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YR6 Rotations > Medicine - Cardiology > Flashcards

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)

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2
Q

Define hypertension

A

Clinical BP >140/90 mmHg
or
24h BP average >135/85 mmHg

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3
Q

List 4 renal causes of secondary hypertension

A

Glomerulonephritis
Chronic pyelonephritis
Adult PKD
Renal artery stenosis

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4
Q

List 6 endocrine causes of secondary hypertension

A

Primary hyperaldosteronism
Phaeochromocytoma
Cushing’s syndrome
Liddle’s syndrome
Congenital adrenal hyperplasia
Acromegaly

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5
Q

List 5 other causes of secondary hypertension

A

Pregnancy
COCP
Coarctation of the aorta
NSAIDS
Glucocorticoids

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6
Q

List 3 symptoms that may be experienced from sever hypertension e.g. 200/120 mmHg

A

Headaches
Visual disturbance
Seizures

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7
Q

What investigations can be used to detect end-organ damage in hypertension?

A

Fundoscopy: hypertensive retinopathy
Urine dip: renal disease (cause/ consequence)
ECG: LV hypertrophy/ ischaemic heart disease

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8
Q

What bloods should be performed following hypertension diagnosis?

A

U+Es: renal disease (cause/ consequence)
HbA1c: co-existing DM
Lipids: co-existing hyperlipidaemia

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9
Q

List 3 common side effects of ACE inhibitors

A

Cough
Angioedema
Hyperkalaemia

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10
Q

What monitoring requirement applies to ACE inhibitors?

A

Renal function must be checked 2-3w after initiation due to risk of worsening renal function in patients with renovascular disease

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11
Q

3 side effects of calcium channel blockers

A

Flushing
Ankle swelling
Headache

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12
Q

MOA of thiazide type diuretics

A

Inhibit sodium absorption at the beginning of the distal convoluted tubule

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13
Q

3 side effects of thiazide type diuretics

A

Hyponatraemia
Hypokalaemia
Dehydration

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14
Q

Name 1 side effect of angiotensin II receptor blockers

A

Hyperkalaemia

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15
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

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16
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

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17
Q

How can you hear the difference between an S3 and S4 heart sound?

A

S3 is early diastolic

S4 is late diastolic

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18
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

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19
Q

What might a CXR reveal in aortic stenosis?

A

Left ventricular hypertrophy
Pulmonary oedema
Valve calcification

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20
Q

What is the most useful investigation for assessing the severity of aortic stenosis?

A

Echo +/- doppler

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21
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

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22
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

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23
Q

What does CABG stand for?

A

Coronary artery bypass graft

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24
Q

What are the 2 main types of artificial aortic valve?

A

Ball-in-cage

Bileaflet/ tilting disc

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25
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

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26
Q

What is a balloon aortic valvuloplasty

A

Procedure which stretches the aortic valve to improve symptoms of aortic stenosis

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27
Q

When is the aortic stenosis murmur heard vs aortic regurgitation?

A

AS: Ejection systolic
AR: Early diastolic

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28
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
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29
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

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30
Q

Which heart murmurs are best heard on expiration?

A

Left heart murmurs

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31
Q

Where is the aortic regurgitation murmur best auscultated?

A

Erb’s point - Left 3rd ICS parasternal

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32
Q

Where is the main site of production of BNP?

A

Left ventricle (not actually brain, as name may suggest)

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33
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

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34
Q

What can an echo and doppler be used to determine in cases of aortic regurgitation?

A

Severity
LV function
Cause

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35
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)

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36
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)

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37
Q

Which heart murmur is most associated with atrial fibrillation?

A

Mitral stenosis

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38
Q

Which of the left heart murmurs will NOT produce a displaced apex beat?

A

Mitral stenosis (causes atrial hypertrophy not ventricular)

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39
Q

By what mechanism can heart valve disease cause a parasternal heave, and which murmurs can cause this?

A

Right ventricular hypertrophy (RVH) is cause of PSH (RV 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

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40
Q

Why might the apex beat be displaced in mitral regurgitation?

A

Left ventricle is pumping the stroke volume AND the regurgitant volume

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41
Q

Differentiate the timing of mitral stenosis and mitral regurgitation

A

Mitral stenosis is a MID DIAstolic murmur
Mitral regurgitation is a pan SYStolic murmur

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42
Q

Which of the heart murmurs might radiate to the axilla?

A

Mitral regurgitation

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43
Q

Recall some clinical signs of pulmonary hypertension

A

Malar flush
Raised JVP
Right ventricular (parasternal) heave
Loud S2

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44
Q

What might be seen on an ECG in mitral valve disease

A 
Atrial fibrillation 
P mitrale (bifid 'm-shaped' p waves in lead II as well as V1-V6)
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45
Q

What is the mainstay of medical management for mitral stenosis, other than heart disease risk modification eg statins?

A

RhF prophylaxis with benzylpenicillin
AF (rate control + DOAC)
Diuretics for symptomatic relief

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46
Q

What is the first line surgical treatment for mitral stenosis?

A

Balloon valvuloplasty

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47
Q

What is the mainstay of medical management for mitral regurgitation (other than managing cardiac risk with statins etc)?

A

Like AR, reduce afterload - can use:
ACE inhibitors (eg enalopril/ captopril)
Beta blockers (bisoprolol etc)
Diuretics (furosemide etc)

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48
Q

What are the classifications of heart failure based on ejection fraction?

A

LV EF >50% - preserved = HF-PEF
LV EF 41-49% - mildly reduced = HFmrEF
LV EF <40% - reduced = HFrEF

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49
Q

What are the 3 most common causes of chronic heart failure?

A

Coronary artery disease
DM
HTN

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50
Q

List 4 cardiac causes of heart failure

A

Valvular disease e.g. aortic stenosis
Cardiomyopathies
Constrictive pericarditis
Arrhythmias e.g. AF

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51
Q

What is heart failure?

A

Syndrome with typical Sx (SOB, ankle swelling, fatigue) + signs (elevated JVP, basal crepitations + peripheral oedema)

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52
Q

Give 4 symptoms of chronic heart failure

A

Breathlessness: exertional, rest, orthopnoea, PND
Fluid retention: ankle swelling, bloating, weight gain
Fatigue: decreased exercise tolerance/ increased recovery time
Lightheadedness/ hx of syncope

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53
Q

Give 3 signs of heart failure on examination

A

Tachycardia
S3/S4 gallop
Pulsus alternans

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54
Q

Give 3 findings on examination of a patient with left heart failure

A

Bibasal fine crackles/ rales
Laterally displaced apex beat (cardiomegaly)
Coolness + pallor of lower extremities

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55
Q

Give 5 findings on examination of a patient with right heart failure

A

Peripheral pitting oedema
Raised JVP
Hepatosplenomegaly
Weight gain due to fluid retention
Anorexia (‘cardiac cachexia’)

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56
Q

Describe briefly the NYHA classifications

A
  1. no limitation on activity
  2. comfortable at rest but dyspnoea on ordinary activity
  3. marked limitation on ordinary activity
  4. dyspnoea at rest
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57
Q

What is the first line investigation for heart failure?

A

NT-proBNP
High (>2000): refer urgently for assessment + TOE within 2w
Raised (>400): refer for assessment + TOE within 6w

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58
Q

What complimentary investigations should be performed in heart failure?

A

ECG
CXR
Bloods: FBC, U+Es, GFR, TFTs, LFTs, HbA1c + lipids
Urine dip (protein + blood)
Lung function tests: peak flow/ spirometry

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59
Q

Name 3 factors that can cause reduced BNP

A

Obesity (BMI >35)
Afro-carribbean
Drugs

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60
Q

List 5 drug classes that can reduce BNP

A

ACEi
B-blockers
ARBs
Aldosterone antagonists
Diuretics

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61
Q

List 11 factors that elevate BNP

A

Age >70
Sepsis
LV hypertrophy, myocardial ischaemia, tachycardia
RV overload
Hypoxia
Pulmonary HTN
Pulmonary embolism
CKD
COPD
DM
Cirrhosis

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62
Q

Recall the broad approach to medically managing heart failure

A

BASHeD up by the heart:
Beta blocker: bisoprolol, carvedilol, nebivolol
ACE inhibitor
Spironolactone (2nd line/ Eplerenone)
Hydralazine (+ nitrate): inidicated in afro-carribbean
Digoxin: improves Sx. Indicated if co-existent AF

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63
Q

What third line therapies can be initiated by a specialist in heart failure?

A

Ivabradine: sinus rhythm, >75 bpm, LVEF <35%

Sacubitril-valsartan: LVEF <35%, following ACEi/ ARB washout period

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64
Q

Which anti-diabetic drug is used in heart failure with reduced ejection fraction?

A

SGLT-2 inhibitors: Dapaglifozin, Empagliflozin
Reduce glucose reabsorption + increase urinary glucose excretion

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65
Q

Which extra immunisations should be offered in patients with heart failure?

A

Annual influenza
Pneumococcal

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66
Q

What must be monitored whilst patients are on spironolactone?

A

Potassium (as is a potassium-sparing diuretic)

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67
Q

Recall some drugs that are contra-indicated in heart failure

A

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

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68
Q

What is high output heart failure?

A

Where a ‘normal’ heart is unable to pump enough blood to meet metabolic needs

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69
Q

List 6 causes of high output heart failure

A

Anaemia
AV malformation
Paget’s disease
Pregnancy
Thyrotoxicosis
Thiamine deficiency (wet Beri-Beri)

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70
Q

What is acute heart failure?

A

Sudden onset / worsening of Sx of HF
No hx HF = de novo AHF
Hx HF = decompensated AHF

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71
Q

What causes de-novo heart failure

A

Increased cardiac filling pressures + myocardial dysfunction usually as a result of ischaemia
Causes reduced CO + hypoperfusion, this can cause pulmonary oedema

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72
Q

Give 4 common precipitants to decompensated AHF

A

Acute coronary syndrome
Hypertensive crisis
Acute arrhythmia
Valvular disease

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73
Q

List 3 symptoms of acute heart failure

A

Breathlessness
Reduced exercise tolerance
Fatigue

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74
Q

List 7 signs of acute heart failure

A

Cyanosis
Tachycardia
Oedema
Elevated JVP
Displaced apex beat
Chest signs: bibasal crackles + wheeze
S3 heart sound

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75
Q

Describe the diagnostic work up for acute heart failure

A

Bloods: anaemia, abnormal electrolytes, infection
CXR: pulmonary venous congestion, interstitial oedema, cardiomegaly
Echo
BNP: >100mg/l support dx + indicate myocardial damage

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76
Q

What is recommended for all patients with acute heart failure?

A

IV Loop diuretics e.g. Furosemide or Bumetanide

+/- O2 to keep sats 94-98%

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77
Q

What management needs to be considered in acute heart failure with hypotension/ cardiogenic shock?

A

Inotropic agents e.g. Dobutamine

Vasopressor agents e.g. Norepinephrine

Mechanical circulatory assistance e.g. intra-aortic balloon counter pulsation/ ventricular assist devices

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78
Q

How quickly should GTN spray relieve angina pain?

A

Within 5 mins

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79
Q

What is the first line investigation for angina in stable patients, and what score is this investigation used to calculate?

A

CT coronary angiography
Calcium score

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80
Q

What are some pharmacological options for preventing angina (NOT symptomatic relief)?

A

Aspirin (75mg, OD)
Atorvastatin (80mg, ON)
ACE inhibitor (esp. if co-existent DM)
Antihypertensives

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81
Q

What calcium score would be classified as low risk, and what score would be high risk?

A

Low risk < 100
High risk > 400

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82
Q

What care needs to be taken when prescribing CCBs and BBs together?

A

If you prescribe a non-dihydropyrimidine CCB (eg verapamil) with a BB it can cause complete heart block

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83
Q

What are some medical options for managing angina symptoms?

A

1st line: GTN (spray or sublingual) + b-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

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84
Q

What are the 3 types of AF?

A

Paroxysmal: episodes >30s <7 days (often <48h), self-terminating + recurrent

Persistent: episodes >7 days or <7d requiring cardioversion

Permanent: cardioversion fails to terminate/ has relapsed within 24h or longstanding >1y when cardioversion not indicated/ attempted

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85
Q

List the 7 cardiac/ valvular causes of atrial fibrillation

A

Congestive HF
Atrial/ Ventricular dilation/ hypertrophy
Pre-excitation syndromes
Sick sinus syndrome
Congenital HD
Inflammatory/ infiltrative disease- pericarditis, amyloidosis, myocarditis
RHD

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86
Q

What 3 conditions is atrial fibrillation most commonly associated with?

A

HTN
Coronary artery disease
MI

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87
Q

List 7 non-cardiac causes of AF

A

PEACHES
P- PE
E- Endo: Thyrotoxicosis, Phaeo
A- Alcohol
C- Caffeine
H- Hypothermia
E- Electrolyte abnormality
S- Sepsis/ acute infection

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88
Q

4 S/S of AF

A

Palpitations
Dyspnoea
Chest pain
Irregularly irregular pulse

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89
Q

ECG characteristics of AF

A

No p waves (irregular baseline)
Irregular QRS
Often 160-180bpm

Normal shape QRS (AVN conduction normal)
Normal T

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90
Q

What bloods should be taken in AF?

A

FBC: anaemia, infection
TFTs: Thyrotoxicosis
U+Es: electrolyte abnormalities

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91
Q

Why is cardioversion only suitable for patients with short duration of symptoms or those who have been anticoagulated?

A

Switching from AF to sinus rhythm could suddenly push a thrombus out of the atrium

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92
Q

How should new onset AF be managed if haemodynamically unstable?

A

Anticoagulate with LMWH: Enoxaparin
Synchronised DC Cardioversion

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93
Q

When is the shock delivered in synchronised DC cardioversion?

A

Synchronised to the R wave to prevent delivery during vulnerable period of cardiac repolarisation (would induce ventricular fibrillaiton)

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94
Q

If a CHA2DS2VASc score suggests no need for anticoagulation what must be done?

A

TTE to r/o valvular heart disease
In combination with AF is an absolute indication for anticoagulation

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95
Q

What anticoagulation approach should be taken in AF?

A

Immediate LMWH (Enoxaparin)
Transition to DOAC

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96
Q

When is rhythm control indicated (instead of rate control)?

A

Reversible cause
Co-existent HF caused by AF
New onset AF <48h
Atrial flutter if suitable for ablation strategy

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97
Q

What parameters make the CHA2DS2VASc score?

A

Congestive heart failure
HTN (inc. treated HTN)
Age >75 (2) or >65 (1)
DM
Stroke, TIA or Thromboembolism
Vascular disease: IHD, PAD
Sex (F)

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98
Q

What is indicated by the CHA2DS2VASc score?

A

0: No Tx
1: Consider anticoagulation in M. No Tx in F
>,2: Offer anticoagulation

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99
Q

What tool is used to assess bleeding risk? What are the parameters?

A

ORBIT
Hb <130 in M or <120 in F (2)
Age >74y
Bleeding Hx: GI/ Intracranial bleed or haemorrhagic stroke (2)
Renal impairmentL GFR <60
Tx with antiplatelet agents

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100
Q

How is ORBIT score interpreted?

A

0-2: Low risk
3: Medium risk
4-7: High risk

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101
Q

What drugs can be used first line for rate control in AF?

A

B-blocker: Metoprolol, Propanolol, Atenolol
Rate-limiting CCB: Diltiazem, Verapamil

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102
Q

What is the second line approach to rate control in AF?

A

Combination therapy with any 2 of:
B-Blocker
Diltiazem
Digoxin

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103
Q

Which anticoagulants are indicated in AF?

A

DOACs
Apixaban
Dabigatran
Edoxaban
Rivaroxaban

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104
Q

Which drugs can be used for pharmacological cardioversion?

A

Flecainide (if no structural heart disease)
Amiodarone

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105
Q

How does anti-clotting drug choice differ following a stroke, depending on whether or not they have AF?

A

If they have AF: anti-coagulant (DOAC or warfarin if DOAC is CI)

If they do NOT have AF: anti-platelet

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106
Q

Why are anti-platelets not used in AF?

A

Anti-platelets are specifically for artherogenic causes of clots eg atheroma

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107
Q

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?

A

AF <48h duration + 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

108
Q

For how long before and after cardioversion for arrhythmia should a patient be anti-coagulated?

A

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

109
Q

How can chadsvasc score be used to determine the need for longterm anticoagulation?

A

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

110
Q

What is the main contraindication to be aware of for all CCBs?

A

Peripheral oedema (increased capillary hydrostatic pressure that results from greater dilation of pre-capillary than post-capillary vessels)

111
Q

What are the 1st, 2nd and 3rd line options for rate control in AF?

A

1st line: beta blocker or CCB (verapamil is better than dilitiazem)
2nd line: digoxin
3rd line: amiodarone

112
Q

With what waveform on the ECG should DC cardioversion be synchronised?

A

R wave
If synchronised with T wave it can cause VT

113
Q

Recall 2 options for chemical cardioversion, and any important indications/ contra-indications for each

A

Flecainide: if young + no structural heart disease
Amiodarone: in structural heart disease (eg HF)

114
Q

Recall 2 surgical options for managing AF

A
  1. Radiofrequency ablation of AV node
  2. Maze procedure
115
Q

Recall the components of the CHA2DS2VASc score

A

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

116
Q

In HTN, what BP is defined as ‘severe’?

A

>180/110

117
Q

What is the first line treatment for HTN for diabetics?

A

ACE inhibitor

118
Q

What is the first line treatment for HTN for black Africans?

A

CCB

119
Q

What is the first line treatment for HTN for under vs over 55s who are not diabetic or Black African?

A

<55: ACE inhibitor or ARB
>55: CCB

120
Q

Recall some side effects of ACE inhibitors

A

Angioedema (for around 4w), cough, hyperkalaemia

121
Q

Recall the name of one thiazide-like diuretic

A

Indapamide
nb bendroflumethiazide is thiazide, not thiazide-like

122
Q

What side effect of thiazide diuretics may be useful for non-cardiac disease?

A

Hypercalcaemia
Causes hypocalciuria which may reduce incidence of renal stones

123
Q

Why do CCBs cause oedema?

A

Cause dilation of arterioles but not venules

124
Q

What is the atorvastatin dose for primary vs secondary prevention?

A

Primary prevention: 20mg OD
Secondary prevention: 80mg OD

125
Q

What is the most commonly affected heart valve in infective endocarditis when the patient is an IVDU?

A

Tricuspid

126
Q

What is the most common pathogen to cause an acute presentation of infective endocarditis?

A

Strep epidermidis

127
Q

How does strep viridans infective endocarditis most commonly present?

A

Subacute presentation, most commonly in the developing world

128
Q

What is Libman-Sacks endocarditis?

A

Non-infective endocarditis caused by SLE

129
Q

Differentiate the empirical antibiotics used in native vs prosthetic valves affected by infective endocarditis

A

Native valve: amoxicillin +/- gentamicin
Prosthetic valve: vancomycin + rifampicin + gentamicin

130
Q

How far apart should blood cultures be taken to investigate infective endocarditis?

A

12 hours

131
Q

What is the most likely pathogen to cause rheumatic fever?

A

GAS (strep pyogenes)

132
Q

What is the broad pathophysiology of rheumatic fever?

A

AB cross reactivity with myosin, muscle glycogen and VSMC

133
Q

What is the latent period between pharyngeal infection and onset of rheumatic fever?

A

2-6 weeks

134
Q

Recall some of the key symptoms of rheumatic fever

A

Pericarditis
Polyarthritis
Erythema marginatum

135
Q

What are sydenham’s chorea?

A

Unwanted jerky movements that appear 2-6 months following rheumatic fever

136
Q

Recall the Duckett-Jones diagnostic criteria

A

For diagnosing rheumatic fever:
CASES (major) FRAPP (minor)
Carditis
Arthritis
Sydenham’s chorea
Erythema marginatum
Subcutaneous nodules

137
Q

What is the antibiotic treatment recommended in rheumatic fever?

A

Phenoxymethylpenicillin QDS 10/7

138
Q

What drugs can be used to treat sydenham’s chorea?

A

Haloperidol
Diazepam

139
Q

How long does penicillin treatment need to continue following an episode of rheumatic fever to prevent rheumatic heart disease?

A

If carditis + residual heart disease: 10y or until age 40 (whichever is longer), possibly lifetime

If carditis but NO residual heart disease: 10y or until age 21 (whichever is longer)

If NO carditis: 5y or until age 21 (whichever is longer)

140
Q

What is ‘fibrinous’ pericarditis?

A

Pericarditis caused by uraemia

141
Q

Recall some signs and symptoms of pericarditis

A

Pleuritic chest pain
Non-productive cough
Dyspnoea
Flu-like symptoms
Pericardial rub
Tachypnoea + tachycardia

142
Q

What are the typical ECG findings in pericarditis?

A

Widespread PR depression or saddle-shaped ST elevation

143
Q

How should pericarditis be broadly managed?

A

Treat cause
NSAIDs + colchicine

144
Q

Recall some cardiac causes of clubbing

A

Atrial myxoma
Cyanotic heart disease
Infective endocarditis

145
Q

What can cause a collapsing pulse other than aortic regurgitation?

A

Pregnancy
Thyrotoxicosis
Anaemia

146
Q

What do the S1 and S2 heart sounds represent?

A 
S1 = mitral valve closure 
S2 = aortic valve closure
147
Q

What would cause a split S1?

A

Mitral + tricuspid valve closing at different times - normal in some

148
Q

What are the 2 types of purely genetic primary cardiomyopathy?

A

HOCM
Arrhythmogenic right ventricular dysplasia

149
Q

What are the 2 types of purely acquired primary cardiomyopathy?

A

Peripartum cardiomyopathy
Takotsubo cardiomyopathy

150
Q

Recall 2 types of primary cardiomyopathy that have mixed genetic/ acquired causes?

A

Dilated cardiomyopathy
Restrictive cardiomyopathy

151
Q

Recall 4 possible causes of dilated cardiomyopathy

A

Alcohol
Cocksackie B
Wet beri beri
Doxorubicin

152
Q

Recall 3 possible causes of restrictive cardiomyopathy

A

Amyloidosis
Post-radiotherapy
Loeffler’s endocarditis (due to eosinophillic infiltration)

153
Q

What is the most common gene mutation causing HOCM?

A

Beta-myosin heavy chain protein mutation

154
Q

What would the following echo findings be suggestive of:
Mitral regurgitation
Systolic anterior motion of the anterior mitral valve
Asymmetrical septal hypertrophy

A

HOCM

155
Q

What is arrhythmogenic right ventricular dysplasia?

A

Replacement of RV myocardium with fatty + fibrofatty tissue

156
Q

What is the following description of an abnormal ECG most suggestive of:
Abnormalities in V1-3, typically T wave inversion. Possible epsilon wave.

A

Arrhythmogenic right ventricular dysplasia

157
Q

What would the following echo findings be suggestive of:
All 4 heart chambers dilated
Tricuspid and mitral regurgitation

A

Dilated cardiomyopathy

158
Q

What condition does the following describe: “transient, apical ballooning of the myocardium”?

A

Takotsubo cardiomyopathy

159
Q

Recall some causes of secondary cardiomyopathy

A

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)

160
Q

Why is long QT syndrome dangerous?

A

Can cause VT –> death

161
Q

Recall 2 causes of congenital long QT syndrome, and how they can be differetiated?

A

Jervell-Lange-Nielsen syndrome (deafness)
Romano-Ward syndrome (no deafness)

162
Q

Recall some drugs that can cause long QT syndrome

A

METH CATS
Methadone
Erythromycin
Terfenadine
Haloperidol

Clarithromycin
Amiodarone/ arythromycin
TCAs
SSRIs (esp. citalopram)

163
Q

What is the 1st line management of torsades de pointes?

A

IV magnesium sulphate

164
Q

What is torsades de pointes?

A

A type of polymorphic VT that is a/w QT prolongation

165
Q

How much does BP have to drop on standing to classify as ‘orthostatic hypertension’?

A

Over 3 mins, BP needs to fall by 20/10

166
Q

What is pulsus paradoxus, and in which conditions would it be seen?

A

>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

167
Q

What is pulsus alternans and in which condition is it seen?

A

Regular alternation of the force of the arterial pulse
Seen in severe LVF

168
Q

In which disease might a ‘jerky’ pulse be felt?

A

HOCM

169
Q

What is the inheritance pattern of HOCM?

A

Autosomal dominant

170
Q

How can HOCM cause sudden death?

A

Can cause spontaneous VF/VT

171
Q

How might the JVP be abnormal in a patient with HOCM?

A

Large a waves

172
Q

What are the 3 key features of HOCM on echo?

A

Mitral regurgitation
Systolic anterior motion (SAM)
Asymmetric hypertrophy

173
Q

Recall some general principles of HOCM management

A

A to E
Amiodarone
B-blockers
Cardioverter defibrillator
Dual chamber pace maker
Endocarditis prophylaxis

174
Q

What are the classical clinical signs of pulmonary oedema?

A

Reduced exercise tolerance
Raised jugular venous pressure
Audible 3rd heart sound

175
Q

Which electrolyte abnormalities may cause torsades de pointes?

A

Hypokalaemia
Hypomagnesaemia
Hypocalcaemia

176
Q

Name 2 drugs that can increase the effect of warfarin

A

Metronidazole
Sertralline

177
Q

Name one drug that can decrease the effect of warfarin

A

Phenobarbital

178
Q

When should DC cardioversion be attempted before chemical cardioversion for a tachyarrhythmia?

A

If SBP <90

179
Q

What should an inferior MI + aortic regurgitation raise suspicion of?

A

Ascending aortic dissection

180
Q

When would thrombolysis be the first line for treating PE, rather than anticoagulative medicines?

A

If circulatory collapse - eg hypotension

181
Q

What is the antibiotic of choice in native valve infective endocarditis?

A

IV amoxicillin

182
Q

What should the initial management be for patients with bradycardia and signs of shock?

A

500micrograms of atropine (repeated up to max 3mg)

183
Q

What ECG abnormality is most likely in hypercalcaemia?

A

Shortened QT interval

184
Q

What are prominent V waves in the JVP indicative of?

A

Tricuspid regurgitation

185
Q

What are cannon A waves in the JVP indicative of?

A

Complete heart block

186
Q

What is a prominent x descent in the JVP indicative of?

A

Can be caused by:
Acute cardiac tamponade
Constrictive pericarditis

187
Q

Which 2 beta blockers have been proven to be effective in stable heart failure?

A

Carvedilol and bisoprolol

188
Q

What are the 3 most-commonly used drugs for treating NSTEMI medically?

A

Aspirin, ticagrelor, and fondaparinux

(Take special care to avoid GTN in hypotensive patients)

189
Q

When would you NOT use flecainide for rate control?

A

In structurally abnormal hearts (which includes those with a PMH of ischaemic heart disease)

190
Q

What is Beurger’s disease also known as?

A

Thromboangiitis obliterans

191
Q

What are the symptoms of Beurger’s disease?

A

Raynaud’s syndrome
Intermittent claudication
Finger ulcerations

192
Q

What is the biggest risk factor for Beurger’s disease?

A

Smoking

193
Q

What is the medical management of choice for conservative management of an NSTEMI?

A

Dual antiplatelet therapy:
Aspirin + clopidogrel/ ticagrelor
Clopidogrel if high bleeding risk, ticagrelor if low bleeding risk

194
Q

What is the biggest risk factor for renal impairment following prescription of an ACE inhibitor?

A

If the patient already has bilateral renal artery stenosis it can cause significant renal impairment

195
Q

What is radiofemoral delay a sign of?

A

Aortic coarctation

196
Q

Which congenital condition is strongly associated with aortic coarctation?

A

Turner’s

197
Q

In which arrhythmia is verapamil contraindicated and why?

A

Ventricular tachycardia
Verapamil is a CCB - may reduce cardiac contractility

198
Q

Recall the location on the praecordium where each valve is best auscultated

A

Aortic: Right 2nd ICS
Pulmonary: Left 2nd ICS
Tricuspid: left 4th ICS at sternal border
Mitral: left 5th ICS, MCL

199
Q

Where is aortic regurgitation best auscultated

A

Tricuspid area: left 3rd ICS parasternally (Erb’s point)

200
Q

At what point in the breathing cycle is aortic regurgitation best auscultated, and in which position?

A

End expiration
Sat up and forward
Put stethoscope at Erb’s point

201
Q

Why are right-sided murmurs louder on inspiration?

A

Increased venous return to the RHS

202
Q

Recall 2 types of murmur that are louder when there is LESS blood flow across the affected area

A

HOCM murmurs
Mitral valve prolapse

203
Q

Which murmur is best auscultated when the patient is in the left lateral decubitus position?

A

Mitral stenosis

204
Q

Which murmurs can radiate? Where do they radiate to?

A

Aortic stenosis –> carotids
Mitral regurgitation –> axilla

205
Q

Describe the meaning of each of the 6 grades of heart murmur

A

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

206
Q

How does mitral stenosis vs regurgitation affect the heart structurally and why?

A

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

207
Q

What are the 2 main possible causes of mitral stenosis?

A

Rheumatic heart disease is the most common
Infective endocarditis

208
Q

Why do you get a loud S1 in mitral stenosis?

A

Thickened valve needs a large systolic force to shut - once this systolic threshold is met the valve will shut very suddenly

209
Q

What is the cause of malar flush in patients with mitral stenosis?

A

Backflow of blood into the pulmonary system –> rise in CO2 and vasodilation

210
Q

Why does mitral stenosis sometimes present with haemoptysis?

A

Increased pressures cause rupture of pulmonary vessels

211
Q

What is the link between mitral regurgitation and congestive heart failure?

A

Backflow of blood –> reduced ejection fraction
–> backlog of blood waiting to pass through left side of heart

212
Q

What are the possible causes of mitral regurgitation and which of them is most common?

A

Age-related weakening is most common
Also associated with:
- IHD
- Infective endocarditis
- Rheumatic heart disease
- Connective tissue disease (EDS/ Marfan’s)

213
Q

Which type of valve disease is associated with exertional syncope and why?

A

Aortic stenosis
Difficulty perfusing brain

214
Q

What is the most common cause of aortic stenosis?

A

Idiopathic age-related calcification

215
Q

What is Corrigan’s pulse?

A

Also known as collapsing pulse
Pulse rapidly appears and then disappears

216
Q

Recall 2 causes of aortic regurgitation

A

Age-related calcification
Connective tissue disease

217
Q

What is paroxysmal nocturnal dyspnoea?

A

Waking up suddenly in the night feeling acutely SOB with a really bad cough/ wheeze
They have to get up + gasp for air
Sx typically improve after a few minutes

218
Q

What is the mechanism of PND (3 aspects)?

A
  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
219
Q

Recall the immediate management of rheumatic fever

A

Aspirin prn
Benzylpenicillin IM stat
10 day course of benzylpenicillin PO

220
Q

When in the course of rheumatic fever/heart disease is valve imcompetence most likely?

A

Acutely

221
Q

Which murmur is best heard at the apex with the bell of the stethoscope?

A

Mitral stenosis

222
Q

Is pericarditis more commonly viral or bacterial?

A

Viral

223
Q

ST elevation in which leads would represent an anteroseptal STEMI?

A

V1-V4

224
Q

In the setting of acute pulmonary oedema post MI, how can severe hypotension be managed?

A

CPAP - it effectively pushes fluid out of your lungs

225
Q

Which artery is occluded in an anterior MI?

A

Left anterior descending

226
Q

Which artery is occluded in an anterolateral MI?

A

Left anterior descending

227
Q

Which artery is occluded in inferior MI?

A

Right coronary artery (RV branch included)

228
Q

Which artery is occluded in a posterior MI?

A

Circumflex

229
Q

In which leads would you see ST elevation in an inferior STEMI?

A

II, III, aVF

230
Q

In which leads would you see ST elevation in an anterior STEMI?

A

V3, V4

231
Q

In which leads would you see ST elevation in a lateral STEMI?

A

I, aVL, V5, V6

232
Q

What is always the first thing to do in an acute exacerbation of heart failure?

A

Sit up and give 60-100% O2

233
Q

Which valve is most commonly affected by strep viridians infective endocarditis, and why?

A

Mitral
Strep viridians usually a/w 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

234
Q

What is the most likely pathogen in infective endocarditis in IVDUs?

A

Staphylococcus

235
Q

Recall some causes of atrial fibrillation

A

PIRATES:
Pulmonary cancer
Ischaemic heart disease
Rheumatic heart disease
Atrial myxoma/ alcohol binge
Thyrotoxicosis
Embolus
Sepsis

236
Q

If you see a Q wave as well as ST elevation on an ECG, what does that mean?

A

Tissue death

237
Q

What may appear to be an anterior STEMI on an ECG post-MI, that is not actually an anterior STEMI?

A

Left ventricular aneurysm

238
Q

What class of drug is ticagrelor?

A

P2 Y12 inhibitor

239
Q

When would heparin be used in MI management?

A

In cath lab prior to PCI to prevent thrombosis

240
Q

Why does ticagrelor work more quickly than clopidogrel?

A

Clopidogrel is a pro-drug so takes longer to work

241
Q

Recall one diuretic that improves prognosis post-MI and one that isn’t proven to

A

Improves prognosis: eplerenone
Does not improve prognosis: furosemide

242
Q

How long can someone not drive for post-MI?

A

If completeley revascularised with okay LVEF = 1w
If severely reduced LVEF = 4w

243
Q

Recall 3 uses of SGLT2 inhibitors

A

Diabetes mellitus
Chronic kidney disease
Symptomatic chronic heart failure with reduced ejection fraction

244
Q

What is sacubitril with valsartan used for?

A

Improves LVF in patients who are already on other heart failure therapy

245
Q

How long after an MI might an ICD (implantable cardioverter defibrillator) be indicated?

A

40 days

246
Q

Which drug should be held 48 hours before and after angiogram?

A

Metformin

247
Q

How do you manage atrial flutter?

A
  1. Treat underlying cause
  2. Anticoagulate as you would for atrial fibrillation

If haemodynamically unstable: rate control or cardioversion

248
Q

How would you manage SVT in an asthmatic patient in whom vagal manoevres have failed?

A

IV verapamil

249
Q

How do you differentiate between aortic stenosis and sclerosis?

A

Aortic sclerosis is:

  • normal in the elderly
  • has a normal pulse (not narrow pulse pressure)
  • No radiation
250
Q

Recall 5 causes of raised JVP other than right-sided heart disease

A

Tricuspid regurgitation
Complete heart block
CCF
Pericardial effusion
SVC obstruction

251
Q

Recall 5 complications of a prosthetic valve

A

Failure
Infection
Bleeding
Anaemia
Thromboembolic

252
Q

Recall 3 causes of an irregularly irregular pulse that aren’t AF

A

Ventricular etopics
Atrial flutter
Sinus arrhythmias

253
Q

If in a suspected DVT the D-dimer is positive but the the USS is negative, what should you do?

A

Stop anticoagulation + repeat scan in 1w

254
Q

What is the most appropriate anti-anginal treatment in a pateint with known heart failure?

A

Bisoprolol (verapamil CI in the case of CF)

255
Q

In ALS, when would 3 shocks be given instead of 1?

A

If arrest witnessed in the cath lab/ CCU/ critical care and rhythmn is VF/pVT

256
Q

What should be the initial drug treatment for patients with low EF heart failure?

A

Bisoprolol + ramipril

257
Q

Which class of abx can cause torsades de pointes?

A

Macrolides eg azithromycin

258
Q

Why is a pericardial friction rub heard in pericarditis?

A

The inflammed visceral + parietal pericardium rub against each other

259
Q

What is the basic pathophysiology of Sydenham’s chorea?

A

Autoimmune reaction against the basal ganglia

260
Q

What drug should be added to CPR for a patient in cardiac arrest if pulomnary emboli are suspected?

A

Alteplase

261
Q

When would you not use IV beta blockers to treat fast AF, and hwat would you do instead?

A

In fast AF not a/w shock, syncope, myocardial ischaemia or heart failure - do up to 3 synchronised DC shocks instead

262
Q

How can nitrate tolerance be prevented when prescribing isosorbide mononitrate?

A

Asymmetric dosing regimen

263
Q

What complication of MI does the following describe: sudden heart failure, raised JVP, pulsus parodoxus

A

Left ventricular free wall rupture

264
Q

What is the most useful blood test for detecting re-infarction post-MI?

A

CK-MB

265
Q

What ECG findings are highly specific for critical stenosis of LAD? What is this indicative of?

A

Deep T wave inversion or biphasic T waves in V2-3
Wellens Syndrome: v high risk for extensive anterior wall MI within days-weeks

YR6 Rotations (22 decks)

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