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RACP Cardio AT > General Cardiology > Flashcards

General Cardiology Flashcards

1
Q

What are the absolute contraindications to EST?

A 
AMI within 2 days 
Ongoing Unstable Angina
Uncontrolled Arrhythmia 
Symptomatic Severe Valvular Stenosis
Decompensated Heart Failure
Active endo/myo/pericarditis 
Aortic Dissection and Acute PE
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2
Q

What are the relative contraindications to EST?

A

Known left main stenosis
Moderate to severe AS with uncertain symptoms
Advanced or complete heart block
Recent Stroke or TIA
Hypertension uncontrolled >200
Uncorrected thyroid disease, anaemia or electrolyte disturbance

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3
Q

What are the limitations of EST?

A
  1. Unable to exercise (severe lung disease, claudication, arthritis, deconditioning)
  2. ECG changes at rest (not including RBBB or ST depression <1mm)
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4
Q

What is the use of the Modified Bruce Protocol?

A

Used in sedentary patients

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5
Q

What are the ECG features that make performing EST difficult?

A 
Ventricular Pre-excitation
Ventricular Paced Rhythm
LBBB
St depression >1mm
Digoxin associated ST Changes
LV hypertrophy changes
Hypokalaemia associated ST changes
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6
Q

What are the absolute indications to stop an EST?

A

Drop in BP by 10 when accompanied by evidence of ischaemia
Moderate to severe angina
Signs of poor perfusion
Patient request
Sustained VT
ST elevation >1mm in leads w/o diagnostic q waves

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7
Q

Recovery protocol after EST if ischaemia is not found and if ischaemia is found?

A

Not Found - recovery in supine position with repeat ECG

Found - recovery in upright position to minimise risk of increasing ischaemia

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8
Q

What is the rate of life threatening complicaionts of EST?

A

1 in 10000

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9
Q

How does the type of ST depression influence interpretation of EST?

A

Horizontal or downsloping ST depression of >1mm is more specific for ischaemia than upsloping depression.

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10
Q

How would you interpret a patients’ EST which shows ST depression confined to inferior leads?

A

Likely false positive.

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11
Q

How would you interpret a patients’ EST which shows upsloping ST depression?

A

Likely not significant given prognosis is no different than those with normal exercise ECG

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12
Q

What is the sensitivity and specificity of >1mm of horizontal or downsloping ST segment depression on EST respectively?

A

60 and 90%

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13
Q

Does ST depression in the lateral leads on EST localise coronary artery lesions?

A

No

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14
Q

What is the sensitivity and specificity of aVR ST segment elevation on EST for coronary lesions respectively?

A

75 and 80 %

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15
Q

Exercise-induced ventricular ectopy is associated with what?

A

Exercise-induced ventricular arrhythmia and increased mortality risk

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16
Q

What is the specificity of anterior ST segment elevation on EST for a coronary lesion?

A

93% LAD

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17
Q

What is the specificity of inferior ST segment elevation on EST for a coronary lesion?

A

86% PDA

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18
Q

What is the significance of transient LBBB on EST?

A

Independent predictor of death and major cardiac events at four years

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19
Q

What is the significance of ST depression after EST during recovery?

A

Same interpretation as depression during exercise

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20
Q

What is the sensitivity and specificity of EST respectively?

A

68 and 77%

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21
Q

What is the sensitivity and specificity of Stress Echo respectively?

A

76 and 88%

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22
Q

What is the sensitivity and specificity of CTCA respectively?

A

90 and 65-90%

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23
Q

In which patient group does EST fit into best?

A

Intermediate probability

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24
Q

What is the preferred cardiac stress test in patients who cannot exercise to satisfactory workload?

A

Pharmacological stress testing with myocardial imaging

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25
Q

What is the preferred cardiac stress test in patients who can exercise and has LBBB or paced ECG?

A

Stress echocardiography or vasodilator stress radionuclide myocardial perfusion imaging

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26
Q

What is the preferred cardiac stress test in patients who can exercise and has abnormal baseline ECG?

A

Stress radionuclide myocardial perfusion imaging or stress echocardiography

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27
Q

What is the sensitivity and specificity of SPECT respectively?

A

88 and 77%

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28
Q

How do you define contrast induced AKI?

A

25% increase in creatinine after 48 hours

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29
Q

What are the interventions that can be used to reduce risk of contrast induced nephropathy?

A
  1. Fluid hydration 12 hours
  2. Sodium bicarbonate bolus 1 hr before
  3. WH nephrotoxics
  4. Statin therapy
  5. Peri-procedural dialysis in CKD 4-5
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30
Q

What are the best ecg leads to use to detect intra-operative ischaemia?

A

V4-5 sensitivity 90-95%

31
Q

What is the sensitivity and specificity of pulsus paradoxus >10 for cardiac tamponade?

A

98% sens

70% spec

32
Q

What are the causes of pulsus paradoxus?

A 
CARDIAC
Cardiac tamponade 
Constructive pericarditis 
RV infarction 
Restrictive Cardiomyopathy 
RESPIRATORY
COPD
asthma 
Large pleural effusion
Tension pneumothorax 
Pulmonary embolism 
OTHER
Obesity
33
Q

What is the spec of rv collapse for cardiac tamponade?

A

90%

34
Q

What are the causes of secondary hypertension?

A 
Renal
- Renal artery stenosis
- Chronic Kidney Disease
Endocrine
- cushings syndrome
- primary hyperaldosteronism 
- Phaeochromocytoma 
- Hypothyroidism 
- Hyperparathyroidism 
Structural
- coarctation of the aorta 
- OSA
Medications
- NSAIDs
- OCP 
- Steroids
- Calcineurin inhibitors
35
Q

What are the indications for revascularisation of unilateral renal artery stenosis?

A 
Short duration of hypertension
Failure of OMT to manage BP
Intolerance to medical therapy 
Recurrent flash APO 
Refractory heart failure
36
Q

What are the indications for revascularisation of bilateral renal artery stenosis?

A 
Short duration of hypertension
Failure of OMT to manage BP
Intolerance to medical therapy 
Recurrent flash APO 
Refractory heart failure 
Unexplained progressive renal insufficiency
37
Q

What is the mortality rate of those with myocardial injury?

A

70% 5 year mortality

38
Q

What is the urine sodium in SIADH?

A

> 40

39
Q

What is the urine osmolality in SIADH?

A

> 100

40
Q

What is the latent period between rheumatic fever and symptomatic mitral stenosis?

A

16 years

41
Q

What is the negative predictive value of reproducible chest wall tenderness for ACS?

A

98%

42
Q

What is the 30 day mortality of patients with unstable angina?

A

1.6%

43
Q

What is the 30 day mortality of patients with NSTEMI?

A

7%

44
Q

What is the difference in 1 year mortality between patients with NSTEMI and STEMI?

A

No difference

45
Q

In which patients with ACS should beta blockers be avoided in the acute setting?

A

Cardiogenic shock
Risk for cardiogenic shock
Coronary vasospasm
Cocaine use

46
Q

If an LDL target is not achieved as secondary prevention (<1.8), what additional agent should be considered?

A

Ezetimibe

47
Q

If an Triglyceride target is not achieved as secondary prevention, what additional agent should be considered?

A

Fenofibrate

Though ACCORD showed no benefit when added to statins in T2DM

48
Q

What are the side effects of ezetimibe?

A

Gastrointestinal intolerance
Hepatitis
Rhabdo

Avoid in liver cirrhosis Child Pugh B and C
Avoid in renal impairment GFR <30

49
Q

What are the adverse events with fenofibrate?

A 
Hepatitis 
Rhabdo
Pancreatitis 
Photosensitivity 
Kidney injury 
Decrease HDL

Avoid in liver disease
Avoid in significant renal disease

50
Q

What is the annual reduction in mortality associated with a decrease in LDL by 1?

A

10%

51
Q

What are the benefits of beta blockers in AMI?

A

Less repeat MI
Less angina
?8-13% mortality benefit in hospital

52
Q

What are the negatives of beta blockers in acute MI?

A

Heart failure

Cardiogenic shock

53
Q

What is the blood supply to the posteromedial papillary muscles?

A

PDA

54
Q

What supply’s the Anteolateral papillary muscle?

A

Diagonals

OM

55
Q

What are the negative prognostic features post cardiac arrest requiring intubation?

A

Clinical - no pupillary response, no corneal reflex, motor response 1/2, status myoclonus <48hours
Laboratory - Neuron specific enolase
Imaging - HBI on brain imaging
Electrophysiology - absent N2O SSEP, EEG

56
Q

Formula for pulmonary vascular resistance?

A

PVR (wood) = (mean PAP - Cap wedge) / pulmonary flow (or CO if no shunt)

57
Q

What is the interpretation of wood units for pulm vascular resistance?

A

Less than 3-5 wood units is normal pulmonary vascular resistance

If more than 5 indicates high PVR and may require lung transplant as well (in appropriate clinical context)

58
Q

What are the features that warrant digibind in the setting of digitalis toxicity?

A

Life threatening arrhythmia
End organ dysfunction
Hyperkalaemia >5.5

59
Q

When is charcoal considered in digitalis overdose?

A

Acute overdose within 2 hours of presentation

Alert patient protecting airway

60
Q

What is sensitivity and specificity of ctca for significant stenosis?

A

Sensitivity 90-95%

Specificity 65-85%

61
Q

What is the evidence supporting rhythm control in AF in the setting of HFPEF?

A

Observational registry data show 7% ARR for all cause death for rhythm control vs rate control.

62
Q

What are the features that identify RA and LA lead reversal?

A

Lead 1 - complete inversion
aVR - positive
Marked right axis deviation

63
Q

What are the features that identify LL and LA lead reversal?

A

Lead 3 - complete inversion

Lead 1 p wave smaller than lead 2

64
Q

What are the features that identify RA and LL lead reversal?

A

Lead 1/2/3 - complete inversion

aVR - positive

65
Q

What are the features that identify RA and RL lead reversal?

A

Lead 2 - very flat

66
Q

What are the features that identify LA and RL lead reversal?

A

Lead 3 - flat

67
Q

What are the features that identify Bilateral arm and leg lead reversal?

A

Lead 1 is flat

68
Q

What are the three risk factors that predict acute heart failure in a patient with takotsubo cardiomyopathy?

A

Age >70
Physical stressor
LVEF <40%

69
Q

What are the major risk factors for poor prognosis with pericarditis?

A
  1. Fever >38
  2. Subacute course
  3. Larger effusion (diastolic >20mm)
  4. Tamponade
  5. No response to NSAIDs in 7 days
70
Q

What are the minor risk factors for poor prognosis with pericarditis?

A
  1. Myopericarditis
  2. Immunosuppression
  3. Trauma
  4. Oral anticoagulant therapy
71
Q

What are the causes of constrictive pericarditis?

A
  1. Idiopathic/viral (50%)
  2. Post Cardiac Surgery (10-40%)
  3. Radiation induced (10-30%)
  4. Connective tissue disease (5%)
  5. Post Infectious (5%)
72
Q

In constrictive pericarditis, does pericardial thickness predict clinical response to pericardiectomy?

A

No

73
Q

What are the three situations where medical therapy is mainstay in the treatment of constrictive pericarditis?

A
  1. TB related constrictive pericarditis (ARR of >70%)
  2. Inflammatory pericarditis related construction (generally resolves with Rx)
  3. Surgery is contraindicated (supportive)
74
Q

What are the features of end stage constrictive pericarditis?

A
  1. Cachexia
  2. Atrial fibrillation
  3. Low cardiac output <1.2 L/m2/min
  4. Cirrhosis
  5. Hypoalbuminaemia

RACP Cardio AT (13 decks)

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