Corrections 2 Flashcards
Which HTN medication can cause hypercalcaemia?
Thiazide diuretics (also cause hypocalciuria)
What K+ level should prompt cessation of ACEi in a patient with CKD?
> 6 mmol/L
Purpose of getting an echo in AF?
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.
If a CHA2DS2-VASc score suggests no need for anticoagulation, what is the next step?
Get an echo to rule out valvular heart disease
What pulse can be found in mixed aortic valve disease?
Bisferiens pulse
This pulse is characterized by having two distinct systolic peaks separated by a mid-systolic dip.
Mx of those with risk factors for asystole in bradycardia?
Transvenous pacing
What type of haemorrhage can cause torsades de pointes?
SAH
What investigation is required in recurrent episodes of collapse and a normal resting ECG,?
24h holter monitor to rule out any abnormal arrhythmias
What is De Musset’s sign?
Head bobbing in time with pulse in aortic regurgitation
Mx of mitral stenosis patients who are asymptomatic?
Generally monitored (echo every 6-12m)
What should all patients with claudication be offered?
Structured exercise programme
This should be offered BEFORE considering angioplasy, surgical intervention or vasodilator therapy.
What is PAD strongly linked to?
Smoking –> give patients help to quit smoking
What medications should all patients with PAD be given?
1) Clopidogrel
2) Atorvastatin 80mh
In PAD, what mx strategy is indicated prior to other interventions?
Supervised exercise programme
Mx options for severe PAD or critical limb ischaemia?
1) Endovascular revascularisation
2) Surgical revascularisation
Patients with a STEMI should be offered dual antiplatelet therapy prior to PCI (aspirin + one other).
What determines the 2nd antiplatelet?
patient is not taking an oral anticoagulant –> prasugrel
patient is taking an oral anticoagulant –> clopidogrel
What is Takayasu’s arteritis?
A large vessel vasculitis that primarily affects the aorta and its main branches.
Causes occlusion of the aorta .
What do questions surrounding Takayasu’s arteritis commonly refer to?
An absent limb pulse
Who is Takayasu’s arteritis more common in?
- Younger females (10-40y)
- Asian people
Features of Takayasu’s arteritis?
- 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%)
What condition is Takayasu’s arteritis associated with?
Renal artery stenosis
Mx of Takayasu’s arteritis?
Steroids
What investigation is required to make a diagnosis of Takayasu’s arteritis?
vascular imaging of the arterial tree e.g. either magnetic resonance angiography (MRA) or CT angiography (CTA)
When is orthostatic hypotension diagnosed?
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.
What is electrical cardioversion synchronised to?
Why?
The R wave
To prevent delivery of a shock during the vulnerable period of cardiac repolarisation when VF can be induced.
What 3 medications are used to control rate in AF?
1) beta blockers (caution of asthma)
2) CCBs
3) digoxin
Changes in which ECG leads indicate an occlusion of the left circumflex artery?
I, aVL +/- V5-6
What can be used as DVT prophylaxis on long-hall flights?
Anti-embolism stockings
After starting an ACEi, significant renal impairment may occur if there is what underlying condition?
Bilateral renal artery stenosis
What defines ‘typical’ angina?
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
What is angina described as if it only meets 2/3 criteria?
Atypical (e.g. if chest pain is described as sharp instead of constricting)
What mx is indicated in all patients with ACUTE heart failure (i.e. an exacerbation)?
Loop diuretics e.g. furosemide
What are 2 additional treatments that can be considered in ACUTE heart failure?
1) oxygen (<94%)
2) vasodilators e.g. nitrates
When are vasodilators indicated in the mx of acute heart failure?
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
Mx of acute heart failure with respiratory failure?
CPAP
Mx of acute heart failure with hypotension/cardiogenic shock?
1) Inotropic agents e.g. dobutamine (1st line)
2) Vasopressors e.g. norepinephrine
3) Mechanical circulatory assistance
When should beta blockers be stopped in HF?
1) HR <50 bpm
2) 2nd or 3rd degree AV block
3) Shock
What rash is seen in rheumatic fever?
Erythema marginatum
What infection is implicated in rheumatic fever?
GAS (S. pyogenes)
Rheumatic fever develops following an immunological reaction to a recent (2-4 weeks ago) S. pyogenes infection.
What is the ‘major’ criteria for rheumatic fever diagnosis?
(2 major criteria required for diagnosis)
1) erythema marginatum
2) Sydenham’s chorea: this is often a late feature
3) polyarthritis
4) carditis and valvulitis (eg, pancarditis)
5) subcutaneous nodules
Which diuretics increases the risk of gout?
Thiazide diuretics –> cause hyperuricaemia
What criteria is used in the diagnosis of infective endocarditis?
Duke’s criteria
What 3 medications are used in the RATE control of AF?
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
Which beta blocker is used for rhythm control instead of rate control?
Sotalol
When is digoxin only indicated in rate control in AF?
In sedentary patients with non-paroxysmal AF
3 options for rhythm control in AF?
1) DC cardioversion
2) Amiodarone
3) Flecainide
Give 2 contraindications for flecainide in AF rhythm control?
1) structural heart disease
2) ischaemic heart disease
Stepwise approach to mx of AF?
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
Mx of AF with haemodynamic instability?
ABCDE
DC cardioversion
What are the 3 key complications of AF?
1) stroke (most common)
2) mesenteric ischaemia
3) acute limb ischaemia
Mx of stroke due to AF?
1) Aspirin for 2 weeks
2) DOAC/warfarin lifelong
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?
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
What is 1st line treatment for long term mx of AF?
What are 2 exceptions to this?
Rate control
Exceptions:
1) there is a clear reversible trigger
2) patients who may benefit more from rhythm control
What is delayed rhythm control in AF?
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.
if anticoagulation cannot be given before cardioversion in AF, what should be done instead?
A transoesophageal echo guided cardioversion should be done to make sure there are no clots in the atria beforehand.
Mx of paroxysmal AF?
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
Why is verapamil contraindicated in VT?
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.
What is a Q wave?
Any negative deflection that precedes an R wave.
When are Q waves considered pathological?
1) >40 ms (1 mm) wide
2) >2 mm deep
3) >25% of depth of QRS complex
4) Seen in leads V1-3
What do pathological Q waves indicate?
Current or prior myocardial infarction
Why are ACEi and ARBs contraindicated in renal artery stenosis?
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.
Side effects of nicorandil?
1) headache
2) flushing
3) skin, mucosal & eye ulceration (GI ulcers including anal ulceration)
What is nicorandil?
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.
Contraindication of nicorandil?
LV failure
Side effects of thiazide diuretics?
1) dehydration
2) postural hypotension
3) hypokalaemia
4) hyponatraemia
5) hypercalcaemia
6) impaired glucose tolerance
7) impotence
What 2 connective tissue conditions can lead to acute pericarditis?
1) SLE
2) RA
What is the most common viral infection causing acute pericarditis?
Coxsackie
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
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
What is Kussmaul’s sign?
a paradoxical rise in JVP during inspiration
What is Kussmaul’s sign seen in?
Constrictive pericarditis (NOT cardiac tamponade)
What is pulsus paradoxus?
An abnormal drop in systolic blood pressure (>10) when you breathe in.
What is pulsus paradoxus seen in?
Cardiac tamponade (NOT constrictive pericarditis)
CXR feature in constrictive pericarditis?
Pericardial calcification
Why should PPIs not be adminstered as part of the acute mx of an upper GI bleed prior to an endoscopy?
As they may mask the site of bleeding.
Give PPIs after endoscopy (if there is evidence of recent non-variceal haemorrhage).
ECG findings in digoxin toxicity?
1) downsloping ST depression (‘reverse tick’)
2) flattened/inverted T waves
3) short QT interval
4) arrhythmias e.g. AV block, bradycardia
What valve defect causes a systolic murmur, loudest in the 2nd intercostal space along the left sternal border?
Pulmonary stenosis
Can result in RHF
Triad of features of RHF?
1) raised JVP
2) hepatomegaly
3) ankle oedema (from increased peripheral venous pressure)
Patients with a STEMI should be offered dual antiplatelet therapy prior to PCI (aspirin + one other).
What determines the 2nd antiplatelet?
patient is not taking an oral anticoagulant –> prasugrel
patient is taking an oral anticoagulant –> clopidogrel
Mx of symptomatic 2nd degree type I heart block
Transcutaneous pacing
Most common cause of long QT syndrome?
loss-of-function/blockage of K+ channels
For a patient with symptomatic stable angina on a CCB but with a contraindication to a beta-blocker, what is the next treatment?
One of the following drugs:
1) long acting nitrate
2) ivabradine
3) nicorandil
4) ranolazine
What are the 2 pharmacological options for the treatment of orthostatis hypotension?
1) fludrocortisone
2) midodrine
