Cardiology I

Question 1

You suspect someone is suffering from digoxin toxicity. What would this look like on an ECG? [1]

What question would you ask them about their symptoms that might suggest this? [1]

Answer 1

Down-sloping ST segments = digoxin toxicty (reverse tick)

Loss of appetite is first symptom - followed by nausea and vomiting

Question 2

Which of the below results is most likely in a patient taking Warfarin?

Normal PT, prolonged APTT
Prolonged PT, normal APTT
Normal PT, normal APTT
Prolonged PT, prolonged APTT
Normal PT, shortened APTT

Answer 2

Which of the below results is most likely in a patient taking Warfarin?

Normal PT, prolonged APTT
Prolonged PT, normal APTT
Normal PT, normal APTT
Prolonged PT, prolonged APTT
Normal PT, shortened APTT

Warfarin affects factor X, IX, VII and II. The extrinsic pathway, affecting the PT, involves factor VII.

Question 3

Describe the aetiological factors that cause secondary HTN? [6]

Answer 3

Essential hypertension: 90%
- Unknown cause

Secondary hypertension:
R enal disease
O besity
P regnancy induced / pre-eclampsia
E ndocrine
D rugs

Question 4

Which endocrine disorders significantly contribute to causing HTN? [6]

Answer 4

• Primary hyperaldosteronism (Conns)
• Phaechromocytoma
• Cushings
• Liddles syndrome
• Congenital adrenal hyperplasia (11 beta-hydroxylase deficiency)
• Acromegaly

Question 5

What investigation should you perform if you consider renal artery stenosis is causing HTN? [1]

Answer 5

Duplex ultrasound
MR or CT angiogram

Question 6

What are the different stages of HTN? [3] (include both clinic and home readings)

Answer 6

Stage 1:
- Clinic: >140/90
- Home / Ambulatory: Above 135/85

Stage 2:
- Clinic: >160/100
- Home / Ambulatory: Above 150/90

Stage 3:
- Clinic: >180/120

Question 7

NICE recommends all patients who are newly diagnosed with hypertension to have which checks to investigate for end organ damage? [4]

Answer 7

Urine albumin:creatinine ratio for proteinuria and dipstick for microscopic haematuria to assess for kidney damage

Bloods for HbA1c, renal function and lipids

Fundus examination for hypertensive retinopathy

ECG for cardiac abnormalities, including left ventricular hypertrophy

Question 8

Describe the specific management plans for treating HTN for patients who are Over 55 / NO DMT2 / Black or Afro-Caribbean [4]

Answer 8

Over 55 / NO DMT2 / Black or Afro-Caribbean:

STEP 1:
- CCB

STEP 2:
- CCB and ACE inhibitor
OR
- CCB and Thiazide-like diuretic

STEP 3:
ACE inhibitor and CCB and Thiazide-like diuretic

STEP 4:
- If K ≤4.5 add low dose spironolactone
- If K ≥4.5 add alpha blocker or beta blocker
- If not controlled with 4 drugs: specialist review

Question 9

What are the specific treatment BP targets for patients over 80 and under 80? [2

Answer 9

Under 80:
- < 140/90

Over 80:
- < 150 / 90

Question 10

What is meant by the term malignant / accelerated hypertension? [1]
What is the management plan for someone with ^? [1]

Answer 10

blood pressure above 180/120, with retinal haemorrhages or papilloedema.

The NICE guidelines recommend a same-day referral

Question 11

What are the IV options for managing an hypertensive emergency [4]

Answer 11

Z2F:
- Sodium nitroprusside
- Labetalol
- Glyceryl trinitrate
- Nicardipine

Lecture:
- BB (bisoprolol)
- Alpha blocker (doxazocin)
- Alpha 2 agonist (moxonidine)
- Hydralazine vasodilator

Question 12

Which drug would be given in a hypertensive emergency caused by pheochromocytoma? [1]

Answer 12

Phentolamine (alpha-adrenergic antagonist)

Question 13

Which patient populations should ACE inhibitors be avoided in? [3]

Answer 13

Pregnant women - teratogenic
AKI
Renal artery stenosis

Question 14

Diltiazem and verapamil are contra-indicated with which medical conditions? [2]

(why?)

Answer 14

• Impaired LV function (can worsen HF)
• AV nodal conduction delay (may provoke heart block)

Question 15

Explain why amlodipine and nifedipine are contra-indicated with which medical conditions? [2]

Answer 15

Unstable angina: vasodilation causes increase in contractility and tachycardia, which increase myocardial oxygen demand

Severe aortic stenosis: can cause myocardial collapse

Question 16

CCBs all cause which side effect? [1]

Answer 16

Gum hypertrophy!

Question 17

Which anti-hypertensive drugs should be prescribed in pregnany? [3]

Answer 17

Labetalol (acts on alpha and beta)
Nifedipine
Methyl dopa

Question 18

What is is the most common identifiable cause of hypertension? [1]

Answer 18

Chronic kidney disease.

Question 19

Under which circumstances would you admit a patient to hospital if their BP was > 180/120 in the clinic [3]

Answer 19

Refer for same-day specialist review if:
* retinal haemorrhage or papilloedema
(accelerated hypertension) or
* life-threatening symptoms or
* suspected pheochromocytoma

Question 20

a. What antihypertensive medication is contraindicated during pregnancy according to NICE guidelines?
- A. Methyldopa
- B. Labetalol
- C. Amlodipine
- D. Enalapril

Answer 20

a. What antihypertensive medication is contraindicated during pregnancy according to NICE guidelines?
- A. Methyldopa
- B. Labetalol
- C. Amlodipine
- D. Enalapril

Enalapril is not recommended in pregnancy. It can reduce the level of fluid around your baby, particularly if you take it in the second and third trimesters

Question 21

a. Which of the following antihypertensive medications requires regular monitoring of serum potassium levels due to the risk of hyperkalemia?
- A. Thiazide diuretics
- B. ACE inhibitors
- C. Calcium channel blockers
- D. Beta-blockers

Answer 21

a. Which of the following antihypertensive medications requires regular monitoring of serum potassium levels due to the risk of hyperkalemia?
- A. Thiazide diuretics
- B. ACE inhibitors
- C. Calcium channel blockers
- D. Beta-blockers

Question 22

What do you need to consider about anti-hypertensive treatment in patients with CKD? [1]

Answer 22

A potassium above 6mmol/L should prompt cessation of ACE inhibitors in a patient with CKD (once other agents that promote hyperkalemia have been stopped)

Question 23

An [investigation] may be required in patients with fever of unknown origin and back pain to exclude [].

Answer 23

This refers to infection/inflammation of an intervertebral disc. This may be a complication of a septic emboli from IE.

Question 24

Acute pulmonary oedema is usually secondary to acute left ventricular dysfunction or renal artery stenosis.

Patients complain of sudden breathlessness and need to be managed quickly on the ward. The acute management can be remembered using the mnemonic []:

Answer 24

FOND
F- furosemide 40mg IV
O - high-flow Oxygen
N - nitrates (Sublingual / infusion)
D - diamorphine IV
If this immediate management fails then patients may be started on continuous positive airway pressure (CPAP).

Question 26

Explain the different clinical features of atrial flutter [5]

Answer 26

**Haemodynamic Manifestations**: - Loss of co-ordinated atrial contractions causes **reduced** **ventricular** **filling** and **reduced CO** - Causes **dyspnea**; **fatigue**; **lightheadedness**; **syncope** **Palpitations** **Chest pain** - Due to **increased** **myocardial** **oxygen** demand **secondary** to **rapid** **ventricular** **rates** or **decreased diastolic filling time** causing **subendocardial ischaemia** **Heart Failure Symptoms** - May get **tachycardia** induced **cardiomyopathy** - **Orthopnea**; **paroxysmal nocturnal dyspnea**, and **peripheral oedema** **Thromboembolic Complications**: - predisposes patients to **thrombus formation**

Question 27

Describe the first line treatment algorithm for a patient with acute atrial flutter who is haemodynamically stable? [3] What is the long term anticoagulation used? [2]

Answer 27

**Primary option**: Use an atrioventricular nodal blocking drug for rate control: **Beta blocker:** - **Bisoprolol** or others OR **N****on-dihydropyridine calcium-channel blockers**: - **Verapamil** - **Diltiazem** **Secondary options**: - **Digoxin** *may convert atrial flutter to atrial fibrillation, which can be easier to manage.* CONSIDER: **Initial anticoagulation:** - **heparin** or - **enoxaparin** **Long term anticoagulation:** - 1st: **apixaban** or ther DOAC - 2nd: **warfarin** | BMJ BP

Question 28

Wht are common causes of AF? [5]

Answer 28

**SMITH** **S** – Sepsis **M** – Mitral valve pathology (stenosis or regurgitation) **I** – Ischaemic heart disease **T** – Thyrotoxicosis **H** – Hypertension Alcohol and caffeine are lifestyle causes worth remembering.

Question 29

Which endocrine pathologies are associated with AF? [2]

Answer 29

**DM** **Hyperthyroidism**

Question 30

Which cardiac conditions are associated with AF? [5]

Answer 30

**HTN**: most common factor **HF** **CAD** **Valve pathologies**: In particular, mitral valve disease and rheumatic heart disease. **Atrial flutter & WPWs**

Question 31

Describe the different classifications of AF [3]

Answer 31

.1. **Persistent AF:** - Experience AF at all times (sustained for **more than 7 days**) .2. **Paroxysmal AF**: - **Experiences AF at certain times.** At all other times their heart contracts in **sinus** **rhythm** - ‘AF that **terminates** **spontaneously** **within** **7** **days** of onset’ .3. **Valvular Atrial Fibrillation**: - AF with **significant** **mitral** **stenosis** or a **mechanical heart valve.** - *NB: Atrial fibrillation without valve pathology or with other valve pathologies, such as mitral regurgitation or aortic stenosis, is classed as non-valvular AF*.

Question 32

The Ssgns of haemodynamic compromise in AF according to NICE CKS (2020) are what? [5]

Answer 32

* Heart Rate **>150 bpm** * Blood Pressure **< 90 mmHg** * **Syncope** or **severe** **dizziness** * **Shortness of breath** * **Chest Pain**

Question 33

An elderly patient with a history of atrial fibrillation presents with a sudden painless loss of vision in one eye. Fundoscopy reveals a 'cherry red' spot on a pale retina is a stereotypical history of:

Answer 33

occlusion of central retinal artery

Question 34

What is the cause of the cherry red spot? [1]

Answer 34

It is most frequently caused by emboli obstructing the retinal artery (e.g. stroke). Occasionally, it can be caused by vasculitis (e.g. giant cell arteritis). Classical appearance is of a “cherry-red spot”. This occurs due to the intact reflex of the fovea standing out against a pale, ischaemic retina.

Question 35

Answer 35

No anticoagulation: CHA2DS2-VASc of **1** (female) CHA2DS2-VASc of **0**

Question 36

A patient has AF, but a CHADSVASC score of 0. What is the next investigational step? [1] Why? [1]

Answer 36

Remember that if a CHA2DS2-VASc score suggests no need for anticoagulation it is important to ensure a **transthoracic echocardiogram** has been done to **exclude valvular heart disease,** which in combination with AF is an absolute indication for anticoagulation.

Question 37

What is vasovagal syncope? [1] What is it caused by? [4]

Answer 37

**Vasovagal Syncope:** - emotional or environmental trigger (e.g. prolonged standing, fasting, dehydration) causes an **activation of the PNS** - Activation of the PNS causes vasovagal reaction: **bradycardia and vasodilation** - Causes a drop in BP and reduction in blood supply to brain - Cerebral hypoperfusion and LOC

Question 38

How can you differentate between cardiac and vaso-vagal syncope?

Answer 38

**Cardiac syncope**: - preceded by exertional chest pain - occurring during exercise or stress - concerning cardiac history - no prodrome - event requiring CPR, - abnormal physical examination **Vasovagal syncope** - Prodromal symptoms: - Hot or clammy - Sweaty - Heavy - Dizzy or lightheaded - Vision going blurry or dark - Headache

Question 39

What are important areas to cover in a history when someone says they've fainted? [4]

Answer 39

**Precipitant/trigger:** - if situational, ask if the trigger consistently causes syncope **Warning symptoms:** - classic pre-syncopal symptoms of nausea, sweating, feeling faint **Position**: - vasovagal syncope usually happens when standing **Underlying cardiac disease?**

Question 40

What are key history areas for arrhythmic and structural syncope? [8]

Answer 40

* **Palpitations** * **Other cardiac symptoms** (e.g. chest pain, breathlessness, oedema) * **No prodromal warning** (unlike in reflex and orthostatic syncope, where there are clear pre-syncopal symptoms) * **Onset when sitting or lying down** * **Onset with exercise** (clarify if it is after or during exercise) * **Presence of any previous heart disease** including myocardial infarctions, surgeries, and any cardiac device details (pacemakers and ICDs) * **Drug history** * **Family history of sudden cardiac death**

Question 41

A patient with **AF + an acute stroke** (not haemorrhagic) should have anticoagulation therapy started **[]** **weeks** after the event

Answer 41

A patient with AF + an acute stroke (not haemorrhagic) should have anticoagulation therapy started **two weeks after the event**

Question 42

Describe the four possible rhythms in a cardiac arrest patient [4]

Answer 42

Shockable rhythms: * **Ventricular tachycardia** * **Ventricular fibrillation** Non-shockable rhythms: * **Pulseless electrical activity** (all electrical activity except VF/VT, including sinus rhythm without a pulse) * **Asystole** (no significant electrical activity)

Question 43

Describe how you would treat the following causes of broad complex tachycardia [4] * Ventricular tachycardia or unclear cause * Polymorphic ventricular tachycardia, such as torsades de pointes * Atrial fibrillation with bundle branch block * Supraventricular tachycardia with bundle branch block

Answer 43

Ventricular tachycardia or unclear cause: - **IV amiodarone** Polymorphic ventricular tachycardia, such as torsades de pointes: - **IV magnesium** Atrial fibrillation with bundle branch block - **AF tx** Supraventricular tachycardia with bundle branch block - **SVT tx**

Question 44

Give four differential diagnoses to VT for a broad complex tachycardia [4]

Answer 44

**SVT with abberancy**: - **SVT** but the **QRS** becomes **broad** because of **bundle branch block** **Paced rhythm**: - An electrocardiographic finding in which the cardiac rhythm is **controlled by an electrical impulse from an artificial cardiac pacemaker** **Anti-dromic AVRT** **Pre-excitation tachycardias (WPW)**

Question 45

Describe what is meant by sick sinus syndrome [1] What can cause sick sinus syndrome? [1]

Answer 45

Sick sinus syndrome encompasses many **conditions** that **cause dysfunction in the sinoatrial node.** It is often caused by **idiopathic degenerative fibrosis of the sinoatrial node**. It can result in sinus bradycardia, sinus arrhythmias and prolonged pauses.

Question 46

What does asytole mean? [1] State 4 cardiac pathologies that increase risk of asytole [4]

Answer 46

**Asytole**: cessation of electrical and mechanical activity of the heart. * **Mobitz type 2** * **Third-degree heart block** (complete heart block) * **Previous asystole** * **Ventricular pauses longer than 3 seconds**

Question 47

Describe the MoA of atropine [1]

Answer 47

Atropine is an **antimuscarinic** **medication** and works by **inhibiting the parasympathetic nervous system.** Inhibiting the parasympathetic nervous system leads to side effects of pupil dilation, dry mouth, urinary retention and constipation.

Question 48

What is corrected QT interval (QTc)? [1] What is prolonged QTc in men [1] and women [1]?

Answer 48

**Corrected QT interval (QTc):** estimates the QT interval if the heart rate were 60 beats per minute Prolonged: * **More** than **440** **milliseconds** in **men** * **More** than **460** **milliseconds** in **women**

Question 49

What does a prolonged QT interval mean physiologically? [1] What are the physiologically consequences of a prolonged QT interval? [1] What is the name for this phenomenom? [1]

Answer 49

A prolonged QT interval represents **prolonged repolarisation** of the heart muscle cells (myocytes) after a contraction. Waiting a long time for repolarisation can **result in spontaneous depolarisation** in some muscle cells These abnormal spontaneous depolarisations before repolarisation are known as **afterdepolarisations**.

Question 50

Describe what is meant torsades de pointes from a physiological perspective? [1] What type of tachycardia is torsades de pointes? [1]

Answer 50

**Recurrent contractions without a normal repolarisation** due to **afterdepolarisations** **spreading** throughout the **ventricles**, causing **contraction** **before** proper **repolarisation** Type of **polymorphic ventricular tachycardia**

Question 51

Describe the prognosis of untreatead torsades de pointes [2]

Answer 51

Torsades de pointes will **terminate spontaneously** and **revert** to **sinus** **rhythm** OR Progress to **ventricular tachycardia.** *Ventricular tachycardia can lead to cardiac arrest.*

Question 52

Which medications can cause prolonged QT intervals? [6]

Answer 52

**M**ethotrexate,** e**rythromycin, **t**erfenadine, **h**aloperidol, **c**italopram/chloroquine, **a**miodarone, **T**CA, **s**otalol

Question 53

Which electrolyte imbalances can cause QT elongation [3]

Answer 53

* **hypokalaemia** * **hypomagnesaemia** * **hypocalcaemia**

Question 54

Describe the resuscitation council treatment algorithm for adult tachycardias (with pulse) if the there are adverse features (e.g. shock, syncope, MI, HF) [5]

Answer 54

**Assess using the ABCDE approach**  Monitor SpO2 and give oxygen if hypoxic  Monitor ECG and BP, and record 12-lead ECG  Obtain IV access  Identify and treat reversible causes (e.g. electrolyte abnormalities) **Adverse features?** *Shock; MI; HF: Syncope* - **IF YES**:  **Synchronised DC shock x3**  **Amiodarone 300 mg IV over 10 - 20 mins**  **Repeat shock**  **Amiodarone 900 mg over 24hrs**

Question 55

What is the treatment algorithm for adult tachycardias (with pulse) once you have have assessed that there are no adverse features present and the **QRS complex is < 0.12 secs** and the **rhythm is regular** but sinus rhythm is NOT achieved? [1]

Answer 55

Assess using the ABCDE approach  Monitor SpO2 and give oxygen if hypoxic  Monitor ECG and BP, and record 12-lead ECG  Obtain IV access  Identify and treat reversible causes (e.g. electrolyte abnormalities) Adverse features? Shock; MI; HF: Syncope - IF NO - Check QRS - If < 0.12s = narrow complex tachycardia If rhythm is regular:  Perform vagal manoeuvres  Adenosine 6 mg rapid IV bolus  If no effect give 12 mg  If no effect give further 12 mg  Monitor/record ECG continuously **Diagnosis is probably atrial flutter: treat rate control - such as a beta blocker**

Question 56

What is the treatment algorithm for adult tachycardias (with pulse) once you have have assessed that there are no adverse features present and the **QRS complex is < 0.12 secs** and the **rhythm is regular** and sinus rhythm IS achieved? [1]

Answer 56

Assess using the ABCDE approach  Monitor SpO2 and give oxygen if hypoxic  Monitor ECG and BP, and record 12-lead ECG  Obtain IV access  Identify and treat reversible causes (e.g. electrolyte abnormalities) Adverse features? Shock; MI; HF: Syncope - IF NO - Check QRS - If < 0.12s = narrow complex tachycardia If rhythm is regular:  Perform vagal manoeuvres  Adenosine 6 mg rapid IV bolus  If no effect give 12 mg  If no effect give further 12 mg  Monitor/record ECG continuously **If sinus rhythm achieved**, **probably re-entry SVT (i.e. AVRT or AVNRT)**: - **Record 12 lead ECG in sinus rhythm** - **If SVT recurs treat again and consider anti-arrhythmic prophylaxis**

Question 57

Describe the treatment algorithm for adult tachycardias (with pulse) once you have have assessed that there are no adverse features present, the **QRS complex is > 0.12 secs** and there is a **regular rhythm** [2]

Answer 57

Assess using the ABCDE approach  Monitor SpO2 and give oxygen if hypoxic  Monitor ECG and BP, and record 12-lead ECG  Obtain IV access  Identify and treat reversible causes (e.g. electrolyte abnormalities) Adverse features? Shock; MI; HF: Syncope - IF NO - Check QRS - **If > 0.12s = broad complex tachycardia** **If regular** - could be: **VT (or uncertain rhythm):**  **Amiodarone** **300** **mg IV over 20- 60 min then 900 mg over 24hr** OR **If known to be SVT with bundle branch block:**  **Treat as for regular narrowcomplex tachycardia**

Question 58

The reversible causes of cardiac arrest are “4Hs and 4Ts”. Name them [8[

Answer 58

**H**ypoxia **H**ypokalaemia/hyperkalaemia **H**ypothermia/hyperthermia **H**ypovolaemia **T**ension pneumothorax **T**amponade **T**hrombosis **T**oxins