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Yr 5 - CVS > Corrections 2 > Flashcards

Corrections 2 Flashcards

1
Q

Which HTN medication can cause hypercalcaemia?

A

Thiazide diuretics (also cause hypocalciuria)

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2
Q

What K+ level should prompt cessation of ACEi in a patient with CKD?

A

> 6 mmol/L

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3
Q

Purpose of getting an echo in AF?

A

To rule out valvular heart disease

If the echo shows a valvular defect, then anticoagulation should be started even with a low CHA2DS2-VASc score, as valvular heart disease in combination with AF is an absolute indication for anticoagulation.

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4
Q

If a CHA2DS2-VASc score suggests no need for anticoagulation, what is the next step?

A

Get an echo to rule out valvular heart disease

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5
Q

What pulse can be found in mixed aortic valve disease?

A

Bisferiens pulse

This pulse is characterized by having two distinct systolic peaks separated by a mid-systolic dip.

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6
Q

Mx of those with risk factors for asystole in bradycardia?

A

Transvenous pacing

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7
Q

What type of haemorrhage can cause torsades de pointes?

A

SAH

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8
Q

What investigation is required in recurrent episodes of collapse and a normal resting ECG,?

A

24h holter monitor to rule out any abnormal arrhythmias

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9
Q

What is De Musset’s sign?

A

Head bobbing in time with pulse in aortic regurgitation

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10
Q

Mx of mitral stenosis patients who are asymptomatic?

A

Generally monitored (echo every 6-12m)

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11
Q

What should all patients with claudication be offered?

A

Structured exercise programme

This should be offered BEFORE considering angioplasy, surgical intervention or vasodilator therapy.

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12
Q

What is PAD strongly linked to?

A

Smoking –> give patients help to quit smoking

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13
Q

What medications should all patients with PAD be given?

A

1) Clopidogrel

2) Atorvastatin 80mh

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14
Q

In PAD, what mx strategy is indicated prior to other interventions?

A

Supervised exercise programme

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15
Q

Mx options for severe PAD or critical limb ischaemia?

A

1) Endovascular revascularisation

2) Surgical revascularisation

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16
Q

Patients with a STEMI should be offered dual antiplatelet therapy prior to PCI (aspirin + one other).

What determines the 2nd antiplatelet?

A

patient is not taking an oral anticoagulant –> prasugrel

patient is taking an oral anticoagulant –> clopidogrel

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17
Q

What is Takayasu’s arteritis?

A

A large vessel vasculitis that primarily affects the aorta and its main branches.

Causes occlusion of the aorta .

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18
Q

What do questions surrounding Takayasu’s arteritis commonly refer to?

A

An absent limb pulse

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19
Q

Who is Takayasu’s arteritis more common in?

A
  • Younger females (10-40y)
  • Asian people
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20
Q

Features of Takayasu’s arteritis?

A
  • systemic features of a vasculitis e.g. malaise, headache
  • unequal blood pressure in the upper limbs
  • carotid bruit and tenderness
  • absent or weak peripheral pulses
  • upper and lower limb claudication on exertion
  • aortic regurgitation (around 20%)
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21
Q

What condition is Takayasu’s arteritis associated with?

A

Renal artery stenosis

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22
Q

Mx of Takayasu’s arteritis?

A

Steroids

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23
Q

What investigation is required to make a diagnosis of Takayasu’s arteritis?

A

vascular imaging of the arterial tree e.g. either magnetic resonance angiography (MRA) or CT angiography (CTA)

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24
Q

When is orthostatic hypotension diagnosed?

A

When there is a drop in SBP of at least 20 mmHg and/or a drop in DBP of at least 10 mmHg after 3 minutes of standing.

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25
Q

What is electrical cardioversion synchronised to?

Why?

A

The R wave

To prevent delivery of a shock during the vulnerable period of cardiac repolarisation when VF can be induced.

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26
Q

What 3 medications are used to control rate in AF?

A

1) beta blockers (caution of asthma)

2) CCBs

3) digoxin

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27
Q

Changes in which ECG leads indicate an occlusion of the left circumflex artery?

A

I, aVL +/- V5-6

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28
Q

What can be used as DVT prophylaxis on long-hall flights?

A

Anti-embolism stockings

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29
Q

After starting an ACEi, significant renal impairment may occur if there is what underlying condition?

A

Bilateral renal artery stenosis

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30
Q

What defines ‘typical’ angina?

A

Any chest discomfort that meets the following 3 criteria:

1) constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms

2) precipitated by physical exertion

3) relieved by rest or GTN in about 5 minutes

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31
Q

What is angina described as if it only meets 2/3 criteria?

A

Atypical (e.g. if chest pain is described as sharp instead of constricting)

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32
Q

What mx is indicated in all patients with ACUTE heart failure (i.e. an exacerbation)?

A

Loop diuretics e.g. furosemide

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33
Q

What are 2 additional treatments that can be considered in ACUTE heart failure?

A

1) oxygen (<94%)

2) vasodilators e.g. nitrates

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34
Q

When are vasodilators indicated in the mx of acute heart failure?

A

Should NOT be routinely given to all patients.

They may have a role if:

1) there is concomitant myocardial ischaemia

or

2) severe HTN

or

3) regurgitant aortic or mitral valve disease

35
Q

Mx of acute heart failure with respiratory failure?

A

CPAP

36
Q

Mx of acute heart failure with hypotension/cardiogenic shock?

A

1) Inotropic agents e.g. dobutamine (1st line)

2) Vasopressors e.g. norepinephrine

3) Mechanical circulatory assistance

37
Q

When should beta blockers be stopped in HF?

A

1) HR <50 bpm

2) 2nd or 3rd degree AV block

3) Shock

38
Q

What rash is seen in rheumatic fever?

A

Erythema marginatum

39
Q

What infection is implicated in rheumatic fever?

A

GAS (S. pyogenes)

Rheumatic fever develops following an immunological reaction to a recent (2-4 weeks ago) S. pyogenes infection.

40
Q

What is the ‘major’ criteria for rheumatic fever diagnosis?

(2 major criteria required for diagnosis)

A

1) erythema marginatum

2) Sydenham’s chorea: this is often a late feature

3) polyarthritis

4) carditis and valvulitis (eg, pancarditis)

5) subcutaneous nodules

41
Q

Which diuretics increases the risk of gout?

A

Thiazide diuretics –> cause hyperuricaemia

42
Q

What criteria is used in the diagnosis of infective endocarditis?

A

Duke’s criteria

43
Q

What 3 medications are used in the RATE control of AF?

A

1) Beta blockers (with the exception of sotalol which is used for rhythm control)

2) Non-dihydropyridine calcium channel blockers e.g. verapamil, diltiazem

3) Digoxin

44
Q

Which beta blocker is used for rhythm control instead of rate control?

A

Sotalol

45
Q

When is digoxin only indicated in rate control in AF?

A

In sedentary patients with non-paroxysmal AF

46
Q

3 options for rhythm control in AF?

A

1) DC cardioversion

2) Amiodarone

3) Flecainide

47
Q

Give 2 contraindications for flecainide in AF rhythm control?

A

1) structural heart disease

2) ischaemic heart disease

48
Q

Stepwise approach to mx of AF?

A

1) Initial assessment for and management of emergency symptoms:
a) Treatment of haemodynamic instability
b) Treatment of complications

2) Management of non life threatening symptoms:
a) Rhythm and rate Control
b) Investigation and mx of underlying causes of AF

3) Management of the risk of complications: anticoagulation

4) Follow up in 1ary care

49
Q

Mx of AF with haemodynamic instability?

A

ABCDE

DC cardioversion

50
Q

What are the 3 key complications of AF?

A

1) stroke (most common)

2) mesenteric ischaemia

3) acute limb ischaemia

51
Q

Mx of stroke due to AF?

A

1) Aspirin for 2 weeks

2) DOAC/warfarin lifelong

52
Q

Mx of AF with non life-threatening symptoms:

1) those who have had symptoms for <48 hours?

2) those who have had symptoms for >48 hours or uncertain of onset?

A

1) Offered rhythm or rate control (rhythm control is recommended in most patients with a new onset of AF presenting at this time)

2) immediate rate control, followed by delayed rhythm control if they desire

53
Q

What is 1st line treatment for long term mx of AF?

What are 2 exceptions to this?

A

Rate control

Exceptions:
1) there is a clear reversible trigger
2) patients who may benefit more from rhythm control

54
Q

What is delayed rhythm control in AF?

A

Cardioversion that takes place after at least 3 weeks of anticoagulation and rate control.

These patients should continue to receive anticoagulation for 4 weeks after their cardioversion to further reduce this risk.

55
Q

if anticoagulation cannot be given before cardioversion in AF, what should be done instead?

A

A transoesophageal echo guided cardioversion should be done to make sure there are no clots in the atria beforehand.

56
Q

Mx of paroxysmal AF?

A

1) these patients are offered rate control as a first line

2) patients with very infrequent episodes of paroxysmal AF can be candidates for a ‘pill in the pocket’ approach

57
Q

Why is verapamil contraindicated in VT?

A

VT causes cardiac output to reduce dramatically.

Verapamil can reduce contractility of the heart even further –> can result in death.

IV administration of a CCB can also precipitate cardiac arrest.

58
Q

What is a Q wave?

A

Any negative deflection that precedes an R wave.

59
Q

When are Q waves considered pathological?

A

1) >40 ms (1 mm) wide

2) >2 mm deep

3) >25% of depth of QRS complex

4) Seen in leads V1-3

60
Q

What do pathological Q waves indicate?

A

Current or prior myocardial infarction

61
Q

Why are ACEi and ARBs contraindicated in renal artery stenosis?

A

1) They reduce intra-glomerular pressure through dilation of the efferent arteriole

2) This, when combined with the pre-existing reduction in perfusion from the renal artery stenosis can cause acute renal failure through further reduction in intra-glomerular blood pressure.

62
Q

Side effects of nicorandil?

A

1) headache

2) flushing

3) skin, mucosal & eye ulceration (GI ulcers including anal ulceration)

63
Q

What is nicorandil?

A

A vasodilatory drug used to treat angina.

It is a potassium-channel activator with vasodilation is through activation of guanylyl cyclase which results in increase cGMP.

64
Q

Contraindication of nicorandil?

A

LV failure

65
Q

Side effects of thiazide diuretics?

A

1) dehydration

2) postural hypotension

3) hypokalaemia

4) hyponatraemia

5) hypercalcaemia

6) impaired glucose tolerance

7) impotence

66
Q

What 2 connective tissue conditions can lead to acute pericarditis?

A

1) SLE

2) RA

67
Q

What is the most common viral infection causing acute pericarditis?

A

Coxsackie

68
Q

Mx of patients on warfarin:

1) major bleeding e.g. variceal haemorrhage, intracranial haemorrhage

2) INR >8.0 & minor bleeding

3) INR >8.0 & no bleeding

4) INR 5.0-8.0 & minor bleeding

5) INR 5.0-8.0 & no bleeding

A

1) stop warfarin, IV vit K 5mg, PCC

2) stop warfarin, IV vit K 1-3mg, restart warfarin when INR <5.0

3) stop warfarin, oral vit K 1-5mg, restart warfarin when INR <5.0

4) stop warfarin, IV vit K 1-3mg, restart warfarin when INR <5.0

5) withhold 1 or 2 doses of warfarin, reduce subsequent maintenance dose

69
Q

What is Kussmaul’s sign?

A

a paradoxical rise in JVP during inspiration

70
Q

What is Kussmaul’s sign seen in?

A

Constrictive pericarditis (NOT cardiac tamponade)

71
Q

What is pulsus paradoxus?

A

An abnormal drop in systolic blood pressure (>10) when you breathe in.

72
Q

What is pulsus paradoxus seen in?

A

Cardiac tamponade (NOT constrictive pericarditis)

73
Q

CXR feature in constrictive pericarditis?

A

Pericardial calcification

74
Q

Why should PPIs not be adminstered as part of the acute mx of an upper GI bleed prior to an endoscopy?

A

As they may mask the site of bleeding.

Give PPIs after endoscopy (if there is evidence of recent non-variceal haemorrhage).

75
Q

ECG findings in digoxin toxicity?

A

1) downsloping ST depression (‘reverse tick’)

2) flattened/inverted T waves

3) short QT interval

4) arrhythmias e.g. AV block, bradycardia

76
Q

What valve defect causes a systolic murmur, loudest in the 2nd intercostal space along the left sternal border?

A

Pulmonary stenosis

Can result in RHF

77
Q

Triad of features of RHF?

A

1) raised JVP

2) hepatomegaly

3) ankle oedema (from increased peripheral venous pressure)

78
Q

Patients with a STEMI should be offered dual antiplatelet therapy prior to PCI (aspirin + one other).

What determines the 2nd antiplatelet?

A

patient is not taking an oral anticoagulant –> prasugrel

patient is taking an oral anticoagulant –> clopidogrel

79
Q

Mx of symptomatic 2nd degree type I heart block

A

Transcutaneous pacing

80
Q

Most common cause of long QT syndrome?

A

loss-of-function/blockage of K+ channels

81
Q

For a patient with symptomatic stable angina on a CCB but with a contraindication to a beta-blocker, what is the next treatment?

A

One of the following drugs:

1) long acting nitrate
2) ivabradine
3) nicorandil
4) ranolazine

82
Q

What are the 2 pharmacological options for the treatment of orthostatis hypotension?

A

1) fludrocortisone
2) midodrine

83
Q
A

Yr 5 - CVS (9 decks)

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