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MRCP > Cardiology > Flashcards

Cardiology Flashcards

1
Q

Effect of inspiration on JVP?

A

causes JVP to fall. - inspiration generates negative intrathoracic pressure + suction of venous blood towards the heart

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2
Q

what causes the normal a wave in JVP waveform?

A

due to right atrial contraction

  • peak of a wave demarcates end of atrial systole
  • actively pushes up into SVC
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3
Q

what causes the c wave in the normal JVP waveform?

A
  • corresponds to closure of the tricuspid valve, bulging towards the R atrium during the start of ventricular systole
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4
Q

what causes the x descent in the normal JVP waveform?

A
  • corresponds to atrial relaxation, stretch and rapid atrial filling due to drop in pressure
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5
Q

what causes the v wave in the normal JVP waveform?

A

due to passive filling of venous blood into the atrium against a closed tricuspid valve

  • occurs during and following the carotid pulse
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6
Q

what is the y descent in the normal JVP waveform?

A
  • opening of the tricuspid valve with passive movement of blood from R atrium into the R ventricle
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7
Q

causes of raised JVP with normal waveform?

A
  • Heart failure: biventricular or isolate R HF
  • fluid overload of any cause
  • severe bradycardia
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8
Q

Causes of Kussmaul’s sign?

A

kussmaul’s sign: raised JVP on inspiration and drops with expiration

  • implies R heart chambers cannot increase in size to accommodate increased venous return
  • due to pericardial disease (constriction) or fluid in pericardial space (pericardial effusion and cardiac tamponade)
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9
Q

Causes of Raised JVP with loss of normal pulsations?

A

SVC syndrome

  • obstruction caused by mediastinal malignancy such as bronchogenic malignancy -> head, neck, arm swelling
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10
Q

causes of absent a waves in JVP?

A

atrial fibrilation

  • no coordinated atrial contraction
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11
Q

causes of large a waves in JVP?

A

Tricuspid stenosis, right heart failure, pulmonary hypertension

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12
Q

Causes of cannon a wave in JVP?

A

caused by AV dissociation - allowing atria and ventricles to contract at same time

  • atrial flutter, atrial tachycardias
  • complete heart block
  • ventricular tachycardia, ventricular ectopics
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13
Q

causes of giant v waves in JVP?

A

tricuspid regurgitation

  • increased RA volume during ventricular systole causes prominent v wave
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14
Q

causes of steep x descent and diminished y descent in JVP?

A

cardiac tamponade

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15
Q

causes of steep y descent in JVP?

A

cardiac constriction e.g. constrictive pericarditis

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16
Q

cause of slow y descent in JVP?

A

tricuspid stenosis

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17
Q

causes of absent radial pulse?

A
  • iatrogenic: post catheterisation or art line
  • Blalock-Taussig shunt for Congen heart disease, eg TOF
  • Aortic dissection with subclavian involvement
  • trauma
  • Takayasu’s arteritis
  • peripheral arterial embolus
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18
Q

causes of collapsing pulse?

A

aortic regurg

AV fistula

patent ductus arteriosus

or other large extracardiac shunt

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19
Q

causes of slow rising pulse?

A

aortic stenosis

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20
Q

causes of jerky radial pulse?

A

HOCM

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21
Q

cause of bisferiens radial pulse?

A

double shudder due to mixed aortic valve disease w significant regurgitation

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22
Q

causes of pulsus alternans?

A

severe LV dysfunction

  • pulses alternate from weak to strong
  • EF reduced meaning that end diastolic volume is elevated -> may sufficiently stretch the myocytes to improve EF of next heart beat
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23
Q

causes of pulsus paradoxus?

A
  • excessive reduction in pulse with inspiration
  • LV compression, tamponade, constrictive pericarditis or severe asthma

where venous return is compromised

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24
Q

Causes of absent apical impulse?

A
  • obesity/ emphysema
  • pericardial effusion/ constriction
  • dextrocardia
  • right pneumonectomy with displacement
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25
Q

cause of heaving apical impulse?

A

LVH

+/- fourth HS

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26
Q

cause of thrusting/ hyperdynamic apical impulse?

A

high LV volume e.g. Mitral regurg, aortic regurg, PDA, VSD

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27
Q

tapping apex beat?

A

palpable first heart sound in mitral stenosis

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28
Q

displaced/ dyskinetic apex beat?

A

LV impairment and dilation

e.g. dilated cardiomyopathy, MI

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29
Q

pericardial knock?

A

constrictive pericarditis

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30
Q

double impulse apex beat?

A

with dyskinesia: LV aneurysm

without dyskinesia: HOCM

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31
Q

parasternal heave?

A

RVH

e.g. Pulmonary hypertension, ASD, COPD, pulmonary stenosis

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32
Q

palpable third HS?

A

due to HF / severe mitral regurg

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33
Q

Poor prognostic factors in ACS?

A
  • age
  • development (or hx of) heart failure
  • peripheral vascular disease
  • reduced systolic BP
  • Killip class
  • initial serum [Cr]
  • elevated trop
  • cardiac arrest on admission
  • ST segment deviation
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34
Q

Medications to continue post MI?

A

ACEi + BB

Statin

Aspirin lifelong

Clopidogrel for 1 year

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35
Q

What additional medication to add to patients who have had an acute MI and who have symptoms +/- signs of heart failure and LV systolic dysfunction?

A

Spironolactone

  • initiated within 3-14 days of the MI, preferably after ACEi therapy
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36
Q

In an MI, what is the first cardiac enzyme to rise?

A

Myoglobin

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37
Q

What cardiac enzyme is most useful to look for reinfarction?

A

CK-MB

  • as it returns to normal after 2-3 days post MI

(Trop T remains elevated for up to 10 days)

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38
Q

Causes of ST elevation?

A

STEMI

acute pericarditis

early repolarization/ high take off

coronary artery spasm

ventricular aneurysm

oesophageal spasm

cardiac contusion

acute cerebral injury

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39
Q

What is the latest cardiac enzyme to rise post MI?

A

LDH

  • peaks at 72 hours
  • starts at 24-48h
  • returns to normal after 8-10 days
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40
Q

Trop vs CK-MB as markers in MI?

A

Troponin is not related to infarct size

CK is directly proportional

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41
Q

What vaccines should be offered to those with heart failure?

A

annual influenza

+

once off pneumococcal

vaccine

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42
Q

management of poorly controlled heart failure despite medical management + broad QRS complex?

A

Cardiac resynchronisation therapy

ie. biventricular pacing

*insertion of electrodes in the L + R ventricles, as well as on occasion the right atrium, to treat HF by coordinating the function of the ventricles via a pacemaker

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43
Q

Ix of Constrictive pericarditis?

A

Echo - thickened pericardium, pericardial effusion, constrictive physiology

CT -

can reveal a calcified pericardium

Right + Left heart catheterisation -

ventricular inter-dependence

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44
Q

Most likely cause of calcification with constrictive pericarditis?

A

prior TB infection

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45
Q

Management of constrictive pericarditis?

A

very difficult to manage

  • medical management for CCF
  • surgical: ‘pericardial stripping’
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46
Q

causes of pericardial effusion?

A

Acute pericarditis

all causes of constrictive pericarditis

aortic dissection

iatrogenic due to pacing/ cardiac cath (rare)

ischaemic heart disease with ventricular rupture (rare)

anticoag assoc w acute pericarditis

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47
Q

Differences in JVP character in cardiac tamponade vs constrictive pericarditis?

A

tamp:

absent Y descent

constrictive pericarditis:

x + y present.

y steep

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48
Q

pulsus paradoxus in cardiac tamp vs constrictive pericarditis?

A

pulsus paradoxus present in cardiac tamponade , absent in constrictive pericarditis

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49
Q

what is the strongest risk factor for developing infective endocarditis?

A

previous episode of IE

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50
Q

risk factors of IE?

A

normal valves (50%, typically acute presentation)

rheumatic valve disease (30%)

prosthetic valves

congenital heart defects

IVDU

immunocompromise

instrumentation

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51
Q

what organism is assoc with colorectal cancer (in infective endocarditis)?

A

Strep bovis

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52
Q

what infective endocarditis organism is most assoc with IVDU/ acute presentations?

A

staph aureus

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53
Q

what infective endocarditis organism is assoc w prosthetic valves?

A

staph epidermidis

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54
Q

most common cause of subacute IE?

A

strep viridans

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55
Q

what are some other causes of infective endocarditis?

A

SLE - libman-sacks

malignancy: marantic endocarditis
- which has platelet- fibrin thrombi prone to embolising

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56
Q

Culture negative causes of infective endocarditis?

A

prior abx therapy

coxiella burnetii

bartonella

brucella

HACEK: haemophilus, actinobacillus, cardiobacterium, eikenella, kingella - slow growing

non-infective

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57
Q

What is the most common cause of IE following prosthetic valve surgery?

A

Staph epidermidis

  • most common in the first 2 months
  • usually the result of periop contamination
  • late endocarditis 2 years post surgery might be strep viridans
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58
Q

Modified Duke criteria for IE?

A
  • 2 major,

1 major + 3 minor

5 minor

or pathological criteria is positive:

  • postive histology/ microbiology of pathological material obtained at autopsy/ cardiac surgery
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59
Q

Major criteria in IE?

A

Positive Blood cultures:

  • 2 positive cultures showing typical organisms e.g. Strep viridans/ HACEK
  • 3 or more cultures where pathogen less specific e.g. staph aureus/ staph epidermidis
  • positive seriology for Coxiella burnetii, bartonella, chlamydia
  • positive molecular assays for specific gene targets

evidence of endocardial involvement:

positive echo

e.g. mobile masses, abscess formation, new valvular regurg/ dehiscence of prosthetic valves

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60
Q

Minor criteria for IE?

A

predisposing heart condition or intravenous drug use

microbiological evidence does not meet major criteria

fever > 38ºC

vascular phenomena: major emboli, splenomegaly, clubbing, splinter haemorrhages, Janeway lesions, petechiae or purpura

immunological phenomena: glomerulonephritis, Osler’s nodes, Roth spots

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61
Q

poor prognostic features in IE?

A
  • staph aureus infection
  • prosthetic valve
  • culture negative endocarditis
  • low complement levels
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62
Q

Indications for surgery in IE?

A
  • severe valvular incompetence
  • aortic abscess (often indicated by a lengthening PR interval)
  • infections resistant to abx/ fungal infections
  • HF refrac to standard medical tx
  • recurr emboli after abx therapy
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63
Q

most common causes of restrictive cardiomyopathy?

A

amyloidosis

idopathic myocardial fibrosis (freq after a heart transplant)

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64
Q

causes of restrictive cardiomyopathy?

A

idiopathic fibrosis

amyloid

carcinoid

sarcoid

haemochromatosis

rare - endomyocardial fibrosis, Loeffler’s syndrome

scleroderma

neoplasms of heart

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65
Q

symptoms of restrictive cardiomyopathy?

A

symptoms of HF usually develop slowly

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66
Q

features of aortic stenosis?

A

narrow pulse pressure

slow rising pulse

ESM radiating to carotids

soft/ absent S2

LV heave

CCF

pulmonary HTN

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67
Q

causes of aortic stenosis?

A

degenerative calcification (most common in elderly)

bicuspid aortic valve (most common in young)

rheumatic valve disease

William’s syndrome (supravalvular AS)

Subvalvular: HOCM

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68
Q

Echo findings in Aortic stenosis?

A
  • Valve area (Mild >1.5cm2, mod: 1-1.5, severe: <1cm2)
  • transvalvular gradient (severe >50mmHg)
  • LVH
  • LV dysfunction and Pulmonary HTN in advanced disease
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69
Q

what is classified as severe AS according to echo findings of valve area?

A

severe = <1cm2

mild = >1.5

mod = 1- 1.5

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70
Q

what transvalvular gradient in echo demonstrates severe Aortic stenosis?

A

>50 mmHg

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71
Q

When to surgically treat Aortic stenosis?

A

symptomatic: chest pain/ SOB/ syncope/ CCF

AND/or

prognostic (severe AS on echo, LV dysfunction on echo, pulmonary hypertension on echo)

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72
Q

indications for aortic valve replacement in aortic regurg?

A

symptomatic

or

progressive LV dilatation

or

systolic ventricular diameter >55 mm on echo

or

immediately if acute

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73
Q

If Onset >48h + wanting to cardiovert someone in AF?

A
  • should have therapeutic anticoag for at least 4 wks before
  • following electrical cardioversion, anticoag for at least 4 wks
  • if high risk of cardioversion failure (e.g. recurrence) -> at least 4 wks of amiodarone or sotalol prior to electrical cardioversion
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74
Q

pharmacological cardioversion of AF?

A

amiodarone

  • if structural heart disease

flecainide

  • if NO structural heart disease
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75
Q

ECG findings of hypotehermia?

A

bradycardia

J waves - small hump at end of QRS

first degree HB

long QT

atrial/ ventricular arrhythmias

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76
Q

causes of a prolonged PR interval?

A

idiopathic

ischaemic heart disease

digoxin toxicity

hypokalaemia*

rheumatic fever

aortic root pathology e.g. abscess secondary to endocarditis

Lyme disease

sarcoidosis

myotonic dystrophy

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77
Q

causes of short PR interval?

A

pre-excitation:

wolff parkinson white

low-ganong-levine

other:

AV junctional rhythm

ventricular extrasystole after P wave

low atrial rhythm

coronary sinus escape rhythm

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78
Q

associations of wollf-parkinson-white?

A

HOCM

mitral valve prolapse

Ebstein’s anomaly

thyrotoxicosis

secundum ASD

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79
Q

what drug should NOT be used in VT?

A

Verapamil

  • Verapamil may cause fatal hypotension in VT

due to negative inotropic and peripheral vasodilatory effects

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80
Q

management of VT if drug therapy fails?

A

elecrophysiological study

Implantable cardioverter-defibrillator- esp if significantly impairved LV fn

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81
Q

features of broad complex tachy consistent w VT?

A

RBBB + LAD

very wide QRS

chest lead concordance

p wave dissociation

capture beats

fusion beats

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82
Q

most common cause of VT?

A

ischaemic heart disease

most commonly through scar-related VT from prev infarct

or acute MI with VT

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83
Q

causes of Long QT syndrome - congenital?

A

Jervell-Lange-Nielson syndrome:

deafness + long QT

Romano-Ward: QT prolongation + T wave abnormalities

  • most common

Brugada syndrome: may present w sudden cardiac death

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84
Q

deafness + long QT?

A

Jervell-Lange-Nielsen

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85
Q

most common cause of congenital Long QT syndrome?

A

Romano-Ward syndrome

  • affects 1 in 7000
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86
Q

Drugs that cause Long QT?

A

Amiodarone

Sotalol

TCAs

chloroquine

class 1a antiarrhythmics: quinidine, procainamide

terfenadine

erythromycin

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87
Q

what intracranial abnormalities cause long QT?

A

subarachnoid haemorrhage

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88
Q

Management of Long QT?

A

Beta blockers

e.g. propranolol, nadolol

metoprolol, atenolol

if high risk: ICD

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89
Q

Ejection systolic murmur feature of HOCM?

A

ESM increases with valsalva and decreases on squatting

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90
Q

features of HOCM on echo?

A
  • systolic anterior motion of the anterior mitral valve leaflet
  • LVH, with asymmetric septal hypertrophy
  • mitral regurg
  • elevated gradient across the LV outflow tract
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91
Q

ECG findings in HOCM?

A

left ventricular hypertrophy

non-specific ST segment and T-wave abnormalities, progressive T wave inversion may be seen

deep Q waves

atrial fibrillation may occasionally be seen

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92
Q

findings of holter monitoring in HOCM?

A

non sustained VT

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93
Q

poor prognostic factors of HOCM?

A

syncope

family history of sudden death

young age at presentation

non-sustained ventricular tachycardia on 24 or 48-hour Holter monitoring

abnormal blood pressure changes on exercise

increased septal wall thickness

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94
Q

management of HOCM?

A

Amiodarone

Beta-blockers or verapamil for symptoms

Cardioverter defibrillator

Dual chamber pacemaker

Endocarditis prophylaxis*

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95
Q

2 main complications of PCI?

A

Stent thrombosis:

most commonly in first month.

1-2%

presents with acute MI

Re-stenosis:

due to excessive tissue proliferation around stent

most commonly in 3-6 mo

5-20% of pts

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96
Q

risk factors of re-stenosis post PCI?

A

diabetes, renal impairment and stents in venous bypass grafts

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97
Q

Most important management to prevent stent thrombosis post PCI?

A

antiplatelet therapy - aspirin should be continued indefinitely

*length of clopidogrel depends on type of stent, reason for insertion and consultant preference

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98
Q

PCI:

bare metal stent

vs drug eluting stent

A

drug eluting stent - paclitaxel/ rapamycin whcih inhibits local tissue growth

  • this reduces restenosis rates

but Increases thrombosis rates (as process of stent endothelisation is slowed)

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99
Q

1st line drug prophylaxis of non-sustained VT?

A

sotalol

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100
Q

indications for ICD insertion for secondary prevention?

A
  • for those who survived cardiac arrest secondary to venticular arrhythmia
  • sustained VT w haemodynamic compromise
  • sustained VT with poor LV fn

in the absence of any identifiable cause of VF/VT

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101
Q

indications for ICD insertion in family conditions w high risk of sudden cardiac death?

A

Long QT

HOCM

Brugada syndrome

Arrhythmogenic Right Ventricular Dysplasia

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102
Q

what ix might support the diagnosis of vasovagal syncope?

A

tilt table test

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103
Q

cyanotic causes of congenital heart disease?

A

TGA

TOF

Tricuspid atresia

Pulmonary valve stenosis

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104
Q

what test can help determine management for primary pulmonary hypertension?

A

acute vasodilator testing

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105
Q

management of primary pulmonary hypertension if +ve response to acute vasodilator testing?

A

oral CCB

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106
Q

management of primary pulmonary hypertension if -ve response to acute vasodilator testing (vast majority)?

A

prostacyclin analogues: treprostinil, iloprost

endothelin receptor antagonists: bosentan, ambrisentan

phosphodiesterase inhibitors: sildenafil

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107
Q

management of secondary pulmonary HTN?

A

treating any underlying conditions

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108
Q

complications of malignant hypertension

A

can lead to cerebral oedema → encephalopathy

retinal haemorrhages

haematuria due to renal damage (benign nephrosclerosis)

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109
Q

management of choice in malignant hypertension?

A

most patients: oral therapy e.g. atenolol

if severe/encephalopathic: IV sodium nitroprusside/labetolol

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110
Q

ix of choice for patent foramen ovale?

A

Transoesophageal Echo

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111
Q

what medication might be started for postural hypotension in certain patients?

A

fludrocortisone

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112
Q

features (signs) of tricuspid regurgitation?

A
  • pan-systolic murmur
  • prominent/giant V waves in JVP
  • pulsatile hepatomegaly
  • left parasternal heave
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113
Q

Stages of Valsalva manoeuvre?

A
  1. Increased intrathoracic pressure
  2. -> reduces venous return
  3. -> Reduced preload leads to a fall in the cardiac output (Frank-Starling mechanism)
  4. fall in cardiac output
  5. Return of normal cardiac output
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114
Q

first step management after witnessed cardiac arrest (VF/VT) on a monitor?

A

up to three quick successive shocks before CPR

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115
Q

which Infective endocarditis organism is most linked with colorectal cancer?

A

Streptococcus bovis

  • subtype: Streptococcus gallolyticus
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116
Q

most common cause of Infective endocarditis?

A

staph aureus

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117
Q

STEMI criteria in ecg?

A

ECG features in ≥ 2 contiguous leads of:

  • 2.5 mm (i.e ≥ 2.5 small squares) ST elevation in V2-3 in men <40yo,

or ≥ 2.0 mm (i.e ≥ 2 small squares) ST elevation in V2-3 in men >40yo

  • 1.5 mm ST elevation in V2-3 in women
  • 1 mm ST elevation in other leads
  • new LBBB
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118
Q

first line medication to start as SVT prophylaxis in pregnancy?

A

metoprolol

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119
Q

most likely organism of IE in patient with poor dentition?

A

strep viridans

e.g. strep sanguinis

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120
Q

features of Takayasu’s arteritis?

A
  • systemic features of vasculitis e.g. fever/ malaise/ headache
  • unequal BP in upper limbs
  • carotid bruit
  • intermittent claudication
  • aortic regurgitation (~20%)
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121
Q

association of Takayasu’s arteritis?

A

renal artery stenosis

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122
Q

management of takayasu’s arteritis?

A

steroids

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123
Q

risk factors for steroid induced myopathy?

A

advanced age, female, low BMI, DM

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124
Q

Target INR for mechanical aortic valve vs mechanical mitral valve?

A

aortic: 3.0
mitral: 3.5

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125
Q

what causes false negative BNP levels?

A

obesity

+ medications e.g. diuretics, ACEi, ARBs

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126
Q

risk factors for asystole?

  • one should consider need for transvenous pacing
A
  • complete Heart block with broad complex QRS
  • recent asystole
  • Mobitz type II AV block
  • ventricular pause >3 seconds
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127
Q

irregular cardiac rhythm caused by at least 3 diff sites in the atria, which may be demonstrated by morphologically distinctive P waves

A

Multifocal atrial tachycardia

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128
Q

management of multifocal atrial tachycardia?

A

1st line: Rate limiting CCBs e.g. verapamil

  • correction of hypoxia/ electrolyte disturbances
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129
Q

DVT -> stroke

A

Patent foramen ovale

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130
Q

best investigation for PFO?

A

transoesophageal echo

  • provides superior views of the atrial septum

(preferred over TTE)

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131
Q

JVP waveform: cardiac tamponade vs constrictive pericarditis?

A

tamponade: absent Y descent

constrictive pericarditis: X + Y present

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132
Q

causes of slow rising pulse?

A

aortic stenosis

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133
Q

causes of collapsing pulse?

A

aortic regur, patent ductus arteriosus

hyperkinetic states (e.g. pregnancy, anaemia, fever, thyrotoxic)

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134
Q

Causes of pulsus paradoxus?

A
  • faint or absent pulse in inspiration
  • > tamponade, severe asthma
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135
Q

causes of pulsus alternans?

A

severe LVF

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136
Q

causes of bisferiens pulse?

A

ie. “double pulse” - 2 systolic peaks
- mixed aortic valve disease

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137
Q

management of pulmonary arterial hypertension if there is a positive response to acute vasodilator testing (ie. IV epoprostenol or inh nitric oxide)

A

oral CCB
e.g. nifedipine, diltiazem and increasingly amlodipine

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138
Q

management of pulmonary arterial hypertension if there is a NEGATIVE response to acute vasodilator testing (ie. IV epoprostenol or inh nitric oxide)

A
  • prostacyclin analogues: treprostinil, iloprost
  • endothelin receptor antagonists: bosentan, ambrisentan
  • phosphodiesterase inhibitors: sildenafil
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139
Q

management of progressive symptoms in pulmonary arterial hypertension?

A

heart-lung transplant

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140
Q

e.g.s of endothelin receptor antagonists

(used in pulm arterial HTN)

A

bosentan, ambrisentan

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141
Q

management of complete heart block secondary to inferior MI?

A

conservative management if asymptomatic / haemodynamically stable

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142
Q

Indications for a temporary pacemaker?

A
  • symptomatic/haemodynamically unstable bradycardia, not responding to atropine
  • post-ANTERIOR MI: type 2 or complete heart block*
  • trifascicular block prior to surgery
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143
Q

management of acute pericarditis?

A

NSAID + colchicine

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144
Q

Associations of Coarctation of Aorta?

A

Turner’s syndrome

bicuspid aortic valve

berry aneurysms

neurofibromatosis

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145
Q

management of SVT in patient with asthma? if vagal manouevres have failed

A

verapamil

as adenosine CI in asthma

146
Q

pulmonary hypertension.

Which one of the following is the best method for deciding upon management strategy?

A

acute vasodilator testing

147
Q

Strep gallolyticus

  • in infective endocarditis

assoc w?

A

Colorectal cancer

  • strep gallolyticus is the subtype of strep bovis
148
Q

what infective endocarditis organism is most common in the 2 months following prosthetic valve surgery/ most commonly colonize indwelling lines?

A

Staph epidermidis

149
Q

What organism is the most common cause of infective endocarditis in prosthetic valve patients >2 months post surgery?

A

staph aureus, as with everyone else

150
Q

streptococcus mitus,

streptoccocus sanguinis

assoc w?

A

poor dental hygiene/ following dental procedure

  • they are subtypes of strep viridans
  • cause IE
151
Q

What part of the ECG does S4 coincide with?

A

P wave

  • s4 is caused by atrial contraction against a stiff ventricle, occuring just before the S1 sound.
  • coincides with P wave, which represents atrial depolarisation.
152
Q

S4 heart sound assoc w?

A

aortic stenosis, HOCM, HTN

  • in HOCM, a douple apical impulse may be felt as a result of a palpable S4
153
Q

S3 heart sound assoc w?

A

LV failure e.g. dilated cardiomyopathy

constrictive pericarditis

mitral regurg

154
Q

What medications should be avoided in patients with Wolff-Parkinson White?

A

Verapamil, Digoxin

  • these might precipitate VT/ VF
155
Q

Associations of WPW?

A

HOCM

Mitral valve prolapse

Thyrotoxicosis

Ebstein’s anomaly

ASD (Secundum)

156
Q

Management of wolff parkinson white?

  • definitive
A

radiofrequency ablation of the accessory pathway

157
Q

medical management of wolff parkinson white?

A

sotalol*, amiodarone, flecainide

*sotalol should be avoided if coexistent AF as might increase rate of transmission through accessory pathway & precipitate VF.

158
Q

Echo findings in HOCM?

A

MR SAM ASH

  • Mitral regurgitation (HOCM might impair mitral valve closure)
  • systolic anterior motion (SAM) of the ant mitral valve leaflet
  • Asymmetric hypertrophy (ASH)
159
Q

Associations of HOCM?

  • conditions
A

Friedreich’s ataxia

Wolff Parkinson White

160
Q

ECG findings in HOCM?

A
  • LVH

non-specific ST segment and T-wave abnormalities, progressive T wave inversion may be seen

deep Q waves

atrial fibrillation may occasionally be seen

161
Q

yMyofibrillar hypertrophy with chaotic and disorganized fashion myocytes “disarray” and fibrosis on biopsy

A

HOCM

162
Q

1st line Ix for stable angina?

A

CT Coronary angio with contrast

163
Q

What radiotracer is used in PET (Positron Emission Tomography) scans?

A

FDG - Fluorodeoxyglucose

164
Q

What radiotracer is used in cardiac SPECT scans?

  • used to assess myocardial perfusion and myocardial viability.
A

technetium (99mTc) sestamibi

165
Q

What agents can cause stress in myocardium?

A

exercise or adenosine/ dipyridamole

166
Q

what is the valvular gradient cut off where patients with aortic stenosis should be considered for surgery?

A

if valvular gradient >40 mmHg + features such as LV systolic dysfunction

167
Q

JVP waveform in tricuspid regurgitation?

A

deep V waves

168
Q

Causes of a loud S2?

A

HTN: systemic (loud A2) or Pulmonary (loud P2)

ASD w/o pulm HTN

hyperdynamic states

169
Q

causes of a soft S2?

A

aortic stenosis

170
Q

causes of fixed split s2?

A

atrial septal defect

171
Q

Causes of a widely split S2?

A

Deep inspiration

RBBB

Pulmonary stenosis

severe mitral regurg

172
Q

Most common causes of viral myocarditis?

A

Parvovirus B19, HHV 6 now most common

used to be enteroviruses/ coxsackievirus

173
Q

MOA of fondaparinux?

A

activates antithrombin III

174
Q

MOA of dabigatran?

A

direct thrombin inhibitor

175
Q

signs of complete heart block on examination?

A

wide pulse pressure

JVP: cannon a waves

Variable intensity of S1

176
Q

management of left ventricular aneurysm?

A

anticoagulation

  • as thrombus may form within the aneurysm and increase risk of stroke
177
Q

management of SVT in asthmatics?

A

verapamil

178
Q

prevention of episodes of SVT?

A

Beta blockers

Radio frequency ablation

179
Q

Drugs to avoid in HOCM management?

A

Nitrates, ACEi, inotropes

180
Q

features of mitral stenosis?

A

mid-late diastolic murmur

loud S1, opening snap

low volume pulse

malar flush

AF

181
Q

features of severe mitral stenosis?

A

length of murmur increases

opening snap becomes closer to S2

182
Q

CXR features of mitral stenosis?

A

left atrial enlargement may be seen

183
Q

Echo findings of mitral stenosis?

A
  • cross sectional area of the mitral valve <1 cm2
184
Q

1st line managment of Stable angina?

A

BB OR a CCB

  • if CCB used alone: should be rate-limiting, ie. verapamil, diltiazem
  • if used TGT: use modified release nifedipine
185
Q

what medication is contraindicated in ventricular tachycardia?

A

verapamil

  • IV administration of CCB can precipitate cardiac arrest
186
Q

Causes of myocarditis?

A

viral: coxsackie B, HIV
bacteria: diphtheria, clostridia
spirochaetes: Lyme disease
protozoa: Chagas’ disease, toxoplasmosis

autoimmune

drugs: doxorubicin

187
Q

Ix of myocarditis?

A

Bloods: raised inflammatory markers, troponin, BNP

ECG: tachycardia, arrhythmias, ST/T wave changes including ST-segment elevation and T wave inversion

188
Q

Management of myocarditis?

A

tx underlying cause

supportive tx of HF/ arrhythmias

189
Q

What is the most important factor assoc w risk of sudden death in the first six months after MI?

A

Presence of new systolic Heart failure

  • up to 10x more likely to die
190
Q

adenosine:

which medications enhance vs reduces the effect?

A

DEAR

Dipyridamole - enhances

Aminophylline - reduces

191
Q

Definition for HTN in pregnancy?

A

systolic > 140 mmHg or diastolic > 90 mmHg

or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic

192
Q

concurrent use of which drug might make clopidogrel less effective?

A

PPIs - omeprazole, esomeprazole

*lansoprazole seems okay

193
Q

genetics of arrhythmogenic right ventricular cardiomyopathy? (ARVC)

A

Auto dominant

  • right ventricular myocardium replaced by fatty and fibrofatty tissue
194
Q

ECG findings in ARVC (arrhythmogenic RV cardiomyopathy)?

A

V1-3 abnormalities, typically TWI.

  • epsilon wave found in 50% - terminanl notch in QRS complex
195
Q

Echo findings in ARVC (Arrhythmogenic RV cardiomyopathy)?

A

may show enlarged, hypokinetic RV with a thin free wall

196
Q

MRI findings in ARVC (Arrhythmogenic RV cardiomyopathy)?

A

useful to show fibrofatty tissue

197
Q

Management of ARVC (arrhythmogenic RV cardiomyopathy)?

A

sotalol (anti-arrhythmic)

catheter ablation to prevent VT

Implantable Cardioverter-defibrillator

198
Q

Features of Naxos disease?

A
  • auto recess variant of ARVC
  • triad of ARVC + palmoplantar keratosis + woolly hair
199
Q

2nd line anti-hypertensive for Black african or Afro-Caribbean pt who is already on CCB?

A

Angiotensin receptor blocker

200
Q

empirical treatment for native valve infective endocarditis?

A

IV amoxicillin + gentamicin

-> if pen allergic/ MSRA/ severe spesis: vancomycin + gentamicin

201
Q

empiric management of infective endocarditis in patients with prosthetic valve?

A

IV vancomycin + rifampicin + gentamicin

202
Q

management of native valve endocarditis caused by staphylococcus?

A

Flucloxacillin

If penicillin allergic or MRSA:

vancomycin + rifampicin

203
Q

management of

Prosthetic valve endocarditis caused by staphylococci

A

flucloxaciliin + rifampicin + gentamicin

if Pen allergic/ MSRA:

vancomycin + rifampicin + gentamicin

204
Q

Management of infective endocardits caused by streptococci?

A

if fully sensitive Ie. viridans: Benzylpenicllin

If less sensitive: Benzylpenicllin + gentamicin

if MSRA/ pen allergic: vancomycin + gentamicin

205
Q

Indications for surgery in infective endocarditis?

A

severe valvular incompetence

aortic abscess (often indicated by a lengthening PR interval)

infections resistant to antibiotics/fungal infections

cardiac failure refractory to standard medical treatment

recurrent emboli after antibiotic therapy

206
Q

MOA of dipyridamole?

A

inhibits phosphodiesterase -> elevates platelet cAMP levels -> reduces intracellular calcium lvls

  • increases cellular uptake of adneosine
  • inhibits thromboxane synthase
207
Q

MOA of clopidogrel/ ticagrelor?

A

ADP receptor antagonist

  • PGY12 receptor inhibitor
208
Q

MOA of aspirin?

A

COX inhibitor

209
Q

MOA of tirofiban/ abciximab?

A

gpIIb/IIIa inhibitor

210
Q

Management of severe mitral stenosis?

A

percutaneous mitral commissurotomy

211
Q

ICD + HGV drivers license?

A

permanent bar

212
Q

what conditions cause Eisenmenger’s?

A

VSD

ASD

PDA

note TOF does not cause eisenmengers as it is a R-> L shunt

213
Q

Type A aortic dissection: what is the target systolic BP

A

100-120 mmHg

214
Q

Electrical cardioversion is synchronised to which part of the ECG QRS complex?

A

R wave

  • to minimize the risk of inducing VF
215
Q

CXR findings of Transposition of great arteries?

A

“egg on side” or “egg on a string” appearance

216
Q

ejection systolic murmurs which are louder on inspiration?

A

atrial septal defect

Pulmonary stenosis

217
Q

rate limiting agent for AF if coexistent heart failure?

A

Digoxin

218
Q

management of INR 5-8, no bleeding?

A

Withhold 1 or 2 doses of warfarin
Reduce subsequent maintenance dose

219
Q

management of INR 5-8, minor bleeding?

A

stop warfarin

IV Vit K 1-3mg

Restart when INR <5.0

220
Q

Management of INR >8.0, no bleeding?

A

Stop warfarin

Vit K 1-5mg PO

Recheck INR after 24h +/- repeat Vit K

Restart when INR <5.0

221
Q

management of INR >8.0, with minor bleeding?

A

stop Warfarin

Give Vit K 1-3mg IV

Recheck INR after 24h +/- rpt Vit K

Restart warfarin when INR <5.0

222
Q

management of major bleeding and high INR?

A

stop warfarin

give IV Vit K 5mg

Prothrombin complex concentrate +/- FFP

223
Q

management of uraemic pericarditis?

A

haemodialysis

224
Q

Bundle branch blocks/ Hemi blocks: Which side axis deviation?

A

LBBB = LAD

Left anterior hemiblock = LAD

Left posterior hemiblock = RAD

225
Q

What types of MI correspond to which side axis deviation?

A

Inferior MI = LAD

Lateral MI = RAD

226
Q

Wolff-Parkinson-White: which side accessory pathway corresponds to which side axis deviation?

A

right sided accessory pathway = LAD

left sided accessory pathway = RAD

227
Q

hyperkalaemia may cause what side axis deviation?

A

LAD

228
Q

ASD, what type corresponds to which type of axis deviation?

A

ostium primum ASD = LAD

ostium secundum ASD = RAD

229
Q

features of coarctation of aorta?

A

infancy: heart failure
adult: HTN

radio-femoral delay

mid systolic murmur, maximal over back

apical click from aortic valve

notching of the inferior border of the ribs (due to collateral vessels) in adults

230
Q

Coarctation of the aorta associations?

A

Turner’s syndrome

bicuspid aortic valve

berry aneurysms

neurofibromatosis

231
Q

ECG features of hypokalaemia

A

U waves

small or absent T waves (occasionally inversion)

prolong PR interval

ST depression

long QT

232
Q

neprilysin inhibitor, sacubitril

  • MOA in heart failure?
A

prevents the degradation of natriuretic peptides such as BNP and ANP.

BNP acts to promote natriuresis and vasodilation. Atrial stretch leads to the production of ANP which has similar biological properties to BNP.

ANP & BNP are inactivated by a membrane bound endopeptidase, neprilysin.

233
Q

poor prognostic factors in infective endocarditis?

A

Staphylococcus aureus infection

prosthetic valve (especially ‘early’, acquired during surgery)

culture negative endocarditis

low complement levels

234
Q

Jvp: cannon waves?

A

Regular cannon waves:

  • VT (with 1:1 ventricular- atrial conduction)
  • AVNRT

irregular:

complete heart block

235
Q

dilated cardiomyopathy: may be caused by which vitamin deficiency?

A

selenium

thiamine (wet beri beri)

236
Q

Histological findings in rheumatic heart disease?

A

Aschoff bodies (granuloma with giant cells)

Anitschkow cells (enlarged macrophages with ovoid, wavy, rod-like nucleus)

237
Q

pathogenesis of rheumatic heart disease?

A
  • strep pyogenes infection
  • molecular mimicry
  • antibodies against M protein cross-react with myosin and smooth muscle of arteries
238
Q

Diagnosis of rheumatic fever?

A

Evidence of recent strep infection

(Raised streptococci abs, +ve throat swab, +v strep antigen test)

+

2 major / 1 major + 2 minor criteria

239
Q

major criteria in rheumatic heart disease?

A

erythema marginatum

sydenhams chorea

polyarthritis

pancarditis - carditis, valvulitis

subcutaneous nodules

240
Q

minor criteria of rheumatic fever?

A

raised ESR or CRP

pyrexia

arthralgia (not if arthritis a major criteria)

prolonged PR interval

241
Q

management of rheumatic fever?

A

oral Pen V

NSAIDs 1st line anti-inflammatory

Tx complications

242
Q

following electrical cardioversion for AF, how long should patients be anticoagulated for if AF onset was more than 48h ago?

A

At least 4 wks

243
Q

if there is a high risk of cardioversion failure, what should be given to patients in addition to electrical cardioversion for AF?

A

At least 4 wks amiodarone or sotalol prior to electrical cardioversion

244
Q

dental procedures in pts on warfarin - what to do?

A

check INR 72 hours before procedure, proceed if INR < 4.0

245
Q

features of eisenmenger’s syndrome

A

original murmur may disappear

cyanosis

clubbing

right ventricular failure

haemoptysis, embolism

246
Q

Causes of eruptive xanthoma

A

Eruptive xanthoma are due to high triglyceride levels and present as multiple red/yellow vesicles on the extensor surfaces (e.g. elbows, knees)

familial hypertriglyceridaemia

lipoprotein lipase deficiency

247
Q

causes of

Tendon xanthoma, tuberous xanthoma, xanthelasma

A

familial hypercholesterolaemia

remnant hyperlipidaemia

248
Q

Management of xanthelasma?

A

surgical excision

topical trichloroacetic acid

laser therapy

electrodesiccation

249
Q

Causes of palmar xanthoma?

A

remnant hyperlipidaemia

may less commonly be seen in familial hypercholesterolaemia

250
Q

Causes of Aortic regurgitation due to valve disease?

A

rheumatic fever

infective endocarditis

connective tissue diseases e.g. RA/SLE

bicuspid aortic valve

251
Q

Causes of aortic regurgitation due to aortic root disease?

A

aortic dissection

spondylarthropathies (e.g. ankylosing spondylitis)

hypertension

syphilis

Marfan’s, Ehler-Danlos syndrome

252
Q

What is the main reason for checking the urea and electrolytes prior to commencing a patient on amiodarone?

A

to detect hypoK.

-> coexistent hypoK significantly increases the risk of arrhythmia

253
Q

Causes of widely split S2?

  • NOTE S2 is caused by closure of Aortic valve followed by pulmonary
A

deep inspiration

RBBB

pulmonary stenosis

severe mitral regurgitation

254
Q

Causes of a reversed (paradoxical) split S2 (P2 occurs before A2)?

A

LBBB

severe aortic stenosis

right ventricular pacing

WPW type B (causes early P2)

patent ductus arteriosus

255
Q

Cause of fixed split S2?

A

ASD

256
Q

features of severe aortic stenosis

A

narrow pulse pressure

slow rising pulse

delayed ESM

soft/absent S2

S4

thrill

duration of murmur

left ventricular hypertrophy or failure

257
Q

management of patent ductus arteriosus?

A

indomethacin

258
Q

Ix of choice for aortic dissection in patients who are too risky to take to CT scanner?

A

Transoesophageal echo

259
Q

what medication used in ACS treatment might cause dyspnoea several days after?

A

Ticagrelor - related dysponea

  • transient, generally within 1st wk
  • due to impaired clearance of adenosine
260
Q

Contraindications to prasugrel use?

A

prior stroke/ TIA

high risk of bleeding

prasugrel hypersensitivity

261
Q

Contraindications to ticagrelor use?

A

high risk of bleeding (ie. Prev intracranial haemorrhage, liver dysfunction)

use in caution in asthma/ COPD as higher rates of ticagrelor- assoc dyspnoea

262
Q

Associations of Ebstein’s Anomaly?

A

WPW syndrome

PFO or ASD in ~80%

263
Q

Features of Ebstein’s Anomaly?

A

cyanosis

prominent A wave in the distended JVP

hepatomegaly

Tricuspid regurg

RBBB -> widely split S1 and S2

264
Q

causes of ST depression on ECG?

A

secondary to abnormal QRS (LVH, LBBB, RBBB)

ischaemia

digoxin

hypokalaemia

syndrome X

265
Q

Stent thrombosis in PCI: what is the biggest risk factor?

A

withdrawal of antiplatelets

  • aspirin indefinitely, length of clopi depends on type of stent, reason for insertion and consultant preference
266
Q

Risk factors for restenosis post PCI?

A
  • usually in first 3-6 mo due to excessive tissue proliferation around stent
  • T2DM
  • renal impairment
  • stents in venous bypass grafts
267
Q

Effects of BNP?

A

vasodilator

diuretic and natriuretic

suppresses both sympathetic tone and the renin-angiotensin-aldosterone system

268
Q

PCI: drug eluting stents

  • effect on duration of clopidogrel therapy?
A

drug-eluting stents-> require a longer duration of clopi

as restenosis rates are reduced, but stent thrombosis rates are increased with drug eluting stents

269
Q

What is the most accurate investigation to measure LV function?

A

MUGA

Multi Gated Acquisition Scan,

aka radionuclide angiography

270
Q

SE of nicorandil?

A

headache

flushing

skin, mucosal and eye ulceration

gastrointestinal ulcers including anal ulceration

271
Q

Contraindication of nicorandil?

A

LVF

272
Q

In TIA secondary to AF, when to start anticoagulation?

A

CT head to rule out cerbreal haemorrhage/ infarct

-> start anticoagulation therapy asap

273
Q

Heart failure + driving?

A

if symptomatic -> NO group 2 license

if on asymptomatic, LVEF<40% -> NO group 2 license

group 1 license okay

274
Q

What investigations are most useful in predicting symptomatic response to cardiac resynchronisation therapy?

A

TTE and ECG

  • Those with LVEF <35% and a LBBB (QRS duration greater than 120 ms) on ECG are excellent candidates for CRT (biventricular pacing).
  • The echo will show asynchronous contraction of the LV and RV and subsequently reduced ejection fraction.
275
Q

thiazide diuretics: what common adverse effects?

A

dehydration, postural hypotension

hypoNa, hypoK, hyperCa*

gout

impaired glucose tolerance

impotence

276
Q

thiazide diuretics: rare side effects?

A

thrombocytopaenia

agranulocytosis

photosensitivity rash

pancreatitis

277
Q

Where is the most common site for primary cardiac tumours to occur in adults?

A

at the fossa ovalis border in the left atrium

278
Q

congenital heart defects associated with a bicuspid aortic valve

A

coarctation of the aorta

279
Q

features of bicuspid aortic valve?

A
  • eventually -> AS/ AR
  • assoc w left dominant coronary circulation (the posterior descending artery arises from the circumflex instead of the RCA) and Turner’s syndrome
  • 5% have coarctation of aorta
280
Q

Complications of Bicuspid aortic valve

A

aortic stenosis/ regurgitation

higher risk for aortic dissection and aneurysm formation of the ascending aorta

281
Q

What is the most important ECG change to monitor for in Infective endocarditis of aortic valve?

A

prolonged PR interval - aortic root abscess

282
Q

classical presentation of pulmonary hypertension

A

progressive exertional dyspnoea

283
Q

when to start statin?

A
  • ALL with cardiovascular disease (stroke, TIA, ischaemic heart disease, peripheral arterial disease)
  • 10 year QRISK >=10%
  • T1DM + diagnosed more than 10 yrs ago OR >40 OR established nephropathy
284
Q

RF for myopathy with statins?

A

advanced age, female sex, low BMI and presence of multisystem disease such as diabetes mellitus.

  • more common with simvastatin/ atorvastatin
285
Q

What should be monitored while on IV MgSo4 for pre-eclampsia?

A

urine output, reflexes, Resp rate, oxygen sats

  • resp depression can occur
286
Q

1st line mx of Respiratory depression secondary to IV MgSO4

A

Calcium. gluconate

287
Q

pathophysiology of cholesterol embolisation?

A

cholesterol emboli may break off causing renal disease

the majority of cases are secondary to vascular surgery or angiography. Other causes include severe atherosclerosis, particularly in large arteries such as the aorta

288
Q

BP target in age <80

A

Clinic: 140/90

ABPM/HBPM: 135/85

289
Q

BP target in age> 80

A

clinic: 150/90

ABPM/ HBPM: 145/ 85

290
Q

features of cardiac syndrome X?

A

angina-like chest pain on exertion

ST depression on exercise stress test

but normal coronary arteries on angiography

291
Q

Management of syndrome X?

A

nitrates may be beneficial

292
Q

ostium secundum ASD - ECG findings?

A

RBBB w RAD

293
Q

ostium primum ASD - ECG findings?

A

RBBB with LAD, prolonged PR

294
Q

Rate control in AF?

A

Beta blockers

CCB

Digoxin - preferred choice if there is coexistent heart failure

295
Q

Bleeding on rivaroxaban/ apixaban?

A

Andexenet alfa - recombinant form of fXa

296
Q

Bleeding on Dabigatran?

A

idarucizumab

  • binds and inactivates dabigatran
297
Q

JVP waveform - what corresponds to closing of the tricuspid valve?

A

c wave

298
Q

JVP waveform - what corresponds to opening of the tricuspid valve?

A

y descent

299
Q

half life

why is a loading dose used with amiodarone?

A

very long half life (20-100 days)

300
Q

Why does amiodarone have proarrhythmic effects?

A

lengthens QT interval

301
Q

Main MOA of amiodarone?

A

block K+ channels which inhibits repolarisation -> prolongs action potential

302
Q

Which part of the jugular venous waveform is associated with the fall in atrial pressure during ventricular systole?

A

x descent

303
Q

time frame for primary PCI in STEMI?

A

should be within 2 hours

if not, deliver thrombolysis within 12h onset of symptoms

304
Q

What medications should be given during PCI with radial access?

A

unfractionated heparin + bailout glycoprotein IIb/IIIa inhibitor (e.g. tirofiban)

305
Q

Drug therapy during PCI with femoral access?

A

bivalirudin (thrombin inhibitor)

with bailout glycoprotein IIb/IIIa inhibitor (e.g. tirofiban)

-

306
Q

Normal oxygen saturation levels in right atrium (RA), right ventricle (RV) and pulmonary artery (PA)

A

~70%

307
Q

normal oxygenation levels in left atrium (LA), left ventricle (LV) and aorta

A

98-100%

308
Q

Management of warfarinised patient undergoing emergency surgery?

A

give four-factor prothrombin complex concentrate 25-50 units/kg

309
Q

Management of warfarinised patient if surgery can wait 6-8 hours?

A

5mg Vit K IV

310
Q

Features suggesting VT rather than SVT with aberrant conduction

A

AV dissociation

fusion or capture beats

positive QRS concordance in chest leads

marked left axis deviation

history of IHD

lack of response to adenosine or carotid sinus massage

QRS > 160 ms

311
Q

mx of WPW + AF?

A

flecainide / procainamide

312
Q

what cardiac enzyme rises first post MI?

A

myoglobin

  • rises 1-2h post MI
313
Q

what cardiac enzyme is most useful to look for reinfarction?

A

CK-MB

  • returns to normal after 2-3 days
314
Q

curative management of Atrial flutter?

A

radiofrequency ablation of the tricuspid valve isthmus is curative for most

315
Q

ASD murmur?

A

ejection systolic murmur louder on inspiration

316
Q

Associations of Aortic Dissection?

A

hypertension: the most important risk factor

trauma

bicuspid aortic valve

collagens: Marfan’s syndrome, Ehlers-Danlos syndrome

Turner’s and Noonan’s syndrome

pregnancy

syphilis

317
Q

what medication should be avoided in the likely diagnosis of right ventricular myocardial infarct

A

nitrates

  • due to their peripheral venodilatory effects, which would reduce right ventricular filling and thus preload.
  • responsible for severe drops in systolic blood pressure and exacerbation of symptoms
318
Q

what is catecholaminergic polymorphic VT? (CPVT)

  • genetics
A

inherited cardiac disease assoc w sudden cardiac death

  • auto dominant
  • defect in RYR2 (ryanodine) receptor which is found in the muocardial sarcoplasmic reticulum - most common cause
319
Q

features of Catecholaminergic polymorphic ventricular tachycardia

A

exercise or emotion induced polymorphic VT resulting in syncope

sudden cardiac death

symptoms generally develop

320
Q

management of Catecholaminergic polymorphic ventricular tachycardia

A

Beta blockers

Implantable cardioverter-defibrillator

321
Q

what gene abnormality is seen in Brugada syndrome?

A

20-40% mutation in SCN5A gene -> encodes the myocardial sodium ion channel protein

322
Q

Management of Prinzmetal angina?

A

dihydropyridine calcium channel blocker e.g. felodipine

323
Q

what channel is affected in Long QT syndrome?

A

usually due to blockage of K+ channels

324
Q

If high-risk of failure of cardioversion (previous failure), offer electrical cardioversion after at least 4 weeks treatment with…?

A

amiodarone

325
Q

Contraindications of Exercise tolerance test?

A

MI less than 7 days ago

unstable angina

uncontrolled hypertension (systolic BP > 180 mmHg) or hypotension (systolic BP < 90 mmHg)

aortic stenosis

LBBB

326
Q

MOA of Nicorandil

A
  • vasodilatory drug used to treat angina
  • K+ channel activatior
  • activation of guanylyl cyclase which results in increased cGMP
327
Q

features of carcinoid heart disease?

A
  • assoc Tricuspid stenosis / regurg

+ pulmonary stenosis/ regurg

328
Q

Features of supravalvular aortic stenosis?

A
  • narrowing usually found just beyond the origin of left subclavian artery
  • HTN in arms, weak femoral pulses
  • Difference in carotid pulsation/ arm BP measurements
  • murmur of aortic stenosis may be present
329
Q

Tuboeruptive xanthomas

A

Type III hyperlipoproteinaemia

  • high numbers of chylomicrons and high intermediate density lipoprotein
  • high VLDL
  • assoc w Hypercholesterolaemia, hypertriglyceridaemia, normal [apoprotein B]
  • assoc palmar xanthomata/ orange discoloration of skin creases
  • tuberoeruptive xanthomata on elbows/ knees
330
Q

eruptive xanthomas

A

type I and type IV hyperlipoproteinaemia

331
Q

Loud S1 / opening snap in mitral stenosis is due to?

A

mobile leaflets of mitral valve

  • high left atrial pressure causes snap
332
Q

most likely lipid abnormality in asian man?

A

low HDL/ high triglycerides

  • measurement of LDL alone may underestimate their CV risk
333
Q

palmar crease xanthomas?

A

type III hyperlipidaemia

  • aka broad beta disease
334
Q

what type of cell receptor does adenosine act on?

A

G protein coupled receptor agonist of the adenosine A1 receptor

335
Q

Absolute contraindications to carotid sinus massage?

A

Carotid artery occlusion / atherosclerosis

MI

TIA in last 3 mo

CVA in last 3 mo

Prev ventricular arrhythmia

336
Q

Features of carotid sinus hypersensitivity?

A
  • cardioinhibitory: cardiac asystole >3s
  • vasodepressor: systolic BP drop >50 mmHg
  • AV block: some form of ventricular +/- atrial pacing generally required
337
Q

Most likely cause of STEMI in young lady with no conventional risk factors for coronary artery disease, just after giving birth?

A

Coronary artery dissection

  • well recognised cause of MI in relation to pregnancy
338
Q

Sinus bradycardia management in heart transplant patient?

A

IV theophylline - atropine CI bc hearts of heart transplant patients are denervated and do not respond to vagal blockade by atropine, which might precipitate paradoxical sinus arrest of high-grade block

339
Q

What is the most reliable indicator of prognosis at 72 hours post-arrest?

A

lack of pupillary light or corneal reflex at 72 hours = reliable predictor of death.

340
Q

Ventricular tachycardia: what drug therapy has to be used in caution with severe Left ventricular impairment?

A

Lidocaine

341
Q

Brugada syndrome: what medications make the ECG changes more apparent?

A

flecainide or ajmaline

342
Q

management of symptomatic trifascicular block with pre-syncope or syncope on exertion?

A

pacemaker

343
Q

Dextrocardia: associated ECG changes?

A

inverted P wave in lead I, right axis deviation, and loss of R wave progression

344
Q

What is the criteria for starting ivabradine in HF patients as a third line?

A

HR >75 And LVEF <35%

345
Q

In what population is hydralazine and nitrate most indicated for third line treatment in HF?

A

Afro Caribbean patients

346
Q

Digoxin use in cardiac amyloidosis?

A

higher risk of digoxin toxicity, as the drug binds avidly to amyloid fibril

347
Q

most sensitive investigation for diagnosing myopericarditis?

A

Cardiac MRI

348
Q

Mitral valve gradient calculation?

A

capillary wedge pressure (same as the left atrial pressure) MINUS diastolic left ventricular pressure

349
Q

Normal mitral valve gradient?

A

5 mmHg If >5, suggests mitral stenosis

350
Q

Aortic dissection: Indications for endovascular stenting ?

A
  • Rapidly expanding dissections (>1cm per year) - Critical diameter (>5.5cm) - Refractory pain - Malperfusion syndrome - Blunt chest trauma - Penetrating aortic ulcers
351
Q

Pacemaker: Increasing the pacing output?

A

when there is insufficient capture (the pacing spikes are not at a sufficient voltage to elicit a corresponding QRS complex)

352
Q

Pacemaker: increase of pacing sensitivity?

A

increases the voltage required to inhibit the pacemaker > helpful if the pacemaker was being inappropriately inhibited (potentially by noise)

353
Q

Pacemaker: reduction in the pacing output?

A

to preserve the pacemaker’s battery life > the lowest output required to safely and reliably achieve capture should be used at all times

354
Q

Pacemaker: Reducing the pacing sensitivity?

A

reduces the voltage required to inhibit the pacemaker > if the patient’s native rhythm was faster than the rate of the pacemaker but was still not inhibiting the pacemaker from firing

355
Q

Accelerated idioventricular rhythm: what is this?

A

benign ectopic rhythm of ventricular origin > usually following the reperfusion of an ischaemic myocardium > 50-110 bpm, which helps differentiate it from ventricular bradycardia or ventricular tachycardia

356
Q

Treatment of Accelerated idioventricular rhythm?

A

usually self-limiting > occasionally atropine can be used to increase the sinus rate to overcome AIVR

357
Q

Normal ecg variants in athletes?

A
  • sinus bradycardia - junctional rhythm - first degree heart block - Mobitz type 1 (Wenckebach phenomenon)
358
Q

What scan can help to look for phaeochromocytoma?

A

MIBG scan - radioactive iodine as a tracer for phaeochromocytoma tumour cells, then use a gamma camera to look

359
Q

Management of symptomatic HOCM despite mono therapy with BB/ CCb?

A

disopyramide - a negative inotropic 1a anti-arrhythmic that demonstrated a significant decrease of LVOT gradients and mortality when compared to placebo

360
Q

Oxygen saturations in SVC vs IVC?

A

Should always be lower in SVC due to higher oxygen demand in the brain > if SVC oxygen sats higher than IVC, might demonstrate a left to right shunt

MRCP (21 decks)

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