Medicine - Cardiology Flashcards
1
Q
Recall 2 observations about a person’s pulse that may be seen if they have aortic stenosis vs aortic regurgitation
A
Aortic stenosis: NARROW pulse pressure, slow rising pulse
Aortic regurgitation: WIDE pulse pressure, ‘waterhammer’ pulse (Corrigan’s pulse)
Pulse pressure = SBP-DBP (eg if BP = 120/80, PP = 40)
2
Q
How would you describe the heart sounds that are auscultated in aortic stenosis vs regurgitation?
A
Aortic stenosis = soft S2 +/- S4
Aortic regurgitation = soft S2 +/- S3
3
Q
What is the difference in cause between an S3 and S4 heart sound?
A
S3 heart sound is caused by blood filling against a non-compliant ventricle, whereas S4 is blood filling against a compliant ventricle
4
Q
How can you hear the difference between an S3 and S4 heart sound?
A
S3 is early diastolic
S4 is late diastolic
5
Q
What clinical examination findings can help differentiate aortic stenosis caused by valve sclerosis from aortic stenosis caused by HOCM?
A
In HOCM, the valsalva manoevre increases the volume of the murmur, whereas squatting decreases it
6
Q
What might a CXR reveal in aortic stenosis?
A
Left ventricular hypertrophy
Pulmonary oedema
Valve calcification
7
Q
What is the most useful investigation for assessing the severity of aortic stenosis?
A
Echo +/- doppler
8
Q
Recall some general principles of management of heart valve disease
A
QRISK3 score to stratify risk
Manage risk with a statin (eg atorvastatin) and an antiplatelet (aspirin/ clopidogrel)
Manage coexistent HTN/ angina etc
9
Q
Recall some indications for open replacement of the aortic valve (rather than cath lab procedure)
A
Symptomatic
Non-symptomatic with a low EF
Severe undergoing CABG
10
Q
What does CABG stand for?
A
Coronary artery bypass graft
11
Q
What are the 2 main types of artificial aortic valve?
A
Ball-in-cage
Bileaflet/ tilting disc
12
Q
Recall some pros and cons of TAVI
A
Pros: no bypass required, no large scars
Cons: higher risk of stroke compared to open replacement
13
Q
What is a balloon aortic valvuloplasty
A
Procedure which stretches the aortic valve to improve symptoms of aortic stenosis
14
Q
When is the aortic stenosis murmur heard vs aortic regurgitation?
A
AS: Ejection systolic
AR: Early diastolic
15
Q
What is an Austin Flint murmur?
A
‘Rumbling diastolic murmur’
- Associated with severe aortic regurgitation
- Best auscultated in 5th ICS in MCL
- Caused by blood flowing back through the aortic valve and over the mitral valve
16
Q
When in the heart cycle is an Austin flint murmur heard, and what causes it?
A
Mid-diastole
Caused by regurgitant jet that runs over the mitral valve leaflets
17
Q
Which heart murmurs are best heard on expiration?
A
Left heart murmurs
18
Q
Where is the aortic regurgitation murmur best auscultated?
A
Erb’s point - Left 3rd ICS parasternal
19
Q
Where is the main site of production of BNP?
A
Left ventricle (not actually brain, as name may suggest)
20
Q
What is the advantage of measuring NT-proBNP over BNP?
A
NT-proBNP has a much longer half life as it is inactive - BNP, being an active hormone, has a much shorter half life
21
Q
What can an echo and doppler be used to determine in cases of aortic regurgitation?
A
Severity
LV function
Cause
22
Q
What is the mainstay of medical management for aortic regurgitation (other than managing cardiac risk with statins etc)?
A
Reduce afterload - can use:
ACE inhibitors (eg enalopril/ captopril)
Beta blockers (bisoprolol etc)
Diuretics (furosemide etc)
23
Q
Which 2 antihypertensives are contra-indicated in aortic stenosis?
A
Beta blockers (don't want to depress LV function) Nitrates (may precipitate life-thretening hypotension)
24
Q
Which heart murmur is most associated with atrial fibrillation?
A
Mitral stenosis
25
Which of the left heart murmurs will NOT produce a displaced apex beat?
Mitral stenosis (causes atrial hypertrophy not ventricular)
26
By what mechanism can heart valve disease cause a parasternal heave, and which murmurs can cause this?
Right ventricular hypertrophy (RVH) is cause of PSH (right ventricle is most anterior chamber of the heart so can cause heave)
MS and MR can cause RVH - as increased left atrial pressure --\> pulmonary HTN --\> RVH
27
Why might the apex beat be displaced in mitral regurgitation?
Left ventricle is pumping the stroke volume AND the regurgitant volume
28
Differentiate the timing of mitral stenosis and mitral regurgitation
Mitral stenosis is a MID DIAstolic murmur
Mitral regurgitation is a pan SYStolic murmur
29
Which of the heart murmurs might radiate to the axilla?
Mitral regurgitation
30
Recall some clinical signs of pulmonary hypertension
Malar flush
Raised JVP
Right ventricular (parasternal) heave
Loud S2
31
What might be seen on an ECG in mitral valve disease
```
Atrial fibrillation
P mitrale (bifid 'm-shaped' p waves in lead II as well as V1-V6)
```
32
What is the mainstay of medical management for mitral stenosis, other than heart disease risk modification eg statins?
RhF prophylaxis with benzylpenicillin
AF (rate control + DOAC)
Diuretics for symptomatic relief
33
What is the first line surgical treatment for mitral stenosis?
Balloon valvuloplasty
34
What is the mainstay of medical management for mitral regurgitation (other than managing cardiac risk with statins etc)?
Like AR, reduce afterload - can use:
ACE inhibitors (eg enalopril/ captopril)
Beta blockers (bisoprolol etc)
Diuretics (furosemide etc)
35
Describe briefly the NYHA classifications
1 - no limitation on activity
2 - comfortable at rest but dyspnoea on ordinary activity
3 - marked limitation on ordinary activity
4 - dyspnoea at rest
36
Recall the broad approach to medically managing heart failure
BASHeD up by the heart:
(Beta blocker or
ACE inhibitor)
Spironolactone
Hydralazine (+ nitrate)
Digoxin
37
Which extra immunisations should be offered in patients with heart failure?
Annual influenza
Pneumococcal
38
What must be monitored whilst patients are on spironolactone?
Potassium (as is a potassium-sparing diuretic)
39
Recall some drugs that are contra-indicated in heart failure
Thiozolidinediones (type 2 diabetes)
Verapamil (as is negative inotrope)
NSAIDs (can cause fluid retention)
Glucocorticoids (can cause fluid retention)
Flecainide (negative inotrope, arrhythmogenic)
40
How quickly should GTN spray relieve angina pain?
Within 5 minutes
41
What is the first line investigation for angina in stable patients, and what score is this investigation used to calculate?
CT coronary angiography
Calcium score
42
What are some pharmacological options for preventing angina (NOT symptomatic relief)?
Aspirin (75mg, OD)
Atorvastatin (80mg, ON)
ACE inhibitor (especially if co-existent DM)
Antihypertensives
43
What calcium score would be classified as low risk, and what score would be high risk?
Low risk \< 100
High risk \> 400
44
What care needs to be taken when prescribing CCBs and BBs together?
If you prescribe a non-dihydropyrimidine CCB (eg verapamil) with a BB it can cause complete heart block
45
What are some medical options for managing angina symptoms?
1st line: GTN (spray or sublingual) + beta blocker or CCB (if CCB used as monotherapy, use a rate limiting one like verapamil or dilitiazem)
2nd line: GTN + BB AND CCB
3rd line options:
- Long-acting nitrates eg Isosorbide mononitrate
- Ivabradine
46
What are the 3 types of AF?
Acute (\<48 hours)
Paroxysmal (self-limiting, \<7 days, recurs)
Persistent (\>7 days, may recur even after cardioversion)
47
How does anti-clotting drug choice differ following a stroke, depending on whether or not they have AF?
If they have AF --\> anti-coagulant (DOAC or warfarin if DOAC is CI)
If they do NOT have AF --\> anti-platelet
48
Why are anti-platelets not used in AF?
Anti-platelets are specifically for artherogenic causes of clots eg atheroma
49
Within what window of AF beginning can it be treated differently to longer-standing AF? What is this different treatment? Why is it so difficult to treat within the initial window of time?
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
50
For how long before and after cardioversion for arrhythmia should a patient be anti-coagulated?
3w before and 4w after OR lifelong (if CHA2DS2VASc high or if paroxysmal AF)
51
How can chadsvasc score be used to determine the need for longterm anticoagulation?
Score:
0 = no need for longterm anticoagulation
1 = anticoagulate if male, do not anticoagulate if female
2 or more: anticoagulate
52
What is the main contraindication to be aware of for all CCBs?
Peripheral oedema (increased capillary hydrostatic pressure that results from greater dilation of pre-capillary than post-capillary vessels)
53
What are the 1st, 2nd and 3rd line options for rate control in AF?
1st line: beta blocker or CCB (verapamil is better than dilitiazem)
2nd line: digoxin
3rd line: amiodarone
54
With what waveform on the ECG should DC cardioversion be synchronised?
R wave
If synchronised with T wave it can cause VT
55
Recall 2 options for chemical cardioversion, and any important indications/ contra-indications for each
Flecainide - if young and no structural heart disease
Amiodarone - in structural heart disease (eg HF)
56
Recall 2 surgical options for managing AF
1. Radiofrequency ablation of AV node
2. Maze procedure
57
Recall the components of the CHA2DS2VASc score
CHF
HTN
Age \>75
DM
Stroke
Vascular disease
Age 65-74
Sex Category (female)
58
In HTN, what BP is defined as 'severe'?
\>180/110
59
What is the first line treatment for HTN for diabetics?
ACE inhibitor
60
What is the first line treatment for HTN for black Africans?
CCB
61
What is the first line treatment for HTN for under vs over 55s who are not diabetic or Black African?
Under 55: ACE inhibitor or ARB
Over 55: CCB
62
Recall some side effects of ACE inhibitors
Angioedema (for around 4 weeks), cough, hyperkalaemia
63
Recall the name of one thiazide-like diuretic
Indapamide
nb bendoflumethiazide is thiazide, not thiazide-like
64
Why do CCBs cause oedema?
Cause dilation of arterioles but not venules
65
What is the atorvastatin dose for primary vs secondary prevention?
Primary prevention: 20mg OD
Secondary prevention: 80mg OD
66
What is the most commonly affected heart valve in infective endocarditis when the patient is an IVDU?
Tricuspid
67
What is the most common pathogen to cause an acute presentation of infective endocarditis?
Strep epidermidis
68
How does strep viridans infective endocarditis most commonly present?
Subacute presentation, most commonly in the developing world
69
What is Libman-Sacks endocarditis?
Non-infective endocarditis caused by SLE
70
Differentiate the empirical antibiotics used in native vs prosthetic valves affected by infective endocarditis
Native valve: amoxicillin +/- gentamicin
Prosthetic valve: vancomycin + rifampicin + gentamicin
71
How far apart should blood cultures be taken to investigate infective endocarditis?
12 hours
72
What is the most likely pathogen to cause rheumatic fever?
GAS (strep pyogenes)
73
What is the broad pathophysiology of rheumatic fever?
AB cross reactivity with myosin, muscle glycogen and VSMC
74
What is the latent period between pharyngeal infection and onset of rheumatic fever?
2-6 weeks
75
Recall some of the key symptoms of rheumatic fever
Pericarditis
Polyarthritis
Erythema marginatum
76
What are sydenham's chorea?
Unwanted jerky movements that appear 2-6 months following rheumatic fever
77
Recall the Duckett-Jones diagnostic criteria
For diagnosing rheumatic fever:
CASES (major) FRAPP (minor)
Carditis
Arthritis
Sydenham's chorea
Erythema marginatum
Subcutaneous nodules
78
What is the antibiotic treatment recommended in rheumatic fever?
Phenoxymethylpenicillin QDS 10/7
79
What drugs can be used to treat sydenham's chorea?
Haloperidol
Diazepam
80
How long does penicillin treatment need to continue following an episode of rheumatic fever to prevent rheumatic heart disease?
If carditis and residual heart disease: 10 years or until age 40 (whichever is longer), possibly lifetime
If carditis but NO residual heart disease: 10 years or until age 21 (whichever is longer)
If NO carditis: 5 years or until age 21 (whichever is longer)
81
What is 'fibrinous' pericarditis?
Pericarditis caused by uraemia
82
Recall some signs and symptoms of pericarditis
Pleuritic chest pain
Non-productive cough
Dyspnoea
Flu-like symptoms
Pericardial rub
Tachypnoea + tachycardia
83
What are the typical ECG findings in pericarditis?
Widespread PR depression or saddle-shaped ST elevation
84
How should pericarditis be broadly managed?
Treat cause
NSAIDs and colchicine
85
Recall some cardiac causes of clubbing
Atrial myxoma
Cyanotic heart disease
Infective endocarditis
86
What can cause a collapsing pulse other than aortic regurgitation?
Pregnancy
Thyrotoxicosis
Anaemia
87
What do the S1 and S2 heart sounds represent?
```
S1 = mitral valve closure
S2 = aortic valve closure
```
88
What would cause a split S1?
Mitral and tricuspid valve closing at different times - normal in some
89
What are the 2 types of purely genetic primary cardiomyopathy?
HOCM
Arrhythmogenic right ventricular dysplasia
90
What are the 2 types of purely acquired primary cardiomyopathy?
Peripartum cardiomyopathy
Takotsubo cardiomyopathy
91
Recall 2 types of primary cardiomyopathy that have mixed genetic/ acquired causes?
Dilated cardiomyopathy
Restrictive cardiomyopathy
92
Recall 4 possible causes of dilated cardiomyopathy
Alcohol
Cocksackie B
Wet beri beri
Doxorubicin
93
Recall 3 possible causes of restrictive cardiomyopathy
Amyloidosis
Post-radiotherapy
Loeffler's endocarditis (due to eosinophillic infiltration)
94
What is the most common gene mutation causing HOCM?
Beta-myosin heavy chain protein mutation
95
What would the following echo findings be suggestive of:
Mitral regurgitation
Systolic anterior motion of the anterior mitral valve
Asymmetrical septal hypertrophy
HOCM
96
What is arrhythmogenic right ventricular dysplasia?
Replacement of right ventricular myocardium with fatty and fibrofatty tissue
97
What is the following description of an abnormal ECG most suggestive of:
Abnormalities in V1-3, typically T wave inversion. Possible epsilon wave.
Arrhythmogenic right ventricular dysplasia
98
What would the following echo findings be suggestive of:
All 4 heart chambers dilated
Tricuspid and mitral regurgitation
Dilated cardiomyopathy
99
What condition does the following describe: "transient, apical ballooning of the myocardium"?
Takotsubo cardiomyopathy
100
Recall some causes of secondary cardiomyopathy
Infiltration (eg amyloidosis )
Inflammation (eg sarcoidosis)
Storage (eg haemochromatosis)
Deficiencies (eg beri beri)
Neuromuscular (eg Friedereich's ataxia, duchenne-becker musculdystrophy)
Infective (cocksackie B, chagas)
Endocrine (thyrotoxicus, diabetes mellitis, acromegaly)
101
Why is long QT syndrome dangerous?
Can cause VT --\> death
102
Recall 2 causes of congenital long QT syndrome, and how they can be differetiated?
Jervell-Lange-Nielsen syndrome (deafness)
Romano-Ward syndrome (no deafness)
103
Recall some drugs that can cause long QT syndrome
METH CATS
Methadone
Erythromycin
Terfenadine
Haloperidol
Clarithromycin
Amiodarone/ arythromycin
TCAs
SSRIs (especially citalopram)
104
What is the 1st line management of torsades de pointes?
IV magnesium sulphate
105
What is torsades de pointes?
A type of polymorphic VT that is associated with QT prolongation
106
How much does BP have to drop on standing to classify as 'orthostatic hypertension'?
Over 3 mins, BP needs to fall by 20/10
107
What is pulsus paradoxus, and in which conditions would it be seen?
\>10mmHg fall in SBP during inspiration
Seen in severe asthma and cardiac tamponade - why?:
Inspiration --\> reduced intrathoracic pressure --\> blood pulled into right side of heart
Interventricular septum bulges into the left side of the heart --\> reduced CO --\> transient BP drop
You will feel varying strength of the pulse with inspiration and expiration
108
What is pulsus alternans and in which condition is it seen?
Regular alternation of the force of the arterial pulse
Seen in severe LVF
109
In which disease might a 'jerky' pulse be felt?
HOCM
110
What is the inheritance pattern of HOCM?
Autosomal dominant
111
How can HOCM cause sudden death?
Can cause spontaneous VF/VT
112
How might the JVP be abnormal in a patient with HOCM?
Large a waves
113
What are the 3 key features of HOCM on echo?
Mitral regurgitation
Systolic anterior motion (SAM)
Asymmetric hypertrophy
114
Recall some general principles of HOCM management
A to E
Amiodarone
Beta blockers
Cardioverter defibrillator
Dual chamber pace maker
Endocarditis prophylaxis
115
What are the classical clinical signs of pulmonary oedema?
Reduced exercise tolerance
Raised jugular venous pressure
Audible third heart sound
116
Which electrolyte abnormalities may cause torsades de pointes?
Hypocalcaemia
Hypokalaemia
Hypomagnesaemia
117
Name 2 drugs that can increase the effect of warfarin
Metronidazole
Sertralline
118
Name one drug that can decrease the effect of warfarin
Phenobarbital
119
When should DC cardioversion be attempted before chemical cardioversion for a tachyarrhythmia?
If SBP \<90
120
What should an inferior MI + aortic regurgitation raise suspicion of?
Ascending aortic dissection
121
When would thrombolysis be the first line for treating PE, rather than anticoagulative medicines?
If circulatory collapse - eg hypotension
122
What is the antibiotic of choice in native valve infective endocarditis?
IV amoxicillin
123
What should the initial management be for patients with bradycardia and signs of shock?
500micrograms of atropine (repeated up to max 3mg)
124
What ECG abnormality is most likely in hypercalcaemia?
Lengthened QT interval
125
What are prominent V waves in the JVP indicative of?
Tricuspid regurgitation
126
What are cannon A waves in the JVP indicative of?
Complete heart block
127
What is a prominent x descent in the JVP indicative of?
Can be caused by:
Acute cardiac tamponade
Constrictive pericarditis
128
Which 2 beta blockers have been proven to be effective in stable heart failure?
Carvedilol and bisoprolol
129
What are the 3 most-commonly used drugs for treating NSTEMI medically?
Aspirin, ticagrelor, and fondaparinux
| (Take special care to avoid GTN in hypotensive patients)
130
When would you NOT use flecainide for rate control?
In structurally abnormal hearts (which includes those with a PMH of ischaemic heart disease)
131
What is Beurger's disease also known as?
Thromboangiitis obliterans
132
What are the symptoms of Beurger's disease?
Raynaud's syndrome, intermittent claudication and finger ulcerations
133
What is the biggest risk factor for Beurger's disease?
Smoking
134
What is the medical management of choice for conservative management of an NSTEMI?
Dual antiplatelet therapy:
Aspirin + clopidogrel/ ticagrelor
Clopidogrel if high bleeding risk, ticagrelor if low bleeding risk
135
What is the biggest risk factor for renal impairment following prescription of an ACE inhibitor?
If the patient already has bilateral renal artery stenosis it can cause significant renal impairment
136
What is radiofemoral delay a sign of?
Aortic coarctation
137
Which congenital condition is strongly associated with aortic coarctation?
Turner's
138
In which arrhythmia is verapamil contraindicated and why?
Ventricular tachycardia
Verapamil is a CCB - may reduce cardiac contractility
139
Recall the location on the praecordium where each valve is best auscultated
Aortic: Right 2nd ICS
Pulmonary: Left 2nd ICS
Tricuspid: left 4th ICS at sternal border
Mitral: left 5th ICS, MCL
140
Where is aortic regurgitation best auscultated
Tricuspid area: left 3rd ICS parasternally (Erb's point)
141
At what point in the breathing cycle is aortic regurgitation best auscultated, and in which position?
End expiration
Sat up and forward
Put stethoscope at Erb's point
142
Why are right-sided murmurs louder on inspiration?
Increased venous return to the RHS
143
Recall 2 types of murmur that are louder when there is LESS blood flow across the affected area
HOCM murmurs
Mitral valve prolapse
144
Which murmur is best auscultated when the patient is in the left lateral decubitus position?
Mitral stenosis
145
Which murmurs can radiate? Where do they radiate to?
Aortic stenosis --\> carotids
Mitral regurgitation --\> axilla
146
Describe the meaning of each of the 6 grades of heart murmur
Grade 1 - Difficut to hear
Grade 2 - Quiet
Grade 3 - Easy to hear
Grade 4 - Easy to hear with a palpable thrill
Grade 5 - Easy to hear with stethoscope barely touching chest
Grade 6 - Easy to hear with stethoscope away from patient
147
How does mitral stenosis vs regurgitation affect the heart structurally and why?
Stenosis --\> atria have to work really hard to push blood through valve --\> hypertrophic left artium
Regurgitation --\> backflow of blood into atria stretches chamber --\> left atrial dilatation
148
What are the 2 main possible causes of mitral stenosis?
Rheumatic heart disease is the most common (learn!)
Infective endocarditis
149
Why do you get a loud S1 in mitral stenosis?
Thickened valve needs a large systolic force to shut - once this systolic threshold is met the valve will shut very suddenly
150
What is the cause of malar flush in patients with mitral stenosis?
Backflow of blood into the pulmonary system --\> rise in CO2 and vasodilation
151
What is the link between mitral regurgitation and congestive heart failure?
Backflow of blood --\> reduced ejection fraction
--\> backlog of blood waiting to pass through left side of heart
152
What are the possible causes of mitral regurgitation and which of them is most common?
Age-related weakening is most common
Also associated with:
- IHD
- Infective endocarditis
- Rheumatic heart disease
- Connective tissue disease (EDS/Marfan's)
153
Which type of valve disease is associated with exertional syncope and why?
Aortic stenosis
Difficulty perfusing brain
154
What is the most common cause of aortic stenosis?
Idiopathic age-related calcification
155
What is Corrigan's pulse?
Also known as collapsing pulse
Pulse rapidly appears and then disappears
156
Recall 2 causes of aortic regurgitation
Age-related calcification
Connective tissue disease
157
What is paroxysmal nocturnal dyspnoea?
Waking up suddenly in the night feeling acutely SOB with a really bad cough/ wheeze
They have to get up and gasp for air
Symptoms typically improve after a few minutes
158
What is the mechanism of PND (3 aspects)?
1. Lying flat --\> fluid settling across large surface area of lungs
2. Respiratory centre in the brain is less responsive during sleep - so lungs can become much more congested that they would normaly do before they wake up
3. Adrenaline levels are much lower at night so myocardium is more relaxed --\> reduced CO
159
Recall the immediate management of rheumatic fever
Aspirin prn
Benzylpenicillin IM stat
10 day course of benzylpenicillin PO
160
When in the course of rheumatic fever/heart disease is valve imcompetence most likely?
Acutely
161
Which murmur is best heard at the apex with the bell of the stethoscope?
Mitral stenosis
162
Is pericarditis more commonly viral or bacterial?
Viral
163
ST elevation in which leads would represent an anteroseptal STEMI?
V1-V4
164
In the setting of acute pulmonary oedema post MI, how can severe hypotension be managed?
CPAP - it effectively pushes fluid out of your lungs
165
Which artery is occluded in an anterior MI?
Left anterior descending
166
Which artery is occluded in an anterolateral MI?
Left anterior descending
167
Which artery is occluded in inferior MI?
Right coronary artery (RV branch included)
168
Which artery is occluded in a posterior MI?
Circumflex
169
In which leads would you see ST elevation in an inferior STEMI?
II, III, aVF
170
In which leads would you see ST elevation in an anterior STEMI?
V3, V4
171
In which leads would you see ST elevation in a lateral STEMI?
I, aVL, V5, V6
172
What is always the first thing to do in an acute exacerbation of heart failure?
Sit up and give 60-100% O2
173
Which valve is most commonly affected by strep viridians infective endocarditis, and why?
Mitral
Strep viridians usually associated with teeth (commensal there)
Affects mitral valve as this valve is under higher pressures than in right side of heart and so is under higher pressure
174
What is the most likely pathogen in infective endocarditis in IVDUs?
Staphylococcus
175
Recall some causes of atrial fibrillation
PIRATES:
Pulmonary cancer
Ischaemic heart disease
Rheumatic heart disease
Atrial myxoma/ alcohol binge
Thyrotoxicosis
Embolus
Sepsis
176
If you see a Q wave as well as ST elevation on an ECG, what does that mean?
Tissue death
177
What may appear to be an anterior STEMI on an ECG post-MI, that is not actually an anterior STEMI?
Left ventricular aneurysm
178
What class of drug is ticagrelor?
P2 Y12 inhibitor
179
When would heparin be used in MI management?
In cath lab prior to PCI to prevent thrombosis
180
Why does ticagrelor work more quickly than clopidogrel?
Clopidogrel is a pro-drug and so takes longer to work
181
Recall one diuretic that improves prognosis post-MI and one that isn't proven to
Improves prognosis: eplerenone
Does not improve prognosis: furosemide
182
How long can someone not drive for post-MI?
- Patients who are completeley revascularised with okay LVEF = 1 week
- Patients with severely reduced LVEF = 4 weeks
183
Recall 3 uses of SGLT2 inhibitors
Diabetes mellitus
Chronic kidney disease
Symptomatic chronic heart failure with reduced ejection fraction
184
What is sacubitril with valsartan used for?
Improves LVF in patients who are already on other heart failure therapy
185
How long after an MI might an ICD (implantable cardioverter defibrillator) be indicated?
40 days
186
Which drug should be held 48 hours before and after angiogram?
Metformin
187
How do you manage atrial flutter?
1. Treat underlying cause
2. Anticoagulate as you would for atrial fibrillation
If haemodynamically unstable: rate control or cardioversion
188
How would you manage SVT in an asthmatic patient in whom vagal manoevres have failed?
IV verapamil
189
How do you differentiate between aortic stenosis and sclerosis?
Aortic sclerosis is:
- normal in the elderly
- has a normal pulse (not narrow pulse pressure)
- No radiation
190
Recall 5 causes of raised JVP other than right-sided heart disease
Tricuspid regurgitation
Complete heart block
CCF
Pericardial effusion
SVC obstruction
191
Recall 5 complications of a prosthetic valve
Failure
Infection
Bleeding
Anaemia
Thromboembolic
192
Recall 3 causes of an irregularly irregular pulse that aren't AF
Ventricular etopics
Atrial flutter
Sinus arrhythmias
193
If in a suspected DVT the D-dimer is positive but the the USS is negative, what should you do?
Stop anticoagulation and repeat scan in one week
194
What is the most appropriate anti-anginal treatment in a pateint with known heart failure?
Bisoprolol (verapamil CI in the case of CF)
195
In ALS, when would 3 shocks be given instead of 1?
If arrest witnessed in the cath lab/ CCU/ critical care and rhythmn is VF/pVT
196
What should be the initial drug treatment for patients with low EF heart failure?
Bisoprolol + ramipril
197
Which class of abx can cause torsades de pointes?
Macrolides eg azithromycin
198
Why is a pericardial friction rub heard in pericarditis?
The inflammed visceral and parietal pericardium rub against each other
199
What is the basic pathophysiology of Sydenham's chorea?
Autoimmune reaction against the basal ganglia
200
What drug should be added to CPR for a patient in cardiac arrest if pulomnary emboli are suspected?
Alteplase
201
When would you *not* use IV beta blockers to treat fast AF, and hwat would you do instead?
In fast atrial fibrillation not associated with shock, syncope, myocardial ischaemia or heart failure - do up to 3 synchronised DC shocks instead
202
How can nitrate tolerance be prevented when prescribing isosorbide mononitrate?
Asymmetric dosing regimen
203
What complication of MI does the following describe: sudden heart failure, raised JVP, pulsus parodoxus
Left ventricular free wall rupture
204
What is the most useful blood test for detecting re-infarction post-MI?
CK-MB
