Cardiology II Flashcards by patrick ellis

Synchronised DC cardioversion aims to deliver a shock with which part of the ECG? [1]

R wave

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A patient presents with AF. Describe a clinical sign you might see relating to their radial pulse [1]

Apical to radial pulse deficit occurs as not all atrial impulses (palpable at the apex) are mechanically conducted to the ventricles (palpable as a peripheral pulse)

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Where do you place the electrode for V1 on an ECG? [1]

4th intercostal space, right sternal edge

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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]

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.

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Nicorandil is most useful in the management of:

Hypertension
Heart failure
Angina
Atrial fibrillation
Acute coronary syndrome

Nicorandil is most useful in the management of:

Hypertension
Heart failure
Angina
Atrial fibrillation
Acute coronary syndrome

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

What ECG would you likely see? [1]

Subarachnoid haemorrhage is a cause of torsdaes de pointes

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

What is first line? [1]

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.

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

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

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Synchronised DC cardioversion aims to avoid delivering a shock with which part of the ECG? [1]

T wave - risk of causing VF

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

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

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

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

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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Describe the dosing regimen of apixaban and dabigatran compared to edoxaban and rivaroxaban? [2]

Apixaban and dabigatran are taken twice daily

Edoxaban and rivaroxaban are taken once daily.

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Describe what is meant by INR with regards to warfarin treatment [1]

The INR (international normalised ratio) is used to assess how anticoagulated the patient is by warfarin.

The INR calculates the patient’s prothrombin time (time to clot) compared with the prothrombin time of an average healthy adult.

An INR of 2 means the patient has a prothrombin time twice that of an average healthy adult (it takes them twice as long to form a blood clot).

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Which factors contribute to the CHA2DS2-VASc score? [8]

CHA2DS2-VASc is a mnemonic for the factors that score a point:

C – Congestive heart failure
H – Hypertension
A2 – Age above 75 (scores 2)
D – Diabetes
S2 – Stroke or TIA previously (scores 2)
V – Vascular disease
A – Age 65 – 74
S – Sex (female)

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What CHA2DS2-VASc indicates anticoagulation treatment for AF? [3]
(NICE, 2021)

0 – no anticoagulation

1 – consider anticoagulation in men (women automatically score 1)

2+ – offer anticoagulation

NB: Aspirin alone is NOT used for stroke prevention in atrial fibrillation (using aspirin was an option years ago).

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The NICE guidelines recommend using the [] score for assessing the risk of major bleeding in patients with atrial fibrillation taking anticoagulation.

The NICE guidelines recommend using the ORBIT score for assessing the risk of major bleeding in patients with atrial fibrillation taking anticoagulation.

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

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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What is the difference in when digoxin and CCBs such as verapamil and diltiazem are effective? [2]

Digoxin: only works when at rest (therefore less preferable)
Verapamil and Diltiazem: work at rest and during exercise

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Name five side effect of amiodarone use [5]

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

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Descrbe the MoA of digoxin? [2]

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

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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State 4 side effects of digoxin use [4]

Bradycardia
GI upset
Rash
Dizziness
Visual disturbance

Digoxin is contraindicated in which conditions [2]

Second degree heart block
Ventricular arrhythmias

Which drug classes can increase digoxin toxicity? [2]

**Thiazide** and **loop** **diuretics** (by causing hypokalaemia)

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

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

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

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)**

Following cardioversion for acute AF, anticoagulation is commonly given for a minimum of **[]** weeks, even in patients at low-risk because of the risk of thromboembolism from **[]** Long-term continuation is then guided by usual risk stratification (i.e. CHADS-VASc).

Following cardioversion, anticoagulation is commonly given for a **minimum of 4 weeks,** even in patients at low-risk because of the risk of thromboembolism from **atrial stunning post-restoration of sinus rhythm**. Long-term continuation is then guided by usual risk stratification (i.e. CHADS-VASc).

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

**Aspirin 300mg OD for two weeks** AND **lifelong** **clopidogrel**

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

**CoA**

Coarctation of the aorta is associated with which specific valve pathology? [1]

**Bicuspid aortic valve**

*Consecutive, normally-conducted QRS complexes that alternate in height* refers to what ECG phenomona? [1] What pathology does it suggest? [1]

**Electrical alternans - suggests cardiac tamponade**

What pathology does this ECG suggest? [1]

Alternating QRS amplitude and axis = electrical alterans - cardiac tamponade

An out-of-hospital cardiac arrest has arrived in the emergency department. After 2 minutes of chest compressions, the rhythm check shows asystole. Adrenaline 1mg is drawn up to be administered. However, after 4 failed attempts, the resuscitation team are unable to establish intravenous access with a peripheral cannula. What is the next best site to use for drug delivery? Deltoid muscle Endotracheal tube Femoral vein Internal jugular vein Proximal tibia

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

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

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

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

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

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

Describe the two types of WPW [2]

**type A (left-sided pathway):** - dominant R wave in V1 **type B (right-sided pathway):** - no dominant R wave in V1

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

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

What common ECG changes do you see in AVRT? [2]

**Pre-excitation**: - **Initial slurring of QRS complex**: the **first part of QRS is less steep** due to **activation** of an **accessory pathway** - **Reduced PR interval** ADD PHOTO to this from lecture

Which drugs are contra-indicated in a patient with known atrial fibrillation (or atrial flutter) and Wolff-Parkinson-White? [4] Why? [1]

- **Beta blockers** - **CCBs** - **digoxin** - **adenosine** These medications may **trigger ventricular fibrillation.**

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

**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

Describe the MoA of adenosine [1]

**Interrupts the AV node** or **accessory** **pathway** during **SVT** and “**resets**” it to **sinus rhythm.**

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

**Increases AV block** & create more flutter waves *C.f. AVRT & AVNRT which have excitation in the AVN, so adenosine works to treat them*

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]

1st line: - **radio-frequency ablation** 2nd line (if decline RAB) - **BB or CCB** 3rd line: - **flecainide** and **sotalol**

Describe how Synchronised DC Cardioversion works [1]

**Synchronised DC Cardioversion**: - electric shock applied to the heart to restore normal sinus rhythm - A defibrillator machine monitors the electrical signal, particularly identifying the R waves. - **An electric shock is synchronised with a ventricular contraction, at the R wave on the ECG. If successful, the shock will be followed by sinus rhythm**.

Describe why pre-excitation & afib is bad [1] How do you tx this? [2]

**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**

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

**Hyperkalaemia**

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

Hypothyroidism.

What is the most common cause of sick sinus syndrome Idiopathic Degenerative Fibrosis Ischaemia. Cardiomyopathies. Infiltrative Diseases e.g. sarcoidosis, haemochromatosis. Congenital abnormalities.

What is the most common cause of sick sinus syndrome **Idiopathic Degenerative Fibrosis** Ischaemia. Cardiomyopathies. Infiltrative Diseases e.g. sarcoidosis, haemochromatosis. Congenital abnormalities.

Which of the following does the drug MoA refer to *antimuscarinic medication that works by inhibiting the parasympathetic nervous system* Atropine Adenosine Amadiorone Adrenaline

Which of the following does the drug MoA refer to *antimuscarinic medication that works by inhibiting the parasympathetic nervous system* **Atropine** Adenosine Amadiorone Adrenaline

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

Describe what is meant by an Austin-Flint murmur

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.

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

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

systolic anterior movement (SAM) of the anterior leaflet of mitral valve on echocardiogram or cMR support what diagnosis? [1]

**HOCM**

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

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