Cardiology Flashcards
1
Q
What is the ideal blood pressure range?
A
90/60 - 120/80
2
Q
At what blood pressure would you consider treatment for hypertension?
A
Clinical BP >160/100
OR >140/90 + signs of CVD or eng organ damage
3
Q
What is the target BP for patients with hypertension?
A
<140/85
Unless diabetic with organ damage <130/80
4
Q
Draw/describe the Renin Angiotensin System.
A
Macula Densa in kidneys detect drop in GFR via Na+ levels.
Juxtaglomerular Complex releases Renin.
Renin catalyses the conversion of Angiotensin (produced by liver) to Angiotensin I.
Angiotensin converting enzyme [ACE] converts Angiotensin I to Angiotensin II [vasoconstrictor].
Angiotensin II acts on andrenal gland causing release of aldosterone.
Aldosterone causes reabsorption of H20 via Na resorption.
5
Q
Name two things that influence ADH (vasporessin release)
A
BARORECEPTORS:
Stretch receptors in arteries and large veins (particularly carotid sinus and aortic arch). Send signals to medulla when BP falls.
ANGIOTENSIN II:
Directly stimulates ADH release.
OSMORECEPTORS:
In hypothalamus detect when osmolality rises e.g. due to dehydration.
6
Q
Where is ADH produced?
A
Hypothalamus
It is stored and released from the posterior pituitary.
7
Q
Give two pieces of lifestyle advice for hypertension
A
Reduce stress Exercise Stop smoking Reduce salt intake Reduce weight Vegetarian diet
8
Q
What is a homocystein test for?
A
Vitamin B12, B6 and Folate levels.
Homocystein is an amino acid found in high amounts in meat and it can cause damage to blood vessels increasing risk of CVD. B vitamins are required for its breakdown.
9
Q
What is the 1st line antihypertensive treatment for a patient under 55yrs and white?
A
ACE inhibitor
10
Q
What is the 1st line antihypertensive treatment for patients over 55yrs or Black?
A
Calcium Channel Blocker [CCB]
If not tolerated, then thiazide-like diuretic e.g. indapamide.
11
Q
True or false, in diabetic patients, ACEi/ARB is the 1st line treatment for hypertension?
A
True
12
Q
True or false, ACE inhibitors are safe during pregnancy?
A
False. ACEi such as Ramipril are teratogenic (particuarly in first trimester). Use Beta Blocker instead.
13
Q
True or false, a contraindication for ACEi is renal failure?
A
True. ACEi are not nephrotoxic but they do reduce GFR.
14
Q
Give two contraindications for beta blockers
A
Asthma
Complete Heart block
Bradycardia
15
Q
What is heart failure?
A
When cardiac output is insufficient to meet the body’s needs
16
Q
What is the difference between HFrEF and HFpEF?
A
HFrEF: Reduced ejection fraction [<40%]. The heart won’t contract appropriately [aka Systolic HF]
HFpEF: Preserved ejection fraction. Heart wont fill appropriately [aka Diastolic HF].
17
Q
What is cor pulmonale?
A
Right sided heart failure
Blood can’t return to the heart effectively resulting in peripheral swelling.
18
Q
What is the difference in symptoms between right and left heart failure?
A
Right (cor pulmonale): Primarily oedema as blood can’t return to the heart effectively.
Left: Dyspnoea, fatigue, chest pain as blood can’t return from the lungs.
19
Q
What is the classification system used to assess heart failure? What are the 4 stages?
A
New York Classification
1) No limitation of physical activity
2) Slight limitation of physical activity. Unduly breathless with normal activities. Comfortable at rest.
3) Marked limitation. Breathless with less than ordinary activity. Comfortable at rest.
4) Symptoms present at rest.
20
Q
What is the gold standard clinical test for heart failure?
A
Natriuretic Peptide Levels
[Also do CXR, ECG, Echocardiogram, FBC]
21
Q
What is the treatment regimen for heart failure?
A
HFrEF: [LAB]
Loop diuretic
ACEi
Beta Blocker (carvedilol/bisoprolol)
HFpEF:
Loop diuretic
22
Q
What is DASH?
A
Dietary Approaches to Stop Hypertension
[Low fat, low salt, medeterranean diet]
23
Q
What kind of diuretic is best for pulmonary oedema? Which diuretic is best for peripheral oedema?
A
Loop diuretics e.g. furosemide, bumetanide.
[L for lungs]
Thiazide diuretics
e.g. Indapamide, Bendrofluazide.
[Remember azides affect NaCl channels and salt balance].
24
Q
What channels do thiazide diuretics affect?
A
NaCl symporters in the DCT
[Contraindicated in gout, liver/renal failure]
25
What channels do loop diuretics affect?
NaK2Cl cotransporter in ascending loop
[Contraindicated in renal failure]
26
Name a potassium sparing diuretic
Spironolactone
| Amiloride
27
How does the diuretic mannitol work?
Increases osmolarity in the proximal tubules
[Used for cerebral oedema and rhabdomyolysis]
28
True or false, Addison's disease is a contraindication for potassium sparing diuretics
True.
Addisons [double down]
Cortisol and Aldosterone are low. Therefore, potassium is already higher than normal. Risk is hyperkalaemia.
29
Why do you tend to get pulmonary oedema with Left sided Heart Failure?
Blood is unable to return from the lungs to the left ventricle resulting in back pressure in the lungs.
30
Name two CXR signs of heart failure
Pulmonary oedema (Bat wing opacities)
Kerley B lines (horizontal lines in the lower aspect of the lungs)
Cardiomegaly (>50% thoraccic width)
Dilated upper lobe vessels
Pleural effusion
31
What is the Frank Starling law?
Stroke volume increases with end diastolic volume.
[Essentially, more blood in means more blood out].
32
What criteria are used for the diagnosis of Heart Failure?
Framingham Criteria
Major:
- Paroxysmal nocturnal dyspnoea/orthopnoea
- Neck vein distension
- Cardiomegaly
- Pulmonary oedema
- S3 gallop
- Rales (crackling lungs on inalation)
Minor:
- Ankle oedema
- Night cough
- Dyspnoea on exertion
- Hepatomegaly
- Tachycardia
- Pleural effusion
[2 major or 2 minor = Dx]
33
True or false, in heart failure you do not give NSAIDs.
True. Due to risk to kidneys.
34
How do you determine the cardiac axis from an ECG?
['Stand on one foot to find axis' & if its Right its No -ve Problem +ve]
Normal
Lead I: +ve
aVF: +ve
Right
Lead I: -ve
aVF: +ve
Left
Lead I: +ve
aVF: -ve
35
What is the normal speed of an ECG?
25mm/second
36
How many seconds is one small square and one large square?
40ms (small)
| 200ms (large)
37
How many volts is one small square and one large square?
0. 1mV (small)
| 0. 5mV (large)
38
How does the P wave differ in P Mitrale vs P Pulmonale?
P Mitrale (left atrial enlargement) = Biphasic P wave (just like 'M')
P Pulmonale (right atrial enlargement) = Enlarged P wave.
39
What is the normal axis of an ECG?
-30 to +90
40
How do you calculate the rate of an ECG?
300/number large squares between consecutive R spikes.
41
What is a normal PR interval?
120 - 200 ms
| [3-5 small squares]
42
What are the three degrees of heart block? How do they present differently on ECG?
1st Degree:
- Fixed prolonged PR interval (>200ms)
- No lost QRS complexes
```
2nd Degree:
Mobitz I (Wenckebach)
- PR interval gets longer until QRS is dropped.
```
Mobitz II
- PR interval fixed but QRS drops intermittently.
3rd Degree:
- Complete dissociation between P waves and QRS complexes.
- Ps remain regular
- QRS remain regular
[In 3rd degree some Ps may get lost in QRS complexes]
43
If the PR interval is less than 120ms, there is a wide QRS and delta wave present, what does this suggest?
An accessory pathway e.g. Wolff Parkinson White syndrome.
[The accessory pathway in WPW is known as the Bundle of Kent]
44
What is the treatment for Wolff-Parkinson White syndrome?
If in AVRT:
- Vagal manoeuvers e.g. carotid sinus massage or ask patient to blow on 50 ml syringe
- Adenosine (not if AF!)
If symptomatic:
- Radiofrequency ablation
- Amiodarone
- Sotalol
NB: Don't give digoxin. Increases risk of death!
45
What is the normal width of the QRS complex?
120ms
| [3 small squares]
46
How do you tell if an ECG is in sinus rhythm? What possible diagnoses would you consider if not?
There should be clear P waves present. If not, then consider Atrial Flutter or Atrial Fibrillation.
47
How do you tell if a Q wave is present? What does it indicate?
If the Q is >25% the amplitude of the R then its a Q wave. This indicates an MI.
[Q waves appear around 1-12 hours into an MI]
48
What is the difference between ST elevation and ST depression?
ST elevation indicates full thickness MI i.e. infarction.
ST depression indicates myocardial ischaemia.
49
What is represented by the T wave?
Repolarisation of the ventricles.
50
In which leads is it normal to find T wave inversion?
V1 and Lead III
[
51
What are the ECG findings with Right and Left Bundle Branch Block?
RBBB: [MaRRoW]
V1: M
V6: W
LBBB: [WiLLiaM]
V1: W
V6: M
52
What is the difference between a pacemaker and an ICD?
Pacemakers deliver regular pulses to maintain a healthy cardiac rhythm e.g. in sick sinus syndrome, AF or heart block.
Implantable Cardioverter Defibrillator (ICD) only shocks the heart in the event of a cardiac arrest.
53
True or false, hair dryers are a risk for pacemakers?
True.
Any device that produces an EM field can interfere with pacemakers e.g. microwaves, induction hobs, and hairdryers.
Patients are advised to keep at least 2 ft away from such devices.
54
What are the ECG findings with Hyper and Hypokalaemia?
Hyperkalaemia:
- Tall tented T waves
- Wide QRS
Hypokalaemia: [PR STUF]
- PR int prolonged
- ST depression
- U waves
- Flat/bifid T wave
55
What is the treatment for Hyperkalaemia?
IV Calcium gluconate [cardio protective]
Soluble insulin + 50ml glucose
Salbutamol
Calcium resonium [K excretion]
56
What are the 4 categories of anti-arrhythmic drug according to the Vaughan Williams Classification? What is the mechanism of each?
1. Na block
Mild: Procainamide
Moderate: Lidocaine
Strong: Flecainide
2. B1 Adrenergic block
e. g. Propanolol [B = 2nd letter]
3. K channel block e.g. Amiodarone
4. Calcium Channel Block e.g. Diltiazem, Verapamil
57
Give two side effects of amiodarone
Pulmonary fibrosis
Thyroid issues
Slate grey skin
58
What are the three main categories of calcium channel blocker?
Dihydropyridines
[smooth muscle] lower peripheral resistance e.g. amlodipine, felodipine, nifedipine.
Benzothiazepines
[cardiac + smooth]
e.g. Diltiazem
Phenylalkylamines
[Cardiac] e.g. verapamil.
[From out to in DBP]
59
What are the four signs of Tetralogy of Fallot?
Pulmonary Stenosis
RV hypertrophy
VSD
Overriding Aorta
[Aorta receives from both R+L ventricles]
60
Give a risk factor for Tetralogy of Fallot
Rubella
Alcohol
Diabetes
61
What is Eisenmenger syndrome?
Blood flow is typically from the left ventricle to the right. However, overtime, it reverses as the right ventricle hypertrophies.
62
What are the two cyanotic heart defects?
Tetralogy of Fallot
Transposition of the Great Arteries
ToGA - Pulmonary and Aorta are switched over in terms of ventricles.
63
Name 2 acyanotic heart defects
```
ASD
VSD
PDA
AS
PS
Coarctation of the Aorta
```
64
What is the treatment for Transposition of the Great Arteries?
Prostaglandins to keep the ductus arteriosus open, then surgery
65
What is used to keep the PDA open or to close it?
Open: Prostaglandins
Closed: NSAID (ibuprofen)
66
True or false, the ECG for a patient with stable angina is most likely normal?
True
67
What investigations would you perform for a patient presenting with stable angina (exertional chest pain)?
CT coronary angiography (1st line)
Stress/exercise tolerance test
Echocardiogram
ECG
Bloods
Troponin
68
True or false, stable angina is part of ACS?
False.
ACS
- Unstable angina
- STEMI
- NSTEMI
69
What is the treatment for stable angina?
Beta blocker
CCB
Nitrates
Aspirin
70
True or false, troponin is likely normal in unstable angina?
True
71
Of the ACS conditions, which two would you expect to find raised troponins?
NSTEMI
| STEMI
72
How quickly can cardiac markers be used to identify an MI?
Troponin I/T - post 3hrs
High sensivity - 90mins
Creatine Kinase - post 3hrs
[Lactate Dehydrogenase (LDH) is another marker]
73
Give two other reasons other than an MI for raised troponin
Myocarditis
PE
Sepsis
Kidney failure
74
What is the ECG finding with PE?
[S1Q3T3]
S wave in I
Q wave in III
inverted T in III
75
What are the pathological steps of atherosclerosis?
```
Endothelial injury
Monocyte infiltration
Foam cells form
Smooth muscle growth
Fatty streaks
Plaque formation
Rupture
Platelet formation
```
76
Name two things that can injur the endothelium
```
Lipids
Smoking
Toxins
HTN
Viruses
```
77
Give two causes of myocarditis
```
Coxsackie
Flu
Adenovirus
Diphtheria
Drug reaction
SLE
DM
```
78
Which is the most common valve affected by infective endocarditis?
```
Tricuspid valve
(50% of cases)
```
79
Give two clinical signs of infective endocarditis
New onset murmur
Fever
Osler nodes (fingers, painful)
Janeway lesions (palmar non-tender)
Roth spots (retinal haemorrhage)
Splinter haemorrhages
Petechiae
80
What is the criteria for assessing the likelihood of infective endocarditis?
Duke's critera
Major:
2 or more +ve blood cultures for known IE organism.
Echo evidence of mass.
Minor
Fever >38
Predisposing factor e.g. cardiac lesion.
Vascular phenomenon
Immunological phenomenon
+ve blood culture
+ve echo
[2 major or 1 major 3 minor or 5 minor]
81
How many blood cultures do you take if you suspect Infective endocarditis?
3-6 samples in 24hrs.
NB: Some bacteria wont show e.g. chlamydia, coxiella, legionella.
82
Which of transthoracic echo (TTE) or Transoesophageal echo (TOE) is preferred in a patient suspected of infective endocarditis and why?
TTE as non invasive.
[Use TOE if they have a prosthetic valve as better specificity].
83
What is the treatment for infective endocarditis?
Flucloxacillin or Gentamicin
If prosthetic valve then Vancomycin + Gentamicin + Rifampicin.
Surgery if echo shows significant change.
84
Give two causes of pericarditis
```
Coxsackie
Influenza
Echovirus
Adenovirus
Secondary to MI [aka Dressler's syndrome]
```
85
What ECG changes would you expect with pericarditis?
Widespread ST elevation
(Saddle shaped)
PR depression (especially lead II).
[Check troponin to exclude MI]
86
What is the treatment for pericarditis?
Most resolve on their own
NSAIDs
Colchicine
Restrict activity
87
True or false, NSAIDs are recommended in the week following an MI?
False. It is not recommended to give NSAIDs for the first 2 weeks post MI as this increases risk of myocardial rupture.
88
What can cause prolonged QRS?
Tricyclic acid toxicity
| Treatment = Bicarbonate
89
What is the ECG pattern associated with Multifocal Atrial Tachycardia [MAT]?
3+ P waves with different morphology/shape.
90
What are the anatomical locations of the heart valves?
Aortic: 2nd ICS right sternal border
Pulmonic: 2nd ICS left sternal border
Tricuspid: 4th ICS left sternal border
Mitral: 5th ICS midclavicular line
91
Which valvular heart sounds are best heard on inhalation and which on exhalation?
RIght = Inhalation
- Tricuspid
- Pulmonic
LEft = Exhalation
- Mitral
- Aortic
92
True or false, the majority of children at some point have a heart murmur?
True. 70% of children will have a functional murmur at some point. It goes away with age.
93
What is the most common heart murmur in the developed world?
Aortic Stenosis
94
Which heart murmur can cause bifid P waves or absent P waves?
Mitral stenosis
95
What are the Systolic and Diastolc murmurs?
Systolic: [ASPS & MRTR]
AS/PS [Crescendo-Descrescendo]
MR/TR [Pan-systolic]
VSD [Pan-systolic, high pitch, left sternal border]
Diastolic [ARPR & MSTS]
AR/PR [Descrescendo]
MR/TR [Low rumbling]
96
What condition is suggested by a sawtooth P-wave pattern on ECG?
Atrial Flutter
97
Give two risk factors for Atrial flutter or Atrial Fibrillation
```
Alcohol
Cardiomyopathy
Diabetes
HTN
MI
Caffeine
DM
Smoking
```
98
How is Atrial flutter treated?
```
Anticoagulant
Beta blocker
CCB
Cardioversion (amiodarone/flecainide]
Ablation
```
99
How do you tell if an ECG is in sinus rhythm?
[I want II put my P in the V1]
If no P waves in lead II and V1 then its no sinus rhythm, therefore think atrial flutter or fibrillation.
100
What are the 4 types of AF?
Paroxysmal: >2 episodes but stops within 7 days.
Persistent: Lasts longer than 7 days.
Long-term: Lasts >1 year
Permanent: Decided on no treatment.
101
How do you treat AF?
Acute: Cardioversion (IV amiodarone, flecainide) beta blocker.
Non-acute: Warfarin/DOAC, Beta blocker/CCB/digoxin.
102
What is the Chasdvasc score for? What are the elements?
Risk of stroke in patients with AF
```
Congestive HF
HTN
Age >75 [2pts]
DM
Stroke or TIA
Vascular disease e.g. MI
Age 65-74yrs
Sex category (female)
```
103
What is the most common type of Supraventricular Tachycardia?
Atrioventricular nodal reentrant tachycardia (AVNRT)
104
What is the treatment for AVNRT?
Valsalva manoeuvres e.g. face in cold water, pressing on eyes. carotid massage which slow AV conduction by vagus nerve stimulation).
IV adenosine or flecainide
Ablation
105
What is the difference between AVRT and AVNRT?
AVNRT is a reentrant circuit in the AV node itself.
AVRT is outside the AV node e.g. WPW.
106
Give a major risk factor for Pulmonary Embolism
Spinal/lower limb surgery/injury
Stroke
MI
107
What is the first line investigation if you suspect a PE?
```
CTPA (gold standard)
Troponin
Well's score
D-Dimer
VQ perfusion (if allergic to contrast or renal impairment)
```
[Always do a CXR before CTPA to rule out any other causes as this minimises radiation exposure]
108
What is the treatment for a PE?
LMWH e.g. dalteparin
Alteplase
Surgical embolectomy
Catheter thrombolysis
109
What do vertical line spike artefacts on an ECG suggest?
A pacemaker
110
What is the PESI score used for?
Indicator of mortality/prognosis following a PE
111
How long should a patient be kept on anticoagulation following a PE?
3-6 months post
112
What is the common causative organism of Rheumatic fever?
Group A strep
| [Strep Pyogenes]
113
What criteria are used to diagnose Rheumatic fever?
Modified Jones Criteria
Evidence of Strep infection + 2 major (or 1 major + 2 minor)
```
Major:
Carditis
Chorea
Polyarthritis
Subcutaneous nodules
Erythema Marginatum
```
Minor:
Fever
PR prolongation
Elevated ESR/CRP
114
True or false, patients with rheumatic fever may require lifelong antibiotics?
True. Recurrence is common.
115
What is the ECG pattern for RBBB and LBBB?
RBBB: [MaRRoW]
V1: M
V6: W
LBBB: [WiLLiaM]
V1: W
V6: M
116
What is the difference between Type A Aortic Dissection and Type B?
Type A = Ascending aorta
| Type B = Descending aorta involved.
117
How is aortic dissection managed?
Type A (ascending) = Oxygen, antihypertensives (Beta blockers), analgesia and surgical repair.
```
Type B (descending) =
Can often be managed just with blood pressure management.
```
118
Give two risk factors for aortic dissection?
Connective tissue disorder e.g. Marfan's
Long-term Hypertension
119
What is the most common cause of sudden cardiac death in young fit patients? What preventative treatment is there?
Hypertrophic Cardiomyopathy (genetic thickening of the heart)
Treatment: Beta blockers and amiodarone to reduce load on the heart and the chance of arrhythmia.
120
Give two risk factors for a DVT
```
HRT
Oral contraceptives
Cancer
Surgery
Prolonged bed rest
Smoking
Age
Pregnancy
Male
Heart failure
Clotting disorders:
- Factor V Leiden
- Protein C deficiency
```
121
What investigations would you perform in a patient you suspect of DVT?
D-Dimer test
If +ve then venous US
If -ve then unlikely DVT
122
Is D-Dimer sensitive or specific?
D-Dimer is sensitive to clot breakdown going on in the body but is not specific. Therefore, in a true DVT or PE D-Dimer should be +ve, if its -ve then its unlikely there is a clot.
123
True or false, warfarin is safe in pregnancy?
False. It is teratogenic and increases the risk of bleeding complications.
124
Give two contraindications for anticoagulants
```
Active bleeding
Recent stroke or CNS trauma (L3M)
Pregnancy
Recent surgery
Breast feeding
Malignant Hypertension
Haemophilia
```
125
How long does warfarin take to work?
Around 48 hrs
| Therefore bridging therapy is needed with LMWH.
126
What is the therapeutic range for warfarin?
2-3
127
What surgical intervention to prevent PE would be appropriate in a patient at risk of PE if anticoagulants are contraindicated?
Insertion of an IVC filter
128
What is the normal range of heart rate?
60-100
129
Give two causes of hyperlipidemia
```
Genetic
DM
Alcoholism
Obesity
Hypothyroidism
```
130
True or false, combined oral contraceptives are not advised in patients with hyperlipidemia?
True. They increase the risk of CVD.
131
What does the Q Risk score indicate?
Predicts 10 year risk of MI or Stroke.
132
At what level of QRisk score would a statin be indicated?
>10%
[Before treating, a lipid profile must be done].
133
Give two common side effects of statins
```
Physical weakness
Muscle pain
Headache
Nausea
Dizziness
```
134
True or false, statins are safe in pregnancy?
False.
They are teratogenic and are not advised in pregnancy or if breast feeding. Women of childbearing age should be warned of the risks of statins.
135
What systolic and diastolc drops in blood pressure constitute postural hypotension (orthostatic hypotension)?
Systolic drop >20mmHg
Diastolic drop >10mmHg
[Or if symptomatic]
136
How is postural hypotension tested?
Lie down 5 mins; record BP
| Stand up. Repeat at 1 & 3 mins.
137
What is the treatment for postural hypotension (orthostatic hypotension)?
Fludrocortisone (increases blood volume via salt retention) [1st line]
Midodrine [2nd line]
138
Which heart murmur can cause a malar flush?
Mitral Stenosis
139
Whatis Xanthomata a sign of?
Hyperlipidemia
140
What is radio-radial delay a sign of?
Coarctation of the aorta
Aortic Dissection
Subclavian artery stenosis
141
What is angular stomatitis associated with?
Iron Deficiency
142
What heart murmur is associarted with a slow rising pulse?
Aortic stenosis
143
What heart condition can cause a collapsing pulse?
Aortic regurgitation
| [+ Fever and pregnancy}
144
What heart condition can cause raised JVP?
Right Heart Failure
| Venous Hypertension
145
What heart condition can cause a parasternal heave?
Right Ventricular Hypertrophy
146
What heart condition causes a wide pulse pressure and what causes a narrow pulse pressure?
```
Wide = Aortic Regurgitation
Narrow = Aortic Stenosis
```
[Narrow is Narrow!]
