Cardiology Flashcards
1
Q
Ticagrelor MOA
A
- Direct acting (non-pro-drug)
- reversible
- Inhibitor of P2Y12
2
Q
Cause of ARVD and ECG changes
A
fibro-fatty infiltration of the myocardium. Mutation in desmosome genes and intercalated discs.
V1- V5 T wave inversion and epsilon waves
3
Q
Catecholaminergic Polymorphic VT gene mutation
A
RYR2 gene - defect in calcium channels - VT triggered by catecholamines
4
Q
Wolf-Parkinson white
ECG findings and defect
A
short PR interval and delta wave
due to accessory pathway
5
Q
HOCM - genetic defect and effect
A
Defect in sarcomere genes (beta myosin, troponin T)
multiple gene causes
autosomal dominant
LVH and asymmetrical septal hypertrophy
6
Q
Brugada ECG changes and gene mutation
A
SCN5A
Brugada wave - coved ST segment or saddle shaped.
7
Q
Long QT 1 gene mutation and trigger
A
K+ channels - KCNQ1 mutation
Exercise
8
Q
Long QT 2 gene mutation and trigger
A
K+ channels - HERG mutation
Noise
9
Q
Long QT 3 gene mutation and trigger
A
Na+ channel - SCN5A
Sleep
10
Q
In what phase of the cardiac action potential is the heart not refractory to a new action potential
A
phase 4
11
Q
Class 1 antiarrhythmics
A
Na+ blockers - work on phase zero
- Flecanide, Lignocaine, Procanamide, Phenytoin
12
Q
Class 2 antiarrhythmics
A
K+ equilibrium blockers - Beta blockers - work on phase 4
- propanolol, metoprolol
13
Q
Class 3 antiarrhythmics
A
K+ channel blockers - work on phase 3
- Sotalol, Amiodarone
14
Q
Class 4 antiarrhythmics
A
Ca2+ channel blockers - work on phase 2
- Verapamil, Diltiazem
15
Q
Biggest RF for CVD
A
AGE
up to 15 points on Framingham risk calculator
16
Q
Patient cohorts that would need infective endocarditis prophylaxis peri-procedure
A
- prosthetic valves/ cardiac structures
- PMHx IE
- congenital heart disease with ongoing defects
- transplanted heart with leaky valves
17
Q
Procedures needing ABx prophylaxis for infective endocarditis for high risk patient cohorts.
A
- respiratory biopsy
- dental procedures breaking the mucosa
- surgical procedure for infected skin
- cardiac surgery with prosthetic material.
ABx NOT required for GI procedures.
18
Q
Cause of hyponatremia in heart failure
A
Increased ADH.
Although oedematous patients with heart failure have increased plasma and extracellular fluid volumes, the body perceives volume depletion (reduced effective arterial blood volume) since the low cardiac output decreases the pressure perfusing the baroreceptors in the carotid sinus and the renal afferent arteriole.
19
Q
What is Pulsus paradoxus
A
Is the exaggerated drop in systemic blood pressure on inspiration.
20
Q
What is Kussmaul’s sign
A
JVP not decreasing on inspiration
21
Q
Complications of TAVI vs SAVR
A
SAVR - major bleeding and atrial fibrillation
TAVI - short-term aortic valve reintervention, pacemaker implantation, and aortic regurgitation compared with SAVR.
22
Q
Features of Acute rheumatic heart disease
A
Major criteria - JONES
Joint involvement - migratory polyarthritis
O – “O” looks like a heart shape – carditis and valvulitis
N – nodules that are subcutaneous
E – Erythema marginatum which is a rash of ring-like lesions that can start in the trunk or arms. When joined with other rings, it can create a snake-like appearance
S – Sydenham chorea is a late feature which is characterized by jerky, uncontrollable, and purposeless movements resembling twitches
Minor criteria – CAFÉ P C – CRP Increased A – Arthralgia F – Fever E – Elevated ESR P – Prolonged PR Interval
23
Q
Muscle contraction inhibitors
A
Tropomyosin - controlled by troponin.
Tropomyosin/Troponin is inactivated by high levels of Ca2+, allowing muscle contraction.
24
Q
Worst arrhythmia for prognosis in OOHCA
A
Asystole.
25
Most common cardiac abnormality occuring with coarctation of the aorta
bicuspid aortic valve.
26
NSAID with highest risk of AMI
Voltaren (Diclofenac)
27
Another name for P2Y12 drugs
Adenosine diphosphate (ADP) receptor inhibitors
28
Cause of death in cardiac transplant at 30 days, 1 year and 5 years
1. Graft failure: Primary graft failure accounts for the majority of mortality within the first 30 days after transplantation.
2. Infections are the leading single cause of death between six months to one year post-transplant.
3. Malignancy is the most frequent cause of death beginning at five years post-cardiac transplantation. malignancies (both lymphoma and solid tumors) are more common in heart compared with renal transplant recipients
29
Biggest risk factor for mortality (1 yr mortality) after cardiac transplant
1. use of a total artificial heart as a bridge to transplant,
2. end-organ support with mechanical ventilation or dialysis,
30
Drug that should be avoided when using clopidogrel
PPI's - both clopidogrel and PPIs use the same CYP2C19 pathway. Clopidogrel is a prodrug so this reduces efficacy and increases MACE.
Best PPI if required is pantoprazole.
31
Criteria for severe aortic stenosis
aortic jet velocity over ≥4.0 m/s
or mean transvalvular pressure gradient ≥40 mmHg
+/ -an aortic valve area ≤1.0 cm
may be symptomatic OR asymptomatic
32
Criteria for aortic valve replacement in ASYMPTOMATIC severe aortic stenosis
1. Symptoms on exercise testing
2. EF <50%
3. If undergoing another cardiac surgery
4. Very severe (velocity gradient > 4.5) and low procedure risk
5. If hypotensive with exercise
33
Myocardial infarction types
1. Spontaneous AMI - usually due to plaque
2. Ischaemia/ demand related
3. Assumed to be AMI - usually in the case of sudden death
4a. Post PCI
4b. post stent thrombosis
5. Post CABG
34
Branches of the Aorta
Brachiocephalic
L common carotid
L Subclavian
35
Commonest site of coarctation of the aorta
Just distal to the L Subclavian at the site of the ductus arteriosus
36
Cardiac SE of 5FU
coronary vasospasm
37
Cardio selective beta blockers
Atenolol, Metoprolol, Bisoprolol, Nebivolol.
38
Non-selective Beta blockers
Propanolol, Sotalol, Timolol, Labetalol, Carvidelol
39
Beta blockers with alpha blocker activity
Labetalol, Carvidelol
40
Which beta blocker also blocks potassium channels?
Sotalol
41
Effect of B1 inhibition
Decrease HR and contractility
Decrease AV node conduction
Block juxtaglomerular cells to reduce renin release, therefore increases water excretion to reduce BP.
42
Effect of B2 inhibition
Vasoconstriction and bronchoconstriction
Decrease intra-ocular pressure
Decrease insulin release - Increase diabetes.
Decrease liver glycogenolysis - increase hypo's
Inhibits lipase - increases hyperlipidaemia
43
Effect of B3 inhibition
Decreases lypolysis - increased weight gain.
44
When are beta blockers contra-indicated?
1. Decompensated heart failure
2. Phaeochromocytoma - need alpha blocker first
3. Sick sinus syndrome
4. cardiogenic shock
45
Function of Titin
To recoil the muscle fibres and prevent overstretching.
46
Indications for surgery in infective endocarditis
- valve dysfunction causing heart failure
- L sided IE from fungal/ highly resistant bug.
- heart block
- abscess (cardiac)
- destructive lesions
- persistant bacteremia/fevers 1 week after starting treatment.
47
Management in stable angina
Medical Mx.
Stenting is for symptomatic Mx only if medical Mx does not work, no mortality benefit.
(exception is if they have L main disease)
48
Management of stable angina with L main disease
CABG - has survival benefit.
| CABG would be the answer over PCI in L main disease.
49
Electrical alternans is seen in which condition
large pericardial effusion
50
ECG finding for cardiac amyloid
low voltage QRS
51
ECG in Takasubo
deep anterior T wave
ST elevation
Long QT
Long PR
52
Ebsteins abnormality is associated with which other cardiac condition
wolf parkinson white
53
Carcinoid syndrome causes which cardiac condition
heart failure caused by R sided valve dysfunction (hormone secreted from tumour into R heart causes valve abnormalities)
54
Treatment of RV infarct
1. IV fluids ++++
2. Dobutamine
to improve LV preload
55
Causes of falsely low BNP in heart failure
obesity
pericardial constriction
flash APO
56
When is PCI/stenting harmful?
In patients with CKD and stable angina. Causes INCREASED morbidity and mortality.
57
What is the calcium score used for?
Risk stratification. Improves mortality by accurate primary prevention interventions (aspirin + statin).
0 = no risk
1-100 = moderate risk, consider aspirin/statin
>100 = high risk - aspirin and statin for primary prevention.
58
What should be done if a patient comes in with a STEMI and has severe stenosis in a NON-culprit vessel also.
Should stent that vessel. Although this is technically a non-symptomatic occlusion, this patient has proven to be a plaque rupturer. Therefore there is benefit in stenting over medical management.
59
How urgently do OOHCA patients need to go to Cath lab?
- If ST elevation is present after defibrillation - need urgent cath lab
- If ST elevation not present - non urgent cath lab - up to 1 week.
60
Does aspirin have a benefit for patients above age 70 without specific cardiac risk factors.
No benefit
61
What is the benefit of Colchicine after AMI?
Reduced stroke risk
| Reduced recurrent angina
62
What cardiac outcome does Empagliflozin improve?
```
Heart failure (particularly HEFrEF)
All cause mortality
```
63
For a patient with an indication for anticoagulation (PE/AF/prosthetic valve), what should the medication regime be if the have a stent inserted?
Clopidogrel + anticoagulation for 12m then anticoagulation alone ongoing.
If very high risk AMI - can also add aspirin for triple therapy for the first month only.
64
When does AF ablation have a MORTALITY benefit?
If EF is <35%
65
Lifestyle factor which has significant affect on AF burden
Alcohol intake.
| Alcohol abstinence has a significant effect on reducing AF in heavy drinkers.
66
In which patients with HEFREF does ICD implantation have a mortality benefit?
Those with ischaemic cause of HEFREF
67
When is the best time for antihypertensives to be taken?
At night BEFORE bed. Has a mortality benefit.
| This is because the biggest cortisol surge occurs in the morning.
68
Emery-Dreifuss muscular dystrophy is associated with what type of cardiomyopathy and gene mutation
Dilated cardiomyopathy and Lamin A/C genes
69
Management of Long QT
Without cardiac arrest - Beta blockers. Can consider ICD only if ongoing symptoms.
Cardiac arrest - ICD
70
Management of ARVD
- Avoid high intensity exercise
- beta blocker if symptomatic
- ICD if high risk features or secondary prevention post SCA.
71
First line drug for chest pain in HOCM
Verapamil
72
Cause of stable raised troponins (no incrementation)
Chronic myocardial injury. If it is acute, then troponin will increment (up or down depending on if it is before or after the peak)
73
Stent thrombosis definitions of definite, probable and possible.
- Definite – Angiographic confirmation of a thrombus that originates in the stent or in the segment 5 mm proximal or distal to the stent, with or without vessel occlusion, which is associated with acute onset of ischemic symptoms at rest or ECG signs of acute ischemia or typical rise and fall of in cardiac biomarkers within 48 hours of angiography OR pathologic confirmation of stent thrombosis determined at autopsy or from tissue obtained following thrombectomy.
- Probable – Unexplained death occurring within 30 days after the index procedure, or an MI occurring at any time after the index procedure that was documented by ECG or imaging to occur in an area supplied by the stented vessel in the absence of angiographic confirmation of stent thrombosis or other culprit lesion.
- Possible – Unexplained death occurring more than 30 days after the index procedure.
74
Benefit of the new generation drug eluting stents
Reduced "very late" stent thrombosis
75
Biggest RF for in stent thrombosis
improper use of antiplatelets
76
Difference between stent types for stent thrombosis
BMS - more late stent thrombosis (1 m-12 m)
1st Gen DES - more very late stent thrombosis
2nd Gen DES - no data
77
Stent thrombosis categories (by time frame)
Acute - 24hrs
Sub acute - 24hrs - 30 days
Late - 30days - 1yr
Very late - >1yr
78
which layer of the coronary artery does artherosclerosis affect?
intima and media
79
Management of antiplatelets with stents and surgery
If within 1 year:
- postpone elective surgeries
- emergency surgeries - complete on DAPT if able.
- If unable, complete on aspirin alone then recommence 2nd agent immediately after
If after 1 year
- complete on aspirin alone if able.
80
Cardiac side effect of Propofol
decreased contractility
81
LDL aims based on risk score
very high CV risk - LDL <1.8 mmol/L
high risk <2.5 mmol/L
moderate risk,<3 mmol/L
82
How much does lowering the LDL by 1 improve outcomes
reduces mortality by 21%
83
Features of vulnerable plaques (3)
1. positive remodelling
2. low-attenuation plaque (soft plaque)
3. spotty calcification
84
Heart failure drugs to avoid in HEFREF
diltiazem, verapamil and moxonidine
85
Indications for angiogram prior to mitral valve surgery
- Patients with angina, objective evidence of ischemia, decreased left ventricular systolic function, or a history of coronary disease.
- In patients at risk for coronary disease, including men >40 years old and postmenopausal women with high pretest likelihood of cardiovascular disease.
86
Indications for Mitral valve surgery over percutaneous mitral balloon valvotomy.
- Suboptimal valve anatomy for PMBV such as severe valve leaflet thickening/calcification/immobility with subvalvular fibrosis
- Left atrial thrombus that persists despite anticoagulation
- Concomitant moderate to severe mitral regurgitation
- Concomitant severe tricuspid regurgitation
87
Drugs for heart failure
```
ACEi, ARB, ARNI
Beta blockers
Diuretics
Ivabradine
Hydralazine
```
88
Drugs for angina
```
Beta blockers
Ca channel blockers
Nitrates
Nicorandil- potassium channel activator
Perhexiline - high hepatotoxicity
Ivabradine - in co-existing heart failure only
```
89
MOA Hydralazine and SE
MOA: Direct vasodilation of arterioles with decreased systemic resistance. occur via inhibition of calcium release from the sarcoplasmic reticulum and inhibition of myosin phosphorylation in arterial smooth muscle cells.
SE: rebound tachycardia, rebound hypertension
90
When to do a flecanide challenge
When Brugada is suspected - unmasks type 1 ECG findings (saddle back), if only type 2 findings can be seen at rest
91
Most common ASD
Ostium secundum
92
Takasubo features (3)
1. New ECG changes (ST elevation or T wave inversion) or moderate troponin rise.
2. Transient akinesis / dyskinesis of left ventricle (apical and mid-ventricular segments) with regional wall abnormalities extending beyond a single vascular territory.
3. Absence of coronary artery stenosis >50% or culprit lesion.
93
Biggest RF for stroke in AF
1. Valvular AF
2. Age >65
3. Prior stroke/ TIA
94
Can heart/lung transplants be done in HCV positive donors?
Yes - antiviral treatment for 4 weeks prevents HCV infection
95
Benefit of early cardioversion in new symptomatic AF
No benefit - was found that delayed cardioversion was non-inferior to early cardioversion in terms of percentage in sinus rhythm at 4 weeks.
96
MOA of inclisiran
Works on PCSK9 to reduce LDL - however unlike evolucumab which works directly on the protein, inclisiran works as a small interfering RNA to prevent translation of the protein.
97
Difference between rate control and rhythm control for early AF
rhythm control has lower AF related adverse outcomes.
