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Cardiology Flashcards

1
Q

What is acute coronary syndrome (ACS)?

A
  • STEMI
  • NSTEMI
  • Unstable angina
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2
Q

What are non-modifiable RFs for ACS?

A
  • increasing age
  • male
  • FHx premature CHD
  • premature menopause
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3
Q

What are modifiable RFs for atherosclerosis causing ACS?

A
  • smoking
  • DM and impaired glucose tolerance
  • HTN
  • dyslipidaemia
  • obesity
  • physical inactivity
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4
Q

Causes of ACS?

A

Coronary occlusion due to:

  • atherosclerosis
  • vasculitis
  • CHD
  • cocaine use
  • coronary trauma
  • congenital cardiac problems
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5
Q

How do unstable angina and NSTEMIs present?

A
  1. Prolonged chest pain at rest
  2. Sweating
  3. Nausea
  4. Vomiting
  5. Fatigue
  6. SoB
  7. Palpitations
  8. Little/no response to GTN spray
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6
Q

Which groups of patients may present atypically with ACS?

A
  1. Diabetics
  2. Women
    (they may complain of fatigue, nausea, jaw pain/numbness)
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7
Q

What are some differential diagnosis for acute chest pain?

A
  1. Angina, STEMI, NSTEMI
  2. Oesophagitis
  3. Pneumothorax, PE
  4. Dissecting thoracic aortic aneurysm
  5. Chest wall pain
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8
Q

What might suggest chest pain is due to oesophagitis rather than a cardiac cause?

A
  1. Previous episodes of pain when supine, after food, alcohol and NSAIDS
  2. Relieved by antacids
  3. No increase in troponin after 12h
  4. No serial changes on ECG
  5. Oesophagitis on endoscopy
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9
Q

What might suggest chest pain is due to pulmonary embolus rather than a cardiac cause?

A
  1. Sudden SoB, pleural rub, cyanosis/hypoxia, tachycardia, loud P2, signs of DVT
  2. Presence of RFs (recent surgery, immobility, prev emboli, malignancy)
  3. CTPA showing clot in pulmonary artery
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10
Q

Management of oesophagitis?

A
  1. PPI and lifestyle modification

2. Calcium antagonist (nifedipine) if spasm

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11
Q

Management of PE?

A
  1. O2 to maintain sats 94%
  2. LMW heparin, then warfarin
  3. Thrombolysis if hypotension, or acutely dilated RV on echo
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12
Q

What might suggest chest pain is due to pneumothorax?

A
  1. Pain in centre/side chest with abrupt breathlessness
  2. Diminished breath sounds
  3. Hyper-resonance to percussion
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13
Q

Management of pneumothorax?

A
  1. If tension: Large Venflon inserted into 2nd IC space, mid-clavicular line
  2. O2 if hypoxic
  3. Analgesia
  4. Aspiration (if moderate) or IC drain (if severe)
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14
Q

What might suggest chest pain is due to aortic dissection?

A
  1. Tearing pain - often radiating to back
  2. Abnormal/absent peripheral pulses
  3. Early diastolic murmur
  4. Low BP
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15
Q

Management of aortic dissection?

A
  1. O2
  2. Analgesia
  3. Large-bore IV access
  4. Blood transfusion (crossmatching 6 units)
  5. Urgent surgical intervention
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16
Q

MI. How long following an MI might myocardial rupture develop?

A

3-14 days

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17
Q

MI. Which NSAID is useful in prophylaxis and management of MI?

A

Aspirin

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18
Q

MI. What is the post-MI complication that may occur when there is an autoimmune response to myocardial antigen which results in pericarditis?

A

Dressler syndrome

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19
Q

MI. What is Dressler syndrome?

How is it treated?

A

Autoimmune pericarditis that can arise several weeks after a MI; consists of fever, pleuritic pain, pericarditis and/or pericardial effusion

Treated with NSAIDs

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20
Q

MI. An MI has most likely occurred in the _____ wall of the heart if there are pathological Q-waves in electrocardiogram leads II, III, and aVF.

A

Inferior

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21
Q

MI. An MI has most likely occurred in the _____ wall of the heart if there are pathological Q-waves in electrocardiogram leads V1-V2.

A

Septal

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22
Q

MI. An MI has most likely occurred in the _____ wall of the heart if there are pathological Q-waves in electrocardiogram leads V4-V6.

A

Anterolateral

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23
Q

MI. Blockage of which coronary artery is the leading cause of a myocardial infarction?

A

LAD (Left anterior descending)

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24
Q

MI. Which is the most specific cardiac protein marker for diagnosing an MI?

A

Troponin I

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25
Q

MI. An MI causes severe, crushing chest pain that typically lasts longer than how many minutes?

A

20

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26
Q

MI. What type of mitral valve pathology may develop approx. 3-14 days post-MI? Why?

A

Mitral regurgitation due to papillary muscle damage

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27
Q

What is the first line treatment for Prinzmetal angina?

A

Calcium channel blockers

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28
Q

MI. Which ventricle is likely to be involved in an inferior wall MI?

A

Right

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29
Q

MI. Why are nitrates contraindicated in inferior wall MI?

A

Likely to be RV involvement; as RV depends on preload to maintain CO, nitrates could cause hypotension and cardiogenic shock

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30
Q

MI. What type of murmur might be heard in mitral regurgitation?

A

High-pitched holosystolic murmur at the apex

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31
Q

MI. Other than a high-pitched holosystolic murmur heard at the apex, give 2 other features that may be auscultated in a patient with mitral regurgitation following an MI.

A
  1. Basal lung crackles (due to pulmonary oedema from increased pressure in lung capillaries)
  2. Murmur radiates to back or clavicular area
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32
Q

MI. What does ST-elevations in leads V1-V6 and reciprocal changes (ST-depressions) in lead III and aVF suggest?

A

Anterior MI

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33
Q

MI. What is the leading cause of acute death following MI?

A

Ventricular tachycardia, leading to VFib, pulleys electrical activity, and asystole

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34
Q

MI. What does ST-elevation in leads II, III and aVF, Q-wave formation in leads III and aVF, and reciprocal ST-depression and T-wave inversion in aVL suggest?

A

Inferior STEMI

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35
Q

MI. What does ST-elevation in leads I, aVL, V5-6 and reciprocal-ST depression in the inferior leads (III and aVF) suggest?

A

Lateral MI

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36
Q

MI. Give 2 key biomarkers of severe myocardial ischaemia

A
  1. Troponin I
  2. CK-MB (MB isoenzyme of creatinine kinase)
  3. Also: Troponin T
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37
Q

MI. What does diaphoretic mean?

A

Sweaty

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38
Q

In what condition would you see diffuse ST-elevation on ECG?

A

Acute pericarditis

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39
Q

MI. What is Beck’s triad?

A
  1. Hypotension
  2. Jugular venous distension
  3. Distant/muffled heart sounds

Seen in cardiac tamponade

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40
Q

MI. What triad is seen in cardiac tamponade?

A

Beck’s triad (hypotension, jugular venous distension, distant/muffled heart sounds)

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41
Q

MI. What might occur in the days following an MI that could result in Beck’s triad?

A

Myocardial wall rupture; causes acute cardiac tamponade

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42
Q

MI. How would you treat myocardial rupture?

A

Pericardiocentesis

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43
Q

MI. What are the characteristic signs of pericarditis?

A
  1. Pain, worse when lying flat
  2. Pericardial rub
  3. Pericardial effusion
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44
Q

MI. Give 4 RFs for myocardial rupture following MI

A
  1. Female
  2. Advanced age
  3. First MI
  4. HTN
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45
Q

Why should nitrates be avoided in patients with aortic stenosis or a Hx of inferior MI?

A

Because they are preload dependent, so giving them nitrates could lead to decreased CO and severe hypotension

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46
Q

What type of calcium channel blocker is amlodipine?

A

Dihydropyridine CCB

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47
Q

MI. Is significant HTN (>180/100) a CI to fibrinolytic drugs?

A

Yes

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48
Q

What is tPA?

A

Tissue plasminogen activator (fibrinolytic drug)

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49
Q

MI. What is the gold standard treatment for acute MI?

A

PCI (percutaneous coronary intervention)

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50
Q

What causes Prinzmetal’s angina?

A

Coronary artery vasospasm

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51
Q

What is the first line treatment for Prinzmetal’s angina?

A

CCB

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52
Q

Management of VT/VF?

A

Defibrillate!
If awake, anaesthetist GA/midazolam, then defib
If can’t have GA, amiodarone IV +/- BB

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53
Q

Symptoms of VF?

A

Syncope/LoC

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54
Q

Symptoms of VT?

A

Palpitations
SoB
Syncope/pre-syncope
Chest pain

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55
Q

Causes of VT/VF?

A 
MI
Drugs
LV impairment
Electrolytes
Channelopathies (long QT/Brugada)
HCM
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56
Q

If the patient went into VT/VF due to MI, recurrence not very likely unless another MI. If cause is still there, e.g. HCM, how would you manage?

A

Amiodarone/BB
ICD (internal cardiac defib)
Maybe ablation

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57
Q

VT ECG findings?

A

Broad complex

Regular

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58
Q

VF ECG findings?

A

Broad complex

Irregular

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59
Q

Atrial flutter ECG findings?

A

Saw tooth

Regular

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60
Q

SVT ECG findings?

A

Narrow complex

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61
Q

SVT symptoms?

A

Palpitations

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62
Q

Management of SVT?

A

Vagal manouevres (syringe + carotid massage)
Adenosine 6mg, then try 12mg
Verapamil
If compromised, DC cardioversion

Long term: BB, flecainide, CCB, ?ablation

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63
Q

Causes of AF?

A 
PIRATE
Pulmonary embolism
Ischaemia
Respiratory disease
Atrial enlargement/myxoma
Thyroid disease
Ethanol
Sepsis/sleep apnoea
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64
Q

What is the tool to decide whether to anticoagulate a patient with AF? What score would indicate anticoagulation

A

CHA2DS2-VaSc
Males: 1+
Females: 2+

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65
Q

What are the components of the CHA2DS2-VaSc score?

A 
Congestive heart failure
Hypertension
Age (75+ = 2 points; 65-74 = 1 point)
Diabetes
Previous Stroke or TIA
Vascular disease (IHD, PAD)
Sex (female)
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66
Q

What is the management of chronic AF?

A

Warfarin/NOAC
Metoprolol (/diltiazem/verepamil/amiodarone)
Digoxin in sedentary
Cardioversion +/- amiodarone, or fleicanide

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67
Q

Should the AVR lead on an ECG have a +ve or -ve tracing?

A

-ve

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68
Q

How can you identify a patient is in sinus rhythm from an ECG?

A

P wave before every QRS
Regular
Rate 60-100

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69
Q

How do you work out the axis from an ECG?

A

Lead 1 and AVF should both be positive

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70
Q

What is sinus arrhythmia?

A

Slight shortening and lengthening with respiration, common in young

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71
Q

What causes a prolonged PR interval?

A

Heart block

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72
Q

What causes a short PR interval?

A

Accessory pathway, e.g. WPW

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73
Q

How long should the PR interval be?

A

3-5 small squares

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74
Q

Describe the degrees of heart block

A

1st: constant prolonged PR
2nd: Mobitz 1 = lengthening then drops 1
2nd: Mobitz 2 = constant prolonged then drops 1
3rd: no relationship between P and QRS

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75
Q

Management of heart block?

A

Pacemaker

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76
Q

Define heart block

A

Disrupted passage of impulse through the atrioventricular node (AVN)

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77
Q

What might cause 1st and 2nd degree heart block?

A 
IHD/MI
Myoacrditis
Athletes
Sick sinus syndrome
Drugs: digoxin, BB
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78
Q

What is sick sinus syndrome?

A

Dysfunctional sinus node (fibrosis)
Can cause brady/tachycardia, AF, sinus pause
Usually in the elderly

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79
Q

What causes a deep/pathological Q wave on ECG?

A

Previous MI

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80
Q

What causes a tall/big QRS on ECG?

A

LV hypertrophy

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81
Q

What causes a long/wide QRS on ECG?

A

BBB (ventricle conduction problem)

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82
Q

Signs of hyperkalaemia on ECG?

A

Tall tented T waves

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83
Q

What does T wave inversion on ECG indicate?

A

Infarct/ischaemia

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84
Q

Leads II, III and AVF affected. Likely site of infarct and vessel?

A

Inferior

Right coronary artery

85
Q

Leads I, aVL, V5-6 affected. Likely site of infarct + vessel?

A

Lateral

Circumflex

86
Q

Leads V1-4 affected. Likely site of infarct + vessel?

A

Anterioseptal

LAD

87
Q

Causes of long QT on ECG?

A

Genetic predisposition (long-QT syndrome)
Drugs: antipsychotics, macrolides
Hypocalc/hypokal

88
Q

What hormone abnormality might cause someone to go in and out of AF?

A

Hyperthyroidism

89
Q

If the SAN gives HR of 100bpm, what slows the heart rate?

A

Vagal tone (activity of the vagus nerve)

90
Q

Signs of ischaemia/infarct on ECG?

A

ST elevation/depression
T wave inversion
Q waves

91
Q

What blood results/ biomarkers may be seen in alcoholism?

A

^GGT
Low urea
^MCV
^AST/ALT

92
Q

What is the most common ECG finding in PE?

A

Sinus tachy

other less common: RBBB, T-wave inversion/ST depression in V1 and V2, S1Q3T3

93
Q

Name of the condition where narrowing of the aorta leading to hypoperfusion of the lower body?

What murmur is heard?

A

Coarctation of the aorta

Systolic murmur best heard in left sternal edge

94
Q

Hypertension. Give 3 lifestyle modifications a patient with HTN could make

A

Low salt diet (<6g/day)
Reduce caffeine intake
Stop smoking, less alcohol, balanced diet, more exercise, lose weight

95
Q

HTN Step 1. What would you prescribe for a patient:

a) <55 or with DM?
b) 55+ or Afro-Carib?

A

a) ACEi or ARB

b) CCB

96
Q

HTN Step 2. What would you prescribe for a patient:

a) already taking ACEi/ARB?
b) already taking CCB?

A

a) CCB or thiazide-like diuretic

b) ACEi or ARB
ARB > ACEi for Afro-Carib

97
Q

HTN Step 3. What would you prescribe for a patient:

a) on an ACEi/ARB + thiazide-like diuretic?
b) on a CCB + ACEi/ARB?

A

a) CCB

b) thiazide-like diuretic

98
Q

HTN Step 4 (resistant hypertension). What 3 things do you need to check before adding further anti-HTN medication?

A

Confirm elevated BP with ABPM or HBPM
Assess for postural hypotension
Discuss adherence

99
Q

HTN Step 4 (resistant hypertension). What medication medication would you add for a patient with:

a) K+ <4.5 mmol/L
b) K+ >4.5 mmol/L

A

a) low-dose spironolactone

b) alpha/ beta-blocker

100
Q

Heart failure. Give 4 symptoms

A

Breathlessness
Reduced exercise tolerance
Oedema
Fatigue

101
Q

Heart failure. Give 4 signs

A 
Cyanosis
Tachycardia
Elevated JVP
Displaced apex beat
Chest Sx: bibasal crackles, wheeze
S3-heart sound
102
Q

Heart failure. 4 investigations?

A

Blood tests (anaemia, electrolytes, infection)

CXR (pulmonary venous congestion, interstitial oedema, cardiomegaly)

Echo (pericardial effusion and cardiac tamponade)

BNP (^levels indicate myocardial damage)

103
Q

How do statins work?

A

Inhibit action of HMG-CoA reductase (rate-limiting enzyme in hepatic cholesterol synthesis)

104
Q

3 key adverse effects of statins?

A

Myopathy

Liver impairment (check LFTs at baseline, 3 mo, 12 mo)

Intracerebral haemorrhage in prev. stroke patients

105
Q

Give 2 contraindications to statins?

A

Macrolides (e.g. erythromycin)

Preganancy

106
Q

What dose of atorvastatin should be given in:

a) primary prevention
b) secondary prevention

A

a) 20mg OD

b) 80mg OD

107
Q

What are the components of CHA2S2VASc score?

A 
CHF - 1
HTN - 1
Age (75+ or 65-74) - 1 or 2
DM - 1
Stroke/TIA - 2
Vascular (IHD, etc) - 1
Sex category - 1 if female
108
Q

A 74-year-old man presents to his GP for a medication review. Blood pressure is recorded as 184/72. This is confirmed on two further occasions. What is the most appropriate first line therapy?

A

CCB e.g. amlodipine

109
Q

Heart failure. Give an example of a thiazide-like diuretic

A

Indapamide

Chlortalidone

110
Q

What type of diuretic is bendroflumethiazide?

A

Thiazide diuretic

111
Q

What type of diuretic is indapamide?

A

Thiazide-like

112
Q

A 53-year-old man is reviewed in clinic. Two months ago he was started on ramipril after being diagnosed with stage 2 hypertension following ambulatory blood pressure monitoring. His clinic readings had decreased from 164/96 mmHg to 142/84 mmHg. Unfortunately he has developed a troublesome, dry cough over the past 4 weeks. What is the most appropriate course of action?

A

Stop ACEi (eg ramipril) and start ARB (eg losartan)

113
Q

Give an example of an ARB

A

Losartan

114
Q

8 reversible causes of cardiac arrest?

A 
4Hs and 4Ts
Hypo:
- thermia
- xia
- volaemia
- kalaemia/glycaemia (and hyperkalaemia)

Tension pneumothorax
Toxins
Tamponade
Thrombosis

115
Q

Why should beta blockers not be prescribed with verapamil?

A

Risk of complete heart block

116
Q

Management of angina pectoris?

A

1) aspirin and statin
2) + GTN spray
3) + BB OR CCB (e.g. verapamil, diltiazem)
4) + long-acting dihydropyridine CCB, e.g. nifedipine
5) ^to max tolerated dose
6) If still symptomatic after mono therapy, add either CCB or BB (nb NOT BB + verapamil)
7) If on mono therapy and cannot tolerate CCB/BB, + long-acting nitrate, e.g. ivabradine, nicorandil, ranozaline

117
Q

Heart failure. How does furosemide work?

A

Inhibits Na-K-Cl cotransporter in asc. LoH

Reduced absorption of NaCl

118
Q

What type of diuretic causes hypocalcaemia?

A

Loop diuretic, e.g. furosemide

119
Q

Ejection systolic murmur loudest in the aortic region.

2 possible causes? How would you differentiate?

A

Aortic stenosis
Aortic sclerosis

No radiation to carotids in aortic sclerosis, and no ECG changes

120
Q

A 23-year-old man is given intravenous adenosine to treat a supraventricular tachycardia. What is the approximate half-life of adenosine?

A

8-10 seconds

121
Q

Which group of patients should adenosine be avoided in?

A

Asthmatics

122
Q

How does adenosine work?

A

Causes transient heart block in AV node

Used to stop SVTs

123
Q

Give 3 examples of thrombolytic drugs

A

Alteplase
Tenecteplase
Streptokinase

124
Q

How do thrombolytic drugs, e.g. alteplase, work?

A

Activate plasminogen to form plasmin

This degrades fibrin and helps break up emboli

125
Q

Give 3 contraindications to thrombolysis

A 
Active internal bleeding
Recent haemorrhage, trauma, or surgery
Coagulation/bleeding disorders
Intracranial neoplasm
Stroke <3 months
Aortic dissection
Recent head injury
Pregnancy
Severe HTN
126
Q

Most common cause of death in patients following a myocardial infarction?

A

Ventricular fibrillation

127
Q

Peri-arrest bradycardia. What is the first line treatment if the patient is showing signs of haemodynamic compromise/risk of asytole?

What could be done after this?

A

Atropine 500mcg IV

Atropine (up to max 3mg)
Transcutaneous pacing
Isoprenaline/adrenaline infusion

128
Q

What is torsades de pointes?

How is it treated?

A

Form of polymorphic ventricular tachycardia (occurs due to prolonged QT)

IV MgSO4 and Stop offending agent (e.g. haloperidol)

129
Q

Give 4 causes of dilated cardiomyopathy

A 
Alcohol
Coxsackie B virus
Wet beri beri
Doxorubicin
Postpartum
Hypertension
130
Q

Conduction blocks. What ECG changes are seen in First-Degree Heart Block?

A

PR interval >200ms (1 large square)

131
Q

Conduction blocks. What ECG changes are seen in Mobitz Type I Second-Degree Heart Block?

A

Progressive prolongation of the PR interval before the missed QRS complex

132
Q

Conduction blocks. What ECG changes are seen in Mobitz Type II Second-Degree Heart Block?

A

Absence of progressive prolongation of the PR interval before the missed QRS complex.

133
Q

Conduction blocks. What ECG changes are seen in Third-Degree Heart Block?

A

Absence of relationship between P waves and QRS complexes

134
Q

Conduction blocks. What is a bifascicular block?

A

RBBB + LAFB/LPFB

LAFB = left anterior fascicular block
LPFB = left posterior fascicular block
135
Q

Conduction blocks. What is left anterior fascicular block?

A

L-axis deviation
Q waves in leads I and aVL
Small R in lead III (in absence of LVH)

136
Q

Conduction blocks. What is left posterior fascicular block?

A

R-axis deviation
Small R in lead I
Small Q in lead III (in absence of RVH)

137
Q

Conduction blocks. What is RBBB?

A

QRS > 120ms
Dominant R wave in V1
RSR’ pattern (M) in V1, wide S wave (W) in V6 (MaRRoW)

138
Q

Conduction blocks. What is LBBB?

A

QRS > 120ms
Dominant S wave in V1
Deep S wave (W) in V1 with slurred R wave (M) in V6 (WiLLiaM)

139
Q

Conduction blocks. What is trifascicular block?

A

Bifascicular block + evidence of 1st/2nd degree AV block

bifascicular block = RBBB + LAFB/LPFB

140
Q

How can you calculate the rate from an ECG?

A

Slow/irreg: [no. R-waves] x 6

Fast: 1500/[no. small squares R-R]

Normal: 300/[no. large squares R-R]

141
Q

ECG. How many ms in:

a) small square
b) big square

A

a) 40ms (0.04s)

b) 200ms (0.2s)

142
Q

74F presents with falls.

O/E: HR 64bpm. Known 1st degree heart block. L-axis deviation + RBBB seen on ECG.

Most likely diagnosis?

A

Trifascicular block

143
Q

HTN. Why are ACE inhibitors recommended first-line in patients with DM?

A

ACEi = renoprotective as they inhibit the action of AngII.
This reduces action of prostaglandin E2
This causes constriction of the efferent arteriole
Therefore reducing kidney workload

144
Q

Scoring systems. What is used to determine the need to anticoagulate a patient in atrial fibrillation

A

CHA2DS2-VASc

145
Q

Scoring systems. Prognostic score for risk stratifying patients who’ve had a suspected TIA?

A

ABCD2

146
Q

Scoring systems. Heart failure severity scale?

A

NYHA

147
Q

Scoring systems. Disease activity in RA?

A

DAS28

148
Q

Scoring systems. Severity of liver cirrhosis?

A

Child-Pugh classification

149
Q

Scoring systems. Risk of DVT?

A

Wells score

150
Q

Scoring systems. Assess cognitive impairment?

A

MMSE (several others too)

151
Q

Scoring systems. Assess severity of anxiety + depression symptoms?

A

HAD (hospital anxiety and depression) scale

152
Q

Scoring systems. Assess severity of depression symptoms?

A

PHQ-9

153
Q

Scoring systems. Severity of generalised anxiety disorder?

A

GAD-7

154
Q

Scoring systems. Postnatal depression?

A

Edinburgh Postnatal Depression Score

155
Q

Scoring systems. Eating disorders?

A

SCOFF

156
Q

Scoring systems. Alcohol screening?

A

AUDIT
CAGE
FAST

157
Q

Scoring systems. Pneumonia prognosis?

A

CURB-65

158
Q

Scoring systems. Assessment of suspected obstructive sleep apnoea?

A

Epworth sleepiness scale

159
Q

Scoring systems. Prostate symptoms?

A

IPSS (international prostate symptom score)

160
Q

Scoring systems. Prognosis in prostate cancer?

A

Gleason score

161
Q

Scoring systems. Health of newborn immediately after birth?

A

APGAR

162
Q

Scoring systems. Assess whether induction of labour required

A

Bishop

163
Q

Scoring systems. Risk of developing pressure sore

A

Waterlow

164
Q

DVLA. How long does a patient have to wait before driving after an ACS?

How is this different if they are successfully treated by angioplasty?

A

4 weeks

only 1 week

165
Q

DVLA. How long does a patient have to take off driving after insertion of a pacemaker?

A

1 week

166
Q

DVLA. How long does a patient have to take off driving after a CABG?

A

4 weeks

167
Q

MI. An MI has most likely occurred in the ___ wall of the heart if there is reciprocal ST segment depression in leads V1-V3?

A

Posterior

168
Q

What is the classical triad of symptoms seen in aortic stenosis?

What murmur is heard?

A

SAD- Syncope, Angina, Dyspnoea

Ejection systolic

169
Q

What valve pathology would you suspect with systolic murmur with an opening click?

A

Mitral valve prolapse

170
Q

Which valves are affected if an early diastolic murmur is heard?

A

Aortic/Pulmonary (regurgitation)

171
Q

Which valves are affected if a mid-late diastolic murmur is heard?

A

Mitral/Tricuspid (stenosis)

172
Q

Give 3 causes of ejection systolic murmurs, and describe the murmur for each

A

Aortic/Pulmonary stenosis (crescendo-decrescendo)

Mitral/Tricuspid regurgitation (pan systolic)

Aortic stenosis and HOCM (loudest in aortic valve area during expiration) and AS radiates to carotids (HOCM does not)

173
Q

Most common cause of aortic stenosis?

A

Degenerative age-related calcification

174
Q

Condition with congenital narrowing of the descending aorta?

A

Coarctation of the aorta

175
Q

Signs of coarctation of the aorta?

A

Hypertension
Radio-femoral delay
Mid-systolic murmur, maximal over the back
Apical click from aortic valve
Notching of inferior border of ribs (due to collateral vessels)

176
Q

What is the mode of inheritance of Hypertrophic Obstructive Cardiomyopathy (HOCM)?

What is the basic pathology?

A

Autosomal dominant

Defect in genes encoding contractile proteins

Common cause of sudden cardiac death in the young

177
Q

List 4 signs you would seen on examination of a patient with aortic stenosis

A 
SAD (syncope, angina, dyspnoea)
Ejection systolic murmur radiating to carotids
Narrow pulse pressure
Slow rising pulse
Thrill over apex
S4 (LVH)
Soft/absent S2
178
Q

What is a fourth heart sound (S4) indicative of?

A

Left ventricular hypertrophy

179
Q

What investigations must be carried out before starting a patient on amiodarone?

A

TFT
LFT
U+E
CXR

Baseline CXR required due to risk of pulmonary fibrosis/pneumonitis in patients treated with amiodarone

180
Q

Give 3 SE of amiodarone

A 
Thyroid dysfunction
Corneal deposits
Pulmonary fibrosis/pneumonitis
Liver fibrosis/hepatitis
Peripheral neuropathy, myopathy
Photosensitivity
Slate-grey appearance
Thrombophlebitis and injection site reactions
Bradycardia
Longer QT interval
181
Q

AF. Name a fast-acting beta blocker

A

Metoprolol

182
Q

MI. What are the criteria for diagnosing MI?

A

Rise +/- fall in cardiac biomarkers (cTn)

Plus at least one of:

  • Symptoms of ischaemia
  • New ST changes or LBBB
  • Q waves
  • Imaging evidence
  • Intracoronary thrombus on angiography
183
Q

What might cause raised troponin?

A

Myocarditis
Aortic dissection
Pulmonary embolism

184
Q

Hypertension. What is the target BP for patients with:

a) diabetes
b) diabetes with end-organ damage (e.g. retinopathy)?

A

a) <140/80

b) <130/80

185
Q

What is the Levine scale?

Briefly describe the grades

A

Grading scale for murmurs

Grade 1 = v faint murmur
Grade 2 = slight murmur
Grade 3 = moderate murmur w/o palpable thrill
Grade 4 = loud murmur w/ palpable thrill
Grade 5 = v loud murmur w/ v palpable thrill
Grade 6 = v loud murmur (heard w/o stethoscope)

186
Q

What are the NHYA stages of Heart Failure?

A

I - no limitation on ordinary physical activity
II - normal at rest, breathless w/ ordinary activity
III - normal at rest, breathless w/ less-than-ordinary activity
IV - Sx at rest

187
Q

Management of heart failure?

A
  1. ACEi and BB
  2. Aldosterone antagonist, AngIIRB or Hydralazine + Nitrate
  3. Cardiac resynchronisation therapy or digoxin or ivabradine

Diuretics for fluid overload
Annual flu vaccine
One-off pneumococcal vaccine

188
Q

Ventricular Tachycardia. Initial assessment/management?

A 
ABCDE
SpO2
BP
ECG
IV Access
Rx reversible causes
189
Q

Ventricular Tachycardia. What are some signs the patient is unstable?

A

Shock
Syncope
MI
Heart Failure

190
Q

Ventricular Tachycardia. What are the management steps for a patient with unstable VT?

A
  1. Synchronised DC shock (up to 3 attempts)
  2. Seek expert help
  3. Amiodarone 300mg IV over 10-20 mins
  4. Repeat shock then give amiodarone 900mg over 24h
191
Q

Ventricular Tachycardia. What are the management steps for a patient with stable VT and a narrow QRS? (regular and irregular)

A

Regular:

  1. Vagal manoeuvres
  2. Adenosine 6-12-12

Irregular

  1. Rate control: BB or Diltiazem
  2. Consider digoxin in HF
  3. Consider anticoagulation
192
Q

Ventricular Tachycardia. What are the management steps for a patient with stable VT and a broad QRS? (irregular and regular)

A

Irregular:
Seek expert help (consider AF w/ BBB - treat like narrow complex)

Regular:
Amiodarone 300mg IV over 20-60min then 900mg over 24h

193
Q

Give 2 agents used to rate-control in patients with atrial fibrillation

A

BB
CCB (e.g. Diltiazem)

If co-existent heart failure: Digoxin or Amiodarone

194
Q

ECG. What is the J point?

A

End of QRS and onset of ST segment

195
Q

ECG. J waves can be confused for ST-elevation. Give some cause of J waves?

A

Hypothermia
Hypercalcaemia
Neuro (SAH, intracranial HTN, etc)
Brugada syndrome

196
Q

What is the mechanism of action of dipyridamole?

A

Antiplatelet used w/ aspirin after ischaemic stroke/TIA

Phosphodiesterase inhibitor

197
Q

What is Cor Pulmonale?

A

Hypertrophy of RV and RHF

Caused by pulmonary arterial HTN

198
Q

How does COPD cause Cor Pulmonale?

A

Hypoxia causes pulmonary vasoconstriction, which causes pulmonary HTN

This leads to RVH and R-sided HF

199
Q

Give 3 signs of R-sided heart failure

A

Hepatomegaly
Raised JVP
Bilateral ankle oedema

200
Q

Give 3 signs of L-sided heart failure

A

SoB on exertion
Orthopnoea
Paroxysmal nocturnal dyspnoea
Wheeze and cough

201
Q

What is the first line treatment for supra ventricular tachycardia in a stable patient?

A

Valsalva manouevres

202
Q

Give 4 medications a patient should receive following an MI?

A

Dual anti platelet therapy (aspirin + ticagrelor or prasugrel)
ACEi
BB
Statin

203
Q

What is Nicorandil?

What is it used to manage?

3 side effects?

A

Potassium channel activator

Angina

S/E: headache, flushing, anal ulceration

204
Q

What are some environmental factors which may exacerbate angina?

A

Cold weather
Heavy meals
Emotional stress

205
Q

Which other medical conditions/states can exacerbate angina due to a decreased supply of blood?

A 
Anaemia 
Hypoxaemia
Polycythaemia
Hypothermia
Hypovolaemia
206
Q

Which other medical conditions/states can exacerbate angina due to an increased need for blood in the heart?

A 
Hypertension
Tachyarrhythmia
Valvular heart disease
Hyperthyroidism
Hypertrophic cardiomyopathy
207
Q

Give 3 RFs for angina

A 
Increasing age
Smoking
FHx
Diabetes 
Hyperlipidaemia
Hypertension
Kidney disease
Obesity
Physical inactivity
Stress
208
Q

Give 4 key clinical features of angina

A

Crushing central chest pain
May be short of breath
Provoked by physical exertion, esp after large meal, cold weather, or strong emotion
Relieved with rest/GTN spray

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