Cardiology + MCQBank Flashcards
what treatment to start if there is acute heart failure resistant to treatment (furosemide and oxygen)?
CPAP
It is recommended to start if there is acute heart failure with evidence of acidosis (as seen with the patient’s pH of 7.27). The patient is acidotic due to a combination of lactic acidosis caused by low tissue perfusion and hypoxaemia and a reduced plasma renal flow, causing renal failure.
ECG criteria for STEMI
Persistent (> 20 minutes) ECG features in ≥ 2 contiguous leads of:
2.5 mm (i.e ≥ 2.5 small squares) ST elevation in leads V2-3 in men under 40 years OR
≥ 2.0 mm (i.e ≥ 2 small squares) ST elevation in leads V2-3 in men over 40 years OR
1.5 mm ST elevation in V2-3 in women
1 mm ST elevation in other leads
New LBBB
For STEMI, when would patients be offered PCI?
if the presentation is within 12 hours of the onset of symptoms AND PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given
if patients present after 12 hours and still have evidence of ongoing ischaemia
If still ongoing ischaemia 60-90minutes post-fibrinolysis
Management of STEMI
Everyone gets aspirin 300mg
If can go for PCI:
-give prasugrel (ADP inhibitor if not already on anticoagulant - stop after 1 year) or clopidogrel (if already on anticoagulant)
- also giveUF heparin, glycoprotein IIb/IIIa inhibitor
- use drug-eluting stents
- Secondary prevention: add beta-blocker, statins, ACEi
If can only do fibrinolysis:
- give antithrombin (eg fondaparinucx) and fibrinolytic agent
- after procedure, give ticagrelor
Management of NSTEMI
Everyone gets aspirin 300mg, bisoprolol, ACEi and statin.
Do 6-month mortality score (eg Grace score):
- low risk (<3%)
- high risk (>3%)
LOW RISK - conservative
- Give fondaparinux (WRONG!)
- Give ticagrelor and aspirin (for low bleeding risk) OR give clopidogrel and aspiring (for high bleeding risk)
HIGH RISK- PCI (offer immediately in clinically unstable if not within 72 hours)
- Give prasugrel and UFH only before PCI
- Give ticagrelor and aspirin (for low bleeding risk) OR give clopidogrel and aspiring (for high bleeding risk)
Young male smoker with symptoms similar to limb ischaemia - diagnosis?
Buerger’s disease (thromboangiitis obliterans)
what happens in WPW?
accessory pathway between atria and ventricles
Management of angina
1st line: Beta-blocker or CCB
(CCB - rate-limiting such as verapamil or diltiazem if used as monotherapy , OR, longer acting dihydropyridine such as amlodipine or MR nifedipine if used with beta-blocker)
2nd line: if either/both doesn’t work: consider a long-acting nitrate, ivabradine, nicorandil, ranolazine (AND await assessment for PCI/CABG).
*Rate-limiting CCB can decrease myocardial contractility and heart rate.
Drugs for secondary prevention of CVS disease:
- Aspirin
- Statin
- ACEi for stable angina and diabetes
- S/L GTN
which drug can verapamil NOT be used with?
beta-blocker
(risk of heart block)
Recent guidelines on antiplatelets:
- ACS
- PCI
- TIA
- Ischaemic stroke
- peripheral artery disease
Acute coronary syndrome (medically treated)
With ST-E: Aspirin (lifelong) & clopi (1 month) or ticagrelor (12month)[
Without SE-E: Aspirin (lifelong) & ticagrelor/clopidogrel (12 months)
Percutaneous coronary intervention Aspirin (lifelong) & prasugrel or ticagrelor or clopidogrel (12 months)
TIA
FIRST LINE: Clopidogrel (lifelong)
SECOND LINE: Aspirin (lifelong) & dipyridamole (lifelong)
Ischaemic stroke
FIRST LINE: Clopidogrel (lifelong)
SECOND LINE: Aspirin (lifelong) & dipyridamole (lifelong)
Peripheral arterial disease
FIRST LINE: Clopidogrel (lifelong)
SECOND LINE: Asprin (lifelong)
Management of heart failure
SGLT2 antagonist
Annual influenza vaccine
One-off pneumococcal vaccine
1st line: ACEi & BB(Bisoprolol, Carvedilol)
2nd line: Aldosterone antagonist(Spironolactone, Eplerenone) or ARBs
3rd line: involve a specialist for
-Ivabradine(SR, HR>75+ EF<35%)
-Sacubitril-valsartan( EF <35%+ Symptoms despite ACEi/ARB)
-Digoxin( if coexistent AF)
- Hydralazine+Nitrate( in Afro-Caribbean)
-Cardiac resynchronization therapy( Widened QRS e.g. LBBB)
Amiodarone VS Adenosine
Amiodarone
- for broad complex tachycardia
- K channel blocker
- affecting myocardial depolarisation and repolarisation by primarily blocking potassium channels.
Adenosine
- for narrow complex tachycardia
- AVN blocker
- stimulates A1 receptors on the surface of cardiac cells, influencing adenosine-sensitive potassium channels and cAMP production. This leads to prolonged conduction through the AV node and an AV block (often high degree).
Echo findings for HOCUM
MR SAM ASH
Mitral regurg
Systolic anterior motion of anterior mitral leaflet
Assymmetric hypertrophy
Inheritance pattern for HOCUM
autosomal dominant
Drug to treat torsades de point
Magnesium sulphate
ECG signs for hypokalaemia
U waves
small or absent T waves (occasionally inversion)
prolong PR interval
ST depression
long QT
which medication is contraindicated in VT?
verapamil
if patient has SVT (with BBB) and ?broad-complex tachycardia, which medication should we start?
Adenosine (no contraindication for broad-complex tachy)
A sharp central chest pain which eases on sitting up and leaning forward and is exacerbated when lying flat or inhaling deep breaths. Diagnosis?
Pericarditis
What are the target for different stages of HTN?
Stage 1 hypertension: Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg
Stage 2 hypertension: Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg
Severe hypertension: Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 120 mmHg
Blood pressure targets for:
<80y/o
>80y/o
Age < 80 years: clinic 140/90 mmHg, ambulatory 135/85 mmHg
Age > 80 years: clinic 150/90 mmHg 145/85 mmHg
what medication should NOT be given with statins?
macrolide (erythromycin, clarithromycin etc)
pregnancy state too (esp first trimester)
what are the different dose of statin for primary VS secondary prevention of CVS disease?
Primary prevention: Atorvastatin 20mg ON
Secondary: Atorvastatin 80mg ON
*primary = 10yr CVS risk >=10% OR T1DM OR eGFR<60
*secondary = known IHD OR CVA OR peripheral arterial disease
What medical conditions increases BNP?
Left ventricular hypertrophy
Ischaemia
Tachycardia
Right ventricular overload
Hypoxaemia (including pulmonary embolism)
GFR < 60 ml/min
Sepsis
COPD
Diabetes
Age > 70
Liver cirrhosis
What medical conditions reduce BNP?
Obesity
Diuretics
ACE inhibitors
Beta-blockers
Angiotensin 2 receptor blockers
Aldosterone antagonists
how many levels for NYH classification? and what is it used for?
NYH 1-4
HF
One day following a thrombolysed inferior myocardial infarction, a 72-year-old man develops signs of left ventricular failure. His blood pressure drops to 100/70mmHg. On examination he has a new early-to-mid systolic murmur. Diagnosis (complication of MI)?
Papillary muscle rupture
This patient has developed acute mitral regurgitation secondary to papillary muscle rupture.
* common in infero-posterior MI
* can also get acute hypotension and pulmonary oedema
* tx: vasodilator therapy but will often need surgical repair
The differential diagnosis is ventricular septal rupture.
Complications post-MI (with timelines):
- within 24 hours
- 1 to 3 days
- first week to first month
- first week to months
24 hours: systemic (cardiogenic shock, heart failure, embolic cardiovascular accident, MI, systemic/lower extremity embolism)
1-3 days: arrhythmic (heart blocks, atrial or ventricular arrhythmia) OR ischaemic (re-infarction)
first week to first month: mechanical (mitral valve.chorda tendinae rupture, VSD, ventricular free wall rupture, aneurysm)
first week to months: inflammatory (pericarditis, Dressler’s syndrome)
Four weeks after an anterior myocardial infarction a 69-year-old presents with pulmonary oedema. The ECG shows persistent ST elevation in the anterior leads. Diagnosis (complication of MI)?
Left ventricular aneurysm
Patients present with acute heart failure secondary to cardiac tamponade (raised JVP, pulsus paradoxus, diminished heart sounds) post-MI. What is the diagnosis/complication post-MI?
Left ventricular free wall rupture
> 55 y/o, HTN, diabetic - first line treatment?
ACEi for all HTN patients with diabetes (regardless of age)
Uses of carvedilol VS bisoprolol
Carvedilol - use prophylaxis in oesophageal varices
Bisoprolol - secondary prevention of ACS
difference between thiazide and thiazide-like diuretics
thiazide-like diuretics are longer acting and reduce BP without side effects such as hypokalaemia, hyponatraemia or glucose or cholesterol changes
what drugs causes long QT syndrome?
antiarrhythmics: amiodarone, sotalol, class 1a antiarrhythmic drugs
tricyclic antidepressants
antipsychotics
chloroquine
terfenadine
erythromycin, clarithromycin
ciprofloxacin
which diuretic is used to reduce incidence of renal stones?
thiazide
which diuretic increases risk of gout?
thiazide, loop diuretics - increase gout
what CVS disorders do we need to declare to DVLA?
hypertension (type 1 drivers with malignant HTN or type 2 drivers)
angioplasty (elective) - 1 week off driving
CABG - 4 weeks off driving
acute coronary syndrome- 4 weeks off driving,1 week if successfully treated by angioplasty
angina - driving must cease if symptoms occur at rest/at the wheel
pacemaker insertion - 1 week off driving
implantable cardioverter-defibrillator (ICD)
if implanted for sustained ventricular arrhythmia: cease driving for 6 months
if implanted prophylactically then cease driving for 1 month. Having an ICD results in a permanent bar for Group 2 drivers
successful catheter ablation for an arrhythmia- 2 days off driving
aortic aneurysm of 6cm or more - notify DVLA. Licensing will be permitted subject to annual review.
an aortic diameter of 6.5 cm or more disqualifies patients from driving
heart transplant: do not drive for 6 weeks, no need to notify DVLA
Calcium channel blockers - 2 types and what are they used for?
Dihydropyridine eg amlodipine, nifedipine
- used for angina as dual-therapy with b-blocker
- used for
Non-dihydropyridine (rate-limiting) eg verapamil, diltiazem
- used for angina as monotherapy
which diuretic causes hypokalaemia and hypocalcaemia?
loop diuretic
how much increase of creatinine/reduction of eGFR is acceptable when starting ACEi??
creatinine increase by 30%
eGFR drop by more than 25%
side effect of nicorandil
anal ulcer
nicorandil is a vasodilator for angina
specific ECG finding for pericarditis (not saddle ST elevation)
PR depression
Acute AF- management?
If a patient has signs of haemodynamic instability (e.g. hypotension, heart failure) they should be electrically cardioverted, as per the peri-arrest tachycardia guidelines.
For haemodynamically stable patients, the management depends on how acute the AF is:
< 48 hours: rate or rhythm control (DC cardioversion or amiodarone if no structural heart problem OR fleicainide/amiodarone if structural heart disease)
≥ 48 hours or uncertain (e.g. patient not sure when symptoms started): rate control
(if considered for long‑term rhythm control, delay cardioversion until they have been maintained on therapeutic anticoagulation for a minimum of 3 weeks)
Rate-control drugs for AF
beta-blockers
calcium channel blockers
digoxin
Rhythm control drugs for AF
beta-blockers
dronedarone: second-line in patients following cardioversion
amiodarone: particularly if coexisting heart failure
Which type of aortic valve can be put in a young VS old patient?
Young : mechanical (but have warfarin - +aspirin if there is IHD)
Old : bovine (warfarin only for 3 months due to patient factors)
contraindication of thrombolysis
recent haemorrhage
trauma or surgery or dental extraction
coagulation defects
aortic dissection
aneurysm
coma
history of CVA
recent peptic ulcer
heavy vaginal bleeding
severe HTN
active pulmonary disease with cavitation
acute pancreatitis
pericarditis
bacterial endocarditis
severe liver disease
oesophageal varices
ECG changes: ST elevation >2mm in >1 of V1-3 followed with negative T-wave
Brugada syndrome
This must be ECG changes AND one of the following:
- documented VF/pVT
- FHx sudden death <45yo
- coved-type ECG in family member
- inducibility of VT with programmed electrical stimulation
- syncope
- nocturnal agonal respiration
Tx: ICD
ECG changes: prominent U wave, prolonged PR, depressed ST, small inverted T wave
Hypokalaemia
ECG changes: wide QRS, elongate QT and PR, AF, J-waves. What is diagnosis?
Hypothermia
ECG changes: prolonged QT. Low or high calcium electrolyte cause?
Low calcium
DOAC is considered first line tx for VTE. In what cases would you not use DOAC for?
anti-phospholipid syndrome
prosthetic heart valves
pregnancy or breastfeeding
severe hepatic impairment that is associated with coagulopathy
renal impairment (use with caution) and stop if eGFR<15
PS: warfarin is favoured over DOAC if eGFR<30, significant liver impairment or weight >120g
PS: dOaC is less likely to cause major bleeding when compared to warfarin
Endomyocardial biopsy shows Aschoff bodies - diagnosis?
Rheumatic fever (Group A strep)
Aschoff bodies are persistent local inflamatory lesions
Troponin - when does it appear in blood post-MI?
starts to be detected 4-8 hours but maximum concentration (& most accurate) at 12 hours.
will remain elevated for 7-10days post MI
what is pulsus paradoxus?
exaggeration (>12mmHg or 9%) of normal inspiratory decrease in systemic blood pressure
caused by: constrictive pericarditis, severe obstructive pulmonary disease, restrictive cardiomyopathy, PE, rapid and laboured breathing, right ventricular infarct with shock
NOT seen in: markedly raised LV diastolic pressure, ASD, pul HTN, aortic regurg
STEMI : ECG changes and corresponding coronary artery affected please
- II, III, aVF
- V1-V3
- I, aVL, V5-6
II, III, aVF: right coronary artery (inferior)
V1-V3: LAD (anterior)
I, aVL, V5-6: circumflex artery (lateral)
What is the Simon Broome criteria?
Used to detect heterozygous familial hypercholesterolaemia
DEFINITIVE
TC>7.5mmol/L
LDL>4.9mmol/L
tendon xanthoma in patient or 1st/2nd degree relative
identified mutation of FH
PROBABLE
TC>7.5mmol/L
LDL>4.9mmol/L
And >=1 of the following: FHx of MI, FHx of raiseTC
What is Beck’s triad?
increased JVP, hypotension and diminished heart sounds
seen in cardiac tamponade
What is Kussmaul sign?
paradoxical increase in venous distension and right atrial pressure in inspiration
What is Ewart sign or Ping sign?
seen as an area of dullness with bronchial breath sounds and bronchophony below the angle of the left scapula
seen in patients with large pericardial effusion
signs and symptoms of acute limb ischaemia?
Pain
Pulseless
Pale
Paralysed
Paraesthesia
Perishingly cold
What is the risk of tenecteplase (Metalyse)?
all bleeding complications 25%
major bleed 5%
intracranial haemorrhage 1%
intracranial haemorrhage in >75y/o approx 2%
ECG changes: ST depression of V1-3 with tall upright and symmetrical R-wave and tall symmetrical T-wave
Posterior MI
(check that they have ST-elevation for V7-9)
what is lone AF?
AF in young adults (<60y/o) with no clinical or echocardiographic evidence of concomitant cardiovascular or pulmonary conditions or acute trigger.
what is phlegmasia cerulea dolens?
severe complication where the DVT is so big that it blocks both venous and arterial supply.
it is life & limb threatening
systolic murmur at the left sternal edge, ECG showed sinus bradycardia, LAD, LVH. Diagnosis?
HOCUM
Non-cardiogenic causes of pulmonary oedema
NOTCARDIAC
Near drowning
O2 therapy/post-intubation pul oedema
Trauma/Transfusion
CNS: neurogenic pul oedema
Allergic alveolitis
Renal failure
Drugs
Inhaled toxins
Altitude
Contusion
How do you describe pericardial friction rub?
High pitched, scratching and grating.
Best elicited when listen over left sternal edge, patient leaning forward and exhaling
Difference in ECG between WPW and Lown-Ganong-Levine syndrome.
Both have: short PR interval and SVT.
WPW: slow slurred upstroke of QRS waveform (delta wave). Also has wide QRS and secondary ST-T changes.
Criteria for low voltage of ECG results
Voltage of entire QRS in all limb leads <5mm
Voltage of entire QRS in all precordial leads <10mm
Causes of low voltage ECG lead results
Increased distance of the heart
- pericardial effusion
- obesity
- COPD with inflation
- pleural effusion
- constrictive pericarditis
Infiltration of heart muscle
- amyloidosis
- scleroderma
- haemochromatosis
Metabolic abnormalities
- myxoedema
Tietze’s syndrome VS costochondritis
Tietze’s syndrome : swelling of costal cartilage
Costochondritis: no swelling
Definition of malignant/accelerated hypertension
increased BP up to >= 180/120 WITH signs of retinal haemorrhage +/- papilloedema
Drug treatments for malignant/accelerated HTN
1st line: IV GTN
IV sodium nitroprusside
IV labetalol (first line for aortic dissection but not for pulmonary oedema)
IV nicardipine
IV phentolamine (drug of choice for phaeochromocytoma crisis)
Drugs that causes LOW potassium
Thiazide diuretics
Loop diuretics
Osmotic diuretics
Drugs that causes HIGH potassium
ACEi and ARBs
aldosterone antagonist: spironolactone
K sparing diuretic: amiloride
Beta-blocker
Digoxin at toxic levels
Heparin
Trimethoprim
short QT interval and widened T-waves - > diagnosis
hypercalcaemia
- ST depression, TWI
- TWI, ST elevation
- sinus tachycardia, RAD, RBBB
- tall tented T-waves, widen QRS, absent P waves
- small T wave, prominent U wave, prolonged PR, depressed ST
- ST depression, TWI of V5-V6 (reverse tick)
- short QT
- long QT, small T wave
- STEMI
- STEMI
- PE
- high potassium
- low potassium
- digoxin toxicity
- -
Duke’s criteria of infective endocarditis
2 major and 1 minor criterion or
1 major and 3 minor criteria or
5 minor criteria
Major and Minor criteria for Duke’s criteria
Major: positive blood cultures, typical organism in 2 separate blood cultures, evidence of endocardial involvement
Minor: fever >38, positive blood culture but not meeting major criteria, echo not meeting major criteria, immunologic phenomena, vascular phenomena, predisposing heart condition or IVDU
which calcium channel blocker should be avoided for heart failure patients?
which drugs should not be used to treat HTN and not used for patients who have urinary incontinence?
diltiazem
alpha blocker: doxazosin
Difference pulse found in:
- aortic regurgitation
- aortic stenosis
- left ventricular failure
- mixed aortic stenosis and incompetence
- toxic myocarditis
- Cardiac tamponade, constrictive pericarditis, chronic sleep apnoea, croup, COPD
AR: collapsing
AS: plateau (low amplitude, slow rise and fall)
LVF: pulsus paradoxus &pulsus alternans (alternate large and small amplitude beats due to alternate contractions)
Mixed: pulsus bisferens (rapid rising, twice beating pulse)
toxic myocarditis: pulsus alternans
CT/CP/CSA/C/COPD: pulsus paradoxus (large decrease in systolic BP and pulse wave amplitude during inspiration)
PS:
** pulsus alternans is usually found when taking BP. Apparent doubling in rate is noted as the mercury level falls.
** pulsus paradoxus - volume reduces in inspiration
** plateau pulse has a slow upstroke and prominent in brachial and carotid pulses
ECG signs for right vs left ventricular hypertrophy
RVH: large R waves in V1-2, large S waves in V5-6
LVH: large R waves in V5-6, large S waves in V1-2
Anti-HTN drugs for pregnant ladies
Labetalol
Nifedipine
Methyldopa
Hydralazine
Treatment of pericarditis
NSAIDS and colchicine
(NSAIDS to taper down when CRP normalises or symptoms gone)
(Colchicine for 3 months)
which MI-drugs reduce mortality?
anti-platelet
beta-blocker
ACEi
statins
post-STEMI,how soon until:
- drive
- have sex
- time off work as postman
- 1 month
- 1 month
- 2 months
- intrascapular pain
- chest pain radiate to neck/jaw
?diagnosis of aortic dissection
- descending aorta
- anterior aorta/aortic root
lipid-lowering drugs
- which one can be used when pregnant?
- can predispose to gallstones through increase biliary cholesterol excretion
- should be offered to all patients (esp elderly with symptomatic CVS disease)
- cause severe flushing
- NONE! Ladies are advised to stop taking 3 months before attempt to conceive. ?maybe bile acid sequestrant (eg colesevelam)
- cholestyramine
- simvastatin
- nicotinic acid
Vincent angina - what is it?
unilateral tonsillitis due to a mixed infection by spirochetes and fusobacteria that manifests as a one-sided sore throat and difficulty swallowing.
elderly lady chest pain (retrosternal and crushing) radiated to jaw. intermittent pain over the last 3 years and all previous investigations are normal
?diagnosis
oesophageal spasm
what does lone AF mean?
develop in younger patient(<60yo) without any evident cardiac or other disease
difference between provoked and unprovoked DVT
provoked: transient risk factor present (immobility, surgery, trauma, pregnancy, puerperium,COCP, HRT)
unprovoked: absence of transient risk factirs OR risk factor that is persistent and not easily correctable such as cancer or thrombophilia
treatment of DVT/PE
- no renal impairment/active cancer, anti-phospholipid, haemodynamic instability
- renal impairment
- active cancer
- anti-phospholipid syndrome
- apixaban or rivaroxaban (if not LMWH for 5/7 the dabigatran or doxaban. OR. LMWH and VKA)
- CrCl15-50: aixaban or rivaroxaban or LMWH 5/7 etc, LMWH/VKA.
CrCl <15: LMWH or UFH or (LMWH/UFH) &VKA - DOAC. if not suitable, LMWH or LMWH/VKA.
- LMWH/VKA
most common organism for infective endocarditis
staph aureus!
