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MRCP Part 1 > MRCP Cardio > Flashcards

MRCP Cardio Flashcards

1
Q

What are the 3 electrolyte imbalances that causes long QTc?

A

Hypocalaemia
Hypokalaemia
Hypomagnesaemia

Hypothermina

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2
Q

What are the ECG changes you see in acute pericarditis 2 weeks after wide spread concave ST elevation?

A

flattened T wave or T wave inversion

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3
Q

Viruses cause up to 85% of all cases of pericarditis; the most common cause in the developed world is?

A

coxsackie B virus.

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4
Q

What is the first line of treatment for pericarditis? And what should be prescribed for prevention of recurrence?

A

NSAIDS are 1st line
Colchicine prevent recurrent pericarditis

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5
Q

If right arm BP is significantly higher than left arm BP, what level is coarctation of aorta at? and what is the usual commonest site?

A

proximal to left subclavian vein.
distal to left subclavian vein

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6
Q

What are the four stages of ECG changes associated with pericarditis

A
  1. diffuse concave ST elevation, ST depression in aVR or V1, PR depression, no reciprocal changes
  2. ST returns, T wave flatten
  3. T wave inverts

4: resolution of t wave inversion

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7
Q

What test is performed in family screening for HOCM?

A

ECHO

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8
Q

What structural featur of HOCM increases the risk of sudden death?

A

septal hypertrophy (causing LVOT obstruct)

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9
Q

Which antihypertensive should you give pregnant women who are asthmatic?

A

Nifedipine

Labetalol is firstline but CI in asthma
Methydopa is relative contraindication with asthma.

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10
Q

Why does Eisenmenger syndrome occur?

A

reversal of left to right shunt due to advanced pulmonary hypertension (>25mmHg)

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11
Q

What drug should be given to pregnant women with paroxysmal SVT?

A

Metoprolol

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12
Q

Which heart block should be referred for permanent pacemaker (PPM) even if asymptomatic?

A

Mobitz type 2 and CHB

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13
Q

In new fast AF (no previous AF or pAF) within last 48 hrs, what should be prioritised rate or rhythm?

A

Rhythm control

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14
Q

What are the 2 methods of cardioversion in AF <48 hrs?

A

Electrical in emergency (unstable)

Chemical cardioversion:
- Amiodarone (if structural heart disease)
- Flecainide (if NO structural/ischaemic heart disease)

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15
Q

Which valvular disease presented with pansystolic murmur, louder with inspiration, along the lower left sternal border?

A

Tricuspid regurgitation

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16
Q

What is TR associated with?

A

cor pulmonale
IE
carcinoid syndrome
ebstein anomaly

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17
Q

What aortic valvular abnormality is coarctation of aorta associated with?

A

bicuspid aortic valve

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18
Q

What valvular lesions is marfarn’s associated with?

A

Aortic regurgitation

Mitral valve prolapse

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19
Q

In New LBBB: what are the first and second heart sounds like?

A

First soft

Second- reversed splitting (pulmonary valve closes before aortic valve due to delay in depol)

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20
Q

What ECG changes do u see in HOCM?

A

ST-T abnormalities
LVH and LAD
Q waves in inferior or V2-6 leads

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21
Q

What is paradoxical embolism (crossed embolism), and what are the consequences?

A

when venous clot enters arterial side or vice versa. (DVT to stroke)

through patent foramen ovale.

bubble TTE ECHO would diagnose.

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22
Q

Anti-arrhythmic classes

A

1- Na channel blocker (flecainide/lidocaine/procaimide)
- QRS broaden hence long QTc
- work on His-purkinje

2-Beta blocker (atenolol/biso/meto/propan)
- slow SNS through AVN

3-K channel blocker (sotalol/amiodarone)
- long QTc
- prolong refractory period

4-Ca channel blocker non dihydropyridine (diltiazem/verapamil)
- work on SAN and AVN

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23
Q

What does S4 heart sound indicate?

A

Non compliant stiff ventricle and pressure overload (HFPEF)

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24
Q

Thiazide side effects?

A

Exacerbate hyperglycaemia
low sodium and potassium

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25
Q

What are the symptoms and consequences of Trypanosoma cruzi?

A

Changas disease

spread by blood sucking bugs

acute:
fever, myalgia, hepatosplenomegaly, myocarditis

consequence:
dilated heart, oesophagus and colon -> heart failure

romana sign- periorbital swelling and oedema from bite

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26
Q

Absolute contraindication of thrombolytic treatment

A
  • active bleed
  • recent head trauma <2 wks
  • known intracranial cancer
  • hx of stroke <2months ago
  • uncontrolled HTN >200/120
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27
Q

Relative contraindication of thrombolytic treatment?

A
  • Traumatic prolonged CPR
  • Bleeding disorder
  • Recent surgery
  • Intracardiac thrombus
  • DOAC or INR >1.8
  • Pregnancy
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28
Q

What is the best imaging for cardiac embolism post MI?

A

TTE - ventricles
TOE - atrial/valvular lesion

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29
Q

STEMI ECG criteria diagnosis

A

at least 2 contiguous lead of 1mm or more (other than V2-3)
in V2-3:
Men:
- 2.5mm or more in young men (<40)
- 2mm or more in older men (>40)

women:
1.5mm or more in women any age

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30
Q

What is the difference between ostium secundum ASD and ostium primum ASD

A

secundum 90% of case, asymptomatic until adulthood, left to right shunt between the wall.

primum is abnormal mitral and tricuspid valve and VSD seen, present in childhood due to HF.

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31
Q

What is the HS like in severe aortic stenosis?

A

Quieting of second HS = severe due to immobile valve

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32
Q

What are the HS like in aortic stenosis?

A

soft first HS
reverse splitting of second HS in LVF

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33
Q

What is the most common genetic mutation in HOCM?

A

sarcomere protein gene in 60%
autosomal dominant mutation
MYH7 (beta myosin heavy chain)
MYBPC3 (myosin-binding protein C)

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34
Q

What other rare conditions are associated with HOCM?

A

Amyloid
Friedreich’s ataxia
Wolff-Parkinson White

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35
Q

What is the pathophysiology of WPW?

A

atrioventricular re-entry tachycardia (AVRT)

narrow complex with anterograde through AVN and retrograde through accessory pathway

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36
Q

What happens when WPW syndrome develop AF?

A

VF (broad QRS- SVT with aberrancy)

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37
Q

Patients on life long warfarin requiring dental procedure- what is target INR?

A

INR<4

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38
Q

What are the 3 causes of reverse splitting S2?

A

LBBB (signal from right bundle)
Aortic stenosis (narrow tunnel)
HOCM (more cardiomyocyte need activating)

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39
Q

What happens to the S2 heart sound in RBBB?

A

Wide physiological splitting S2

Persistent in both inspiration and expiration

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40
Q

What are 3 indications of temporary pacing?

A

symptomatic bradycardia (failed atropine)

complete heart block at risk of haemodynamic compromise (and prior to surgery)

suppression of tachyarrhythmia not amenable to drug therapy (enable overdrive pacing)

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41
Q

What 5 indications for permanent pacemaker

A

CHB
Drug resistant tachyarrhythmia
mobitz type 2
persistent AV block post MI
sick sinus syndrome
sinus pause >3s
trifascicular block

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42
Q

What is the order of NNT for drugs prolonging survival post MI?

A

ACEi > statin > aspirin > beta blocker

ASAB

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43
Q

What is the auscultation sound you would hear for complete heart block?

A

variable intensity of first heart sound

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44
Q

At what week can pregnant women be diagnosed of pre-existing HTN?

A

<20 weeks

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45
Q

What is the diagnostic criteria for pre-eclampsia?

A

proteinturia and or oedema

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46
Q

Where does atrial myxoma originate from 75% of the time?

A

left atrium (interatrial septum)

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47
Q

What is the murmur like in atrial myxoma?

A

Diastolic murmur changing in character with position.

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48
Q

What is pulsus paradoxus and when can it be seen?

A

Exaggerated drop in BP in inspiration >10mmHg.

Seen in cardiac tamponade and acute severe asthma

COAT
constrictive pericarditis
obstructive airway
asthma
TAMPONADE

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49
Q

What does S3 heart sound indicate?

A

Rapid Diastolic filling
Fluid overload

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50
Q

What drugs predispose to long QTc?

A

Antiarrhythmic: amiodarone/sotalol
Antipsychotic: haloperidol/risperidone/lithium/TCA
Antidepressant: citalopram
Antibiotic: erythromycin/trimethoprim/quinolone
Antihitamine: terfenadine
Antifungal: ketoconazole/fluconazole

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51
Q

Which coronary artery is blocked in anterior MI?

A

LAD - left ANTERIOR descending

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52
Q

Which coronary artery is blocked in inferior MI?

A

right coronary artery

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53
Q

Which coronary artery is blocked in lateral MI?

A

Left CIRCUMFLEX

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54
Q

Acute STEMI treatment

A

Oxygen <95%
GTN
Analgesia
Antiplt (DAPT- clopi if >75/high risk bleed)
URGENT ANGIO!

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55
Q

How should you take out a person in cold water drowning?

A

pull out and leave prone position to prevent venous pooling and circulatory collapse.

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56
Q

Definitive management for STEMI?

A

PCI for those presenting <12 hrs of symptom onset and if PPCI can be undertaken within 120 minutes of time

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57
Q

When is IV thrombolysis indicated in ACS?

A

STEMI

symptom onset within 12 hrs where PPCI within 120min for first medical contact is not possible.

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58
Q

What is the character of the pulse for patent ductus arteriosus?

A

Collapsing due to wide pulse pressure as seen in AR.

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59
Q

Why does isometric handgrip exercise accentuates mitral regurgitation?

A

due to increased BP and afterload hence increased backflow murmur

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60
Q

In ASD, what is the second heart sound like and why?

A

Wide fixed S2 splitting due to delay in pulmonary valve closure from left to right shunt

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61
Q

What is the problem in Young patient with high BP, and reduced renal function…

A

Renal artery stenosis can cause secondary hypertension

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62
Q

Hypertensive emergency (>180/120) how much should you reduce BP by and with what?

A

reduce MAP by 25% due to risk of hypoperfusion

IV labetalol/GTN

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63
Q

Which bacteria has higher prognosis on infective endocarditis compared to s.aureus?

A

strep viridans

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64
Q

What is carotid sinus syndrome

A

Hypersensitive carotid sinus - causing reflex bradycardia and hypotension - if syncopal need pacemaker

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65
Q

What are the causes of constrictive pericarditis

  • inflammation (chronic)
A

Any cause of pericarditis
Particularly TB

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66
Q

What is pulsus paradoxus

A

when breathing in BP dropping by >10mmHg.

due to stiff heart, blood fills the right side, right bulges and presses on left, hence reduced left stroke volume and BP.

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67
Q

Describe the JVP waveforms (AxCx’Vy)

A

Atria contracts

x- reLAX atria

Closed tricuspid (as ventricle contract against)

x’ - reverse heart (passive filling ofatria)

Venous filling maxed out against closed tricuspid

y (tricuspid valve forced open and passive ventricular filling from atria)

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68
Q

In constrictive pericarditis what happens to JVP waveform?

A

more prominent x and y

(as atria and ventrical are stiff hence early diastolic filling - imagine thick elastic band going back to original shape)

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69
Q

In severe mitral regurgitation what happens to the end diastolic left ventricular pressure?

A

increases as blood goes back and forth into atrium and ventricle overtime stretching the mitral annulus.

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70
Q

What is pleural rub commonly associated with?

A

PE

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71
Q

What is pericardial rub associated with?

A

pericardial effusion

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72
Q

What is systolic click associated with?

A

mitral valve prolapse

also in pneumothorax

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73
Q

How does paradoxical embolism occur in PFO?

A

right atrium to left atrium shunt on valsava (straining/diving) causing venous content to enter arterial content.

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74
Q

Most common organism causing acute bacterial IE?

A

S.aureus (also in IVDU)

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75
Q

which organism in IE associated with dental procedures?

A

Strep. viridans

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76
Q

which organism in IE associated with GI procedures?

A

Enterococcus

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77
Q

What does VSD murmur sound like?

A

Pansystolic murmur in left sternal edge

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78
Q

What medications can cause pulmonary hypertension in a patient that does not have acute or chronic lung condition?

A

appetite suppressant

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79
Q

Complications of MI?

A

Death
Arrhythmia
Rupture (free ventricular wall/ ventricular septum/ papillary muscles)
Tamponade
Heart failure (acute or chronic)
Valve disease
Aneurysm of ventricle
Dressler’s syndrome- autoimmune pericarditis (months later)
thromboEmbolism (mural thrombus)
Recurrence/ mitral Regurgitation

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80
Q

What is the pathophysiology of ASD

A

foramen ovale patent and secudum/primum opened-> causing hole between 2 atria.

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81
Q

Ebstein’s anomaly pathophysiology

A

large right atrium as tricuspid valve is lower down, small right ventricle.

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82
Q

What arrhythmia is ebstein’s associated with?

A

associated with WPW

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83
Q

Which valvular abnormality is ebstein associated with?

A

Tricuspid regurgitation

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84
Q

Patent ductus arteriosus heart sound and murmur

A

continuous crescendo-decrescendo “machinery” murmur, heard loudest below the clavicle

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85
Q

Pathophysiology of PDA

A

connecting pulmonary artery and aorta leading to pulmonary HTN and RHF.

kept opened with prostaglandin E2

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86
Q

Murmur for coarctation of aorta

just like AS

A

systolic murmur heard below the left clavicle (left infraclavicular area) and below the left scapula.

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87
Q

When is biventricular pacemaker (CRT) used?

A

HF

Failed medical mx

right atrium
right ventricle
left ventricle

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88
Q

When is ICD used?

A

VT and VF that predispose to sudden cardiac death

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89
Q

What ICD types are there?

A

Single chamber - right ventricle
dual chamber - right atrium and ventricle
biventricular ICD- right atrium, both ventricles

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90
Q

What is type 3 hyperlipoproteinaemia

A

apolipoprotein E2 genotype

palmar xanthomata (orange skin creases)
tuberoeruptive xanothomata

High LDL + TG

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91
Q

What is type 1 hyperlipoproteinaemia?

familial

A

Lipoprotein lipase deficiency OR
Apolipoprotein C2 deficiency

High Chylomicron + TG

ERUPTIVE xanthomas

Causing:
retinal vein occlusion
acute pancreatitis
steatosis
organomegaly
lipaemia retinalis

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92
Q

Eruptive xanthoma lipidaemia types

A

Type 1 & 4 (hyperchylomicronemia, hypertriglyceridemia) = eruptive

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93
Q

Tendon, tuberous palmar xanthoma lipidaemia types

A

Type 2 & 3 (hypercholesteremia, remnant hyperlipidemia) = tendon, tuberous, palmar (more common in 3 than 2)

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94
Q

What is type 2 hyperlipoproteinaemia (most common form)?

A

Apo B100

xanothoma TENDINOSUM

High LDL

Dietary/genetic

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95
Q

What is type 4 hyperlipoproteinaemia

A

VLDL OVERPRODUCTION

High TG

ERUPTIVE xanothomas

Pancreatitis

severe increase in the triglycerides contained in VLDL.

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96
Q

What is type 5 hyperlipoproteinaemia?

A

associated with glucose intolerance and hyperuricaemia

VERY high VLDL and chylomicrons

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97
Q

What duration should patient be anticoagulated (warfarin) pre and post cardioversion for AF?

A

3 WEEKS PRE
4 WEEKS POST

target INR 2.5

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98
Q

In new AF within 48 hrs, when should cardioversion be done for rhythm control?

A

Immediately if unstable/evidence of heart failure/MI/syncope.

Stable:
Cardioversion:
anticoagulate with heparin and give synchronised DCCV electrical if emergency/AF <48hrs

OR chemical
- amiodarone (if LVH)
- flecainide (if no IHD)

AF = AmioFlec

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99
Q

In new AF after 48 hrs when should you cardiovert?

A

Anticoagulate for 3 weeks then electrical DCCV cardioversion preferred

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100
Q

In haemodynamically stable patient how should new onset AF be managed (<48hrs and >48hrs)

A

<48 hrs = rate or rhythm
>48hr or uncertain = rate

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101
Q

What rate control is recommended for AF >48hrs

A

Biso (not sotalol)
CCB (Diltiazem/verapamil)
Digoxin (HF)

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102
Q

Which agents are used to maintain sinus in patients with history of AF?

A

Beta blocker
Amiodarone (HF patients)

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103
Q

What are the causes of restrictive cardiomyopathy? (RASH)

A

Radiotherapy
amyloidosis
sarcoidosis
haemochromatosis

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104
Q

What bundle branch block and axis do u see in ASD secundum?

A

RBBB + RAD

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105
Q

What bundle branch block and axis do u see in ASD primum?

A

RBBB + LAD

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106
Q

Why do you get fixed splitting of S2 in ASD?

A

because of left to right shunt irregardless of inspiration/expiration, there is fixed splitting of delayed P2 due to RBBB

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107
Q

Management of SVT

A

DC cardiovert if haemodynamically compromised

Non-pharm
- vagal manoeuvre

Pharm
- IV adenosine (CI in asthma)/verapamil

Prevention of episodes:
- betablocker/flecainide
- ablation

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108
Q

In pregnant women with SVT that self terminates, what is the management?

A

conservative management with vagal manoeuvre

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109
Q

What CHA2DS2VASc for AF would you give DOAC?

A

Male >1
Female >2

Given ORBIT score is less

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110
Q

If stroke with AF, what is the long term management?

A

Anticoagulation (not clopidogrel)

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111
Q

What bug causes prosthetic valve endocarditis?

A

staph.epidermidis IE (only in first 2 months)

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112
Q

Why would a patient with prostehtic heart valve present with normocytic anaemia and isolated bilirubinaemia?

A

Haemolysis

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113
Q

What is the treatment for IE in native valve?

A

IV amoxicillin 2g, 4hrly (vanc if pen allg)
Gentamicin (1mg/kg BD)

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114
Q

What is the treatment for IE in prosthetic valve?

A

Vanc
Gent
Rifampicin

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115
Q

What are the common causes of pericarditis?

A

Coxackie
TB
Uraemia
MI
- days fibrous
- months dressler (autoimmune)
Radiotherapy
Hypothyroidism
Connective tissue (SLE/RA)
Cancer
Trauma

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116
Q

What is the treatment option for patients with AF with failed medical treatment for rate and rhythm control including cardioversion?

A

Radiofrequency pulmonary vein isolation with ablation

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117
Q

Which coronary artery occlusion is associated with complete heart block?

A

proximal right coronary (supplies AVN)

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118
Q

Which coronary artery occlusion is associated with first degree AV block and wenckebach type 1?

A

Distal right coronary artery

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119
Q

What causes loud first heart sound?

A

Opening snap in mitral stenosis (mobile valve)

atriventricular valve lesion

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120
Q

What is soft first heart sound indicative of?

A

immobile mitral stenosis
hypodynamic state
mitral regurgitation
long PR interval

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121
Q

what is splitting S1 indicative of?

A

RBBB
LBBB
VT
Ebstein’s anomaly

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122
Q

What is variable S1 indicative of?

A

AF
CHB

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123
Q

What is loud S2 indicative of?

A

HTN
Tachycardia
ASD

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124
Q

What is soft/absent S2 indicative of?

A

severe AS (due to calcified immobile valve)

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125
Q

What is fixed splitting S2 indicative of?

A

ASD

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126
Q

What are the causes of wide split S2?

A

RBBB
deep inspiration

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127
Q

What is revered split S2 indicative of?

A

LBBB
AS
HOCM

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128
Q

What is the Duke’s criteria for IE?

A

Modified Duke Criteria
One major plus three minor criteria
Five minor criteria

Major criteria are:
B (blood culture)
E (ECHO)

Minor criteria are:
F (fever)
E (immunological- osler node, roth spot)
V (vascular- janeway lesion)
E (echo/blood culture)
Risk (IVDU/heart valve)

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129
Q

What medication is associated with allergic myocarditis?

A

co-trimoxazole

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130
Q

What medications are contraindicated in WPW and why?

A

adenosine,
CCB (BOTH DIHYDRO AND NONDIHYDRO)
beta-blockers.

They can exacerbate the syndrome by blocking AVN and facilitating antegrade conduction via the accessory pathway.

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131
Q

What is the medical management of WPW?

A
  • sotalol
  • amiodarone
  • flecainide
132
Q

What ECG findings are in WPW

A

shortened PR
Delta wave
prolonged QRS

133
Q

What are the causes of DCM?

A

ALCOHOL
cytotocxic drugs
- doxorubicin
- herceptin
heart disease
end stage IHD/HTN
haemochromatosis/sarcoid/amyloid
CTD- SLE

134
Q

How should you manage AF with WPW and haemodynamically unstable?

A

DC cardioversion

135
Q

What is the first and second line management for stable angina?

A

Initial: GTN spray
First: beta blocker or CCB (nondihydro)
Second: Nicorandil/ISMN/Ranolazine/ivabradine (if monotherapy BB/CCB fail)

if a calcium channel blocker is used as monotherapy a rate-limiting one such as verapamil or diltiazem should be used
if used in combination with a beta-blocker then use a longer-acting dihydropyridine calcium channel blocker (e.g. amlodipine, modified-release nifedipine)

136
Q

What bacteria is associated with colorectal cancer and infective endocarditis?

A

Strep.bovis (strep,gallolyticus)

137
Q

What is the advantage of continuous loop recorder?

A

Picking up arrythmia without pattern or triggers (will catch it during symptoms)

138
Q

What does IRREGULAR cannon a waves on JVP indicate?

A

CHB

Note:
atria contracting on closed tricuspid valve.

139
Q

What changes in JVP waveform in Tricuspid regurgitation?

A

**Giant v wave **
- as c and v combine to produce

**Loss of x wave **
(due to loss of downward movement of tricuspid valve annulus during ventricular systole)

Prominent y descent
- tricuspid opens early on ventricular filling

140
Q

What condition causes absent a wave in jvp?

A

AF due to uncoordinated atrial contraction

141
Q

Caused of large A waves on JVP

A

large if atrial pressure
tricuspid stenosis
pulmonary stenosis
pulmonary hypertension

142
Q

What suggests cardiogenic syncope?

A

sudden LOC without prodrome or during exercise

143
Q

What is the first and second commonest cardiovascular abnormality in adult Marfan’s?

A
  1. Aortic root dilatation
  2. mitral valve prolapse

(fibrillen gene defect in tunica media hence weakened from pressure)

144
Q

What is wolff chaikoff effect?

A

transient inhibition of thyroid hormone production due to high iodine levels.

145
Q

What disease is wolff chaikoff effect associated with?

A

Grave’s disease

146
Q

Why should you perform a thyroid radionuclide isotope scan prior to cardiac catheterisation?

A

iodine contrast may worsen hyperthyroidism in toxic multinodular goitre but improve in Grave’s due to Wolff chaikoff.

147
Q

What is the management for asymptomatic aortic stenosis?

A

Monitor until sx

148
Q

What is orthodromic tachycardia in WPW?

A

conduction via AVN to ventricles and back via accessory pathway hence narrow complex SVT

AVNRT

149
Q

What is antidromic tachycardia in WPW?

A

conduction from atria to ventricle directly via accessory pathway hence broad complex tachy

150
Q

What are the 3 types of SVT?

A
  1. AVNRT - most common
  2. AVRT - WPW accessory
  3. AT - heart disease

Others: AF and flutter and MAT

151
Q

What is treatment for orthodromic SVT?
AVNRT

A

IV adenosine (block AVN)

152
Q

What is the treatment for antidromic SVT?
AVRT

A

DC cardioversion

153
Q

Why is septal thickness associated with worst prognosis in HOCM?

A

Risk of VF/VT

154
Q

What is acrocyanosis a sign of and complication of what?

A

cholesterol embolism (blue big toe)
Complication of MI- angio/surgical valvular procedure.

155
Q

What part of conduction system does vagal manoeuvres help?

A

AVN but not distal conducting system`

Slows AVN

156
Q

What part of conduction system does atropine worsen?

A

Block in His-Purkinje system

157
Q

What causes reverse tick sign a sign of on ECG?

A

Digoxin toxicity

158
Q

What is Romano Ward syndrome?

A

Long QTc congenital

No deafness

159
Q

Outline treatment of NSTEMI

A

DAPT
Fondaparnux
Oramorph
GTN

BB- anti-ischaemic therapy (verapamil/diltiazem if CI)
Statin 80mg

GRACE score to risk stratify for PCI

160
Q

What is high GRACE score?

A

> 3% - medium or high risk

early angio +/- PCI (within 72hrs)

Note- bridge with IV glycoprotein 2b/3a inhibitor abciximab pre-PCI

161
Q

What is trifasicular block?

A

bifascivular block with 1st degree HB

162
Q

What is bifascicular block?

A

RBBB+ left anterior (LAD)/posterior fascicular block (RAD)

163
Q

What is the management for asymptomatic pericardial effusion?

A

reassure and monitor if no haemodynamic compromise (even if large effusion)

164
Q

What is the management for secondary prevention of sudden cardiac death in HOCM?

165
Q

What are the medical management of HOCM?

A

Amiodarone
Beta-blockers or verapamil for symptoms
Cardioverter defibrillator
Dual chamber pacemaker
Endocarditis prophylaxis*

ABCDE

ABC drugs like VT

166
Q

What are the p waves like in AVNRT?

167
Q

In refractory pulseless VT/VF, what should you give after 3 shocks?

A

300mg amiodarone

168
Q

What is the management for broad complex tachycardia with haemodynamic compromise?

A

DC cardioversion

169
Q

What is pathophysiology of sick sinus syndrome?

A

fibrosis or fatty infiltration of SAN/AVN/His bundle/branches

170
Q

What 4 complications is sick sinus syndrome characterised by?

A

Bradycardia
Arrest
SAN and AVN conduction defect
SVT causing tachyarrhythmias

171
Q

What is the treatment of choice for sick sinus syndrome?

A

permanent pacemaker

(tachyarrhythmias treated by betaclockers will be protected by pacemaker)

172
Q

When is irregular cannon waves seen in JVP and why?

A

Due to CHB

atria contracting against closed tricuspid valve due to loss of coordination.

173
Q

Which medications are associated with improved mortality from cardiovascular disease?

A

ACEi
BB
Spironolactone
nitrate and hydralazine

174
Q

When do you see jerky bisferiens pulse?

A

HOCM - collapsing pulse followed by secondary rise

175
Q

What is the difference between critical stenosis vs complete occlusion of coronary arteries?

A

critical stenosis T wave inv
complete occlusion ST elev

176
Q

What is QRISK?

A

risk of developing cardiovascular disease in 10 years (up to age 82)

if >10% start statin

177
Q

When is RBBB seen

A

can be physiological
Pathological in ASD/PE

178
Q

When is LBBB seen

A

ALWAYS PATHOLOGICAL

179
Q

What second antiplatelet should be given on top of aspirin for ACS?

A

Prasugrel
Clopidogrel (if >75 years and on DOAC) - reduced efficacy with omeprazole
Ticagrelor - can cause bronchospasm due to adenosine

180
Q

What is the commonest cause of cardiac arrest outside the hospital?

181
Q

What would make VT more likely than SVT with aberrancy?

A
  1. More rapid ventricular rate >160ms
  2. AV dissociation
  3. Capture beats (intermittent narrow complex from normal conduction via AVN)
  4. Fusion beats (fusing of narrow and broad)
  5. Concordance in precordial leads
  6. Rsr’ rabbit ear in V1 (left rabbit ear longer)
  7. Brugada sign (R-S’ >100ms)
  8. Josephson sign (notching S slope in V1 and V2)
  9. variable intensity first HS (AV dissociation)
  10. RBBB (right rabbit ear longer) with LAD
182
Q

Outline the 5 groups of pulmonary HTN (>25mmHg)

A
  1. Primary (congenital shunts)/idiopathic
  2. Left heart disease including valves
  3. Lung disease/hypoxia (COPD/ILD)
  4. Chronic PE
  5. Multifactorial
183
Q

Outline management of HTN

A

A
C
D (thiazide- indapamide) - worsen gout
alpha/beta blocker if K >4.5
spironolactone if K <4.5

<55 or diabetic any age
- ACE/ARB first

> 55 or afrocarribean
- CCB first then ARB

184
Q

What social drug history is important in chest pain ACS?

A

Cocaine abuse as cause cause vasocontriction/atheroma rupture/dissection

BB contraindicated in cocaine use

185
Q

What is rheumatic fever?

A

Previous pharyngitis causing fever, polyarthritis, carditis, subcut extensor nodules.

ASTOT +ve (Strep pyogenes throat)

Treat: penicillin (allg erythromycin) for GAS.

186
Q

Patient with myaesthenia gravis, HF and new AF which rate control is preferred?

A

DIGOXIN

bisoprolol worsen muscle weakness
diltiazem may worsen cardiac failure

187
Q

Outline management of shockable cardiac arrest
pulseless VT/VF

A

Chest compressions
30:2 compression to ventilation

Shock asap
- BACK TO BACK X3 shock if VF seen on monitor

Single shock given -> then resume 2min of CPR (back to chest)
unsynchronized defibrillation at 120 - 200 J as soon as identified.

Adrenaline 1mg once CPR restarted after third shock
Repeat adrenaline every 3-5min

Amiodarone 300mg once CPR restarted after third shock
Repeat 150mg if still in VT/VF after five shocks

188
Q

What happens to QT with hypercalcaemia?

A

shortened QTc

189
Q

What is BNP?

A

releases in ventricles from stretch
has vasodilatory and natriuretic properties (sodium excretion)

190
Q

What is pulsus alterans?

A

Associated with acute left ventricular failure or pericarditis

alternate weak and strong pulse regularly

associated with S3

191
Q

What arrhythmia shows shortened PR and inferior Q waves, but no wide QRS/delta wave?

A

Lown Ganong Levine (LGL)

accessory pathway connecting atria to bundle of His (by passing AVN)

192
Q

Ouline the management for vasospastic angina?

A

CCB first line
ISMN alternative or combination

193
Q

What 3 mechanical complications of MI?

A
  1. acute MR (pansystolic murmur) from papillary muscle dysfunction
  2. acute VSD (pansystolic murmur)
  3. acute ventricular rupture (muffled HS->tamponade)
194
Q

Outline management of acute MR post MI

A
  1. urgent ECHO
  2. vasodilators- IV GTN, nitroprusside, ACEi
  3. Inotrope- dopamine/dobutamine
  4. Haemodynamic support with intra-aortic balloon
  5. Urgent replacement via cardiothoracics
195
Q

Describe 3 types of long QT syndromes

A

LQT1- most common, **slow delayed rectifier potassium **channel mutation.

LQT2- rapid delayed rectifier potassium channel mutation.

LQT3- sodium channel mutation causing brugada syndrome, SIDS, sick sinus syndrome, familial dilated cardiomyopathy.

Note:
jarvell and lange nielsen syndrome: associated with deafness too

196
Q

Outline treatment for acute heart failure

A
  1. IV furosemide
  2. IV opiate
  3. Oxygen if hypoxic
  4. Vasodilators GTN IV
197
Q

What is considered severe aortic stenosis and what is the treatment?

A

mean gradient >40mmHg

Surgical AVR in severe symptomatic AS (angina/SOBOE/syncope)

Note: valvuloplasty only for critical AS unfit for surgery.

TAVI is used if inoperable.

198
Q

Outline DVLA regulations for coronary artery disease

A

Group 2- all ACS, should not drive 6 weeks, relicense if Bruce protocol 8mins achieved in ETT without sx/ECG or haemodynamic changes.

199
Q

What is carcinoid heart disease?

A

accumulation of fibrous tissue in the heart (esp under surface of tricuspid valve)

primary carcinoid tumour in bowel with liver mets causing serotonin and kallikrein from liver- leaving liver and into inferior vena cava to right heart -> tricuspid regurgitation

200
Q

Which congenital heart disease cause biventricular hypertrophy?

A

VSD

biphasic QRS complex in V2-5 (katz wachtel phenomenon)

201
Q

Which cardiac conditions is troponin elevated and for how long?

A

MI (NSTEMI and STEMI) - first 4-6 hrs of damage up to 2 weeks

Myocarditis/contusion from trauma

Coronary spasm

HF (low leak)

Cardiomyopathy

Pericarditis

Cocaine

Athletes

202
Q

What are non cardiac causes of trop rise?

A

Critical illness
ITU/sepsis
Hypotension
Hypertensive crisis
PE
IECOPD
AAA
GI bleed
Chemo
CKD

203
Q

Which cardiac marker is elevated from DC cardioversion?

A

CK from skeletal muscle damage

204
Q

When is sacubitril/valsartan (entresto) recommended in HF?

A

LV failure with reduced EF - symptomatic despite ACEi

205
Q

Which murmur is louder with valsalva and quieter with squatting?

A

HOCM

Note:
valsalva should attenuate mumurs due to reduced preload hence underfilled ventricle

squatting increases afterload

206
Q

What are the 4 ECHO findings of HOCM?

A

elevated flow velocity in LVOT
diastolic dysfunction reduced compliance
systolic anterior motion (SAM)
asymmetrical septal hypertrophy

207
Q

What is flutter rate like?

A

150 bpm (2:1)
100 bpm (3:1)

208
Q

What conditions are associated with pAF?

A

AF causes:
Idiopathic
Cardiac (HF/MI/Valvular)
Respiratory (PE/pneumonia)
Systemic (thyrotoxicosis/HTN/Alcohol/sepsis)

209
Q

What does increasing PR interval suggest in IE?

A

increasing PR interval -> suggest myocardial infection possible abscess

URGENT surgical intervention IE

210
Q

Which murmurs become louder in pregnancy?

A

Pulmonary stenosis
Aortic stenosis
ASD
Tricuspid stenosis

Due to increased blood volume and cardiac output

211
Q

Which murmur becomes quieter in pregnancy?

A

Aortic regurgitation

212
Q

which other diuretic could you add in CHF on furosemide?

A

spironolactone with monitoring renal function (if K <4.5)

213
Q

What biochemical sign is suggestive of cholesterol embolism?

A

eosinophilia,
hyaline cast,
microscopic haematuria

214
Q

Which cardiovascular condition is absolutely contraindicated from pregnancy?

A

Primary pulmonary HTN

215
Q

What is the treatment for acute fast VT that are haemodynamically stable?

A

Amiodarone

216
Q

Outline management of VT to prevent recurrence?

A

First line: BB (metoprolol) or CCB (verapamil)

Not group 1 or 3 anti arrhythmic

217
Q

Outline management of phaeochromocytoma HTN?

A

First: alphablockade with phenoxybenzamine
Second: betablockade

218
Q

Outline management of CHF after offloading?

A

First: BB and ACEi

Second: add Spironolactone/epleronone

Third:
- Ivabradine
…….if EF<35% despite 1st and 2nd line, HR >75
- Entresto
….if EF <35% and ongoing sx despite ACEi/ARB

219
Q

What is the defibrillator joules for cardiac arrest- pulseless VT/VF

A

Biphasic 150-200 J unsynchronised
Monophasic 360 J

220
Q

What does new RBBB , with raised JVP?

A

PE causing right heart strain.

221
Q

Outline the treatment of WPW?

A

Medical:
Antiarrhythmic drugs class 1 + 3
(NOT VERAPAMIL AND DIGOXIN)

  • sotalol
  • amiodarone
  • flecainide

Surgical:
If high risk profession/symptomatic- ablation

222
Q

Which valves are at high risk of bacterial endocarditis?

A

Mitral > aortic > tricuspid (in IVDU) > pulmonary

LEFT > RIGHT due to higher turbulence

223
Q

Treatment for Ventricular arrhythmias unresponsive to amiodarone

A

lidocaine

CI in HF

224
Q

What is the character of aortic stenosis murmur and what attenuates it?

A

crescendo-decrescendo ESM, right 2nd ICS
radiate to carotid

softer murmur when cardiac output falls i.e AF.

225
Q

What are normal physiological changes in pregnancy?

A

drop in diastolic BP by 10mmHg in 2nd trimester

increase in cardiac output by 50%

tachycardia

pulmonary systolic murmur from high flow

physiologic S3

226
Q

What is the beck’s triad for tamponade?

A
  1. elevated JVP
  2. hypotension
  3. muffled HS (most specific)
227
Q

What is HACEK organism in IE?

A

culture negative endocarditis

Haemophilus influenzae

228
Q

Which valve is most anterior of the human heart?

A

Pulmonary > mitral >aortic

left sided valves are more posterior

229
Q

What coronary artery is occluded in right ventricular MI?

A

right coronary artery hence causing inferior wall MI

230
Q

What is the difference between WPW type A and WPW type B?

A

Type A:
- short PR, delta wave, wide QRS
- normal QT
- Tall R wave in V1

Type B:
- As above
- Deep S wave in V1

RABS (A=R wave, B=S wave)

231
Q

What ECG changes in hyperkalaemia?

A

Tall tented T wave
widened QRS
absent p wave

232
Q

What ECG changes in hypokalaemia?

A

U waves

Prolong PR

ST depression

233
Q

What is the mode of action of adenosine?

A

G protein coupled receptor agonist of A1 receptor

inhibit adenylate cyclase

reduce cAMP -> slowing AVN

234
Q

Which thrombolytic agent is associated with minimum risk of haemorrhagic stroke?

A

Streptokinase (IV infusion over 1hr)

235
Q

Which phase of pregnancy are pregnant women at greatest risk of DVT?

A

First 6 weeks after delivery.

236
Q

What is the population that is affected by Rheumatic fever?

A

West Africa

237
Q

Which valvular lesion is associated with rheumatic fever and atrial fibrillation?

A

Mitral Stenosis

238
Q

How is multiple myeloma associated with restrictive cardiomyopathy?

A

XS immunoglobulin light chain causes secondary cardiac amyloid

239
Q

What are ECG finding of restrictive cardiomyopathy?

A

diffusely diminished voltages

240
Q

What is type A aortic dissection and what is the treatment?

A

Ascending aorta

Immediate BP management with IV BB (labetalol)

If BB CI- IV nitroprusside/IV ditiazem/GTN inf

urgent surgical intervention

241
Q

Which valve lesion is common in Turner’s?

A

Bicuspid aortic valve
Coarctation of aorta
VSD
ASD

242
Q

What is the order of cardiac enzyme peak?

A

GBBB > myoglobin > CK MB > Trop > LDH

243
Q

Which cardiac enzyme rises first?

244
Q

How does sepsis cause T2MI?

A

inadequate perfusion of tissues.

In peripheral tissues, this causes lactate to be released,

but in the heart it can cause troponin release.

245
Q

Which cardiac enzyme should be checked for reinfarction?

A

CK-MB is useful to look for reinfarction as it returns to normal after 2-3 days (troponin T remains elevated for up to 10 days)

246
Q

In AF with pre-excitation (antidromic re-entrant tachycardia) in WPW, what is the management?

A

If haemodynamically stable, give procainamide

247
Q

How is lithium cleared?

A

renal clearance

248
Q

What BP delay do you see in coarctation of aorta

A

Radiofemoral delay

249
Q

Which papillary muscle is most likely to rupture, and what are their blood supplies?

A

Posteromedial > anterolateral

posteriomedial is supplied by right coronary artery only

anterolateral supplied by LAD and left Cx

250
Q

audible diastolic murmur and
unequal BP both arms

A

aortic dissection causing AR

251
Q

What ECG changes can u see in aortic dissection?

A

backward tear can dissect right coronary artery causing inferior ST depression (isch)

252
Q

What is the investigation of choice for irregular palpitations (pAF)?

A

72hr holter

253
Q

Which valvular lesion is ankylosing spondylitis associated with?

A

Aortic regurgitation

Aortitis -> aortic root dilatation -> AR

254
Q

What are the signs of aortic regurgitation?

A

Collapsing pulse
Wide pulse pressure
Corrigan’s - neck pulsation
De Musset- head nodding
Quincke - nail bed pulsation
Duroziez - diastolic murmur proximal to femoral artery compresison
Early diastolic murmur left sternal edge (exp)

Severity: presence of collapsing pulse, wide PP, pulmonary oedema.

255
Q

Which medication should be avoided in aortic regurgitation?

A

BB

(Increase diiastolic volume due to bradycardia)

256
Q

Which medication should be avoided in HOCM and AS?

A

ACEI and GTN- reduced afterload and worsen outflow

257
Q

What is Buerger’s disease

A

Thromboangiitis obliterans

occlusive inflammatory disease of small to medium arteries in upper and lower extremities, causing claudication and thrombophlebitis.

258
Q

What is the risk factor for bueger’s?

259
Q

What is Heyde syndrome?

A

High shear stress and velocity across aortic stenosis -> unfold vWF -> prevent binding to collagen -> hence platelet cannot attach -> may present with angiodysplasia in GI tract

260
Q

What are the absolute contraindications for carotid sinus massage?

A

MI
TIA/CVA in last 3 months
carotid artery occlusion (bruit)
previous VT/VF

261
Q

What is early onset aortic stenosis caused by?

A

bicuspid aortic valve

262
Q

Outline DVLA laws for initial implantation of ICD?

A

Should not drive for 6 months after shock delivery.

Group 2 drivers- large goods vehicles and buses permanently cannot drive

263
Q

Outline DVLA laws for defib box change:

A

cannot drive for 1 week

264
Q

Outline DVLA laws for revised electrode/altered anti-arrhythmic drug?

A

Should not drive for 1 month

265
Q

What is haemodynamic compromise in PE?

A

Systolic <90 mmHg
>40 mmHg drop for >15 min

266
Q

Why is coronary angio done before valve replacement?

A

to assess the need for concomitant CABG.

267
Q

Compare signs and symptoms of AS and HOCM

A

HOCM pulse is jerky

Valsalva increases HOCM murmur, but decreases in AS

Sudden death in HOCM during or after exercise.

268
Q

What is mid systolic click syndrome?

A

mitral valve prolapse and recurrent non cardiac chest pain.

XS stress on papillary muscle-> ischemia and CP -> but no coronary disease

Standing/valsalva manoeuvre -> ventricular volume gets smaller -> click and murmur occur earlier in systole

269
Q

Describe ECG waveform with heart sounds

A

R wave: first heart sound

P wave: pathological S4

S wave: between S1 and S2

T wave: between S2 and pathological (except young and athletes) S3

U wave: follow T wave (Showing repolarisation of purkinje)

270
Q

Outline treatment for VT:

A

Stable:
amiodarone
(lidocaine CI in HF)
(procaimide SVT with aberrancy)

Unstable: DCCV

Chronic drug therapy:
ABC
- Amio
- Betablock
- CCB (NOT VERAPAMIL)

271
Q

When does PFO open?

A

in valsalva - straining/diving

272
Q

What is subclavian steal syndrome?

A

Occlusion/stenosis of proximal subclavian artery -> drop in antegrade/retrograde in ipsilateral vertebral artery causing neuro sx.

273
Q

Which medication has prognostic benefit for HF?

A

Betablocker and ACEi

274
Q

What drug causes shortened QT?

275
Q

What should INR be prior to elective DCCV for AF? And what is the alternative method to check for clot?

A

INR >2 for 3-4weeks prior

TOE

276
Q

Outline the steps for synchronised DCCV

A

Initial shock 100J -> 200J -> 360J
Sync with R wave.

277
Q

Which procedure needs abx prophylaxis for IE in high risk patients?

A

Permanent pacemaker insertion

278
Q

Which patients are deemed high risk of endocarditis requiring prophylactic abx?

A

acquired valvular heart disease
valve replacement
structural congenital heart disease including surgically corrected
previous IE
HOCM

279
Q

Which procedure does no longer need abx prophylaxis for IE?

A

dental procedure

280
Q

What ECG changes do you see in Brugada syndrome?

A

Incomplete RBBB and ST elevation in anterior precordial leads

281
Q

What arrhythmia is high dose methadone replacement associated with?

A

Long QT syndrome

282
Q

What is the treatment for multifocal atrial tachycardia?

A

CCB (Verapamil or diltiazem)

suppress atrial rate hence reduce conduction through AVN.

283
Q

What is the treatment for primary pulmonary hypertension who fail the vasodilation test (NO)

A

sildenafil (CI in hx of stroke)
ambriosentan

284
Q

What is the treatment for primary pulmonary hypertension who pass the vasodilation test (NO)

285
Q

How should ACEi and ARB be uptitrated?

A

Intervals of 2 weeks or more
Reduce dose if creatinine increases >30% or eGFR reduced >25% or K+ > 6

286
Q

What are the ECHO findings of myocarditis?

A

dilated hypokinetic chambers
segmental wall motion abnormalities

287
Q

What is the management for torsades de pointes (polymorphic VT with varying amplitude of QRS)?

A

IV magsulf

288
Q

Why is flecainide contraindicated in structural heart or ischaemic heart or HF?

A

Can trigger VF

289
Q

Which anti-arrhytmics should be avoided in HF?

A

Lidocaine
Beta blocker like sotalol
Flecainide

290
Q

What is the management for long QT rate control?

A

Beta blockers

Avoid intensive sporting activity.

note sotalol may exacerbate long QT syndrome

291
Q

What is definition of HTN in pregnany?

A

> 140/90 OR rise of 25/15 above baseline

292
Q

Which juice does warfarin interact with?

A

Cranberry (inhibits CYP450) -> prolong INR

293
Q

What are CYP450 inhibitors?

A

G PACMAN

Grapefruit
Protease inhibitors
Antifungals
Cyclosporin
Macrolide
Amiodarone
Non-dihydropyridine

294
Q

What are CYP450 inducers

A

CRAP GPs

Carbamazepine,
Rifampicin,
Alcohol (chronic),
Phenytoin,
Griseofulvin,
Phenobarbitone,
Sulphonylureas (also St. John’s Wort and smoking)

295
Q

Which lipid is main carrier of cholesterol and cause of atherosclerosis?

296
Q

What is the BP difference in both arms associated with?

A
  1. Coarctation of aorta if proximal to left subclavian artery (lower limb BP lower)
  2. Aortic dissection
  3. Peripheral vascular disease (>15mmHg diff)
  4. Subclavian steal syndrome (dizzy painter)
297
Q

What are the normal pressures of the heart chambers?

A

Central venous: 3-8

Right ventricle: <25/5

Pulmonary artery: (<25/10)

Pulmonary capillary wedge pressure/left atrial pressure: (<12)

Left ventricular: 100-140/3-12

298
Q

What happens if a patient fails a Bruce protocol

A

Refer for CT angio

299
Q

Where is the most common site for radiofrequency ablation for AF?

A

Pulmonary veins joining with atrium

300
Q

How does statin work?

A

inhibit 3-hydroxy-3-methylglutaryl coenzyme A reductase in liver

301
Q

What cholesterol level and above would primary prevention with statin be of benefit?

A

> 4 mmol/L

302
Q

Hypertension target:

A

<80 - 140/90

> 80 - 150/90

T2DM or HF - 135/85

303
Q

Describe posterior MI

A

ECG- ST depression in V1-5 but elev in reciprocal leads

Left circumflex artery occlusion

304
Q

What is the mechanism of action for clopidogrel?

A

Irreversible blocking of ADP receptor

305
Q

What is the mechanism of action for ticagrelor?

A

Reversible blocking of ADP receptor (P2Y12)

306
Q

What is the mechanism of action of LMWH (clexane/dalteparin)

A

Potentiates anti-thrombin 3

307
Q

What is the murmur like in mitral valve prolapse?

A

mid systolic click and late systolic murmur at apex

louder on standing

308
Q

Which cyanotic heart disease require prostaglandin to keep the PDA open?

A

Tricuspid atresia

309
Q

Why can ticagrelor cause SOB?

A

Build up of adenosine

310
Q

What does Q wave indicate on ECG?

A

Full thickness scarring

311
Q

What is the mechanism of action of digoxin?

A

inhibit cardiac Na/K ATPase

312
Q

What does SVT look like on ECG

A

Narrow complex tachycardia
No p waves
Regular

313
Q

What is the INR range for mechanical aortic valve?

314
Q

What are the 4 features of ToF?

A

VSD
Overriding aorta
Right ventricular outflow obstruction
Right ventricular hypertrophy

315
Q

Causes of reversed splitting S2:

A

Delayed A2
- LBBB, AS, HOCM

Early P2
- WPW type B (right accessory pathway)

316
Q

Why is amiodarone avoided in young patients as prophylaxis of ventricular and supraventricular arrhythmias?

A

Potential lung fibrosis

317
Q

What is Kussmaul’s sign in constrictive pericarditis?

A

JVP rise with inspiration

318
Q

What is most characteristically seen on ECG with severe hypothermia?

A

J waves in chest leads (dome/hump after QRS)

319
Q

Which congenital conditions are associated with coarctation of aorta?

A

Turner’s
Williams

320
Q

What is J point depression and what does it signify?

A

Physiological response to high HR

321
Q

Which medication should not be taken with sildenafil?

A

Nicorandil due to fatal drop in BP

322
Q

What is sildenafil used in? (phosphodiesterase 5 inhibitor

A

Erectile dysfunction
Pulmonary Hypertension

323
Q

Describe COX 1 and COX 2 with examples

A

COX 1 - naproxen (increased risk of bleed)
Mixed - ibuprofen
COX 2 - Celecoxib (increased risk of thrombus)

324
Q

Which clotting factors are vitamin K dependent

325
Q

What is the difference between sustained and unsustained VT?

A

Sustained if lasting >30 seconds

unsustained <30 sec and self terminate

326
Q

Outline management of nonshockable rhythm
PEA/asystole

A

Chest compressions
30:2 compression to ventilation

Adrenaline
Non shockable- adrenaline 1mg ASAP.
Repeat adrenaline every 3-5min (2 loops of CPR)

Amiodarone
Nonshockable- DO NOT GIVE

327
Q

What is the JVP waveform for cardiac tamponade?

A

TAMPAX

Absent Y wave

MRCP Part 1 (17 decks)

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