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Yr 3: CN2 > Cardiology I > Flashcards

Cardiology I Flashcards

1
Q

[] access is preferred to femoral access for primary PCI

A

Radial access is preferred to femoral access for primary PCI

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2
Q

Describe the treatment used for rhythm control for AF (electrical and pharmological) [3]

A

DC Cardioversion
- electrical stimulation to restore sinus rhythm

Amiodarone
- antiarrhythmic drug which can restore sinus rhythm on its own. It is suitable in most patients

Flecainide
- an antiarrhythmic drug that can be used in some patients to restore sinus rhythm, but is contraindicated in those with possible structural or ischaemic heart disease

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3
Q

NICE guidelines (2021) suggest all patients with AF should have rate control as first-line, except in which four instances? [4]

A

NICE guidelines (2021) suggest all patients with AF should have rate control as first-line, except with:

  • A reversible cause for their AF
  • New onset atrial fibrillation (within the last 48 hours)
  • Heart failure caused by atrial fibrillation
  • Symptoms despite being effectively rate controlled
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4
Q

Long-term AF rhythm control is with which drugs? [3]

A

Beta blockers first-line

Dronedarone second-line for maintaining normal rhythm where patients have had successful cardioversion

Amiodarone is useful in patients with heart failure or left ventricular dysfunction

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5
Q

Describe the process of AVN ablation to treat AF [3]

A

Atrioventricular node ablation involves destroying the connection between the atria and ventricles (the atrioventricular node)

After the procedure, the irregular electrical activity in the atria cannot pass through to the ventricles

A permanent pacemaker is required to control ventricular contraction

Anticoagulation is still needed to prevent strokes.

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6
Q

Explain the treatment that can be used as an option for those with contraindications to anticoagulation and a high stroke risk [1]

A

Left atrial appendage occlusion:

  • The left atrial appendage is a small pouch in the wall of the left atrium. It is the most common site for a thrombus to form.
  • Left atrial appendage occlusion involves inserting a catheter into the femoral vein, feeding that through the venous system to the right atrium and puncturing the septum between the atria to access the left atrium. Then, a plug is placed in the left atrial appendage, preventing blood from entering that area.
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7
Q

Name five side effect of amiodarone use [5]

A
  • Pneumonitis
  • Bradycardia and Heart Block
  • Hepatitis
  • Photosensitivty and grey discolouration
  • Thyroid abnormalties (hyper & hypo): amIODarone - iodine in the drug
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8
Q

Descrbe the MoA of digoxin? [2]

How does it specifically work to treat AF or atrial flutter [2]

A

Negatively chronotropic (decreases HR); but positively inotropic (increases contraction)

In AF & atrial flutter: causes increased vagal (parasympathetic tone) - reducing conduction at the AVN

(In HR: inhibits Na/K ATP pumps, causing Na to accumulate in the cells; causing increased Ca2+ intracellularly too - increasing contraction)

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9
Q

State 4 side effects of digoxin use [4]

A

Bradycardia
GI upset
Rash
Dizziness
Visual disturbance

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10
Q

Digoxin is contraindicated in which conditions [2]

A
  • Second degree heart block
  • Ventricular arrhythmias
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11
Q

Which drug classes can increase digoxin toxicity? [2]

A

Thiazide and loop diuretics (by causing hypokalaemia)

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12
Q

In patients presenting acutely with AF, it is first important to perform a clinical assessment (e.g. ABCDE) and determine haemodynamic stability.

If a patient is haemodynamically stable - describe the next stages of treatment

A

If AF has started within 48hrs of presentation
- Immediate pharmalogical cardioversion

If AF has started in more than 48hrs of presentation:
- Delayed, electrical cardioversion

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13
Q

Why is assessment of the cardiac function with echocardiography is required when cardioversion is being considered? [1]

A

Assessment of the cardiac function with echocardiography is required because flecainide (type I antiarrhythmic) is dangerous in structural heart disease (pro-arrhythmic and increased risk of sudden cardiac death)

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14
Q

Describe the managment plan after a stroke caused by AF [2]

A

Aspirin 300mg OD for two weeks AND lifelong clopidogrel

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15
Q

High blood pressure in young person + holosystolic murmur suggests which pathology? [1]

A

CoA

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16
Q

Statins must be temporarily stopped when a [] antibiotic is started

A

Statins must be temporarily stopped when a macrolide antibiotic is started
- e.g clarithromycin

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17
Q

What is the mechanism of action of alteplase?

ADP-receptor blocker
Activates plasminogen to form plasmin
Inhibits plasmin
Inhibits the conversion of fibrinogen to fibrin
Activates thrombin to form thromboplastin

A

What is the mechanism of action of alteplase?

ADP-receptor blocker
Activates plasminogen to form plasmin
Inhibits plasmin
Inhibits the conversion of fibrinogen to fibrin
Activates thrombin to form thromboplastin

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18
Q

in the majority of cases, or in a question without qualification, Wolff-Parkinson-White syndrome is associated with [] axis deviation

A

in the majority of cases, or in a question without qualification, Wolff-Parkinson-White syndrome is associated with left axis deviation

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19
Q

Describe the difference between Atrio-ventricular nodal re-entrant tachycardia (AVNRT)
and Atrio-ventricular re-entrant tachycardia (AVRT)

A

Atrio-ventricular nodal re-entrant tachycardia (AVNRT):
- Originates from a re-entrant retrograde electrical circuit involving the AV node, resulting in initiation and propagation of a cardiac tachyarrhythmia
- The re-entrant cycle occurs around the AVN

Atrio-ventricular re-entrant tachycardia (AVRT):
- originates via a re-entrant retrograde electrical circuit
- involves an accessory pathway between the atria and the ventricles, rather than the AV node
- This returning pathway causes causes the atria to contract BEFORE the SAN sends out another signal
- Some forms of AVRT may exhibit a Wolff-Parkinson-White pattern

https://www.osmosis.org/learn/Atrioventricular_nodal_reentrant_tachycardia_%28AVNRT%29

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20
Q

Which drugs are contra-indicated in a patient with known atrial fibrillation (or atrial flutter) and Wolff-Parkinson-White? [4]

Why? [1]

A
  • Beta blockers
  • CCBs
  • digoxin
  • adenosine

These medications may trigger ventricular fibrillation.

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21
Q

Describe the stepwise acute managment of SVT of patients without life-threatening features

A

Continuous ECG monitoring during management

Step 1: Vagal manoeuvres
Step 2: Adenosine (6,12,18 mg)
Step 3: Verapamil or a beta blocker
Step 4: Synchronised DC cardioversion

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22
Q

Describe what happens if you give adenosine to someone with atrial tachycardia (e.g. atrial flutter)

A

Increases AV block & create more flutter waves

C.f. AVRT & AVNRT which have excitation in the AVN, so adenosine works to treat them

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23
Q

Usually, long-term management of SVT is only indicated if the frequency and severity of SVT episodes significantly impacts on the patients quality of life and functioning.

What is the stepwise treatment options for long term management? [3]

A

1st line:
- radio-frequency ablation

2nd line (if decline RAB)
- BB or CCB

3rd line:
- flecainide and sotalol

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24
Q

Describe why pre-excitation & afib is bad [1]

How do you tx this? [2]

A

Atrial fibrillation is conducted down to the ventricle via the AVN AND the accessory pathway

Can lead to VF

Treat with DC cardioversion & ablation of accessory pathway

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25
Q

Name an electrolyte abnormality that could trigger sick sinus syndrome [1]

A

Hyperkalaemia

26
Q

Name an endocrine pathology that could trigger sick sinus syndrome [1]

A

Hypothyroidism.

27
Q

Which of the following does the drug MoA refer to

antimuscarinic medication that works by inhibiting the parasympathetic nervous system

Atropine
Adenosine
Amadiorone
Adrenaline

A

Which of the following does the drug MoA refer to

antimuscarinic medication that works by inhibiting the parasympathetic nervous system

Atropine
Adenosine
Amadiorone
Adrenaline

28
Q

Aortic regurgitation may be associated with an Austin-Flint murmur.

Which of the following best describes the classical Austin-Flint murmur?

A Early diastolic murmur
B Ejection systolic murmur
C Pansystolic murmur
D Mid-diastolic murmur
E Gallop rhythm

A

Aortic regurgitation may be associated with an Austin-Flint murmur.

Which of the following best describes the classical Austin-Flint murmur?

A Early diastolic murmur
B Ejection systolic murmur
C Pansystolic murmur
D Mid-diastolic murmur
E Gallop rhythm

29
Q

Describe what is meant by an Austin-Flint murmur

A

An Austin-Flint murmur is thought to occur due to a regurgitant jet of blood striking the anterior leaflet of the mitral valve as the atria attempt to force blood into the ventricles.

30
Q

Mechanical valves - target INR:
aortic: []
mitral: []

A

Mechanical valves - target INR:
aortic: 3.0
mitral: 3.5

31
Q

When is treatment indicated in Mobitz type I? [1]

What is first line? [1]

A

However, in cases such as this where the patient is symptomatic (typically pre-syncope/syncope, hypotension, bradycardia) and particularly in elderly patients, treatment might be considered, which would primarily consist of transcutaneous pacing.

32
Q

Crossmatch should be arranged in patients with suspected ruptured abdominal aorta aneurysm, most commonly [] units are ordered

A

Crossmatch should be arranged in patients with suspected ruptured abdominal aorta aneurysm, most commonly 6 units are ordered

33
Q

A patient falls and hits their head, investigations reveal SAH.

What ECG would you likely see? [1]

A

Subarachnoid haemorrhage is a cause of torsdaes de pointes

34
Q

Nicorandil is most useful in the management of:

Hypertension
Heart failure
Angina
Atrial fibrillation
Acute coronary syndrome

A

Nicorandil is most useful in the management of:

Hypertension
Heart failure
Angina
Atrial fibrillation
Acute coronary syndrome

35
Q

A patient has been admitted last week for infective endocarditis.

They have an ECG performed which shows new onset PR prolongation.

What is the likely diagnosis [1] and treatment? [1]

A

The newly lengthened PR interval (1st degree heart block) suggests peri-valvular abscess as a complication of infective endocarditis. Abscess is an indication for valve replacement.

36
Q

[] is the only calcium channel blocker licensed for use in heart failure.

A

amlodipine is the only calcium channel blocker licensed for use in heart failure.

37
Q

What would PR interval elongation be a sign of in infective endocarditis? [1]

A

Patients with aortic valve infective endocarditis are at risk of developing an aortic valve abscess which would be poor prognostically. One sign of an abscess formation is a progressive elongation of the PR interval

38
Q

A trans-thoracic echocardiogram is performed which shows a 5mm vegetation on a tricuspid valve leaflet. A blood culture has also returned positive for Staph aureus. He is admitted and commenced on IV antibiotics.

The day following his admission, his ECG shows the following:

Which of the following complications is likely to have manifested?

A

Perivavlular or aortic root abscesses are a potential complication of infective endocarditis.

39
Q

A 44 year old presents to the emergency department with a four week history of malaise, fevers and recent concerns over painful purple spots on his fingertips. He has been treated by his GP for a lower respiratory tract infection with a short course of doxycycline but this has done little to abate his symptoms. He is otherwise fit and well and takes no regular medications.

On examination he has raised, red and painful lesions on his fingertips and an ejection systolic murmur on auscultation of his chest. His lung fields are clear and he has non-swollen calves bilaterally.

His blood tests show a raised white cell count and a high C-reactive protein

An ECG shows normal sinus rhythm

Blood cultures have grown gram positive cocci in two different bottles

What would be the most appropriate antibiotic regimen for this gentleman?

Gentamicin 360mg once daily

1
Ciprofloxacin 500mg twice daily

2
Temocillin 2g twice daily

3
Nitrofurantoin 100mg three times daily

4
Flucloxacillin 2g 4-6 hourly

A

Flucloxacillin 2g 4-6 hourly
Flucloxacillin at high dose, sometimes with the addition of gentamicin at twice daily dosing, is the initial optimal management out of the options given. The high dose flucloxacillin will provide good gram positive cover against the suspected pathogen. Treatment course would be discussed with a microbiologist but often runs to between 6 and 8 weeks with re-imaging at this point

40
Q

A single positive blood culture of [3] meets a major criterion for infective endocarditis, for a total of two major criteria.

Note that this differs from other organisms such as** viridans streptococci, Staphylococcus aureus, Streptococcus bovis** and the HACEK group TWO separate blood cultures are required

A

Coxiella burnetii, Bartonella species or Chlamydia psittaci

41
Q

Describe the treatment
for:

TIA due to AF: [1]

TIA not due to AF [2]

Stroke due to AF: [2]

Stroke not due to AF: [2]

A

TIA due to AF: DOAC immediately and continue for life

TIA not due to AF: Aspirin 300mg immediately for 2 weeks and then clopidogrel lifelong

Stroke due to AF: Aspirin 300mg for 2 weeks and then DOAC lifelong

Stroke not due to AF: Aspirin 300mg for 2 weeks and then clopidogrel lifelong

42
Q

Describe different causes of postural (orthostatic hypotension) syncope [4]

A

Autonomic nervous failure secondary to drugs:
- this is the commonest cause of orthostatic hypotension.
- Common drugs include antihypertensives, diuretics, tricyclic antidepressants, antipsychotics and alcohol.

Hypovolaemia:
- hypovolaemia may be a key contributing factor in syncope.
- There may be a sinister underlying cause such as a gastrointestinal bleed.

Primary autonomic nervous failure:
- this is usually present to some degree in the spectrum of disorders which includes Parkinson’s disease, Lewy body dementia and multi-system atrophy.

Secondary autonomic nervous failure:
- occurs secondary to other conditions such as diabetes, uraemia and spinal cord lesions

43
Q

What are the investigations should do for orthostatic syncope? [2]

A

Lying and standing blood pressure

Tilt table testing:this will distinguish between postural and vasovagal syncope
- Tilt table testing: recreates trigger/situation while measuring BP and other signs to confirm the diagnosis

44
Q

Describe how bradyarrhythmia syncopes occur [3]

A

Usually there is either failure of impulse initiation by the sinus node (sick sinus syndrome) or impulse conduction to the ventricles.

When this occurs sporadically, there is usually an ectopic site further down the pathway which will take over and continue to beat at its own slower rate.

The reduction in blood pressure responsible for the syncope occurs when there is a long pause (usually >3 secs) between the impulse conduction failure and the ectopic escape mechanism.

45
Q

Describe how structural syncope occurs

A

Structural causes of syncope are usually due to mechanical obstruction in the left ventricular inflow or outflow tract.

Normally during exertion, systemic vasodilatation occurs in order to increase perfusion to skeletal muscle and the reduction in blood pressure is compensated for by an increased stroke volume and heart rate.

However, when there is an obstruction to outflow, this compensation does not happen and exertional syncope can occur due to a reduction in blood pressure during exercise.

46
Q

State 5 causes of structural syncope [5]

A

Causes of structural syncope include:

  • Valvular disease (e.g. aortic stenosis)
  • Cardiac masses (e.g. atrial myxoma)
  • Cardiomyopathy (e.g. hypertrophic cardiomyopathy)
  • Pericardial disease (e.g. constrictive pericarditis)
  • Non-cardiac causes (e.g. pulmonary embolism, aortic dissection)
47
Q

What is the first line treatment if someone is exhibiting bradycardia with sympptoms / evidence of life threatening signs? [1]

A

IV atropine 500 mcg

48
Q

A patient is exhibiting bradycardia with signs of MI. You give 500mg of IV atropine.

There is no satisfactory response. What is the next step in management? [4]

A
  • IV Atropine 500 mcg, repeat to maximum of 3mg
  • Isoprenaline 5mcg IV
  • Adrenaline 2-10mcg IV

OR

  • Transcutaneous pacing
49
Q

A patient has bradycardia and has no signs of shock / syncope / MI / HF but is at risk of asytole.

What are 4 conditions that means person is at risk of asytole? [4]

A
  • Recent asytole
  • Mobitz II AV block
  • Complete Heart Block with broad QRS
  • Ventricular pause > 3secs
50
Q

A patient has bradycardia and has no signs of shock / syncope / MI / HF but is at risk of asytole.

What is the next appropriate managemet steps? [4]

A
51
Q

Describe the treatment algorithm for ALS

A
  1. CPR 30:2
  2. Attach defibrillator
  3. Assess rhythm:
    - If shockable (VF / Pulseless VT): one shock, then resume CPR for 2 min then assess rhythm again and repeat
    - If non-shockable: immediately resume CPR for 2 mins and assess rhythm again

Adrenaline:
- 1 mg as soon as possible for non-shockable rhythms
- during a VF/VT cardiac arrest, adrenaline 1 mg is given once chest compressions have restarted after the third shock
- repeat adrenaline 1mg every 3-5 minutes whilst ALS continues

amiodarone:
* 300 mg should be given to patients who are in VF/pulseless VT after 3 shocks have been administered.
* a further dose of amiodarone 150 mg should be given to patients who are in VF/pulseless VT after 5 shocks have been administered

thrombolytic drugs:
* should be considered if a pulmonary embolus is suspected
* if given, CPR should be continued for an extended period of 60-90 minutes

52
Q

When performing ALS, under which conditions do you give three successive shocks? [1]

A

if the cardiac arrested is witnessed in a monitored patient (e.g. in a coronary care unit) then the 2015 guidelines recommend ‘up to three quick successive (stacked) shocks’, rather than 1 shock followed by CPR
&
if in ventricular fibrillation or pulseless VT

53
Q

When performing ALS, under which conditions do you give adrenaline? [1]

A

Non-shockable rhythms:
- adrenaline 1 mg as soon as possible

Shockable rhythms:
- adrenaline 1 mg is given once chest compressions have restarted after the third shock

repeat adrenaline 1mg every 3-5 minutes whilst ALS continues

54
Q

Which drugs should you stop prior to surgery? [4]

Give a timeline [4]

A

Cardiovascular drugs:
- Clopidogrel should be stopped 7 days before surgery
- warfarin should be (generally) stopped 5 days before surgery and instead patients should be on low molecular weight heparin until the night before
- ACE inhibitors should be stopped the day before surgery.

Combined oral contraceptive pill should be stopped 4-6 weeks before surgery, and re-started at least 2 weeks after surgery (when the patient is mobile). This reduces the risk of DVT.

55
Q

How do you treat Dresslers? [1]

A

Post infarction pericarditis or Dressler’s syndrome can occur in 5-10% of patients after an acute MI

Treat with high dose aspirin

56
Q

Concurrent use of clopidogrel and [] can make clopidogrel less effective

A

Concurrent use of clopidogrel and omeprazole/esomeprazole can make clopidogrel less effective

57
Q

A patient has neutropenic sepsis. What Abx should you give? [1]

A

IV tazocin

58
Q

Which antiplatelets alongside aspirin do you give a STEMI patient depending on their current anticoagulation? [2]

A

NO medication - pragusel
Anticoagulation: Clopidogrel

59
Q

Which antiplatelets alongside aspirin do you give an NSTEMI patient depending on their risk of bleeding? [2]

A

Low risk of bleeding:
- Aspirin; Ticagrelor; Fondaparinoux

High risk of bleeding:
- Aspirin; Clopidogrel; Fondaparinoux

60
Q

A 47 year old woman presents to her GP with a history of breathlessness of 6 months duration. On examination she has a large a wave of her jugular venous pressure.

Which condition is likely to be the cause of the large a wave?

Heart failure

Mitral valve prolapse

Mitral regurgitation

Pulmonary hypertension

Tricuspid regurgitation

A

Pulmonary hypertension

61
Q

What is Carvallo’s sign? [1]

A

Tricuspid regurgitationm murmur being louder on inspiration

62
Q

What is psoas sign and what does it indicate? [1]

A

Extend right hip
If positive: feel pain in RIF
Indicates appendicitis
Caused by appendix in the retrocaecal position moving agaisnt iliopsoas muscle and causing irritation

Yr 3: CN2 (29 decks)

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