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MRCP Part 1 > General Medicine: Cardio > Flashcards

General Medicine: Cardio Flashcards

1
Q

Patient with BP of 145/96, what investigation findings would confirm a diagnosis of HTN?

A

ABPM reading of >=135/85

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2
Q

How do you manage a patient with BP >180/110

A

Start drugs immediately
Same day referral if
- retinal haemorrhage
- Life-threatening symptoms
- Suspected phaeochromocytoma

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3
Q

For HTN who gets the following first line
ACEi/ARB
CCB

A

A: <55yrs, T2DM
C: >55yrs, Black

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4
Q

What do you give after first line treatments for HTN?

A

A+C/D
A+C+D

If black, give ARB over ACEi

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5
Q

After triple therapy, how d you determine what drug to add for HTN?

A

LD spironolactone <= K+ @4.5 < a/B blocker

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6
Q

What are the blood pressure targets (clinic + ABPM) for
<80yrs
>80yrs

A

<80yrs
Clinic <140/90mmHg
ABPM <135/85mmHg
>80yrs
Clinic <150/90mmHg
ABPM < 145/85mmHg

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7
Q

What antihypertensive drug causes
Gout
Cough
High blood glucose
Headaches
Hypotension
Cold peripheries
Postural hypotension

A

Gout, glucose: thiazide
Cough: ACEi
Headache: CCBs
Hypotension: nd-CCBs
Cold peripheries: B-blockers, bronchospasm
Postural hypertension: doxazosin

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8
Q

How is stable angina different from acute coronary syndrome?

A

Chest tightness only present on exertion

Settles within 5 mins of rest

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9
Q

What investigation findings would you see for stable angina

A

cardiac markers and ECG normal

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10
Q

What entails symptom control in stable angina?

A

Mono: Nd-CCB OR B-blocker
Combo: d-CCB + B-blocker
+ GTN to relieve attacks

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11
Q

What drugs can you give for angina if CCBs or BBs not tolerated?

A

Nitrates
Ivabradine
Ranolazine
Nicorandil

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12
Q

How do you reduce chances of cardioembolism in stable angina

A

Aspirin + Statin

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13
Q

What are the risk factors for ACS?

A

2 non-modifiable

Age, Male

3-4 modifiable

Diabetes

Lifestyle (obesity, smoking, alcohol)

Hypertension

Hyperlipidaemia

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14
Q

How does unstable angina differ from other ACS types

A

No cardiac markers, no ECG changes

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15
Q

What ECG changes are seen in an NSTEMI?

A

ST-depression

T wave inversion

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16
Q

Whaat criteria must ST elevation meet for it to be a STEMI?

A

>1mm in 2 limbs

>2mm in a chest

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17
Q

Outline STEMI management

A

Aspirin 300mg

<120 mins: PCI

Give prasurgel (clopidogrel if already anticoagulated)

Stent or revascularise (if mutlivessel disease)

>120 mins: Fibrinolysis

Give ticagrelor + aspirin (aspirin +/- clopidogrel if high bleed risk)

Assess PCI need

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18
Q

Outline initial NSTEMI management for

<=3% mortality

>3% mortality

A

Aspirin 300mg

Fondapirinux (UFH if creat >265)

GRACE <=3% mortality

Ticagrelor + aspirin (aspirin +/-clopidogrel if high bleed risk)

GRACE >3% risk

Angiography: immediate if unstable, <72hrs otherwise

Prasurgel/tigagrelor, + aspirin (UFH during PCI)

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19
Q

What entails secondary prevention in ACS?

A

Risk factor modification

Aspirin 75mg + clopidogrel >= 12 months

Anticoagulate with LMWH until discharge

B-blokcade

80mg atorvostatin

+ ACEIs if LV dysfunction, HT, or DM

+ if echo <40% function: eplernone

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20
Q

What features carry a particularly poor prognosis for an ACS patient?

A

Frank pulmonary oedema (38%)

Features of cardiogenic shock (81%)

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21
Q

Chest pain relieved on sitting forwards and a pericardial rub indiate which condition?

A

Acute pericarditis

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22
Q

What are the ECG changes seen in acute pericarditis?

A

Widespread ST elevation, ‘saddle shaped’

PR depression is quite specific

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23
Q

What are the causes of pericarditis

A

Infections: Viral, TB

Tissue damage: trauma, MI (dressler’s)

Cancer

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24
Q

For pericarditis, what is the

Definitive investigation

Treatment

A

TT echo

NSAIDs + colchicine

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25
Q

How do you treat a tachycardia in a haemodynamically compromised patient?

A

up to 3 synchronised shocks

+/- amiodarone

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26
Q

What control is typically offered first in AF?

A

Rate control

  1. B-blocker (not sotalol) OR nd-CCB (if not in heart failiure) OR digoxin (if sedentary, others CI)
  2. Combo of 2 above
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27
Q

Who gets rhythm control…

Generally

Before rate control

A

Generally if…

Symptoms persist despite rate-control strategy

Before rate if

  • Reversible cause
  • new onset
  • Ablation would help
  • Clinical judgement
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28
Q

How do you manage acutely presenting AF that is

<48hrs

>48hrs

Unstable

A

<48hrs: Electrical* OR Flecainide/amiodarone cardioversion

>48hrs: Electrical cardioversion* +/- 4 weeks amiodarone/sotalol before, continuing for up to 12 months

Unstable: Shock

*Anticoagulate for 4 weeks after electrical cardioversion*

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29
Q

What do you offer if rhythm control of AF is not successful/wanted?

A

Left atrial ablation

4 weeks anticoagulation before

+ 3 months antiarrhythmic treatment after to prevent again

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30
Q

What drugs are used in maintaining rhythm control in AF?

A

B-blockers

Dronendarone: 2nd line if cardioverted

Amiodarone: If co-existing HF

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31
Q

How do you anticoagulate in acute AF?

A

Heparin if new acute AF

DOACs if confirmed, high recurrence risk

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32
Q

How is AF anticoagulated post stroke

A

Aspirin for 2 weeks

Then warfarin/DOAC

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33
Q

How can you distinguish between Fast AF and SVT

A

SVT regular and has p-waves

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34
Q

How do you treat SVTs

A

Valsalva manourvre

Carotid massage

Adenosine: Rapid 6mg bolus –> 12mg more –> 18mg more

(verapamil if adenosine contraindicated)

Cardioversion

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35
Q

How is atrial flutter distinguished from other tachycardias?

How do you treat it?

A

P:QRS complexes 2:1

HR tends to hit 50s (eg 150, 200, 250)

Electrical cardioversion

If fails: Ablate tricuspid valve isthmus

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36
Q

Is this VF or VT?

A

VT

VT: Very Tidy

VF: Very Funny (see pic)

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37
Q

How do you treat ventricular tachycardia?

A

Unstable: Shock

Stable

Amiodarone/lidocaine/procainamide

Get electrophysiology + ICD if fails

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38
Q

What drug is avoided in VT?

A

Verapamil

Dampens normal SA node so promotes aberrant circuit .’. risk of Vfib

39
Q

Slurred QRS, predominant R wave in V1 and Inverted T waves (inferior leads) are features in which condition?

A

Wolff-Parkinson-White syndrome

40
Q

For Wolff-Parkinson-White what drugs do you…

Give

Avoid

A

Give: Amiodarone, flecainide + refer for ablation

Avoid: Digoxin, verapamil and bisoprolol

41
Q

How do you distinguish between the AV blocks

A

1st: Consistent PR >0.2

2 type I: Progressive PR lengthening, dropped beat

2 type II: No progression, 2-3 Ps : QRS

3rd: No association between Ps and QRS

42
Q

How is sinus bradycardia/complete heart block treated?

A

Acute:

ABCDE

Atropine 0.5mg IV every 2-3 mins

Correct precipitants

Chronic

24hr taping + pacemaker

43
Q

What drugs can precipitate bradycardia

A

B-blockers

nd-CCBs

Digoxin

Ivabradine

a-agonists

44
Q

What does this show?

A

Left bundle branch block

WiLLaM

V1: ‘W’/rS

V6: ‘M’/R

45
Q

What does this show?

A

Right bundle branch block

MoRRoW

V1: M (RsR)

V6: W (qRS)

46
Q

What is more worrying LBBB, RBBB

A

LBBB IS ALWAYS PATHOLOGICAL

RBBB can be normal variant but acute resp/cardiac stuff can have it

47
Q

How does a chronic heart failure patient present?

A

Breathlessness: Exertion, lying flat

Coughing: Worse at night, wheezy

Signs: Raised JVP, oedema

48
Q

For suspected heart failure what is the first line investigation and how does this guide further investigation?

A

NT-proBNP

400-2000pgml (47-236pmol/L): Raised

>2000pgml (236pmol/L): High

Raised: 6 week echo

High: Urgent

49
Q

What is the management of chronic heart failure?

A
  1. B-blocker + ACE inihibitor
    • Aldosterone antagonist (spironolactone, eplernone), MONITOR POTASSIUM
50
Q

Failing initial management of chronic heart failure, when would you use

Ivabradine

Sacubitril-valsartan

Digoxin

Hydralazine

A

I: LVEF <35% + sinus >75/min

S: LVEF <35% + symptoms on other therapy

D: Coexistent AF

H: Afro-Carribbean

51
Q

Acute shortness of breath with pink sputum, bibasal creps and 3rd heart sound indicative of what?

A

Acute heart failure

52
Q

What does a firm, smooth, tender liver that can be pulsatile indicate?

A

Right heart failure

53
Q

What investigations should you perform in acute heart failure?

A

BNP to rule it out

CXR cardiothoracic ratio >0.5

Echo to assess ejection fraction

54
Q

What is the management of acute heart failure?

A

POUR SOD

POUR away fluids

Sit up

Oxygen

Diuretics (40mg IV furosemide)

55
Q

Match the features to its cardiomyopathy

Mitral regurgitation, anterior valve motion

Alcohol, B1, reduced output

Scarring procedures

QRS notching in a fatty heart

39 weeks –> 5 months post partum

Stress

A

HOCM

Dilated

Restrictive

ARVD

Peripartum

Takutsubo

56
Q

When do you treat aortic stenosis?

How do you treat it?

A

Symptomatic OR >=40mmHg gradient

Valve replacement if well

Balloon valvuloplasty if unsuitable or children without calcification

57
Q

What is the cause and treatment of rheumatic fever?

A

S.pyogenes

Pen V 10 days

58
Q

What electrolyte imbalance causes

Small T-waves, U waves

PR prolonged

ST depression

A

Hypokalaemia (or magnasaemia)

59
Q

What electrolyte imbalance gives the following ECG changes

Prolonged QT

A

Hypocalcaemia

Twitching, depression, cataracts are all features

60
Q

What electrolyte disturbance shows the following

Broad QRS

Tall Tented T waves

A

Hyperkalaemia

61
Q

What is the treatment for

Hypocalcaemia?

A

IV Ca gluconate

10% 10ml 10 mins

62
Q

What is the treatment for hyperkalaemia?

A

Stabilise: IV Ca gluconate

Shift: insulin/dextrose + salbutamol

Send: Ca resonium/ haemodialysis/diuretics

63
Q

What is the treatment for hypomagnasaemia?

A

<0.4mmol/L: IV MgSO4 over 24hrs

>0.4mmol/L: 10-20ml oral salts

64
Q

Muffled heart sounds, raised JVP and hypotension indicates what cardiac condition?

A

Cardiac tamponade

65
Q

How can you differentiate between constrictive pericarditis and cardiac tamponade?

JVP

Pulsus parodoxus

Kussmaul’s sign

Characteristic features

A

Tamponade // Constrictive pericarditis

X (tampaX) // X + Y

Present // Absent

Rare // Present

Electrical alternans // Pericardial calcification on CXR

66
Q

How do you treat cardiac tamponade

A

Pericardiocentesis

67
Q

Which members of the following drug groups cause QT prolongation?

Antibiotics

Antidepressants

Anti-psychotics

Anti-emetics

Opioid replacement

Anti-arrhythmics

A

Erythromycin

TCAs, SSRIs (citalopram)

Haloperidol

Odansetron

Methadone

Amiodarone, quinidine, sotalol

68
Q

What condition presents with severe dyspnoea, often triggered by exertion?

A

HOCM

Autosomal dominant

69
Q

Outline PE anticoagulation where

Provoked

Unprovoked or cancer

Unstable

A

3 Months DOAC (Heparin then VKA if renal impairment) +/3 further 3 months if bleeding risk allows

6 months DOAC

Thrombolysis

70
Q

How is adenosine administered?

A

16G cannula in right ACF vein or centrally

71
Q

How do you treat aortic dissection if its

Proximal/ascending aorta

Distal/Descending

A

Proximal is type A: ASS

Aortic root replacement

Systolic BP 100-120

Surgery

Type B: BooBs

Bed rest + Beta blockers

72
Q

As distended neck veins and hypotension are common, how do you distinguish between haemothorax and tamponade?

A

Haemothorax has reduced breath sounds on affected side

Due to blood build up

73
Q

How do you treat Mobitz II block?

A

Pacemaker

74
Q

Which cardiac drug reduces hypo awareness?

A

B-blockers

Reduces the physical symptoms (eg shaking)

75
Q

Which cardiac marker is helpful to look for reinfarction 4-10 days from initial insult?

A

CK-MB

Only elevated 3-4 days post event whereas troponin is 10 days, so CK-MB will spike again

76
Q

What pulse changes are seen in aortic dissection?

A

Absent carotid, brachial or femoral pulses

Arm pressure difference >=20mmHg

77
Q

What vaccinations are offered in heart failure

A

Yearly flu

Single pneumococcal

78
Q

How can AR and MS be differentiated by timing and conditions?

A

AR: Early diastolic, rheumatic fever

MS: mid-late diastolic, rheumatic fever

79
Q

How do thiazide and loop diuretics differ in terms of electrolyte imbalances?

A

Thiazides cause hypercalcaemia

Loop cause hypocalcaemia

80
Q

J-waves are seen in what acute condition?

A

Hypothermia

81
Q

How do ACEis affect potassium levels?

A

Increase K+ as they reduce Na+

82
Q

When does tachycardia require DC cardioversion?

A

Shock

MI

Heart failure

83
Q

What do if haem instability and on warfarin?

A

Stop Warfarin

Give vit K

PCC/ FFP if not available

84
Q

How do you manage a warfarin INR >8.0 if…

Minor bleeding

No bleeding

A

Both get

Stop warfarin

Give Vit K*, repeat if still high after 24 hrs

Restart warfarin when <5.0

Minor bleed dose: 1-3mg

No bleed dose: 1-5mg, give IV prep orally

85
Q

How does management of warfarin INR of 5.0-8.0 differ where

Minor

No bleed

A

Minor

Stop warfarin, 1-3mg vit K, restart at 5.0

No bleed

Withhold 1-2 doses

Reduce subsequent maintenance

86
Q

DVT causing stroke in patient with systolic murmur?

A

Atrial septal defect

Allows embolism to bypass lungs to get to brain instead

87
Q

What causes an S2 that is

Loud

Reverse split

Widely split

Fixed split

Soft

A

Hypertension

LBBB/Severe aortic stenosis

RBBB

Atrial septal defect

Aortic stenosis

88
Q

How do tricuspid regurg and mitral stenosis differ?

A

TR is systolic, MS is diastolic

TR louder on inspiration, MS quieter

89
Q

Persitent ST elevation following MI indicates what complication?

A

LV thromboembolism

Blood stagnation in LV causes thombus formation

90
Q

What anticoagulation is used for heart valves?

A

Warfarin

Bioprosthetic: 3 months then aspirin if needed

Mechanical: Warfarin with INR of 3.0 (aortic), 3.5 (mitral)

91
Q

Sudden pan-systolic murmur following MI indicates what?

A

Acute mitral valve regurgitation

Secondary to flash pulmonary oedema

92
Q

How to separate pulomary stenosis and aortic stenosis?

A

Pulmonary louder on inspiration

Aortic louder on expiratory

93
Q

What post-MI complication can present similarly to cardiac tamponade?

A

Left ventricular free wall rupture

94
Q

How can the R-R interval help determine what degree of heart block is present?

A

If the RR is not constant then its likely Mobitz II

Since there is a dropped beat in there somewhere

MRCP Part 1 (32 decks)

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