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.
2
Q
What is the preferred stent type for primary PCI?
A
Drug-eluting stents
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.
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).
5
Q
What is the key complication of Kawasaki disease?
How can this be screened for?
A
Coronary artery aneurysm: echocardiogram
6
Q
What is Kawasaki disease?
A
A type of vasculitis which is predominately seen in children.
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
8
Q
How is a diagnosis of Kawasaki disease made?
A
Kawasaki disease is a clinical diagnosis as there is no specific diagnostic test.
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
10
Q
Why is aspirin normally contraindicated in children?
A
Due to the risk of Reye’s syndrome
11
Q
What is Reye’s syndrome?
A
A rare but serious condition that causes swelling in the liver and brain.
12
Q
What class of drug is nicorandil?
A
A potassium channel activator.
13
Q
Indication of Nicorandil?
A
Angina: has a vasodilatory effect on the coronary arteries.
14
Q
Side effect of nicorandil?
A
- headache
- flushing
- anal ulceration
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
16
Q
What investigation is important in post-op ileus?
A
U&Es: Deranged electrolytes can contribute to the development of postoperative ileus.
17
Q
What should an inferior myocardial infarction and aortic regurgitation murmur raise suspicion of?
A
Aortic dissection
18
Q
Why is an ECG required prior to prescribing antipsychotics?
A
Can cause QT prolongation
19
Q
What is the most common cause of mitral stenosis?
A
Rheumatic fever
20
Q
What is rheumatic fever caused by?
A
group A Streptococcus species (GAS)
21
Q
Where is the mitral valve located?
A
Between LA and LV
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
23
Q
What is first line radiological investigation for suspected stroke?
A
Non-contrast CT head scan
24
Q
In ACS where morphine is not indicated (i.e. pain not severe enough), what can be given instead?
A
Paracetamol.
25
Why are NSAIDs not given in the management of ACS?
This is because they will be given an array of antiplatelet drugs, which can interact with NSAIDs to precipitate bleeding (e.g. aspirin, ticagrelor).
26
what is adenosine most cimmonly used to treat?
Supraventricular tachycardias.
27
What are the effects of adenosine:
a) blocked by
b) enchanced by?
a) theophyllines
b) dipyridamole (antiplatelet agent)
28
Who should adenosine be avoided in?
Asthmatics due to possible bronchospasm
29
Mechanism of action of adenosine?
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.
30
Half life of adenosine?
Adenosine has a very short half-life of about 8-10 seconds --> should ideally be infused via a large-calibre cannula.
31
Adverse effects of adenosine?
1) chest pain
2) bronchospasm
3) transient flushing
4) can enhance conduction down accessory pathways, resulting in increased ventricular rate (e.g. WPW syndrome)
32
Should a single episode of paroxysmal atrial fibrillation, even if provoked, prompt consideration of anticoagulation?
Yes
33
What is the threshold for transfusion of RBCs in patients:
1) with ACS
2) without ACS
1) 80 g/L
2) 70 g/L
34
What causes crepitus over the chest wall in Boerhaave's syndrome?
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.
35
How does a posterior MI typically present on an ECG?
- Tall R waves in V1-3
- ST depression
36
What are poor prognostic factors in ACS?
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
37
What is the Killip class system?
Used to stratify risk post myocardial infarction:
I - No clinical signs heart failure
II - Lung crackles, S3
III - Frank pulmonary oedema
IV - Cardiogenic shock
38
RBBB is most likely to be caused by occlusion of which artery?
LAD
39
What is Wellen's syndrome?
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
40
What is the reversal agent for dabigatran?
Idarucizumab
41
What is the reversal agent for rivaroxaban or apixaban?
Andexanet alfa
42
What is the reversal agent for heparin or LMWH?
Protamine sulphate
43
Give the reversal agent for the following drugs:
1) dabigatran
2) rivaroxaban
3) apixaban
4) heparin
5) warfarin
1) idarucizumab
2) Andexanet alfa
3) Andexanet alf
4) Protamine sulphate
5) vit K
44
What is Andexanet alfa?
a recombinant form of factor Xa
45
What murmur does aortic regurg typically cause?
Early diastolic
46
What is aortic regurg?
The leaking of the aortic valve of the heart that causes blood to flow in the reverse direction during ventricular diastole.
47
Wht are the 2 groups of causes of aortic regurg?
1) disease of the aortic valve
2) distortion or dilation of the aortic root and ascending aorta
These can be acute or chronic.
48
Causes of aortic regurg due to valve disease?
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
Causes of aortic regurg due to aortic root disease?
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
Features of aortic regurg?
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
What is the handgrip manoeuvre?
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
What manouevre can make aortic regurg murmurs easier to hear?
Handgrip manouevre
53
What is a useful investigation in clinically unstable patients with a suspected aortic dissection?
A transoesophageal echocardiography.
This investigation is portable and safe to use in unstable patients.
54
ECG findings in hypokalaemia?
1) T wave inversion
2) Prominent U waves
3) Prolonged PR interval
4) ST depression
55
What murmur is heard in anaemia?
Soft ejection systolic murmur that doesn't radiate (aortic flow murmur).
56
What class of drug is amiodarone?
Class III antiarrhythmic
57
Indication of amiodarone?
Atrial, nodal & ventricular tachycardias.
58
Main mechanism of amiodarone?
The main mechanism of action is by blocking potassium channels which inhibits repolarisation and hence prolongs the action potentia
59
What are the main limitations of the use of amiodarone?
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
What is thrombophlebitis?
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
How can thrombophlebitis be reduced when giving amiodarone?
Give via central line
62
Side effects of amiodarone?
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
What is torsades de pointes?
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
What is the most common cause of torsades de pointes?
Medications e.g. tricyclic antidepressants, erythromycin, antipsychotics etc.
65
What is the management of torsades de pointes?
IV magnesium sulphate (regardless of the cause)
66
Causes of a long QT interval?
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
1st line management of bradycardia in a peri-arrest situation e.g. complete heart block?
Atropine (500mcg IV)
68
What are risk factors for asystole?
1) complete heart block with broad complex QRS
2) recent asystole
3) Mobitz type II AV block
4) ventricular pause > 3 seconds
69
When is adenosine indicated?
Indicated in the ALS algorithm management of stable, narrow complex tachycardias.
70
When is amiodarone indicated?
Amiodarone is indicated for use in the management of ventricular fibrillation/ventricular tachycardia arrests or for stable tachycardia as per the ALS algorithm.
71
2ary prevention following an MI?
1) aspirin
2) 2nd antiplatelet e.g. ticagrelor, clopidogrel
3) statin
4) ACEi
5) beta blocker
72
What is the most common cause of 2ary HTN?
Primary hyperaldosteronism
73
What is the triad of features seen in cardiac tamponade?
Beck's triad:
1) hypotension
2) raised JVP
3) muffled heart sounds
74
Is antibiotic prohylaxis to prevent infective endocarditis routinely recommended in the UK for dental and other procedures?
No
75
What type of BBB can a PE cause?
RBBB
76
What murmur is heard in aortic regurg?
Early diastolic murmur
77
What murmur is heard in mitral regurg?
A pansystolic murmur
78
What heart defect is a continuous 'machinery' murmur associated with ?
Patent ductus arteriosus
79
1st line management of acute pulmonary oedema?
position patient upright and commence IV loop diuretic (furosemide)
80
What makes up the CHA2DS2-VASc score?
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
What medication should be given in all types of aortic dissection?
IV labetalol (to manage HTN effectively and enhance prognosis)
82
Management of type A aortic dissection?
IV labetalol + surgery
83
Which class of medication can lead to unawareness of hypoglycemic events?
Beta blockers (as can theoretically suppress all of the adrenergically mediated symptoms of hypoglycemia).
84
Stepwise management of severe bradycardia?
1) Atropine (up to 3mg)
2) Transcutaneous pacing
3) Isoprenaline/adrenaline infusion titrated to response
4) Transvenous pacing
85
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?
1) Shock: hypotension (systolic <90 mmHg), pallor, sweating, cold, clammy extremities, confusion or impaired consciousness
2) Syncope
3) Myocardial ischaemia
4) Severe HF
86
If any life threatening features are present in tachycardia, what is immediate management?
Synchronised DC shock, up to 3 attempts
87
Stepwise acute management of HF?
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
What is the major side effect /contraindication of nitrates in acute HF?
Hypotension
89
When may nitrates be indicated in acute HF?
They may have a role if concomitant myocardial ischaemia, severe hypertension or regurgitant aortic or mitral valve disease.
90
1st line Abx in native valve infective endocarditis?
IV amoxicillin
91
What are the 2 main contraindications to statin therapy?
1) macrolides (e.g. erythromycin, clarithromycin) --> statins should be stopped until patients complete the course
2) pregnancy
92
Are statins safe in pregnancy?
NO
93
What class of drug is indapamide?
Thiazide like diuretic
94
Management of a massive PE + hypotension?
Thombolysis e.g. alteplase
95
What are some acquired causes of a long QT syndrome?
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
Can hyper or hyokalaemia cause a long QT interval?
Hypokalaemia
97
What is isosorbide mononitrate?
A long acting nitrate
98
What drug is contraindicated in VT?
Verapamil
99
Why is verapamil contraindicated in VT?
IV administration of a calcium channel blocker can precipitate cardiac arrest.
100
Management of AF post-stroke?
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
Management of AF post-stroke?
1) Exclude a haemorrhage before starting any anticoagulation or antiplatelet therapy
2) Anticoagulation for AF should start immediately once imaging has excluded haemorrhage
102
What is next step in suspected PE with a Wells PE score ≤4?
D-dimer
103
What is next step in suspected PE with a Wells PE score >4?
CTPA
104
How does a left ventricular aneurysm post-MI typicallyu present?
- persistent ST elevation
- LV failure
- thrombus may form within aneurysm (anticoagulate these patients)
105
What should be given to patients who are in VF/pulseless VT after 3 shocks have been administered?
IV amiodarone 300mg & IV adrenaline 1mg
106
General stepwise management of angina?
1) aspirin & statin --> all patients
2) GTN spray
3) beta blocker and/or CCB
107
Which bacteria is commonly associated with infective endocarditis amongst IVDU?
Staph. aureus
108
Diastolic murmur + AF → ?
Mitral stenosis
109
Describe murmur heard in mitral stenosis
mid-diastolic and it is heard over the fifth intercostal space, on the midclavicular line.
110
How can mitral stenosis result in AF?
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
What is mitral stenosis most commonly caused by?
Rheumatic fever
112
What is the only ECG lead truly reciprocal to the inferior wall?
aVL
It is thus a sensitive marker for inferior infarction (i.e. reciprocal ST depression seen).
113
