Cardiology III Flashcards
What is the treatment for antiphospholipid syndrome in pregnancy? [2]
aspirin + LMWH
Describe the pathophysiology, triggers and diagnosis of Brugada syndrome [3]
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
What is the first and second line treatment for Brugada syndrome? [2]
- Lifestyle (avoid XS alcohol, fever treated with paracetamol, hydration)
- Definitive management: ICD. Can use Quinidine if needed on top
A patient presents with nausea and vomiting, blurred vision/discolouration of vision, fatigue and syncope.
They tell you they are on a medication for their heart but can’t remember which one.
What is the most likely drug? [1]
Digoxin
- suffering from digoxin toxicity
Which electrolyte imbalances are a risk factor for digoxin toxicity? [3]
hypokalaemia, hypomagnesaemia or hypercalcaemia.
State the three steps to manage digoxin toxicity [3]
The management of digoxin toxicity depends on the severity of symptoms, ECG features and the serum digoxin levels.
Stop digoxin
Correct dyselectrolytaemia
Administer digifab (digoxin specific antibody indicated in lifethreatening digoxin toxicity).
What is the most appropriate management strategy for patients with rheumatic fever? [1]
Secondary prophylaxis with long-term penicillin is the most appropriate management strategy for patients with rheumatic fever. It helps prevent recurrent group A streptococcal infections, which can lead to further episodes of rheumatic fever and potential complications, such as rheumatic heart disease.
A patient presents to the hospital after an MI with acute SOB with a new systolic murmur loudest at the apex radiating to the axilla.
What is the most likely cause? [1]
Flash pulmonary oedema can occur after acute mitral valve regurgitation due to myocardial infarction
A patient presents with features that suggest an MI, such as crushing chest pain, sweating and a feeling of dread. After an hour this has resolved. She has a background of ischaemic heart disease.
You perform an ECG and see deeply inverted T-waves in leads V2-V3 (which may extend to V1-V6) with no or minimal ST-elevation and preserved R wave progression.
What is the most likely diagnosis? [1]
Describe the pathophysiology [1]
Wellens syndrome:
Critical stenosis of the left anterior descending artery and is a medical emergency, requiring urgent PCI as per ACS protocol
A patient is diagnosed with HOCM.
What medication should be avoided in this patient?
Amiodarone
Atenolol
Disopyramide
Ramipril
Verapamil
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
What is the pneumonic for signs of HOCM on ECHO? [3]
MR SAM ASH
- mitral regurgitation (MR)
- systolic anterior motion (SAM) of the anterior mitral valve leaflet
- asymmetric hypertrophy (ASH)
A patient presents with fever, neuro signs, thrombocytopenia, haemolytic anaemia and renal failure. What is the most likely diagnosis? [1]
TTP
Think FATRN - fever, anaemia, thrombocytopenia, renal failure, neuro features
What are the risk factors for IE?
- Intravenous drug use
- Structural heart pathology
- Chronic kidney disease (particularly on dialysis)
- Immunocompromised (e.g., cancer, HIV or immunosuppressive medications)
- History of infective endocarditis
Describe the symptoms of IE [7]
- Fever (90%)
- Malaise, lethargy
- Anorexia
- Weight loss
- Abdominal pain: splenic abscess
- Haematuria: renal embolic phenomenon
- Cardiac symptoms: shortness of breath, chest pain, palpitations
Name and describe this sign of IE [1]
Is it more likely in acute or subacute?
Roth spots: exudative, oedematous hemorrhagic lesions of the retina with pale centre (immune complex deposition)
Subacute > acute.
Name this sign of IE [1]
Conjunctival petechiae in infective endocarditis
Which neurological emboli can IE cause? [4]
cerebral abscess
intracerebral haemorrhage
embolic stroke
seizures
Describe the investigations used to investigate IE
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
What is the name for the criteria used for IE? [1]
Describe how a diagnosis is made from Dukes criteria [1]
Modified Duke criteria
A diagnosis requires either:
* One major plus three minor criteria
* Five minor criteria
What are the major criteria in Dukes classification of IE? [2]
What are the minor criteria in Dukes classification of IE? [5]
Major criteria:
* Persistently positive blood cultures (typical bacteria on multiple cultures)
* Specific imaging findings (e.g., a vegetation seen on the echocardiogram)
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)
Which Abx are the mainstay treatment for IE? [1]
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.
Describe the treatment regime for Staphylococcus aureus IE:
Methicillin-sensitive staphylococcus aureus (MSSA)? [1]
Methicillin-resistance staphylococcus aureus (MRSA)? or penicillin allergy? [1]
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.
How do you alter Staph. aureus treatment of IE if a patient has a prosethetic valve? [3]
NOTE: in the presence of a prosthetic valve, rifampicin and gentamicin should be added to both regimens and the duration should be ≥6 weeks.
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]
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
Describe the tx regime if orgnaism not yet known:
Native valve or late prosthetic valve? [3]
Early prosthetic valve endocarditis? [2]
Native valve endocarditis or late prothetic valve endocarditis:
- Ampicillin & flucloxacillin
& gentamicin
OR
- vancomycin & gentamicin.
Early prosthetic valve endocarditis:
- vancomycin & gentamicin & rifampicin.
IE management:
Antibiotics are typically continued for at least:
[] weeks for with native heart valves
[] weeks for patients with prosthetic heart valves
Antibiotics are typically continued for at least:
4 weeks for with native heart valves
6 weeks for patients with prosthetic heart valves
When might surgery be indicated in IE? [3]
- Heart failure relating to valve pathology
- Large vegetations or abscesses: prevention of embolism
- Infections not responding to antibiotics
Infective endocarditis has a high mortality rate
What are four key complications that patients are at risk of? [4]
- Heart valve damage, causing regurgitation
- Heart failure
- Infective and non-infective emboli (causing abscesses, strokes and splenic infarction)
- Glomerulonephritis, causing renal impairment
Describe the surgical management of IE [1]
The two main aims of surgery are removal of infected tissue and reconstruction of cardiac anatomy (i.e. valve repair or replacement).
Staphylococcus aureus is most likely to cause IE in which three populations? [3]
- patients with no past medical history
- IVDUs who present acutely
- prosthetic valves after two months
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
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
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
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
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
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
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
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
Which of the following is associated most with IVDU who present acutely?
Staphylococcus epidermidis
Streptococcus viridans
Staphylococcus aureus
Streptococcus bovis
Streptococcus sanguinis
Which of the following is associated most with IVDU who present acutely?
Staphylococcus epidermidis
Streptococcus viridans
Staphylococcus aureus
Streptococcus bovis
Streptococcus sanguinis
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
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
Gentamicin has a risk of causing what as a side effect? [1]
AKI
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
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
Patients may develop tolerance to this medication necessitating a change in dosing regime
A. Verapamil
B. Amlodipine
C. Nifedipine
D. Bisoprolol
E. Nicorandil
F. Isosorbide mononitrate
Patients may develop tolerance to this medication necessitating a change in dosing regime
A. Verapamil
B. Amlodipine
C. Nifedipine
D. Bisoprolol
E. Nicorandil
F. Isosorbide mononitrate
Infective endocarditis:
Acute endocarditis is most commonly caused by []
Subacute cases are most commonly caused by [] .
Acute endocarditis is most commonly caused by Staphylococcus
Subacute cases are most commonly caused by Streptococcus species.
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
Native valve endocarditis
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
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
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
Prosthetic valve endocarditis
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
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
Which of the following would you use to treat native valve endocarditis?
vancomycin + gentamicin
vancomycin + meropenem
vancomycin, gentamicin + rifampacin
amoxicillin + gentamicin
Which of the following would you use to treat native valve endocarditis?
vancomycin + gentamicin
vancomycin + meropenem
vancomycin, gentamicin + rifampacin
amoxicillin + gentamicin
Which of the following would you use to treat MRSA +ve endocarditis?
vancomycin + gentamicin
vancomycin + meropenem
vancomycin, gentamicin + rifampacin
amoxicillin + gentamicin
Which of the following would you use to treat MRSA +ve endocarditis?
vancomycin + gentamicin
vancomycin + meropenem
vancomycin, gentamicin + rifampacin
amoxicillin + gentamicin
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
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
Which of the following would you use to treat prosethetic valve endocarditis?
vancomycin + gentamicin
vancomycin + meropenem
vancomycin, gentamicin + rifampacin
amoxicillin + gentamicin
Which of the following would you use to treat prosethetic valve endocarditis?
vancomycin + gentamicin
vancomycin + meropenem
vancomycin, gentamicin + rifampacin
amoxicillin + gentamicin
What findings would indicate that a person is suffering from aortic sclerosis not stenosis? [2]
no radiation, no ECG changes are more consistent with sclerosis than stenosis.
HOCM is associated with which pulse changes? [2]
Jerky pulse
bisferiens pulse
Reversal agents for apixaban / rivaroxaban [1] and dabigatran [1]?
AndeXanet alfa - ApiXaban, RivaroXaban
InDArucizaumab - DAbigatran
A diabetic patient has a high HbA1C.
What anti-hypertensive is CI and why? [1]
Thiazides can worsen glucose tolerance
Indapamide is a thiazide diuretic and should be avoided as this patient likely has inadequate glucose control at present.
How do you treat thrombophlebitis? [3]
Compression stockings (but do ABPI before)
NSAIDs
Consider LMWH to decrease risk of DVT
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 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
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 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.
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 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
A patient has bubbly urine.
What might be the cause? [1]
An enterovesical fistula may cause bubbly urine
Describe the three main types of fistulae:
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.
