q

JVP pathology

A

A waves:

  • Absent - AF
  • Large - RHFx/Pulm HTN
  • Cannon : Reg AVNRT/VT Irreg - 3rd degree HB

V waves:
- Giant = TR

X wave
- Steep = Tamponade/constriction

Y wave:

  • Steep = Constriction
  • Slow = TS
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50
Q

Apexe Pulses pathology

A
Heaving = LVH
Thrusting = LV vol incre = MR/AR/PDA/VSD
Tapping = M.S
Displaced = LV impairment/dilatation
Dbl impact - w/dyskinesia = LV aneurysm    w/o dyskinesia = HOCM
Pericardial knock = Constrictive
parasternal heave = RVH
palpable 3rd heart sound = HFx/Sev MR
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51
Q

PAthological S2

A

Wid split:

  • A2 early: MR/VSD
  • P2 Late; RBBB/PS/ASD

Single HS:
- A2 Soft - AS
P2 Soft - PS/TOF

Reverse split:

  • A2 late - LBBB/HOCM/A.S
  • P2 early - TR/PDA/WPW

Fixed split:
- ASD - When prssure is equal across atria - no widening with Exp/

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52
Q

Opening snap

A

Mitral stenosis
just after S2

closer it is to S2 the more severe the stenosis.

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53
Q

Mitral stenosis

A

Most commonly post rheumatic Heart dx - rare carcinoid/SLE/mucopolysacchridosis.

Ft:
0 Mid-late dias urmur 
- loud S1
- low vol pulse
- Malar flush 
AF

Ft of severity:

  • Increase length of murmur
  • opening snap closer to S2

CXR:
- LA enlargement -> dysphagia

Echo
X section <1sq cm (nornlaa 4-6)

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54
Q

Mitral regurg

A

Can be common in healthy

increase sev –> CO cant meet O2 supply.

RF:

  • Female
  • low bmi
  • age
  • renal dysgn
  • prev mi
  • prior MS r prolapse
  • Collagen disorder - MArfans - Ehlers-D

Causes:

  • MI –> apillary muscle rupture
  • MV prolase
  • I.E.
  • Rhuemativ fever
  • congenital

Ft:

  • Asx
  • LVF/arrythmia/pulmHTN
  • pansystolic murmur/ Sev –> Wide split S2

inx:

  • Broad P wave –> Atrial enlarg
  • CXR –> cardiomegaly
  • ECHOCARFIOGRAPHY

Mx:
- Acute = medical - Nitratrs/ diuretics/ psitive imotropes –> intraortic baloon pump

  • HFx mx.
  • acute severe regurg –> Surgery
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5
Perfectly
55
Q

A.R. - features

A

Early diastolic murmur –> increase on handgrip
Collapsing pulse
Wide PP
Quinkes sign - nail bed pulse
De Mussets sign - head bobbing
Flint’s murmur - mid diastolic - partial closure of valve due to backflow.

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56
Q

AR causes

A

Valvular:

  • rheumativc fever
  • IE
  • CT dx - SLE/RA
  • Bicuspid
Aortic root :
- Aortc dissection 
- ankylosing spondylitits 
- Collagen disorders 
- Syphilis 
HTN
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57
Q

Tricuspid regurg

A

Low freq pansystolic murmur
Giant V wave

Causes:

  • RV dialation
  • Carcinoid
  • infective
  • post rheumatic fever
  • Ebsteins anomaly
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58
Q

PEricarditis vs dresslers post-MI

A

both saddle shaped

PEricarditis is more acute i.e. - 48hrs
Dresslers = 2-6 weeks = A.I.

Dressler shave mild temp/ESR/effusion

Mx - NSAIDs

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59
Q

Reinfarction - cardiac marker

A

use CK-MB - as returns to nprmal much quicker

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60
Q

Indications for temproary pacing

A

Anterior MI –> Mobitz type 2 or complete HB
Trifasicular block - prior to surgeyr
Symptomatic/decompensated bradycardia - not responding to Atroopine

note - Complete HB after POSTERIOR MI is VVVV COMMON –> Doesnt require temporary pacing

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61
Q

Ivabradine

A

Works as antiangival by reducing HR

acts on SAN –> Funny current

S.e:

  • HEartblock
  • Visual phenomena - bright spots
  • headache
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62
Q

Aortic dissection

A

Tear in tunica intima

Assoc:
HTN
Trauma 
Bicuspid valve 
Collagen disorders 
Turners and noonans 
Pregnancy 
Syphillis 

Ft:
Chest pain
Aortic regurgitate
Htn

Specific ft of ischaemia to distal supply

Classification
Stanford type A - ascending sort
Stanford type B - descending

Inx —> CT with IV contrast

Mx

  • ascending —> IV labetolol and surgery
  • descending —> IV labetolol
63
Q

Heart failure drugs with improved mortality

A

Beta blocker
Ace inhibitiors
Spironolactone
Nitrates and hydralazine

64
Q

Stable angina and suspect CAD Inx

A

Contrast CT Angio

65
Q

Anticoags

A

Heparin - activates anti-thrombin 3

Clo-P-idogrel - P2Y12 inhibitor

A-b-ciximab - glycoproteins IIb/IIIa inhibitor

D-abigatran - D irect thrombin inhibito

Rivaroxaban - Factor X inhibitor

66
Q

PE anticoagulation length

A

Eovokd - 3/12

unprovoked 6/12

Ca - 6/12 of LMWH

67
Q

Prosthetic heart valves antithrombotic therapy

A

Biprosthetic - ASA

Mexhanical - ASA + warfarin

68
Q

Pinzmental

Angina mx

A

Dihydropyridine CCB

69
Q

Second heart sound

A

Loud - HTN
soft - AS
Fixed split - ASD
Reversed - LBBB

70
Q

S4

A

S4 is seen in aortic stenosis

Associated with atrial contract against stiff ventricle

Associated with P wave

71
Q

Flutter definitive management

A

Radio frequency ablation of tricuspid valve isthmus

72
Q

Infective endocarditis Mx

A

Blind treatment:

  • Native - amoxicillin (+/-gent)
  • Pen allerg - Vanc + low dose gent
  • Prosthetic - Vanc+ rifamp + ld-GEnt

Staph A:

  • Native - Fluclox
  • NAtiv + Pen - Vanc + rifamp
  • Prosthetic - FLuclox + rifamp + ld-gent
  • PRosthetic + pen allergic - Vanc + rifamp + gent

Strep:

  • Fully sensitive (Viridans) - Benzylpenicillin
  • pen allergy - Vanc + gent
  • low sens - Benzpen + gent
73
Q

SVT prophylaxis in pregnancy

A

Used metoprolol

Adenosine and verapamil - decreases uterine Bf

Amiodarone - teratogenic

Flecainide only specialist

74
Q

Hyperlipidaemi xanthomata

A

Palmar - remnant hyperlipidaemi

Tendon/tuberous - familial hypercholesterolaemia

Eruptive xanthoma - familial hyperTG.

Mx 
Surgical excision 
Topical trichloroacetjc acid 
Laser therapy 
Electrodessication
75
Q

Congenital Heart dx:

Acynatoc vs Cyanotic

A

Acyanotic:

  • shunt - VSD/ASD/PDA/Aortic coarctation
  • No shunt - Aortic coarctation/ congenital AS

Cyanotic:

  • Shunt = TOF/ Transposition/Ebsteins anomaly.
  • w/o shunt = Tricuspid atresia/pulm stenosis/pulm atresia/ hypoplastic L heart
76
Q

ASD

A

2types - primum and secundum
secundum most common
most common congenital heart dxin adults

Features:

  • ESM and fixed S2 split
  • paradoxical embolus

secundum:

  • assoc w/ holt-oram syndrome - triphalangeal thumbs
  • ECG - RBBB + RAD

Primum

  • px earlier
  • ECG: RBBB + LAD + increased PR
  • assoc abnormal AV valves.
77
Q

ASD - indications for surgery

A
Worsening dyspnoea 
increased R heart pressure 
Chamber dilatation 
sig L --> R shunt
Systemic emboli.
78
Q

VSD

A

Most common congenital heart disease
50% sponatneosuly close

assoc with patau/Edwards/Downs syndrome

Ft:
- pansystolic murmur - louder with smaller defects

Assoc:

  • Aortic regurg
  • Eissenmengers
  • I.E.
  • RHFx
  • Pulm HTN
79
Q

VSD - indications for closure

A
Sig L--R shunt 
Pulm HTN/ Right heart pressure
Other cardiac abnormalities 
Endocarditis 
Membranous VSD --> A.R.
80
Q

PDA

A

Common in:

  • Prmeature babies
  • high alt
  • Rubella infection in 3rd trimester

Ft:

  • Left Subclavian thrill
  • L heart enlarged + heave
  • Machinary murmer
  • Wide pulse P + Bounding pulse

Mx:
- Indometacin

81
Q

Coarctation

A

Life threatening in early life –> Use PG to maintain PDA
- HFx / Metabolic acidosis

Ft:

  • Heart failure in infancy
  • HTN in adulthood
  • Radio-femorla delay
  • leg cramping
  • Aortic click and apex
  • Mid systolic murmur - loudest at back
  • Notchinf of inferior ribs - CXR
  • Post stenoit c dilatation –> Oesophageal compression –> Dysphagia.

Assoc:

  • Turners
  • Bicuspid Aortic Valve
  • berry aneurysms
  • Neurofibromatosis
82
Q

Atrial fib - Types

A

1) First episode
2) paroxysmal or persistent (<7days or >7days)
3) Permanent - persistent and not cardivertable.

83
Q

A fib management

A

1st line is rate control on:

  • <65 yrs
  • 1st episode
  • HFx
  • Reversible cause

Rate control@
- Beta-blocker and rate limting -CCB (diltiazem)

2nd line - 2of:

  • Betablocker
  • CCB
  • Dig
84
Q

AF - Cardioversion

A

If HD unstable or <65/HFx/1st episode/reversible

Pharmacological - Flecainide or amiodarone (structural)

Onset <48 hrs:

  • Herparines
  • DC or pharmacological

Onset >48hrs:
- Anticoag for 4/52 or TOE to exclude thrombus

Prev fx of cardioversion or recurrence –> 4/52 of amiodarone or sotalol before reattempts.

85
Q

CHADVASC and HASBLED

A

CHADVASC:

  • > 1 and male - consider
  • > 2 - anticoag.

HASBLED:

  • HTN/abnormal RFX or LFT cr>200 or Transaminas >3x/ stroke hx/ bleed risk/Labile INR/Elderly >65/ drugs (NSAIDS/ASA etx.) or EtOH
  • 1 for each
  • > 3 is high risk
86
Q

Indication for pacing in CHFx

A

NYHA 3 - 4
QRS >120
LVEF >35% with dilated ventricle and pt on optimum medical mx.

Biventriuclar pacing.

87
Q

Angina - types

A

Decubitus - Worse on lying down

Pinzmental - Coronary A spasm - Transient ST elevation

Syndrome X: - Middle aged female - ST depression on exercise.

88
Q

Angina grades

A

1 - strnouous exercise
2 - 2 flights of stairs
3 - one block on level ground
4 - at rest

89
Q

Angina - Mx

A

1st line:
- GTN + ASA + STATIN + Beta block or RL-CCB

2nd - increase mac dose of mon

3rd - Try other monotherapy

4th - can tolerate combo-> combo

4th - cant tolerate - LA nitrates/Ivabradine/ Nicorandil/ranolazine

5th - + 3rd drug from above list - only if WAITING PC

90
Q

Angina 1st line of Inx - if ?CAD

A

CT Angiogram

91
Q

S.E. of anti-anginals

A

CCB:

  • Headache
  • Flushing
  • ankle oedema

Beta-blocker:

  • Bronchospasm
  • fatigue
  • cold peripheries
  • sleep disturbance

Nitrates:

  • headache
  • Postural drop
  • Tachy

Nicorandil

  • Headache
  • flushing
  • Anal ulceration
92
Q

NSTEMI Mx

A

MONAC

LT ASA and 12 motnh of ticagrelor/prasugrel=(preferred of PCI)

if angiography >24 hrs or not at all - Fondaparinux

Angiography <24 hr - unfrac hep

High risk of bleed and Andiography < 96hrs - IV tirofiban

93
Q

Causes of raised BNP

A
LVH
ischemia
tachy 
RV overload
low PO2
Stress/sepsis 
COPD 
Low GFR
94
Q

Primary cardiomyopathies - Genetic

A

HOCM:

  • AD = beta myosin heavy chain
  • MR
  • Septal hypertrophy
  • Poor prognosis : BP change during ex/Young age/ Syncope/ FHx/ non sustained VT.
  • Tc = A + B + C + D + E
  • Avoid nitrates/inotropes/ACEI

Arrythmogenic RV dysplasia:

  • RV myocardium replace with fatty fibrous tissue.
  • ECG - V1-V2 T wave inversion + Epsilon wave
  • MRI
  • Mx = Sotalol
95
Q

Primary cardiomyopathies - mixed

A

Dilated:

  • EtoH
  • Coxsackie
  • beri beri
  • Doxorubicin

Restrictive

  • Amyloidosis
  • Post-RT
  • Lefflers
96
Q

primary cardiomyopathies - Acquired

A

Peripartum Cardiomyopathy

  • Last 1/12 preg –> 5/12 post partum
  • RF - Inc Age, parity and gestation #

Takotsubo Cardiomyopathy

  • stress/broken heart syndrome
  • Octopus pot
  • Transient - Mx = supportive.
97
Q

Secondary Cardiomyopathy

A
Infective - Coxsackie 
Infiltrative - Amyloidosis 
Storage - haemochromatosis 
Toxicity - Doxyrubicin 
Inflamm: - Sarcoidosis 
Endocrine - DB/Acromegaly/Thryotoxicosis 
Neuromuscular - muscular dystrophies/dystrophies/myotonic dystrophies 
Nutritional - Thiamine --> Beri Beri 
A.I.  - SLE
98
Q

Restrictive cardiomyopathy vs Constrictive pericarditis.

A

cardiomyopathy > pericarditis.

  • Prominent apical pulse
  • Cardiomegaly
  • ECG changes - Q wave LBBB
  • Don’t get pericaridial calc on CXR
99
Q

Pericarditis

A

Chest pain relief on sitting forward
Flu like sx
ECG - widespread saddle shaped ST elevation & PR DEPRESSION (most spec)

Causes:
- Viral / TB / uraemia. Dresslers / trauma. hypothyroid/ malignancy

Inx - ECG + Echo

Mx : tx causes + NSAID

100
Q

Constrictive pericarditis

A

primarily caused by TB

Ft

  • SOB
  • HFx
  • Raised JVP - prominent X + Y descent
  • Loud S3 = pericardial knock
  • Kussmauls sign

inx - CXR

101
Q

Contrictive pericarditis vs tamponade

A

Pericarditis > Tamponade:

  • Increased X + Y descent
  • Kusmaulls sign
  • CXR - pericardial calc

Tamponade = Becks triad & ECG = electrical alternans + pulsus paradoxus.

102
Q

Pericardial effusion

A

Can develop 2L
Pulsus pardoxus + pulsus alternans
CXR –> globular cardiac enlargemnent

Causes:

  • pericarditis causes
  • aortic dissection
  • iatrogenic
  • IHD –> ventricular wall rupture
103
Q

myocarditis

A
viral - Coxsakie/HIV
bacteria - Diptheria/Clostridia 
Spirochetes - Lyme dx 
protozoa - Chagas/lyme 
AI
Doxyrubicin 

Px - young pt w/ acute chest pain + dyspnoea

Inx:

  • increased inflamm markers
  • ECG St elevation/ Twave inversion
104
Q

Rheumatic fever

A

2-6/52 after strep pyogenes infection
IgG + IgM –> CD4 T cell

X reaction w/ M protein

Get aschoff bodies

Diagnosis = Evidence of recent infection + (2 Maj) or (1 major + 2minor)

Recent infection:
+ throat swab
+ strep antibodies
+ Group A strep antigen

Major:
Erythema Marginatum 
Sydenhams chorea
Polyarthritis 
Subcut nodules 
cardits/valvulitis 
Minor:
Raisesd ESR/CRP
Temp
Arthritis
High PR
105
Q

Cardiac tumours

A

Atrial mycoma most common

75% in LA - Fossa ovalis
Female>Male

Ft:
- systemic
- Emboli
AF

MID DIAS MURMUR WITH TUMOUR PLOP

106
Q

who gets statin

A

Anyone with secondary for prevention for - CVD/CBVdx/PAD

Primary:

  • any pt with 10 year CV risk >10%
  • DB1 with QRISK
  • DB 2 who >10 yrs / >40 ye old / DB nephropathy
107
Q

stopping statin

A

Transaminases >3x ULN = PERSISTS

108
Q

SVT w/ Aberrant conduction vs VT

A
VT>SVT 
- Concordant QRS 
- capture + fusion beats 
RBB w/ LAD 
- CRS > 140 
- Hx IHD 
- Vent rate <170
109
Q

Hypothermia - ECG changes

A
Prolonged PR 
J wave 
Long QT 
Bradycardia 
Arrythmias.
110
Q

Bradycardia management

A

Give six doses of atropine —:> fx –> External pacing or isoprenaline/adrenaline

111
Q

Multifocal atrial tachycardia

A

Tachy cardic - narrow complex - caused by at least 3 different sites

different P wave morphologies

Mx:

  • short electrolytes and hypoxia
  • Rate limiting CCB
112
Q

Cardiac syndrome X

A

Angina ike chest pain on exertion
ST Depression n exercise ECG
Normal coronaries

Mx: Nitrates

113
Q

When to start anti HTN

A

ABPI > 135/85 and end organ damage, DB2, Renal dx, CVD or Q risk >10%

ABPI 150/95 anyone

114
Q

BP Targets

A

<80 - <140/90 or 135/85

> 80 - 150/90 or 145/85

115
Q

PRe-eclampsia RF

A
Obesity 
smoking
twins 
nulliparity 
DB
116
Q

PE anticoagulation length

A

Eovokd - 3/12

unprovoked >3/12

Ca >6/12

117
Q

Hydralazine

A

increase cc-GMP –> relaxation of SM of Arterioles>veins

118
Q

BEst cardiac scans

A

Structural - Cardiac MRI

CAD - Cardiac CT

PErfusion etc. - nuclear imaging - SPECT

119
Q

Warfarin and bleeding

A

Major bleeding - IV Vit K 5 mg + PTTC

INR>8.0 + minor bleed - IV vit K 1-3m - rpt Vit K at 24hr

INR >8 no bleed - PO vit K 1-5mg - rpt Vit K

INR 5 –> 8 w/ minor bleed - IV Vit K 1-3mg

INR 5 - 8 no bleed - just withold two doses

with all- restart warfarin when INR

120
Q

Complete HB with narrow QRS

A

lower risk than wde QRS for asystole

121
Q

Post thrombolysis aim for resolution

A

if <50% –. PCI

122
Q

Infective endocarditis Mx

A

Blind treatment:

  • Native - amoxicillin (+/-gent)
  • Pen allerg - Vanc + low dose gent
  • Prosthetic - Vanc+ rifamp + ld-GEnt

Staph A:

  • Native - Fluclox
  • NAtiv + Pen - Vanc + rifamp
  • Prosthetic - FLuclox + rifamp + ld-gent
  • PRosthetic + pen allergic - Vanc + rifamp + gent
123
Q

AF with heart failure and reduced EF

A

AVOID BEtablocker and rl-CCB –> negatively inotropic

use Dig

124
Q

Statin monitoring

A

BAseline –> 3/12 —> 12/12

Remember AST/ALT >3x ULN and PERSISTENT - stop

125
Q

What med in articular makes clopi less effective

A

PPIs

126
Q

Dypiridamole MOA

A

Inhibit phosphodiesterase –> elevate platelet cGMP –> reduce intracellular Ca

also it:

  • Thromboxane inhib
  • reduced cellular uptake of adenosine
127
Q

Centrally acting anti-HTN

A

MEthyldopa - used in preg induced HTN
Moxonidine - USed in essential HTN when other fail
Clonidine - stim alpha-2 adrenoreceptocepter in vasomotor centre

128
Q

ACEI first dose side effect

A

first dose hypotensio

129
Q

ACS common meds MOA

A

Aspirin - Antiplatelet - inhibit production of thromboxane

Clopi - Inhibit ADP binding site of platelets

Enoxaparin - activates antithrombin 3 –> potentiate facto Xa

Fondaparinux - activates antithrombin 3 –> potentiate factor Xa

Bivalarudin - Direct thrombin inhib

Abciximab, eptifibatide, tirofiban - glycoprotein 3a/2b recepto antagonist

130
Q

Amiodarone

A

MOA - Blocks K+ channels

prior to tx - TFT/LFT/U+E/CXR

TFT/LFT - 6/12

131
Q

Hyperkalaemia

A

K+ >6 –> Stop ACEI

Switch for another

132
Q

What medication if ? SVT with aberrant conduction over VT

A

Amiodarone

133
Q

Adenosine interactions

A

Blocked by theophyllines

increased by dipyradimole

134
Q

Post anaphylaxis monitoring length

A

8 hours

135
Q

Most important prognostic factor pst STEMI

A

LV ejection fraction

136
Q

Statin + clarithromycin/erthromycin

A

Myalgia and rise in CK

137
Q

RF for statin induced myopathy

A

Age
Female
low BMI
multisystem dx

138
Q

Catecholaminergic polymorphic VT

A

AD

Mutation i gene for ryanodine receptor which is found in SR

Ex –> polymorphic VT
Syncope
Sudden death
Sx bf age of 20

Mx:
Beta block
ICD

139
Q

VTE and when to start IVC filter

A

If recurrent despite:

  • increasing therapeutic range to 3-4
  • USing LWH –> still get
140
Q

Myotonic dystrophy cardiac manifestations

A

PROLONGEED PR - most common

cardiomyopathy

141
Q

Most prothrombotic factor in anti-phospholipid syndrome

A

Lupus Anticoagulant

other factors:

  • Anticardiolipin
  • beta - 2- glycoprotein 1
142
Q

Brugada syndrome ecg changes

A

ST elevation in V1 - V3 and partial RBBB

143
Q

Poor prognostic indicators in ACS

A
ST deviation
Heart failure 
PVD
Age
Fall in SBP 
Elevated cardiac markers
Cardiac arrest on admisipn 
raised Cr 
Killip clas
144
Q

Ivabradine indications for use

A

Angina in HR >70 if 1st lines havent worked and pt cannot tolerate combo f CCB/betablocker

CHFx:
- in addition to standard tehrapy if HR >75

145
Q

Causes of raised BNP

A
LVH
Ischameia
Tachy RV overload
sepsis
CKD
Liver cirrgosis 
Hypoxaemia
COPD
DB
Age >70
146
Q

Which organism has the highest mortality in I.E.

A

Staph

147
Q

ICD insertion and group 2

A

permanent Bar

148
Q

Who gets ticagrelor in NSTEMI patient

A

a

ALL PATIENTS

149
Q

Adenosine

A

GPCR agonist of adenosine type 1 receptor in avn

This leads to decreased cAMP

150
Q

Management of long QT

A

Bisoprolol is goof for immediate managemenr.

Conventional anti-arryrhmics (amiodarone and flecainide) can lengthen QT

151
Q

Causes of secondary hypertension

ABCDE

A

A - Apnoea (OSA), Aldosteronism, Accuracy of measure
B - Renal A Bruits (Stenosis), Bad Kidneys (Renal dx)
c - Cushings, Coarctation, Catecholamines
D - Diet, Drugs
E - Endocrine - phaeo/hypothyroid/hyperPTH/Excess EPO

152
Q

Most common cause of viral myocardtis

A

PARVOVIRS B19 _ HHV6

153
Q

pre-test scores of Coronary artery disease

A

<30% - CT Ca Score

30-60% - Mycoradial perfusion scitography

> 60% - Invasive coronary angio

154
Q

NSTEMI and LT management

A

MAny still use GRACE score

<1.5% - Aspirin 12 months

1.3 - 3% - Aspirn + Clopi 12 months & OP perfusion/stress imaging

> 3%
- glycoprotein inhibitor (Tirofiban) and angiography in 96hrs