Cardiology Medicine incorrects

Question 1

in people with heart valves, what prophylactic antibiotics are administered before procedures?

Answer 1

oral amoxicillin - before dental or resp procedures

iv vancomycin - if skin and soft tissue infections

Question 2

patient with new onset AF. transthoracic echo has been done to rule out valvular dysfunction or LV failure as the cause. what is the next best investigation?

Answer 2

serum TSH levels!!!

hyperthyroidism is a trigger!

Question 3

describe the mechanism of nitrates as anti anginal drugs

Answer 3

systemic vasodilation!!! (not coronary) -> lowers preload and LV end diastolic volume!!!

Question 4

what is the management of ventricular tachycardia??

1. in a pulseless patient?
2. pulse but hemodynamically unstable (angina, hypotension, confusion)??
3. pulse and stable??

Answer 4

1. defibrillation
2. dc cardioversion
3. amiodarone!!!!. use drugs if stable

AAAAmiodarone is used to treat
Ventricular AAArythmiass

(also used for rhythm control in patients with a fibrillation or left ventricular systolic disfunction)

contrast to stable NARROW complex tachycardias eg AVNRT (a type of SVT) which is treated with adenosine

Question 5

patients with severe mitral regurgitation (holosystolic murmur at the apex) develop LV overload and dilation with an audible S3 gallop

dypnea on exertion due to reduced cardiac output. may progress to heart failure.

Question 6

A 32!! year old woman comes in with

shortness of breath, orthopnea, bilateral ankle oedema. S3 on cardiac exam. CXR reveals enlarged cardiac silhoutte and small bilateral effusions. ECG shows non specific st segment changes

what is the diagnosis and what is the most likely cause?

Answer 6

decompensated heart failure and dilated cardiomyopathy ->

Viral myocarditis!!!. most likely cause of HF in young patient.

Question 7

21 year old. syncope repeatedly

prodrome of warmth!!! lightheadedness, diaphoresis111 nausea.

first episode when blood drawn. others standing in a crowded church

most likely diagnosis?

what would be seen in ecg immediately before the syncopal episode?

if ECG is normal and physical examination is normal, next step in management?

Answer 7

-:> vasovagal syncope -> triggers are pain, anxiety, emotional stress, heat, prolonged standing!!

-> sinus bradycardia and asystole due to sinus arrest

typical prodrome of warmth etc

no further testing needed!!! no eeg needed if no classic seizure symptoms

recurrent episodes -> counsel avoid trigegrs and counter techniques

there is also something caled situational syncope-> cough, micturition, defecating, eating, hair-combing

Question 8

man with palpitations. high amplitude jugular venous pulsations seen intermittently. ECG revelas regular wide complex tachycardia.
history of MI

what best explains physical findings?

Answer 8

atrioventricular dissociation!!

jugular venous pulsation waveform represents right atrial dynamics. cannon a waves are waves caused by surge in jugular venous pressure occuring due to right atrium contracting against a closed tricuspid valve (atrium and ventricle contracting same time).

waves indicate arythmia involving arioventricular dissociation!! -> eg ventricular tachycardia, complete atrioventricular block

not history of MI is risk factor for VT

Question 9

young patient with palpitations, dsypnea, 3/6 holoSYSTOLIC murmur that decreases in intensity with squatting and increases with standing and vasalva.

no peripheral edema or jugular venous distention. most likely diagnosis?

where is murmur heard?

why does it increase with standing?

Answer 9

Hypertrophic cardiomyopathy

• Note that HCM is a SYSTOLIC murmur heard at the LEFT STERNAL border

standing -> decreases venous return to heart as blood pools in legs. LV collapses in as volume decreases -> worsening of LV outflow obstruction

Question 10

describe the steps in peripheral artery disease management

Answer 10

step 1 - stop smoking, aspirin and statin!!! -> important to reduce cardiovascular risk
diabetes/htn control

step 1b - supervised exercise programme

step 2 - cilostazol (preffered to pentoxyfyline)

step 3 - angioplasty with stent

Question 11

management of acute coronary syndrome (unstable angina, nstemi, stemi)

Answer 11

nitrates -> to reduce ischemia!! (only used if chest pain is actively present)

beta blocker!! -> to reduce myocardial oxygen demand

antiplatelet agents and anticoagulation -> aspirin!!, (P2y12 inhibitors later) heparin!!! to reduce thrombus

NOTE - DOACS eg apixaban not used in ACS

statin -> to stabilze the plaque

NSTEMI or stable angina = coronary angiography!!!

STEMI - PCI, or fibrinolytics if PCI unavailable !!!

Question 12

37 year old woman with left sided weakness/hemiparises. over 6 months, exertional dyspnea, nocturnal cough and occasional hemoptysis. frequent episodes of palpitations and irregular heartbeat. emigrated from cambodia 2 years ago.

most likely diagnosis?

Answer 12

mitral stenosis!!

stroke from afib in setting of mitral stenosis

patient from a developing country with progressive dsypnea, nocturnal cough and orthopnea, hemoptysis, PND -> suggestive of mitral stenosis due to rhuematic heart disease

MS causes increase in atrial pressure -> increase in pulmonary pressure -> dyspnea symptoms

MS causes left atrial enlargement -> afib

ruling out other things:
pulmonary arterial hypertension does not affect the atrium so afib is not expected

(also note mitral stenosis can be radiation induces in history of lymphoma)

Question 13

what is the management of uremic pericarditis? (occurs in setting of acute or chronic kidney failure.

Answer 13

rule out cardiac tamponade as 50% of cases accompanied by pericardial effusion. -> then dialysis!!!

Question 14

patient comes in with popliteal aneurysm. what else do you need to screen/ further management?

Answer 14

ultrasound other leg in popliteal region

AND

abdominal ultraosund to rule out abdominal aorta anuerysm!!!

Question 15

shortness of breath and dry cough. feeling weak over last coup le days with dyspnea on exertion. elevated bNP. TEMP 37.1

what other signs will most likely be found

Answer 15

S3!

congestive heart failure -> fatigue, dypsnea, elevated BNP

normal body temp ends at 37.2!!

Question 16

you need to be able to identify paroxysmal sypraventricular tachycardia (SVT) on an ecg
what are the ecg findings?

what is the most common type of PSVT affecting young patients below 40? and what is the mechansim of action of this condition?

Answer 16

NARROW QRS complex tachycardia
-> regular rate helps rule out AFib

AVNRT affects young people -> 2 distinct conduction pathways in the AV node!!!!

Question 17

chest pain brought on by walking that subsides. htn and hyperlipidemia.

echo shows left atrial dilation and mild concentric left ventricular hypertrophy.

aortic valve is calcified with restricted opening. aortic valve area = 1.6cm

most likely condition?

Answer 17

coronary artery disease!!! = unstable angina

aortic stenosis does not cause symptoms unless valve area is <1 cm so not responsible for chest pain or left ventricular hypertrophy here

LVH most likely due to HTN

Question 18

what does the S4 sound sound like? it can be heard over the cardiac apex

name a cause of this

name symptoms that can develop?

Answer 18

TEN-nes-see . du du, du du, du du, du-du du

normal finding in elderly patients over 70.

in younger, indicated ventricular wall stiffening such as in LVH which occurs with chronic hypertension!!!!

symptoms
- dyspnea!!! LVH progression -> heart failure with preserved ejection fraction

Question 19

s4 causes vs s3 heart sound causes

Answer 19

s3 = HF with REDUCED ejection fraction, mitral or aortic regurg, high output states eg thyrotoxicosis

s4 = concenctric LV hypertrophy and HF with preserved ejection fraction!, restrictive cardiomyopathy, acute MI (due to left ventricular stiffening and impaired relaxation due to ischemia)!!

Question 20

how to distinguish athletes heart from Hypertrophic cardiomopathy?

Answer 20

both cause LVH

unlike HCM, athletes heart does not cause impaired diastolic filling, atrial enlargement or ecg changes

Question 21

how does sinus sick syndrome present?

Answer 21

bradycardia leading to fatigue dyspnea, syncope

in elderly patients

ecg shows bradycardia with delayed or dropped p waves. but patients may experience a bradycardia-tachycardia syndrome with palpitations/atrial fibrillation

caused by degeneration of sinoatrial node

treat with pacemaker

Question 22

sharp intense chest pain radiating t neck and scapula. diaphoretic and uncomfortable

early decrescendo diastolic murmur in the upper sternal area

patient is hypotensive

most likely diagnosis?

management after resus?

Answer 22

aortic dissection

transesophageal echo as patient is hypotensive!!!!
if not -> CT angiography of chest!!!

Question 23

first line management for cocaine induced chest pain?

Answer 23

IV benzodiazepine

Question 24

what is part of the dual antiplatelet
therapy post MI eg STEMI or NSTEMI?

Answer 24

PY12 inhibitor eg clopidogrel (for 12 months) and aspirin long term!!

post MI, patients also given statin, beta blocker, ace inhibitor or arb to inhibit cardiac remodelling and spirinolactone if evidence of reduced LVEF

different from UK strokeeee management guidlines where aspirin is given for 2 weeks and then clopidogrel long term

Question 25

patient with exertional shortness of breath, exertional chest pain, and exertional lightheadedness

ecg shows sinus rhythm with LVH

most important next step in diagnosis?

Answer 25

TRANSTHORACIC ECHO!!!

Patient most likely has aortic stenosis

remember SAD - syncope/pressyncope (lightheadedness), angina, dyspnea for aortic stenosis

exercise stress test is used for stable angina butttt if you suspect aortic stenosis, transthoracic echo first!!! as exercise is a contraindication

Question 26

when would you give a statin in addition to lifestyle modifications for primary prevention of cardiovascular risk?

Answer 26

age >/= 40 with diabetes mellitus

OR
LDL > = 190

or
estimated 10 year CV risk >7.5%

Question 27

patient on digoxin
now started on amiodarone as well after hospital admision

profound anorexia, nausea, vomiting, weakness

most likely cause?

Answer 27

drug interaction!!

amiodarone can increase serum levels of digoxin and cause digoxin toxicity

digoxin toxcity acute = profound anorexia, nausea and vomiting, abdominal pain, weakness, confusion

chronic toxicity - same neuro findings and visual changes

Question 28

patient suicide attempt

presents with profound bradycardia, atrioventricular block, hypotension, diffuse wheezing

atropine has not helped

what is the diagnosis?
next step in management

Answer 28

beta blocker toxicity

glucagon counteracts toxicity!!!

Question 29

decompensated heart failure is a common cause of secondary mitral regurgitation (holosystolic murmur best heard at heart apex)

describe the mechanism behind the mitral regurgitation

Answer 29

left ventricular papillary muscle displacement

increased LVEDV causes impaired valve closure. this resolves/murmur resolves with reduction of LVEDV

*contrast to primary mitral regurg caused by problems with valve

contrast to dynamic left ventricular outflow obstruction which occurs in HOCM which causes crescendo-decrescendo murmur which intensifies/decreases with certain maneuvres

Question 30

what are the things you check for cardiovascular risk before non cardiac surgery (RCRI points)

Answer 30

1. high risk sugery - vascular or intrathoracic
2. IHD
3. History of congestive HF
4. history of stroke or TIA
5. Diabetes mellitus treated with INSULIN
6. preoperative creatinine > 2

> /= 2 is higher risk so you check functional capacity and if less than 4 METS -> You do a pharmacological!! stress test!!!

Question 31

premature atrial complexes captured on a patients routine ecg
no symptoms.

next step in management?

Answer 31

advice to limit tobacco and alcohol use!!!!

if symptomatic -> beta blocker therapy

24 hour holter monitor is used to capture intermittent arrhythmias in patients with symptoms eg syncope palpitations -> does not require this as patient is asymptomatic and arrhythmia has already been captured on standard ecg!

Question 32

ventricular arythmias (premature ventricular contractions, VT and VF) occur frequently with MIs. VF is the most common cause of sudden cardiac death with acute MIs

Question 33

32 YO man, has palpitations. family history of heart problems.
decrescendo early DIASTOLIC mumur at the LEFT sternal border which increases with leaning forward and holding breath in full expiration

most likely diagnosis?

what are the symptoms of this condition?

Answer 33

BICUSPID AORTIC VALVE!! -> CAUSING (valvular) AORTIC REGURITATION!

valvular aortic regurgitation heard at left sternal border. contrast to aortic regurgitation due to root dilation (seen in marfans, syphliis) which is heard in the classic aortic area!!

note that despite location, aortic regurg is always a decrescendo diastolic murmur.

diastolic murmur in LSB therefore aortic regurgitaiton. constrast SYSTOLIC murmur of HCM in LSB

AR may be asymptomatic or cause palpitations, chest pain, dyspnea

*bicuspid aortic valve can cause valvular AR more commonly or AR due to aortic root dilation

Question 34

76 year old woman, cancer and has been unable to eat or drink for past few days. blood pressure 80/30. mucous membranes dry. pulse 60 (just normal)

ecg shows no p waves!!! and a sine wave pattern

next step in management?

Answer 34

administer calcium gluconate!!! and insulin

ecg indicates hyperkalemic emergency. progressive changes tall t waves -> loss of p waves -> widened qrs -> sine wave pattern -> asystole

diminished food and water intake _> hypovolemic shock -> severe electrolyte abnormalities so hypernatremia/hypo, hyperkalemia, metabolic acidosis

Question 35

management of symptomatic HCM?

Answer 35

beta blocker! eg metoprolol!!!

Question 36

in addition to IV furosemide for acute heart failure, what should be used if uncontrolled HTN is present?

Answer 36

nitroprusside, a vasodilator

Question 37

what causes poor renal function/cardiorenal syndrome in acute heart failure?

how does iV furosemide help?

Answer 37

back pressure from failing heart. increased central venous and renal venous pressure so theres no gradient and eggr decreases

furosemide decreases renal venous pressure

Question 38

PCI involves cardiac catheterization!!

Question 39

what anatomic site does atrial fibrillation origiinate?

Answer 39

pulmonary veins

Question 40

after adminstration of a statin which is first line for hypertryglyceride. next step in managament?

Answer 40

limit alcohol intake!!!!!

omega fatty acids also help

Question 41

54 YO man, shortness of breath and abdominal distention. treated for hodgkins lymphoma with radiation and chemo 18 years ago. JCP 9 cm above sternal angle, abdomen distended iwth fluid wave, liver 5 cm below costal margin. bilateral pitting edema

most likley cause of patients condition?

Answer 41

inelastic pericardium -> constrictive pericarditis!!!

patient presents with right heart failure signs, most likely due to constrictive pericarditis

mediastinal radiation = risk factor for constrictive pericarditis!!!

others include:
tuberculosis!!!
viral pericarditis
cardiac surgery

Question 42

management of first degree AV block?

Answer 42

benign finding -> observation only

Question 43

which class of antihypertensives is associated with weight gain and impaired glucose control?

Answer 43

beta blockers - conventional ones eg metoprolol, atenolol, propanolol

increased risk of T2DM

Question 44

atrial fibrillation with a high pulse rate>100 can cause tachycardia induced cardiomyopathy, this is reversible with rate and rhythm control

Question 45

which extra heart sound can be heard in an MI and why?

Answer 45

S4 - left ventricular stiffening and impaired relaxation due to ischemia

Question 46

diastolic and continuous murmurs require workup with echo. mid systolic murmur in a young asymptomatic adult is typically benign and does not require further workup

Question 47

statins are used in patients with established ASCVD as is aspirin.

However, aspirin is not used in patients with a high ASCD risk eg 10.5% without evidence of ASCD. only statins are used here. unless patients are over 50 where aspirins may be used too

Question 48

learn st segment elevations and what the occluded artery will be

Question 49

patient with acute heart failure. resp rate is 30/min (tachypnea as more than 20 breaths per minute) and there is accessory muscle use. next step in management?

Answer 49

non invasive positive pressure ventilation!!! = BIPAP

patient is experiencing respiratory failure due to HF

Question 50

patient with a fibrillation. becomes unresponsive. no pulses. cardiac monitor still shows a fib at same rate. next step in management?

Answer 50

chest compressions!!

patient has pulseless electrical activity/PEA. ie no pulse but organized cardiac activity (bradycardia, afib).

managed by chest compressions + identification and treatment of cause. can progress to asystole which is treated the same

CONTRAST to patients with
Pulselessness VT OR VF which are treated with defibrillation.