Cardiology_Medicine Flashcards

Question 1

Q

IHD - Types? Definition? Dx? Mx?

Answer

A

Stable angina - chest pain on exertion relieved by rest

Path - mismatch in O2 supply and demand to the myocardium
Ix: CT-angiogram
Mx:
- B-blockers - reduces HR req for activity –> reduced likelihood of mismatch in O2 supply & demand
- GTN spray - reduce myocardial preload + reduces strain
- RF modification –> reduced risk of progression

Acute coronary syndrome - Sx caused by sudden reduced BF to the myocardium

Dx:
- ST-elevation = STEMI
- Troponin raised = NSTEMI (+ dynamic T-wave inversion, ST depression)
- Unstable angina pectoris (pain at rest) = ischemia NOT infarct
Generic ACS Mx - MONA BASH
- ALL immediate:
  - 5-10mg Morphine IV + Nitrates (GTN spray)
  - Dual antiplatelet therapy (DAPT) - 300mg Aspirin STAT + 300mg Clopidogrel STAT (or 180mg PO Ticagrelor)
- ALL long-term:
  - Continue DAPT
    - 1 year: 75mg OD Aspirin + 75mg OD Clopidogrel (or 90mg BD Ticagrelor)
    - >1yr - 75mg OD Aspirin
  - B-blocker (1.25-10mg Bisoprolol OD)
  - ACEi (1.25-10mg Ramipril OD)
  - Statin (80mg Atorvastatin OD)
STEMI Mx: establish coronary reperfusion ASAP
- Sx <12hrs: PCI BUT if no PCI within 2hrs Dx –> thrombolysis (e.g. tPA - tissue plasminogen activator)
- Sx >12hrs: invasive coronary angiography ± PCI if needed
- PCI:
  - If having PCI give Prasugrel (instead of Clopi/Ticagrelor)
  - PCI accessed via radial (or femoral) artery, guidewire passed via X-ray guidance into the affected coronary artery AND IV unfractionated heparin during the procedure –> stent inserted impregnated with an anti-proliferative agent (e.g. Tacrolimus - to prevent adverse tissue reaction) –> takes longer for endothelialization of stent so DAPT needed for 1yr
  - If PCI with stents inserted –> DAPT 12 months
NSTEMI Mx:
- 2.5mg SC Fondaparinux (direct factor 10a inhibitor)
- Risk stratify - GRACE criteria (& others)
- High risk = invasive coronary angiography (within 48-72hrs)

Question 2

Q

Angiography & PCI

Answer

A

Access usually gained through radial artery (or femoral) –> guide wire passed up through axillary artery –> subclavian artery –> relevant coronary artery
Guidewire passed via X-ray guidance into the affected coronary artery
IV unfractionated heparin during the procedure
PCI - stent inserted impregnated with an anti-proliferative agent** (e.g. Tacrolimus - to prevent adverse tissue reaction) –> takes longer for endothelialization of stent so **DAPT needed for 1yr

Question 3

Q

Heart failure def? Pathophysiology? Categories & Causes? Ix? Mx?

Answer

A

Def: pumping of blood by heart insufficient to meet the demands of the body

Pathophysiology:

RHF - right side of the heart pumps deoxygenated blood from the body to the lungs to be reperfused - if the RH is not pumping effectively you get the fluid collection in the peripheries = PERIPHERAL OEDEMA
LHF - left side of the heart pumps oxygenated blood from the lungs to the body - if the LH is not pumping effectively you pooling of blood in the lungs = PULMONARY OEDEMA
Reduced CO –> shock, tachycardia, AKI
- CO = SV*HR
- Ejection fraction = SV/End-diastolic Volume

Categories:

HF w/ preserved ejection fraction (left ventricular >50%) = inadequate filling of ventricles during diastole (from ventricular stiffness)
- Causes of ventricular stiffness:
  - Volume overload (valve regurg)
  - Pressure overload (HTN)
  - Decreased distensibility (constrictive pericarditis)
HF w/ reduced ejection fraction (left ventricular <40%) = inadequate emptying of ventricles during systoles (from outflow obstruction/impaired contractility)
- Causes of outflow obstruction/impaired contractility:
  - MI, Cardiomyopathy, Arrythmia

Ix:

Bedside: ECG - detects if anything precipitating HF (arrhythmia/ischaemic event)
Bloods: ABG (if resp compromise from pul oedema), troponin (ACS), BNP (HF screening)
Imaging: CXR (visualise pul oedema, cardiomegaly), ECHO (valvular abn/regional wall mov abn)

Mx: MON BA (out of MONA BASH)

Immediate:
- Sit the patient up (reduce venous return to heart –> less strain)
- O2 15L/min NRM
Medical:
- IV furosemide (loop diuretic) - remove excess fluid + venous dilation (reduce preload)
- Nitrates (GTN/Isosobide Mononitrate) AND Morphine - reduce preload on the heart
Long-term:
- Reduced ejection fraction - prognostic benefit:
  - B-blocker (bisoprolol) - reduce strain on heart, do not give acutely if severe HF as will kill them
  - ACEi - reduce strain on heart
    - After the above if LVEF <35% & Sx –> mineralocorticoid antagonist e.g. spironolactone
    - 3rd line - by specialist: Sacubitril/Valsartan (entresto), Ivabradine & CRT
  - SGLT2 inhibitors (dapagliflozin)
- RF modification - poor glycaemic control/high cholesterol
- Sx (diuretics)

Question 4

Q

How does heart failure look on CXR?

Answer

A

Pulmonary oedema (fluffy alveolar shadowing = bilateral perihilar consolidation = batwings distribution) ±:

Kurly B-lines (peripheral septal lines)
Cardiomegaly (thoracic ratio >0.5)
Upper lobe venous diversions (tubes going up towards apex instead of lines)
Pleural effusion (costo-phrenic blunting)

Question 5

Q

Atrial fibrillation (AF)

Def? Causes? Ix? Mx?

Answer

A

Def: rapid, chaotic, and ineffective atrial electrical conduction

ECG def: irregularly irregular narrow complex tachycardia with no p waves

Causes: idiopathic, cardio (IHD, valvular disease, cardiomyopathy), resp (PE, pneumonia), hyperthyroidism, alcohol

Ix: ECG (absence of p-waves, irregularly irreg rhythm)

Mx:

Haemodynamically unstable (≤90 BP, chest pain, acute HF) –> DC Cardioversion

OR

Rate control –> B-blocker (bisoprolol) OR rate-limiting CCB (verapamil - asthma)

OR

Rhythm control - ONLY if clear reversible cause
- Sx onset <48hrs –> DC/chemical cardioversion (amiodarone/flecanide)
  - NOTE: IV heparin started prior to cardioversion
- Sx onset >48hrs –> anticoagulate for 3wks –> elective cardioversion (also anticoag for 4wks after)

AND

Stroke risk - CHADS-Vasc Vs Orbit/HAS-BLED score –> DOAC (Apixaban)
- If metallic heart valve –> warfarin INR 3-3.5
- Otherwise DOAC
- NOTE: if incidental non-symptomatic AF - normal rate, no other RFs, CHA2DS2-VASc 0 –> anticoagulation not recommended
- CHF, HTN, Age ≥75rs (2), DM, Stroke (2), Vascular disease, Age 65-74, Sex - female
  - Score 1 - consider; ≥2 - DOAC/Warfarin needed
  - Lifetime risk = annual risk x estimated years of life left (up to 80 yrs e.g. if 60 then x annual risk by 20)

Question 6

Q

Types of anticoagulant

Answer

A

Heparins

LMWH (SC) - VTE prophylaxis BUT bad for renal function
UFH (SC/IV) - GOOD for renal function as a rapid reversal BUT heparin-induced thrombocytopenia (hypercoag state) risk needs APTT ratio monitoring

DOACs - oral + no monitoring BUT bad for renal function e.g. Apixaban (BD), Rivaroxaban (OD)

Vit K antagonist = Warfarin if weight extremes, reduced renal function or AF w/ MS/mechanical heart valve BUT INR monitoring + drug interactions

Question 7

Q

Virchow’s triad to determine anticoag vs antiplatelets

Answer

A

1) Stasis - coag factor activation–> venous clot (AF, DVT/PE)
* Anticoags (DOAC/Hep/Warfarin) are most effective as coag factors cause clot
2) Vessel wall injury - plaque rupture - thrombogenic material release –> platelets activated –> arterial thrombosis (MI, stroke)
* Antiplatelets (Aspirin/Clopidogrel) most effective as platelets cause clots
3) Hypercoagulability - does not change acutely

Question 8

Q

SVT - Def? Types? Presentation - case example? Mx?

Answer

A

Def: regular narrow-complex tachycardia with no p-waves + supraventricular origin

Junctional types:

AVNRT - local re-entry circuit within AV node
AVRT - re-entry circuit between atria and ventricles –> after SVT termination = delta wave = WPW syndrome:
- Assoc w/ HOCM
- Avoid digoxin, verapamil, amiodarone (reduce conduction down SAN –> worsen retrograde conduction –> risk of VT)
- Can use B-blocker/flecainide instead

Case example: 23yrs, 1-hr palpitations + SoB, 2 similar episodes prev following alcohol, this time severe chest pain

Mx:

Unstable tachycardia (<90 BP/chest pain/acute heart failure) –> synchronised DC Cardioversion
Vagal manoeuvres (increase parasympathetic stim via vagus nerve to slow conduction via AV node)
- Valsalva manoeuvre (blow out through nose while pinching + shut mouth) - breath through 50ml syringe
Adenosine 6mg –> 12 mg –> 12mg
- NOTE: if adenosine CI (e.g. asthma) –> VERAPAMIL (rate-limiting CCB)
Other:
- IV B-blocker/amiodarone/digoxin
- Synchronised DC Cardioversion

Question 9

Q

Key heart murmurs?

Accentuation manoeuvres?

Causes?

Left vs right heart valve abn epidemiology?

Mx?

Answer

A

Key murmurs:

AS = ejection systolic + radiates to carotids, slow rising pulse, narrow pulse pressure, heaving apex beat
- Sound: Wooooshhh
- Severe AS - absent/soft 2nd heart sound, reversed splitting of 2nd HS, heaving apex beat
  - A longer murmur is worse (small space for blood to pass through = takes longer)
MS = mid-diastolic + LLP, malar flush, AF, loud/palpable S1 “tapping” apex, pul HTN (loud P2 - pul thrill)
- Sound: Wooosh de (loud S1) de (early diastolic snap)
AR = early diastolic + sitting forward (LLSE), collapsing pulse, wide pulse pressure, displaced apex
- Sound: de woooshhhh
- Severe AR –> Austin-flint murmur = ‘Rumbling mid-diastolic murmur’
  - Best heard at apex, caused by blood flowing back through aortic valve and over mitral valve
  - Shorter murmur is worse (quicker to flow back through large hole)
MR = pan-_systolic_ + radiates to left axilla, AF, displaced thrusting apex, LVF/pul HTN
- Sound: Woooooshhh (holosystolic)
NOTE: same pattern for pulmonary & tricuspid (pul stenosis & tricuspid regurgitation = systolic)
- TR - pulsatile liver
- PS - radiates to back, assoc w/ Noonan’s (AD, webbed neck, wide-spaced eyes etc.)

Accentuation manoeuvres:

R-sided murmurs (tricuspid + pulmonary) –> louder on INspiration = blood goes IN to right-side of heart
L-sided murmurs (aortic + mitral) –> louder on EXpiration = blood EXits left-side of heart
AS radiates to the carotids + louder on leaning forward + listen on right sternal edge
MS louder on turning to the left, MR radiates to axilla

Causes:

AS (stenosis/sclerosis): senile calcification (aortic valve)
MR: IHD (papillary-muscle dysfunction post-MI), Infective endocarditis, cardiomyopathy, RHD
AR: acute (infective endocarditis, aortic dissection), chronic (CTD, RHD, HTN, congenital)
MS: rheumatic heart disease (RHD)

Left vs Right valve abn:

Left = more common as higher pressure system, more likely in damaged valves, commonly Strep Viridans
Right = more common in IV drug users –> tricuspid valve is first valve reached, commonly S. aureus

Management:

AS:
- C: 6-monthly ECHO, exercise-stress test if asymptomatic
- M: RF optimisation (statins, HTN, DM), HF Sx (diuretics, ACEi)
- S: Based on severity/comorbid - STS-PROM (surgical risk calc)
  - If severe AS:
    - Medically fit (req midline sternotomy & cardiopul bypass) = Surgical aortic valve replacement (SAVR)
    - Not fit = Transcatheter aortic valve replacement (TAVR)
  - Acutely Sx/cardiogenic shock = Balloon valvuloplasty
MR:
- M:
  - ACEi ± B-blockers (as HTN worsens MR)
  - Tx AF & anti-coagulate
  - Diuretic (if refractory to surgery)
- S: for acute MR (post-MI, chordae tendinae rupture), asymptomatic LVEF <60%, symptomatic LVEF >30%
  - Valve _R_epair > _R_eplacement
AR:
- M: asym + Reassurance (good prog)
  - Unfit for surgery/waiting - ACEi & vasodilators (e.g. hydralazine)
- S: acute/Sx/severe = surgery
  - Valve _R_eplacement > _R_epair
MS:
- C: asymptomatic - Monitor
- M:
  - AF Tx, anti-coagulate & diuretics (if Sx/severe)
- S: Sx/severe - can do balloon valvuloplasty/replacement
  - Valvuloplasty = lateral thoracotomy scar
  - Do not do percutaneously if persistent left atrial thrombus/rigid calcified valve –> need open heart surgery (CABG, concurrent severe MS)

Question 10

Q

MI location based on ECG

Answer

A

Inferior – right coronary artery (2,3, aVF foot)
Anterior – left anterior descending artery (V1-2)
Lateral – circumflex artery (1 ,aVL, V5/6)
Posterior - ST depression in V2-4, abnormal R wave in V2

Question 11

Q

Infective endocarditis - RFs? Ix? Dx criteria? Mx?

Acute vs subacute bacterial endocarditis - what hearts affected? who are commonly affected? What bacteria most likely?

Answer

A

Def: infection of heart valves (typically mitral/aortic or tricuspid in IVDU)

RFs: bacteraemia (long-term lines, IVDU, dental work), abn valves (prosthetic, RHD), prev endocarditis, VSD, piercings

Presentation: low-grade fevers, night sweats

Exam:
- Splenomegaly
- Splinter haemorrhages, osler’s nodes, Janeway lesions, petechiae, Roth spots (eyes)
- Chronic = clubbing (rare, mostly acute now)

Ix:

Urine dip - haematuria
Serial BCs (x3 but start empirical abx), ESR
Transoesophageal Echo (TOE - vegetations)

Dx: DUKE’S CRITERIA (2 major OR 1 major + 3 minor OR 5 minor):

Major: +ve BC (typical organism), new regurg murmur/veg on echo
Minor: RF, fever (>38), embolic (vascular) phenomena, immune phenomena, +ve BC (another organism)
Mx: IV abx for 6wks – fluclox/vanc/gent

Acute in structurally normal heart – In IV drug user the first valve met is tricuspid valve, commonly S. aureus (also most common cause in prosthetic valve endocarditis)

Subacute in structurally abn heart – mitral & aortic valves more commonly affected as high pressure system, more likely damaged valves, commonly Strep Viridans (overall most common cause of endocarditis)

Question 12

Q

ECG Important Considerations

Answer

A

Make sure to compare to a previous ECG = dynamic changes (acute)
Coronary infarcts commonly present as T-wave inversion/RBBB/LBBB, not always with ST-elevation/depression

Question 13

Q

NSTEMI Mx? Scoring? Ix?

Answer

A

Immediate:

Aspirin PO stat AND Ticagrelor OR Clopidogrel PO stat
Fondaparinux SC

On discharge (give all despite BP/HR):

Aspirin for life
Ticagrelor OR Clopidogrel for 1 year (2 needed for 1 year as stent impregnated with Tacrolimus
Ramipril (ACEi) - titrate up to 10mg
Atorvastatin
Bisoprolol (B-blocker) - titrate up to 10mg

Scoring Risk: GRACE score

Ix if high risk: cathlab for angiogram (will be started on IV unfractionated heparin instead of fondaparinux as procedure is very thrombogenic) –> PCI (stent)

Question 14

Q

Heart failure key consequences x2

Answer

A

1) Reduced CO (SV*HR) –> shock, tachycardia, AKI
2) Congestion –> pulmonary oedema + peripheral oedema

Question 15

Q

Acute HF vs ACS

Question 16

Q

Irregularly irregular heart rhythm - Dx? Ix? Mx?

Answer

A

AF - narrow complex tachycardia with no p-waves

Ix:

ECG, Echo (valve check)
Bloods - U&E, Mg (QT interval), Troponin (ischaemic), TFTs

Mx:

Haemodynamically unstable –> DC cardioversion
Rate control - Bisoprolol 2.5mg OD (max 10mg, can use rate-lim CCB)
Rhythm control - if clear reversible cause: <48hrs = DC/chemical cardioversion (flecanide/amiodarone); >48hrs = anticoag 3-4wks (clot may have formed)
Stroke risk Mx - CHADS-Vasc Vs HAS-BLED/ORBIT - Apixabab 5mg BD (DOAC, can use Warfarin)

Question 17

Q

How do you calculate ejection fraction? What are the different types of HF based on ejection fraction?

Answer

A

Ejection fraction = SV/End Diastolic Volume

HF w/ preserved EF: >50% - inadequate filling of stiff ventricles

Causes: volume overload (valve regurg), pressure overload (HTN), decreased distensibility (constrictive pericarditis)
No drugs w/ prognostic benefit, Mx Sx w/ diuretics

HF w/ reduced EF: <40% - inadequate emptying of ventricles from outflow obstruction or impaired contractility

Causes: MI, cardiomyopathy, arrhythmia

Question 18

Q

Types of anticoagulant

Answer

A

Heparins
- LMWH (SC) - VTE prophylaxis BUT bad for renal function
- UFH (SC/IV) - GOOD for renal function as a rapid reversal BUT heparin-induced thrombocytopenia (hypercoag state) risk needs APTT ratio monitoring
DOACs - oral + no monitoring BUT bad for renal function e.g. Apixaban (BD), Rivaroxaban (OD)
Vit K antagonist = Warfarin if weight extremes, reduced renal function or AF w/ MS/mechanical heart valve BUT INR monitoring + drug interactions

Question 19

Q

Virchow’s triad + anticoagulants vs antiplatelets

Answer

A

1) Stasis - coag factor activation–> venous clot (AF, DVT)
* Anticoags are most effective as coag factors cause clot
2) Vessel wall injury - plaque rupture - thrombogenic material release –> platelets activated –> arterial thrombosis (MI, stroke)
* Antiplatelets most effective as platelets cause clots
3) Hypercoagulability - does not change acutely

Question 20

Q

Bibasal crackles indicates what? Ix? Mx?

Answer

A

Fluid overloaded with pulmonary oedema = acute heart failure

HF = pumping of blood by heart isn’t meeting body demands

Ix:

Bedside - ECG
Bloods - ABG, troponin, BNP
Imaging - CXR, Echo (further down the line)

Acute HF Initial Mx:

Immediate: sit patient up, O2 15L/min NRM
Medical: IV furosemide (higher dose if on LT Tx), GTN, Morphine IV
If no improvement: repeat furosemide (after 15mins) –> consider CPAP

Long-term HF Mx:

Reduced ejection fraction - prognostic benefit:
B-blocker (bisoprolol) - reduce strain on heart
ACEi - reduce strain on heart
SGLT2 inhibitors (dapagliflozin)
RF modification - poor glycaemic control/high cholesterol
Sx (diuretics)

Question 21

Q

ECG changes in IHD

Answer

A

ST-elevation

Ischaemic changes

Dynamic T-wave inversion
ST depression

Question 22

Q

What heart condition is malar flush associated with?

Answer

A

Mitral stenosis

Question 23

Q

Key features of mitral stenosis

Answer

A

Malar flush
Middle-aged female
AF
Tapping apex beat (palpable/loud first heart sound)
Quiet blowing mid-diastolic murmur –> accentuate leaning to left and listening over mitral area while holding breath exhaled –> if can’t be heard then would get the patient to do exercise

Question 24

Q

Complications of MI

Answer

A

FAP (failure, arrhythmias, pericarditis)

Arrythmias (incl. VF)

Heart failure

Pericarditis

Early - positional chest pain day after MI –> give NSAIDs
Late - Dressler’s syndrome - immune response @6wks (fever, pleuritic chest pain, pericarditis/pericardial effusion)

Question 25

Q

3rd & 4th heart sounds - sounds & cause?

Answer

A

3rd = rapid ventricular filling = HF (reduced EF/systolic)

KEN…TU.CKY (deee. de.de)

4th = atrial contraction against stiff ventricles = longstanding AS & other causes of left ventricular hypertrophy (HTN heart disease, HOCM, HF with preserved EF/diastolic)

TE.NE..SSEE (de.de.deee)

Question 26

Q

In the context of HF what is cardiogenic shock? How do you treat? How do you treat rate-dependent cardiogenic shock (complete heart block)?

How will they describe cardiogenic shock in question?

Answer

A

HF so severe pressure insufficient to perfuse brain & heart alone –> 100% death if untreated
Treat with inotrope - dobutamine/dopamine –> increase perfusion of coronary arteries (saves 1/10)
Temporary external pacing –> permanent pacemaker

Q: cold peripheries & low UO

Question 27

Q

Apex beat displacement vs left ventricular hypertrophy?

Answer

A

Apex beat displaced by dilation = exam finding – caused by fluid overload
LVH = ECG Dx (peaked R-waves, ST depression and T-wave inversion in lateral leads) – caused by pressure overload e.g. HTN

Question 28

Q

What is widespread ST elevation?

Answer

A

Acute pericarditis

Question 29

Q

RFs for IHD?

Answer

A

HTN, DM, Smoking, FHx IHD, Hypercholesterolaemia

Question 30

Q

What drug should be held for 48hrs before and after an angiogram?

Answer

A

Metformin

Question 31

Q

What drug caused this ECG in AF patient

Answer

A

Flecainide can convert AF to 1-1 atrial flutter (normally given with bisoprolol to compensate) >200bpm

Question 32

Q

Complications of prosthetic heart valves

Answer

A

FIBAT

Failure
Infection
Bleeding - MAHA
Anaemia
Thromboembolic phenomena

Question 33

Q

AS vs aortic sclerosis signs?

Answer

A

AS:

Radiates to carotids
Slow-rising pulse
Narrow pulse pressure
Heaving apex beat
Severe = absent 2nd heart sound

Aortic sclerosis (calcification) = just murmur

Question 34

Q

AS - causes? Sx? Signs? Indications for surgery?

Answer

A

Causes:

Calcific degeneration
Bicuspid valve e.g. Turner’s syndrome (XO female) - develop 10yrs earlier

Sx: ASH (in this order)

A - angina
S - syncope
H - HF

Signs:

Key:
- Radiates to carotids
- Slow-rising pulse
- Narrow pulse pressure
Severe = absent/soft 2nd heart sound, reversed splitting of 2nd HS, heaving apex beat, longer murmur is worse

Indications for surgery: symptomatic (syncope) OR CCF

Mx: TAVI (transcatheter aortic valve implantation) or surgical replacement

- inf endocarditis abx prophylaxis
- long-term Warfarin (not DOAC)
Medical Mx: anti-HTN + anti-lipids + statin

Question 35

Q

What arrhythmia is common in AS and metallic aortic valve?

Question 36

Q

What should I look for if they have a midline sternotomy scar (cardio)?

Answer

A

Long saphenous vein harvesting in the leg = CABG

Question 37

Q

Indications for CABG? Vessels used for graft? Meds post-CABG?

Answer

A

Indications:

Left main-stem disease
2+ vessel disease
Failure of medical Mx
Concomitant (aortic) valvular replacement

Grafts:

Great saphenous vein
Internal thoracic (mammary) artery - NOW the most commonly used

Meds post-CABG:

DAPT - aspirin + ticagrelor (for 12 months then just aspirin) ± specialist opinion
Cardio-selective beta-blocker (bisoprolol)
ACEi (or ARB)
*

Question 38

Q

Mitral regurgitation - causes? presentation?

Answer

A

Causes:

Chr:
- Myxomatous degeneration
- Functional (w/ LV dilatation)
Acute:
- IE
- Papillary muscle rupture (supplied by posterior intraventricular artery, after inferior/posterior MI)

Presentation:

Pan-systolic murmur
Radiates to axilla
Severe: displaced/thrusting apex beat, LVF, 3rd HS

Question 39

Q

Causes of HF?

Question 40

Q

Distinguishing between observations during cardio PACES station

Answer

A

Murmur - AS, aortic sclerosis, MR
Sternotomy w/ Warfarin - Metalic valve, CABG + AF
Sternotomy no Warfarin - Tissue valve, CABG
Oedema (& none of above) - CCF

Question 41

Q

What does bradycardia with AV nodal block indicate?

Answer

A

Inferior MI

Question 42

Q

2 days of chest pain following 4 days of generalised muscle aches

Worse on inspiration & lying flat
Low-grade fever
Exam: pericardial rub

Causes? Dx? Ix? Mx?

Answer

A

Pericarditis

Causes:

Viral (most common)
MI (can be Dressler’s syndrome)
TB (constrictive)
Uraemia (CKD where urea high –> pericarditis) = indication for haemodialysis (HUMP)
Hydralazine (AI pericarditis)
- NOTE: also causes drug-induced lupus
SLE, RF, radiation

Presentation:

Pleuritic chest pain, worse lying flat
Exam: pericardial rub - “creaking/scratching”
- Tip - put on all-fours, put stethoscope on sternal edge, hold inspiration

Ix:

ECG: ST elevation widespread
Only slightly raised/normal troponin

Mx: colchicine (3 months) + NSAIDs (ibuprofen, max 2wks)

Question 43

Q

I am treating AF, what is C/I in structural heart disease?

Answer

A

Flecainide, CCB

Question 44

Q

In context of AF patient, patient is on Dabigatran, what do I do?

Answer

A

Only DOAC with reversible agent –> Idarucizumab

Question 45

Q

Facial swelling after starting ACEi/Entresto (Sacubitril/Valsartan)?

Answer

A

From angioedema (not anaphylaxis)

Question 46

Q

What is a loop diuretic with better oral bioavailability than furosemide?

Answer

A

Bumetanide

Question 47

Q

HTN Mx?

Question 48

Q

What is Dressler’s syndrome?

Answer

A

AI pericarditis (pleuritic chest pain + fever, global ST-elevation + PR depression) weeks-months after acute MI

Question 49

Q

When to Ix cause of HTN?

Causes of secondary HTN?

Answer

A

When:

<40 - without clear FHx/RFs
Severe/resistant HTN
Malignant HTN w/ evidence of end-organ damage
HTN with electrolyte disorders

Causes:

Renal artery stenosis - renal artery duplex scan, note: sign rise in creatinine after starting ACEi
Primary kidney disease
Sleep apnoea syndrome
Endo:
- Primary aldosteronism (Conn’s) - renin: creatinine ratio
- Cushing’s syndrome
- Hypothyroidism
- Phaeochromocytoma

Question 50

Q

What is headache, sweating, palpitations, severe HTN

Answer

A

Phaeochromocytoma

Question 51

Q

What is AV nipping on fundoscopy?

Answer

A

Hypertensive retinopathy

Question 52

Q

Pedal oedema resistant to diuretics is S/E of what drugs?

Question 53

Q

What BP is Dx of HTN? Vs Severe?

Answer

A

>140 = HTN

> 180 = Severe HTN

Question 54

Q

Prolonged QT, twisting of QRS complexes - Dx? Causes of long QT?

How to Tx?

Answer

A

Torsades de pointes (form of VT)

Causes:

Low Ca/Mg/K –> Prolongs QT
Drugs - Clari, Ciprofloxacin, Haloperidol
Inherited - Romano- Ward (AD no deafness), Jervell-Lange-Nielsen (AR sensorineural deafness)

Tx: IV Mg SO4 (also used for refractory VF, all other VTs treated with Amiodarone)

Question 55

Q

In cardiac exam - what should I not forget?

Answer

A

Hands/arms:

CRT, clubbing, arm bruising
Radio-radial delay
Collapsing pulse (lightly palpate radial and brachial pulses –> feel stronger for a few pulses) = AR
BP standing/sitting

Head/neck:

Check for carotid bruits before taking carotid pulse (character, volume) - slow rising = AS, bounding = AR
JVP + hepatojugular pressure (RUQ), rockstar hand
- PQRST: Pul HTN/PE/Pericarditis/Pericardial effusion, Quantity of fluid, RHF, SVC obstruction, Tamponade/TR

Auscultation:

Feel carotid pulse while listening to all below heart valves
Mitral valve - diaphragm mitral + axilla (MR) –> roll onto left side and listen mitral with bell + hold on expiration (MS - low tones)
Tricuspid valve
Pulmonary valve - listen for loud P2 (loud vs A2 = pul HTN)
Aortic valve - aortic area then lean forward & listen at left sternal edge + expiration (AR)
Listen @carotids (radiation = AS + bruits)
NOTE: on woman listen at submammary fold not on top of breast
NOTE: right valves heard best on inspiration; left heard best on expiration

Other: lung bases (pul HTN), peripheral oedema (RHF)

Question 56

Q

Causes of raised JVP (>4cm)?

Answer

A

JVP + hepatojugular pressure (RUQ), rockstar hand

PQRST:

Pul HTN/PE/Pericarditis/Pericardial effusion/PS
Quantity of fluid (fluid overloaded)
RHF
SVC obstruction
Tamponade/TR

Question 57

Q

“The heart stops for a second followed by a pounding sensation? - Dx?

Answer

A

Ectopics - supraventricular (younger) or ventricular premature beats

Question 58

Q

SVC obstruction - presentation? Tx?

Answer

A

Presentation: swollen face and neck and distended veins on her chest in background of cancer

Mx: dexamethasone to reduce tumour swelling

Insert EV stent if stridor (after intubation and steroids)

Question 59

Q

Bradycardia arrhythmia with a palpable pulse (peri-arrest) - Mx?

Answer

A

Innitial: A-E

If unstable - 500mcg IV atropine (/5mins up to 3mg)
- Also considered unstable if:
  - Recent asystole >3s/Mobitz T2 AV block/3rd degree heart block
- Caution in acute MI, C/I if heart transplant
If persistent –> transcutaneous pacing + analgesia/sedation (very painful)
- If can’t be achieved properly –> IV isoprenaline/adrenaline (specialist help)
Arrange transvenous pacing (temporary if recent asystole >3s/Mobitz T2 AV block/3rd degree heart block)

Question 60

Q

Heart block causes? types? Ix? Mx? Complications?

Answer

A

Causes:

MI/IHD (MOST COMMON)
Inf (RHD, IE)
Drugs (digoxin)
Metabolic (hyperkalaemia)
Infiltration of conducting system (e.g. sarcoidosis)
Degeneration of conducting system

Types:

First Degree AV block - fixed prolonged PR interval (> 0.2 s) - ASYMPTOMATIC
Second degree AV block:
- Mobitz TI (Wenckebach) - progressively prolonged PR interval –> P-wave NOT followed by a QRS complex = ‘going, going, gone’
  - Normally asymptomatic
- Mobitz Type II - intermittently P wave NOT followed by a QRS
  - May be regular pattern of P waves not followed by QRS (e.g. 2:1 or 3:1)
  - Can cause:
    - Stokes-Adams Attacks (syncope caused by ventricular asystole)
    - Dizziness, palps, chest pain, HF
Complete AV heart block - no relationship between P waves and QRS complexes
- Presentation as in Mobitz T2

Ix: ECG

Bloods: TFTs, Digoxin, cardiac enzymes (troponin, CK, BNP)
CXR (cardiac enlargement, pulmonary oedema)
Echo (wall motion abn, aortic valve disease, vegitations)

Mx:

Acute block - if clinical deterioration:
- IV atropine
- Consider temporary transcutaneous pacing
Chronic block:
- 1st degree monitored
- Permanent pacemaker in:
  - Symptomatic Mobitz T1
  - Advanced Mobitz T2
  - Complete heart block

Complications: asystole, cardiac arrest, HF, surgical complications of pacemaker insertion

Question 61

Q

Types of pacemaker? When to use each type? Complications?

Answer

A

Types:

Implantable Cardioverter Defibrillator (ICD, has a thicker end)
Single-chamber pacemaker (right ventricle)
- Used in permanent AF (no organised atrial contraction so atrial lead not required to sense contraction)
- Rarely can have atrial lead only - if SA disease in young with good AV conduction
Dual-chamber pacemaker (right atrium & ventricle)
- Can have ICD dual-chamber pacemaker
- Used in paroxysmal AF/all other scenarios (there is sometimes organised atrial contraction - this is sensed by the atrial lead)
Cardiac Resynchronisation Therapy/Biventricular pacemaker (right ventricle, left ventricle ± right atrial lead)
- Can have ICD biventricular pacemaker

When to use each type:

Atrial lead only → Sino-atrial disease in young people with good AV node conduction
RV lead only → Pacing whilst in permanent atrial fibrillation
Dual-lead → All other scenarios (paroxysmal AF, bradycardia)
CRT → LV dysfunction + broad QRS –> end-stage HF
Indications for ICD:
- Primary prevention = @risk of serious ventricular arrhythmia
  - Familial cardiac conditions (hypertrophic cardiomyopathy, long QT)
  - Previous surgical repair of congenital HD
  - Previous MI + LVEF <35% + HF Sx
- Secondary prevention = had previous serious ventricular arrhythmia wo/ treatable cause
  - Cardiac arrest from VT/VT
  - Spontaneous sustained VT AND:
    - Syncope/haemodynamic compromise OR
    - LVEF <35% + sign HF Sx (NYHA 3+)
  - NOTE: VT/VF from STEMI has treatable cause (open occluded vessel)

Complications:

Surgical complications - infection, bleeding, damage to underlying structures
Displacement (of lead)
Pacemaker syndrome (if ventricular lead with no atrial) –> AV node conducts in retrograde direction = mitral/tricuspid regurge + HF Sx

Question 62

Q

What are prominent V waves in the JVP indicative of?

What are cannon A waves in the JVP indicative of?

What is a prominent x descent in the JVP indicative of?

Answer

A

Tricuspid regurgitation

Complete heart block

Acute cardiac tamponade/Constrictive pericarditis

Question 63

Q

What is radio-femoral delay a sign of? Which congenital condition is strongly associated?

Answer

A

Aortic coarctation

Turner’s (1 X chromosome in female)

Question 64

Q

Immediate Mx of rheumatic fever?

Answer

A

Aspirin prn
Benzylpenicillin IM stat –> 10 day course of benzylpenicillin PO

Answer 60

A

Patients who are completeley revascularised with okay LVEF = 1 week
Patients with severely reduced LVEF = 4 weeks

Answer 61

A

Metformin

Answer 62

A

Treat underlying cause
Anticoagulate as you would for atrial fibrillation

If haemodynamically unstable: rate control or cardioversion

Answer 63

A

Ventricular etopics
Atrial flutter

Answer 64

A

Stop anticoagulation and repeat scan in one week

Answer 65

A

Left ventricular hypertrophy
Pulmonary oedema
Valve calcification

Answer 66

A

QRISK3 score to stratify risk
Manage risk with a statin (eg atorvastatin) and an antiplatelet (aspirin/ clopidogrel)
Manage coexistent HTN/ angina etc

Valve replacement if Sx/acute

AR/MR - reduce afterload:

ACE inhibitors
Beta-blockers
Diuretics (furosemide)

MS:

RhF prophylaxis with benzylpenicillin
AF (rate control + DOAC)
Diuretics for symptomatic relief (furosemide)
1st line surgical - Balloon valvuloplasty

Answer 67

A

Pros: no bypass required, no large scars
Cons: higher risk of stroke compared to open replacement

Answer 68

A

What:

‘Rumbling mid-diastolic murmur’
Associated with severe aortic regurgitation
Best auscultated in 5th ICS in MCL
Caused by blood flowing back through the aortic valve and over the mitral valve

When:

Mid-diastole
Caused by regurgitant jet that runs over the mitral valve leaflets

Answer 69

A

Malar flush
Raised JVP
Right ventricular (parasternal) heave, pulmonary thrill
Loud S2

Answer 70

A

For HF

1 - no limitation on activity
2 - comfortable at rest but dyspnoea on ordinary activity

3 - marked limitation on ordinary activity
4 - dyspnoea at rest

Answer 71

A

Low-voltage complexes

Answer 72

A

Pulsus paradoxus - greater than the normal (10 mmHg) fall in systolic blood pressure during inspiration → faint or absent pulse in inspiration

severe asthma, cardiac tamponade

Slow-rising/plateau

AS

Collapsing

AR, PDA
hyperkinetic states (anaemia, thyrotoxic, fever, exercise/pregnancy)

Pulsus alternans - regular alternation of the force of the arterial pulse

severe LVF

Bisferiens pulse - ‘double pulse’ - two systolic peaks

Mixed aortic valve disease
HOCM (also causes ‘Jerky’ pulse)

Answer 73

A

Delta wave - WPW

Can’t give digoxin, verapamil, amiodarone
Can give B-blockers, flecainide

Answer 74

A

VT or SVT w/ aberrancy

SVT >200bpm, also often irregular
VT more likely if LAD
Acutely treat any broad complex tachy as VT until proven otherwise

Presentation: palpitations, light-headed, chest pain, syncope, seizure

Tachycardia, LVF
ACS most common cause
NEVER IGNORE palpitations & light-headedness

Ix: ECG - regular broad complex tachycardia

U&E (Mg, Ca, K), TFTs, Troponins

Mx:

Unstable tachycardia (BP <90, chest pain, acute cardiac failure) = DC cardioversion
Stable:
- Prepare for DC cardioversion
- IV amiodarone, b-blocker

Answer 75

A

Pulsus paradoxus - BP variation between inspiration & expiration (≥10)

Beck’s triad (50%):

Raised JVP
Muffled heart sounds
Hypotension

Mx:

IV fluids (RV filling depends on venous pressure & effusion is constricting)
Echo –> refer to cardiology for pericardiocentesis
- Coagulation profile (to prep for pericardiocentesis)

Answer 76

A

Tricuspid regurgitation

Answer 77

A

Dx: Noonan’s syndrome (AD) - short stature, scoliosis, webbed neck, wide-spaced eyes, nystagmus

Associated with PS, ASD, HOCM
NOTE: if it was a woman & no murmur could be Turner’s syndrome

Murmur was louder on inspiration = PS - ejection systolic, radiates to back

Answer 78

A

S. aureus

Answer 79

A

Strep. bovis

If they have S. bovis endocarditis –> colonoscopy (as may have colon cancer)

Answer 80

A

VSD

Endocarditis

Answer 81

A

Libman-Sacks = non-bacterial thrombotic endocarditis (marantic endocarditis) - occurs in SLE

Assoc w/ malignancy/AI conditions/hypercoagulable states

Answer 82

A

ASD - commonest is ostium secundum

Mid-diastolic murmur + fixed split S2
High risk of AF & paradoxical emboli (prev stroke?)
NOTE: commonest inherited cardiac condition to present in adulthood (as can be asymptomatic in childhood)
NOTE: this is not Eisenmenger’s syndrome as patient not cyanotic

Assoc w/ down’s syndrome (& AVSD), Turner’s & Noonan’s syndrome

Ix:

ECG - incomplete RBBB (90%, can be normal variant), RVH (T-wave inversion V1-3), P pulmonale (tented P-waves), AF
Ix: bubble study (+ RV dilatation)
- Also done for patent foramen ovale (PFO)

Answer 83

A

Def: chr inflamed pericardium (this is why colchicine is given for 3 months in normal pericarditis)

Cause: classically previous TB in the pericardium

Ix:

(Exam - pericardial knock on auscultation (bit old school))
Kussmaul’s sign - JVP rises on breathing in
Small heart on CXR ± calcifications
Low voltage ECG w/ T-wave inversion/flattening (could also be pericardial effusion)

Complication: cardiac liver cirrhosis

Right ventricle struggles –> tricuspid regurg (pulsatile liver) –> liver failure (oedema +++)

Answer 84

A

AI pericarditis

Drug-induced lupus - anti-histone ab

Answer 85

A

Young + very high BP –> must be secondary HTN (causes: endo - Conn’s, Phaeo; coarctation of Aorta (CoA), renal artery stenosis, chronic renal failure)

CoA - tissue restricting flow across aortic arch

Murmur across the coarctation = left infrascapular area (due to turbulent BF)
Lower body underdeveloped vs upper (97% men going to gym)
Assoc: Turner’s (+ Marfan’s, Ehlers-Danlos)
- Short stature, webbed neck, wide-spaced eyes, lack of other secondary sexual characteristics, shield-like chest, short 4th metacarpals/tarsals
Advice: avoid extreme isometric exercises e.g. weight-lifting –> risk of aortic dissection
- How do you Dx dissection? CT aortogram w/ contrast

Answer 86

A

Not palpable
Double pulsation
Obliterated when pressure applied at base of neck
Rises with hepatojugular reflux
Height changes with respiration

Answer 87

A

Midline sternotomy + leg scar = CABG
Midline sternotomy (no leg scar) = Valve replacement most likely (rarely can be CABG without vein graft)
Left subclavicular -> pacemaker, debfibrillator, resynchronisation device
L shaped scars under either breast -> L/R Thoracotomy

Answer 88

A

Coaractation
Congenital Cervical Rib (> subclavian steal syndrome)
Coronary Angiography previously
Arterial embolism e.g. due to AF

Answer 89

A

Coarctation of aorta
Subclavian stenosis
Takasayu’s arteritis

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