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MCCQE1 > Medicine- cardiology > Flashcards

Medicine- cardiology Flashcards

1
Q

Non-ACS causes of raised troponin

A

Chronic renal failure

Sepsis

Myocarditis

Aortic dissection

Pulmonary embolism

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2
Q

Initial investigations in stable angina

A
  • Physical Examination (heart sounds, signs of heart failure, BMI)
  • ECG
  • FBC (check for anaemia)
  • U+Es (prior to ACEi and other meds)
  • LFTs (prior to statins)
  • Lipid profile
  • Thyroid function tests
  • HbA1C and fasting glucose
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3
Q

Treatment for acute NSTEMI

A

Acute NSTEMI treatment: BATMAN B –

Beta blockers unless contraindicated

A – Aspirin 300mg stat dose

T – Ticagrelor 180mg stat dose (clopidogrel 300mg is an alternative)

M – Morphine titrated to control pain

A – Anticoagulant: Low Molecular Weight Heparin (LMWH) at treatment dose (e.g. enoxaparin 1mg/kg twice daily for 2-8 days)

N – Nitrates (e.g. GTN) to relieve coronary artery spasm Give oxygen only if their oxygen saturations are dropping (i.e. <95%).

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4
Q

What is Dressler’s Syndrome?

A

This is also called post-myocardial infarction syndrome. It usually occurs around 2-3 weeks after an MI. It is caused by a localised immune response and causes pericarditis (inflammation of the pericardium around the heart). It is less common as the management of ACS becomes more advanced.

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5
Q

Secondary prevention after ACS

A

Secondary Prevention Medical Management (6 As)

Aspirin 75mg once daily

Another antiplatelet: e.g. clopidogrel or ticagrelor for up to 12 months

Atorvastatin 80mg once daily

ACE inhibitors (e.g. ramipril titrated as tolerated to 10mg once daily)

Atenolol (or other beta blocker titrated as high as tolerated)

Aldosterone antagonist for those with clinical heart failure (i.e. eplerenone titrated to 50mg once daily)

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6
Q

Some medical comorbidities which raise the risk of atherosclerosis

A

Diabetes

Hypertension

Chronic Kidney Disease

Inflammatory conditions such as rheumatoid arthritis

Atypical Antipsychotic Medications

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7
Q

Difference between primary and secondary prevention of cardiovascular disease

A

Primary Prevention – for patients that have never had cardiovascular disease in the past.

Secondary Prevention – for patients that have had angina, myocardial infarction, TIA, stroke or peripheral vascular disease.

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8
Q

Check LFTs within 3 months of starting a statin and again at 12 months why?

A

Statins can cause a transient and mild rise in ALT and AST in the first few weeks of use and they often don’t need stopping if the rise is less than 3 times the upper limit of normal.

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9
Q

Notable side effects of statins

A

Myopathy (check creatine kinase in patients with muscle pain or weakness)

Type 2 Diabetes

Haemorrhagic Strokes (very rarely)

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10
Q

Definition of stable angina

A

Angina is “stable” when symptoms are always relieved by rest or glyceryl trinitrate (GTN)

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11
Q

Gold standard diagnosis angina

A

CT Coronary Angiography

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12
Q

What should a person with angina who has chest pain 5 minutes after their second dose of GTN do?

A

Call an ambulance

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13
Q

Drugs (2) for long term symptomatic angina relief

A

Beta blocker (e.g. bisoprolol 5mg once daily) or;

Calcium channel blocker (e.g. amlodipine 5mg once daily)

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14
Q

Levine’s sign

A

Clutching fist over sternum when describing chest pain

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15
Q

TIMI Risk score factors

A

Historical (1 point for each factor) Age 65 yr 3 risk factors for CAD Known CAD (stenosis 50%) Aspirin use in past 7 d Presentation Recent (24 h) severe angina ST-segment deviation 0.5 mm Increased cardiac markers

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16
Q

How soon after a diagnosis of STEMI do you initiate reperfusion therapy?

A

Immediately and without waiting for other investigations

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17
Q

Goal of treatment for STEMI

A

Goal is to re-perfuse artery:

thrombolysis (“EMS-to-needle”) within 30 min or

primary PCI (“EMS-to-balloon”) within 90 min (if available)

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18
Q

Which is better in STEMI, thrombolysis or PTI?

A

Early PCI (12 h after symptom onset and <90 min after presentation) improves mortality vs. thrombolysis with fewer intra-cranial hemorrhages and recurrent MIs

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19
Q

Absolute contraindications to thrombolysis

A
  • Prior intracranial haemorrhage
  • Known vascular lesion
  • Intracranial neoplasm
  • Closed head or facial trauma
  • Ischaemic stoke <3months
  • Active bleeding
  • Suspected aortic dissection
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20
Q

Useful prognostic factor post STEMI

A

Resting LVEF

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21
Q

Pre-hospital medications to administer possible ACS

A

Aspirin, oxygen, SL nitroglycerine and morphine

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22
Q

Goal for stent placement or balloon inflation in STEMI should be within how long?

A

within 90 min

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23
Q

Goal for thrombolysis in STEMI should be within how long?

A

within 30 minutes

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24
Q

Indications for CABG

A

Triple-vessel or left main disease

DM

Plaque morphology unfavourable for PCI

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25
Drugs that lower mortality in MI
Aspirin (chew it) Beta blockers
26
Beta blocker contraindications
Systolic BP \<90 Cardiogenic shock Severe bradycardia Second or third degree heart block Asthma/ emphysema Peripheral vascular disease Uncompensated CHF
27
Which drug should be administered immediately to unstable anginas who are to be managed conservatively?
Ticagrelor a P2Y12 receptor antagonist + aspirin dual therapy
28
What does the Framingham data calculate?
10 year risk of CAD in a patient with dyslipidemia
29
Aneurysm size threshold for surgery in men and women
Men 5-5.5cm Women 4.5cm
30
Contraindications to statins
Active liver disease High ALT + AST
31
Triggers for Acute LVF
Iatrogenic (e.g. aggressive IV fluids in frail elderly patient with impaired left ventricular function) Sepsis Myocardial Infarction Arrhythmias
32
What is the main measure of left ventricular function on echo?
The ejection fraction. This is the percentage of the blood in the left ventricle which is squeezed out with each ventricular contraction. An ejection fraction above 50% is considered normal.
33
How is the grade of LV failure calculated?
Use Ejection Fraction to Grade LV Dysfunction • Grade I (EF \>60%) (Normal) • Grade II (EF = 40-59%) • Grade III (EF = 21-39%) • Grade IV (EF 20%)
34
CXR findings in Acute LVF
- Cardiomegaly on CXR - defined as cardiothoracic ratio \> 0.5. - Upper lobe venous diversion Fluid leaking from oedematous lung tissue causes additional xray findings of: Bilateral pleural effusions Fluid in interlobar fissures Fluid in the septal lines (Kerley lines)
35
Management Acute LVF
Use the simple mnemonic Pour SOD for acute LVF: Pour away (stop) their IV fluids Sit up Oxygen Diuretics
36
Diagnosis of chronic heart failure
Clinical presentation BNP blood test (specifically “N-terminal pro-B-type natriuretic peptide” – NT‑proBNP) Echocardiogram ECG
37
First line treatment chronic heart failure
ACE inhibitor (e.g. ramipril titrated as tolerated up to 10mg once daily) Beta Blocker (e.g. bisoprolol titrated as tolerated up to 10mg once daily) Aldosterone antagonist when symptoms not controlled with A and B (spironolactone or eplerenone) Loop diuretics improve symptoms (e.g. furosemide 40mg once daily) If the cause is an MI add aspirin and a statin
38
Acute treatment of pulmonary oedema
* L – Lasix (furosemide) 40-500 mg IV * M – morphine 2-4 mg IV: decreases anxiety and preload (venodilation) * N – nitroglycerin: topical/IV/SL - use with caution in preload-dependent patients (e.g. right HF or RV infarction) as it may precipitate CV collapse * O – oxygen: in hypoxemic patients * P – positive airway pressure (CPAP/BiPAP): decreases preload and need for ventilation when appropriate • P – position: sit patient up with legs hanging down unless patient is hypotensive
39
Drugs that improve survival in heart failure
ACE inhibitors Beta Blockers ± Mineralocorticoid receptor antagonists
40
Major risk factors for dilated cardiomyopathy (3)
Alcohol, cocaine, family history
41
Precipitants of acute pulmonary oedema
Acute tachy- or bradyarrhythmia Infection, fever Acute MI Severe hypertension Acute mitral or aortic regurgitation Increased circulating volume (Na+ ingestion, blood transfusion, pregnancy) Increased metabolic demands (exercise, hyperthyroidism) Pulmonary embolism Noncompliance (sudden discontinuation) of chronic CHF medications
42
CXR signs of dilated cardiomyopathy
Global cardiomegaly (i.e. globular heart), signs of CHF, pleural effusion
43
Acute pericarditis triad
* Chest pain * Friction rub * ECG changes
44
Acute pericarditis ECG changes
Diffuse ST elevation and PR depression with reciprocal changes in aVR)
45
Treatment of acute pericarditis
* treat the underlying disease * anti-inflammatory agents (i.e. high dose NSAIDs/ASA), analgesics * colchicine reduces the rate of incessant/recurrent pericarditis (ICAP N Engl J Med 2013; 369:1522-1528) * physical activity restriction until symptom resolution
46
Classic quartet of cardiac tamponade
* Hypotension * Increased JVP * Tachycardia * Pulsus paradoxus
47
Medical vs surgical Rx for TIAs/ carotid artery stenosis- what's the best evidence?
Medical intervention is superior to surgical intervention for symptomatic carotid artery stenosis in terms of stroke prevention \*\*\*
48
What does this CXR show?
Acute LVF
49
Homan's sign
DVT The sign is present where pain in the calf is produced by passive dorsiflexion of the foot.
50
What's this?
AF No p waves, variable and irregular QRS response
51
Causes of acute AF
PIRATES ## Footnote P- Pulmonary disease I- Ischaemia R- Rheumatic heart disease A- Anaemia/ Atrial myxoma T- Thyrotoxicosis E- Ethanol S- Sepsis
52
What is this? What's the treatment?
Phlegmasia cerulea dolens An uncommon severe form of deep venous thrombosiswhich results from extensive thrombotic occlusion (blockage by a thrombus) of the major and the collateral veins of an extremity Treatment is by catheter-directed thrombolytic therapy, a type of thrombolysis
53
What does this CXR show?
Aortic dissection
54
What is this and how does it present?
Kartagener syndrome is characterized by the clinical triad of: situs inversus chronic sinusitis and/or nasal polyposis bronchiectasis
55
What's this? And what are some causes of it?
Torsades de pointes Medications Hypokalemia (low serum potassium) Hypomagnesemia (low serum magnesium) Hypocalcemia (low serum calcium) Bradycardia (slow heartbeat) Heart failure Left ventricular hypertrophy Hypothermia Subarachnoid hemorrhage Hypothyroidism
56
Dose of clexane (enoxaparin) for DVT Rx
The recommended dosage for treatment of established deep vein thrombosis with CLEXANE is 1.5 mg/kg body weight once daily (150 IU anti-Xa activity/kg body weight) or 1 mg/kg body weight (100 IU anti-Xa activity/kg bodyweight) twice daily subcutaneously.
57
An otherwise healthy person with a DVT should be anticoagulated for how long and with what INR?
3-6 months, INR 2-3
58
What are the primary goals of AF treatment?
Rate control Prevention of thromboembolism
59
The three major causes of aortic stenosis
Degenerative calcification Bicuspid aortic valve Rheumatic heart disease
60
Signs of aortic stenosis
Characteristic murmur is systolic, mid-to-late peaking with a crescendo-decrescendo pattern, and radiates to the carotids. Paradoxical splitting
61
Aortic stenosis Ix and Mx
Doppler echo is essential to the diagnosis and will show a pressure gradient across the stenotic aortic valve. Surgical aortic valve replacement was the only effective therapy for aortic stenosis for over 50 years. However there are now transcatheter valve therapies
62
The DOC in hypertrophic cardiomyopathy, and what sorts of drugs to avoid
Beta blockers. Avoid things that reduce pre-load like diuretics, ACEIs and nitrates
63
Signs of WPW syndrome on ECG
Short PR interval Delta waves Wide QRS complex
64
Severe sudden chest pain, blood pressure differences between arms, and a widened mediastinum on CXR are suspicious of what?
Aortic dissection
65
Characteristics of WPW syndrome
Symptoms can include an abnormally fast heartbeat, palpitations, shortness of breath, lightheadedness, or syncope. Rarely, cardiac arrest may occur. The most common type of irregular heartbeat that occurs is known as paroxysmal supraventricular tachycardia
66
Management of a stable patient with WPW with a) normal heart rate and b) tachyarrythmia
a) Amiodarone or procainamide b) Synchronised cardioversion
67
Cardiac conditions that require antibiotic prophylaxis before dental procedures
1. Prosthetic heart valve 2. Valve repair with prosthetic material 3. Prior hx of infective endocarditis 4. Cyantic congenital heart abnormalities even after repair Oral amoxycillin an hour before the procedure is the standard regimen
68
Examples of non-invasive arterial evaluations (2)
Ankle-brachial index Transcutaneous oxygen measurement
69
What cardiovascular event is Marfan's associated with?
Aortic dissection
70
Which cardiovascular problem is Kawasaki disease associated with?
Coronary artery aneurysms
71
Which cardiovascular problem is Turner syndrome associated with?
Coarctation of the aorta
72
Which cardiovascular problem is Down Syndrome associated with?
Ostium primum type of atrial septal defect
73
Chronic alcohol use does what to the heart?
It causes dilated cardiomyopathy
74
A harsh systolic crescendo-decrescendo murmur best heard at the left lower sternal border. Valsalva maneuver will increase the intensity of the murmur, as will changing positions from squatting to standing.
Hypertrophic obstructive cardiomyopathy
75
A systolic murmur with wide splitting of S2 which persists during expiration
Atrial septal defect Best heard left upper sternal border
76
An effective treatment for torsades de pointes
Magnesium
77
Causes of cor pulmonale
Sarcoidosis Systemic sclerosis Massive PE Obstructove sleep apnea kyphoscoliosis Obesity with alveolar hypoventilation End stage pneumoconiosis Sickle cell anaemia
78
The most common hereditary thrombophilia
Factor V Leiden
79
What is angina decubitus?
Decubitus angina occurs when the patient lies down. It is usually a complication of cardiac failure due to the strain on the heart resulting from the increased intravascular volume. Patients usually have severe coronary artery disease.
80
Asymptomatic severe aortic stenosis patients should be offered what?
Exercise testing
81
Drugs that slow the heart rate
Beta blockers Calcium channel blockers Amiodarone Digoxin
82
Antihypertensive for a diabetic patient with proteinuria
ACEI or ARB
83
Signs of active ischaemia during stress testing
Angina ST segment changes on ECG Reduced BP
84
The coagulation parameter affected by warfarin
Prothrombin time
85
Virchow triad
Hypercoaguability Stasis Endothelial damage
86
Causes of pericarditis
* Infectious – mainly viral (e.g. coxsackie virus); occasionally bacterial, fungal, TB. * Immunological – SLE, rheumatic fever * Uraemia * Post-myocardial infarction / Dressler’s syndrome * Trauma * Following cardiac surgery (post pericardiotomy syndrome) * Paraneoplastic syndromes * Drug-induced (e.g. isoniazid, cyclosporin) * Post-radiotherapy
87
Calcium Channel Blocker indications
Cardiovascular indications include * hypertension * coronary spasm * angina * supraventricular dysrhythmias * hypertrophic cardiomyopathy * pulmonary hypertension Also * Raynaud phenomenon * subarachnoid hemorrhage * migraine headaches
88
Test to confirm diagnosis of hypertension
Home or ambulatory readings
89
Secondary casues of hypertension
**ROPE** Renal disease Obesity Pregnancy Endocrine
90
Investigations for a newly disgnosed hypertensive patient
* Urine dipstick and albumin-creatinine ratio * Bloods (HbA1c, U+Es, lipids) * Fundoscopy * ECG
91
First line therapy hypertension \<55 and \>55
\<55 ACEI \>55 CCB

MCCQE1 (20 decks)

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