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Yr 4 - ACC > Corrections - Cardiology > Flashcards

Corrections - Cardiology Flashcards

1
Q

A posterior STEMI can present with ST depression.

What leads would this typically be seen in?

A

This is generally seen in V1-3.

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2
Q

What is the preferred stent type for primary PCI?

A

Drug-eluting stents

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3
Q

Why are drug-eluting stents the preferred stent type for primary PCI?

A

As they release anti-proliferative drugs that significantly decrease the likelihood of restenosis.

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4
Q

What artery is typically affected in a posterior STEMI?

A

Usually occurring in the context of an inferior or lateral infarction (i.e. RCA or left circumflex artery).

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5
Q

What is the key complication of Kawasaki disease?

How can this be screened for?

A

Coronary artery aneurysm: echocardiogram

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6
Q

What is Kawasaki disease?

A

A type of vasculitis which is predominately seen in children.

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7
Q

Features of Kawasaki disease?

A

1) high-grade fever which lasts for > 5 days (characteristically resistant to antipyretics)

2) conjunctival injection

3) bright red, cracked lips

4) strawberry tongue

5) cervical lymphadenopathy

6) red palms of the hands and the soles of the feet which later peel

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8
Q

How is a diagnosis of Kawasaki disease made?

A

Kawasaki disease is a clinical diagnosis as there is no specific diagnostic test.

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9
Q

Management of Kawasaki disease?

A

1) high dose aspirin (Kawasaki disease is one of the few indications for the use of aspirin in children)

2) IV immunoglobulin

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10
Q

Why is aspirin normally contraindicated in children?

A

Due to the risk of Reye’s syndrome

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11
Q

What is Reye’s syndrome?

A

A rare but serious condition that causes swelling in the liver and brain.

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12
Q

What class of drug is nicorandil?

A

A potassium channel activator.

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13
Q

Indication of Nicorandil?

A

Angina: has a vasodilatory effect on the coronary arteries.

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14
Q

Side effect of nicorandil?

A
  • headache
  • flushing
  • anal ulceration
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15
Q

What would global T wave inversion (i.e. not fitting a coronary artery territory) indicate?

A

Non-cardiac cause e.g. head injury

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16
Q

What investigation is important in post-op ileus?

A

U&Es: Deranged electrolytes can contribute to the development of postoperative ileus.

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17
Q

What should an inferior myocardial infarction and aortic regurgitation murmur raise suspicion of?

A

Aortic dissection

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18
Q

Why is an ECG required prior to prescribing antipsychotics?

A

Can cause QT prolongation

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19
Q

What is the most common cause of mitral stenosis?

A

Rheumatic fever

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20
Q

What is rheumatic fever caused by?

A

group A Streptococcus species (GAS)

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21
Q

Where is the mitral valve located?

A

Between LA and LV

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22
Q

What investigation should be considered in elderly patients with new sudden onset psychosis?

A

CT head scan: to rule out organic causes e.g. brain tumour, stroke

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23
Q

What is first line radiological investigation for suspected stroke?

A

Non-contrast CT head scan

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24
Q

In ACS where morphine is not indicated (i.e. pain not severe enough), what can be given instead?

A

Paracetamol.

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25
Q

Why are NSAIDs not given in the management of ACS?

A

This is because they will be given an array of antiplatelet drugs, which can interact with NSAIDs to precipitate bleeding (e.g. aspirin, ticagrelor).

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26
Q

what is adenosine most cimmonly used to treat?

A

Supraventricular tachycardias.

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27
Q

What are the effects of adenosine:
a) blocked by
b) enchanced by?

A

a) theophyllines
b) dipyridamole (antiplatelet agent)

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28
Q

Who should adenosine be avoided in?

A

Asthmatics due to possible bronchospasm

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29
Q

Mechanism of action of adenosine?

A

Causes transient heart block in the AV node:

Agonist of the A1 receptor in the atrioventricular node, which inhibits adenylyl cyclase thus reducing cAMP and causing hyperpolarisation by increasing outward potassium flux.

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30
Q

Half life of adenosine?

A

Adenosine has a very short half-life of about 8-10 seconds –> should ideally be infused via a large-calibre cannula.

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31
Q

Adverse effects of adenosine?

A

1) chest pain

2) bronchospasm

3) transient flushing

4) can enhance conduction down accessory pathways, resulting in increased ventricular rate (e.g. WPW syndrome)

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32
Q

Should a single episode of paroxysmal atrial fibrillation, even if provoked, prompt consideration of anticoagulation?

A

Yes

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33
Q

What is the threshold for transfusion of RBCs in patients:

1) with ACS

2) without ACS

A

1) 80 g/L

2) 70 g/L

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34
Q

What causes crepitus over the chest wall in Boerhaave’s syndrome?

A

Subcutaneous emphysema:

1) In Boerhaave’s syndrome, barotrauma (usually from severe, repeated vomiting) causes a full-thickness tear in the oesophagus.

2) This enables air to travel up the fascial planes in the mediastinum to the subcutaneous tissues, resulting in the characteristic ‘rice krispies’ crepitus.

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35
Q

How does a posterior MI typically present on an ECG?

A
  • Tall R waves in V1-3
  • ST depression
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36
Q

What are poor prognostic factors in ACS?

A

1) age
2) development (or history) of heart failure
3) peripheral vascular disease
4) reduced systolic blood pressure
5) Killip class
6) initial serum creatinine concentration
7) elevated initial cardiac markers
8) cardiac arrest on admission
9) ST segment deviation

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37
Q

What is the Killip class system?

A

Used to stratify risk post myocardial infarction:

I - No clinical signs heart failure
II - Lung crackles, S3
III - Frank pulmonary oedema
IV - Cardiogenic shock

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38
Q

RBBB is most likely to be caused by occlusion of which artery?

A

LAD

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39
Q

What is Wellen’s syndrome?

A

An ECG pattern that is typically caused by high-grade stenosis in the LAD coronary artery.

The patient’s pain may have resolved at the time of presentation and cardiac enzymes may be normal/minimally elevated.

ECG features:
1) biphasic or deep T wave inversion in V2-3
2) minimal ST elevation
3) no Q waves

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40
Q

What is the reversal agent for dabigatran?

A

Idarucizumab

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41
Q

What is the reversal agent for rivaroxaban or apixaban?

A

Andexanet alfa

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42
Q

What is the reversal agent for heparin or LMWH?

A

Protamine sulphate

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43
Q

Give the reversal agent for the following drugs:

1) dabigatran
2) rivaroxaban
3) apixaban
4) heparin
5) warfarin

A

1) idarucizumab
2) Andexanet alfa
3) Andexanet alf
4) Protamine sulphate
5) vit K

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44
Q

What is Andexanet alfa?

A

a recombinant form of factor Xa

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45
Q

What murmur does aortic regurg typically cause?

A

Early diastolic

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46
Q

What is aortic regurg?

A

The leaking of the aortic valve of the heart that causes blood to flow in the reverse direction during ventricular diastole.

47
Q

Wht are the 2 groups of causes of aortic regurg?

A

1) disease of the aortic valve

2) distortion or dilation of the aortic root and ascending aorta

These can be acute or chronic.

48
Q

Causes of aortic regurg due to valve disease?

A

Chronic:

1) rheumatic fever: the most common cause in the developing world

2) calcific valve disease

3) connective tissue diseases e.g. rheumatoid arthritis/SLE

4) bicuspid aortic valve (affects both the valves and the aortic root)

Acute:

1) infective endocarditis

49
Q

Causes of aortic regurg due to aortic root disease?

A

Chronic:

1) bicuspid aortic valve (affects both the valves and the aortic root)

2) spondylarthropathies (e.g. ankylosing spondylitis)

3) hypertension

4) syphilis

5) Marfan’s, Ehler-Danlos syndrome

Acute:

1) aortic dissection

50
Q

Features of aortic regurg?

A

1) early diastolic murmur: intensity of the murmur is increased by the handgrip manoeuvre

2) collapsing pulse

3) wide pulse pressure

4) Quincke’s sign (nailbed pulsation)

5) De Musset’s sign (head bobbing)

6) mid-diastolic Austin-Flint murmur in severe AR - due to partial closure of the anterior mitral valve cusps caused by the regurgitation streams

51
Q

What is the handgrip manoeuvre?

A

Ask the patient to squeeze with both hands an object such as a rolled-up piece of paper. This will cause an increase in the afterload and as a consequence in the regurgitant blood flow across the aortic valve, making the aortic regurgitation murmur louder and easier to hear.

52
Q

What manouevre can make aortic regurg murmurs easier to hear?

A

Handgrip manouevre

53
Q

What is a useful investigation in clinically unstable patients with a suspected aortic dissection?

A

A transoesophageal echocardiography.

This investigation is portable and safe to use in unstable patients.

54
Q

ECG findings in hypokalaemia?

A

1) T wave inversion
2) Prominent U waves
3) Prolonged PR interval
4) ST depression

55
Q

What murmur is heard in anaemia?

A

Soft ejection systolic murmur that doesn’t radiate (aortic flow murmur).

56
Q

What class of drug is amiodarone?

A

Class III antiarrhythmic

57
Q

Indication of amiodarone?

A

Atrial, nodal & ventricular tachycardias.

58
Q

Main mechanism of amiodarone?

A

The main mechanism of action is by blocking potassium channels which inhibits repolarisation and hence prolongs the action potentia

59
Q

What are the main limitations of the use of amiodarone?

A

1) very long half-life (20-100 days) –> loading doses are frequently used

2) should ideally be given into central veins (causes thrombophlebitis)

3) has proarrhythmic effects due to lengthening of the QT interval

4) interacts with drugs commonly used concurrently (p450 inhibitor) e.g. decreases metabolism of warfarin

60
Q

What is thrombophlebitis?

A

Phlebitis is inflammation of a vein. An inflamed vein near the surface of the skin caused by a blood clot is known as superficial thrombophlebitis.

61
Q

How can thrombophlebitis be reduced when giving amiodarone?

A

Give via central line

62
Q

Side effects of amiodarone?

A

1) thyroid dysfunction: both hypothyroidism and hyper-thyroidism

2) corneal deposits

3) pulmonary fibrosis/pneumonitis

4) liver fibrosis/hepatitis

5) peripheral neuropathy, myopathy

6) photosensitivity

7) ‘slate-grey’ appearance

8) thrombophlebitis and injection site reactions

9) bradycardia

10) lengths QT interval

63
Q

What is torsades de pointes?

A

A life-threatening form of polymorphic ventricular tachycardia and QT prolongation where the QRS vary in size and duration (hence the name polymorphic).

It may deteriorate into ventricular fibrillation and hence lead to sudden death.

64
Q

What is the most common cause of torsades de pointes?

A

Medications e.g. tricyclic antidepressants, erythromycin, antipsychotics etc.

65
Q

What is the management of torsades de pointes?

A

IV magnesium sulphate (regardless of the cause)

66
Q

Causes of a long QT interval?

A

1) congenital:
- Jervell-Lange-Nielsen syndrome
- Romano-Ward syndrome

2) antiarrhythmics: amiodarone, sotalol, class 1a antiarrhythmic drugs

3) tricyclic antidepressants

4) antipsychotics

5) chloroquine

6) terfenadine

7) erythromycin

8) electrolyte: hypocalcaemia, hypokalaemia, hypomagnesaemia

9) myocarditis

10) hypothermia

11) subarachnoid haemorrhage

67
Q

1st line management of bradycardia in a peri-arrest situation e.g. complete heart block?

A

Atropine (500mcg IV)

68
Q

What are risk factors for asystole?

A

1) complete heart block with broad complex QRS

2) recent asystole

3) Mobitz type II AV block

4) ventricular pause > 3 seconds

69
Q

When is adenosine indicated?

A

Indicated in the ALS algorithm management of stable, narrow complex tachycardias.

70
Q

When is amiodarone indicated?

A

Amiodarone is indicated for use in the management of ventricular fibrillation/ventricular tachycardia arrests or for stable tachycardia as per the ALS algorithm.

71
Q

2ary prevention following an MI?

A

1) aspirin
2) 2nd antiplatelet e.g. ticagrelor, clopidogrel
3) statin
4) ACEi
5) beta blocker

72
Q

What is the most common cause of 2ary HTN?

A

Primary hyperaldosteronism

73
Q

What is the triad of features seen in cardiac tamponade?

A

Beck’s triad:

1) hypotension
2) raised JVP
3) muffled heart sounds

74
Q

Is antibiotic prohylaxis to prevent infective endocarditis routinely recommended in the UK for dental and other procedures?

A

No

75
Q

What type of BBB can a PE cause?

A

RBBB

76
Q

What murmur is heard in aortic regurg?

A

Early diastolic murmur

77
Q

What murmur is heard in mitral regurg?

A

A pansystolic murmur

78
Q

What heart defect is a continuous ‘machinery’ murmur associated with ?

A

Patent ductus arteriosus

79
Q

1st line management of acute pulmonary oedema?

A

position patient upright and commence IV loop diuretic (furosemide)

80
Q

What makes up the CHA2DS2-VASc score?

A

C - Congestive heart failure
H - Hypertension (controlled or uncontrolled)
A2 - Age (1 point for 65-74, 2 points for >75)
D - Diabetes
S - Prior stroke, TIA or VTE (2 points)

V - Vascular disease
S - Sex (female)

81
Q

What medication should be given in all types of aortic dissection?

A

IV labetalol (to manage HTN effectively and enhance prognosis)

82
Q

Management of type A aortic dissection?

A

IV labetalol + surgery

83
Q

Which class of medication can lead to unawareness of hypoglycemic events?

A

Beta blockers (as can theoretically suppress all of the adrenergically mediated symptoms of hypoglycemia).

84
Q

Stepwise management of severe bradycardia?

A

1) Atropine (up to 3mg)

2) Transcutaneous pacing

3) Isoprenaline/adrenaline infusion titrated to response

4) Transvenous pacing

85
Q

Following basic ABC assessment, patients with tachycardia are classified as being stable or unstable according to the presence of any adverse signs.

What are the life threatening features?

A

1) Shock: hypotension (systolic <90 mmHg), pallor, sweating, cold, clammy extremities, confusion or impaired consciousness

2) Syncope

3) Myocardial ischaemia

4) Severe HF

86
Q

If any life threatening features are present in tachycardia, what is immediate management?

A

Synchronised DC shock, up to 3 attempts

87
Q

Stepwise acute management of HF?

A

1) IV loop diuretics

2) O2 (if needed)

3) Vasodilators i.e. nitrates (if needed)

4) CPAP - if resp failure

5) In patients with hypotension/cardiogenic shock:
- ionotropes e.g. dobutamine
- vasopressors e.g. norepinephrine
- mechanical circulatory assistance

88
Q

What is the major side effect /contraindication of nitrates in acute HF?

A

Hypotension

89
Q

When may nitrates be indicated in acute HF?

A

They may have a role if concomitant myocardial ischaemia, severe hypertension or regurgitant aortic or mitral valve disease.

90
Q

1st line Abx in native valve infective endocarditis?

A

IV amoxicillin

91
Q

What are the 2 main contraindications to statin therapy?

A

1) macrolides (e.g. erythromycin, clarithromycin) –> statins should be stopped until patients complete the course

2) pregnancy

92
Q

Are statins safe in pregnancy?

A

NO

93
Q

What class of drug is indapamide?

A

Thiazide like diuretic

94
Q

Management of a massive PE + hypotension?

A

Thombolysis e.g. alteplase

95
Q

What are some acquired causes of a long QT syndrome?

A

1) Electrolyte imbalance: hypokalaemia, hypocalcaemia and hypomagnesaemia

2) Medications: amiodarone, sotalol, TCAs, SSRIs (especially citalopram), erythromycin, haloperidol, ondansetron

3) CNS lesions: subarachnoid haemorrhage and ischaemic stroke

4) Malnutrition

5) Hypothermia

96
Q

Can hyper or hyokalaemia cause a long QT interval?

A

Hypokalaemia

97
Q

What is isosorbide mononitrate?

A

A long acting nitrate

98
Q

What drug is contraindicated in VT?

A

Verapamil

99
Q

Why is verapamil contraindicated in VT?

A

IV administration of a calcium channel blocker can precipitate cardiac arrest.

100
Q

Management of AF post-stroke?

A

1) Exclude a haemorrhage before starting any anticoagulation or antiplatelet therapy.

2) Anticoagulation therapy should be commenced after 2 weeks (give antiplatelet therapy in the intervening period).

101
Q

Management of AF post-stroke?

A

1) Exclude a haemorrhage before starting any anticoagulation or antiplatelet therapy

2) Anticoagulation for AF should start immediately once imaging has excluded haemorrhage

102
Q

What is next step in suspected PE with a Wells PE score ≤4?

A

D-dimer

103
Q

What is next step in suspected PE with a Wells PE score >4?

A

CTPA

104
Q

How does a left ventricular aneurysm post-MI typicallyu present?

A
  • persistent ST elevation
  • LV failure
  • thrombus may form within aneurysm (anticoagulate these patients)
105
Q

What should be given to patients who are in VF/pulseless VT after 3 shocks have been administered?

A

IV amiodarone 300mg & IV adrenaline 1mg

106
Q

General stepwise management of angina?

A

1) aspirin & statin –> all patients

2) GTN spray

3) beta blocker and/or CCB

107
Q

Which bacteria is commonly associated with infective endocarditis amongst IVDU?

A

Staph. aureus

108
Q

Diastolic murmur + AF → ?

A

Mitral stenosis

109
Q

Describe murmur heard in mitral stenosis

A

mid-diastolic and it is heard over the fifth intercostal space, on the midclavicular line.

110
Q

How can mitral stenosis result in AF?

A

Mitral stenosis causes an increase in left atrial pressure, leading to an increase in the size of the left atrium, which in turn leads to AF.

111
Q

What is mitral stenosis most commonly caused by?

A

Rheumatic fever

112
Q

What is the only ECG lead truly reciprocal to the inferior wall?

A

aVL

It is thus a sensitive marker for inferior infarction (i.e. reciprocal ST depression seen).

113
Q
A

Yr 4 - ACC (73 decks)

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