Cardiovascular Flashcards
1
Q
When would you use rhythm control in the management of AF?
A
If there is coexistent heart failure, first onset AF or an obvious reversible cause
2
Q
What is the diagnosis?
A
Aortic dissection (type A) - an intraluminal tear has formed a ‘flap’ that can be clearly seen in the ascending aorta
3
Q
How do thiazide diuretics cause hypokalaemia?
A
Thiazide diuretics work by inhibiting sodium reabsorption at the beginning of the distal convoluted tubule (DCT) by blocking the thiazide-sensitive Na+-Cl symporter
Delivery of sodium to the distal part of the distal convoluted tubule is increased → increased sodium reabsorption in exchange for potassium and hydrogen ions
4
Q
What ECG changes are seen in hypokalaemia?
A
- Prominent U waves
- Small or absent T waves (occasionally inversion)
- Prolonged PR
- ST depression
- Long QT
5
Q
How does Conn’s syndrome/bilateral adrenal hyperplasia cause hypokalaemia?
A
Due to increased levels of aldosterone, there is more sodium reabsorption in the kidneys and an increase in the excretion of potassium (hence hypokalemia)
This also leads to volume expansion, and increased blood pressure
6
Q
Describe the initial drug management for all patients with ACS
A
- Aspirin 300mg
- Oxygen if sats < 94%
- Morphine only if patient in severe pain
- Nitrates (caution if hypotensive)
7
Q
How would you manage an NSTEMI patient who is clinically unstable (e.g. hypotensive)?
A
- Unfractionated heparin
- Immediate coronary angiography with follow-on PCI if necessary
8
Q
What drug would you give to an NSTEMI patient who is not at a high risk of bleeding and who is not having angiography immediately?
A
Fondaparinux
9
Q
How would you manage an NSTEMI patient with a GRACE score > 3%?
A
Coronary angiography with follow-on PCI if necessary within 72 hours
10
Q
How would you convervatively manage a patient with an NSTEMI/unstable angina?
A
Further antiplatelet (‘dual antiplatelet therapy’, i.e. aspirin + another drug)
- If the patient is not at a high risk of bleeding: ticagrelor
- If the patient is at a high risk of bleeding: clopidogrel
11
Q
What diagnosis does the ECG suggest?
A
MI - massive ST elevation with associated hyperacute T waves in the anterior leads suggestive of an ongoing myocardial infarction
12
Q
How long should a patient with an ‘unprovoked’ DVT be on anticoagulation?
A
6 months
13
Q
What CHA2DS2-VASC score indicates a need for anticoagulation?
A
Men: CHA2DS2-VASc >= 1
Women CHA2DS2-VASc >= 2
14
Q
What are the components of the CHA2DS2-VASc score?
A
15
Q
What is the surgical invention of choice for mitral stenosis?
A
Percutaneous mitral commissurotomy
16
Q
What clinical findings are associated with mitral stenosis?
A
- Rumbling mid-late diastolic murmur, best heard in expiration
- Loud S1
- Opening snap after S2
- Low volume pulse
- Malar flush
17
Q
How does mitral stenosis present?
A
- Hx of rheumatic fever
- Dyspnoea
- Orthopnoea
- Haemoptysis
- AF
18
Q
A 58-year-old female on the respiratory ward was admitted with a pulmonary embolism one week ago and was started on warfarin at the time of diagnosis. She was covered with low molecular weight heparin until the INR was > 2 for 24 hours. For the past week she has been taking 4mg of warfarin and her INR four days ago was 2.2. Her INR has been checked today and is 1.3.
What is the most appropriate action to take?
A
Increase dose of warfarin to 6mg and start LMWH
As her INR is < 2 she needs immediate anti-coagulation with rapid acting low molecular weight heparin. Her warfarin dose should also be increased to 6mg. Her INR should be carefully monitored and the LMWH discontinued when has adequate anti-coagulation.
18
Q
A 76-year-old man is seen by his GP. He recently had an ambulatory blood pressure monitor which showed frequent readings above 160/95 mmHg. The man has a background of well controlled heart failure (New York Heart Association stage 2) and chronic kidney disease. He takes ramipril, bisoprolol and atorvastatin; he has been established on this regime for one year and doses have been optimised.
What would be the most appropriate next step?
A
Add a calcium channel blocker (e.g. amlodipine) or a thiazide-like diuretic e.g. indapamide)
18
Q
What is the first line investigation for PE?
A
CTPA
18
Q
When would you DC cardiovert a patient wtih a tachyarrhythmia?
A
Systolic BP < 90 mmHg
18
Q
What is the most likely diagnosis?
A
PE - shows a large saddle embolus
18
Q
What is the investigation of choice in a patient with suspected PE who has renal impairment?
A
V/Q scan
18
Q
How many sets of blood cultures are required to make a diagnosis of infective endocarditis?
A
3
18
What non-cardiac conditions may cause a rise in troponin?
A troponin rise may occur in conditions where there is myocardial ischaemia from a supply-demand-mismatch secondary to another primary condition (e.g. sepsis)
18
What does the ECG show?
Trifascicular block
## Footnote
RBBB +left anterior or posterior hemiblock + 1st-degree heart block = trifasicular block
18
Why should amiodarone be given into central veins?
Common cause of thrombophlebitis - reduces the risk of injection site reactions
18
What drug would you give in the following scenario: poorly controlled hypertension, already taking an ACE inhibitor, calcium channel blocker and a thiazide diuretic. K+ < 4.5mmol/l
Spironolactone
19
What effect will a P450 inducer have on INR in a patient taking warfarin?
INR will decrease
19
What are the main examples of P450 inducers?
* Antiepileptics: phenytoin, carbamazepine
* Barbiturates: phenobarbitone
* Rifampicin
* St John's Wort
* Chronic alcohol intake
* Griseofulvin
* Smoking (affects CYP1A2, reason why smokers require more aminophylline)
19
What effect will a P450 inhibitor have on INR in a patient taking warfarin?
INR will increase
19
What are the main examples of P450 inhibitors?
* Antibiotics: ciprofloxacin, clarithromycine/erythromycin
* Isoniazid
* Cimetidine, omeprazole
* Amiodarone
* Allopurinol
* Imidazoles: ketoconazole, fluconazole
* SSRIs: fluoxetine, sertraline
* Ritonavir
* Sodium valproate
* Acute alcohol intake
* Quinupristin
20
What clinical signs are associated with tricuspid regurgitation?
* Pan-systolic murmur
* Prominent/giant V waves in JVP
* Pulsatile hepatomegaly
* Left parasternal heave
21
What is the most common cause of tricuspid regurgitation?
Secondary to pulmonsy hypertension as a result of chronic lung disease such as COPD
22
What are the common side effects of beta blockers?
* Bronchospasm
* Cold peripheries
* Fatigue
* Sleep disturbances, including nightmares
* Erectile dysfunction
23
Describe the features of NYHA class I heart failure
* No symptoms
* No limitation: ordinary physical exercise does not cause undue fatigue, dyspnoea or palpitations
24
Describe the features of NYHA class II heart failure
* Mild symptoms
* Slight limitation of physical activity: comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea
25
Describe the features of NYHA class III heart failure
* Moderate symptoms
Marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms
26
Describe the features of NYHA class IV heart failure
Severe symptoms
Unable to carry out any physical activity without discomfort: symptoms of heart failure are present even at rest with increased discomfort with any physical activity
27
Why should verapamil and beta-blockers should never be taken concurrently?
Possibility of heart block and fatal arrest
28
How would you manage a patient with stable CVD and AF?
Stop antiplatelet and switch to oral anticoagulant monotherapy
29
What murmur is associated with pulmonary stenosis?
Ejection systolic murmur typically heard best in the second left intercostal space and may radiate towards the left shoulder
Louder on inspiration
30
What clinical findings are associated with aortic regurgitation?
* Early diastolic murmur
* Collapsing pulse
* Wide pulse pressure
* Quincke's sign (nailbed pulsation)
* De Musset's sign (head bobbing)
31
A 25-year-old female is found to have a left hemiparesis following a deep vein thrombosis. An ECG shows RBBB with right axis deviation. What is the most likely underlying diagnosis?
Ostium secundum atrial septal defect
32
What cardiomyopathy is associated with Wolff-Parkinson White?
HOCM
33
A cardiologist has asked you to start oral amiodarone for a patient who has previously been admitted with ventricular tachycardia. What tests is it important to ensure the patient has had prior to starting treatment?
TFT + LFT + U&E + CXR
## Footnote
A baseline chest x-ray is required due to the risk of pulmonary fibrosis / pneumonitis in patients treated with amiodarone. Urea and electrolytes are suggested by the BNF to detect hypokalaemia which may increase the risk of arrhythmias developing.
34
What is the most specific ECG finding in acute pericarditis?
PR depression
35
What drug is the first line treatment in a non-diabetic patient of black African or African-Caribbean origin with hypertension?
Calcium channel blocker e.g. nifedipine
36
What is the most common cause of death following an MI?
VF
37
What is Dressler's syndrome
* Tends to occur around 2-6 weeks following a MI
* The underlying pathophysiology is thought to be an autoimmune reaction against antigenic proteins formed as the myocardium recovers
* It is characterised by a combination of fever, pleuritic pain, pericardial effusion and a raised ESR
* It is treated with NSAIDs
38
What is a left ventricular aneurysm?
* Following an MI, tschaemic damage sustained may weaken the myocardium resulting in aneurysm formation
* This is typically associated with persistent ST elevation and left ventricular failure (in exam q - persistent ST elevation following recent MI, no chest pain)
* Thrombus may form within the aneurysm increasing the risk of stroke; patients are therefore anticoagulated
39
What is left ventricular free wall rupture?
* Complication seen in around 3% of MIs and occurs around 1-2 weeks afterwards
* Patients present with acute heart failure secondary to cardiac tamponade (raised JVP, pulsus paradoxus, diminished heart sounds)
* Urgent pericardiocentesis and thoracotomy are required
40
How might an MI cause acute mitral regurgitation? How would you treat it?
More common with infero-posterior infarction and may be due to ischaemia or rupture of the papillary muscle
Acute hypotension and pulmonary oedema may occur
An early-to-mid systolic murmur is typically heard
Patients are treated with vasodilator therapy but often require emergency surgical repair
41
A 61-year-old man with peripheral arterial disease is prescribed simvastatin. What is the most appropriate blood test monitoring?
* LFTs at baseline, 3 months and 12 months
* A fasting lipid profile may also be checked during monitoring to assess response to treatment
42
What is a bisferiens pulse?
* Seen in mixed aortic valve disease
* A bisferiens pulse is a specific type of arterial pulse waveform observed during palpation of the pulse at various pulse points in the body, typically the radial artery
* This pulse is characterized by having two distinct systolic peaks separated by a mid-systolic dip
* Caused by the complex interactions between the regurgitant and stenotic flows
43
What adverse effects are associated with loop diuretics?
* Hypotension
* Hyponatraemia
* Hypokalaemia, hypomagnesaemia
* Hypochloraemic alkalosis
* Ototoxicity
* Hypocalcaemia
* Renal impairment (from dehydration + direct toxic effect)
* Hyperglycaemia (less common than with thiazides)
* Gout
44
When is nicorandil indicated in angina?
Second-line drug treatment for angina pectoris if first-line drugs (beta-blockers or calcium channel blockers) are contraindicated or not tolerated
45
What are the adverse effects of nicorandil?
* Headache
* Flushing
* Skin, mucosal and eye ulceration - GI ulcers including anal ulceration
46
What is the definition of stage 1 hypertension in clinic?
140/90 mmHg
47
What are the risk factors for asystole in bradycardia (? needs transvenous pacing)?
* Complete heart block with broad complex QRS
* Recent asystole
* Mobitz type II AV block
* Ventricular pause > 3 seconds
48
For a patient with symptomatic stable angina on a calcium channel blocker but with a contraindication to a beta-blocker, what is the next line treatment?
Long-acting nitrate, ivabradine, nicorandil or ranolazine
49
Management of high INR: major bleeding (e.g. variceal haemorrhage, intracranial haemorrhage)
* Stop warfarin
* Give intravenous vitamin K 5mg
* Prothrombin complex concentrate - if not available then FFP
50
Management of high INR: INR > 8.0 with minor bleeding
* Stop warfarin
* Give intravenous vitamin K 1-3mg
* Repeat dose of vitamin K if INR still too high after 24 hours
* Restart warfarin when INR < 5.0
51
Management of high INR: INR > 8.0 no bleeding
* Stop warfarin
* Give vitamin K 1-5mg by mouth, using the intravenous preparation orally
* Repeat dose of vitamin K if INR still too high after 24 hours
* Restart when INR < 5.0
52
Management of high INR: INR 5.0-8.0 with minor bleeding
* Stop warfarin
* Give intravenous vitamin K 1-3mg
* Restart when INR < 5.0
53
Management of high INR: INR 5.0-8.0 with no bleeding
* Withhold 1 or 2 doses of warfarin
* Reduce subsequent maintenance dose
54
What is the shown on the ECG?
Atrial flutter with variable block
## Footnote
Whilst 'sawtooth' waves are seen the rhythm is irregular suggesting a diagnosis of atrial flutter with variable block
55
What is Eisenmenger's syndrome?
* Describes the reversal of a left-to-right shunt in a congenital heart defect due to pulmonary hypertension
* This occurs when an uncorrected left-to-right leads to remodeling of the pulmonary microvasculature, eventually causing obstruction to pulmonary blood and pulmonary hypertension
56
What ECG findings are associated with Eisenmenger's syndrome?
Right ventricular hypertrophy
57
What is pulsus paradoxus?
Clincial sign associated with cardiac tamponade
Abnormally large drop in BP during inspiration
58
What type of heart failure is associated with HCOM?
Diastolic dysfunction (heart failure with preserved ejection fraction)
59
What is the inheritance pattern of HOCM?
Autosomal dominant
60
What murmur is associated with atrial septal defect?
Ejection systolic murmur louder on inspiration
61
How long can a patient not drive for following MI?
4 weeks
62
In which bronchus are inhaled foreign objects most likely to be found?
Right main bronchus
63
What is the blood pressure target for a patient < 80 years with hypertension?
140/90 mmHg
64
What ECG changes are associated with a posterior MI?
* Horizontal ST depression
* Tall, broad R waves
* Upright T waves
* Dominant R wave in V2
65
What cardiomyopathy are alcoholics at risk of?
Dilated cardiomyopathy
66
What echocardiogram findings are associated with dilated cardiomyopathy?
Left ventricular ejection fraction < 55%, dilated left ventricle, no motion wall abnormalities
67
What electolyte disturbance can lead to long QT?
Hypokalaemia
68
What is long QT?
* Occurs when the QT interval is >450ms
* This can predispose an individual to developing Torsade de Pointes
69
How do you manage a patient with aortic stenosis?
AVR if symptomatic, otherwise cut-off is gradient of 40 mmHg
70
How long are 'provoked' PEs treated for?
3 months
71
When is new onset AF considered for electrical cardioversion?
If it presents within 48 hours of onset
72
What is the most common cause of aortic stenosis in younger patients (<65 years)?
Bicuspid aortic valve
73
What is the most common cause of aortic stenosis in older patients (> 65 years)?
Calcification of the aortic valve
74
What is the next line therapy for a hypertensive patient < 55 years old who is on an ACE-i and is intolerant to calcium channel blockers?
Thiazide-like diuretics
75
What is the best site for insertion for primary PCI?
Radial artery
76
If a patient goes into witnessed cardiac arrest with a shockable rhythm while on a monitor, how does this change your ALS management?
Give up to three successive shocks before CPR
77
Describe anticoagulation when considering cardioversion for AF
If a patient has been in AF for more than 48 hours then anticoagulation should be given for at least 3 weeks prior to cardioversion
An alternative strategy is to perform a transoesophageal echo (TOE) to exclude a left atrial appendage (LAA) thrombus
78
How should adenosine be given in SVT?
As a rapid IV bolus
79
What are the doses of atorvostatin for primary and secondary prevention of CVD?
Atorvastatin 20mg for primary prevention, 80mg for secondary prevention
80
What is the main ECG abnormality seen with hypercalcaemia?
Shortening of the QT interval
81
When should beta blockers be stopped in acute heart failure?
If the patient has heart rate < 50/min, second or third degree AV block, or shock
82
What drug should be considered as second-line therapy in patients with HFrEF in addition to optimised standard care?
SGLT-2 inhibitors
83
What drug is used to anticoagulate patients with mechanical heart valves?
Warfarin
84
If fibrinolysis is given for an ACS, when should an ECG be repeated?
After 60-90 minutes
85
What is the recommended dose of adrenaline to give during advanced ALS?
1mg
86
What is the first line treatment for a hypertensive diabetic?
ACE inhibitors/A2RBs are first-line regardless of age
87
What are the clinical signs of right-sided heart failure?
Signs of right-sided heart failure are raised JVP, ankle oedema and hepatomegaly
88
A 64-year-old man with a history of ischaemic heart disease and poor left ventricular function presents with a broad complex tachycardia of 140 bpm. On examination blood pressure is 110/74 mmHg. Fusion and capture beats are seen on the 12 lead ECG. What is the first line drug management?
Amiodarone
## Footnote
Preferred due to poor left ventricular function
89
What is the initial management of acute pulmonary oedema?
Sit up, loop diuretic
90
What drug should be given to patients with bradycardia and signs of shock?
500 micrograms of atropine (repeated up to max 3mg)
91
State the area of myocardium and coronary artery affected:
ST elevation in II, III and aVF
Inferior
RCA
92
State the area of myocardium and coronary artery affected:
ST elevation in V1-V2
Septal
Proximal LAD
93
State the area of myocardium and coronary artery affected:
ST elevation in V3-V4
Anterior
LAD
94
State the area of myocardium and coronary artery affected:
ST elevation in V5-V6
Apex
Distal LAD/LCx/RCA
95
State the area of myocardium and coronary artery affected:
ST elevation in I, aVL
Lateral
LCx
96
State the area of myocardium and coronary artery affected:
ST elevation in V7-V9 (ST depression V1-V3)
Posterolateral
RCA/LCx
97
What are the major Duke criteria for infective endocarditis?
Positive blood cultures or evidence of endocardial involvement
98
What criteria need to be fulfilled in order to confirm positive blood cultures according to the Dukes criteria?
* Two positive blood cultures showing typical organisms consistent with infective endocarditis, such as Streptococcus viridans and the HACEK group, or
* Persistent bacteraemia from two blood cultures taken > 12 hours apart or three or more positive blood cultures where the pathogen is less specific such as Staph aureus and Staph epidermidis
* Positive serology for Coxiella burnetii, Bartonella species or Chlamydia psittaci
* Positive molecular assays for specific gene targets
99
What criteria need to be fulfilled in order to confirm evidence of endocardial involvement according to the Dukes criteria?
* Positive echocardiogram (oscillating structures, abscess formation, new valvular regurgitation or dehiscence of prosthetic valves) or
* New valvular regurgitation
100
What are the minor Duke criteria for infective endocarditis?
* Predisposing heart condition or intravenous drug use
* Microbiological evidence does not meet major criteria
* Fever > 38ºC
* Vascular phenomena: major emboli, splenomegaly, clubbing, splinter haemorrhages, Janeway lesions, petechiae or purpura
* Immunological phenomena: glomerulonephritis, Osler's nodes, Roth spots
101
How many of the Duke criteria need to be positive to diagnose infective endocarditis?
2 major criteria, or
1 major and 3 minor criteria, or
5 minor criteria
102
What forms of malignancy can predispose to pericarditis?
Lung cancer, breast cancer
103
What is the investigation of choice for a patient with suspected PE who has renal impairment?
V/Q scan
104
A 67-year-old female with a history of chronic lymphocytic leukaemia presents with a 3 day history of burning pain in the right lower chest wall. Clinical examination is unremarkable
What is the most likely diagnosis?
Shingles
105
Name one drug contraindicated in ventricular tachcardia?
Verapamil
106
What is the mechanism of action of alteplase?
Activates plasminogen to form plasmin
107
What is shown on the ECG?
Right bundle branch block:
* Broad QRS > 120 ms
* rSR' pattern in V1-3 ('M' shaped QRS complex)
* wide, slurred S wave in the lateral leads (aVL, V5-6)
108
How do you calculate a CHA2DS2-VASc score?
One point would be allocated for each of the following:
* Congestive heart failure
* Hypertension (controlled or uncontrolled)
* Age of 65-74 years
* Diabetes
* Vascular disease
* Female sex
Two points would be awarded in two instances:
* An age of 75 years or over
* Prior stroke or thromboembolism.
109
What are the adverse effects of loop diuretics?
* Hypotension
* Hyponatraemia
* Hypokalaemia, hypomagnesaemia
* Hypochloraemic alkalosis
* Ototoxicity
* Hypocalcaemia
* Renal impairment (from dehydration + direct toxic effect)
* Hyperglycaemia (less common than with thiazides)
* Gout
110
What complication of HCOM is associated with sudden death in young athletes?
Ventricular arrhythmia
111
How does coarctation of the aorta usually present?
* Acute circulatory collapse at 2 days of age (when duct closes)
* Heart failure & absent femoral pulses
* Systolic murmur heard under the left clavicle and over the back
112
List the side effects of adenosine
* Chest pain
* Flushing, hypotension
* Bronchospasm (avoid in asthmatics)
* Abdominal discomfort
* 'Impending sense of doom'
113
What is the first-line treatment for regular broad complex tachycardias without adverse features?
IV amiodarone
114
What is the investigation of choice for suspected aortic dissection?
* CT angio (depending on stability of the patient)
* TOE is more suitable for patients with suspected aortic dissection who are unstable and therefore too risky to take to the CT scanner
115
What antiplatelets should be given before PCI?
* If the patient is not taking an oral anticoagulant: aspirin + prasugrel
* If taking an oral anticoagulant: aspirin + clopidogrel
116
What are the adverse effects of ACEi?
* Cough
* Angioedema
* Hyperkalaemia
* First dose hypotension (more common in patients taking diuretics)
117
Which drug is most appropriate for long-term anticoagulation after mechanical heart valve replacement?
Warfarin
118
If angina is not controlled with a beta-blocker, what drug should be added?
Longer-acting dihydropyridine calcium channel blocker e.g. amlodipine, nifedipine
119
Where is the site of action of loop diuretics?
Inhibits the Na-K-Cl cotransporter in the thick ascending limb of the loop of Henle
120
What dose of atorvastatin is given for primary prevention?
20mg
121
What dose of atorvastatin is given for secondary prevention?
80mg
122
What rheumatological condition can cause aortic regurgitation?
Anklosing spondylitis
123
List 4 potential causes of TdP
Hypocalcaemia, hypokalemia, hypomagnesaemia, hypothermia
124
What is pulsus paradoxus?
Sign of cardiac tamponade
Abnormally large drop in blood pressure during inspiration, recognisable by the radial pulse disappearance during inspiration
125
Patient presents with TIA. AF picked up on ECG. When to anticoagulate?
Apixaban (lifelong) immediately once imaging has excluded a haemorrhage
126
What is the murmur associated with an atrial septal defect?
Ejection systolic murmur louder on inspiration
127
Name the drug which has only been demonstrated to improve mortality in patients with NYHA class III or IV heart failure who are already taking an ACE inhibitor
Spironolactone
128
What drugs should be introduced first-line in patients with stable impaired left ventricular function?
ACE inhibitor + beta-blocker
129
What is Eisenmenger's syndrome?
The reversal of a left-to-right shunt in a congenital heart defect due to pulmonary hypertension
This occurs when an uncorrected left-to-right leads to remodeling of the pulmonary microvasculature, eventually causing obstruction to pulmonary blood and pulmonary hypertension
130
What is the initial management for a patient with bradycardia and signs of shock?
500micrograms of atropine (repeated up to max 3mg)
131
What medication should be given before fibrinolysis?
Fondaparinux
132
A 14-year-old boy presents to the Emergency Department as he is unable to control his facial muscles and arm movements. For the last 5 weeks, following a throat infection, he has been experiencing ongoing fever, worsening shortness of breath and joint pains, mainly in his legs which have not been effectively managed
What is the most likely cause of the patient's recent symptoms?
Sydenham's chorea - late complication of rheumatic fever
133
When is external pacing indicated in complete heart block following MI?
After an anterior MI - likely to cause prolonged/permanent arrhythmia
In inferior MI usually due to AV block and bradyarrhythmias are usually transient
134
What foods should a patient taking warfarin avoid?
Foods high in vitamin K, such as sprouts, spinach, kale and broccoli
135
Poorly controlled hypertension, already taking an ACE inhibitor, calcium channel blocker and a standard-dose thiazide diuretic. K+ > 4.5mmol/l
What drug do you add?
Alpha- or beta-blocker
136
Poorly controlled hypertension, already taking an ACE inhibitor, calcium channel blocker and a standard-dose thiazide diuretic. K+ < 4.5mmol/l
What drug do you add?
Low-dose spironolactone
137
How do you manage a type A aortic dissection?
Ascending aortia - contol BP (IV labetalol) + surgery
138
How do you manage a type B aortic dissection?
Descending aorta - control BP (IV labetalol)
139
What cardiovascular drug can cause ulcers anywhere along the GI tract?
Nicorandil
140
Patient on isosorbide mononitrate for angina has noticed symptoms getting worse. What has caused this and what do you do?
* Continuous treatment with nitrates is associated with the development of tolerance, which results in reduced therapeutic effects
* As a result, it is recommended that a nitrate-free interval each day (lasting at least 4 hours) should be ensured to maintain sensitivity - this involves either taking the second dose at an earlier time (e.g. 8 am and 3 pm) or switching to a once-daily modified-release preparation
141
What cardiovascular drug can cause sexual dysfunction?
Beta blockers
142
What is the first line treatment for angina?
Beta blocker or CCB (if CCB monotherapy use rate limiting e.g. verapamil or diltiazem)
143
What treatment option should be given to older children with WPW who remain symptomatic without adverse features?
Radiofrequency ablation
144
What does this ECG show?
Wolf-Parkinson-White syndrome
* Delta waves
* Dominant R waves in V1
145
A 55-year-old man presents to the emergency department with acute-onset shortness of breath and cough. He was successfully treated with fibrinolysis for a myocardial infarction two weeks ago. ECG shown. What is the diagnosis?
Left ventricular aneurysm
Sustained ST elevation and deep QRS complexes in leads V1, V2, and V3
146
What antibiotics can cause TdP?
Macrolides (e.g. azithromycin, erythromycin)
147
In cardiac arrest due to PE, how long should CPR be continued for?
60-90 mins
148
What ECG abnormality is associated with arrhythmogenic right ventricular cardiomyopathy?
T wave inversion in V1-3
149
What is the BP cut off for a clinic reading which would require same day secondary care review?
180/120 mmHg
150
What is the most likely cause of this ECG appearance?
Digoxin therapy (in a patient with AF)
There is a 'scooped' ST depression in leads II, III, aVF, v5, and V6. The presence of this 'scooping' or 'reverse-tick sign' is a typical finding in patients taking digoxin.
151
An ECG shows new widening QRS complexes and a notched morphology of the QRS complexes in the lateral leads.
What diagnostic workup should you do?
New LBBB - investigation for an ACS
152
A 28-year-old who is 10 weeks pregnant is noted to be hypertensive on her booking visit. Blood show a potassium of 2.9 mmol/l. Clinical examination is unremarkable.
What is the most likely diagnosis?
Primary hyperaldosteronism
153
A 39-year-old man presents with headaches and excessive sweating. He also reports some visual loss. Visual fields testing reveal loss of temporal vision bilaterally.
What is the most likely diagnosis?
Acromegaly
154
A 68-year-old with a history of ischaemic heart disease is seen in the hypertension clinic. Despite four antihypertensives his blood pressure is 172/94 mmHg. An abdominal ultrasound shows asymmetrical kidneys.
What is the most likely diagnosis?
Renal artery stenosis
155
What type of prosthetic valve is most appropriate for a younger patient?
Mechanical valve - last longer
HOWEVER require lifelong warfarin so need to consider this in a women of childbearing age
156
Poorly controlled hypertension, already taking an ACE inhibitor and a calcium channel blocker. What do you add?
Thiazide-like diuretic e.g. indapamide
157
What are the signs of right-sided heart failure?
Raised JVP, ankle oedema and hepatomegaly
158
What is the diagnosis?
Electrical alternans (alternation of QRS complex amplitude between beats) - suggestive of cardiac tamponade
159
Name a drug that can be added as a second line treatment for rate control in AF in sedendary individuals
Digoxin
160
Can warfain be used when breastfeeding?
Yes
161
A 12-year-old female from Bulgaria presents to the surgery. She reports being unwell for the past 2 weeks. Initially she had a sore throat but she is now experiencing joint pains intermittently in her knees, hips and ankles. On examination there are some pink, ring shaped lesions on the trunk and occasional jerking movements of the face and hands. What is the most likely diagnosis?
Rheumatic fever
162
What are the indications for valve replacement in aortic stenosis?
* Symptomatic
* If asymptomatic: valvular gradient > 40 mmHg and features such as left ventricular systolic dysfunction
163
Name a possible feature of left-sided heart failure on ausultation
Third heart sound
164
New systolic murmur loudest at apex radiating to axilla following MI. What is the diagnosis?
Acute mitral valve regurgitation
Caused by rupture of the papillary muscle
Can present with flash pulmonary oedema
165
Nicorandil is most useful in the management of what condition?
Angina
166
What is the most likey pathophysiology of long QT syndrome?
Usually due to loss-of-function/blockage of K+ channels
167
When are nitrates useful in acute heart failure?
If the patient has concomitant myocardial ischaemia or severe hypertension
168
NSTEMI + unstable. Management?
Immediate coronary angiography
169
What GI drug should not be prescribed to a patient on clopidogrel?
Omeprazole and esomeprazole
Omeprazole is an inhibitor of CYP2C19 meaning concurrent use can reduce plasma levels of activated clopidogrel
170
List the common P450 inducers + state their effect on INR if patient on warfarin
INR will decrease:
* Antiepileptics: phenytoin, carbamazepine
* Barbiturates: phenobarbitone
* Rifampicin
* St John's Wort
* Chronic alcohol intake
* Griseofulvin
* Smoking (affects CYP1A2, reason why smokers require more aminophylline)
171
List the common P450 inhibitors + state their effect on INR if patient on warfarin
INR will increase:
* Antibiotics: ciprofloxacin, clarithromycine/erythromycin
* Isoniazid
* Cimetidine, omeprazole
* Amiodarone
* Allopurinol
* Imidazoles: ketoconazole, fluconazole
* SSRIs: fluoxetine, sertraline
* Ritonavir
* Sodium valproate
* Acute alcohol intake
* Quinupristin
172
What murmur is associated with tricuspid regurgitation?
Systolic murmur over the 4th intercostal left parasternal region
Louder during inspiration
173
What is the diagnosis?
Posterolateral myocardial infarction
* There is some ST elevation in leads I, aVL and V6, which is consistent with a lateral MI
* ST depression in V1-V3 (significant in V3) and large, broad R waves in several leads are consistent with a posterior myocardial infarction
174
What ECG changes are associated with hypothermia?
* Bradycardia
* 'J' wave (Osborne waves) - small hump at the end of the QRS complex
* First degree heart block
* Long QT interval
* Atrial and ventricular arrhythmias
175
What findings on CXR are associated with aortic dissection?
* May be normal
* Widened mediastinum: > 8.0-8.8 cm at the level of the aortic knob on portable anteroposterior chest films
* Double aortic contour
* Irregular aortic contour
* Inward displacement of atherosclerotic calcification (>1 cm from the aortic margin)
176
What blood test is the most useful in detecting re-infarction 4-10 days following initial MI?
Creatine kinase (CK-MB)
177
Narrow complex tachycardia. Signs of shock, syncope, myocardial ischaemia or heart failure. Management?
Up to 3 synchronised DC shocks
178
What is the most appropriate treatment for an unstable patient in VT?
Synchronised cardioversion
179
What is the most common cause of death in patients following a myocardial infarction?
Ventricular fibrillation
180
What drug can be used instead of amiodarone if it is not avaliable?
Lidocaine
181
Patient presents with stroke and signs of DVT. What cardiac defect are they likely to have?
Atrial septal defect - allows a 'paradoxical' stroke where an embolism from peripheral veins may bypass pulmonary circulation
182
When would you medically treat a patient under 80 with stage 1 HTN?
Diabetic, renal disease, QRISK2 >10%, established coronary vascular disease, or end organ damage
183
What is the BP cut off for stage 1 HTN?
Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg
184
What is the cut off for stage 2 HTN?
Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg
185
What is cut off for severe HTN?
Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 120 mmHg
186
What are the blood pressure targets for patients < 80 years?
Clinic: 140/90 mmHg
ABPM / HBPM: 135/85 mmHg
187
What are the blood pressure targets for patients > 80 years?
Clinic: 150/90 mmHg
ABPM / HBPM: 145/85 mmHg
188
Patient in AF for more than 48 hours and you want to cardiovert. What do you do?
* Anticoagulation should be given for at least 3 weeks prior to cardioversion
* An alternative strategy is to perform a transoesophageal echo (TOE) to exclude a left atrial appendage (LAA) thrombus
189
What is the most likely diagnosis?
Pericarditis - widespread ST elevation and PR depression
190
ECG shows T wave inversion in all leads and QT prolongation. What is the most likely diagnosis?
'Global' T wave inversion (not fitting a coronary artery territory) - think non-cardiac cause of abnormal ECG
191
In cardiac catheterisation, a jump in oxygen saturation from right atrium to right ventricle indicates what?
VSD
192
What ABG result is associated with a PE?
Respiratory alkalosis (causes hyperventilation)
193
A 33-year-old woman presents with sudden onset hemiparesis affecting the right face, arm and leg. On examination you note right sided hemiparesis, aphasia, a right homonymous hemianopia, and a harsh pansystolic murmur. Over the past few weeks she has been complaining of low grade fever.
What is the most likely cause of the stroke?
Emboli from infective endocarditis vegetation
194
Name the drug which is given to manage symptoms of HF but has no prognostic benefits
Furosemide
195
What cranial pathology can cause TdP
Subarachnoid haemorrhage
196
What is the first line management of acute pericarditis?
Combination of NSAID and colchicine
197
Describe the conservative management of NSTEMI
Aspirin, plus either:
* Ticagrelor, if not high bleeding risk
* Clopidogrel, if high bleeding risk
198
What cardiovascular drug should be stopped in a patient taking erythromycin/clarithromycin?
Statins
199
What does the ECG show?
Resent/resolving inferior-lateral MI
* Q waves inferiorly (II, III and aVF) and V5-6 suggestive of previous myocardial infarction
* There is also T wave inversion inferiorly again and in V3-V6 - suggests myocardial ischaemia
200
In ALS, if IV access cannot be achieved, how should drugs be given?
Intraosseous route (proximal tibia)
201
NSTEMI management: patients with a GRACE score > 3%
Coronary angiography within 72 hours of admission
202
What is the Levine grading scale for murmurs?
* Grade 1 - Very faint murmur, frequently overlooked
* Grade 2 - Slight murmur
* Grade 3 - Moderate murmur without palpable thrill
* Grade 4 - Loud murmur with palpable thrill
* Grade 5 - Very loud murmur with extremely palpable thrill. Can be heard with stethoscope edge
* Grade 6 - Extremely loud murmur - can be heard without stethoscope touching the chest wall
203
What ECG features are an indication for urgent coronary thrombolysis or PCI?
* ST elevation of > 2mm (2 small squares) in 2 or more consecutive anterior leads (V1-V6) OR
* ST elevation of greater than 1mm (1 small square) in greater than 2 consecutive inferior leads (II, III, avF, avL) OR
* New left bundle branch block
204
How does a posterior MI usually present?
Tall R waves V1-2
205
What is the first line investigation for stable chest pain of suspected coronary artery disease aetiology?
CT angiography
206
Acute heart failure with hypotension - what drug should be considered for patients with severe left ventricular dysfunction who have potentially reversible cardiogenic shock?
Inotropes (in HDU)
207
What is the first-line management of SVT?
Vagal manoeuvres: e.g. Valsalva manoeuvre or carotid sinus massage
208
After being admitted to the coronary care unit a middle aged man develops a regular, broad complex tachycardia. His blood pressure drops to 88/50 mmHg. He was admitted 6 hours previously following an anterolateral myocardial infarction.
What is the most likely diagnosis?
Ventricular tachycardia
209
A 66-year-old woman suddenly develops dyspnoea 10 days after having an anterior myocardial infarction. Her blood pressure is 78/50 mmHg, JVP is elevated and the heart sounds are muffled. There are widespread crackles on her chest and the oxygen saturations are 84% on room air.
What is the most likely diagnosis?
Left ventricular free wall rupture
The prognosis from such a catastrophic event is clearly poor unless this patient has immediate surgery
210
What is the most common cause of mitral stenosis?
Rheumatic fever
211
What murmur is associated with VSD?
Pansystolic murmur
212
What is the most likely diagnosis?
First degree heart block
Pronged PR
213
What variables are accounted for in the ORBIT score?
* Haemoglobin (low)
* Age > 74
* Bleeding history
* Renal impairment
* Treatment with antiplatelets
214
A pulse deficit (weak or absent carotid, brachial, or femoral pulse, or variation > 20 mmHg in systolic BP between arms) is associated with what diagnosis?
Aortic dissection
215
What drugs are used in pharmacological cardioversion? Which one is preferred in structural heart disease?
* Flecainide or amiodarone
* Amiodarone preferred in structural heart disease
216
What ECG finding can be associated with severe mitral stenosis?
ECG will often show a bifid P wave (P mitrale) - caused by left atrial enlargement/hypertrophy
217
What is the reveral agent for dabigatran?
Idarucizumab
218
List 3 causes of a loud S2
* Hypertension: systemic (loud A2) or pulmonary (loud P2)
* Hyperdynamic states
* Atrial septal defect without pulmonary hypertension
219
In SVT, if the first dose of 6mg IV adenosine is not successful, what should be done?
Escalating adenosine doses of 6mg → 12mg → 18 mg
220
What are the adverse effects of thiazide diuretics?
* Dehydration
* Postural hypotension
* Hypokalaemia - due to increased delivery of sodium to the distal part of the distal convoluted tubule → increased sodium reabsorption in exchange for potassium and hydrogen ions
* Hyponatraemia
* Hypercalcaemia (+ hypocalciuria - may be useful in reducing the incidence of renal stones)
* Gout
* Impaired glucose tolerance
* Impotence
221
What is the ideal time to advise patients to take a statin?
Statins should be taken at night as this is when the majority of cholesterol synthesis takes place
This is especially true for simvastatin which has a shorter half-life than other statins
222
What do the following results indicate:
* Pulmonary artery occlusion pressure: low
* Cardiac output: low
* SVR: high
Hypovolaemia
223
What do the following results indicate:
* Pulmonary artery occlusion pressure: high
* Cardiac output: low
* SVR: high
Cardiogenic shock
224
What do the following results indicate:
* Pulmonary artery occlusion pressure: low
* Cardiac output: high
* SVR: low
Septic shock
225
When should treatment with statins be discontinued?
If serum transaminase concentrations rise to and persist at 3 times the upper limit of the reference range
226
What is the management of nfective endocarditis causing congestive cardiac failure?
Emergency valve replacement surgery
227
What is the most significant risk factor for post-ACS mortality?
Cardiogenic shock
228
What is the target INR for a patient with a mechanical aortic valve?
3.0
229
What is the target INR for a patient with a mechanical mitral valve?
3.5
230
Acute or subacute chest pain in a post-menopausal woman after an emotionally stressful experience or situation suggests what diagnosis?
Takotsubo cardiomyopathy
231
Inhaled foreign objects are most likely to be found in which bronchus?
Right main bronchus
232
Investigating suspected PE: if the CTPA is negative then consider what test if DVT suspected?
Proximal vein ultrasound
233
Patient presents to ED with palpitations that have now stopped. ECG normal. What is the best next step in management?
Arrange Holter monitoring
234
A 24-year-old female presents to her GP with lethargy and dizzy spells. On examination she is noted to have an absent left radial pulse. Blood results show raised ESR.
What is the most likely diagnosis?
Takayasu's arteritis
235
What vaccinations should be recommended to a patient with chronic heart failure?
Annual influenza vaccination, single pneumococcal vaccination
236
What does the ECG show?
Left ventricular hypertrophy
* The ECG shows large R waves in the left-sided leads (V5, V6) and deep S-waves in the right-sided leads (V1, V2)
* There is also ST elevation in leads V2-3
* There is also T-wave inversion present in leads V5 and V6, known as the left ventricular 'strain' pattern; in this case, the most likely cause of left ventricular hypertrophy is hypertension
237
What echocardiogram findings are associated with HOCM
Asymmetric septal hypertrophy and systolic anterior movement (SAM) of the anterior leaflet of mitral valve
238
Patient has HOCM. What is the individual risk his sister will also have the same underlying disorder?
50%
239
What ECG changes are associated with dextrocardia?
Inverted P wave in lead I, right axis deviation, and loss of R wave progression
240
Strong suspicion of PE but a delay in the scan. Management?
Start on treatment dose anticoagulant in the mean time
241
What is the mechanism of action of fondaparinux?
Activates antithrombin III
242
A 45-year-old man with a medical history of type II diabetes mellitus is found to have hypertension on home blood pressure recordings (155/105mmHg). His notes show a recent hospital admission with pyelonephritis where he was found to have renal artery stenosis.
What is the most appropriate medication to start to treat his hypertension?
Amlodipine - ACEi contraindicated in patients ith renovascular disease
243
Patient presents with AF < 48 hours and signs of heart failure. Rate or rhythm control?
Rhythm control
244
A patient develops acute heart failure 5 days after a myocardial infarction. A new pan-systolic murmur is noted on examination.
What is the diagnosis?
Ventricular septal defect
245
ST elevation and acute pulmonary oedema in a young patient with a recent flu-like illness. Inflammatory markers and troponin raised.
What is the most likely diagnosis?
Myocarditis
246
What are the signs indicated an unstable patient in VT requiring synchronised cardioversion?
Shock (systolic BP of <90), syncope, myocardial ischemia and heart failure
247
What is the target blood pressure for T2DM?
< 140/90 mmHg
248
What is the ratio of chest compressions to ventilation in ALS?
30:2
249
Poorly controlled hypertension, already taking an ACE inhibitor. What do you do?
Add a calcium channel blocker (e.g. amlodipine) or a thiazide-like diuretic (e.g. indapamide)
250
Poorly controlled hypertension, already taking a calcium channel blocker.
What do you do?
Add an ACE inhibitor or an angiotensin receptor blocker or a thiazide-like diuretic
251
What is the most likely diagnosis?
HCOM
* Bifid p waves → left atrial enlargement
* High-voltage QRS → extreme left ventricular hypertrophy
* High-voltage R waves in V1-6 → septal hypertrophy
* ST depression in the precordial leads and T-wave inversion in the anterolateral leads (I/avL/V2-V6) → ischaemia secondary to LVH
252
Diastolic murmur + AF. What murmur should you think of?
Mitral stenosis
253
What is Beck's triad?
Cardiac tamponade: falling BP, rising JVP and muffled heart sounds
254
First line drug for newly diagnosed hypertension in patient under 55?
ACEi/ARB
255
Does paroxysmal atrial fibrillation require anticoagulation?
Should be considered (CHADVASc score)
256
What findings on echocardiogram are associated with Takotsubo cardiomyopathy?
Apical ballooning of myocardium (resembling an octopus pot)
257
Do patients who've had a catheter ablation for atrial fibrillation still require long-term anticoagulation?
Yes (depending on CHADVASc)
258
What is Quincke's sign?
Nailbed pulsation: clinical sign of aortic regurgitation
259
What does the ECG show?
Bifascicular block - shows both right bundle branch block and left axis deviation
260
What cardiovascular drug should be avoided in HOCM?
ACEi
261
What two beta blockers have been shown to reduce mortality in HF?
Carvedilol and bisoprolol
262
Patient has persistent myocardial ischaemia following fibrinolysis. What should you do?
PCI
263
MI + 1st degree heart block. What area of the heart is most likely affected?
Inferior heart (II, III, aVF)
Right coronary artery occluded → affects AV node
264
Name two pharmacological options for treatment of orthostatic hypotension
Fludrocortisone and midodrinec
265
Name an antihypertensive which can worsen glucose tolerance
Indapamide (thiazides)
266
What is the most common cause of secondary hypertension?
Primary hyperaldosteronism
267
Name 3 causes of raised BNP
MI
Valvular disease
CKD
268
Name 3 causes of reduced BNP
ACEi
ARB
Diuretics
269
What is the empirical treatment of choice in native valve endocarditis?
IV amoxicillin
270
What is the empirical treatment of choice in native valve endocarditis, penicillin allergic or severe sepsis?
Vancomycin + low-dose gentamicin
271
What is the suggested antibiotic therapy for native valve endocarditis caused by staphylococci?
Flucloxacillin
If penicillin allergic or MRSA
vancomycin + rifampicin
272
What is the suggested antibiotic therapy for prosthetic valve endocarditis caused by staphylococci?
Flucloxacillin + rifampicin + low-dose gentamicin
If penicillin allergic or MRSA
vancomycin + rifampicin + low-dose gentamicin
273
What is the suggested antibiotic therapy for endocarditis caused by strep viridans?
Benzylpenicillin
274
Which form of cardiomyopathy is associated with S3?
Dilated
275
Which form of cardiomyopathy is associated with S4?
HCOM
276
277
All patients with non-ST elevation myocardial infarction should receive?
300mg aspirin
278
Name a dermatological adverse effect of warfarin
Skin necrosis
279
What is the approximate half-life of adenosine?
8-10 seconds
280
What valve is most commonly affected in infective endocarditis?
Mitral valve
281
What factors can exacerbate orthostatic hypotension?
Venous pooling during exercise (exercise-induced), after meals (postprandial hypotension) and after prolonged bed rest (deconditioning)
282
Ejection systolic murmur loudest in the aortic region. There is no radiation of the murmur to the carotid arteries.
What is the most likely diagnosis?
Aortic sclerosis
283
Patient with symptomatic stable angina on a calcium channel blocker but with a contraindication to a beta-blocker. Next line treatment?
Long-acting nitrate, ivabradine, nicorandil or ranolazine
284
What is most common cause of endocarditis within 2 months of prosthetic valve surgery?
Staphylococcus epidermis
285
What is usually the most common cause of endocarditis?
Staphylococcus aureus
286
What drugs should be given to a patient with symptomatic HFrEF if they are already on ACEi/ARB and a beta blocker?
Mineralcorticoid receptor antagonist
287
What is the main ECG abnormality seen in hypercalcaemia?
Shortening of the QT interval
288
Patient develops infective endocarditis. Streptococcus sanguinis isolated. What is the most appropriate followup?
Dental review
289
How does VSD present in a newborn?
Heart failure after a few weeks of life, or asymptomatic, pansystolic murmur at lower left sternal edge and louder P2
290
What is the PESI score?
The Pulmonary Embolism Severity Index (PESI) score is recommended by BTS guidelines to be used to help identify patients with a pulmonary embolism that can be managed as outpatients
291
Symptomatic bradycardia, atropine has failed. Next step in management?
External pacing
292
STEMI undergoing PCI, not taking oral anticoagulant prior to MI. What drugs?
Aspirin and prasugrel
293
STEMI undergoing PCI, taking oral anticoagulant prior to MI. What drugs?
Aspirin and clopidogrel
