Cardiomyopathies

Question 1

Frederichs ataxia and WPW

Leading cause of sudden cardiac death in young athletes

S4. Mid EJECTION SYS MURMUR
Mitral regurg; concentric hypertrophy
BISFRIENS PULSE!!! JERKY PULSE!!!!

Which mutation?
TransThoracic Echo show? MR SAM ASH

Tx?

Answer 1

HOCM

BETA myosin heavy chain

MR/Sys Ant Motion/Asym Sys Hypertrophy

Amiodarone @ arrhythmia 
Beta block/CCB-verap
Cardiovert defibrillate implantable 
DC pacemaker implantable
Endocarditis proph
Surg = myomectomy

Question 2

Guys got 
Loefflers endocarditis, 
Amyloidosis, 
Radiotherapy, 
Sarcoidosis/scleroderma

Presents as RHF!!!

Answer 2

Restrictive cardiomyopathy - RestrRHF

Jvp high, ascites, HMeg

Question 3

Alcohol,
Beri beri wet B1 def
*Coxsackie Chagas (trypanosomacmv ebv parvo flu adeno hhv 6 hep c
Doxorubicin

Guys got most COMMON CMyopathy - 90%

LHF + RHF symptoms
S3 sys murmur; eccentric hypertrophy

Mitral regurg/Tricuspid regurg

Answer 3

Dilated cardiomyopathy LHF>RHF

HF Tx ie ABCDES!!

*all those fkn viruses cause myocarditis which leads to DCM

Question 4

Person had bereavement/breakup!!!

Patient just found a family member dies then

suddenly develops chest pain + HF

Apical ballooning of myocardium

Stress induced cardiomyopathy

Answer 4

Takotsubo - type of dilated CMyopathy

BROKEN HEART SYNDROME!!!

Question 5

Pregnancy:

Last five months

Five months postpartum

Answer 5

Peripartum cardiomyopathy

Question 6

Cyanotic congenital disease

Acyanotic congen diseases

Answer 6

TruncArt 1 vessel
TransGA 2 vessels
TricAtresia 3 vessels
ToF 4 vessels
TAPVR

VSD>ASD>PDA>coarctation

Question 7

TA fails to what?

TGA: blood =
RV -> ???
LV -> ???

What to give before TGA surgery and why?

TricAtresia: ???

Answer 7

TA fails 2 divide in 2 (pul art and aorta)

TGA: blood =
RV -> Aorta
LV -> Pul Art

Prostaglandins keeps it open @ TGA to allow some oxygenation before surgical fixing

TricAtresia: no tric valve + hypoplastic RV

Question 8

Features of ToF?

Baby cries and turns blue - tet spells

CXR shows boot shape. What does this mean?

What manoeure gets rid of cyanosis?

Answer 8

ToF:
Pul stenosis @ infund -> pushes blood through VSD #R->L shunt
RVH
Overiiding arota
VSD

boot shape = RVH

Valsalva =
SVR -> lower R->L shunt

Question 9

Whats PDA?

Why PDA legit in utero?

Why not need after born?

If persists whats the issue?

Similar to Aortic regurg, what kind of pulse you get?

Tx?

Answer 9

PDA= connection between pul art + aorta

inutero R->L shunt fine cos of pul HTN i.e. need it go through PDA

after born, dont need PDA cos Pul HTN gone.

If it persists, L->R shunt = RVH = corpulmonale EISENMENGER

COLLAPSING PULSE!! + continuous MACHINE

Tx = Indomethacin closes PDA!!
Prostaglandins keeps it open @ TGA to allow some oxygenation before surgical fixing

Question 10

Explain eisenmenger

Sx?

Ax?
____________

RBBB+RAD ?
RBBB+LAD ?

Answer 10

L->R shunt = PAH ->
RVH -> R->L shunt

@Eisenmenger = flow reverses –>
-murmur = disappears –> i
nfant becomes Cyanotic rather than shocked and pale.

CCPP:

• cyanosis clubbing
• polycythemia PAH

Ax = VSD, ASD, PDA.
_____________

ASD:

RBBB+RAD = secundum dx
-EMBOLUS SHOOT OFF -> STROKE!!!!!!

RBBB+LAD = primum dx

Question 11

Man/Turner’s girl = HTN in arms and R-F delay
Got TURNERS!!!

Mid ejection systolic @ LUSE through to
BACK!!

Explain pathology.

CXR = notched ribs cos of?

Answer 11

Coarctation

Aorta narrow near PDA ->

HTN in bracioceph + LSubclavian + R-F delay

CXR = notched ribs cos of collats eroding ribs

Question 12

Late MI complications

Early MI complications

Answer 12

Late

LV Aneurysm - persistent ST elevation!!

LV Rupture JVP high, muffled heart sounds, low BP

Early:

Pericarditis – Pleuritic chest pain eased sitting upright

Ventricular tachycardia – Guy develops broad complex tachycardia blood pressure drops

ventricular fibrillation – Guy goes into cardiac arrest dies

Papillary muscle rupture - Blood pressure drops and new mid-sys murmur

Question 13

Late:

persistent ST elevation!!

JVP high, muffled heart sounds, low BP

Early:

Pleuritic chest pain eased sitting upright

Guy develops broad complex tachycardia blood pressure drops

Guy goes into cardiac arrest dies

Blood pressure drops and new mid-sys murmur

Answer 13

Late

LV Aneurysm - persistent ST elevation!!

LV Rupture JVP high, muffled heart sounds, low BP

Early:

Pericarditis – Pleuritic chest pain eased sitting upright

Ventricular tachycardia – Guy develops broad complex tachycardia blood pressure drops

ventricular fibrillation – Guy goes into cardiac arrest dies

Papillary muscle rupture - Blood pressure drops and new mid-sys murmur

Question 14

Midsystolic crescendoed decrescendo murmur radiating to the carotids @ RUSE

Midsystolic murmur @ LUSE

• fixed split?
• s4?

Mid ejection syatolic murmur @ BACK

What is carcinoid assoc with?!
_________

Pansystolic @LLSE

• blowing high pitched
• harsh V2

Diastolic @ LLSE

Pansystolic @ apex

• blowing high pitch
• mid ejection systolic click

Diastolic @ apex = LHS hold breath + opening snap
____________

Pansystolic @LLSE

• blowing high pitched
• harsh V2

Diastolic @ LLSE

Pansystolic @ apex

• blowing high pitch
• mid ejection systolic click

Diastolic @ apex = LHS hold breath + opening snap

Answer 14

EJECTION MSys@RUSE Aortic Stenosis Sys-mid C-D

EJECTION Sys=MSys@LUSE= PS, ASD fixed split, ToF, HOCM S4, innocent!!!!

Late MESys @ back = coarctation

Carcinoid -> PUL STENOSIS/TricInsuff
___________

PSys LLSE = TR/VSD

Dias LLSE = TSten

PSys = MR/MP(actually is late sys)

Late Diastolic = MS = LHS Hold Breath, Opening snap
____________

PSys LLSE = TR/VSD

Dias LLSE = TSten

PSys = MR/MP(actually is late sys)

Late Diastolic = MS = LHS Hold Breath, Opening snap

Question 15

Pansystolic @LLSE

• blowing high pitched
• harsh V2

Diastolic @ LLSE

Pansystolic @ apex

• blowing high pitch
• mid ejection systolic click

Diastolic @ apex = LHS hold breath + opening snap

Answer 15

PSys LLSE = TR/VSD

Dias LLSE = TSten

PSys = MR/MP(actually is late sys)

Late Diastolic = MS = LHS Hold Breath, Opening snap

Question 16

AD - long QT + NO sensorineural deafness

AR - long QT + sensorineural deafness

AD Asian men pseudoRBBB + ST elevation (downsloping mostly V1-3ish). Risk? Tx? Gene?

Antiarryhtmics causing long QT?
Others?
Electrolytes?

CASQ2 and RYR2 encodes for?

Answer 16

Romano Ward, KCN(Q1+H2) fucked K channels

Jervell Nielsen

Brugada = tachy-arrhythmias, sudden cardiac death. ICD!! Gene SCN5A mutation -> fucked Na Channel

Not flecainide, amiodarone, procainamide, sotalol
SSRI/TCA; Typ»»Atyp APsych; Li; macrolides
Low Mg K Ca
HYPO FUCKING THERMIA!!!

CASQ2 = calsequestrin fucked -> Ca can’t bind -> Catecholaminergic Polymorphic VT (CPVT)
and RYR2 = ryanodine receptor -> CPVT also

Question 17

Some features of a Aortic stenosis?

Treatment

Common Ax <65 and >65

Answer 17

LVH = LAD LBBB
Pulse = narrow pressure/ slow rising
Apex = thrill
S4

Asymptomatic = observe
Asymptomatic >40/50mmHg + LV sys dx = surg

Symptomatic = valve replacement -> balloon valvuloplasty

<65 - bicuspid aortic valve
>65 - calcification

Question 18

Pulses paradoxes?

Slow rising/plateau?

Collapsing?

Pulsus alternans?

Bisfriens pulse?

Jerky

J wave Osborn

Widespread/SADDLE ST elevation

PR depression?!

pericardial knock

Answer 18

Severe asthma/cardiac tamponade

Aortic stenosis

Aortic regurg/PDA/increased requirement (anaemia hyperthyroid/)Pregnancy/fever/exercise

Left ventricle failure

Mixed aortic valve disease/HOCM

Jerky = HOCM

J = hypothermia HyperCalcemia

Widespread ST elevate = pericarditis

PR depression = most sensitive for pericarditis!!!!!

pericardial knock = constr pericard

Question 19

Diastolic murmur @ LUSE

• high pitched
• Rumbling/SIT forward = MADCAT PAQ???

Ax??

Answer 19

Diastolic murmur @ LUSE
PR - Graham Steel murmur HighPitched
AR - Rumbling Austin Flint Sit forward!!!

Musset nodding, Austin Flint, Dariosz Fem

Corrigan carotid, Traube Pistol Fem

Pulse = collapsing/wide split;
Apex displaced;
Quincke nail bed hemorrhage

Ax of Aortic regurg =
Valve dx = SLE/infection (rheum+endo), RA
Aortic root dx =
Ank spond, Marf/EDanlos, ADiss/HTN, syphilis

Question 20

S1-4 sounds?

Wide split ??
Paradox split??
Fixed split??

Answer 20

S1 = mitral/tricuspid closing
soft @regurg
loud @MS

S2 = Aortic/pul closing
soft @ASten
Loud @ HTN, Hyperdymamic states, ASD-PulHtn

Wide s2-
delay RV empty(PS; PAH{MRegurg severe}; RBBB)

Paradox s2 - WPW-b, AS/LBBB, RVPacing, PDA

Fixed s2 - ASD

S4 = atria contract against STIFF ventricle
HOCM/HTN
ASten
(think about it this way, if it’s AS here, then S3 is opp ie mitral regurg )

S3 = diastolic filling of ventricle 
Const pericarditis - pericard knock, X+Y, X ✔️; 
Dilated CM, 
MRegug
NORMAL<30y

Question 21

Causes of first and second degree HB KIMBAD

Causes of third degree complete HB FASTI

Pericardial rub - ??
Pleural rub - ??
Pericardial knock - ??

Answer 21

First and second degree:
K+low; IHD; myocarditis;
Beta-blockers; Athletes; Digoxin

Third degree complete block:
Fibrosis; AS; Surg Trauma; IHD/Congen

Pericardial rub - pericarditis
Pleural rub - pneumonia/PE
Pericardial knock - C. Pericarditis

Question 22

Causes of LBBB

RBBB causes?

Wide split ??
Fixed split??
Paradox split??

Answer 22

Causes of LBBB

RBBB causes?

LBBB=CM, HTN, AS, IHD

RBBB=PE, ASD, Normal

Wide -
delay RV empty(PS; PAH{MRegurg severe}; RBBB)

Paradox - WPW-b, AS/LBBB, RVPacing, PDA

Fixed - ASD

Question 23

ST elevation Ax?

ST depression AX? VICD

T wave inversion Ax? DRILb

Answer 23

ST elevation =
MI/pericarditis

ST dep + T invert =
VHypert + Ischemia + Conduction dx + Digox

T invert =
ischemia/old 
Brugada 
VHypert*
Digoxin

Question 24

What sign is and what’s it found in?!

BP/pulse drops on inspiration?

JVP rises on inspiration?

Answer 24

Pulsus paradoxus!!! Tamponade TampaX: ✔️; X

Kussmauls!!! Constrictive pericarditis X+Y; X; ✔️

Question 25

ECG signs for:

LVH, RVH, LAH, RAH

Answer 25

LVH:
R>25mm V5+6
Inverted T @ V5+6, 1, VL
LBBB+LAD

RVH:
R tall @ V1
Inverted T @ V1+2,
RBBB+RAD

LAH: BPM
Bifid P-mitrale +/- AF = MS/R

RAH: PPP
Peaked P-pulmonale= TS>PS/PAH

Question 26

White wash on CXR:

What causes trachea:

towards white wash
away white wash

Answer 26

Towards:
Pneumonectomy; hypoplasia; collapse

Away:
Pneumothorax; effusion; diaph hernia; tumour

Normal:

MESOTHELIOMA; pneumonia; pul oed

Question 27

Ax LAD

Ax RAD

Answer 27

RAD vs LAD

A(R>S @ V1) - WWPW - B (S»>R + Tinvert)+ VT
AAAArm switch/dextrocardia
RRRRVH - LVH
Lat (circumflex) - MMMMI - Inf (RCA)
TTTTall thin = RAD
Left post fasicle - HHHHemiblock - left ant fasicle/(bifasicular)

p176 ECG John Hampton book

Question 28

Ax for increased troponin

Non palpable apex

Raised JVP

Answer 28

Sepsis shock
PE/pericard
RF
MI/F+

Non palp apex = 
COPD
Obesity
PEffusion(as well as percardial)/Px
Dextrocardia 

JVP inc = M-HF
I - LNodes/CPericarditis
C - SVCO
E - Tamponade

Question 29

Normally in V1 S>R. But why would R>S?

Normally in V5/6, R<25mm. But why would R>25mm?

Where can small Qs normally be found?
Where can T inversion be normally found?

Answer 29

R>S = RVH/posterior MI

R>25mm = LVH

Q - 1, aVL, V6 - lat side circumflex
T-invert - 3, aVR, V1 + V2-3(Black)

Question 30

Ax 
MR parcel 
MS crem 
AR smear
AS RCC

Answer 30

MR: prolapse/appetite suppressants/rheum fever/Calcification;ChordaePapillaeDX/ Endocarditis/LVDilate - CM/Congen

MS: congen/rheum fever/EndoFibroelastosis/malig carcinoid

AR: syphilis/marfan ehlors/endocarditis/ADiss-HTN/Rheum fever/ology(2nd page of diseases in notes!!!)

AS: rheum fever/calcified/congen

Question 31

Clubbing Ax

Cardio CoME
Resp S(cote)IC
GI CLIT

Answer 31

Cardio: COngen/Myxoma/Endocarditis

Resp:
suppurative (Collection abscess/outside empyema/Tubes bronchiectasis/Everywhere CF

GI: cirrhosis/CDx; lymphoma; IBD; Thyroid graves acropachy

Question 32

Oedema Ax
Pitting CAN RICO MEN
Npitting MICE
Unilat DCP

Answer 32

Pitting
Drugs = csteds/amytriptiline/NSAIDs
VP inc = RF/immobility/CPericard/Obese
OP dec = low albumin - malnutrition/exfoliative dermatitis/nephrotic+cirrhosis

NPitting
M - milroys/Thyroid dx
I - filariasis
C - cancer 
E - RT/Node clearance

Unilat - DVT/cellulitis/PTSynd

Question 33

Causes of HF:

Preload high
Pump failure
Afterload high

Answer 33

Preload - Regurg(any valve)/overload/VSD

Pump failure - CM/CPericard; IHD/Ionotrope neg; Arrhythmia

Afterload - Stenosis (any valve)/HTN(periph/pul-corpulmonale)

High output - Preg/Anemia/Thyrotoxicosis

Question 34

Periph cyanosis Ax - blue fingers

Central cyanosis - blue lips tongue

LVHeave Ax

Answer 34

Periph:
PVD/HF/Shock
Raynauds

Central:
Shunts/Lung dx/MetHbemia

LVHeave:
HOCM/HTN; AS; Coarctation

Question 35

Ecg Changes of digoxin?

Answer 35

Flat T
AV block
Short QT
Tick-reverse = downslope ST

Question 36

Action of adenosine?

Which drugs enhances/reduces action of adenosine?

Answer 36

A1 receptor agonist @ AV node-> inhibits aCyclase -> reduce camp -> hyperpolarization

Dipyramidole/Bupivicane = Enhances Action

Aminopyhlline reduces action of adenosine

Question 37

Pt had DE stent put in, on aspirin and ticagrelor. Gets breathless. What to do?

Answer 37

Sub ticag for clopi

Cos ticag = stops adenosine clearance ->
incr adenosine –> SOB sx

Question 38

JVP a c v x y waves

Answer 38

A - atrial contraction -
Large is atria pushing agasint resistance
Absent in AF
Cannon @ atria contract agasint closed vent eg at 3rd HB/arrhythmias

C - tricuspid close

V - passive filling of blood at diastole @ atrium agasint closed tric valve
Giant at tric regurg

X descent - Decr atrial pressure @ vent contraction

Y descent - opening of tric valve

Question 39

WPW
A - which sided pathway ->?AD = dom R wave @ which lead??
B - which sided pathway ->?AD = dom R wave @ which lead??

Assoc:?

Tx:?

Avoid sotalol when? Why?

Answer 39

WPW
A - left sided RAD = dom R wave @ V1
B - right sided LAD = no dom R wave @ V1

Assoc: MESH
MVP, Ebstein anomaly, Secundum ASD, HOCM/HyperT

Tx: radioFreq ablation of acc pathway
FAPS

Avoid sotalol @AF cos
it prolongs refractory period @AVN -> inc rate of transmission through acc pathway -> Inc vent rate = VF

Question 40

Most common cardiac tumour?

Attached to what?

Standard cancer symptoms, clubbing SOB
In AF.

echo shows?

Answer 40

Atrial myxoma

Fossa ovalis

Echo shows pedunculated mass.

Question 41

For bioprosthetic valve:
Inc risk of?? 
>age? get aortic one
>age? get mitral one
AC needed? give what antithrombotic Tx? 

For mechanical valve:
Inc risk of??
AC needed? And what else if IHD??

Answer 41

For bioprosthetic valve:
Inc risk of calcification 
>65 get aortic one
>70 get mitral one
Long term AC not needed, give aspirin

For mechanical valve:
Inc risk of thrombosis
Give warfarin + aspirin if IHD.

Question 42

Pts on warfarin who need emergency surgery:

Can wait 6-8hrs = give??
Cant wait - PTC 25-50 units

Answer 42

Pts on warfarin who need emergency surgery:

Can wait 6-8hrs = give 5mg Vit K
Cant wait - PTC 25-50 units

Question 43

Tropomyosin associates with actin in muscle fibres -> regulates muscle contraction by regulating the binding of myosin

In MI:

?? is the first to rise.
Mctal??

Answer 43

Tropomyosin is a protein which regulates actin. It associates with actin in muscle fibres and regulates muscle contraction by regulating the binding of myosin

Myglobin 2hrs, CK MB 4hrs, Trop 6hrs, AST 1day, LDH 2 days

Question 44

What investigation is most useful in predicting symptomatic response to cardiac resynchronisation therapy?

Answer 44

TTE and ECG

Question 45

What meds exacerbate CCF? - CASP

Answer 45

Neg inotrope:
CCB - verapamil
Antiarryhtmic - flecainide

Fluid retention:
Steds/NSAIDs
Pioglit

Question 46

Explain RAAS and ANP/BNP

Answer 46

ANP/BNP regulates the dangerous effects of RAAS activation in heart failure.

Pump fail -> reduced flow/Na -> RAAS ->
Na + H2O retention and v.constriction ->
Sympathetic nervous system and the action of ADH ->
incr vent pre+afterload & incr wall stress ->
incr ANP+BNP ->
natriuresis + v.dilation + stop RAAS

Atrial stretch = incr ANP = similar to BNP

Question 47

Right side of heart sats =?%

Left side of heart sats = ?%

Answer 47

Right side of heart sats = 70%
Left side of heart sats = 100%

ASD
RA RV PA LA LV Ao
85 85 85 100 100 100

ASD w/ Eisenmenger
RA RV PA LA LV Ao
70 70 70 85 85 85

VSD
RA RV PA LA LV Ao
70 85 85 100 100 100

VSD w/ Eisenmenger
RA RV PA LA LV Ao
70 70 70 100 85 85

PDA
RA RV PA LA LV Ao
70 70 85 100 100 100

PDA w/ Eisenmenger
RA RV PA LA LV Ao
70 70 70 100 100 85

Question 48

Aspirin Antiplatelet - inhibits the production of??

Clopidogrel Antiplatelet - inhibits ?? binding to??

Enoxaparin/Fonda Activates ?? -> potentiates the inhibition of ??

Bivalirudin Reversible ?? inhibitor

Abciximab, eptifibatide, tirofiban ???

Answer 48

TxA2, ADP plt receptor, aAT3 stop f10a, DTi, gp2b3a blocker

Aspirin Antiplatelet - inhibits the production of thromboxane A2

Clopidogrel Antiplatelet - inhibits ADP binding to its platelet receptor

Enox/fonda Activates antithrombin III, which in turn potentiates the inhibition of coagulation factors Xa

Bivalirudin Reversible direct thrombin inhibitor

Abciximab, eptifibatide, tirofiban Glycoprotein IIb/IIIa receptor antagonists

Question 49

exertional dyspnoea is classic

exertional syncope, exertional chest pain, peripheral oedema and cyanosis

raised JVP with prominent ‘a’ waves
right ventricular heave,
loud P2, tricuspid regurgitation

mean pulmonary artery pressure of >=?? mHg

Ix?? To measure what??

1. Tx underlying condition eg chronic lung dx copd
2. Do what test? Aim? What to administer?

Positive: give what??

Neg: give what??

progressive symptoms should be considered for a??

Answer 49

mean pulmonary artery pressure of >= 25 mHg

Ix: cardiac catheterization to measure right heart pressures

1. Tx underlying condition eg chronic lung dx copd
2. Acute vasodilator testing aims to decide which pts have fall in PAP after vasodilators eg. IV epoprostenol/inhaled NO

Positive: oral CCB

Neg: Prosta-ilopr, Endo-bosentan, PDEi-sildenafil
Prostacyclins: treprostinil, iloprost
Endothelin receptor blockers: bosentan, ambrisentan - decrease pulmonary vascular resistance in PPHtn

Phosphodiesterase inhibitors: sildenafil

progressive symptoms should be considered for a heart-lung transplant.

Question 50

HTN > 200/130

Headaches, n+v, visual dx, papilledema,
Encephalopathy/seizures

Answer 50

Reduce diastolic < 100 within 12hrs
Atenolol PO
Nitroprusside/Labetalol IV