Pass Med App Know Test Card

Question 1

ACS NSTEMI medical Rx (NICE ‘13)

Answer 1

1. Aspirin 300mg STAT then 75mg LT.
2. Clopidogrel 300mg STAT then 75mg for 12/12 (alternative = ticagrelor).
3. Analgesia (GTN, morphine, etc.)
4. Fondaparinux for 5/7.
5. Statin.
6. Beta blocker.

N.B. if predicted 6/12 mortality >3% then coronary angiography (within 4/7 of admission) + IV glycoprotein IIb/IIIa receptor antagonist (e.g. tirofiban).

Question 2

Amiodarone

1. Class/MOA.
2. Indication.
3. A/Es.
4. Half life.
5. Monitoring.

Answer 2

1. Antiarrhythmic class III (K+ ch blocker)&raquo_space; class I (Na+ ch blocker).
   i. e. inhibits myocyte repolarisation.
2. Tachycardias (atrial, nodal, VT)
3. hypo > hyperthyroidism, corneal deposits, photosensitivity, pulmonary fibrosis/pneumonitis, liver fibrosis/hepatitis, peripheral neuropathy, slate-grey appearance, thrombophlebitis (try to give via cntl vein), increased QT interval, bradycardia, P450 inhibitor.
4. Variable 20-100 days.
5. Baseline CXR, TFTs, LFTs, UEs then 6/12 TFTs + LFTs

Question 3

Anaphylaxis drug doses

1. < 6 months.
2. 6 months to 6 years.
3. 6 to 12 years.
4. 12+ years.

Answer 3

1. IM ad. (1:1,000) 150mcg + HC 25mg + chlor. 250mcg/kg.
2. IM ad. 150mcg + HC 50mg + chlorphenamine 2.5mg.
3. IM ad. 300mcg + HC 100mg + chlorphenamine 5mg.
4. IM ad. 500mcg + HC 200mg + chlorphenamine 10mg

Question 4

Angina drug Rx (NICE ‘11)

Answer 4

All = aspirin + statin + GTN.
1st L = BB vs. rate-limiting CCB.
2nd L = up-titrate monotherapy.
3rd L = BB + long-acting CCB (e.g. nifedipine MR).
4th L = + 3rd drug* +/- PCI or CABG.

*long acting nitrates, ivabradine, nicorandil, ranolazine.

Question 5

Angioedema

1. Definition.
2. Angioedema vs. anaphylaxis.
3. Angioedema vs. urticaria/hives.
4. Causes.
5. Rx.

Answer 5

1. T1 hypersensitivity rxn causing CT swelling under skin (dermis, hypodermis, mucosa, submucosa).
2. Normal vital signs and no airway compromise.
3. Does not affect upper dermis/skin.
   N.B. angioedema may present with anaphylaxis + hives.
4. ACEIs, A2RBs, NSAIDs, other allergens, hereditary (autosomal dominant).
5. Antihistamines only needed, identify/avoid allergen

Question 6

Bonus card - hypersensitivity rxns.

Answer 6

T1 = MC + basophil/IgE mediated/”allergy”/”atopic” e.g. allergic rhinitis, asthma, eczema, urticaria/hives, angioedema, anaphylaxis.

T2 = antibody mediated/cytotoxic (IgM or IgG bind to enemy cell - lysis/complement + neuts/macs) e.g. haemolytic anaemia, pernicious anaemia, ITP, acute haemolytic transfusion rxn, rheumatic fever, goodpasture’s syndrome, bullous pemphigoid, pemphigus vulgaris, Grave’s, MG.

T3 = immune complex (antigen + IgG) e.g. SLE, RA, PAN, PSGN, serum sickness, arthus rxn (following tetanus vaccine), hypersensitivity pneumonitis (e.g. farmer’s lung).

T4 = T cell mediated/delayed e.g. T1DM, MS, GBS, graft vs. host, contact dermatitis, Hashimoto’s.

Question 7

ACEIs

1. MOA.
2. AEs.
3. CIs.
4. Monitoring.

Answer 7

1. Inhibit ACE (converts angiotensin I to angiotensin II).
2. Cough 15% (up to 1y after starting), angioedema (up to 1y after starting), high K+, first dose hypoTN (esp. + diuretics).
3. Pregnancy, breastfeeding, renovascular disease, AS (drops BP), idiopathic angioedema, high dose diuretics, Cr rise >30%, K+ up to 5.5mmol/L.
4. Baseline UEs - rpt after starting and increasing dose.

Question 8

A2RBs - when to use?

Answer 8

When ACEI not tolerated i.e. cough (will not inhibit ACE from bradykinin degradation).

N.B. otherwise similar properties to ACEIs.

Question 9

Bonus card - RAAS.

Answer 9

1. Angiotensiogen release from liver.
2. Renin release from kidney JXA: triggered by low BP (juxtaglomerular/granular cells), low Na+ (JXA macula densa cells), and sympNS.
3. Renin converts angiotensinogen to AT1.
4. ACE in lungs and kidneys convert AT1 to AT2.
5. AT2 vasoconstricts (AT2 rec. VSM), increases FF/preserves GFR by constricting glomerular aa, triggers thirst (hypothalamus), releases aldosterone and ADH.

Question 10

Antiplatelet Rx guidelines.

1. ACS - NSTEMI/UA.
2. ACS - STEMI.
3. TIA and ischaemic stroke.
4. PAD.

Answer 10

1. 1st L = aspirin 75mg LT + clopidogrel (or ticagrelor) 12/12; 2nd L = clopidogrel LT.
2. 1st L = aspirin LT + clopidogrel (or ticagrelor) for 1/12 if no or bare stent, or 12/12 if drug eluting stent; 2nd L = clopidogrel LT.
3. 1st L = clopidogrel; 2nd L = aspirin + dipyridamole.
4. 1ST L = clopidogrel; 2nd L = aspirin.

Question 11

Aortic dissection.

1. Stanford classification.
2. DeBakey classification.
3. Associations/causes.
4. Backward tear cx.
5. Forward tear cx.

Answer 11

1. Type A = 2/3 cases, ascending aorta; type B = desc. a.
2. T1 = ascending, then arch, +/- desc. a.; T2 = confined to ascending a.; T3 = desc. a. +/- distal ext. (rarely proximal).
3. HTN, Marfan’s, Ehlers-Danlos, Noonan’s, pregnancy, syphilis, bicuspid AV, trauma.
4. AR, MI (usually inferior/RCA).
5. ULs unequal pulses + BP, renal failure, CVA.

Question 12

AR

1. Clinical features.
2. AV causes.
3. Aortic root causes.

Answer 12

1. Early DM, mid-DM/Austin-Flint murmur (if severe), wide PP, collapsing pulse.
2. Rheumatic fever, IE, bicuspid valve, CT disease (e.g. RA, SLE).
3. Marfan’s, Ehlers-Danlos, spondyloarthropathies (e.g. AS), HTN, syphilis, aortic dissection (if forward tear)

Question 13

Bonus card - valve replacements.

1. Mechanical valve types.
2. Mechanical valve disadvantage.
3. Mechanical valve anticoagulation target INRs.
4. Bioprosthetic valve disadvantage.
5. Bioprosthetic valve medical Rx.

Answer 13

1. Bileaflet&raquo_space; ball and cage (older).
2. Thrombosis risk.
3. Aortic = 3.0, mitral = 3.5.
4. Deterioration + calcification (i.e. use in older patients).
5. Usually warfarin 3/12 then 75mg aspirin LT.

N.B. bioprosthetic valves usually bovine or porcine.

Question 14

AS

1. Features.
2. Causes.
3. Rx.

Answer 14

1. CP, SOB/SOBOE, presyncope/syncope, narrow PP, slow rising pulse, ESM radiating carotids, soft/absent S2, thrill, S4, LVH/LVF.
2. Calcification (esp. >65 years), bicuspid AV (esp. <65 years), post rheumatic fever cx, HOCM (subvalvular), William’s disease (supravalvular).
3. Observe vs. AVR* (Rx if symptomatic, LVF/LVSD, >40mmHg valvular gradient).

*If not suitable for surgery then balloon valvuloplasty.

Question 15

Assessment of suspected cardiac CP - Rx acute vs. “stable”.

Answer 15

Acute = aspirin 300mg STAT, GTN, SpO2 94-98%, EM admission +/- ECG (if time).

“Stable” = ?anginal pain, CAD risk assessment and relevant Ix.

Question 16

Assessment of suspected “stable”cardiac CP - ?angina

Answer 16

1) Constricting pain chest, neck/jaw, shoulders, arms.
2) Exertional.
3) Relieved by rest and/or GTN.

If 3 = typical angina, 2 = atypical angina, <2 non-anginal.

Question 17

Bonus card - stable angina immediate management.

Answer 17

1. Refer to rapid access CP clinic*.
2. Arrange ECG.
3. Bloods (FBC, lipids, VBG/HbA1c).
4. QRISK and BP check.
5. Consider angina medical Rx.
6. Lifestyle advice (e.g. VBA, diet).

CP assessment may advise/perform exercise TT but this is not recommended by NICE GLs. CAD Ix is determined by risk tables and may involve CA angiogram, stress echo, MR ror SPECT perfusion scan.

Urgent referred if Hx of UA i.e. severe CP, can occur at rest, last >10 mins, rapidly worsening.

Question 18

AF

1. Rate control.
2. CHA2DS2-Vasc score.
3. HAS-BLED score.

Answer 18

1. BB or rate limiting CCB > digoxin.
2. CCF +1, HTN, 75+ yrs +2, 65-74 yrs + 1, DM +1, stroke/TIA +2, vascular d (e.g. PAD, IHD) +1, female +1.
   If 0 = no Rx, 1 = consider OAC if male 2+ = give OAC.
3. HTN, abnormal renal or liver function, stroke, bleeding, labile INRs, elderly/65+ yrs, drugs predisposing to bleeding (e.g. NSAIDs) or alcohol.
   If >2 then “high risk” (make of that what you will ! ).

Question 19

Atrial flutter

1. ECG features.
2. Rx.

Answer 19

1. “Sawtooth” appearance, ventricular rate 300 bpm or dependent on degree of AV block (e.g. 150 bpm if 1st deg.)
2. Cardioversion (more sensitive to this than AF), radio ablation of the tricuspid valve isthmus (curative in most patients), otherwise rate control +/- OACs.

Question 20

LAD causes

Answer 20

Left anterior hemiblock (left ant. fascicular block/LAFB).
LBBB
WPW (rarely causes RAD)
High K+
Obesity (minor LAD only)
Congenital - ostium primum ASD, tricuspid atresia.

Question 21

RAD causes

Answer 21

Left posterior hemiblock (left post. fascicular block/LPFB)
RVH (including cor pulmonale).
PE.
Tall (minor RAD only)
Congenital - ostium secundum ASD.
WPW syndrome (rare, usually causes LAD).

Question 22

Beta blockers

1. Indications.
2. A/Es.
3. Contraindications.

Answer 22

1. Angina, MI/UA, arrhythmia rate cntl (esp. AF/flutter), HTN, migraine prophylaxis, anxiety, thyrotoxicosis.
2. Bronchospasm, nightmares/sleep disturbance, fatigue, cold peripheries.
3. Asthma, uncontrolled HF, SSS, verapamil.

Question 23

BNP / NT-proBNP

1. Uses
2. Good predictive value?
3. High reading causes (think of false +ve risk).
4. Low reading causes (i.e. risk of false -ve).

Answer 23

1. ?HF (if Hx of MI then straight to echo), prognostic marker in HF.
2. Good NPV and sensitivity, poor PPV and specificity.
3. HF, MI, LVH, pulm. HTN, AF, PE and RV strain, COPD, DM, AKI/CKD, sepsis, hypoxia.
4. ACEIs, A2RBs, BBs, diuretics, obesity.

Question 24

Brugada syndrome

1. Definition.
2. Genetics.
3. ECG features.
4. Rx.

Answer 24

1. Inherited (AD) conduction disorder with risk of sudden death.
2. 20-40% SCN5A mutation, many other causes, > Asians.
3. Convex ST seg. elevation (V1-3) with negative T wave + incomplete RBBB
4. ICM.

Question 25

Buerger's disease (thromboangiitis obliterans) 1. Classification. 2. Main association 3. Features.

Answer 25

1. Small and medium vessel vasculitis. 2. Smoking. 3. Raynaud's, superficial thrombophlebitis, extremity ischaemia (e.g. arterial ulcers, intermittent claudication).

Question 26

Cardiac tamponade 1. Features. 2. vs. constrictive pericarditis. 3, Why does the raised JVP have absent Y descent in cardiac tamponade? 4. Define Kussmaul's sign.

Answer 26

1. SOB, raised JVP + absent Y descent, Kussmaul's sign, pulsus paradoxus, hypoTN, electrical alternans on ECG. 2. Tamponade displays absent Y descent and pulsus paradoxus, Kussmaul's sign is RARE in tamponade but common in constrictive pericarditis. Pericardial calcifications are also often seen on CXR in constrictive pericarditis. 3. Poor ventricular filling. 4. Paradoxical JVP rise on inspiration (vs. Kussmaul's respiration, an abnormal breathing pattern in severe metabolic acidosis e.g. DKA or respiratory centre lesion e.g. stroke).

Question 27

Cardiomyopathies - classification.

Answer 27

Old method = dilated, restricted, hypertrophic. ``` Primary = genetic, acquired, "mixed" (i.e. multifactorial). Genetic = HOCM, arrhythmogenic RV dysplasia. Acquired = peripartum, Takotsubo/"broken heart" "Mixed" = dilated, restricted. Dilated = alcohol, coxsackie B, beri beri, doxorubicin. Restrictive = amyloidosis, Loeffler's endocarditis, radioTx. ``` Secondary (i.e. cardiomyopathy as part of a systemic disorder) = coxsackie B, Chagas, amyloidosis, alcohol, beri beri/thiamine def., doxorubicin, haemochromatosis, sarcoidosis, DM, acromegaly, thyrotoxicosis, Friedreich's ataxia, MD, Duchenne MD, SLE.

Question 28

HOCM.

Answer 28

1. Autosomal dominant. 2. Echo = MR, systolic anterior motion (SAM) of MV, and asymmetric atrial hypertrophy. 3. Beta myosin gene (usually). 4. Leading cause sudden death in younger athletes.

Question 29

Arrhythmogenic right ventricular dysfunction.

Answer 29

1. Autosomal dominant. 2. RV myocardium is replaced by fatty +/- fibrous tissue. 3. Dermosome coding gene mutation in 50%. 4. ECG = epsilon wave in 50% (terminal notch in QRS), T wave inversion V1 to 3.

Question 30

Peripartum cardiomyopathy.

Answer 30

Usually between last month of pregnancy to five months postpartum. RFs older woman and high parity/multiple gestations.

Question 31

Takotsubo cardiomyopathy.

Answer 31

"Stress induced" / "broken heart" e.g. bereavement. CP + HF features. Rx is supportive.

Question 32

Choking (Resus Council guidelines)

Answer 32

"Are you choking?" If can answer = partial ob., encourage coughing. No answer = ob. 5 back-blows + 5 abdo. thrusts. Unconscious = CPR + 999.

Question 33

Clopidogrel - MOA, interactions.

Answer 33

MOA = antiplatelet / P2Y12 ADP receptor antagonist. Interaction with PPIs = can be used with lansoprazole.

Question 34

Combination antiplatelet and anticoagulant therapy 1. 2ndary prevention of stable cardiovascular disease with need for an anticoagulant (e.g. AF, mechanical heart valve, etc.). 2. 2ndary prevention of ACS and after PPCI with need for an anticoagulant (e.g. AF, mechanical heart valve, etc.). 3. VTE Rx and need for an antiplatelet (e.g. PAD, angina, stroke/TIA, etc.).

Answer 34

1. Usually stop the antiplatelet. 2. Usually "triple therapy" (i.e. 2 antiplatelets + 1 anticoag.) for 4 weeks to 6/12 then "dual therapy" to complete the 12/12. 3. Continue antiplatelet if low HAS-BLED score.

Question 35

CA territoritories.

Answer 35

Anteroseptal (RCA) = V1 to 4. Anterolateral (LAD or LCX) = V4 to 6, aVL, I. Lateral (LCX) = aVL, I, +/- V5 to 6. Inferior (RCA) = aVF, II, III. Posterior (LCX > RCA) = tall R waves V1 to 2.

Question 36

Dabigatran's main contraindication (MHRA)?

Answer 36

Mechanical heart valves.

Question 37

HTN Rx in DM. 1. BP targets. 2, Drug choice. 3. Avoid? 4. Beware of which antihypertensive side effect?

Answer 37

1. <130/80 if end-organ damage (e.g. CKD, retinopathy), otherwise <140/80 (note relatively lower DBP target). 2. Ideally ACEI as renoprotective (even if >55 years, might need to give +CCB or thiazide if Afro-Caribbean). 3. Beta blockers as may impair insulin secretion and alter ANS response to hypos. 4. Postural hypotension as exacerbated by autonomic neuropathy.

Question 38

Digoxin 1. MOA. 2. Indications. 3. ECG features. 4. Toxidrome features. 5. Factors precipitating toxicity. 6. Toxicity Rx.

Answer 38

1. Cardiac glycoside / slows AVN conduction + inhibits myocyte Na+/K+ ATPase + vagus nerve stimulation. 2. HF (+ve inotrope), rate control. 3. downsloping QRS ("reverse tick"), flattened/inverted T waves, narrow QT, AV block, bradycardia. 4. Unwell, lethargy, yellow-green vision, N&V, confusion, ataxia, arrhythmias (AV block, bradycardia), gynaecomastia. 5. Low K+ (rarely high K+), age, renal failure, myocardial ischaemia, low Mg, high Ca, high Na+, acidosis, hypoalbuminaemia, hypothermia, hypothyroidism, amiodarone, quinine, verapamil, diltiazem, spironolactone, cyclosporin, any drug raising K+. 6. Digibind / antidote, correct arrhythmia, monitor K+.

Question 39

DVLA driving restrictions 1. HTN. 2. Angioplasty (elective). 3. CABG. 4. ACS. 5. Angina. 6. PPM. 7. ICD. 8. Catheter ablation (i.e. arrhythmia Rx). 9. AAA. 10. Heart transplant.

Answer 39

1. Can drive unless unacceptable medication A/Es. Note group 2 cannot drive if BP >180/100. 2. 1 week.* 3. 4 weeks.* 4. 4 weeks (unless angioplasty = 1 week). 5. Cannot drive if sy at rest / at the wheel. 6. 1 week.* 7. If for arrhythmia = 6 months. If prophylactic = 1 month. No driving with ICD if group 2. 8. 2 days.* 9. Annual review if 6cm or more. No driving if 6.5cm or more. 10. No restrictions outlined.* *assumes successful Rx.

Question 40

Heart (AV) block - overview

Answer 40

1st degree = PR >0.2s. 2nd degree type 1 / Mobitz type 1 / Wenckebach = progressive PR prolongation then "dropped beat". 2nd degree type 2 / Mobitz type 2 = e.g. 2:1 block, 3:1 block etc. 3rd degree / complete block = no relation between ventricle rate (escape rhythm) and P waves.

Question 41

Bonus card - Stokes-Adams attack

Answer 41

Syncope classically associated with 3rd degree AV block. Can however occur in other conditions (e.g. tachy-brady syndrome). N.B. cardiologists now do not widely use this term. Characteristics = TLOC at any posture, abrupt onset, flushed on recovery, often lasts >30 secs, can occur during sleep, can cause twitching due to cerebral anoxia (DDx seizure), can cause death.

Question 42

Heart failure drug Rx.

Answer 42

1st L = ACEI + BB. 2nd L = add on: aldosterone antagonist / A2RB / hydralazine + nitrate. 3rd L = resynchronisation Rx / digoxin / ivabradine.* Peripheral oedema = diuretics. Vaccination = annual flu, one-off PPV (or 5 yearly if CKD or hyposplenic). *If HFrEF and not bradycardic i.e. HR >75 and LVEF <35%.