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MRCP 1 > Cardiovascular > Flashcards

Cardiovascular Flashcards

1
Q

inheritance of HOCM

A

autosomal dominant

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2
Q

where is the hypertrophy in HOCM and how does it lead to sudden death

A

septal hypertrophy causing LV outflow obstruction

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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
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4
Q

ECG changes of Wolf-Parkinson-White

A

short PR interval

wide QRS with delta waves (slurred upstroke)

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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
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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
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7
Q

methodone can have what affect on the heart

A

prolong QT

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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

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9
Q

normal corrected QT range

how do you calculate it?

A

<450 in women

QT/squ root of RR (60 divided by HR)

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10
Q

congenital causes of prolonged QT

A

Jervell-Lange-Nielsen syndrome (inc deafness)

Romano-Ward syndrome (no deafness)

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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
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12
Q

electrolyte and pathological causes of prolonged QT

A

low K, Ca, Mg, temperature
MI
myocarditis
SAH

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13
Q

Mx of prolonged QT

A 
avoid precipitating drugs/factors
B blockers (note sotalol can lengthen QT)
implantable cardioverter defibrillators in high risk
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14
Q

Mx of Torsades de pointes

A

IV Magnesium sulphate

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15
Q

action of enoxaparin/fondaparinux

A

activates antithrombin III, which potentiates inactivation of Xa

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16
Q

factors in GRACE score

A 
age
SBP
HR
creatinine
HF stage
cardiac arrest at presentation
ST deviation
elevated cardiac enzymes
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17
Q

what does GRACE score predict

A

ACS pts’ risk of in hospital and 6 month mortality

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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
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19
Q

Causes of pericarditis

A 
viral (Coxsackie)
TB
post MI (Dressler's syndrome)
hypothyroidism
trauma
uraemia (fibrous pericarditis)
connective tissue disease
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20
Q

ECG changes of pericarditis

A

widespread ‘saddle shaped’ ST elevation

PR depression

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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

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22
Q

most common congenital heart defect

A

atrial septal defect - ostium secondum (70%)

ECG- RBBB with RAD

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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

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24
Q

C/I to B blockers

A

uncontrolled HF
asthma
sick sinus syndrome
concurrent verapamil therapy (leads to severe bradycardias)

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25
Q

define pulsus paradoxus

causes

A

a decrease SBP >10mmHg on inspiration, leading to inability to feel/weakening of radial pulse
severe asthma, cardiac tamponade

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26
Q

define pulsus alternans

cause

A

alternating strong and weak pulses

severe LVF

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27
Q

define bisferians pulse

cause

A

“double pulse” - 2 systolic peaks

mixed aortic valve disease

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28
Q

what is a cannon a wave on a JVP and what is the cause

A

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

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29
Q

pathology of the 3rd heart sound?

what conditions are it associated with?

A

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)

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30
Q

pathology of the 4th heart sound?

causes?

A

atrial contraction against a stiff ventricle

AS, hypertension, HOCM

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31
Q

what does IV adenosine do to the heart?

and on the lungs?

A

causes transient AV heart block

and bronchospasm therefore C/I in asthma

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32
Q

which cardiac enzyme is the first to rise

A

myoglobin (1-2 hrs, peaks 6-8 hrs)

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33
Q

how long does trop T stay elevated for after MI?

when does it peak?

A

7-10 days,

4-6hrs

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34
Q

What is the maximum time a patient can be in AF to be cardioverted?

A

<48 hours - heparinise and DC cardiovert with 4 weeks of anticoagulation afterwards
or pharmacological cardioversion (flecainide if no structural heart dz, otherwise amiodarone)

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35
Q

how common is a patent foramen ovale?

A

~20% of population

36
Q

What is the scoring system for AF risk profiling and Mx?

A

CHADSVASc
0 - no Rx
1 - oral anticoagulant (dabigatran an alternative) aspirin 2nd choice
>1 - oral anticoagulant (dabigatran an alternative)

37
Q

Features and scores of CHADSVASc

what is it used for?

A

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
Q

Action of dabigatran

A

Direct thrombin (factor 2a) inhibitor

39
Q

What is the indication for dabigatran?

A

Non valvular AF with a CHADSVASc score >1 in patients who have difficulty maintaining INR control with warfarin or impractical to use warfarin

40
Q

Mode of action of fondaparinux?

When is it used?

A

Antithrombin 3 activator (similar to LMWH (enoxaparin) but no heparin induced thrombocytopenia)

Used in ACS treatment

41
Q

Mx of ACS

A

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
Q

what is Ebstein’s anomaly?

A

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
Q 
driving restrictions on :
elective angioplasty
CABG
ACS
pacemaker insertion
ICD
A

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
Q

Causes of cyanotic heart disease

A

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
Q

causes of acyanotic heart disease

A 
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
Q

classify aortic dissection

what is the anatomical border?

A

type A - ascending
type B - descending

type B begins distal to the origin of the left subclavian artery

47
Q

what is the management of an aortic dissection?

A

type A - BP control (labetalol) aim SBP 100-120, and refer for surgery.
type B - BP control (labetalol), bed rest.

48
Q

ECG changes due to digoxin

A

down sloping ST depression (reverse tick)
flattened/inverted T waves
short QT interval
bardycardia, AV block

49
Q

Good and poor prognostic features of infective endocarditis

A

Good: Strep infection
Poor: low complement levels, negative blood culture, prosthetic valve, staph aureus

50
Q 
Types of drug in each of the Vaughan Williams antiarrhythmic categories
1 a/b/c
2
3
4
A

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
Q

Classify stages of heart failure

A

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
Q

Define a capture beat

A

occasional narrow complex QRS when others are broad, occuring sooner than expected.
indicates normal AV conduction, so SVT unlikely

53
Q

causes of an early diastolic murmur

A 
aortic regurgitation
pulmonary regurgitation (Graham-Steel murmur)
54
Q

Causes of a prolonged PR interval

A 
idiopathic
hypokalaemia
IHD
digoxin toxicity 
aortic root disease eg abscess
myotonic dystrophy
sarcoidosis
lyme disease
rheumatic fever
55
Q

best way of assessing LV function

A

MUGA nuclear scan, can be performed as a stress test

56
Q

gold standard for structural imaging of the heart

A

cardiac MRI

57
Q

Mx of a PDA

A

closure with indomethacin (NSAID, PG inhibitor)

58
Q

beta blockers proven to reduce mortality in HF

A

bisoprolol and carvedilol

59
Q

Features of Williams syndrome

A

rare neurodevelopmental disorder
developmental delay, good language skills, overfamiliar with strangers
supravalvular aortic stenosis
transient hypercalcaemia

60
Q

contraindication to thrombolysis

A 
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
Q

Moxonidine:
mechonism of action
use

A

centrally active antihypertensive by decreasing sympathetic tone
used for essential hypertension when other antihypertensives have failed

62
Q

Complications of PCI

A

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
Q

Risk factors for restenosis of PCI stent

A

diabetes mellitus
renal failure
stent in a venous bypass graft

64
Q

pros and cons of drug eluding stent

A

slows proliferation so slows restenosis but increases risk of thrombosis - need clopidogrel cover for longer

65
Q

features of Brugada syndrome?

A

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
Q

How do you diagnose HF

A

previous MI - echo within 2 weeks
no MI -> BNP
BNP high –> echo within 2 weeks
BNP raised –> echo within 6 weeks

67
Q

factors which increase BNP level

A

ischaemia
LVH and RV overload
tachycardia
renal failure

68
Q

what is the definition of a high and raised BNP

A

high BNP >400 –> echo within 2 weeks
raised 100-400 –> echo within 6 weeks
normal <100

69
Q

factors increasing risk of asystole in a bradycardic patient

A

ventricular pauses >3s
complete HB with broad QRS
recent asystole
mobitz type 2 (2:1 etc)

70
Q

blind treatment of endocarditis

A

native valve - amoxicillin
pen allergic/severe/MRSA - vanc + gent
prosthetic valve - vanc + rifampicin + gent

71
Q

Prinzmetal angina
pathology
Mx

A

coronary artery vasospasm

Dihydropyridine calcium channel blocker (eg felodipine)

72
Q

causes of eruptive xanthoma

A

high TG levels

  • familial hypertriglyceridaemia
  • lipoprotein lipase deficiency
73
Q

cause of palmar xanthoma

A

Remnant hyperlipidaemia

74
Q

features of tetralogy of Fallot

A

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
Q

indications for ICD

A 
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
Q

Indications for temporary pacemaker

A

symptomatic/haemodynamically unstable bradycardia resistant to atropine
post Anterior MI with CHB or Mobitz type 2
trifasicular block prior to surgery

77
Q

what is Beck’s triad and what does it indicate?

A

hypotension, quiet heart sounds, prominent neck vessels

cardiac tamponade

78
Q

causes of a split S2 on expiration

A 
aortic stenosis, 
hypertrophic cardiomyopathy, 
LBBB, 
ventricular pacemaker
split S2 on inspiration is nomal
79
Q

causes of a fixed split S2

A

fixed split = split S2 on both inspiration and expiration

ASD or VSD

80
Q

features of Takasubo cardiomyopathy

A

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
Q

Mx of patient with new onset AF >48 hours

A

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
Q

Drugs to avoid in wolf parkinson white syndrome

A

ABCD

adenosine, beta-blocker, calcium channel blockers, digoxin

83
Q

Classifications of aortic stenosis

A

normal valve size 3-4 square cm
mild - valve size 2-1.5cm(squ) - pressure gradient 40mmHg
critical - valve <0.6cm squared

84
Q

Indications for aortic valve replacement

A

symptomatic severe aortic stenosis
severe or moderate AS pt undergoing CABG or aorta surgery
severe AS with ejection fraction <50%

85
Q

distinguishing features between SVT with aberrant conduction and VT?

A

SVT + aberrant conduction - L or R BBB

VT - capture beats, fusion beats, QRS >160ms

MRCP 1 (15 decks)

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