Cardiology Flashcards
What are the indications for Cardiac resynchronisation therapy in HFrEF?
- LVEF <35% on optimal therapy + QRS >150ms
- consider also if QRS >130ms
- consider if condition requiring pacing + LVEF <50%
No longer required to be LBBB morphology
Can be done in AF, but needs >92% BiV capture
What is the median survival of a cardiac transplant?
11 years
2016B Q59
Which of the following most strongly supports a non-cardiogenic cause of pulmonary oedema?
A. APO due to sepsis
B. Normal pulmonary capillary wedge pressure
C. Normal left ventricular ejection fraction on echocardiography
D. Normal troponin
E. Abnormal CXR
A. ARDS is a cause of non-cardiogenic PO but doesn’t really exclude concurrent cardiogenic element
B. YES as this appears to be the major diagnostic tool
C. can have normal LVEF in cardiogenic PO (in diastolic HF, volume overload of any cause, hypertensive crisis)
D. don’t need to be ischaemic to be in cardiogenic APO
E. not helpful at all, will just see pulmonary oedema
2009 B QUESTION 11
Which of the following is the strongest indication for the implantation of a biventricular pacemaker defibrillator in a patient with heart failure who survives an out‐of‐hospital arrest?
A. An ejection fraction of 20% on gated blood pool scan
B. QRS of 190ms on ECG
C. BNP 500 (normal <125)
D. A normal coronary angiogram
E. Abnormal Doppler Index on echocardiography
B. QRS of 190ms on ECG -> wide QRS
2010 A Question 61 What is the most characteristic ECG finding which differentiates between wide QRS SVT and VT? A. AV dissociation B. QRS>140 C. Bizarre ECG changes neither RBBB nor LBBB D. Axis -90 to 180
A - AV dissociation Pre-test probability of a wide complex tachycardia being VT is 80%. Key features that favour VT in a wide complex tachycardia: - AV dissociation - fusion beats / capture beats - concordance - extreme Right axis deviation
HR x ____ = Cardiac output
Stroke volume
In AF, when is warfarin required rather than a NOAC?
Mechanical heart valve / severe mitral stenosis eGFR <30
Those on interacting drugs such as phenytoin or HIV protease inhibitors
In HFrEF, who should be on an ACEI?
What is the benefit?
Everyone should be on an ACEI, unless it is not tolerated. Mortality and decreased hospitalisations
If truly not tolerate -> ARB
Management of new onset AF: What is the management of new onset AF of <48 hours duration, including anticoagulation?
HD unstable -> urgent cardioversion HD stable -> Acute rate control with BB or CCB Check UEC and TFT Do TTE to check for structural heart disease Reasonable to try and revert Anticoagulation -> Start NOAC simultaneously and continue for 4 weeks
Medication options for rate control in AF?
1st line: beta blockers - atenolol - metoprolol *if HF, then use a cardioselective BB Alternative: non-dihydropyridine calcium channel blockers (do not use in LVF) - verapamil - diltiazem 2nd line: Can add amiodarone Can add digoxin
Name 5 key risk factors in HCM that would lead to insertion of an ICD?
Family hx of SCD Syncope nSVT Septum >30mm Abnormal BP response during exercise
Of the HF-specific beta blockers, which is least cardioselective and should be avoided in airways disease?
Which beta blockers should be chosen in COPD?
Carvedilol (good to treat co-morbid HTN)
In airways disease -> bisoprolol or metoprolol XR
Pathophysiology of AF - Where does the arrhythmic foci initially begin?
Pulmonary veins This then leads to atrial remodelling, further perpetuating the cycle and leading to permanent AF
What is the Sokolov-Lyon criteria for LVH on ECG?
S wave depth in V1 + tallest R wave height in V5-V6 > 35 mm
What are some key risk factors for AF? (name 10)
Demographic:
- age
- male
Co-morbidities:
- HTN
- Valvular heart disease (MS)
- heart failure
- HOCM
- Hyperthyroidism
- lung disease
- obesity
- diabetes
What are the benefits of using beta blockade in HFrEF?
Decreased mortality
Decreased risk of SCD
Reduced hospitalisations
What are the indications for ICD in primary prevention of sudden cardiac death? What is the indication for CRT-D within this?
Ischaemic cardiomyopathy: >40 days after AMI
- LVEF <35% and NYHA class 2-3
- LVEF <30% and NYHA class 1
- Non-ischaemic dilated cardiomyopathy:
- LVEF <35% and NYHA class 2-3
If LVEF <35% and NYHA class 2-3 PLUS broadened QRS >120ms, should have combined CRT-D device
What are the main causes of AF-related mortality? (2)
Stroke Heart failure
What condition is the commonest cause of sudden cardiac death in people <35 years of age? What is the most sensitive test for this?
Hypertrophic cardiomyopathy ECG is most sensitive test (may have normal echo)
What does this image show?
Epsilon wave -> specific sign for ARVC
Other features
- TWI in V1-3
- Prolonged S-wave upstroke of 55ms in V1-3
What does this ECG show?
Wolff-Parkinson-White (pre-excitation)
- Sinus rhythm with very short PR interval (< 120 ms)
- Broad QRS complexes with a slurred upstroke to the QRS complexes (DELTA wave)
What does this ECG show?
Brugada Syndrome
Sodium channelopathy
Type 1 = Coved ST segment elevation >2mm in >1 of V1-V3 followed by a negative T wave.
Only ECG abnormality that is potentially diagnostic.
It is often referred to as Brugada sign
What does this ECG show?
HCM
Classic HCM pattern with asymmetrical septal hypertrophy
- Voltage criteria for left ventricular hypertrophy.
- Deep narrow Q waves < 40 ms wide in the lateral leads I, aVL and V5-6.
What is a very effective medication for congenital long QT syndrome?
Beta blockers
What is rhythm control strategy for new onset AF of >48 hours or unknown duration?
Cardioversion options: - anticoagulate for at least 3 weeks -> cardiovert -> continue anticoagulation for 4 weeks post - perform TOE to rule out LA thrombus -> cardiovert -> continue anticoagulation for 4 weeks post
What is the CHADSVasc score?
Used to determine if someone with AF should be anticoagulated. C - congestive cardiac failure H - hypertension A2 - age >75 D - diabetes S - stroke / TIA V - vascular disease (MI, PVD) A - age 65-74 Sc - female Benefit usually outweighs risk at score >1 At score 2 -> ~3.7% annual stroke risk
What is the difference between NYHA Class II and Class III HF?
Class II - reduced physical capacity during medium exercise
Class III - severely reduced physical capacity with slight exercise
What is the indication for ablation in AF?
Symptomatic AF refractory to medications *does not change need for anticoagulation **may improve mortality in heart failure only (not in other populations)
What is the most reliable feature on history or exam which correlates with elevated PCWP?
Orthopnea
What is the role of loop diuretics in HF?
Symptomatic benefit, not mortality
To achieve euvolaemia
What is the treatment of choice for atrial flutter?
Catheter ablation It is difficult to rate control or revert pharmacologically
What kind of AV blocks require a PPM?
2nd degree AV block -> Mobitz Type II - fixed PR interval with non-conducted P waves - PPM indicated if symptomatic or very bradycardic 3rd degree AV block
What should be the HR target in chronic asymptomatic AF?
Lenient as per RACE II Trial -> Less than 110 bpm No difference in HF, stroke, mortality compared with strict control
When initiating beta blocker therapy, when are the adverse effects most promiment?
In the first 3 months
Where is the re-entrant circuit in atrial flutter?
Right atrium
Which anti-hypertensives should be avoided in HFrEF? (3)
Non-dihydropyridine CCBs: Verapamil / diltiazem
Moxonidine
Alpha-1 blockers e.g. prazosin
Which ARBs have RCT data in HFrEF? (3)
Candesartan
Losartan
Valsartan
Which are the HF-specific beta blockers?
Carvedilol
Bisoprolol
Nebivolol
Metoprolol XR
2009 B QUESTION 68
An 82 year old female with chronic renal impairment (estimated GFR 30), obesity, and COPD presents with shortness of breath. Her plasma BNP is 922 (normal < 125). What is the most likely cause of her elevated BNP?
A. Advanced age
B. Chronic renal failure
C. Congestive cardiac failure
D. COPD
E. Obesity
B - chronic renal failure
Factors which can increase BNP =
- Age
- female gender
- AF
- renal failure
Obese BMI decreases BNP
What is the significance of transmural myocardial fibrosis on MRI for revascularisation?
This means the damage is not amenable to revascularisation
What is the role of dapagliflozin in HFrEF?
Now recommended even for those without diabetes, for patients with HFrEF who have persistent symptoms and an elevated BNP on optimal pharmacologic and device therapy.
Name 5 key causes of heart failure
Ischaemic heart disease
Valvular disease
Hypertension
Arrhythmias
Thyrotoxicosis
What are the classical TTE findings in cardiac amyloid?
- abnormal global longitudinal strain with apical sparing
- diastolic dysfunction
- dilated atria
- speckled myocardium
What are the group of chemotherapy agents with most cardiotoxic effects?
Anthracyclines e.g. doxorubicin
What does measurement of PCWP reflect?
Left atrial pressure / left ventricular preload.
Elevated in conditions which raise LV end-diastolic pressure:
- LV systolic heart failure
- LV diastolic heart failure
- Hypervolaemia
What is a normal PCWP?
<12 mmHg
What is numerical cut-off in HF for reduced ejection fraction?
Less than 50%
What is the diagnostic criteria for HFpEF?
Symptoms and signs of HF
AND
LVEF >50%
AND
evidence of diastolic dysfunction/high filling pressures on TTE / RHC / BNP
OR
evidence of relevant structural heart disease (LV hypertrophy / LA enlargement)
What is the indication for Entresto (sacubitril / valsartan) in HFrEF?
Switch to this from ACEI if ongoing symptomatic HF and LVEF <40% after 3-6 months of optimal therapy
Need to washout ACEI for 36 hours prior to commencement
What is the indication for ivabradine in HFrEF?
If HR remains >70 despite maximal BB. Must be in sinus rhythm
What is the investigation of choice to diagnose cardiac amyloid?
MRI +/- cardiac biopsy
What is the main benefit of eplerenone over spironolactone?
Eplerenone is more specific for mineralocorticoid receptor than spiro, so has less gynacomastia/endocrine effects
What is the typical finding on electron microscopy of amyloidosis?
Congo red staining with apple green birefringence
What should happen to HF therapy if LVEF normalises on optimal treatment?
It should be continued.
Evidence has shown that cessation of therapy has high risk of recurrence, unless there was a very clearly reversible cause of HF
When should a mineralocorticoid receptor antagonist be used in HFrEF?
What are the main risks?
For patients with symptomatic HFrEF and LVEF ≤35% on optimal ACEI / BB (LVEF ≤40% if post AMI)
Main risk is hyperkalaemia