Corrections - Cardiology pt2 Flashcards by Esme Cosham

What are the 2 management options for symptomatic aortic stenosis?

1) Surgical aortic valve replacement –> for low/medium operative risk patients

2) Transcatheter aortic valve replacement –> for high operative risk patients

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management of patients on warfarin who have an INR >8 (who aren’t bleeding)?

Stop warfarin and give oral vitamin K

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2nd line management of symptomatic bradycardia if atropine fails?

Immediate external pacing (transcutaneous)

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When is new onset AF considered for electrical cardioversion?

If presents within 48 hours

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What is coarctation of the aorta?

Congenital abnormality where there is narrowing of the aorta, leading to hypoperfusion of lower body.

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How can coarctaction of aorta affect pulses in legs?

Can present with weakened femoral pulses.

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Why are ACEi contraindicated in hypertrophic obstructive cardiomyopathy (HOCM)?

ACEi reduce afterload which may worsen the LVOT gradient.

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Why is upper limb BP often greater than lower limb BP in coarctation of aorta?

As the narrowing often occurs after the left subclavian artery branches from the aorta

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What murmur is heard in pulmonary stenosis?

Ejection systolic murmur that is louder on inspiration.

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Why is the ejection systolic murmur in pulmonary stenosis louder on inspiration?

This is due to blood flowing through the narrow pulmonary valve throughout systole.

It is affected by inspiration as this increases venous blood return to the right side of the heart.

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Is an ejection systolic murmur characteristic of aortic stenosis louder on inspiration or expiration?

Expiration.

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Management of uncomplicated aortic dissection of the descending aorta?

Medical management with IV labetalol

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At what age do patients with stage 1 HTN not require treatment?

> 80 y/o

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What pulse deficits may be seen in aortic dissection?

1) weak or absent carotid, brachial, or femoral pulse

2) variation in arm BP

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Why is moderate to severe aortic stenosis a contraindication to ACEi?

As the vasodilator effect of ACEi might lead to a reduction in coronary perfusion pressure, leading to cardiac ischaemia.

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What is the site of action of furosemide?

Ascending loop of Henle - inhibits the Na-K-Cl cotransporter.

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What are the ECG changes criteria for PCI or thrombolysis?

1) ST elevation of >2mm (2 small squares) in 2 or more consecutive anterior leads (V1-V6)

2) ST elevation of >1mm (1 small square) in greater than 2 consecutive inferior leads (II, III, aVF, aVL)

3) New LBBB

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Which class of Abx can cause torsades de pointes?

Macrolides

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How can potassium affect QT interval?

Hypokalaemia can cause long QT syndrome

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Management of infective endocarditis causing HF?

Indication for emergency valve replacement surgery

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What is the 2nd line drug treatment for angina pectoris if 1st line drugs (beta blockers or CCBs) are contraindicated or not tolerated?

Nicorandil

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What is a key side effect of nicorandil?

GI tract ulceration

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What is nicorandil?

A vasodilatory drug used to treat angina.

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

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Adverse effects of nicorandil?

1) headache
2) flushing
3) skin, mucosal & eye ulceration (includes GI & anal ulcers)

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Contraindication of nicorandil?

LV failure

What valvular abnormality is most commonly associated with coarctation of the aorta?

Bicuspid aortic valve

What is the JVP increasing with inspiration known as?

Kussmaul's sign

What is the JVP increasing with inspiration a feature of?

Constrictive pericarditis

2nd line therapy in HF with reduced EF?

Add spironolactone and consider SGLT-2 inhibitor (empagliflozin)

What is the most specific ECG finding in pericarditis?

PR depression

In ALS, what should be given to patients who are in VF/pulseless VT after 5 shocks have been administered?

Amiodarone 150mg

What should patients in pulseless electrical activity and asystole immediately receive?

1mg IV adrenaline 1:10,000 (repeat every 3-5 minutes during alternate 2min loops of CPR)

Management of broad complex tachycardia?

Assume that broad-complex tachycardia is VT unless there is a documented history of SVT with BBB. Treat with IV amiodarone.

Management of VF/pulseless VT as soon as identified?

1 shock

Management of widened QRS or arrhythmia in tricyclic overdose?

IV bicarb

Which Abx is a well-recognised cause of cholestasis?

Co-amoxiclav

What are the adverse 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

What are 2 important drug interactions of amiodarone?

1) decreased metabolism of warfarin, therefore increased INR 2) increased digoxin levels

How does amiodarone affect digoxin levels?

Increased digoxin levels

How does amiodarone affect warfarin levels?

decreased metabolism of warfarin, therefore increased INR

What can be added as a second line treatment for rate control in atrial fibrillation?

Digoxin

Give 3 drugs causing lung fibrosis

1) amiodarone 2) bleomycin 3) methotrexate

Does drug-induced fibrosis (amiodarone, bleomycin & methotrexate) cause upper or lower zone lung fibrosis?

Lower zones

Does TB cause upper or lower zone fibrosis?

Upper

What is the most likely cause of an irregular broad complex tachycardia in a stable patient?

AF with BBB

What is the 1st line investigation for stable chest pain of suspected coronary artery disease aetiology?

Contrast CT coronary angiogram

If angina is not controlled with a beta blocker, what is the next step?

Add a longer acting dihydropyridine calcium channel blocker e.g. amlodipine

Which medication used in IHD can patients develop a tolerance to, necessitating a change in dosing regime?

Isosorbide mononitrate

What is the 1st line anti-anginal for stable angina in a patient with known HF?

Bisoprolol (if no contraindications)

Why can patients taking standard release isosorbide mononitrate experience a relief and then return of symptoms?

Due to development of nitrate tolerance (only seen in standard-release, not modified-release)

Management of development of tolerance in isosorbide mononitrate?

Change dosing times (asymmetric dosing regimes)

What is Beck's triad?

Seen in cardiac tamponade: 1) raised JVP (does not change with breathing i.e. negative Kussmaul's sign) 2) muffled heart sounds 3) hypotension

Features of mitral stenosis?

- haemoptysis - SOB - irregularly irregular pulse (can be 2ary to AF) - mid diastolic murmur

What feature may suggest that the leaflets still have some mobility in mitral stenosis?

An opening snap

Management of major bleeding in patients taking warfarin (regardless of INR)? e.g. variceal haemorrhage, intracranial haemorrhage

1) stop warfarin 2) give IV vitamin K 5mg 3) prothrombin complex concentrate (if not available then FFP)

Management of minor bleeding in patients on warfarin whose INR is >8.0?

1) stop warfarin 2) give IV vitamin K 1-3mg 3) repeat dose of vitamin K if INR still too high after 24 hours 4) restart warfarin when INR < 5.0

Management of patients on warfarin whose INR is >8.0 but no bleeding?

1) stop warfarin 2) give vitamin K 1-5mg orally 3) repeat dose of vitamin K if INR still too high after 24 hours 4) restart when INR < 5.0

Management of minor bleeding in patients on warfarin whose INR is 5.0-8.0?

1) Stop warfarin 2) Give intravenous vitamin K 1-3mg 3) Restart when INR < 5.0

Management of patients on warfarin whose INR is 5.0-8.0 but with no bleeding?

1) Withhold 1 or 2 doses of warfarin 2) Reduce subsequent maintenance dose

Stepwise management of HTN for patients aged <55 or type 2 diabetes?

1) ACEi or ARB 2) ACEi/ARB + CCB or ACEi/ARB + thiazide-like diuretic 3) ACEi/ARB + CCB + thiazide-like diuretic 4) Depending on K+, add spironolactone or alpha/beta blocker

Stepwise management of HTN for patients aged ≥55 or Black African or African-Caribbean ethnicity?

1) CCB 2) CCB + ACEi/ARB or CCB + thiazide-like diuretic 3) ACEi/ARB + CCB + thiazide-like diuretic 4) Depending on K+ (>/< 4.5), add spironolactone or alpha/beta blocker

What is Sydenham's chorea a complication of?

Rheumatic fever (following strep infection)

What cardiac defect are alcoholics at risk of?

Dilated cardiomyopathy This would cause a reduction in LV EF, with a dilated LV.

Management of major bleeding for patients on warfarin?

Stop warfarin, give 5mg vit K IV, give prothrombin complex concentrate IV

Management of AF following an acute stroke (not haemorrhagic)?

Long term anticoagulation (DOAC) started 2 weeks after the event. 300mg aspirin during these 2 weeks.

How can acute mitral valve regurgitation post-MI present?

Flash pulmonary oedema. In mitral regurg, regurgitant jets of blood are directed back towards the pulmonary veins, causing fluid congestion in the lungs.

If a patients BP is >180/120 mmHg but there are no worrying signs, what is the first step in management?

Investigations for end-organ damage.

What vaccinations are offered to patients with HF?

Annual influenza & once off pneumococcal

Which patients groups require a pneumococcal revaccination every 5 years?

Asplenia, splenic dysfunction or CKD

What ECG changes are associated with hypothermia?

- bradycardia - prolonged QT interval - 'J waves': a small hump at the end of the QRS complex - 1st degree heart block

What are 'J waves' on an ECG?

A small hump at the end of the QRS complex

How long does troponin remain elevated for post-MI?

10 days

How long does creatine kinase (CK-MB) remain elevated for post-MI?

3-4 days (useful for detecting re-infarction in the window of 4-10 days after initial insult).

What class of medication is bumetanide?

Loop diuretic

How can loop diuretics affect K+?

Can cause hypokalaemia

Which type of diuretic can cause ototoxicity?

Loop diuretics

Haemoptysis can be a symptom of what valve defect?

Mitral stenosis

1st line investigation for stable chest pain of suspected coronary artery disease aetiology?

Contrast-enhanced CT coronary angiogram

What is the most common organism causing infective endocarditis (not <2 months post-valve surgery)?

Staph. aureus

What is the most common organism causing infective endocarditis if <2 months post-valve surgery?

Staph. epidermidis

What are some contraindications to thrombolysis?

- active internal bleeding - recent haemorrhage, trauma or surgery (including dental extraction) - coagulation and bleeding disorders - intracranial neoplasm - stroke <3 months - aortic dissection - recent head injury - severe HTN

Why are intracranial tumours an absolute contraindication to thrombolysis?

Because of their association with spontaneous intracranial haemorrhage.

What should patients on warfarin undergoing emergency surgery receive?

Four-factor prothrombin complex concentrate

What can be offered to patients with HF with reduced EF who are already on ACEi (or ARB) and a beta blocker?

Mineralcorticoid receptor antagonist e.g. spironolactone

What is used 1st line to prevent angina attacks?

Beta blocker or CCB

How can ACEi affect BNP levels?

Can give falsely low BNP results

How do thiazide diuretics affect calcium?

Can cause hypercalcaemia (and hypocalciuria)

How can thiazide diuretics affect sodium?

Can cause hyponatraemia

How is hypertrophic obstructive cardiomyopathy inherited?

Autosomal dominant disorder

What class of drug is digoxin?

Cardiac glycoside

What is the main indication for dignoxin?

1) Rate control in management of AF 2) Sometimes used for improving symptoms (but not mortality) in patients with heart failure - due to positive inotropic properties

Mechanism of digoxin?

1) Decreases conduction through the AV node which slows the ventricular rate in atrial fibrillation and flutter. 2) increases the force of cardiac muscle contraction due to inhibition of the Na+/K+ ATPase pump. Also stimulates vagus nerve

Digoxin has a narrow therapeutic index. Features of digoxin toxicity?

- generally unwell, lethargy - nausea & vomiting - anorexia - confusion - yellow-green vision - gynaecomastia - arrhythmias (e.g. AV block, bradycardia)

How can digoxin toxicity affect vision?

Yellow-green vision

What is the classic precipitating factor for digoxin toxicity?

Hypokalaemia.

How can hypokalaemia precipitate digoxin toxicity?

Digoxin normally binds to the ATPase pump on the same site as potassium. Hypokalaemia → digoxin more easily bind to the ATPase pump → increased inhibitory effects.

What is the most common feature of carbon monoxide poisoning?

Headache (often described as dull, throbbing and frontal).

What investigation should all patients with suspected acute pericarditis have?

Transthoracic echocardiography

Should patients with AF who have had catheter ablation still be anticoagulated?

Yes - as per their CHA2DS2-VASc score

Typical patient group with myocarditis?

Young (<50) with history of recent viral illness, acute history.

Presentation of myocarditis?

- chest pain - dyspnoea - arrhythmias

Troponin in myocarditis?

Raised

ECG changes in myocarditis?

- tachycardia arrhythmias - ST/T wave changes including ST-segment elevation and T wave inversion

What is acute chest syndrome?

A complication of sickle-cell disease and presents with dyspnoea, chest pain, cough, hypoxia and new pulmonary infiltrates seen on CXR.

What is electrical alterans?

Alternating QRS amplitudes in any or all leads on an ECG

What does electrical alterans indicate?

Cardiac tamponade