MRCP Cardio Flashcards
In New LBBB: what are the first and second heart sounds like?
First soft
Second- reversed splitting (pulmonary valve closes before aortic valve due to delay in depol)
What is paradoxical embolism (crossed embolism), and what are the consequences?
when venous clot enters arterial side or vice versa. (DVT to stroke)
through patent foramen ovale.
bubble TTE ECHO would diagnose.
What does S4 heart sound indicate?
Non compliant stiff ventricle and pressure overload (HFPEF)
Thiazide side effects?
Exacerbate hyperglycaemia
low sodium and potassium
What are the symptoms and consequences of Trypanosoma cruzi?
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
Absolute contraindication of thrombolytic treatment
- active bleed
- recent head trauma <2 wks
- known intracranial cancer
- hx of stroke <2months ago
- uncontrolled HTN >200/120
What is the HS like in severe aortic stenosis?
Quieting of second HS = severe due to immobile valve
What are the HS like in aortic stenosis?
soft first HS
reverse splitting of second HS in LVF
What is the pathophysiology of WPW?
atrioventricular re-entry tachycardia (AVRT)
narrow complex with anterograde through AVN and retrograde through accessory pathway
What happens when WPW syndrome develop AF?
VF (broad QRS- SVT with aberrancy)
Patients on life long warfarin requiring dental procedure- what is target INR?
INR<4
What happens to the S2 heart sound in RBBB?
Wide physiological splitting S2
Persistent in both inspiration and expiration
What are 3 indications of temporary pacing?
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)
What 5 indications for permanent pacemaker
CHB
Drug resistant tachyarrhythmia
mobitz type 2
persistent AV block post MI
sick sinus syndrome
sinus pause >3s
trifascicular block
What is the order of NNT for drugs prolonging survival post MI?
ACEi > statin > aspirin > beta blocker
ASAB
What is the auscultation sound you would hear for complete heart block?
variable intensity of first heart sound
Where does atrial myxoma originate from 75% of the time?
left atrium (interatrial septum)
What is the murmur like in atrial myxoma?
Diastolic murmur changing in character with position.
What does S3 heart sound indicate?
Rapid Diastolic filling
Fluid overload
Which coronary artery is blocked in anterior MI?
LAD - left ANTERIOR descending
Which coronary artery is blocked in inferior MI?
right coronary artery
Which coronary artery is blocked in lateral MI?
Left CIRCUMFLEX
How should you take out a person in cold water drowning?
pull out and leave prone position to prevent venous pooling and circulatory collapse.
Why does isometric handgrip exercise accentuates mitral regurgitation?
due to increased BP and afterload hence increased backflow murmur
What is the problem in Young patient with high BP, and reduced renal function…
Renal artery stenosis can cause secondary hypertension
What are the causes of constrictive pericarditis
- inflammation (chronic)
Any cause of pericarditis
Particularly TB
What is pulsus paradoxus
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.
Describe the JVP waveforms (AxCx’Vy)
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)
In constrictive pericarditis what happens to JVP waveform?
more prominent x and y
(as atria and ventrical are stiff hence early diastolic filling - imagine thick elastic band going back to original shape)
What is pleural rub commonly associated with?
PE
What is pericardial rub associated with?
pericardial effusion
What is systolic click associated with?
mitral valve prolapse
also in pneumothorax
How does paradoxical embolism occur in PFO?
right atrium to left atrium shunt on valsava (straining/diving) causing venous content to enter arterial content.
Complications of MI?
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
What duration should patient be anticoagulated (warfarin) pre and post cardioversion for AF?
3 WEEKS PRE
4 WEEKS POST
target INR 2.5
Management of SVT
DC cardiovert if haemodynamically compromised
Non-pharm
- vagal manoeuvre
Pharm
- IV adenosine (CI in asthma)/verapamil
Prevention of episodes:
- betablocker/flecainide
- ablation
If stroke with AF, what is the long term management?
Anticoagulation (not clopidogrel)
What are the common causes of pericarditis?
Coxackie
TB
Uraemia
MI
- days fibrous
- months dressler (autoimmune)
Radiotherapy
Hypothyroidism
Connective tissue (SLE/RA)
Cancer
Trauma
Which coronary artery occlusion is associated with complete heart block?
proximal right coronary (supplies AVN)
Which coronary artery occlusion is associated with first degree AV block and wenckebach type 1?
Distal right coronary artery
What causes loud first heart sound?
Opening snap in mitral stenosis (mobile valve)
atriventricular valve lesion
What is soft first heart sound indicative of?
immobile mitral stenosis
hypodynamic state
mitral regurgitation
long PR interval
what is splitting S1 indicative of?
RBBB
LBBB
VT
Ebstein’s anomaly
What is variable S1 indicative of?
AF
CHB
What is loud S2 indicative of?
HTN
Tachycardia
ASD
What is soft/absent S2 indicative of?
severe AS (due to calcified immobile valve)
What is fixed splitting S2 indicative of?
ASD
What are the causes of wide split S2?
RBBB
deep inspiration
What is revered split S2 indicative of?
LBBB
AS
HOCM
What is the first and second line management for stable angina?
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)
What is the advantage of continuous loop recorder?
Picking up arrythmia without pattern or triggers (will catch it during symptoms)
What does IRREGULAR cannon a waves on JVP indicate?
CHB
Note:
atria contracting on closed tricuspid valve.
What changes in JVP waveform in Tricuspid regurgitation?
**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
What condition causes absent a wave in jvp?
AF due to uncoordinated atrial contraction
Caused of large A waves on JVP
large if atrial pressure
tricuspid stenosis
pulmonary stenosis
pulmonary hypertension
What suggests cardiogenic syncope?
sudden LOC without prodrome or during exercise
What is the first and second commonest cardiovascular abnormality in adult Marfan’s?
- Aortic root dilatation
- mitral valve prolapse
(fibrillen gene defect in tunica media hence weakened from pressure)
What is wolff chaikoff effect?
transient inhibition of thyroid hormone production due to high iodine levels.
Why should you perform a thyroid radionuclide isotope scan prior to cardiac catheterisation?
iodine contrast may worsen hyperthyroidism in toxic multinodular goitre but improve in Grave’s due to Wolff chaikoff.
What is acrocyanosis a sign of and complication of what?
cholesterol embolism (blue big toe)
Complication of MI- angio/surgical valvular procedure.
What part of conduction system does vagal manoeuvres help?
AVN but not distal conducting system`
Slows AVN
What part of conduction system does atropine worsen?
Block in His-Purkinje system
What is trifasicular block?
bifascivular block with 1st degree HB
What is bifascicular block?
RBBB+ left anterior (LAD)/posterior fascicular block (RAD)
What is the management for asymptomatic pericardial effusion?
reassure and monitor if no haemodynamic compromise (even if large effusion)
Which medications are associated with improved mortality from cardiovascular disease?
ACEi
BB
Spironolactone
nitrate and hydralazine
When do you see jerky bisferiens pulse?
HOCM - collapsing pulse followed by secondary rise
What is the difference between critical stenosis vs complete occlusion of coronary arteries?
critical stenosis T wave inv
complete occlusion ST elev
What is QRISK?
risk of developing cardiovascular disease in 10 years (up to age 82)
if >10% start statin
When is RBBB seen
can be physiological
Pathological in ASD/PE
When is LBBB seen
ALWAYS PATHOLOGICAL
What is the commonest cause of cardiac arrest outside the hospital?
VF
What social drug history is important in chest pain ACS?
Cocaine abuse as cause cause vasocontriction/atheroma rupture/dissection
BB contraindicated in cocaine use
Patient with myaesthenia gravis, HF and new AF which rate control is preferred?
DIGOXIN
bisoprolol worsen muscle weakness
diltiazem may worsen cardiac failure
Outline management of shockable cardiac arrest
pulseless VT/VF
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
What arrhythmia shows shortened PR and inferior Q waves, but no wide QRS/delta wave?
Lown Ganong Levine (LGL)
accessory pathway connecting atria to bundle of His (by passing AVN)
Ouline the management for vasospastic angina?
CCB first line
ISMN alternative or combination
Which murmurs become louder in pregnancy?
stenosis and ASD murmurs are louder
Due to increased blood volume and cardiac output
Which murmur becomes quieter in pregnancy?
Aortic regurgitation
(regurgitations)
What is the defibrillator joules for cardiac arrest- pulseless VT/VF
Biphasic 150-200 J unsynchronised
Monophasic 360 J
What does new RBBB , with raised JVP?
PE causing right heart strain.
Treatment for Ventricular arrhythmias unresponsive to amiodarone
lidocaine
CI in HF
CI in HF
What are normal physiological changes in pregnancy?
drop in diastolic BP by 10mmHg in 2nd trimester
increase in cardiac output by 50%
tachycardia
pulmonary systolic murmur from high flow
physiologic S3
Which valve is most anterior of the human heart?
Pulmonary > mitral >aortic
left sided valves are more posterior
What coronary artery is occluded in right ventricular MI?
right coronary artery hence causing inferior wall MI
What is the difference between WPW type A and WPW type B?
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)
Which thrombolytic agent is associated with minimum risk of haemorrhagic stroke?
Streptokinase (IV infusion over 1hr)
Which phase of pregnancy are pregnant women at greatest risk of DVT?
First 6 weeks after delivery.
Which papillary muscle is most likely to rupture, and what are their blood supplies?
Posteromedial > anterolateral
posteriomedial is supplied by right coronary artery only
anterolateral supplied by LAD and left Cx
What is the investigation of choice for irregular palpitations (pAF)?
72hr holter
Which valvular lesion is ankylosing spondylitis associated with?
Aortic regurgitation
Aortitis -> aortic root dilatation -> AR
What are the signs of aortic regurgitation?
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.
Which medication should be avoided in HOCM and AS?
ACEI and GTN- reduced afterload and worsen outflow
What are the absolute contraindications for carotid sinus massage?
MI
TIA/CVA in last 3 months
carotid artery occlusion (bruit)
previous VT/VF
What is haemodynamic compromise in PE?
Systolic <90 mmHg
>40 mmHg drop for >15 min
Why is coronary angio done before valve replacement?
to assess the need for concomitant CABG.
Compare signs and symptoms of AS and HOCM
HOCM pulse is jerky
Valsalva increases HOCM murmur, but decreases in AS
Sudden death in HOCM during or after exercise.
What is mid systolic click syndrome?
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
Describe ECG waveform with heart sounds
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)
Which medication has prognostic benefit for HF?
Betablocker and ACEi
Which procedure needs abx prophylaxis for IE in high risk patients?
Permanent pacemaker insertion
Which patients are deemed high risk of endocarditis requiring prophylactic abx?
acquired valvular heart disease
valve replacement
structural congenital heart disease including surgically corrected
previous IE
HOCM
Which procedure does no longer need abx prophylaxis for IE?
dental procedure
What is the treatment for multifocal atrial tachycardia?
CCB (Verapamil or diltiazem)
suppress atrial rate hence reduce conduction through AVN.
How should ACEi and ARB be uptitrated?
Intervals of 2 weeks or more
Reduce dose if creatinine increases >30% or eGFR reduced >25% or K+ > 6
What are the ECHO findings of myocarditis?
dilated hypokinetic chambers
segmental wall motion abnormalities
What is the BP difference in both arms associated with?
- Coarctation of aorta if proximal to left subclavian artery (lower limb BP lower)
- Aortic dissection
- Peripheral vascular disease (>15mmHg diff)
- Subclavian steal syndrome (dizzy painter)
What happens if a patient fails a Bruce protocol
Refer for CT angio
How does statin work?
inhibit 3-hydroxy-3-methylglutaryl coenzyme A reductase in liver
What cholesterol level and above would primary prevention with statin be of benefit?
> 4 mmol/L
Hypertension target:
<80 - 140/90
> 80 - 150/90
T2DM or HF - 135/85
What is the mechanism of action for clopidogrel?
Irreversible blocking of ADP receptor
What is the mechanism of action for ticagrelor?
Reversible blocking of ADP receptor (P2Y12)
What is the mechanism of action of LMWH (clexane/dalteparin)
Potentiates anti-thrombin 3
Which cyanotic heart disease require prostaglandin to keep the PDA open?
Tricuspid atresia
What does Q wave indicate on ECG?
Full thickness scarring
What is the mechanism of action of digoxin?
inhibit cardiac Na/K ATPase
What is the INR range for mechanical aortic valve?
2.5-3.5
Which congenital conditions are associated with coarctation of aorta?
Turner’s
Williams
What is J point depression and what does it signify?
Physiological response to high HR
Which medication should not be taken with sildenafil?
Nicorandil due to fatal drop in BP
What is sildenafil used in? (phosphodiesterase 5 inhibitor
Erectile dysfunction
Pulmonary Hypertension
Describe COX 1 and COX 2 with examples
COX 1 - naproxen (increased risk of bleed)
Mixed - ibuprofen
COX 2 - Celecoxib (increased risk of thrombus)
Which clotting factors are vitamin K dependent
1972
