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Yr 3: CN2 > Cardiology II > Flashcards

Cardiology II Flashcards

1
Q
A
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2
Q

Describe the investigations used to investigate IE

A

Blood cultures BEFORE Abx:
- Three blood culture samples are recommended, usually separated by at least 6 hours and taken from different sites.

Transoesophageal echocardiography (TOE)
- Vegetations (an abnormal mass or collection) may be seen on the valves

Special imaging investigations may be used in patients with prosthetic heart valves:
- 18F-FDG PET/CT
- SPECT-CT

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3
Q

What is the name for the criteria used for IE? [1]

Describe how a diagnosis is made from Dukes criteria [1]

A

Modified Duke criteria

A diagnosis requires either:
* One major plus three minor criteria
* Five minor criteria

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4
Q

What are the major criteria in Dukes classification of IE? [2]

What are the minor criteria in Dukes classification of IE? [5]

A

Major criteria:
* Persistently positive blood cultures (typical bacteria on multiple cultures) - persistent bacteraemia with 2x blood cultures >12 hours apart or =>3 positive blood cultures with less specific microorganisms (S.aureus or S. epidermidis).
* Specific imaging findings (e.g., a vegetation seen on the echocardiogram)
* Single positive blood culture for Coxiella burnetti or positive antibody titre

Minor criteria are:
* Predisposition (e.g., IV drug use or heart valve pathology)
* Fever above 38°C
* Vascular phenomena (e.g., splenic infarction, intracranial haemorrhage and Janeway lesions)
* Immunological phenomena (e.g., Osler’s nodes, Roth spots and glomerulonephritis)
* Microbiological phenomena (e.g., positive cultures not qualifying as a major criterion)

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5
Q

Which Abx are the mainstay treatment for IE? [1]

A

Intravenous broad-spectrum antibiotics (e.g., amoxicillin and optional gentamicin) are the mainstay of treatment

The choice of antibiotic may be more specific once the causative organism is identified on cultures.

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6
Q

Describe the treatment regime for Staphylococcus aureus IE:

Methicillin-sensitive staphylococcus aureus (MSSA)? [1]

Methicillin-resistance staphylococcus aureus (MRSA)? or penicillin allergy? [1]

A

Methicillin-sensitive staphylococcus aureus (MSSA):
* flucloxacillin 12 g/day in 4-6 doses. Duration 4-6 weeks.

Methicillin-resistance staphylococcus aureus (MRSA) or penicillin allergy:
* vancomycin 30-60 mg/kg/day in 2-3 doses. Duration 4-6 weeks.

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7
Q

How do you alter Staph. aureus treatment of IE if a patient has a prosethetic valve? [3]

A

NOTE: in the presence of a prosthetic valve, rifampicin and gentamicin should be added to both regimens and the duration should be ≥6 weeks.

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8
Q

Describe the treatment regimes for difference IE valves / pathogens

A
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9
Q

Describe the treatment regimes for IE, typically used for oral Streptococci and Streptococcus bovis:

Standard four-week regimen [1]

Standard two-week regimen [1]

Penicillin allergic [1]

A

The regimen depends on how resistant the organism is to penicillin. If no resistance, the usual antibiotics may include:

  • Standard four-week regimen: penicillin G, OR amoxicillin, OR ceftriaxone
  • Standard two-week regimen: penicillin G, OR amoxicillin, OR ceftriaxone combined with gentamicin.
  • Penicillin allergic: vancomycin for four weeks
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10
Q

Describe the tx regime if orgnaism not yet known:

Native valve or late prosthetic valve? [3]
Early prosthetic valve endocarditis? [2]

A

Native valve endocarditis or late prothetic valve endocarditis:
- Ampicillin & flucloxacillin
& gentamicin

OR
- vancomycin & gentamicin.

Early prosthetic valve endocarditis:
- vancomycin & gentamicin & rifampicin.

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11
Q

IE management:

Antibiotics are typically continued for at least:

[] weeks for with native heart valves
[] weeks for patients with prosthetic heart valves

A

Antibiotics are typically continued for at least:

4 weeks for with native heart valves
6 weeks for patients with prosthetic heart valves

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12
Q

Staphylococcus aureus is most likely to cause IE in which three populations? [3]

A
  • patients with no past medical history
  • IVDUs who present acutely
  • prosthetic valves after two months
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13
Q

Which of the following is the most cause of endocarditis in patients following prosthetic valve surgery?

Staphylococcus epidermidis
Streptococcus viridans
Staphylococcus aureus
Streptococcus bovis
Streptococcus sanguinis

A

Which of the following is the most cause of endocarditis in patients following prosthetic valve surgery?

Staphylococcus epidermidis
Streptococcus viridans
Staphylococcus aureus
Streptococcus bovis
Streptococcus sanguinis

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14
Q

Which of the following is the most cause of endocarditis in patients with colorectal cancer?

Staphylococcus epidermidis
Streptococcus viridans
Staphylococcus aureus
Streptococcus bovis
Streptococcus sanguinis

A

Which of the following is the most cause of endocarditis in patients with colorectal cancer?

Staphylococcus epidermidis
Streptococcus viridans
Staphylococcus aureus
Streptococcus bovis
Streptococcus sanguinis

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15
Q

Which of the following is associated most with poor dental hygiene / following a dental procedure?

Staphylococcus epidermidis
Streptococcus viridans
Staphylococcus aureus
Streptococcus bovis
Streptococcus sanguinis

A

Which of the following is associated most with poor dental hygiene / following a dental procedure?

Staphylococcus epidermidis
Streptococcus viridans
Staphylococcus aureus
Streptococcus bovis
Streptococcus sanguinis

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16
Q

Which of the following is associated most with patients with no prior past medical history?

Staphylococcus epidermidis
Streptococcus viridans
Staphylococcus aureus
Streptococcus bovis
Streptococcus sanguinis

A

Which of the following is associated most with patients with no prior past medical history?

Staphylococcus epidermidis
Streptococcus viridans
Staphylococcus aureus
Streptococcus bovis
Streptococcus sanguinis

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17
Q

Which of the following is associated most with IVDU who present acutely?

Staphylococcus epidermidis
Streptococcus viridans
Staphylococcus aureus
Streptococcus bovis
Streptococcus sanguinis

A

Which of the following is associated most with IVDU who present acutely?

Staphylococcus epidermidis
Streptococcus viridans
Staphylococcus aureus
Streptococcus bovis
Streptococcus sanguinis

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18
Q

Which of the following is associated most with IE in the first 2 months following prosthetic valve surgery

Staphylococcus epidermidis
Streptococcus viridans
Staphylococcus aureus
Streptococcus bovis
Streptococcus sanguinis

A

Which of the following is associated most with IE in the first 2 months following prosthetic valve surgery

Staphylococcus epidermidis
Streptococcus viridans
Staphylococcus aureus
Streptococcus bovis
Streptococcus sanguinis

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19
Q

Gentamicin has a risk of causing what as a side effect? [1]

A

AKI

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20
Q

Is the most appropriate first-line anti-anginal for stable angina in a patient with known heart failure, if there are no contraindications?

A. Verapamil
B. Amlodipine
C. Nifedipine
D. Bisoprolol
E. Nicorandil
F. Isosorbide mononitrate

A

Is the most appropriate first-line anti-anginal for stable angina in a patient with known heart failure, if there are no contraindications?

A. Verapamil
B. Amlodipine
C. Nifedipine
D. Bisoprolol
E. Nicorandil
F. Isosorbide mononitrate

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21
Q

amoxicillin + gentamicin is the treatment for:

native valve endocarditis with severe sepsis, penicillin allergy or suspected methicillin-resistent staphylococcus aureus (MRSA)
Native valve endocarditis
Prosthetic valve endocarditis
NVE with severe sepsis and risk factors gram negative infection

A

Native valve endocarditis

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22
Q

vancomycin + meropenem is the treatment for:

native valve endocarditis with severe sepsis, penicillin allergy or suspected methicillin-resistent staphylococcus aureus (MRSA)
Native valve endocarditis
Prosthetic valve endocarditis
NVE with severe sepsis and risk factors gram negative infection

A

vancomycin + meropenem is the treatment for:

native valve endocarditis with severe sepsis, penicillin allergy or suspected methicillin-resistent staphylococcus aureus (MRSA)
Native valve endocarditis
Prosthetic valve endocarditis
NVE with severe sepsis and risk factors gram negative infection

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23
Q

vancomycin, gentamicin + rifampacin is the treatment for

native valve endocarditis with severe sepsis, penicillin allergy or suspected methicillin-resistent staphylococcus aureus (MRSA)
Native valve endocarditis
Prosthetic valve endocarditis
NVE with severe sepsis and risk factors gram negative infection

A

Prosthetic valve endocarditis

24
Q

vancomycin + gentamicin is the treatment for

native valve endocarditis with severe sepsis, penicillin allergy or suspected methicillin-resistent staphylococcus aureus (MRSA)
Native valve endocarditis
Prosthetic valve endocarditis
NVE with severe sepsis and risk factors gram negative infection

A

vancomycin + gentamicin is the treatment for

native valve endocarditis with severe sepsis, penicillin allergy or suspected methicillin-resistent staphylococcus aureus (MRSA)
Native valve endocarditis
Prosthetic valve endocarditis
NVE with severe sepsis and risk factors gram negative infection

25
Q

Which of the following would you use to treat native valve endocarditis?

vancomycin + gentamicin
vancomycin + meropenem
vancomycin, gentamicin + rifampacin
amoxicillin + gentamicin

A

Which of the following would you use to treat native valve endocarditis?

vancomycin + gentamicin
vancomycin + meropenem
vancomycin, gentamicin + rifampacin
amoxicillin + gentamicin

26
Q

Which of the following would you use to treat MRSA +ve endocarditis?

vancomycin + gentamicin
vancomycin + meropenem
vancomycin, gentamicin + rifampacin
amoxicillin + gentamicin

A

Which of the following would you use to treat MRSA +ve endocarditis?

vancomycin + gentamicin
vancomycin + meropenem
vancomycin, gentamicin + rifampacin
amoxicillin + gentamicin

27
Q

Which of the following would you use to treat NVE with severe sepsis and risk factors gram negative infection?

vancomycin + gentamicin
vancomycin + meropenem
vancomycin, gentamicin + rifampacin
amoxicillin + gentamicin

A

Which of the following would you use to treat NVE with severe sepsis and risk factors gram negative infection?

vancomycin + gentamicin
vancomycin + meropenem
vancomycin, gentamicin + rifampacin
amoxicillin + gentamicin

28
Q

Which of the following would you use to treat prosethetic valve endocarditis?

vancomycin + gentamicin
vancomycin + meropenem
vancomycin, gentamicin + rifampacin
amoxicillin + gentamicin

A

Which of the following would you use to treat prosethetic valve endocarditis?

vancomycin + gentamicin
vancomycin + meropenem
vancomycin, gentamicin + rifampacin
amoxicillin + gentamicin

29
Q

A patient is diagnosed with HOCM.

What medication should be avoided in this patient?

Amiodarone
Atenolol
Disopyramide
Ramipril
Verapamil

A

A patient is diagnosed with HOCM.

What medication should be avoided in this patient?

Amiodarone
Atenolol
Disopyramide
Ramipril
Verapamil

Angiotensin-converting enzyme (ACE) inhibitors are contraindicated in hypertrophic obstructive cardiomyopathy (HOCM) with left ventricular outflow tract (LVOT) obstruction. ACE inhibitors can reduce afterload which may worsen the LVOT gradient

30
Q

What is the pneumonic for signs of HOCM on ECHO? [3]

A

MR SAM ASH

  • mitral regurgitation (MR)
  • systolic anterior motion (SAM) of the anterior mitral valve leaflet
  • asymmetric hypertrophy (ASH)
31
Q

A patient presents with fever, neuro signs, thrombocytopenia, haemolytic anaemia and renal failure. What is the most likely diagnosis? [1]

A

TTP
Think FATRN - fever, anaemia, thrombocytopenia, renal failure, neuro features

32
Q

What findings would indicate that a person is suffering from aortic sclerosis not stenosis? [2]

A

no radiation, no ECG changes are more consistent with sclerosis than stenosis.

33
Q

HOCM is associated with which pulse changes? [2]

A

Jerky pulse
bisferiens pulse

34
Q

A diabetic patient has a high HbA1C.

What anti-hypertensive is CI and why? [1]

A

Thiazides can worsen glucose tolerance

Indapamide is a thiazide diuretic and should be avoided as this patient likely has inadequate glucose control at present.

35
Q

Which electrolyte imbalances are a risk factor for digoxin toxicity? [3]

A

hypokalaemia, hypomagnesaemia or hypercalcaemia.

36
Q

Describe the pathophysiology, triggers and diagnosis of Brugada syndrome [3]

A

Automsomal dominant Na channelopathy associated with arrythmias such as VF or VT
- Triggers typically are heavy alcohol use, fever, heavy meal, dehydration, certain medications
- Diagnosis is via ECG

37
Q

What is the first and second line treatment for Brugada syndrome? [2]

A
  1. Lifestyle (avoid XS alcohol, fever treated with paracetamol, hydration)
  2. Definitive management: ICD. Can use Quinidine if needed on top
38
Q

How do you treat thrombophlebitis? [3]

A

Compression stockings (but do ABPI before)
NSAIDs
Consider LMWH to decrease risk of DVT

39
Q

A 48-year-old man notices that he is becoming increasingly dizzy when he plays squash, in addition he has also developed cramping pain in his left arm. One day he is inflating his car tyre with a hand held pump, he collapses and is brought to hospital.

Subclavian steal syndrome
Takayasu’s arteritis
Cervical rib
Aortic coarctation
Patent ductus arteriosus

A

A 48-year-old man notices that he is becoming increasingly dizzy when he plays squash, in addition he has also developed cramping pain in his left arm. One day he is inflating his car tyre with a hand held pump, he collapses and is brought to hospital.

Subclavian steal syndrome

  • Due to proximal stenotic lesion of the subclavian artery
  • Results in retrograte flow through vertebral or internal thoracic arteries
  • The result is that decrease in cerebral blood flow may occur and produce syncopal symptoms
  • A duplex scan and/ or angiogram will delineate the lesion and allow treatment to be planned
40
Q

A 24-year-old lady from Western India presents with symptoms of lethargy and dizziness, worse on turning her head. On examination her systolic blood pressure is 176/128. Her pulses are impalpable at all peripheral sites. Auscultation of her chest reveals a systolic heart murmur.

Subclavian steal syndrome
Takayasu’s arteritis
Cervical rib
Aortic coarctation
Patent ductus arteriosus

A

A 24-year-old lady from Western India presents with symptoms of lethargy and dizziness, worse on turning her head. On examination her systolic blood pressure is 176/128. Her pulses are impalpable at all peripheral sites. Auscultation of her chest reveals a systolic heart murmur.

Takayasu’s arteritis
- Takayasu’s arteritis most commonly affects young Asian females. Pulseless peripheries are a classical finding. The CNS symptoms may be variable.

41
Q

A 25-year-old junior doctor has a chest x-ray performed as part of a routine insurance medical examination. The x-ray shows evidence of rib notching. Auscultation of his chest reveals a systolic murmur which is loudest at the posterior aspect of the fourth intercostal space.

Subclavian steal syndrome
Takayasu’s arteritis
Cervical rib
Aortic coarctation
Patent ductus arteriosus

A

A 25-year-old junior doctor has a chest x-ray performed as part of a routine insurance medical examination. The x-ray shows evidence of rib notching. Auscultation of his chest reveals a systolic murmur which is loudest at the posterior aspect of the fourth intercostal space.

Subclavian steal syndrome
Takayasu’s arteritis
Cervical rib
Aortic coarctation
Patent ductus arteriosus
- Untreated patients develop symptoms of congestive cardiac failure

42
Q

A patient has bubbly urine.

What might be the cause? [1]

A

An enterovesical fistula may cause bubbly urine

43
Q

Describe the three main types of fistulae:

A

Enterocutaneous:
- link the intestine to the skin
- They may be high (> 500ml) or low output (< 250ml) depending upon source
- may result from the spontaneous rupture of an abscess cavity onto the skin (such as following perianal abscess drainage) or may occur as a result of iatrogenic input.

Enteroenteric; Enterovaginal; Enterocolic
- involves the large or small intestine.
- bacterial overgrowth may precipitate malabsorption syndromes; this may be particularly serious in inflammatory bowel disease.

Enterovesicular;
- This type of fistula goes to the bladder. These fistulas may result in frequent urinary tract infections, or the passage of gas from the urethra during urination.

44
Q

What is the name of this sign when asked for description of chest pain? [1]

A

Levine’s sign

45
Q

What is decubitus angina? [1]

A

Form of stable angina where get pain when lying down without any apparent cause

46
Q

What is meant by Prinzmetal’s or variant angina? [1]

A

When you get transient ST elevation due to coronary vasopasm (artery isn’t blocked, but muscle is in spasm)

47
Q

What is meant by cardiac syndrome X? [1]

A

St depression on excerise ECG but normal angiogram

Sign of microvascular angina

48
Q

What is the name for this sign of hyperlipdaemia? [1]

A

corneal arcus lipid deposits that appear as rings on the outer region of the cornea

49
Q

NICE:
What investigations are used to investigate angina? [3]

A

1st line:
- CTCA (+calcium score)

2nd line:
- Non-invasive functional imaging (looking for reversible myocardial ischaemia)

3rd line:
- Invasive coronary angiography

50
Q

Describe the treatment algorithm for stable angina patients [5]

A

Sublingual glyceryl trinitrate to abort angina attacks

All patients:
- Aspirin 75 mg
- Statin

1st line:
- Beta blocker: e.g. metoprolol
- CCB: e.g. Amlodopine
- If there is a poor response to initial treatment then medication should be increased to the maximum tolerated dose (e.g. for atenolol 100mg od)
- If a patient is still symptomatic after monotherapy with a beta-blocker add a calcium channel blocker and vice versa

2nd line:
- a long-acting nitrate: Isosorbide mononitrate
- ivabradine
- nicorandil
- ranolazine

3rd line:
- CABG
- PCI

51
Q

Describe the MoA of ivabradine [1]

A

pacemaker current inhibitor: slows the HR down (not a Beta blocker)

52
Q

Describe the MoA of ranolizine [1]

A

Late Na current blocker

53
Q

Nicorandil has a rare AE of ? [1]

A

GI ulceration

54
Q

How can you remember the drugs used for secondary prevention of stable angina patients? [4]

A

4 As:

A – Aspirin 75mg once daily
A – Atorvastatin 80mg once daily
A – ACE inhibitor (if diabetes, hypertension, CKD or heart failure are also present)
A – Already on a beta blocker for symptomatic relief

55
Q

What are target times for coronary angiography for:

STEMI [1]
NSTEMI [1]

A

STEMI: < 6 hours
NSTEMI: < 72 hours

56
Q

In cases of primary PCI, which is the first line P2Y12 inhibitor? [1]

Why? [1]

A

Ticagrelor: most rapidly acting

Yr 3: CN2 (29 decks)

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