Cardiovascular Flashcards
1
Q
inheritance of HOCM
A
autosomal dominant
2
Q
where is the hypertrophy in HOCM and how does it lead to sudden death
A
septal hypertrophy causing LV outflow obstruction
3
Q
poor prognostic factors in HOCM
A
young age presentation family history of sudden death abnormal BP changes on exercise non-sustained VT on 24 or 48 hr monitoring syncope increased septal wall thickness
4
Q
ECG changes of Wolf-Parkinson-White
A
short PR interval
wide QRS with delta waves (slurred upstroke)
5
Q
causes of left axis deviation
A
LBBB left anterior hemiblock WPW with right accessory pathway hyperkalaemia congenital: ostium primum ASD, tricuspid atresia LVH minor LAD in obesity
6
Q
causes of right axis deviation
A
Chronic lung disease PE right ventricular hypertrophy left posterior hemiblock ostium secundum ASD WPW with left sided accessory pathway normal in infants <1yr minor RAD in tall people
7
Q
methodone can have what affect on the heart
A
prolong QT
8
Q
what is the physiological reason for prolonged QTs
A
delayed repolarisation of the ventricles
most commonly defects in the alpha subunit of the slow rectifier potassium channel
9
Q
normal corrected QT range
how do you calculate it?
A
<450 in women
QT/squ root of RR (60 divided by HR)
10
Q
congenital causes of prolonged QT
A
Jervell-Lange-Nielsen syndrome (inc deafness)
Romano-Ward syndrome (no deafness)
11
Q
drug causes of prolonged QT
A
amiodarone, sotalol class 1a antiarrhythmic agents (disopyramide, quinidine, procainamide) TCAs and SSRIs (esp citalopram) methodone chloroquine erythromycin and ciprofloxacin antipsychotics terfenadine (an antihistamine) cocaine
12
Q
electrolyte and pathological causes of prolonged QT
A
low K, Ca, Mg, temperature
MI
myocarditis
SAH
13
Q
Mx of prolonged QT
A
avoid precipitating drugs/factors B blockers (note sotalol can lengthen QT) implantable cardioverter defibrillators in high risk
14
Q
Mx of Torsades de pointes
A
IV Magnesium sulphate
15
Q
action of enoxaparin/fondaparinux
A
activates antithrombin III, which potentiates inactivation of Xa
16
Q
factors in GRACE score
A
age SBP HR creatinine HF stage cardiac arrest at presentation ST deviation elevated cardiac enzymes
17
Q
what does GRACE score predict
A
ACS pts’ risk of in hospital and 6 month mortality
18
Q
features of pericarditis
A
chest pain (may be pleuritic) relieved sitting forward non productive cough flu-like symptoms SOB pericardial rub tachypnoea tachycardia
19
Q
Causes of pericarditis
A
viral (Coxsackie) TB post MI (Dressler's syndrome) hypothyroidism trauma uraemia (fibrous pericarditis) connective tissue disease
20
Q
ECG changes of pericarditis
A
widespread ‘saddle shaped’ ST elevation
PR depression
21
Q
medical management of stable angina
A
1.aspirin and statin and b-blocker/CCB (verapamil or diltiazem)
2. increase to max dose (100mg atenolol)
3. add BB or CCB (eg MR nifedipine)
NB dont use BB with verapamil! risk of complete HB
4. add long acting nitrate/ivabradine/nicorandil while awaiting CABG/PCI
22
Q
most common congenital heart defect
A
atrial septal defect - ostium secondum (70%)
ECG- RBBB with RAD
23
Q
Mx of stable SVT
A
vagal manouvers (valsalva, carotid sinus massage)
adenosine IV 6mg –> 12mg –> 12mg
- C/I in asthmatics, use verapamil
electrical cardioversion
prevention - B-blockers, radio-frequency ablation
24
Q
C/I to B blockers
A
uncontrolled HF
asthma
sick sinus syndrome
concurrent verapamil therapy (leads to severe bradycardias)
25
define pulsus paradoxus
| causes
a decrease SBP >10mmHg on inspiration, leading to inability to feel/weakening of radial pulse
severe asthma, cardiac tamponade
26
define pulsus alternans
| cause
alternating strong and weak pulses
| severe LVF
27
define bisferians pulse
| cause
"double pulse" - 2 systolic peaks
| mixed aortic valve disease
28
what is a cannon a wave on a JVP and what is the cause
very large a wave (seen due to filling of atria)
due to atrial compression against a closed tricuspid valve
complete heart block, VT/ectopics, nodal rhythm
29
pathology of the 3rd heart sound?
| what conditions are it associated with?
heard in diastolic filling of the ventricle
normal in <30
early sign of LVF (eg dilated cardiomyopathy), also heard in and constrictive pericarditis (pericardial knock)
30
pathology of the 4th heart sound?
| causes?
atrial contraction against a stiff ventricle
| AS, hypertension, HOCM
31
what does IV adenosine do to the heart?
| and on the lungs?
causes transient AV heart block
| and bronchospasm therefore C/I in asthma
32
which cardiac enzyme is the first to rise
myoglobin (1-2 hrs, peaks 6-8 hrs)
33
how long does trop T stay elevated for after MI?
| when does it peak?
7-10 days,
| 4-6hrs
34
What is the maximum time a patient can be in AF to be cardioverted?
<48 hours - heparinise and DC cardiovert with 4 weeks of anticoagulation afterwards
or pharmacological cardioversion (flecainide if no structural heart dz, otherwise amiodarone)
35
how common is a patent foramen ovale?
~20% of population
36
What is the scoring system for AF risk profiling and Mx?
CHADSVASc
0 - no Rx
1 - oral anticoagulant (dabigatran an alternative) aspirin 2nd choice
>1 - oral anticoagulant (dabigatran an alternative)
37
Features and scores of CHADSVASc
| what is it used for?
Congestive heart failure, Hypertension, Age (>75=2),Diabetes, Stroke or TIA (2), Vascular dz (PVD and IHD), Age (>65=1), Sex (female=1)
To assess need for medical management of AF
38
Action of dabigatran
Direct thrombin (factor 2a) inhibitor
39
What is the indication for dabigatran?
Non valvular AF with a CHADSVASc score >1 in patients who have difficulty maintaining INR control with warfarin or impractical to use warfarin
40
Mode of action of fondaparinux?
| When is it used?
Antithrombin 3 activator (similar to LMWH (enoxaparin) but no heparin induced thrombocytopenia)
Used in ACS treatment
41
Mx of ACS
300Mg aspirin, O2/pain/n&v, fondaparinux 2.5mg SC OD or unfractionated heparin if angio within 24hrs
GRACE score:
Low risk (1.5-3% 6/12 mortality):300mg clopidogrel then 75mg for 12/12
Higher risk (>3%): clopidogrel plus GP2b/3a inhib (tirofiban/eptifibatide)
NSTEMI risk >3% - angio within 96hrs
42
what is Ebstein's anomaly?
congenital cardiac abnormality in which the tricuspid valve septal leaflet is displaced towards the apex, giving a tricuspid regurgitation (pan systolic murmur, pulsatile hepatomegaly, giant v waves on JVP)
43
```
driving restrictions on :
elective angioplasty
CABG
ACS
pacemaker insertion
ICD
```
angio - 1 week
CABD - 4 weeks
ACS - 4 weeks, or 1 if sucessfully Rx with angio
PPM - 1 week
ICD - for sustained VT - 6 months. If prophylactic - 1 month.
44
Causes of cyanotic heart disease
tetralogy of Fallot
transposition of the great arteries
tricuspid atresia
pulmonary valve stenosis
Fallot is more common than TGA but TGA seen more commonly in neonates, Fallot in 1-2 months
45
causes of acyanotic heart disease
```
VSD (most common)
ASD
PDA
coarctation of the aorta
aortic valve stenosis
```
VSD more common than ASD, but in adults ASD is more commonly a new diagnosis.
46
classify aortic dissection
| what is the anatomical border?
type A - ascending
type B - descending
type B begins distal to the origin of the left subclavian artery
47
what is the management of an aortic dissection?
type A - BP control (labetalol) aim SBP 100-120, and refer for surgery.
type B - BP control (labetalol), bed rest.
48
ECG changes due to digoxin
down sloping ST depression (reverse tick)
flattened/inverted T waves
short QT interval
bardycardia, AV block
49
Good and poor prognostic features of infective endocarditis
Good: Strep infection
Poor: low complement levels, negative blood culture, prosthetic valve, staph aureus
50
```
Types of drug in each of the Vaughan Williams antiarrhythmic categories
1 a/b/c
2
3
4
```
1a - (quinidine, procainamide) Na channel blocker, increases AP
1b - (lidocaine, tocainide) Na channel blocker, decreases AP
1c - (flecainide, propafenone) Na channel blocker, no effect on AP
2 - beta blockers
3 - (amiodarone, sotalol) K channel blockers
4 - calcium channel blockers
51
Classify stages of heart failure
NYHA classification
Stage 1 - no limitation on Activity
Stage 2 - slight limitation, ordinary activity -> fatigue/SOB. comfortable at rest
Stage 3 - marked limitation, less than ordinary activity -> fatigue/SOB. comfortable at rest
Stage 4 - severe. SOB at rest
52
Define a capture beat
occasional narrow complex QRS when others are broad, occuring sooner than expected.
indicates normal AV conduction, so SVT unlikely
53
causes of an early diastolic murmur
```
aortic regurgitation
pulmonary regurgitation (Graham-Steel murmur)
```
54
Causes of a prolonged PR interval
```
idiopathic
hypokalaemia
IHD
digoxin toxicity
aortic root disease eg abscess
myotonic dystrophy
sarcoidosis
lyme disease
rheumatic fever
```
55
best way of assessing LV function
MUGA nuclear scan, can be performed as a stress test
56
gold standard for structural imaging of the heart
cardiac MRI
57
Mx of a PDA
closure with indomethacin (NSAID, PG inhibitor)
58
beta blockers proven to reduce mortality in HF
bisoprolol and carvedilol
59
Features of Williams syndrome
rare neurodevelopmental disorder
developmental delay, good language skills, overfamiliar with strangers
supravalvular aortic stenosis
transient hypercalcaemia
60
contraindication to thrombolysis
```
active bleeding
recent surgery, trauma or haemorrhage
coagulation or bleeding disorders
severe hypertension >200
stroke <3 months ago
pregnancy
recent head injury
aortic dissection
intracranial neoplasm
```
61
Moxonidine:
mechonism of action
use
centrally active antihypertensive by decreasing sympathetic tone
used for essential hypertension when other antihypertensives have failed
62
Complications of PCI
stent thrombosis - 1-2% usually within 1st month. due to platelet aggregation. Presents with MI
restenosis - in 5-20%, within 3-6months. Due to excessive tissue proliferation around stent. Recurrence of angina symptoms.
63
Risk factors for restenosis of PCI stent
diabetes mellitus
renal failure
stent in a venous bypass graft
64
pros and cons of drug eluding stent
slows proliferation so slows restenosis but increases risk of thrombosis - need clopidogrel cover for longer
65
features of Brugada syndrome?
auto dom CVD, may present with sudden death
ECG: ST elevation V1-3 with no Sx of ACS
Na channel disorder
changes more prominent after flecainide (blocks Na channels)
Mx: ICD
66
How do you diagnose HF
previous MI - echo within 2 weeks
no MI -> BNP
BNP high --> echo within 2 weeks
BNP raised --> echo within 6 weeks
67
factors which increase BNP level
ischaemia
LVH and RV overload
tachycardia
renal failure
68
what is the definition of a high and raised BNP
high BNP >400 --> echo within 2 weeks
raised 100-400 --> echo within 6 weeks
normal <100
69
factors increasing risk of asystole in a bradycardic patient
ventricular pauses >3s
complete HB with broad QRS
recent asystole
mobitz type 2 (2:1 etc)
70
blind treatment of endocarditis
native valve - amoxicillin
pen allergic/severe/MRSA - vanc + gent
prosthetic valve - vanc + rifampicin + gent
71
Prinzmetal angina
pathology
Mx
coronary artery vasospasm
| Dihydropyridine calcium channel blocker (eg felodipine)
72
causes of eruptive xanthoma
high TG levels
- familial hypertriglyceridaemia
- lipoprotein lipase deficiency
73
cause of palmar xanthoma
Remnant hyperlipidaemia
74
features of tetralogy of Fallot
RV outflow obstruction - varying degrees per pt. Main determinant of TOF severity. resulting R->L shunting
overriding aorta - above both the L and R ventricles.
VSD
RV hypertrophy
75
indications for ICD
```
long QT syndromes
HOCM
previous cardiac arrest due to VT/VF
Brugada syndrome
previous MI with non sustained VT on 24 hour tape, inducible VT and ejection fraction <35%
```
76
Indications for temporary pacemaker
symptomatic/haemodynamically unstable bradycardia resistant to atropine
post Anterior MI with CHB or Mobitz type 2
trifasicular block prior to surgery
77
what is Beck's triad and what does it indicate?
hypotension, quiet heart sounds, prominent neck vessels
| cardiac tamponade
78
causes of a split S2 on expiration
```
aortic stenosis,
hypertrophic cardiomyopathy,
LBBB,
ventricular pacemaker
split S2 on inspiration is nomal
```
79
causes of a fixed split S2
fixed split = split S2 on both inspiration and expiration
| ASD or VSD
80
features of Takasubo cardiomyopathy
non-ischaemic cardiomyopathy
transient apical ballooning of the myocardium
may be triggered by stress (broken heart syndrome)
chest pain, features of HF, ST elevation, normal coronary angiogram
Rx is supportive.
81
Mx of patient with new onset AF >48 hours
warfarinise for >3 weeks prior to cardioversion
or do TOE to exclude thrombus in left atrial appendage (LAA), heparinise and DC cardiovert
If high risk of failure to cardiovert (previous failure, AF recurrence), pt should have 4 weeks of amiodarone or sotalol prior to DC cardioversion
82
Drugs to avoid in wolf parkinson white syndrome
ABCD
| adenosine, beta-blocker, calcium channel blockers, digoxin
83
Classifications of aortic stenosis
normal valve size 3-4 square cm
mild - valve size 2-1.5cm(squ) - pressure gradient 40mmHg
critical - valve <0.6cm squared
84
Indications for aortic valve replacement
symptomatic severe aortic stenosis
severe or moderate AS pt undergoing CABG or aorta surgery
severe AS with ejection fraction <50%
85
distinguishing features between SVT with aberrant conduction and VT?
SVT + aberrant conduction - L or R BBB
| VT - capture beats, fusion beats, QRS >160ms
