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cardiology Flashcards

1
Q

how does GTN spray relieve symptoms of angina?

A

Vasodilates

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2
Q

How should patients be advised to use their GTN spray?

A

Take spray, rest, wait 5 mins, take again if still have sx, then if not relieved sx after a second 5 mins, call 999

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3
Q

which vein commonly used in CABG?

A

Great saphenous vein (leg)
also used for venous cutdown.
anterior to med malleolus

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4
Q

what makes up a thrombus in a fast flowing artery (ACS)?

A

Platelets

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5
Q

What does the LCA become?

A

Circumflex artery

LADA

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6
Q

What does RCA supply?

A

RA
RV
Inferior LV
Posterior septal area

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7
Q

what does circumflex artery supply?

A

LA

post LV

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8
Q

what does LADA supply?

A

Ant LV

Ant septum

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9
Q

ACS - 3 conditions?

A

Unstable angina
STEMI
NSTEMI

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10
Q

How are the 3 ACS differentiated?

A

ECG -
if ST elevation/new LBBB - STEMI
if no ST elevation - trop levels, other ecg changes

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11
Q

How does ACS present?

A

cardiac sounding chest pain
non-pleuritic
non-positional
non-tender

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12
Q

How is NSTEMI identified?

A

Raised troponin levels

ST depression, T wave inversion, pathological Q waves

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13
Q

If troponins normal, and ECG normal - dx?

A

unstable angina

MSK chest pain

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14
Q

cardiac chest pain?

A 
central
constricting/crushing
ass with n/v, sweating, clamminess
SOB
feeling impending doom
palpitations,
radiates to jaw/left arm - numbness
continues at rest >20mins
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15
Q

which patients may experience a silent MI?

A

DM

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16
Q

where is ST elevation seen in STEMI?

A

in leads corresponding with particular area of heart

new LBBB

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17
Q

What indicates a late presentation of ACS?

A

path Q waves

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18
Q

anteriolateral area of heart (front/L side of heart) - which artery?

A

LCA

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19
Q

which leads affected in anteriolateral area infarct?

A

1
AVL
V3-6

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20
Q

which artery affected in anterior (front) area of heart

A

LADA

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21
Q

which leads affected in anterior area infarct?

A

V1-4

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22
Q

Which artery supplies the lateral aspect of heart? (Left side)

A

circumflex artery

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23
Q

which leads affected in lateral aspect infarct?

A

1
AVL
V5-6

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24
Q

Inferior aspect of heart - which artery?

A

RCA

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25
which leads affected in inferior aspect infarct?
2 3 AVF
26
What are troponins?
proteins found in cardiac muscle
27
when would you measure troponins?
baseline 6 hours 12 hours after onset of sx
28
What does raised troponins indicate and why?
myocardial ischemia - the troponins are released from the ischemic muscle in the heart
29
Other causes of raised trops (non-spec):
``` chronic RF sepsis - cap myocarditis aortic dissection PE ```
30
Other cardiac ix for ACS:
``` Ex BMI ECG FBC - anaemia U/E - ACEi LFT - statin Lipid profile TFT HbA1c + CXR - other causes (pneumonia), also oedema - HF ECHO - functional damage CT coronary angiogram ```
31
Acute STEMI treatment:
<2 hours presentation - primary PCI ('cath') / CABG | Thrombolysis if not
32
which arteries is catheter fed into in PCI?
Brachial or femoral
33
Thrombolysis - what kind of medication?
fibrinolytic agent - breaks down fibrin
34
risk of what in thrombolysis?
bleeding | can't use if had a recent stroke
35
examples of thrombolytic agents? (TPA)
streptokinase alteplase tenecteplase
36
Acute NSTEMI tx:
BBs Aspirin 300mg stat Ticagrelor 180mg stat (alt clopidogrel 300mg) Morphine titrated for pain (ony if SEVERE) Anticoagulant - LMWH (eg enoxaparin BD for 8/7) Nitrates - GTN to relieve CA spasm O2 only if drop sats
37
what is the GRACE score used for?
to decide if PCI in NSTEMI
38
what does Grace score measure?
6 month risk of death/repeat MI following NSTEMI
39
how is grace score graded?
low risk <5% med risk 5-10 high risk >10%
40
Who gets early PCI <4 days based on grace score?
medium and high risk patient
41
Cx of MI:
``` Death Rupture of septum or papillary muscles Edema - HF onset Arrhythmia/aneurysm Dressler's syndrome ```
42
What is Dressler's Syndrome?
post MI syndrome 2-3 weeks post MI due to localised immune response pericarditis
43
Dressler's syndrome presentation:
pleuritic chest pain low grade fever pericardial rub on auscultation can cause pericardial effusion/tamponade
44
How is Dressler's syndrome diagnosed?
ECG - GLOBAL ST elevation, T wave inversion (SADDLE ST) (also referred to as concave st) ECHO - pericardial effision raised inflamm markers - ESR, CRP
45
Mx: Dressler's syndrome:
NDAIDs (aspirin/ibuprofen) steroids if severe (pred) pericardiocentesis if tamponade
46
Secondary prevention of MI:
6As Aspirin 75mg OD Another AP - clopidogrel 3/12, ticagrelor 12/12 (P2Y12) Atorvastatin 80mg OD ACEi Atenolol/BB Aldosterone antagonist - if clinical evidence of HF (eplerenone)
47
Secondary prevention lifestyle advice:
``` stop smoking reduce alcohol healthy med diet cardiac rehab - specific exercises for MI optimise other meds - DM, HTN ```
48
Types of MI: 1-4
1 - traditional due to ACS 2 - ischemia secondary due to decreased supply of 02 to heart (anaemia, tachy, Hypotension) 3 - sudden cardiac death/arrest suggestive of ischemic event 4 - MI ass with PCI/stunt/CABG
49
LV failure definition: (pathophys)
LV unable to adequately move blood through the left side of the heart and out into the body causes a backlog of blood behind LV - LA/PVs, lungs Vessels become engorged - increased vol and P - leak fluid - oedema Leads to SOB, 02 desats
50
Triggers for LVF:
Iatrogenic - IV fluids in elderly patients with already impaired LV function Sepsis MI Arrhythmias
51
Presentation acute LVF:
Acute SOB - worse by lying flat, better sitting up T1RF - low sats, w/o hypercapnia look/feel unwell cough up frothy pink/white sputum
52
Examination LVF:
``` Increased RR Decreased sats tachycardia 3rd heart sound apex beat moves down/laterally bilat basal crackles - wet crackling if severe - hypotension - cardiogenic shock abdo pain, weight gain ```
53
signs of RHF:
``` Raised JVP (jugular venous distension) - backlog on RH peripheral oedema (ankles, legs, sacral) hepatosplenomegaly congestive hepatopathy dyspnoea OE ```
54
Ix of acute LVF:
``` hx/ex ECG - ischemia - ACS/arrhythmias (AF) ABG - RF? CXR bloods - inf, renal function, BNP, trops ECHO - function ```
55
what is BNP?
Hormone released from the ventricles when cardiac muscle is stretched beyond normal range
56
High BNP?
heart overloaded beyond its ability to pump effectively
57
Normal action of BNP?
to relax the smooth muscle in BVs reduces systemic vascular resistance acts on kidneys as diuretic
58
BNP - sens/spec??
Sensitive, not specific
59
other causes of high BNP?
``` tachycardia sepsis PE renal impairment COPD ```
60
how will echo inform LVF dx?
Echo assesses function of ventricles, anatomical abnormalities measures ejection fraction (>50% normal) pulmonary artery pressure diastolic function
61
what is an ejection fraction?
the percentage of blood in the LV squeezed out with each ventricular contraction
62
CXR acute LVF:
``` Cardiomegaly (>0.5 ratio) Upper lobe venous diversion bilat pleural effusions fluid in interlobar fissures fluid in septal lines - Kerley B lines ```
63
Mx Acute LVF:
``` Poor sod Pour away IV fluids Sit patient up Oxygen if sats <95% Diuretics - furosemide 40mg stat ``` ``` also LMNOP Lasix / furosemide Morphine (venodilators) Nitrates (venodilator) O2 Position ```
64
2 loop diuretic examples:
furosemide | bumetinide
65
other management options if severe pulmonary oedema/cardiogenic shock: (HF)
IV opiates - morphine vasodilates CPAP Inotropes - NAd ICU/HDU
66
causes of chronic heart failure:
impaired LV contraction - systolic impaired LV relaxation - diastolic both lead to chronic backlog of blood trying to flow through the L side of heart (increase pressure LA, PVs, lungs)
67
presentation chronic HF:
``` breathlessness worse on exertion cough - frothy pink white sputum orthopnoea paroxysmal nocturnal dyspnoea peripheral oedema ```
68
orthopnoea?
worsening SOB on lying flat - how many pillows?
69
PND?
patients experience sudden waking in night with acute SOB, cough, wheeze, suffocating sensation Open window- fresh air. sx improve over mins
70
Diagnosis chronic HF?
hx/ex - bibasal crackles, periph oedema NTproBNP ECHO ECG
71
causes of chr HF?
Ischemic HD Valvular HD - AS HTN arrhythmias - af
72
Mx Chr HF?
1. BNP 2. Refer to cardiology (urgently if BNP>2000ng/L) 3. Medical mx 4. surgical mx (AS/MR) 5. HF specialist nurse
73
additional chr HF mx:
``` yearly flu jab stop smoking advice fluid restrict, salt load down (<2L, <2g) optimise tx of comorbidities exercise as tolerated ```
74
medical chr HF mx:
``` ABAL ACEi (ramipril up to 10mg OD) BB (bisoprolol up to 10mg) Aldosterone antag (spironolactone, eplerenone) Loop diuretics (furosemide, bumetinide) ```
75
If can't tolerate ACEi in chr HF mx:
use ARB (candesartan up to 32mg OD)
76
which type of HF patients should ACEis be avoided in?
valvular HD until specialist has seen them
77
what needs measuring when pts on ACEis, loop diuretics, aldosterone antagonists?
U/Es
78
what is cor pulmonale?
RHF caused by respiratory disease increased pressure and resistance in PAs - PHTN -> RV insufficiency -> back pressure blood RA, vena cava, systemic circulation
79
respiratory causes of cor pulmonale?
``` copd PE interstitial lung disease CF primary pulm HTN ```
80
presentation of cor pulmonale?
``` early - asymptomatic SOB peripheral oedema syncope chest pain ```
81
signs of cor pulmonale?
``` hypoxia cyanosis raised JVP peripheral oedema 3rd HS murmur - tricuspid regurgitation - pansystolic murmur hepatomegaly (pulsatile if TR) ```
82
Mx cor pulmonale:
underlying cause | LTOT
83
Hypertension NICE 2019: dx:
140/90 clinic | 135/85 home readings
84
causes of HTN:
essential 95% - primary | secondary causes 5%
85
secondary causes HTN: ROPE
Renal disease (Renal artery stenosis) Obesity Pregnancy (preeclampsia) Endocrine (hyperaldosteronism - Conn's syndrome) conns is commonest cause of secondary htn
86
Ix: Conn's syndrome:
renin:aldosterone ratio blood test
87
HTN cx:
``` IHD Cerebrovascular accident retinopathy nephropathy HF ```
88
stages of HTN:
1 - >140/90 2- >160/100 3 - >180/120
89
end organ damage: investigations for those newly dx with HTN:
``` urine albumin:creatinine ratio (proteinuria) dipstick - microscopic haematuria Bloods - HbA1c, renal, lipid levels fundus ex ECG ```
90
HTN medications:
ACEis (ramipril) BBs (bisoprolol) CCBs (amlodipine) Diuretics (indapamide) - thiazide-like ARBs (candesartan) - if African/ACEi CI
91
lifestyle advice for HTN:
``` healthy diet stop smoking reducing alcohol, caffeine reduce salt regular exercise ```
92
who gets offered medical mx of HTN (stage related)
- stage 2 or higher | - stage 1 if under 80 with QRisk >10%, DM, CKD, CVD, end organ damage
93
if age <55 and white, what HTN first line drugs: | also T2DM pts
ACEi
94
if age >55 or black, what HTN first line drug:
CCB
95
step 2 of HTN mx:
ACE+CCB, if black ARB+CCB | or A+D or C+D
96
step 3 of HTN mx:
A+C+D
97
step 4 HTN mx:
If serum K<4.5mmol/L - K sparing diuretic - spironolactone if serum K>4.5mmol/L - alpha blocker (doxazosin) or BB (atenolol) refer
98
how does spironolactone work:
K sparing diuretic | Aldosterone antagonist - blocks aldosterone in kidneys->Na excretion, K reabsorption
99
HTN treatment targets:
<140/90 | if >80yo <150/90
100
what is the first heart sound:
closing of AV valves at the start of the systolic contraction of ventricles
101
what is the second heart sound:
closing of the semilunar valves at the end of systolic contraction
102
when is the third hs heard?
0.1 seconds after the second heart sound
103
what causes the third hs?
rapid ventricular filling leading to the chordae tendineaa to pull to their full length and twang like a guitar string can be normal in 15-40yos (healthy) as the ventricles easily allow rapid filling
104
what is cause of third hs in pathology?
elderly - HF - ventricles and chordae stiff and weak and reach their limit much faster ("galloping s3")
105
when is 4th hs heard?
right before s1
106
is hs4 ever normal?
no
107
what does s4 indicate?
stiff or hypertrophic ventricle and caused by turbulent flow from atria contracting against a non-compliant ventricle
108
which part of stethoscope used to listen to low pitched sounds?
bell
109
which part of stethoscope used to listen to high pitched sounds?
diaphragm
110
where do you listen for pulmonary valve?
2nd ICS left sternal border
111
where do you listen for aortic valve?
2nd ICS right sternal border
112
where do you listen for tricuspid valve?
5th ICS left sternal border
113
where do you listen for mitral valve?
5th ICS midclavicular line (apex area)
114
where is Erb's point?
3rd ICS Left sternal border - best place to listen to S1 and S2
115
how do you manouvre patient to listen for mitral stenosis?
left side
116
how do you manouvre patient to listen to aortic regurgitation?
sat up, leaning forwards, holding exhalation
117
assessing a murmur: SCRIPT
Site - where heard loudest Character - soft, blowing, cresc, decresc Radiation - heard over carotids (AS) or left axilla (MR) Intensity - grade Pitch - indicates velocity Timing - systolic, diastolic
118
murmur grade:
1 difficult to hear s1,2> murmur 2 quiet s1,2=murmur 3 easy to hear s1,2 6 - can hear off chest
119
what does mitral stenosis cause in the muscle?
LA hypertrophy
120
what does aortic stenosis cause in the muscle?
LV hypertrophy
121
what does mitral regurgitation cause in the muscle?
LA dilation
122
what does aortic regurgitation cause in the muscle?
LV dilatation
123
what causes mitral stenosis?
Rh disease | Infective endocarditis`
124
mid-diastolic low pitched murmur? (rumbling) | with opening snap
mitral stenosis | lub drrrrrrrrr
125
which valvular condition is associated with malar flush and AF? also tapping apex beat?
mitral stenosis
126
what can mitral regurgitation cause long term?
congestive cardiac failure
127
pan-systolic high pitched whistling/blowing murmur? | (holo-systolic). louder on expiration
mitral regurgitation | brrrrrrrrr throughout systole
128
causes of mitral regurgitation?
``` idiopathic weakening of valve with age ischemic heart disease infective endocarditis rheumatic heart disease CT disorders: Ehlers Danlos/Marfan (Infection or infarction) ```
129
commonest valve disease?
Aortic stenosis
130
ejection-systolic high pitched, crescendo-decrescendo murmur? (louder on expiration)
Aortic stenosis | brrrr dub
131
which murmur radiates to carotids, has slow rising pulse and narrow pulse pressure, also has reporting of exertional sycope ?
Aortic stenosis
132
causes of Aortic stenosis?
atherosclerosis idiopathic age related calcification rheumatic heart disease if <65 - bicuspid valve
133
early diastolic, soft murmur? | rumbling
aortic regurgitation | lub tarrrr
134
which murmur is associated with Corrigan's pulse?
Aortic regurgitation
135
What is Corrigan's pulse?
collapsing pulse rapidly appearing and disappearing pulse at carotids also brachial, femoral weak pulses
136
what does aortic regurgitation often lead to?
heart failure due to backlog of pressure in LV
137
What is an Austin-Flint murmur?
caused by Aortic regurgitation, heard at apex, early diastolic rumbling - blood flowing through the aortic valve and over the mitral valve, causing it to vibrate
138
causes of aortic regurgitation?
idiopathic age related weakness CT disorders - Ehlers Danlos/Marfan infection or infarction aortic dissection
139
what does midline sternotomy scar indicate?
mitral or aortic valve replacement or CABG
140
lateral right sided thoracotomy scar from?
mitral valve replacement
141
where do porcine bioprosthetic heart valves come from?
pigs
142
how long do bioprosthetic heart valves last?
10 years
143
how long do mechanical heart valves last and what do patients need to take?
>20 years, lifelong anticoagulation - warfarin
144
what is the INR range for warfarin patients due to mechanical heart valves?
2.5-3.5
145
name 3 types of mechanical heart valve:
starr-Edwards tilting disc st jude
146
what is a problem with starr edward valves?
high thrombus formation risk
147
mechanical heart valves (3) major complications:
thrombus formation infective endocarditis haemolysis->anaemia
148
click replaces S1 for?
metallic mitral valve
149
click replaces S2 for?
metallic aortic valve
150
what does TAVI stand for?
Transcatheter Aortic Valve Implantation
151
who may have a TAVI?
high risk severe aortic stenosis patients, who can't have open heart surgery
152
what type of valve is implanted in a TAVI?
bioprosthetic
153
which 3 organisms are most likely responsible for infective endocarditis?
staphylococcus (IVDU) Streptococcus Enterococcus
154
describe the pathophysiology of AF?
disorganised electrical activity overrides the normal activity from the SAN contraction of atria is rapid, irregular and uncoordinated -> irregular conduction of ventricles leading to irregularly irregular contractions, tachy, HF, stroke
155
ecg findings AF:
absence of p-waves narrow QRS tachy irregularly irregular ventricular rhythm
156
why is there a risk of stroke in AF?
tendency for blood to collect in LA and clot -> emboli which travel through LV, aorta, carotids, to brain, block cerebral arteries causing ischemic stroke
157
symptoms of AF:
asymptomatic palpitations SOB Syncope
158
ddx for irregularly irregular pulse? (2)
AF | Ventricular ectopics
159
what is valvular AF?
AF in those who have a mod/severe mitral stenosis/mechanical heart valve assumed that valvular pathology lead to AF
160
AF without valve pathology or with other valve pathology such as mitral regurgitation or aortic stenosis is classed as?
non-valvular AF
161
commonest causes of AF? Mrs Smith
``` Sepsis Mitral valve pathology IHD Thyrotoxicosis HTN ```
162
2 principles to treating AF:
rate control OR rhythm control | anticoagulation
163
why does rhythm control help AF patients?
allows ventricles more time to fill during diastole, maintaining a cardiac output
164
4 instances where rate control is NOT first line in AF tx?
There is reversible cause for their AF Their AF is of new onset (within the last 48 hours) Their AF is causing heart failure They remain symptomatic despite being effectively rate controlled younger than 65
165
rate control drugs (AF) 3:
1. BBs (atenolol 50-100mg OD) 2. CCBs (diltiazem - not in HF) 3. Digoxin
166
what is offered to those AF patients unsuited to rate control drugs?
rhythm control drugs
167
2 ways of achieving rhythm control?
cardioversion | long term medical rhythm control
168
who is suitable for immediate cardioversion?
AF has been present for less than 48 hours or they are severely haemodynamically unstable.
169
what should happen to patient in delayed cardioversion (meds given as prep):
anticoagulated 3 weeks prior | rate control while waiting
170
2 options for cardioversion? (+egs) | AF
``` electrical cardioversion (GA+defib) chemical cardioversion (pharmacological) - flecanide -amiodarone (if structural heart disease) ```
171
long term medical rhythm control drugs (3):
BBs first line dronedarone (maintaining cardioversion) amiodarone (HF)
172
define paroxysmal AF:
where the AF comes and goes, usually episodes NOT lasting >48hrs
173
management of paroxysmal AF:
anticoagulated (based on chadsvasc) | pill in pocket approach
174
what is a pill in the pocket approach to paroxysmal AF management?
use of flecanide when patients experience AF sx, with no underlying structural heart disease
175
when should flecanide be avovided
atrial flutter -> extreme tachy
176
where does blood often stagnate in AF?
atrial appendage
177
risk of stroke in AF if no anticoagulation?
5%
178
risk of stroke with anticoagulation meds in AF?
1-2% | 2/3 lower than if not anticoagulated
179
risk of anticoagulation meds ? (risk per year)
risk of serious bleed ( haemorrhage ) | 3% year
180
how is a patients bleeding risk on anticoagulation drugs measured?
HASBLED score
181
what type of drug is warfarin? | how does it act?
vitamin K antagonist vitK is essential for clotting factors prolongs prothrombin time
182
what is INR a measure of?
how anticoagulated someone is by warfarin compares prothrombin time of warfarin patient with that of a healthy adult 1 is normal/ 2 indicates it takes double the time for blood to clot
183
target INR range for warfarin patients?
2-3
184
which system in the liver affects warfarin?
cytochrome p450 system | affected by antibiotics
185
dietary advice to warfarin patients?
``` leafy greens (high vit K) cranberry juice, alcohol (affect cp450) ```
186
what is the half life of warfarin and what can be used as an antidote?
1-3 days | vit K
187
what does DOAC stand for?
Direct Oral Anticoagulant
188
what is the half life of DOAC and what is the risk with doacs?
``` 7-15 hours no antidote (but lower risk of bleeding overall) ```
189
name 4 advantages of DOACs over warfarin?
No monitoring is required No major interaction problems Equal or slightly better than warfarin at preventing strokes in AF Equal or slightly less risk of bleeding than warfarin
190
what does chads2vasc measure?
whether an AF patient should be started on anticoagulation
191
what is no longer recommended for lowering stroke risk in AF?
aspirin
192
what chadsvasc score should consider/give anticoagulation?
1 - consider | 2+ give
193
what does chads2vasc mnemonic stand for?
``` CCF HTN Age >75 (scores 2) DM Stroke/TIA prev (scores 2) Vascular disease Age (65-75) Sex (female) ```
194
what does hasabled assess?
risk of someone having a bleed/stroke while on anticoagulation medication
195
what does HASBLED mnemonic?
``` HTN Abnormal renal/liver function Stroke Bleeding Labile INRs Elderly Drugs/alcohol ```
196
name the 4 cardiac arrest rhythms?
ventricular tachycardia ventricular fibrilation pulseless electrical activity asystole
197
which 2 cardiac arrest rhythms are shockable?
ventricular tachy | v fib
198
if unstable tachycardia, how do you manage?
up to 3 synchronised shocks amiodarone infusion every 3 shocks adrenaline 3-5mins 1mg
199
in a stable patient, what are the 3 possible arrhythmias causing narrow complex (<0.12s) tachycardia?
AF Atrial flutter Supraventricular tachycardia
200
how do you treat atrial flutter?
BB rate control tx underlying radiofrequency ablation of re-entry rhythm anticoag
201
how do you treat SVT?
vagal manouvres and adenosine (Valsava, carotid sinus massage) cardioversion if BP <90
202
in a stable patient, what are the 3 possible arrhythmias causing broad complex tachycardia?
ventricular tachycardia SVT with BBB AF variation
203
how do you treat ventricular tachy>
amiodarone infusion 300mg
204
what causes atrial flutter? | pathophys
re-entry rhythm in either atria aka re-entry loop stimulates atrial contraction at 300bpm signal makes its way to ventricles every second lap -> 150bpm ventricular contraction
205
sawtooth appearance on ecg with p wave after p wave?
atrial flutter
206
conditions associated with atrial flutter (4):
HTN ischemia cadiomyopathy thyrotoxicosis
207
what causes SVT (pathphys)?
re-entry rhythm from ventricles to atria self-perpetuating electrical loop results in NARROW QRS
208
3 main types of SVT:
AV nodal re-entrant tachycardia AV re-entrant tachycardia Atrial tachycardia
209
how does adenosine work?
slowing cardiac conduction primarily through the AV node, interrupting the AVN/accessory pathway during SVT and resets to sinus rhythm half life 8-10 seconds
210
which conditions should adenosine be avoided in?
``` asthma copd HF heart block severe hypotension ```
211
what causes Wolff-Parkinson White syndrome?
extra electrical pathway connecting the atria and ventricles, normally there is only one pathway - the AVN. the extra pathway is called the bundle of kent
212
what is the bundle of kent?
extra electrical pathway connecting the atria and ventricles in WPW syndrome
213
definitive treatment for Wolff-Parkinson White syndrome ?
radiofrequency ablation of the accessory pathway
214
ecg changes in WPW syndrome?
short PR intervals wide QRS Delta wave axis deviation depending on which accessory pathway (L/R)
215
what is torsades de pointes and what does it mean?
polymorphic ventricular tachycardia | means twisting of the tips
216
torsades de pointes ecg changes:
normal ventricular tachy QRS twisted around the baseline height of QRS get progressively smaller then larger then smaller... prolonged QT interval
217
where are afterdepolarisations found?
torsades de pointes
218
what is the prognosis for torsades de pointes?
either spontaneously revert back to sinus or progress to VT (and maybe cardiac arrest)
219
causes of prolonged QT: from start of Q to end of T!
Long QT syndrome (inherited) iatrogenic (APs, ADs, flecanide, sotalol, macrolides) electrolyte disturbance (hypokalaemia, hypomagnesia, hypocalcaemia)
220
acute mx of torsades de pointes?
correct the cause - meds or electrolytes (macrolides - clari) magnesium infusion defib if VT
221
long term mx of torsades de pointes?
BBs | pacemaker
222
ECG changes for ventricular ectopics?
individual, random, abnormal broad QRS complexes on otherwise normal ECG
223
what is bigeminy?
ventricular ectopics are happening so commonly that they occur after every sinus beat
224
mx of bigeminy?
check bloods for anaemia, electrolyte disturbance, thyroid abnormalities
225
what is heart block generally referring to ?
AV node block
226
what is first degree heart block?
delayed AV conduction through AVN every atrial impulse leads to a ventricular contraction every p -> QRS PRI>0.2s
227
what is second degree heart block?
some atrial impulses do not reach the ventricles not all p -> QRS several patterns of 2nd degree HB
228
what is Wenckebach’s phenomenon (Mobitz Type 1) HB? (description)
atrial impulses become gradually weaker until they don't pass through the AVN after failing to stimulate a ventricular contraction, the atrial impulse returns to being strong and cycle repeats
229
ECG changes Wenckebach’s phenomenon (Mobitz Type 1)?
increasing PRI until absent QRS, cycle
230
what is Mobitz type 2 HB? (description)
intermittent failure of AV conduction results in absent QRS complexes, set ratio of p:QRS (eg 3:1 block) PRI normal
231
what happens to PRI in Mobitz type 2 HB? what is there a risk of in this condition?
normal pri | risk of asystole
232
what causes 2:1 block?
either mobitz 1 or 2, hard to tell which | 2 p waves to each QRS
233
3rd degree HB (description and ECG changes)
complete HB no observable relationship between p and QRS significant risk of asystole
234
treatment for stable bradycardia / AV blocks?
observe
235
tx for unstable bradycardia / AV blocks (risk of asystole in Mobitz type 2/ 3rd degree)?
1. atropine 500mcg stat IV up to 6 doses 2. other inotropes (NAd) 3. transcutaneous cardiac pacing (using defib)
236
tx for high risk of asystole (M2/3rd):
temporary transvenous cardiac pacing | permanent implantable pacemaker when available
237
how does atropine work?
antimuscarinic - inhibits parasympathetic NS
238
sfx atropine:
dilated pupils, urinary retention, dry eyes, constipation
239
how do pacemakers work?
deliver controlled electrical impulses to specific areas of the heart to restore normal rhythm and improve heart function consist of pulse generator, pacing leads
240
where are pacemakers commonly implanted?
Left anterior chest wall/axilla
241
how long do pacemaker batteries last?
5 years
242
what can pacemakers be a contraindication for having:
MRI TENS machines, diathermy in surgery
243
indications for pacemaker (5):
Symptomatic bradycardias Mobitz Type 2 AV block Third degree heart block Severe heart failure (biventricular pacemakers) Hypertrophic obstructive cardiomyopathy (ICDs)
244
where are single chamber pacemakers implanted (2 options):
RA | RV
245
where are dual chamber pacemakers implanted?
RA+RV
246
where are biventricular pacemakers inserted?
triple chamber/cardiac resynchronisation pacemakers | RA, RV, LV
247
what continually monitor the heart and apply a defibrillator shock to cardiovert the patient back in to sinus rhythm if they identify a shockable arrhythmia.?
implantable cardioverter defibrilator
248
ECG changes in single chamber pacemaker?
line before each p/QRS in all leads
249
ECG changes in dual chamber pacemaker?
line before each p and QRS in all leads
250
which coronary artery disease is described as 'supply ischemia'
STEMI
251
which coronary artery diseases are described as 'demand ischemia'?
stable angina unstable angina NSTEMI
252
diamond classification for chest pain from HPI (3):
1. left sided 2. worse OE/relieved with rest 3. relieved by nitroglycerin
253
if 3/3 diamond classification for chest pain from HPI: dx:
typical angina
254
if 2/3 diamond class HPI chest pain dx:
atypical angina
255
0/1 out of 3 of diamond classification for chest pain:
non-anginal chest pain
256
if assessing someone on ward who already had NSTEMI and ?another one, why can't you use troponins and what can you use instead?
Can't use troponins as they peak first during first MI, then stay elevated, so won't be sensitive to second MI Instead can check CPK-MB (creatine kinase myocardial band)
257
patient presents with cardiac sounding chest pain, normal ECG normal troponins, what is next in management pathway?
? unstable angina -> need PCI 'cath' anyway | is this cardiac coronary artery ischemia at all? - rule this out with cardiac stress test.
258
if stress test positive, what is the management?
f/u with cardiologist, will need PCI elective
259
how do you carry out stress test?
exercise or pharmacological (exercise if they can exercise) pharm - adenosine, dobutamine
260
how do you evaluate in cardiac stress test?
ECG (when baseline ECG normal) ECHO (when baseline not normal) MRI (when prev CABG/HF)
261
what are ECHO and MRI looking for during stress test?
dead tissue (doesn't move) - scar tissue at risk tissue (at rest and under stress - STUNNING) AREA OF REVERSIBILITY healthy tissue
262
what does angiography determine?
PCI (stent/balloon) - angioplasty | or CABG - if 3+ vessels involved
263
general medical management of ACS: (MONA BASH C) | *all
``` Morphine (worse prog if needed. SEVERE ONLY) O2 (during initial ex, nasal canula) Nitrates (if angina persists) Aspirin* BB* ACEi* Statin* Heparin (therapeutic dose) Clopidogrel (if post stent or high risk STEMI) ```
264
when in a rural setting, and cardiologist who can do PCI is far away, what do you give before transfer?
TPA if >60 mins away | BUT! The time from MI onset to PCI <2hours
265
if person is having a right sided STEMI (2,3,avf) - what tx don't they get and why?
nitrates - right ventricle is pre-load dependent
266
investigations to diagnose heart failure: (3)
BNP ECHO Angiogram - ischemic or non-ischemic?
267
What is heart failure with preserved ejection fraction?
2 types of HF - systolic, diastolic Diastolic the ventricle is thick, has trouble relaxing, ejection fraction normal or increased, but can't relax to fill so well
268
classification of heart failure? how many classes?
New York Heart Association Classification 4 1 - asx 4 SOB rest
269
Heart failure step wise mx based on NYHACHF:
1. BB and ACEi (or ARB) 2. Loop diuretic (furosemide) 3. Isosorbide dinitrate / spironalactone (to adddress pre load and afterload) / digoxin 4. Inotropes
270
if HF, and have an ejection fraction <35% and not class 4, what is mx->
implantable cardiac defibrilator
271
if ejection fraction <30%, LBBB, mx:>
CRT with biventricular pacemaker
272
if ischemic cause of heart failure, in addition to other tx, what do they need:
aspirin, statin
273
how to investigate a murmur and which murmurs to ix?
ECHO systolic g3+ any diastolic
274
how will Mitral stenosis present?
younger patients CHF sx - dyspnoea OE, PND, crackles A Fib
275
what treatment for Mitral stenosis?
balloon valvuloplasty
276
how will aortic regurgitation present?
acute - cardiogenic shock, flash pulmonary oedema | chronic - CHF, chest pain
277
tearing chest pain - classical dx?
aortic dissection
278
treatment for aortic regurgitation?
``` acute - urgent chronic - urgent/elective REPLACEMENT before onset of angina/HF remember to consider cabg ```
279
how will aortic stenosis present?
old man with atherosclerosis chest pain, HF sx, syncope bicuspid Aortic valve accelerates the pathology
280
treatment for Aortic stenosis:
NOT valvuloplasty -> REPLACEMENT | remember to consider CABG
281
mitral regurgitation presentation?
acute - cardiogenic shock, flash pulmonary oedema | chronic - CHF, AF
282
treatment for mitral regurgitation?
emergent valve replacement if acute | elective if chronic but before AF, HF sets in
283
why do you have to consider cabg in aortic valve replacements?
ostea of coronary vessels are in aortic valve | if lose an ostea - lose coronary flow
284
hypertrophic cardiomyopathy - what causes it?
unilateral septum hypertrophy | covers aortic opening -> LV outlet obstruction
285
who gets HCM?
``` patients with sarcomere mutations young athletic sudden death - due to ventricular arrhythmia SOB/syncope OE FHx sudden cardiac death ```
286
systolic murmur, but more blood->less murmur (better when they squat or leg-lift): (like Aortic stenosis)
HCM
287
treatment for HOCM:
``` avoid dehydration Beta blockade transplant alcohol ablation myomectomy AICD ```
288
what is mitral valve prolapse:
leaflets of the mitral valve don't touch well, too big | so during systole they blow through
289
systolic murmur but more blood->less murmur (better when squat or leg lift): (like mitral regurg)
mitral valve prolapse
290
pathophysiology of mitral valve prolapse:
congenital
291
what type of person gets mitral valve prolapse:
young women
292
treatment of mitral valve prolapse:
avoid dehydration BB doesn't need to be replaced
293
dilated cardiomyopathy: pathophys
chambers become dilated minimal actin and myosin overlap so no contractility
294
what generates contractility force in heart muscle?
actin and myosin overlap
295
causes of dilated cardiomyopathy:
``` virus - coxsackie, chagas wet beriberi alcohol ischemia chemo ```
296
how will patient with dilated cardiomyopathy present?
systolic CHF, 3rd HS orthopnoea, PND, dyspnoea OE, crackles, peripheral oedema reduced LVEF<55%, dilated LV TR, MR
297
tx of dilated cardiomyopathy:
CHF sx: BB, ACEi, diuretics (furosemide) definitive: transplant stop alcohol/chemo
298
what should happen to relatives of HCM?
first degree relatives screened by echo
299
concentric hypertrophic cardiomyopathy: causes:
longstanding HTN
300
concentric hypertrophic cardiomyopathy: CP:
diastolic CHF
301
how to treat concentric hypertrophic cardiomyopathy/diastolic CHF:
avoid dehydration BB/ccb transplant HTN control *** (1.)
302
restrictive cardiomyopathy: pathology:
no room for ventricle to relax due to interference in the wall of the ventricle, interfering with the myocyte normal function
303
causes of restrictive cardiomyopathy (3):
amyloid sarcoid haemachromatosis cancers idiopathic fibrosis
304
how will patient with restrictive cardiomyopathy present?
diastolic CHF
305
if restrictive cardiomyopathy + peripheral neuropathy -> dx
amyloidosis
306
if restrictive cardiomyopathy + pulmonary disease->
sarcoidosis
307
if restrictive cardiomyopathy + cirrhosis, bronze diabetes->
haemachromatosis
308
If suspect amyloidosis, which ix?
abdo wall fat pad biopsy | gingiva biopsy
309
is suspect sarcoidosis, which ix?
cardiac MRI then do endomyocardial biopsy
310
is suspect haemachromatosis, which ix?
``` screen ferratin (up) then get genetic test ```
311
tx restrictive cardiomyopathy:
``` diastolic chf so: rate control - BB, CCB gentle diuresis transplant definitive tx underlying disease ```
312
what will echo of HOCM show?
asymmetric hypertrophy of septum
313
in suspected chronic heart failure first line ix?
BNP | then echo
314
45-year-old man is admitted to the intensive care unit following a laparotomy. He has a central line, pulmonary artery catheter and arterial lines inserted. The following results are obtained: low pulm artery occlusion pressure low cardiac output high systemic vascular resistance cause?
hypovolaemia causes low cardiac output due to low preload
315
75-year-old man is admitted to the intensive care unit following a laparotomy. He has a central line, pulmonary artery catheter and arterial lines inserted. The following results are obtained: high pulm artery occlusion pressure low cardiac output high systemic vascular resistance cause:
cardiogenic shock in this, pulm pressures usually high tx using venodilators as in pulm oedema
316
22-year-old lady is admitted to the intensive care unit following a laparotomy. She has a central line, pulmonary artery catheter and arterial lines inserted. The following results are obtained: low pulm artery pressure high cardiac output low systemic vasc resistance cause?
septic shock decresed SVR is often major feature of sepsis hyperdynamic circulation often present tx using vasoconstrictors
317
palpitations ix?
after bloods and ecg | next important is holter monitor
318
60-M -> ED shocked with sudden onset, severe chest pain at rest. radiates to his back and down his arms. PMH HTN, angina and DVT 4 years ago. His regular medications include ramipril, GTN and simvastatin. He has never smoked, doesn't drink alcohol and has not had any recent travel. CXR: widened mediastinum and ECG: sinus tachycardia. Found some relief from the pain 20 minutes after using his GTN spray. dx?
aortic dissection
319
which classification for aortic dissection?
stanford | or debakey
320
Massive PE + hypotension - tx?
thrombolyse
321
what happens to DM meds when someone comes in having been thrombolysed post anterior MI to CCU?
stop metformin and gliclazide | start IV insulin infusion
322
what is kussmauls sign associated with ?
raised JVP on inspiration associated with constrictive pericarditis used to differentiate constrictive pericarditis from tamponade
323
calcification of pericardium?
constrictive pericarditis
324
if ?PE but can't get a scan - mx?
start on treatment dose anticoagulant and wait for scan
325
PE: ECG changes (commonest)?
sinus tachycardia T inversion v1-3 +/- inferior leads (RV strain) s1Q3T3 right axis deviation
326
hypercalcaemia ecg?
short qt interval | J waves if severe
327
right ventricular strain ecg features:
ST depression and T wave inversion v1-3 (+4) 2,3,avf
328
what does RBBB look like on ecg?
first part of QRS normal secondary R wave in v1-3 (looks like M) slurred 'S' in the lateral leads (looks like W) ST depression, T wave inversion in R precordials broad QRS >120ms
329
what does LBBB look like on ecg?
QRS broad >120ms tall R waves in lateral leads (1,v5,v6) (looks like M) deep S waves in R precordials (v1-3) - (looks like W) LAD dominant S wave in v1
330
Right axis deviation on ecg?
QRS is positive in 2,3,avf | QRS is negative in lead 1
331
left axis deviation on ecg?
QRS is positive in lead 1 | QRS is negative in 2, 3, avf
332
which drugs can lead to hypocalcaemia?
furosemide loop diuretics sfx also can cause ototoxicity
333
85 yom, 142/84 BP. Q-Risk of 8% on no meds: tx?
lifestyle advice as risk not >10%, he's over 80, no comorbidities
334
which anti-infective agent will cause the INR to increase?
fluconazole
335
INR 5.0-8.0 (no bleeding) - mx?
withhold 1 or 2 doses of warfarin, reduce subsequent maintenance dose
336
which complications do Type A aortic dissection patients sometimes present with?
hemiplegia | neuro complaints
337
71yof 147/92 BP confirmed on 2 readings - next step?
Ambulatory BPM
338
first line mx acute pericarditis?
NSAIDS AND colchicine
339
``` obvious MI hx with tall R waves in v1-3 - where is MI? ST depression in leads V1-V3 Tall R waves in leads V1-V3 Inverted T-wave in lead aVR All other T-waves are normally oriented ```
posterior MI
340
NSTEMI first line tx?
aspirin 300 to prevent progression to stemi
341
which drug sometimes used as anti htn will worsen glucose control in t2dm?
indapamide
342
A 75-year-old lady presented to the emergency department after suffering a fall 2 hours ago. Before the fall, she was nauseous and experienced sweating, pallor and discomfort in the stomach. She believed that she briefly lost her consciousness but then recovered quickly. She did not have any confusion or weakness after the fall. There were no tongue bites. Neurological examination was normal. Her hearing has always been bad since she was young. What is the diagnosis?
neurally mediated syncope
343
how should adenosine be given?
large bore cannula (16G) or centrally
344
adenosine sfx:
chest pain bronchospasm transient flushing can enhance conduction down accessory pathways, resulting in increased ventricular rate (e.g. WPW syndrome)
345
what type of organism (gram and shape) are the bugs that cause bacterial endocarditis?
gram positive cocci
346
which htn drugs cause cold peripheries?
BBs can also cause reduced awareness of hypos
347
pulsus paradoxus - describe?
In cardiac tamponade, there will be an abnormally large drop in BP during inspiration, known as pulsus paradoxus
348
fondaparinux is sometimes used in nstemi tx - what is it's moda?
activates antithrombin III | LMWH also does this
349
Abciximab, eptifibatide, tirofiban - moda?
Glycoprotein IIb/IIIa receptor antagonists
350
how to calculate the cardiac axis?
find most isoelectric line (pos=neg) out of first 6 (1,2,3,avl,avr,avf). direction of conduction is 90 degrees from that lead on the axis man
351
what condition is associated with an inverted P wave in lead I, right axis deviation, and loss of R wave progression??
dextrocardia | heart apex on the right, flipped heart
352
which drugs actually improve prognosis of heart failure?
ACEIs, BB, spironalactone | not furosemide
353
hypokalaemia ecg?
t wave flattening and u waves present
354
The most common valvular abnormality in infective endocarditis is ???
tricuspid regurgitation
355
tricuspid regurg murmur?
pan-systolic louder during inspiration (aka holo-systolic)
356
what is Beck's triad of cardiac tamponade? (do ECHO)
hypotension soft heart sounds raised JVP
357
cardiac tamponade ECG?
electrical aleternans
358
the CT shows a large saddle embolus where the pulmonary trunk splits - dx?
PE
359
what else other than HF can raise a BNP?
CKD/renal failure
360
Orthostatic hypotension (A fall in SBP of >20mmHg on 3 mins standing) accompanied by an exaggerated increase in HR is indicative of which 2 conditions?
anaemia | hypovolaemia
361
Orthostatic hypotension (A fall in SBP of >20mmHg on 3 mins standing) accompanied by no change in HR is indicative of which condition?
DM
362
well's score >4 which ix first line?
CTPA | if 4 or below do d-dimer to r/o
363
PE + hypotension tx?
alteplase (thrombolysis)
364
when to stop warfarin before surgery?
5 days before | surgery can go ahead after <1.5
365
where do loop diuretics act?
ascending loop of henle
366
how long do trop and CKMB stay elevated for post-MI?
trop 10 days | CK-MB 3-4 days
367
which drug is CI in ventricular tachycardia?
verapamil | can cause haemodynamic collapse
368
which drug is used in pulseless arrest / asystole?
adrenaline stat then 3-5minutely | not atropine anymore
369
which factors should determine if an intravenous glycoprotein Iib/IIIa receptor antagonist is to be given in nstemi?
GRACE score and whether the pt is having PCI | - give alongside
370
PCI criteria stemi?
presents in <12hrs and PCI can be delivered in <120 mins
371
PE + renal failure -> ix?
VQ scan
372
what cause of chest pain is commoner in Marfan's syndrome?
pneumothorax
373
42-year-old overweight man presents with a two day history of anterior chest pain that is worse on deep inspiration and lying down relieved by sitting forwards: dx
pericarditis
374
aortic dissection management:
type A - ascending aorta - control BP(IV labetalol) + surgery type B - descending aorta - control BP(IV labetalol)
375
electrolyte causes of torsades de pointes?
hypokalaemia hypomagnesia hypocalcaemia
376
what examination sign is classic for HCM?
s4 sound
377
What is the most common cause of death in patients following a myocardial infarction?
ventricular fibrilation
378
if d-dimer negative and wells score of 4: mx?
consider alternative dx and reassure patient PE ruled out
379
If patients have persistent myocardial ischaemia following fibrinolysis what is next mx step?
consider PCI
380
when is fondaparinux used in nstemi mx?
those who are NOT having angiography immediately
381
child with inhaled foreign body - where is the blockage likely to occur and which lobe?
right side - right inferior bronchus
382
STEMI and patient suitable for PCI -> which drugs do they get?
aspirin and prasugrel
383
Witnessed cardiac arrest while on a monitor - tx?
3xshocks then CPR if not witnessed on monitor -> do 1 shock then 2 mins CRP
384
hypothermia ecg changes:
``` bradycardia 'J' wave - small hump at the end of the QRS complex first degree heart block long QT interval atrial and ventricular arrhythmias also torsades de pointes ```
385
which rule out criteria used in 18yo with <15% chance PE?
PERC
386
what is a late neuro manifestation (and complication) of rheumatic fever?
sydenham's chorea | loss of control of facial and arm muscles
387
organism responsible for rheumatic fever?
strep pyogenes
388
which drugs can precipitate gout attacks?
thiazide diuretics - bendroflumethiazide | reduces uric acid secretion from kidneys
389
which patients, regardless of age, should be started on statin for primary prevention :
``` T1DMs if: 1 of: over 40 had DM for >10yrs nephropathy other RFs - HTN, obesity qrisk >10% ```
390
how do statins work? (MODA)
inhibit the action of HMG-CoA reductase, the rate-limiting enzyme in hepatic cholesterol synthesis.
391
statin CI:
macrorlides | pregnancy
392
doses of atorvastatin for different preventions:
20mg for primary | 80 for secondary
393
patient is two days following a large abdominal procedure. increased SOB. sinus tachy. reduced AE at both bases. ddimer normal - dx?
basal atelectasis
394
The history of ischaemic heart disease combined with the presence of fusion and capture beats strongly suggests a diagnosis?
Ventricular tachycardia
395
Deep 'arrowhead' T wave inversion in the anterior leads is a sign of ?
wellens syndrome | cardiac ischaemia in the setting of unstable angina and is a high-risk trace
396
hyperkalaemia ecg?
peaked T waves
397
which drug should never be taken with verapamil and why?
BBs | can cause heart block and fatal arrest
398
which cardiomyopathy is WPW associated with?
HOCM | Friedrich's ataxia as well
399
type of inheritance of HOCM?
autosomal dominant
400
ECHO findings HOCM? MR SAM ASH
Mitral regurg Systolic anterior motion Asymmetrical hypertrophy
401
suspected ruptured abdominal aorta aneurysm - which blood procducts?
crossmatch 6 units of blood
402
Major bleeding on warfarin. INR 8.5. mx?
stop warfarin + vit K 5mg IV + prothrombin complex concentrate (only give PCC if MAJOR bleed) restart warfarin when INR<5
403
STEMI presents 6hrs after onset, would take >120mins to transfer to PCI centre - mx?
thrombolysis and repeat ECG 90 mins (cannot wait for more than 120 mins to PCI if thrombolysis could be given) also give unfractioned heparin
404
bendrofluemthiazide MODA?
inhibits Na reabsorption by blocking the Na+-Cl− symporter at the proximal part of the distal convoluted tubule
405
54M obese. ED. sudden onset severe frontal headache and neck pain unbearable. PMH: HTN, aortic regurgitation (bicuspid valve), hyperlipidaemia. 94% air, RR 16/min, hr 117/min, BP 101/68mmHg left arm and 122/82mmHg right arm, temperature 36.8ºC. ECG sinus tachycardia. dx?
aortic dissection | if presents like R-sided stemi and AR murmur -> ascending
406
which comes first in nstemi mx - grace score or DAPT?
grace score
407
NSTEMI first 2 drugs given if not major bleeding risk:
aspirin and fondaparinux if PCI NOT planned for immediately
408
60M is admitted with severe central chest pain to the resus department. The admission ECG shows ST elevation in leads V1-V4 with reciprocal changes in the inferior leads. What % occlusion of which artery likely?
100% occlusion LADA
409
45-F ED chest pain worse on deep inspiration and SOB. denies coryzal symptoms or cough. rr25/min, 96% air, HR 114/min, BP 114/81mmHg, 36.8°C. She is concerned that this may be due to her total mastectomy one week ago for breast cancer despite the wound site appearing to be healing well. What is the next, most appropriate management step?
CTPA | Wells > 4
410
ECG shows both right bundle branch block and left axis deviation indicating???
bifascicular block
411
features of bifascicular block as above + 1st-degree heart block is called?
trifascicular block
412
MI+ bradycardia -> where?
inferior MI
413
STEMI > 12h since onset - ongoing ECG ischemia - mx?
PCI
414
what is a poor prognostic indicator in ACS??
cardiogenic shock - crackles on auscultation age>65 initially raised creatinine
415
Young man with AF, no TIA or risk factors, mx?
no treatment now preferred over aspirin
416
44M central, severe chest pain started around one hour ago. No radiation of the pain or associated shortness-of-breath. He has had some similar fleeting pains over the past two weeks but these settled spontaneously after a few seconds. hr 84 / min, blood pressure 134 / 82 mmHg and respiratory rate 18 / min. dx?
MI
417
25M intermittent central chest pains 4/52. PMH: pilonidal abscess operation 9 months ago. The pain is described as 'heavy' and often associated with tingling in his lips and fingers. The episodes usually happen at rest and last several minutes. dx?
anxiety
418
31F 4/52 retrosternal 'burning' pain. The pain is often worse following eating. PMH depression and she uses Microgynon. Clinical examination is unremarkable. dx?
gord
419
In the context of a tachyarrhythmia, a systolic BP < 90 mmHg →
DC cardioversion
420
77F to ED with 3/7 hx lethargy and shortness-of-breath. She is confused and unable to give much useful history. On examination she is noted to be pale, hr 160/min bp 80/56 mmHg. sats 96% air. anaemic. ECG shows irregularly irregular narrow complex tachycardia. mx?
dc cardioversion due to unstable BP
421
polycystic kidney disease: which murmur?
mitral valve prolapse (and MR)
422
2M ->GP parents are concerned that he is struggling to gain weight and is excessively short of breath on exertion. PMH congenital pulmonary stenosis which was managed conservatively however the parents are now questioning whether surgical intervention may be required. What murmur is likely to be heard on examination?
ejection systolic louder on inspiration
423
late systolic murmur inidcates:
mitral valve prolapse and coarctation of the aorta | associated with bicuspid aortic valve
424
mid-systolic click :
prolapse of the mitral valve
425
tetralogy of fallot murmur:
ejection systolic
426
ventricular septal defect murmur:
pansystolic
427
nicorandil is useful in mx of?
angina - K channel activator - dilates coronary vessels sfx - ulcer anywhere on GI tract
428
A patient develops acute heart failure 5 days after a myocardial infarction. A new pan-systolic murmur is noted on examination - dx?
VSD
429
``` 67-M ->ED sudden onset chest pain. central chest, and started an hour ago. maximal at onset, and is not exacerbated with deep breaths. most intense pain he's ever experienced. nil previous. PMH HTN (ramipril and bendroflumethiazide). He has a 15-pack-year. Drowsy. He has left-sided ptosis and miosis of his left pupil. dx? ```
aortic dissection | can present with neuro sx
430
'Provoked' pulmonary embolisms are typically treated for?
3 months | unprovoked is 6 months
431
41-M ->GP due to erectile dysfunction and dizziness. He has a complex PMH and is on multiple medications. On examination his heart rate does not slow on deep breathing and his lying/standing blood pressure drops significantly. dx?
autonomic dysfunction effects of T2DM
432
Investigating suspected PE: if the CTPA is negative then consider??
proximal leg vein USS if DVT suspected
433
23-F -> ED with palpitations. No chest pain. No signs of shock, heart failure or syncope. ECG: regular narrow complex tachycardia, rate of 168 bpm. There are no obvious P waves visible. Vagal manoeuvres fail to terminate the arrhythmia. What should be the next step in management?
SVT dx | Adenosine is next 6mg->12mg->12mg
434
67M COPD and paroxysmal atrial fibrillation who you are currenly looking after. Around 30 minutes ago he developed retrosternal chest pain which has not settled with Gaviscon. HR 90/min, sats 95% air, bp 134/82 mmHg, The ECG: STE in AVR and STD v2-6: mx:
acs mx - trasnfer to CCU
435
If a patient with AF has a stroke or TIA, the anticoagulant of choice should be?
warfarin or DOAC
436
68-M -> ED with sudden onset pleuritic chest pain. CTPA shows PE. Nil previous, and is normally fit and well, and not on any medications. He is normotensive but tachycardic. What is the most appropriate initial management for this man?
DOAC
437
what is Ivabradine and what are its commonest sfx?
angina tx if HR>70 | visual disturbances including phosphenes and green luminescence, brady, HB
438
alteplase (thrombolysis) MODA:
activates plasminogen -> plasmin
439
which ACS drug to be cautious with if pt normotensive/hypotensive?
nitrates - can cause collapse
440
which bloods indicate stop statin?
serum transaminase concentrations rise to and persist at 3 times the upper limit of the reference range.
441
Complete heart block following an inferior MI: mx?
reassure and observe | this is not an indication for pacing, unlike with anterior MI
442
what will make aortic stenosis murmur quieter?
LV dysfunction - reduced flow over the aortic valve - quieter murmur
443
50M cardiac ward following a stroke. 4/12 hx weight loss and fever. diastolic murmur. ECHO: 'A pedunculated heterogeneous mass attached to the interatrial septum of the left atrium. Mitral valve obstruction also noted'. dx?
atrial myxoma
444
New onset AF presented within <48h - mx?
anticoagulate and dc cardioversion | must be sx for <48h!!!
445
Aortic stenosis management:
AVR if symptomatic otherwise cut-off gradient is 40mmHg
446
Downsloping ST depression ('reverse tick' sign) indicates ?
digoxin toxicity
447
A 50-year-old man complains of central, pleuritic chest pain 24 hours after being admitted with an anterior myocardial infarction. The pain is eased when he sits upright.dx?
pericarditis
448
After being admitted to the coronary care unit a middle aged man develops a regular, broad complex tachycardia. His blood pressure drops to 88/50 mmHg. He was admitted 6 hours previously following an anterolateral myocardial infarction. dx?
ventricular tachycardia
449
A 66-year-old woman suddenly develops dyspnoea 10 days after having an anterior myocardial infarction. Her blood pressure is 78/50 mmHg, JVP is elevated and the heart sounds are muffled. There are widespread crackles on her chest and the oxygen saturations are 84% on room air. dx?
left ventricular free wall rupture | sudden HF, raised JVP, pulsus paradoxus, recent MI
450
which cardiac drugs can cause erectile dysfunction and insomnia?
BB
451
Carotid sinus hypersensitivity may be cardioinhibitory or vasopressive - quantify?
vantricular pause >3seconds | SPB drop >50
452
which valve for infective endocarditis in IVDU?
tricuspid
453
what are pharmacological options for treatment of orthostatic hypotension?
fludrocortisone and midodrine
454
angina and not controlled on BB, next in line is?
CCB
455
If new BP >= 180/120 mmHg + no worrying signs then the first step is ?
ix for end-organ damage | if signs - admit for specialist assessment
456
rate control AF but asthmatic - first line?
CCB - diltiazem
457
second episode AF. During admission he was warfarinised and discharged with planned follow-up in the cardiology clinic. However, on review today he is found to be in sinus rhythm. What should happen regarding anticoagulation?
lifelong warfarin (as 2nd episode)
458
Long Q-T syndrome mx?
stop drugs worsening BB ICD if high risk
459
what is the first line investigation for stable chest pain of suspected coronary artery disease aetiology?
Contrast CT coronary angiogram on-invasive functional imaging 2nd line invasive coronary angiography 3rd line
460
previously asx 30-F -> ED severe dyspnoea while jogging. twice in past month but this time it was more serious which prompted her to seek help. She is adopted and is aware that her biological mother suffered from rheumatic fever as a child and biological father had 'some sort of heart problem'. All vital signs were within normal range. An ECG was done and showed left ventricular hypertrophy. diagnosis?
HOCM
461
if had catheter ablation for AF - what changes regarding anticoag needed?
stay on anticoag per chadsvasc for life
462
what ECG finding is NOT normal variant for young athlete?
LBBB
463
A patient with AF + an acute stroke (not haemorrhagic) should have anticoagulation therapy started when in timeline?
after 2 weeks
464
pericarditis ix?
echo - tte
465
pt on anti-epileptic meds. goes on warfarin. gets skin changes but INR in normal range - what side effect is this?
skin necrosis
466
In Raynaud's phenomenon with extremity ischaemia think??
buerger's disease thromboangiitis obliterans (young male smoker)
467
De Musset's sign (head bobbing) is a clinical sign of ?
aortic regurgitation
468
One day following a thrombolysed inferior myocardial infarction a 72-year-old man develops signs of left ventricular failure. His blood pressure drops to 100/70mmHg. On examination he has a new early-to-mid systolic murmur. dx?
papillary muscle rupture -> acute mitral regurgitation could also be new VSD
469
Four weeks after an anterior myocardial infarction a 69-year-old presents with pulmonary oedema. The ECG shows persistent ST elevation in the anterior leads. dx?
left ventricular aneurysm | no chest pain
470
angina step wise mx:
1. BB 2. CCB 3. long-acting nitrate, ivabradine, nicorandil or ranolazine
471
how do ISMN takers minimise the development of nitrate tolerance?
assymetric dosing regime to maintain a daily nitrate-free time of 10-14 hours no mortality benefit - sx only
472
For adults with type 1 diabetes, if there is no albuminuria the target BP should be < ??
135/85
473
adult with type 1 diabetes has albuminuria or 2 or more features of metabolic syndrome, in which case BP target should be?
130/80
474
Bleeding on dabigatran? (eg haemorrhagic stroke) - which reversal agent??
idarucizumab
475
drug monitoring for statin?
LFTs at baseline, 3months, 12 months
476
when to take statins?
last thing in evening - works overnight
477
Takotsubo cardiomyopathy is associated with which echo change?
apical ballooning of myocardium (resembling an octopus pot)
478
middle-aged lorry driver presents with central chest pain and ST elevation on electrocardiogram. He is treated for myocardial infarction with (PCI) and a stent is deployed to his left circumflex artery to good effect. Now asymptomatic and has been started on secondary prevention medications. He is keen to get back to work. What guidance should he be given on discharge?
contact DVLA and not drive for 6/52 if not lorry driver, should wait 4/52 before driving but no need to tell dvla
479
Acute heart failure not responding to treatment - next step?
CPAP
480
warfarin and pregnancy?
NO - teratogenic | but can be used in breast-feeding mothers
481
dental procedure on background of endocarditis - which abx prophylaxis?
none - not routinely recommended
482
ventricular tachycardia: tx if adverse sign and examples of adverse signs?
synchronised cardioversion | shock (systolic BP of <90), syncope, myocardial ischemia and heart failure.
483
if ventricular tachy without adverse sign (stable) - mx?
amiodarone IV | sfx causes thrombophlebitis
484
which drugs cause orthostatic hypotension?
diuretics, vasodilators (including CCB), alcohol
485
how to treat AF if there is coexistent heart failure, first onset AF or an obvious reversible cause?
rhythm control
486
ace-i in pregnancy?
NO | foetal abnormalities and renal failure
487
useful investigation in clinically unstable patients with a suspected aortic dissection??
TOE (transoesophageal echo) normally ct angiography is ix of choice if clinically stable = false lumen (of CAP)
488
CCB and heart failure:?
CI - negative inotropic effect; they reduce heart rate and cardiac output (except for amlodipine)
489
In cases of hypothermia causing cardiac arrest, defibrillation..............?
do 3 shocks but then if unsuccessful continue chest compressions and only shock again once pt temp >30degrees
490
ECG shows electrical alternans, which is considered pathognomic for?
tamponade | alteration of QRS amplitutes between beats
491
choking - mild mx?
ask are they choking - if yes encourage cough
492
severe choking - mx?
give up to 5 back-blows if unsuccessful give up to 5 abdominal thrusts if unsuccessful continue the above cycle
493
A 24-year-old Asian female presents to her GP with lethargy and dizzy spells. On examination she is noted to have an absent left radial pulse. Blood tests are as follows: ESR high - dx?
takayasu's arteritis associated with renal artery stenosis and different BP in each arm
494
3 of these = typical chest pain 2= atypical what are the three criteria?
pain is described as sharp (rather than constricting) pain may be precipitated by physical exertion pain is relieved by GTN spray within 5 minutes
495
chest pain relieved by sitting forwards?
pericarditis
496
A 52-year-old male presents with central chest pain and vomiting. He has drunk a bottle of vodka. On examination there is some mild crepitus in the epigastric region. dx?
boerhave syndrome | Spontaneous rupture of the oesophagus that occurs as a result of repeated episodes of vomiting.
497
boerhave syndrome: mackler triad?
vomiting, thoracic pain, subcutaneous emphysema. It commonly presents in middle aged men with a background of alcohol abuse.
498
statin + clari ->
an important and common interaction | massively raised CK
499
commonest cause of mitral stenosis?
rheumatic fever
500
55-F -> GP 3/12 hx breathlessness on exertion, fatigue and ankle swelling. She reports that she requires 2 pillows to sleep at night. PMH: feverish illness 4-months previously. Mid-diastolic murmur present and a loud S1 opening snap consistent with mitral stenosis. Annular erythematous rash on her chest. ECG: right ventricular hypertrophy and P-mitrale. dx?
rheumatic fever erythema marginatum
501
45-F->ED sudden onset weakness on the right side of her body. 30m ago. Her vision is unaffected but her speech is confused and slurred. Nil PMH. DH: COCP. 40 pack-years and drinks two bottles of wine/wk. Clinically stable. 2/5 power down her right side. Peripheral cyanosis and clubbing with an ejection systolic murmur at the left upper sternal edge radiating through to the back and fixed splitting s2. There is also erythematous tender enlargement of the right calf. what caused this?
atrial septal defect embolism from peripheral veins may bypass pulmonary circulation
502
62-M 2 episodes of syncope. hr 90 bp 110/86 mmHg, his lungs are clear and there is a systolic murmur which radiates to the carotid area. Which ix first?
ECHO | syncope a late sign in aortic stenosis
503
ACE-I and worsening BP control but doesn't tolerate CCB - which drug to add?
thiazide
504
which AD drug associated with dose dependent QT prolongation?
citalopram
505
used to reduce dyspnoea and anxiety in acute exacerbation of heart failure?
morphine
506
what is CI in aortic stenosis (drug):
nitrates - cause hypotension
507
58-F PE 1/52 ago. Warfarinised. She was covered with low molecular weight heparin until the INR was > 2 for 24 hours. For the past week she has been taking 4mg of warfarin and her INR four days ago was 2.2. Her INR has been checked today and is 1.3. mx?
up warfarin to 6mg/day and LMWH bridge
508
A 12-F from Bulgaria presents to the surgery. She reports being unwell for the past 2 weeks. Initially she had a sore throat but she is now experiencing joint pains intermittently in her knees, hips and ankles. On examination there are some pink, ring shaped lesions on the trunk and occasional jerking movements of the face and hands. dx?
rheumatic fever
509
severe hypertension and bilateral retinal hemorrhages and exudates - ? (or epistaxis)
malignant hypertension
510
If patients treated with PCI for MI are experiencing pain or haemodynamic instability post PCI - mx?
CABG
511
which anti-hypertensives cause hyperkalaemia?
ace-is
512
coarctation mx:
immediate prostaglandins | until corrective surgery can occur
513
ix endocarditis?
3 separate blood cultures taken | ECHO
514
absence of a carotid pulse in the presence of sinus tachycardia indicates that this is?
non-shockable rhythm
515
20-F. On feeling the woman's radial pulse, the doctor can feel 2 separate systolic beats, as if there was a double pulse. dx and name of this phenomenon?
HOCM | bisferiens pulse
516
slight discomfort with ordinary activity. No symptoms on resting - NYHA ??
II
517
recurrent DVTs, warfarinised - target INR?
3.5 (3-4)
518
sfx GTN?
hypotension tachycardia headache flushing
519
VF/pulseless VT should be treated with ?
1 shock as soon as identified then CPR adrenaline after the 3rd shock only ever 3 successive shocks when whole event witnessed on monitor eg post MI
520
ECG HOCM:
left ventricular hypertrophy (deep S in v1, tallest R in V5,6) progressive t-wave inversion deep Q waves
521
A sigmoid colon perforation of unknown cause, given his age; Translucent looking skin and hypermobility of the small joints; A presentation compatible with aortic dissection. cause and ix of aortic dissection?
ehlers-danlos | TOE
522
NSTEMI management: unstable patients should have immediate?
coronary angiography
523
drug causes both hyponatraemia and hypokalaemia.?
bendroflumathiazide | also hypercalcaemia + hypocalciuria
524
A 25-year-old female is found to have a left hemiparesis following a deep vein thrombosis. An ECG shows RBBB with right axis deviation. What is the most likely underlying diagnosis?
ostium secundum atrial septal defect
525
drugs to avoid in HOCM?
ace-inhibitors | reduce afterload
526
falsely low BNP?
on ramipril for BP | angiotensin-II receptor antagonists, beta-blockers and diuretics can all falsely lower BNP levels, as can obesity.
527
commonest association for aortic dissection>
htn
528
NICE HF guidelines - if already on Ace, BB, on step 2:
aldosterone antagonist ARB Hydralazine+ nitrate (especially if black)
529
NICE HF guidelines step 3: cardiac resynchronisation therapy or?
digoxin
530
A 52-year-old male attends the stroke unit with dizziness and vertigo while playing tennis. He is known to have hypertension and a previous myocardial infarct. He now complains of right arm pain. What is the most likely diagnosis?
subclavian steal syndrome
531
thrombolyisis CI:
``` active internal bleeding recent haemorrhage, trauma or surgery (including dental extraction) coagulation and bleeding disorders intracranial neoplasm stroke < 3 months aortic dissection recent head injury severe hypertension ```
532
breathing problems with a clear chest - think?
PE
533
There are regular p waves at a rate of around 90 / min but they do not conduct. The ventricular escape rhythm has a rate of about 36 / min and has a right bundle branch block (RBBB) like morphology. The bizarre, wide, inverted T-waves can be seen in?
stokes-adams attacks
534
Global' T wave inversion (not fitting a coronary artery territory) - think?
non-cardiac cause
535
effect of phenobarbitone on warfarin?
decreases INR
536
first line investigation for stable chest pain of suspected coronary artery disease aetiology (angina):
contrast enhanced CT angiography
537
59F -ED 3/7 hx of new-onset palpitations. She has no structural or ischaemic heart disease. HR 120bpm, and she shows no signs haemodynamic compromise. Her ECG shows an irregularly irregular rhythm with the absence of p waves. The consultant recommends elective cardioversion for this patient. Which mx plan is most appropriate?
bisoprolol and oral anticoagulation for 3 weeks then electrical cardioversion patients must either be anticoagulated or have had symptoms for < 48 hours to reduce the risk of stroke
538
After starting an ACE inhibitor, significant renal impairment may occur if the patient has undiagnosed?
bilateral renal artery stenosis
539
cause of a loud S2 (due to a loud P2)??
pulmonary HTN
540
A 43-year-old lady presents with severe chest pain. Investigations demonstrate a dissecting aneurysm of the ascending aorta which originates at the aortic valve. What is the optimal long term treatment?
aortic root replacement
541
angiodema is sfx of which drug?
ace-i ramipril
542
Tachycardia with a rate of 150/min ?
atrial flutter
543
primary PCI via which artery?
radial
544
Complete heart block following a MI? - where is lesion?
Right coronary artery
545
A newborn child is assessed. They are found to be in the 25th centile for their weight along with a systolic murmur heard best over the back. When feeling the femoral pulses the doctor notices that there is a radio-femoral delay. Which condition causing these examination findings?
coarctation | Tuner's syndrome
546
A 43-year-old lady presents with central chest pain, worse on deep inspiration, and shortness of breath. After her history and examining her, you suspect a pulmonary embolus (PE). Her Wells' score is 9. You plan to do a CTPA, but the radiologists request you order one further investigation prior to a CTPA. What investigation is this likely to be?
CXR - do before CTPA acc to nice
547
Patients on warfarin undergoing emergency surgery -?
give four-factor prothrombin complex concentrate
548
amiodarone sfx?
grey skin appearance
549
ABG in a PE?
respiratory alkalosis
550
which HTN med can increase creat by 30% from baseline but should be continued?
ramipril
551
notching of the rib =
coarctation of aorta
552
ix before starting amiodarone?
CXR - pneumonitis UE - hypokalaemia LFT TFT
553
Infective endocarditis causing congestive cardiac failure is an indication for?
emergency valve replacement
554
what is ebstein's anomoly?
tricuspid regurgitation → pansystolic murmur, worse on inspiration
555
HOCM caused by?
mutation in the gene encoding β-myosin heavy chain protein or myosin binding protein C
556
clubbing, fever, AF, mid-diastolic murmur seen in?
atrial myxoma (more commonly LA)
557
furosemide/bumetanide MOA:
inhibits the Na-K Cl cotransporter in the thick ascending loop of henle
558
what are the name of the nodules found in rheumatic heart fever?
Aschoff bodies are granulomatous nodules
559
65M palpitations. ECG: VR 150/min with an underlying atrial rate of 300/min. Atrial flutter is suspected. What is the treatment of choice to permanently restore sinus rhythm?
radiofrequency ablation of tricuspid valve isthmus

3b/4 (19 decks)

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