Imaging and intervention

Question 1

Stress ECHO:

Answer 1

Measures kinesis at rest and under stress
LAD, RCA and the circumflex artery
85% sensitivity, 87% specificity

Question 2

Advantages of PET perfusion vs SPECT:

Answer 2

Higher resolution, contrast and efficiency

Superior diagnosis - shows peak stress LV ejection fraction

Question 3

CMR uses:

Answer 3

Evaluation of LV function
Viability assessment
Accurate detection of ischaemia
Uses adenosine infusion

Question 4

What is CT FFR?

Answer 4

Non-invasive functional imaging with high diagnostic accuracy
Should be considered for patients with stable recent onset chest pain who are offered CTCA
May avoid need for invasive angiography and revasc

Question 5

When do you offer invasive coronary angiography?

Answer 5

As a third line

Offer if results of non-invasive functional imaging are inconclusive

Question 6

Raised ST in aVR (and lower in inf. and lateral leads) suggests what?

Answer 6

Left main stem stenosis (left coronary artery)

Question 7

Typical ST elevation in anterior leads and extending laterally suggests what?

Answer 7

Left distal main stem stenosis (distal left coronary artery)

Question 8

ST elevation with reciprocal depression in lateral leads suggests what?

Answer 8

Right coronary artery occlusion with right ventricular infection leading to raised JVP and cariogenic shock
This artery also travels up the septum to supply the AVN so you can develop complete block

Question 9

When do you perform CABG?

Answer 9

Stable coronary artery disease

NSTEMI where unable to do primary angioplasty

Question 10

When do you perform CABG?

Answer 10

Left internal mammary artery dropped down as conduit to LAD

Arterial/venous section of radial/saphenous used to bypass RCA to the diagonal arteries or left circumflex arteries

Question 11

What is the number 1 risk factor for re-stenosis of stents?

Answer 11

Diabetes due to endothelial dysfunction making the anti-proliferative medication on the surface of the stent is less effective

Question 12

2 main factors that contribute to peripheral vascular disease?

Answer 12

Diabetes and smoking

Question 13

Treatment for claudication?

Answer 13

Bypass
Angioplasty
Thrombolysis

Question 14

Basis for leg bypass surgery?

Answer 14

Bypass from inflow vessel to distal vessel
Inflow vessels: femoral/superficial femoral/popliteal
Distal vessels: popliteal/anterior tibial/peroneal/posterior tibial/dorsalis pedis

Question 15

Congenital cause of aortic stenosis?

Answer 15

Bicuspid valve

Question 16

What is TAVI?

Answer 16

Transcatheter aortic valve

Better than surgery in low risk population

Question 17

What happens to S2?

Answer 17

It splits on inspiration

Question 18

Which conditions precipitates angina?

Answer 18

Cold (pressures go up, increasing stroke work)

Question 19

Left-sided murmurs are…

Answer 19

Loudest on expiration

Question 20

Systolic murmurs:

Answer 20

Aortic stenosis

Mitral regurgitation

Question 21

What is ST elevation?

Answer 21

Not MI

It is the threat of MI

Question 22

What is the 1st manifestation of ischaemia?

Answer 22

Contractile failure

Change in pH occurs faster than the drop in ATP and dictates function

Question 23

What does troponin indicate?

Answer 23

Number of dead myocytes

Question 24

Which way does infarct transfer?

Answer 24

From the endocardium to the epicardium

Question 25

What is one of the causes of cardiomyopathy?

Answer 25

Alcohol

Question 26

3 primary causes of heart failure?

Answer 26

Pressure overload (afterload) - aortic stenosis, hypertension
Volume overload (preload) - aortic/mitral regurgitation
Contractile dysfunction - IHD, myocardial disease, pregnancy, acquired/inherited cardiomyopathies

Question 27

Why is cardiac hypertrophy pathologic?

Answer 27

Fibrous
Capillary rareification
Abnormal myocytes

Question 28

Normal PR and 1st degree block PR:

Answer 28

Normal = 200ms

1st degree block = 400ms

Question 29

Mobitz I:

Answer 29

Increasing PR until dropped QRS

Disease/vagal innervation of AVN

Question 30

Mobitz II:

Answer 30

Fixed PR then dropped QRS

Problem below level of AVN (more serious)

Question 31

What indicates serious disease in 1st and 2nd degree heart block?

Answer 31

Pauses >2.5s

Don’t treat if asymptomatic in general with 1st and 2nd

Question 32

Escape rhythm in 3rd degree block?

Answer 32

Very low down in the conduction system

Broad

Question 33

Where do you pace for a standard pacemaker?

Answer 33

The RV apex

This means RV is paced first and there is a slight delay -causing a LBBB morphology on the ECG

Question 34

Who is pacing not ideal for?

Answer 34

Patient with sinus rhythm

Question 35

RBBB can be…

Answer 35

Non-pathologic in young males

Question 36

Causes of RBBB?

Answer 36

PE, dextracardo, COPD, pulmonary hypertension, cor pulmonale, MI, CHD, inherited arrhythmial syndromes

Question 37

Symptoms of ventricular tachycardia?

Answer 37

Chest pain, palpitations and low BP
Can be tolerated well but may degenerate to VF
Organised activity

Question 38

What is occlusion of a coronary vessel likely to cause?

Answer 38

VF (not VT)

Question 39

VT causes?

Answer 39

Post-MI, ischaemia, cardiomyopathy, congenital defect, drugs/electrolyte imbalances

Question 40

Drugs for prevention of sudden cardiac death:

Answer 40

Anti-platelets
ACE-inhibitors/ARBs
Beta-blockers
Statins
Aldosterone antagonists
Ivabradine

Question 41

Profile of ivabradine:

Answer 41

Inhibits funny inward Na current
Used for treatment of angina with stable rhythm
Used for mild to severe chronic heart failure
Do not use for unstable angina, 2nd/3rd block, acute MI/cerebrovasc accident, HR <70-75