MED: Cardiology Flashcards

Question

What are the causes of acute pericarditis?

Answer 1

- viral infections (Coxsackie) - tuberculosis - uraemia - post-myocardial infarction - early (1-3 days): fibrinous pericarditis - late (weeks to months): autoimmune pericarditis (Dressler's syndrome) - radiotherapy - connective tissue disease - systemic lupus erythematosus - rheumatoid arthritis - hypothyroidism - malignancy (lung cancer, breast cancer) - trauma

Answer 2

**Retrosternal chest pain:** (85-90%) - Usually sharp and pleuritic in nature - Improved by sitting up and leaning forward - Radiation to the trapezius ridge is considered to be specific for pericarditis **Pericardial friction rub:** (≤33%) - Superficial, scratchy or squeaky quality on auscultation, best heard using the diaphragm of the stethoscope - Usually best heard at the left lower sternal border - Can be differentiated from pleural rub by asking patient to hold their breath - Highly specific for pericarditis but has a low sensitivity *Patients may exhibit other clinical features that suggest an infectious aetiology:* - Low-grade fever - Prodromal myalgia and malaise

Answer 3

*Bedside tests:* **ECG** - Widespread concave ST-elevations with PR-segment depression - PR-segment depression is 85% specific for acute pericarditis, but not sensitive - T-wave changes may last for weeks after resolution of symptoms but are of no clinical significance *Bloods:* - C-reactive protein, ESR, FBC - can also be used to monitor progress - Serum troponins - Urea - elevation suggests uraemic aetiology of the pericarditis *Imaging:* **Echo** - Mild pericardial effusion seen in 60% of patients **Chest X-ray** - Often normal unless there is a large pericardial effusion or lung pathology that can be visualised, such as lung malignancy - New or unexplained cardiomegaly may also suggest acute pericarditis *Further imaging (CT and MRI) considered in unclear diagnostic cases to better visualise pericardial inflammation. MRI may also be used to confirm myocardial involvement* *Pericardiocentesis only indicated when suspicion of bacterial or neoplastic aetiology. It may also be done as a therapeutic intervention for a large pericardial effusion.* *Other investigations can be considered if a specific cause is suspected, but are not routine* - Blood cultures if fever >38ºC, signs of sepsis or concomitant bacterial infection elsewhere - HIV serology - Interferon-gamma release assay or tuberculin skin test

Answer 4

*Majority of patients can be managed as outpatients* // Patients who have high-risk features such as fever >38°C or elevated troponin should be managed as an inpatient - Treat any underlying cause (most patients have pericarditis secondary to viral infection, meaning no specific treatment is indicated) - Strenuous physical activity should be avoided until symptom resolution and normalisation of inflammatory markers - Combination of NSAIDs and colchicine first-line for patients with acute idiopathic or viral pericarditis until symptom resolution and normalisation of inflammatory markers (usually 1-2 weeks) followed by tapering of dose recommended over

Answer 5

**Recurrent pericarditis (15-30%):** - Recurrence after a symptom-free interval of 4-6 weeks - Recurrence rate increased to 50% in patients not treated with colchicine **Acute cardiac tamponade:** - More common in patients with underlying malignancy, TB or purulent pericarditis - Treated by pericardiocentesis **Chronic constrictive pericarditis:** - More common in patients with TB or purulent pericarditis or immune-mediated and neoplastic aetiologies - Treated by surgical pericardial resection

Answer 6

1. Constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms 2. Precipitated by physical exertion 3. Relieved by rest or GTN in about 5 minutes *Interpretation:* - Patients with all 3 features have typical angina - Patients with 2 of the above features have atypical angina - Patients with 1 or none of the above features have non-anginal chest pain

Answer 7

1st line: CT coronary angiography 2nd line: Non-invasive functional imaging (looking for reversible myocardial ischaemia) 3rd line: Invasive coronary angiography *Examples of non-invasive functional imaging:* - Myocardial perfusion scintigraphy with single photon emission computed tomography (MPS with SPECT) or - Stress echocardiography or - First-pass contrast-enhanced magnetic resonance (MR) perfusion or - MR imaging for stress-induced wall motion abnormalities

Answer 8

- All patients should receive aspirin and a statin - Sublingual GTN to abort angina attacks - Beta-blocker or a CCB first-line for prevention - If CCB monotherapy = rate-limiting one e.g. verapamil or diltiazem - If CCB combination with beta-blocker = long-acting CCB (e.g. amlodipine, modified-release nifedipine). - Beta-blockers should not be prescribed with verapamil (risk of complete heart block) - Second line = medication increased to maximum tolerated dose (e.g. for atenolol 100mg od) - Third line = combination therapy (beta-blocker and CCB) - If a patient is on monotherapy and cannot tolerate the addition of a CCB or a beta-blocker then consider one of the following drugs: a long-acting nitrate, ivabradine, nicorandil or ranolazine

Answer 9

Many patients who take nitrates develop tolerance and experience reduced efficacy - The BNF advises that patients who develop tolerance should take the second dose of isosorbide mononitrate after 8 hours, rather than after 12 hours. This allows blood-nitrate levels to fall for 4 hours and maintains effectiveness - This effect is not seen in patients who take modified-release isosorbide mononitrate

Answer 10

Aortic dissection is a severe, life-threatening condition characterized by the separation of the aortic wall layers, resulting in the formation of a false lumen.

Answer 11

- hypertension: the most important risk factor - trauma - bicuspid aortic valve - collagens: Marfan's syndrome, Ehlers-Danlos syndrome - Turner's and Noonan's syndrome - pregnancy - syphilis

Answer 12

**Stanford classification:** - type A - ascending aorta, 2/3 of cases - type B - descending aorta, distal to left subclavian origin, 1/3 of cases **DeBakey classification:** - type I - originates in ascending aorta, propagates to at least the aortic arch and possibly beyond it distally - type II - originates in and is confined to the ascending aorta - type III - originates in descending aorta, rarely extends proximally but will extend distally

Answer 13

- chest pain: typically severe, radiates through to the back and 'tearing' in nature - aortic regurgitation - hypertension - other features may result from the involvement of specific arteries. For example coronary arteries → angina, spinal arteries → paraplegia, distal aorta → limb ischaemia

Answer 14

**Chest x-ray:** - widened mediastinum **CT angiography of the chest, abdomen and pelvis is the investigation of choice** - suitable for stable patients and for planning surgery - a false lumen is a key finding in diagnosing aortic dissection **Transoesophageal echocardiography (TOE):** - more suitable for unstable patients who are too risky to take to CT scanner

Answer 15

**Type A:** - surgical management, but blood pressure should be controlled to a target systolic of 100-120 mmHg whilst awaiting intervention **Type B:** - conservative management - bed rest - reduce blood pressure IV labetalol to prevent progression

Answer 16

**Congenital valvular AS:** - In children, unicuspid aortic valve is the most common cause of symptomatic AS (William syndrome is a RF for supravalvular AS) - In adults, bicuspid aortic valve can lead to AS in people at an earlier age than those who acquire AS The valve is at an increased risk of calcification and degeneration **Acquired valvular AS:** - Initially thought to be a 'wear-and-tear' process due to aging, data now suggests that atherosclerosis plays a role in causing the aortic valve to have endothelial dysfunction and then progress to calcification. - In those aged over 65 years, the frequency of AS is 4-5% - RFs include hypertension, diabetes mellitus, hypercholesterolaemia, smoking (similar to atherosclerosis) - Aortic sclerosis: thickening and calcification of the orifice without a pressure gradient - Progresses to AS at a rate of 1.8-1.9% per year - Rheumatic heart disease can cause fibrosis of the valve leaflets leading to commissural fusion.

Answer 17

>May be asymptomatic for a prolonged period of 10-20 years **Common symptoms:** - Exertional dyspnoea - May have reduced exercise tolerance and fatigability - Exertional angina - Exertional syncope or presyncope **They may have heart failure (HF) with end-stage disease due to left ventricular outflow obstruction:** - This may present with paroxysmal nocturnal dyspnea, orthopnoea, dyspnea on exertion, bilateral lower limb oedema and/or pulmonary oedema. **Also:** - AF also common in patients with HF from AS - Moreover, patients may present with gastrointestinal bleeding due to angiodysplasia (Heyde's syndrome)

Answer 18

**Loud mid-to-late peaking systolic ejection murmur** - Early peaking is more consistent with mild or moderate AS and late peaking is consistent with severe AS - Murmur radiates to the carotids and becomes more prominent with sitting forward and in expiration - Murmur becomes softer the more severe the stenosis - May also radiate to the apex and have a musical quality (gallavardin phenomenon); not to be confused with mitral regurgitation **With severe AS they may also have:** - Slow-rising and low volume carotid pulse (pulsus parvus et tardus) (May not be present in elderly due to stiff vascular vessels) - Soft or absent second heart sound (S2) - Narrow pulse pressure - Reverse splitting of S2 - Heaving apex beat or systolic thrill - Signs of heart failure - pitting lower limb oedema, bilateral basal crackles - S4

Answer 19

*Initial work-up:* **ECG:** may show arrhythmias or signs of left ventricular (LV) strain - LV hypertrophy is present in about 80% of severe AS patients - Atrial fibrillation or coronary artery disease (CAD) can also be detected **Chest X-ray:** **Transthoracic echocardiogram (TTE):** the diagnosis of AS is established by TTE. - It helps to calculate the trans-valvular velocity, mean pressure gradient, and aortic valve area which helps determine the extent of the stenosis. - It also helps asses left ventricular function, flow status, and wall thickness. *Additional tests for prognostic information:* - Exercise stress testing (EST): useful to unmask symptoms in physically active patients if they are asymptomatic or have non-specific symptoms with severe AS - Dobutamine stress echocardiogram: useful for patients who have low-gradient AS - Patients may be symptomatic but have seemingly low pressures due to a low ejection fraction - Gradient will increase > 40 mmHg after administration of low dose dobutamine - B-type natriuretic peptide (BNP): assess for heart failure, predict the timing of intervention for asymptomatic patients and symptom-free survival in severe AS - Multi-slice computed tomography (MSCT): extent of calcification to determine calcium score for severity of AS and may be used to detect CAD in patients who are not eligible for EST - Cardiac magnetic resonance: quantify myocardial fibrosis - Cardiac catheterization: for a definitive diagnosis if noninvasive testing is non-diagnostic however it is not routinely done.

Answer 20

**Coronary angiogram:** - To identify co-existing CAD and conduct concomitant coronary revascularization if possible - Pertinent in patients who have cardiovascular risk factors, prior cardiovascular disease, suspected myocardial ischemia, left ventricular dysfunction, are men > 40 years or post-menopausal women **Trans-oesophageal echocardiogram (TOE):** to assess for endocarditis and mitral valve abnormalities as well as monitoring the TAVI procedure **MSCT:** assess the anatomy and dimensions of the aortic root, shape of the aortic valve annulus and the number of aortic valve cusps

Answer 21

**Indication for surgical treatment:** - Symptomatic - Severe AS: classified as aortic jet velocity ≥4 m/s, mean trans-valvular pressure gradient ≥ 40 mmHg, and aortic valve area ≤1 cm2 - Surgery should be performed promptly after symptom onset. If symptoms are not elicited by history, they should undergo exercise stress testing (~30% of patients will become symptomatic) - Also indicated if asymptomatic but have the following - left ventricular ejection fraction (LVEF) <50%, undergoing other cardiac surgery, a low surgical risk with risk factors or low exercise tolerance **Choice between TAVI and SAVR:** Made by weighing individual patient factors against the risks of providing each modality. - Risk stratification may be carried out using scoring systems like euroSCORE, society of thoracic surgeons (STS), etc. For example, if the euroSCORE/STS score is <4% and patients have co-morbidities, SAVR is preferred. - According to NICE guidelines, sutureless aortic valve replacement (SUAVR) is an effective alternative treatment to SAVR or TAVI as it may be a quicker procedure and allows for both coronary arteries and valve to be treated concurrently. Percutaneous balloon valvotomy is used as a palliative measure for patients that may not be suitable for cardiac surgery or are critically ill. It is also used in children and young adults with congenital AS. **Conservative management is indicated for patients with mild AS who are asymptomatic and have no risk factors** - This may include treating heart failure, maintaining sinus rhythm, and controlling hypertension with regular follow-up. - Serial testing should be done every 6 months for asymptomatic severe AS and yearly for mild-to-moderate AS. - Surgery may be considered if predictive factors of adverse outcomes and symptom development such as elevated BNP, older age, cardiovascular risk factors and extremely abnormal echocardiographic parameters are present.

Answer 22

- Hypertension - Ischaemic Heart Disease - Heart Failure, including due to valvular disease - Cardiomyopathy - Cardiothoracic surgery - Diabetes Mellitus - Obesity - Pneumonia - Smoking - Obstructive Sleep Apnoea - Thyrotoxicosis - Caffeine - Alcohol excess - Chronic kidney disease - Increasing age - Male

Answer 23

Acute (<48 hours) Paroxysmal (self-limiting, <7 days, recurs) Persistent (>7 days, may recur even after cardioversion)

Answer 24

**Asymptomatic** **Non-life threatening:** - Palpitations - Fatigue **Complications:** - Ischaemic stroke - Mesenteric ischaemia - Acute limb ischaemia **Haemodynamic instability:** - Acute heart failure - SOB (pulmonary oedema), raised JVP - Cardiogenic shock - tachycardia >150, hypotension <90, syncope or pre-syncope / dizziness - Cardiac chest pain, including MI - most common in patients with some level of pre-existing coronary heart disease

Answer 25

**Assessment of the radial pulse:** - irregularly irregular - must be followed up with an immediate ECG to confirm the diagnosis **ECG monitoring:** - irregularly irregular QRS complexes with a fibrillating baseline devoid of p-waves **Long term electrical recordings e.g. 24 hour ECGs / event recorders:** - can be used to confirm AF in patients who remain without a diagnosis following normal ECG recordings - most commonly in patients with paroxysmal AF who receive ECG recordings between episodes **To investigate underlying cause:** - Bloods - FBC, U&Es, LFTs, TFTs, Ca and Mg, Blood glucose (finger prick and blood) - Transthoracic echo - CXR

Answer 26

3w before and 4w after OR lifelong (if CHA2DS2VASc high or if paroxysmal AF)

Answer 27

Score: 0 = no need for longterm anticoagulation 1 = anticoagulate if male, do not anticoagulate if female 2 or more: anticoagulate

Answer 28

Peripheral oedema

Answer 29

1st line: beta blocker or CCB (verapamil is better than dilitiazem) 2nd line: combination therapy with any 2 of the following: betablocker diltiazem digoxin

Answer 30

R wave If synchronised with T wave it can cause VT

Answer 31

- DC Cardioversion - use of electrical stimulation to restore sinus rhythm - Chemical cardioversion - Amiodarone (suitable in most patients), flecainide (contraindicated in structural or ischaemic heart disease)

Answer 32

Radiofrequency ablation of AV node Maze procedure

Answer 33

- Patients should be heparinised - Cardioverted with electrical or chemical - Further anticoagulation is unnecessary

Answer 34

- Anticoagulation should be given for at least 3 weeks prior to cardioversion - An alternative strategy is to perform a TOE to exclude a left atrial appendage (LAA) thrombus. If excluded patients may be heparinised and cardioverted immediately. - NICE recommend electrical cardioversion in this scenario - Following electrical cardioversion, patients should be anticoagulated for at least 4 weeks.

Answer 35

CHF HTN Age >75 DM Stroke Vascular disease Age 65-74 Sex Category (female)

Answer 36

**First line = DOACs:** - Oral anticoagulants including Rivaroxaban, Apixaban and Dabigatran **Second line = Warfarin:** - INR of 2-3 for most patients without valve disease - Prescribed with LMWH until its anticoagulant effect is established, as it is initially prothrombotic

Answer 37

AF <48 hours duration and HAEMODYNAMICALLY UNSTABLE can be cardioverted electrically Difficult to establish onset of AF as patient may not have palpitations, or may be unsure as to when they started

Answer 38

3w before and 4w after OR lifelong (if CHA2DS2VASc high or if paroxysmal AF)

Answer 39

A supraventricular tachyarrhythmia characterized by rapid and regular atrial depolarizations typically occurring at a rate of 250-350 beats per minute

Answer 40

- Sx associated with haemodynamic compromise such as dyspnea, fatigue, lightheadedness, presyncope or syncope - Palpitations - abrupt onset and termination of palpitations along with an awareness of rapid or irregular heartbeats - Chest pain - Worsening heart failure symptoms such as orthopnea, paroxysmal nocturnal dyspnea, and peripheral oedema - Individuals are at risk for systemic embolization manifesting as TIAs or cerebrovascular accidents **On examination** - Irregularly irregular pulse - Auscultation of the heart may reveal a “saw-tooth” pattern in the jugular venous waveform and varying intensity of the first heart sound (S1). - Additionally, signs of congestive heart failure such as pulmonary rales or peripheral oedema may be present.

Answer 41

Cardiac tamponade is characterized by the accumulation of pericardial fluid under pressure

Answer 42

**Classical features - Beck's triad:** - Hypotension - Raised JVP - Muffled heart sounds *Other features:* - Dyspnoea - Tachycardia - An absent Y descent on the JVP - this is due to the limited right ventricular filling - Pulsus paradoxus - an abnormally large drop in BP during inspiration - Kussmaul's sign - much debate about this - ECG: electrical alternans

Answer 43

**NYHA Class I:** - No symptoms - No limitation **NYHA Class II:** - Mild symptoms - Slight limitation of physical activity: comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea **NYHA Class III:** - Moderate symptoms - Marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms **NYHA Class IV:** - Severe symptoms - Unable to carry out any physical activity without discomfort: symptoms of heart failure are present even at rest with increased discomfort with any physical activity

Answer 44

- dyspnoea - cough: may be worse at night and associated with pink/frothy sputum - orthopnoea - paroxysmal nocturnal dyspnoea - wheeze ('cardiac wheeze') - weight loss ('cardiac cachexia'): occurs in up to 15% of patients. Remember this may be hidden by weight gained secondary to oedema - bibasal crackles on examination - ankle oedema

Answer 45

>>All patients should have an NT‑proBNP blood test first-line. - If levels are 'high' (>2000) arrange specialist assessment (including transthoracic echocardiography) within 2 weeks - If levels are 'raised' (400-2000) arrange specialist assessment (including transthoracic echocardiography) echocardiogram within 6 weeks

Answer 46

*First-line = BB and ACE-I** - Generally, one drug should be started at a time - No effect on mortality in heart failure with preserved EF **Second-line = Aldosterone antagonist** - E.g. spironolactone and eplerenone **SGLT-2 inhibitors:** - HF with reduced EF - add-on to optimised standard care **Third line:** - Ivabradine - criteria = sinus rhythm >75/min and a left ventricular fraction <35% - Sacubitril-valsartan - criteria = left ventricular fraction < 35%, initiated following ACEi or ARB wash-out period - Hydralazine in combination with nitrate - particularly indicated in Afro-Caribbean patients - Digoxin - strongly indicated if there is coexistent AF - Cardiac resynchronisation therapy - indications = widened QRS (e.g. LBBB) complex **Also:** - Diuretics should be given for fluid overload - Offer annual influenza vaccine - Offer one-off pneumococcal vaccine

Answer 47

Potassium (as is a potassium-sparing diuretic)

Answer 48

Thiozolidinediones (type 2 diabetes) Verapamil (as is negative inotrope) NSAIDs (can cause fluid retention) Glucocorticoids (can cause fluid retention) Flecainide (negative inotrope, arrhythmogenic)

Answer 49

- Male, over 60 - Immobilisation: hospitalisation, bedbound, long haul flights - Inflammatory state: vasculitis, sepsis - Malignancy - patients who have an unprovoked DVT need a thorough history and examination to screen for malignancy - Medication: chemotherapy, hormone replacement therapy/oral contraceptive pill - Obesity - Pregnancy - Previous venous thromboembolism (may indicate underlying thrombophilia) - Recent surgery or trauma - Smoking - Varicose veins

Answer 50

Clinical probability simplified score: DVT likely: 2 points or more DVT unlikely: 1 point or less

Answer 51

**DVT 'likely' (2 points or more):** - Proximal leg vein ultrasound scan within 4 hours - Positive = DVT > start anticoagulant treatment - Negative > D-dimer test - Negative scan and negative D-dimer = diagnosis unlikely > alternative diagnoses should be considered - If proximal leg vein ultrasound scan cannot be carried out within 4 hours > D-dimer test and interim therapeutic anticoagulation administered whilst waiting for the proximal leg vein ultrasound scan (which should be performed within 24 hours) - Interim therapeutic anticoagulation = DOAC such as apixaban or rivaroxaban - If scan is negative but D-dimer is positive = stop interim therapeutic anticoagulation and offer repeat proximal leg vein ultrasound scan 6 to 8 days later **DVT 'unlikely' (1 point or less):** - D-dimer test within 4 hours - If not, interim therapeutic anticoagulation given until result available - Negative = DVT unlikely and alternative diagnoses should be considered - Positive = proximal leg vein ultrasound scan within 4 hours - If scan cannot be carried out within 4 hours interim therapeutic anticoagulation should be administered whilst waiting (which should be performed within 24 hours)

Answer 52

- DOAC - apixaban or rivaroxaban should be offered first-line following the diagnosis of a DVT - If neither apixaban or rivaroxaban are suitable then either LMWH followed by dabigatran or edoxaban OR LMWH followed by a vitamin K antagonist (VKA, i.e. warfarin) - If the patient has active cancer use a DOAC, unless contraindicated - If renal impairment is severe (e.g. < 15/min) then LMWH, unfractionated heparin or LMWH followed by a VKA - If the patient has antiphospholipid syndrome (specifically 'triple positive' in the guidance) then LMWH followed by a VKA should be used

Answer 53

ALL patients should have anticoagulation for at least 3 months - A provoked VTE // due to an obvious precipitating event e.g. immobilisation following major surgery = 3m (3 to 6 months for people with active cancer) - An unprovoked VTE occurs = 6m

Answer 54

*Venous outflow obstruction and venous insufficiency result in chronic venous hypertension. The resulting clinical syndrome is known as post-thrombotic syndrome* - painful, heavy calves - pruritus - swelling - varicose veins - venous ulceration Management = Compression stockings + leg elevation

Answer 55

**Primary / Essential:** - Age, family history, obesity, high salt intake, sedentary lifestyle, and alcohol consumption **Secondary:** - RENAL - Glomerulonephritis, chronic pyelonephritis, adult PKD, renal artery stenosis - ENDO - Primary hyperaldosteronism, phaeochromocytoma, Cushing's syndrome, Congenital adrenal hyperplasia, Acromegaly - Glucocorticoids - NSAIDs - Pregnancy - Coarctation of the aorta - COCP

Answer 56

Doesn't typically cause symptoms unless it is very high, for example > 200/120 mmHg. If very raised patients may experience: - headaches - visual disturbance - seizures

Answer 57

- Fundoscopy: to check for hypertensive retinopathy - Urine dipstick: to check for renal disease, either as a cause or consequence of hypertension - ECG: to check for left ventricular hypertrophy or ischaemic heart disease

Answer 58

**24 hour blood pressure monitoring** is now recommend for the diagnosis of hypertension. If 24 hour blood pressure monitoring is not available then home readings using an automated sphygmomanometer are useful. *Following diagnosis patients typically have the following tests:* - urea and electrolytes: check for renal disease, either as a cause or consequence of hypertension - HbA1c: check for co-existing diabetes mellitus, another important risk factor for cardiovascular disease - lipids: check for hyperlipidaemia, again another important risk factor for cardiovascular disease - ECG - urine dipstick

Answer 59

**Stage 1:** - Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg **Stage 2:** - Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg **Stage 3:** - Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 110 mmHg

Answer 60

- Low salt diet is recommended, aiming for less than 6g/day, ideally 3g/day - Caffeine intake should be reduced - Stop smoking - Drink less alcohol - Eat a balanced diet rich in fruit and vegetables - Exercise more, lose weight

Answer 61

*Stage 1 hypertension:* - Treat if <80yrs AND any of the following apply; target organ damage, established cardiovascular disease, renal disease, diabetes or a 10-year cardiovascular risk equivalent to 10% or greater *Stage 2 hypertension:* - Offer drug treatment regardless of age *Stage 3 hypertension:* - Immediate treatment should be considered - If there are signs of papilloedema or retinal haemorrhages NICE recommend same day assessment by a specialist - NICE also recommend referral if a phaeochromocytoma is suspected (labile or postural hypotension, headache, palpitations, pallor and diaphoresis)

Answer 62

Primarily genetic mutations Autosomal dominant Associations include: Friedreich's ataxia Wolff-Parkinson White

Answer 63

The clinical presentation of HOCM is highly variable, ranging from asymptomatic to severe heart failure - Exertional dyspnoea - Angina - Syncope - Palpitations - Heart failure: In advanced stages, patients can present with symptoms of congestive heart failure, including fatigue, peripheral oedema, and orthopnea

Answer 64

- Harsh systolic ejection murmur, heard best at the left lower sternal border (LVOT obstruction) - Murmur typically increases with Valsalva manoeuvre and decreases with squatting or handgrip. - S4 gallop - Bifid carotid pulse - rapid upstroke followed by a mid-systolic dip ('spike and dome' pulse) - Signs of congestive HF - elevated JVP, hepatojugular reflux, and peripheral oedema.

Answer 65

**Transthoracic echo (TTE)** = primary diagnostic modality - Asymmetric septal hypertrophy - Systolic anterior motion (SAM) of the mitral valve - resulting in mitral regurgitation and contributing to LVOT obstruction. - LVOT obstruction - increased pressure gradient across the LVOT - Diastolic dysfunction **ECG:** - Left ventricular hypertrophy (LVH) - T-wave inversions - deep, symmetric T-wave inversions in the precordial leads - AF or VT may be detected. **Cardiac Magnetic Resonance Imaging (CMR):** - Provides detailed assessment of myocardial hypertrophy, fibrosis, and ventricular function **Exercise stress testing may help to:** - Evaluate functional capacity and symptom severity. - Provoke LVOT obstruction and assess the hemodynamic response. - Unmask exercise-induced arrhythmias. **Genetic testing:** - Identifies sarcomere mutations, confirming HCM diagnosis and enabling family screening

Answer 66

**Pharmacological interventions:** - Beta-blockers = first-line - CCBs: Verapamil is an alternative or adjunct to beta-blockers, particularly in patients with contraindications or intolerance. - Disopyramide: This antiarrhythmic agent may be used as a second-line agent in combination with beta-blockers for refractory symptoms. - Diuretics: Caution is warranted due to the potential for hypovolemia and exacerbation of LVOT obstruction. - Anticoagulation: Indicated in patients with atrial fibrillation or a history of thromboembolic events. **For patients with severe, symptomatic LVOT obstruction refractory to medical therapy, septal reduction may be considered:** - Septal myectomy: Surgical removal of a portion of the hypertrophied septum, with a low operative mortality rate and durable long-term symptomatic relief. - Alcohol septal ablation: A percutaneous approach, involving injection of ethanol into a septal coronary artery to induce localized myocardial infarction and septal thinning. Outcomes are comparable to septal myectomy but may be less effective in patients with extreme septal thickness. **Implantable Cardioverter-Defibrillators (ICDs) are indicated for primary or secondary prevention of sudden cardiac death in high-risk patients, including those with:** - A history of cardiac arrest or sustained ventricular arrhythmias. - Family history of sudden cardiac death. Unexplained syncope. - Severe LVH or marked LVOT obstruction.

Answer 67

*Patient factors:* - Age >60years - Male - IVDU (particularly increased risk of right-sided IE) - Intravascular lines - Chronic haemodialysis (usually have a fistula or a long-term haemodialysis catheter which can become infected) - Immunosuppression - Recent dental or surgical procedure - poor dental hygiene increases the risk of having the specific bacteria present in your mouth, which during gingival manipulation or an invasive dental procedure can be introduced to the blood stream and cause IE *Cardiac factors:* - History of prior IE - Prosthetic heart valve or other cardiac device - Structural heart disease (eg. Valvular heart disease or congenital heart disease)

Answer 68

>Can present as an acute clinical deterioration or a subacute, more chronic development of the following non-specific symptoms: - Fever (90%) - associated with chills, anorexia and weight loss. - Other non-specific features include malaise, arthralgia, myalgia, night sweats, and abdominal pain. Clinical signs: - Heart murmurs (85%) - usually only present in those with left sided IE. - Cutaneous manifestations - petechiae on extremities or mucous membranes, splinter haemorrhages (reddish-brown linear lesion on the nail bed) - Janeway lesions (non-tender macules on palms and soles, more associated with acute onset) - Osler node (tender nodules on fingers and toes) - Roth spots (haemorrhagic retinal lesions with a pale centre) - Clinical manifestations of complications (eg. Congestive heart failure) or systemic embolisation (eg. Embolic stroke) may be present at initial presentation. - Pulmonary septic emboli is the most common presentation (75%) of isolated right-sided IE (10% of all cases of IE). This can present clinically with a cough, dyspnoea, haemoptysis or pleuritic chest pain.

Answer 69

**Blood cultures (diagnostic):** - At least 3 samples from different sites over 30-60 mins is recommended - Adequate blood culture samples must be taken before starting any antibiotics, regardless of the clinical decision to start empirical antibiotics or to delay treatment. **Echocardiogram (diagnostic):** - Transthoracic (TTE) is usually the first line investigation. - Transoesophageal (TOE) has a higher sensitivity than TTE for detecting IE, particularly L sided IE and any structural cardiac complications (intracardiac abscess, leaflet perforation, or pseudoaneurysm) and if available it is preferred as the first-line. **Additional:** - ECG - helps to identify any further extension of the infection that may affect cardiac functioning for example; Heart block, Conduction delay, Ischaemic changes (which would indicate the presence of dispersed emboli affecting the coronary circulation) - Chest x-ray - looks for pulmonary septic emboli, congestive heart failure, any abscess' or is helpful to exclude other differentials. - CT scan (thoracic, abdominal and pelvic) is especially useful to identify the location of any metastatic infections that may require drainage.

Answer 70

**Antibiotic therapy:** - If strong suspicion of IE and patient is acutely unwell, initiating empirical antibiotics is recommended, but only after adequate blood culture samples have been taken - Choice of antibiotic depends on the following factors (which may help predict the different causative organisms); Native valve, Prosthetic valve, IVDUs - When patient is clinically stable, starting antibiotic therapy is usually delayed to choose the most effective one based on blood culture results. **Find source of infection, and remove it if possible, to optimise successful eradication of infection:** - Potentially removable sources of infection may include intravascular catheter, intracardiac devices, or arteriovenous fistula. - Dental evaluation may identify focal source of dental infection which may need treatment. - Colonoscopy - there is a high association between a certain causative organism of IE, and bowel cancer. When group D streptococci (usually only found in the bowel) is identified as the organism on culture results, colonoscopy is warranted to evaluate for any bowel lesions that have facilitated its transfer into the blood stream. **Early valve surgery:** Early surgical intervention, ie. prior to finishing antibiotic therapy, is indicated if the following complications arise; - IE-associated valvular regurgitation/dysfunction - Heart failure - Intracardiac abscess - Persistent infection or difficult to treat organism

Answer 71

Follow-up with echo is indicated if there is any clinical suspicion of complications any clinical manifestations (eg. new murmurs, embolic events, heart failure, conduction abnormalities, or persistent fever). Following antibiotic therapy, even with successful treatment, complete resolution of any valvular vegetation is uncommon, an echo is recommended to establish the new baseline (including valve appearance, vegetation size and heart function). The frequency of follow-up after this is dependent on an individuals new baseline

Answer 72

*Cardiac complications (50%):* - Valvular insufficiency, if left untreated, leading to congestive heart failure is the most common complication of IE, and is therefore the most common indication for surgical management for IE. - Other cardiac complications include pericarditis (which can present with retrosternal chest pain) or a perivalvular abscess (which can disrupt cardiac conduction leading to abnormal ECG's) *Forms of metastatic infection include:* - Embolisation (which can lead to infarction and subsequent damage to various peripheral tissues) - Metastatic abscess formation - Mycotic aneurysms

Answer 73

- Costochondritis - Lower rib pain syndromes - Rib fractures/chest trauma - Fibromyalgia - Primary or secondary bone metastases in the rib - Inflammatory arthritides - generally there will be other joint involvement - Tietze syndrome - Spinal disorders (disc prolapse, cervical spondylosis, facet joint dysfunction)

Answer 74

*Viral infections are the most common cause:* - Enteroviruses especially Coxsackievirus B - Human Herpes virus 6 - Parvovirus B-19 - Influenza A - HIV *Bacterial/parasitic infections:* - Rheumatic fever (streptococcus A) - Trypanosoma cruzi (Chagas disease) - Diphtheria - the most common cause of myocarditis worldwide *Radiation:* - Initially radiation can cause myocarditis and/or pericarditis - The initial inflammation may progress to myocardial or pericardial fibrosis, fibrosis-related coronary artery disease, and/or cardiac valve abnormalities. More rarely, other pathologies may be implicated: *Autoimmune disorders:* - Systemic lupus erythematosus - Sarcoidosis - most patients have evidence of sarcoid disease present in other organs. - Giant cell myocarditis - rare, but associated with fulminant myocarditis. - Kawasaki disease *Drugs:* - Clozapine - NICE BNF recommendations suggest that patients with pre-existing cardiac disease should be carefully monitored and any patients with persistent tachycardia or with any suggestion of worsening cardiac disease should be carefully assessed. - Pembrolizumab - monoclonal antibody used in the treatment of various malignant processes.

Answer 75

>Patients with myocarditis may present with a wide range of signs and symptoms and some patients may be asymptomatic - Chest pain (35%) - also suggests concurrent pericarditis - Patients with concurrent pericarditis can report a diverse range of pain, though commonly they may describe central chest pain relieved by sitting forwards and worsened by deep inspiration, or alternatively may describe ischaemic sounding pain with a sensation of pressure centrally or left-sided radiating to arm and jaw. - Systemic upset - Fatigue, Fevers, generalised lethargy, feeling generally unwell, or may be specific. - Shortness of breath - may be at rest, with minimal exertion or limited to strenuous exercise. - Reduced exercise tolerance, may be difficult to quantify, especially in patients with an unlimited tolerance at baseline. Can be under-recognised. - Palpitations (which may indicate an underlying arrhythmia) which may be regular or irregular. - Tachycardia may overlap with patients describing palpitations - Collapse - may be attributed to arrhythmias leading to low output cardiac state) typically a cardiac syncope i.e. patients describe a sudden onset collapse with no warning symptoms, may be described as dropping to the ground. - Patients may also describe preceding dizziness and/or palpitations, which may indicate an underlying arrhythmia causing the collapse. - Sudden death - The is often a history of a recent preceding viral infection, which may be upper respiratory or gastrointestinal.

Answer 76

- Signs of heart failure e.g. evidence of fluid overload - raised JVP, pulmonary oedema and peripheral oedema - On auscultation of the heart, a pericardial friction rub may be heard in patients with concurrent pericarditis and a pansystolic murmur may be present in patients with functional mitral regurgitation - Patients may also be asymptomatic, but with ECG changes.

Answer 77

*Bedside testing:* **ECG:** - ST-segment elevation/depression - T-wave inversion - Atrial arrhythmias - Transient atrioventricular (AV) block **Respiratory viral screening with a nasopharyngeal aspirate** **Urine dip** for blood and protein *Bloods:* - FBC (may show raised white cell count, suggesting infection/inflammation) - ESR (can be raised, suggesting inflammation) - CRP (may show raised white cell count, suggesting infection/inflammation) - Cardiac enzyme levels e.g. creatine kinase and troponin (likely raised, showing insult to cardiac muscle) - Anti-nuclear antibodies (if positive, may suggest an underlying autoimmune aetiology) - Rheumatoid factor (if positive, may suggest rheumatoid arthritis) - Serum ACE (if positive, may suggest sarcoidosis) - Ds-DNA (if positive, may suggest systemic lupus erythematosus ) - Viral screening: coxsackievirus group B, human immunodeficiency virus (HIV), cytomegalovirus, Ebstein-Barr virus, hepatitis A, B, C *Imaging:* **Echo** - Important to exclude any other pathologies which may be causing the symptoms. - Confirm whether there is any evidence of pericardial effusion and if present, whether this is causing any degree of cardiac tamponade, which may suggest the effusion should be drained. **Cardiac MRI** - clinically useful to identify acute myocarditis vs. infarction. In some cases, an endomyocardial biopsy may be considered, however, this is often only performed in the event the patient is not responding to treatment and/or no underlying cause of the acute heart failure can be found by alternate means.

Answer 78

>Mainstay is supportive management. Given that most myocarditis cases are attributed to viral illnesses, there is often no treatment to target the underlying cause per se. **Principles of management:** - Oxygen where required. - Monitoring for and control of any underlying arrhythmias. - Fluid balance management. - Treat underlying cause if any identified. - Early escalation to specialist intensive care physicians - Organ support as required. Given the propensity for patients to deteriorate rapidly, it is recommended that patients are discussed with a cardiac intensive care unit with a view to escalating early should they develop any signs suggestive of cardiac shock. Patients with cardiac shock or symptomatic hypotension may need vasopressors/inotropes or mechanical cardiac support. **Suspected giant cell myocarditis:** - Steroids are recommended Anti-coagulation may be considered in patients with evidence of arrhythmias, depending upon the patient's individual risk factors

Answer 79

- Genetic - Scleroderma - HIV infection - Persistent pulmonary hypertension of the newborn

Answer 80

Initially, patients present with problems related to right ventricular dysfunction leading to reduced organ perfusion. These symptoms particularly present on exertion when there is higher demand placed on the heart. Symptoms include: - Dyspnoea (presenting complaint in 60% of cases) - Fatigue - Weakness - Angina - Syncope - Cough, sometimes with haemoptysis - Hypotension - Hoarseness - Related to compression of the left recurrent laryngeal nerve. As the disease progresses, patients may have symptoms during periods of rest. In advanced cases, patients may get abdominal distention and peripheral oedema. The symptoms closely resemble those of heart failure and it can be difficult to differentiate between the two. **Physical signs include:** - Cyanosis - Left parasternal heave - Signs on auscultation of the heart including - Tricuspid regurgitation murmur (pansystolic) - Pulmonary regurgitation murmur (diastolic) - Accentuation of the pulmonary component of the second heart sound When examining a patient with possible PAH, it is important to also look for any underlying signs of an aetiological cause, e.g. signs of scleroderma, interstitial lung disease or cirrhosis.

Answer 81

**Chest X-ray:** - May show central pulmonary arterial dilatation and in more severe cases enlargement of the right side of the heart - May also help to differentiate between PAH and other causes of pulmonary hypertension such as due to left heart disease or lung disease. **ECG:** - In mild and moderate cases ECG is likely to be normal - In more severe cases, ECG may show abnormalities related to damage to the right side of the heart including: RAD, RBBB, Right ventricular hypertrophy, QTc prolongation **Pulmonary function tests:** - To look for causes of PH related to lung disease e.g. COPD. **Echo:** - Transthoracic echocardiogram (TTE) can be used to estimate the mPAP, based on analysis of the peak tricuspid regurgitation velocity (TRV), and look at the effects of PAH on the heart. **High-resolution CT scan or cardiac MRI:** - Can be used to assess the size, morphology, and function of the right ventricle and to look for clues as to the underlying cause. **6-minute walking distance (6MWD):** - Used to assess the patient's symptoms and the severity of their disease. **BNP:** - If elevated can suggest a raised mPAP and pulmonary vascular resistance, which can signify PAH. If after these investigations a diagnosis of PAH is suspected, **right heart catheterization (RHC)** is required to diagnose it. These should only be performed by experienced clinicians in expert centres. In RHC, pressure measurements are made in multiple locations including the pulmonary artery, right ventricle, and right atrium to determine the blood pressure within these structures.

Answer 82

**Supportive therapies include:** - Diuretic treatment. Used in patients with fluid retention and oedema (choice of diuretic should be left to the physician and patient). - Oral anticoagulants. There is a higher risk of thrombotic events taking place in patients with PAH, due to both pathophysiological mechanisms of coagulation linked to PAH and increased likelihood of immobility compared to the general population. - Long term oxygen therapy. This is recommended in patients who have an arterial blood oxygen pressure that is consistently less than 8kPa. There is no clear evidence for the use of long term oxygen therapy in patients with PAH with a higher arterial blood oxygen pressure. - Treatment of other conditions that arise secondary to PAH including anaemia and atrial tachyarrhythmias. **Initially, patients should be treated with calcium channel blockers** (such as nifedipine, diltiazem, and amlodipine) if they have a positive response to acute vasoreactivity testing (where patients are administered a small dose of a short-acting vasodilator and have a decrease in mPAP of at least 10mmHg). If after 3-4 months of therapy, then additional therapy should be initiated. **Alternative options for therapy include:** - Endothelin receptor antagonists such as ambrisentan, bosentan or macitentan. - Phosphodiesterase type 5 (PDE5) inhibitors such as sildenafil, tadalafil or vardenafil. - Prostacyclin analogues such as epoprostenol, iloprost or treprostinil. Other therapies, such as balloon atrial septostomy (creation of an inter-atrial right-to-left shunt) and lung transplantation should be considered in the most severe cases, particularly patients who fail on medical therapies and remain in NYHC Class III-IV.

Answer 83

**Cor pulmonale:** - Pulmonary hypertension can lead to overflow of the pulmonary arteries back into the right ventricle, ultimately leaving to right ventricular hypertrophy and right heart failure. - Peripheral oedema, Raised JVP, Hepatomegaly, Parasternal heave. **Arrhythmias:** - Common complication, particularly atrial flutter and atrial fibrillation. - They can both result in worsening of symptoms, deterioration of right ventricular function, and a high mortality rate. **Haemoptysis:** - It is associated with a high mortality rate and may need emergency treatment. **Dilatation of the pulmonary arteries may also result in complications including:** - Aneurysms - Dissection - Compression of other structures within the mediastinum for example: Bronchi, Recurrent laryngeal nerves.

Answer 84

**Atrio-ventricular nodal re-entrant tachycardia (AVNRT):** - Most common form of paroxysmal SVT **Atrio-ventricular re-entrant tachycardia (AVRT):** - The second most common form of paroxysmal SVT - It involves an accessory pathway between the atria and the ventricles - Leads to the characteristic 'delta wave' on ECG, whereby there is up-sloping at the start of the QRS complex due to the early ventricular excitation **Atrial tachycardia:** - May be either focal or multi-focal - Multi-focal is synonymous with atrial flutter **Atrial fibrillation:** - The most common cardiac arrhythmia in general

Answer 85

Common symptoms for SVT include: - Recurrent episodes of palpitations (95%) - Dizziness or light-headedness (75%) - Dyspnoea (45%) - Chest pain or tightness - Progressive fatigue - Pounding in the head and/or neck SVT tends to present in discrete episodes which become more frequent and severe with time: - Recurrent and paroxysmal - Abrupt onset and offset - Average duration of episode 10-15 minutes, but can last any period of time from seconds to hours *Syncope* - Very uncommon - When present, is a warning sign due to significant increase in risk of sudden cardiac death In adults, SVT episodes tend to present with a heart rate greater than 100 beats per minute

Answer 86

**ECG:** - Baseline ECG may be essentially normal - SVT is typically associated with a regular rate, notably AVNRT, AVRT, focal atrial tachycardia, atrial flutter (usually) and sinus tachycardia - Irregular rhythms include atrial fibrillation, and multi-focal atrial tachycardia - If SVT is ongoing during ECG, it is usually a narrow-complex tachycardia (i.e. QRS less than 120 milliseconds) - -If a wide-complex tachycardia is identified, this is usually ventricular in origin, however the exclusions are SVT with aberrant conduction or anti-dromic AVRT, however these are rare - Ambulatory (Holter) monitoring may be required to attempt to identify SVT episodes, however as the episodes are intermittent, a normal 24-48 hour reading should not exclude SVT **Echocardiogram:** - In majority of patients will be normal **Exercise testing:** - Considered for patients in which their symptoms are triggered by exercise, as increased adrenergic tone can sometimes elicit episodes of SVT

Answer 87

Synchronised cardioversion = first-line treatment - Direct current cardioversion is required - Should be performed under sedation or general anaesthesia - This restores normal sinus rhythm in over 95% of cases

Answer 88

>Start with vagal manoeuvres if there is an absence of adverse features, then follow with drug treatment if the arrhythmia is not terminated **Vagal manoeuvres:** - Valsalva manoeuvres - forceful exhalation against a closed airway for approximately 15-20 seconds, blowing into an occluded straw, or adopting a head-down position for approximately 15-20 seconds - Applying a cold stimulus to the face - usually application of a bag filled with ice and cold water over the face, for approximately 15 to 30 seconds - Carotid sinus massage - contraindicated if any history of carotid artery disease, and usually only performed in a monitored healthcare setting **Pharmacological treatment:** - Adenosine in a rapid IV bolus using a relatively large cannula and vein (success rate of approximately 85%) - Example dosing: 6mg → if unsuccessful give 12 mg → if unsuccessful give further 18 mg - If adenosine is contra-indicated or fails, the second-line medication to consider is verapamil, however this is given intravenous over a two-minute period

Answer 89

> This is most likely to be in the setting of atrial fibrillation, or less commonly atrial flutter with a variable atrio-ventricular block **If patient has likely been in AF for >48-hours:** - They should not be treated initially with cardioversion until they have been anti-coagulated for at least three weeks, to reduce the risk of dislodging an atrial thrombus - Note: if a patient is unstable and therefore requires urgent cardioversion, weight-adjusted low molecular weight heparin or unfractionated heparin should be given first - Heparin treatment as well as oral anti-coagulation should be commenced after cardioversion (whether successful or not) **If duration of AF is <48-hours and rhythm control is ideal:** - Chemical cardioversion using flecainide, propafenone or amiodarone may be considered - This is always done with expert consultation - Flecainide or propafenone cannot be used in the setting of known structural heart disease or heart failure

Answer 90

Usually, long-term management is only indicated if the frequency and severity of SVT episodes significantly impacts on the patients quality of life and functioning **Indications for definitive or long-term treatment include:** - Recurrent symptomatic SVT episodes affecting quality of life - Evidence of Wolff-Parkinson-White on ECG and symptoms of SVT episodes - Infrequent SVT episodes but in a profession or sport which puts themselves or others at risk (e.g. drivers, pilots, surgeons) **Options for long-term management:** - For most patients, radio-frequency ablation is preferred due to the low risk of complications and high success rate (>95%) - However, for those who decline ablation, pharmacological treatment usually involves beta blockers or calcium-channel blockers as a first-line option - Second-line medication options include flecainide and sotalol

Answer 91

Gout Can exacerbate

Answer 92

- Shock: hypotension (systolic <90), pallor, sweating, cold, clammy extremities, confusion or impaired consciousness - Syncope - Myocardial ischaemia - Heart failure If any of the above adverse signs are present then synchronised DC shocks should be given. Up to 3 shocks can be given; after this expert help should be sought.

Answer 93

Assume ventricular tachycardia (unless previously confirmed SVT with bundle branch block) - Loading dose of amiodarone followed by 24 hour infusion

Answer 94

Seek expert help. Possibilities include: - atrial fibrillation with bundle branch block - the most likely cause in a stable patient - atrial fibrillation with ventricular pre-excitation - torsade de pointes

Answer 95

vagal manoeuvres followed by IV adenosine if the above is unsuccessful consider a diagnosis of atrial flutter and control rate (e.g. beta-blockers)

Answer 96

probable atrial fibrillation if onset < 48 hr consider electrical or chemical cardioversion rate control: beta-blockers are usually first-line unless there is a contraindication

Answer 97

**Atropine (500mcg IV)** If there is an unsatisfactory response the following interventions may be used: - atropine, up to a maximum of 3mg - transcutaneous pacing - isoprenaline/adrenaline infusion titrated to response

Answer 98

Stop warfarin Give intravenous vitamin K 5mg Prothrombin complex concentrate - if not available then FFP

Answer 99

Drug-eluting stents

Answer 100

A form of polymorphic ventricular tachycardia associated with a long QT interval. It may deteriorate into ventricular fibrillation and hence lead to sudden death.

Answer 101

- congenital - Jervell-Lange-Nielsen syndrome, Romano-Ward syndrome - antiarrhythmics: amiodarone, sotalol, class 1a antiarrhythmic drugs - tricyclic antidepressants - antipsychotics - chloroquine - terfenadine - erythromycin - electrolyte: hypocalcaemia, hypokalaemia, hypomagnesaemia - myocarditis - hypothermia - subarachnoid haemorrhage

Answer 102

Macrolides

Answer 103

Typically occurs 2 weeks after MI with symptoms mimicking heart failure (presenting with SOB, cough, and crackles on auscultation) alongside persistent ST elevation

Answer 104

TFT, LFT, U&E, CXR

Answer 105

IV furosemide GTN

Answer 106

RHF // Cor pulmonale

Answer 107

thiazide like diuretic

Answer 108

Influenza vaccine

Answer 109

Aortic regurgitation

Answer 110

Mitral valve prolapse

Answer 111

Grade 1 - Very faint murmur, frequently overlooked Grade 2 - Slight murmur Grade 3 - Moderate murmur without palpable thrill Grade 4 - Loud murmur with palpable thrill Grade 5 - Very loud murmur with extremely palpable thrill. Can be heard with stethoscope edge Grade 6 - Extremely loud murmur - can be heard without stethoscope touching the chest wall

Answer 112

left ventricular free wall rupture

Answer 113

head injury ?

Answer 114

Triad of mitral valve obstruction, systemic embolisation and constitutional symptoms such as breathlessness, weight loss and fever. +pedunculated heterogeneous mass on echocardiogram

Answer 115

shortening of the QT interval

Answer 116

anticoagulation should be continued even if sinus rhythm is maintained in patients at high risk of stroke, anticoagulation should be continued long-term, even if they remain in sinus rhythm

Answer 117

Creatine kinase (CK-MB)

Answer 118

mitral stenosis

Answer 119

aortic sclerosis

Answer 120

short PR interval (<120 ms)

Answer 121

- PR interval > 0.2 seconds - Asymptomatic first-degree heart block is relatively common and does not need treatment

Answer 122

**Type 1 (Mobitz I, Wenckebach):** progressive prolongation of the PR interval until a dropped beat occurs

Answer 123

**Type 2 (Mobitz II):** PR interval is constant but the P wave is often not followed by a QRS complex

Answer 124

No association between the P waves and QRS complexes

Answer 125

Mobitz type 1 heart block is a normal variant in athletes due to increased vagal tone. Thus, you can discharge and monitor with ECG in primary care.

Answer 126

Drug-induced gynaecomastia

Answer 127

Aortic regurgitation

Answer 128

- down-sloping ST depression ('reverse tick', 'scooped out') - flattened/inverted T waves - short QT interval - arrhythmias e.g. AV block, bradycardia

Answer 129

Acute stroke = two weeks after the event TIA = immediately

Answer 130

thiazide like diuretic

Answer 131

verapamil or diltiazem

Answer 132

amlodipine, modified-release nifedipine

Answer 133

Bradycardia (<60bpm) J waves Prolonged PR, QT and QRS intervals Shivering artefacts VT, VF or asystole

Answer 134

A non-atherosclerotic small and medium vessel vasculitis It most commonly affects young males who smoke.

Answer 135

extremity ischaemia intermittent claudication ischaemic ulcers superficial thrombophlebitis Raynaud's phenomenon

Answer 136

Think Buerger's disease

Answer 137

drop in SBP of at least 20 mmHg and/or a drop in DBP of at least 10 mmHg after 3 minutes of standing

Answer 138

IV mag sulf

Answer 139

PR depression

Answer 140

Transthoracic echocardiogram has been done to exclude valvular heart disease

Answer 141

- pregnancy and breastfeeding - avoid - renovascular disease - may result in renal impairment - aortic stenosis - may result in hypotension - hereditary of idiopathic angioedema - specialist advice should be sought before starting ACE inhibitors in patients with a potassium >= 5.0 mmol/L

Answer 142

**A**lveolar oedema (bat’s wings) Kerley **B** lines (interstitial oedema) **C**ardiomegaly **D**ilated prominent upper lobe vessels **E**ffusion (pleural)

Answer 143

erectile dysfunction

Answer 144

Hypokalaemia

Answer 145

U waves small or absent T waves (occasionally inversion) prolong PR interval ST depression long QT

Answer 146

- normal variant - more common with increasing age - right ventricular hypertrophy - chronically increased right ventricular pressure - e.g. cor pulmonale - pulmonary embolism - myocardial infarction - atrial septal defect (ostium secundum) - cardiomyopathy or myocarditis

Answer 147

WiLLiaM MaRRoW in LBBB there is a 'W' in V1 and a 'M' in V6 in RBBB there is a 'M' in V1 and a 'W' in V6

Answer 148

pulsus paradoxus Typical of cardiac tamponade

Answer 149

Kussmaul's sign Typical of constrictive pericarditis

Answer 150

Abnormally slow conduction through the AV node. ECG = PR interval >0.20 without disruption of atrial to ventricular conduction *Normal variant in an athlete*

Answer 151

Mechanical heart valves (risk of thromboembolic events) Use warfarin

Answer 152

CCB Verapamil

Answer 153

Staphylococcus aureus Staphylococcus epidermidis if < 2 months post valve surgery

Answer 154

Long-term anticoagulation not usually needed. Warfarin may be given for the first 3 months depending on patient factors. Low-dose aspirin is given long-term.

Answer 155

Warfarin Target INR: aortic - 3.0 mitral - 3.5

Answer 156

- Cough - Angioedema - Hyperkalaemia - First-dose hypotension - more common in patients taking diuretics

Answer 157

- Pregnancy and breastfeeding - avoid - Renovascular disease - may result in renal impairment - Aortic stenosis - may result in hypotension - Hereditary or idiopathic angioedema - Specialist advice should be sought before starting ACE inhibitors in patients with a potassium >= 5

Answer 158

- Chest pain - Bronchospasm - avoid in asthmatic - Transient flushing - Can enhance conduction down accessory pathways, resulting in increased ventricular rate (e.g. WPW syndrome)

Answer 159

- ejection systolic murmur - fixed splitting of S2 - embolism may pass from venous system to left side of heart causing a stroke

Answer 160

- bronchospasm - cold peripheries - fatigue - sleep disturbances, including nightmares - erectile dysfunction

Answer 161

implantable cardioverter-defibrillator

Answer 162

urgent pericardiocentesis

Answer 163

- infancy: heart failure - adult: hypertension - radio-femoral delay - mid systolic murmur, maximal over the back - apical click from the aortic valve - notching of the inferior border of the ribs (due to collateral vessels) is not seen in young children

Answer 164

- RHF: elevated JVP, ascites, oedema, hepatomegaly - JVP shows prominent x and y descent - pericardial knock - loud S3 - Kussmaul's sign positive - paradoxical rise in JVP during inspiration

Answer 165

Pericardial calcification

Answer 166

- classic findings of heart failure - systolic murmur: stretching of the valves may result in mitral and tricuspid regurgitation - S3 - 'balloon' appearance of the heart on the chest x-ray

Answer 167

Viridans streptococci e.g. Streptococcus sanguinis