Cardiology and Respiratory Flashcards
Features of EGPA
Asthma
Eosinophilia
Mononeuritis Multiplex
Ostium Primum
The septum primum splits the atria in the neonate/newborn: should seal off after birth
Failure = failure of fusion of the superior and inferior cardiac cushions
Associated with Down’s syndrome
Ostium Secundum
The septum secundum grows to cover the foramen ovale
Failure
1. Large foramen ovale
2. Inadequate growth of the secundum
Ostium Primum VS Secundum
Primum
= less common, presents earlier
Associated with RBBB and LAD, prolonged PR interval
Secundum
= presents later, more common
Associated with RBBB and RAD
QT interval
- Measure on ECG
- Represents?
= start of QRS to the end of the T wave
Ventricular depolarisation adn repolarisation
What is an Epsilon wave?
= small deflection in QRS
Excitation in the R ventricle
= arrhythmogenic right ventricular cardiomyopathy
- Due to replacement of myocytes with fat, delay in excitation of myocytes in R ventricle, seen as separate deflection
Cardiac Action Potenial
Na+ IN
Balance of Ca2+ IN and K+ OUT
K+ OUT
Patent Ductus Arteriosus
Closure =
Maintain patency =
Closure = indomethacin
Open = prostaglandins
Why cannot give NSAIDs in pregnancy/end of pregnancy - close PDA, foetus dependent on that to allow bypass of lungs
Interventions with proven benefit in COPD (3)
Smoking Cessation
LTOT
Lung Volume Reduction Surgery
LBBB
- effect on systole
- heart sounds finding
= delayed closure of the aortic valve as action potential must go right to left
- Reversed split S2
- Quiet S1
Marfan’s Syndrome
- Pathophysiology of aortic dissection
= dilated aortic root
- Aorta usually has x3 small pouches that sit above the aortic valve, which are the sinuses of valsalva
- Weakness of elastic lamina at junction of aortic media and annulus fibrosus (fibrous ring at aortic orfice to front and right of AV root)
PaO2/FiO2 ratio
- cut off value
- how to calculate
> 300 = suggests acute respiratory failure, helpful for determining oxygen pressures
- ABG PaO2 - if 7 = 70 divided by FiO2 if 40% VM = 0.4
Type A Aortic Dissection
Proximal to brachiocephalic vessels
What is the most likely cause of aortic stenosis in <65 years?
Bicuspid aortic valve (more prone to calcifcation)
What are the greatest risk factors for restenosis following PCI?
Diabetes
Renal Failure
What is the greatest risk factor for stent thrombosis following PCI?
Premature anti-platelet withdrawal
What endocrine abnormality is associated with pulmonary TB?
Hyponatraemia due to SIADH
Most likely cause of endocarditis in recent valve surgery
Staph epidermidis
Indication for CRT (2)
LVEF of <35%
AND
LBBB with QRS >130
Deficiency in pulmonary hypertension
- diagnostic test
Relative deficiency of nitric oxide
= inhaled NO reverses
Complete Heart Block in MI
- anterior vs inferior infarction
Anterior = doesn’t usually resolve, may need pacing
Inferior = may resolve once RCA is revascularised
Variable intensity in S1
- why?
Complete heart block
- variable PR interval
- S1 intensity decreases with PR prolongation (<diastolic ventricle pressures increase, mitral leaflets drift together)
Cardiac conduction abnormality in myotonic dystrophy
Prolonged PR interval - disease of His-Purkinje system
Molecular cause of HOCM
Mutation in B-heavy chain protein
TGA vs TOF
TGA = first days of life
TOF = first months of life
Both cyanotic heart disease
Long QT molecular problem
- result
Defect in alpha subunit of slow delayed rectifier K+ channel
= loss of function K+ channels
MI secondary to cocaine use
- Mechanism
- Management
= increased O2 demand due to sympathomimetic drive, coronary artery vasoconstriction and vasospasm
- IV benzodiazepines: control BP and heart rate, reduce the above mechanisms
Most common organism in bronchiectasis
Haemophilus influenzae
Raised eosinophils, brittle asthma, parenchymal infiltrates
- diagnosis
- management
allergic bronchopulmonary aspergillosis
- managed using PO steroids
Marker of disease progression in COPD
FEV1
Calcium and QT interval
Hypocalcaemia - QT prolongation
Hypercalcaemia - QT shortening
What parameters should be measured when delivering MgSO4?
Why?
Reflexes
Respiratory Rate
= magnesium toxicity presents as muscle weakness, respiratory depression and arrest
Condition associated with coarctation of the aorta
Neurofibromatosis
What medication should be avoided in HOCM?
ACE inhibitor
= these decrease afterload and preload
Want to INCREASE afterload/preload to stretch the myocardium
Management of Torsades de Pointes
Magnesium Sulphate 2g IV STAT
Anticoagulation following bioprosthetic valve
Aspirin only
Gene loci associated with bronchiectasis
HLA-DR1
Where is BNP secreted from?
Ventricular myocardium
What is a side effect of verapamil?
Constipation
= relaxes smooth muscle, reduces gut motility
S2
- Fixed split S2
- Wide S2
- Reversed S2
= closure of aortic and pulmonary valve
Fixed = ASD
Wide = delay in closure of pulmonary valve
Reversed = delay in closure of aortic valve
Causes of wide split S2
= delay in closure of pulmonary valve
RBBB, pulmonary stenosis
Cause of reversed split S2
= delayed closure of aortic valve
LBBB, PDA, aortic stenosis
S3
Timing
Cause (2)
Occurs after S2 - diastole
Seen in passive filling of the left ventricle with increased compliance
Cause = DCM, normal variant <30 years
S4
Timing
Cause (2)
Occurs before S1- diastole
Active filling of the left ventricle
Cause = HOCM, diastolic failure
Cause of ejection systolic murmur (4)
Aortic stenosis
HOCM
ToF
ASD
Cause of late systolic murmur
Cause of pansystolic murmur (2)
MV prolapse
Harsh = VSD
Blowing = MR
Continuous machine like murmur
Patent ductus arteriosus
Pulse alternans
= LVSD
ECG changes seen in hypokalaemia (4)
U waves
Flattened T waves
Prolonged PR
Prolonged QTC
ECG changes seen in digoxin (4)
Bradycardia
Prolonged PR
ST depression
Short QTC
Management of left ventricular wall rupture post MI
NOAC to prevent thrombosis
Causes of prolonged PR interval (5)
Digoxin
Hypothermia
Hypokalaemia
Aortic Root Abscess
Myotonic Dystrophy
What medication should be avoided in heart failure?
Rate limiting CCB
e.g. verapamil, diltiazem
Glycoprotein 2B/3A inhibitors (3)
Abciximab
Tirofiban
Eptifibatide
Indication for drugs in HF
- Entresto
- Ivabradine
- Digoxin
Entresto = EF <35%
Ivabradine = EF <35% and HR >75
Digoxin = concomitant AF
Maximum dose of atropine
3mg (i.e. 6x500 microgram rounds)
Mobitz I vs Mobitz II
I = progressive PR prolongation until missed QRS
II = PR interval is constant in conducted beats
Ventricular escape rhythm
= broad QRS + rate 20-40
What is the most common type of WpW syndrome?
Type B = right sided accessory pathway
ECG sign in mitral stenosis
Bifid p wave
What is the management of choice in mitral regurgitation?
Valve repair rather than valve replacement
Junctional escape rhythm
= narrow QRS + rate 40-60
Definition of pulmonary hypertension
- number of groups
- which group is:
A. Idiopathic
B. Respiratory disease
> 25mmHg
Groups 1-5
Idiopathic = group 1
Respiratory = group 3
What would be a contra-indication to introducing spironolactone to control hypertension?
K+ >4.5
+VE response to acute vasodilator testing in pulmonary hypertension
Calcium channel blocker
Associations with coarctation of the aorta (3)
Turner’s syndrome
Bicuspid aortic valve
Neurofibromatosis
Investigating angina
- 1st line
- 2nd line
1st = CT coronary angiogram
2nd = non-invasive functional imaging e.g. stress echo, myocardial perfusion scan
Management of angina
- all patients
1st line
2nd line
All patients = statin, aspirin, GTN
1st = BB or rate limiting CCB
2nd = BB + long acting CCB
Should be on maximum dosing of each drug before next step
Cannon A wave =
= closed tricuspid valve
e.g. VT, complete heart block
Kussmaul’s wave =
= paradoxical JVP rise on inspiration
e.g. constrictive pericarditis
Eisenmenger’s
- pathophysiology
1st left to right shunt, causing pulmonary hypertension
THEN
right to left shunt as pulmonary pressures exceed LV pressure
= cyanosis
Tetralogy of Fallot =
Overriding aorta
VSD
Pulmonary stenosis
Right ventricular hypertrophy
Poor prognostic factors in endocarditis (3)
Staph aureus
Prosthetic valve
Culture negative
Causes of pericarditis (4)
Uraemia
Viral infections
TB
Post MI
Presentation of atrial myxoma (5)
Weight loss
PUO
Fatigue
SOB
Clubbing
= left atrial pedunculated mass
Driving following ACS
4 weeks
Driving following ICD
- symptomatic i.e. sustained VT
- prophylaxis
Symptomatic = 6 months
Prophylaxis = 1 month
If Q Risk >10 =
Start atorvastatin 20mg as primary prevention
Lifestyle advice
DCCV successful - what is the plan for anti-coagulation?
4 weeks
Causes of low transfer factor (5)
= low rate of diffusion
Fibrosis
PE
Pneumonia
Pulmonary Oedema
Emphysema
Causes of high transfer factor (3)
Asthma
Haemorrhage
Pregnancy
Causes of Upper Lobe Fibrosis
CHARTS
C - coal miners lung
H - hypersensitivity pneumonitis
A - ankylosing spondylitis
R - radiation
T - TB
S - silicosis/sarcoidosis
Cause of Lower Lobe Fibrosis
ACID
A - asbestosis
C - CTD
I - idiopathic
D - drugs
Investigation findings in Pulmonary Fibrosis
Restrictive spirometry
Low TLCO/KO
Genetic finding in Kartegener Syndrome
Dynein arm defect
= primary ciliary dyskinesia
First line investigation in adult asthma
Spirometry with bronchodilator reversibility
and FENO testing
Severe VS Life threatening Asthma
- PEF
Severe = PEF 33-50%
Life threatening = PEF <33
What is a positive FeNO test?
> 40 parts per billion
Difference between asthma and COPD on spirometry
COPD = no significant reversibility on spirometry
Indications for LTOT (2)
paO2 = <7.3 kPa
paO2 = 7.3-8.0 + RVH/pulmonary hypertension
Aspergilloma investigation finding =
= rounded crescent sign
When do you use PERC score?
In low risk Wells, if negative then can R/O PE
Management of Primary PTX
- <2cm + not symptomatic
Discharge with F/U
Management of Primary PTX
- >2cm or SOB
Aspirate
Discharge with follow up
- if unsuccessful then chest drain + admit
Features of allergic bronchopulmonary aspergillosis (4)
Investigation of choice
Management
Bronchiectasis
Wheeze
Cough
Eosinophilia
= RAST will be positive to aspergillus
Initially steroids then itraconazole
Indications for VQ scan in suspected PE (2)
Pregnancy
Renal impairment <eGFR 25
Management of Secondary PTX
- <1cm
Observe for 24 hours
Markers of good prognosis in sarcoidosis (2)
Rapid onset
Erythema nodosum
Management of Secondary PTX
- >2cm or SOB
Chest drain
Management of Secondary PTX
- 1-2cm + not SOB
Aspirate then chest drain
What type of hypersensitivity reaction is hypersensitivity pneumonitis?
Acute = type III reaction
Chronic = becomes type IV reaction
What is the mechanism of hypercalcaemia in sarcoidosis?
Over production of 1,25(OD)2D3 by macrophages
Skin features of sarcoidosis (2)
Erythema nodosum
Lupus pernio
Genetic fault in CF
Deletion at dF508 on chromosome 7 in CFTR gene
Spirometry finding in sarcoidosis
Restrictive spirometry
Causes of bronchiectasis (5)
- most common infection cause
CF
Kartagener’s syndrome
Hypogammaglobulinaemia
IgA deficiency
Measles
= haemophilus influenzae
Indications for steroids in sarcoidosis (5)
Symptomatic + CXR findings
Hypercalcaemia
Eye involvement
Neurological involvement
Cardiac involvement
What asbestos fibres are the most dangerous?
Blue fibres
XR signs in bronchiectasis
- Tramlines
- Signet sign
Drug used in CF
Orkambi (lumacaftor/ivacaftor)
Association with mycoplasma
Cold AIHA
Bilateral consolidation
What is the most common cause of pneumonia?
Streptococcus
Management of low severity CURB score pneumonia
Amoxicillin or macrolide antibiotic
Management of severe PCP
- initial is co-trimoxazole (+ steroids if hypoxia)
Can use IV pentamidine in severe disease
Transudate effusion =
Causes (5)
= <30 grams of protein
= causes of low protein
Heart failure
Liver failure
Nephrotic Syndrome
Hypothyroidism
Meig’s Syndrome
Exudate Effusion =
Causes (5)
Indications for chest drain (2)
= >30g/protein
Infection
Malignancy
Autoimmune
Pancreatitis
Pulmonary emboli
Indications = pH <7.2, turbid fluid
Squamous cell lung cancer paraneoplastic syndromes (3)
Hyperthyroidism
Hypercalcaemia
HPOA
Large cell lung cancer association
Can be bHCG positive
Contra-indications to surgical management of lung cancer (3)
FEV <1.5
Hilar malignancy - SVCO, vocal cord paralysis
Malignant effusion
Derivation of lung carcinoid
- finding on bronchoscopy
= APUD cells
- Cherry red balloon appearance on bronchoscopy
Investigation in ARDS
Pulmonary capillary wedge pressures
- help to rule out cardiac causes
Management of aspergilloma
Surgical resection
Most common site for atrial myxoma
Left atria
Valve abnormality associated with HOCM
MR with anterior systolic leaflet movement
Mechanism of clopidogrel and ticagrelor
P2Y12 inhibition
Clopidogrel = IRREVERSIBLE
Ticagrelor = REVERSIBLE
Marker positive in small cell lung cancer
Banbesin
Reduced LV gradient
- good or bad?
= little pressure difference
Minimal LV obstruction
Good
What to avoid in HOCM (medication)?
ACE-I
Histology finding in rheumatic fever
Aschoff bodies
= granulomatous nodules
Indication for LTOT in COPD
Polycythaemia
ECG findings in Brugada Syndrome
ST elevation in V1-V3 and RBBB
What can right axis deviation indicate?
Left posterior hemiblock
ST depression specific for ischaemia
Downsloping
Why aren’t b-blockers used as frequently in hypertension?
Less likely to prevent stroke
Impairment of glucose tolerance
What is alpha-1 antitrypsin?
A protease inhibitor
Genotype of familial hypercholesterolaemia
Heterozygous
Pulmonary HTN heart sound finding
Loud S2
What should you avoid in accessory pathways in AF?
Avoid AV blocking drugs
= encourages atrial fibrillation to travel down the accessory pathway - can become v. fibrillation
Use fleccanide instead
Poor prognosis in HOCM
Septal thickness >3cm
Management of multifocal atrial tachycardia
Verapamil
- DCCV and digoxin not useful
Pulse feature in PDA
Collapsing pulse (left to right shunt, rapidly dropping/changing volumes in aorta)
What is found in EAA?
Circulating IgG preceptins
Give a cause of DCM
Selenium
What is the mechanism of bosentan?
Endothelin A and B antagonist
What is the most common cause of congenital long QT syndrome?
Defects in K+ channel
What is the mechanism of cardiomyopathy with trastuzumab?
erb-b2 blockade (HER2 receptor)
= herceptin
