Passmed Cardiology Mushkies Flashcards
1
Q
How can you classify management of VT?
A
- Haemodynamically stable –> amiodarone through a central line (2nd line = lidocaine (use with caution in severe LV impairment)/procainamide)
- Haemodynamically unstable –> Synchronised DC cardioversion
2
Q
What are some causes of orthostatic hypotension?
A
- Exercise-induced
- Postprandial
- Prolonged bed rest (decondiitoning)
- Primary autonomic failure
- Secondary autonomic failure
- Drug induced = diuretics, alcohol, vasodilators
- Volume depletion = haemorrhage, diarrhoea
3
Q
What are some causes of primary autonomic failure?
A
- Parkinsons
2. LBD
4
Q
What are some causes of secondary autonomic failure?
A
- Diabetic neuropathy
- Amyloidosis
- Uraemia
5
Q
How can syncope be defined?
A
Transient loss of consciousness due to global cerebral hypoperfusion with rapid onset
6
Q
How can you classify the causes of syncope?
A
- Reflex (neurally mediated)
- Orthostatic
- Cardiac
7
Q
What are come causes of reflex syncope?
A
- Vasovagal (emotion/pain/stress)
- Situational (cough, micturition, GI)
- Carotid sinus
8
Q
What are some causes of cardiac syncope?
A
- Arrhythmias (bradycardias/tachycardias)
- Structural = valvular, MI, HOCM
- Other = PE
9
Q
How does one diagnose a postural drop?
A
- A symptomatic fall in systolic BP >20mmHg or diastolic BP >10mmHg
- Decrease in systolic Bp to <90mmHg
10
Q
What are some investigations for syncope?
A
- Examination
- BP lying and standing
- ECG (+/- 24hrs)
- Echo
- Tilt table test
11
Q
What is the management for VF/pulseless VT?
A
- Defib 150J ASAP
- Compressions 30:2 for 2 minutes
- Defib 150J ASAP
- Compressions 30:2 for 2 minutes
- Defib 150J ASAP + 1mg adrenaline + 300mg amiodarone
- Afterwards, adrenlaine should be given after every other shock and 2nd dose of amiodarone considered after a total of 5 defib attempts
12
Q
What is the management of VF/pVT in a CCU/cathlab?
A
3 successive shocks, if 3rd is unsuccessful then CPR should be initiated
13
Q
What has to be given ASAP after diagnosis of asystole/PEA (non-shockable rhythms)?
A
Adrenaline 1mg
14
Q
What should resus oxygen be after successful resuscitation and why?
A
Titrated to sats 94-98% to address potential harm caused by hyperoxaemia
15
Q
What are the 4Hs of reversible causes of cardiac arrest?
A
- Hypoxia
- Hypovolaemia
- Hypothermia
- Hypo/hyperkalaemia, hypoglycaemia, hypocalcaemia, acidaemia
16
Q
What are the 4Ts of reversible causes of cardiac arrest?
A
- Thrombosis (coronary/pulmonary)
- Tension pneumothorax
- Tamponade
- Toxins
17
Q
What is a definition for VT?
A
A broad-complex tachycardia originating fro a ventricular ectopic focus
18
Q
What are the 2 main types of VT?
A
- Monomorphic = most commonly causes by MI
2. Polymorphic VT = e.g. torsades de pointes
19
Q
What are 4 normal ECG variants in an athlete?
A
- Sinus bradycardia
- Junctional rhythm
- 1st degree heart block
- Wenckebach phenomenon
20
Q
What does a posterior MI show on ECG?
A
Tall R waves in V1-V2
21
Q
What is an ECG feature of cardiac tamponade?
A
Electric alternans
22
Q
When should a pt who has had an acute ischaemic stroke have anticoagulation therapy started?
A
2 weeks after the event, due to the risk of haemorrhagic transformation
23
Q
What is Eisenmenger’s syndrome?
A
The reversal of a left-to-right shunt
24
Q
What is the management of a sinus bradycardia in a pt who is showing adverse signs (shock/syncope/MI/HF)?
A
- 500mg IV atropine
- If above fails –> atropine up to 3mg
a. Transcutaneous pacing
b. isoprenaline/adrenaline infusion titrated to response
25
What are 2 indications for loop diuretics?
1. HF (acute and chronic)
| 2. Resistant HTN
26
What medication used to treat HF can cause hearing loss?
Loop diuretics e.g. furosemide can cause ototoxicity
27
What is an example of Glycoprotein IIa/IIIb receptor antagonists used for the tx of NSTEMI?
Tirofiban
28
When should fondaparinux be offered in NSTEMI?
Patients who are not at a high risk of bleeding and who are not having angiography within the next 24 hours
29
When should unfractionated heparin be offered in NSTEMI?
If angiography is likely within 24 hours or a patients creatinine is > 265 µmol/l unfractionated heparin should be given
30
What antiplatelet is now preferred instead of clopidogrel in NSTEMI?
Ticagrelor
31
When should IV glycoprotein IIb/IIIa receptor antagonists be given in NSTEMI?
Patients who have an intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3.0%), and who are scheduled to undergo angiography within 96 hours of hospital admission.
32
What is the investigation of choice for PE in a pt with renal impairment?
V/Q scan due to nephrotoxicity of contrast media
33
What is the management for a PE depending on the Wells' score?
1. If a PE is 'likely' (more than 4 points) arrange an immediate computed tomography pulmonary angiogram (CTPA). If there is a delay in getting the CTPA then give low-molecular-weight heparin until the scan is performed.
2. If a PE is 'unlikely' (4 points or less) arranged a D-dimer test. If this is positive arrange an immediate computed tomography pulmonary angiogram (CTPA). If there is a delay in getting the CTPA then give low-molecular-weight heparin until the scan is performed.
34
What are the ECG changes typically seen with PE?
1. S1Q3T3
2. RBBB and RAD
3. Sinus tachycardia
35
What is the gold standard investigation for PE?
Pulmonary angiography
36
What is the MOA of furosemide?
Inhibits the Na-K-Cl cotransporter in the thick ascending limb of the loop of Henle
37
What are some causes of S3?
1. Normal < 30y/o
2. DCM
3. Constrictive pericarditis
4. Mitral regurgitation
38
What are some causes of S4?
1. AS
2. HOCM
3. HTN
39
How does one manage T2DM in the immediate period following an MI?
IV insulin infusion
40
Rogue mushkie boi
Myocardial infarction: STEMI management
A number of studies over the past 10 years have provided an evidence for the management of ST-elevation myocardial infarction (STEMI)
In the absence of contraindications, all patients should be given
aspirin
P2Y12-receptor antagonist. Clopidogrel was the first P2Y12-receptor antagonist to be widely used but now ticagrelor is often favoured as studies have shown improved outcomes compared to clopidogrel, but at the expense of slightly higher rates of bleeding. This approached is supported in SIGN's 2016 guidelines. They also recommend that prasugrel (another P2Y12-receptor antagonist) could be considered if the patient is going to have a percutaneous coronary intervention
unfractionated heparin is usually given for patients who're are going to have a PCI. Alternatives include low-molecular weight heparin
NICE suggest the following in terms of oxygen therapy:
do not routinely administer oxygen, but monitor oxygen saturation using pulse oximetry as soon as possible, ideally before hospital admission. Only offer supplemental oxygen to:
people with oxygen saturation (SpO2) of less than 94% who are not at risk of hypercapnic respiratory failure, aiming for SpO2 of 94-98%
people with chronic obstructive pulmonary disease who are at risk of hypercapnic respiratory failure, to achieve a target SpO2 of 88-92% until blood gas analysis is available.
Primary percutaneous coronary intervention (PCI) has emerged as the gold-standard treatment for STEMI but is not available in all centres. Thrombolysis should be performed in patients without access to primary PCI
With regards to thrombolysis:
tissue plasminogen activator (tPA) has been shown to offer clear mortality benefits over streptokinase
tenecteplase is easier to administer and has been shown to have non-inferior efficacy to alteplase with a similar adverse effect profile
An ECG should be performed 90 minutes following thrombolysis to assess whether there has been a greater than 50% resolution in the ST elevation
if there has not been adequate resolution then rescue PCI is superior to repeat thrombolysis
for patients successfully treated with thrombolysis PCI has been shown to be beneficial. The optimal timing of this is still under investigation
Glycaemic control in patients with diabetes mellitus
in 2011 NICE issued guidance on the management of hyperglycaemia in acute coronary syndromes
it recommends using a dose-adjusted insulin infusion with regular monitoring of blood glucose levels to glucose below 11.0 mmol/l
intensive insulin therapy (an intravenous infusion of insulin and glucose with or without potassium, sometimes referred to as 'DIGAMI') regimes are not recommended routinely
41
What is the treatment for torsades de pointes?
IV magnesium sulphate
42
What is torsades de pointes?
A form of polymorphic Vt associated with a long QT interval
43
What is the pharmacological cardioversion management for new-onset A?
1, Fleicanide/amiodarone if there is no evidence of structural/IHD
2. Amiodarone if there is evidence of structural heart disease
44
What ECG changes are associated with hypothermia?
1. Bradycardia
2. J wave (small hump at the end of the QRS complex)
3. 1st degree HB
4. Prolongation of all intervals
5. Atrial and ventricular arrhythmias
45
What is a J wave?
A small hump at the end of the QRS complex
46
What is the most common cause of infective endocarditis?
Staphylococcus aureus
47
What is the most common cause of infective endocarditis in a prosthetic valve?
CoNS e.g. S. epidermidis
48
What do you call SLE-associated endocarditis?
Libman-Sacks endocarditis
49
What do you call malignancy associated endocarditis?
Marantic endocarditis
50
What are the HACEK organisms that cause a culture negative infective endocarditis?
```
Haemophilus
Aggregatibacter
Cardiobacterium
Eikenella
Kingella
```
51
What are the two most important causes of VT?
Hypokalaemia and hypomagnesaemia
52
What is the triad of aortic stenosis presentation?
Syncope
Angina
Dyspnoea
53
What is the management for aortic stenosis?
1. Asymptomatic = observe
2. Symptomatic = valve replacement
3. Symptomatic and valvular gradient >40mmHg with features e.g. LV systolic dysfunction = surgery
54
What should never be prescribed alongside CCBs and why?
BBs, due to risk of heart block and fatal arrest
55
What are indications for beta blockers?
1. Angina
2. Post-MI
3. HF
4. Arrhythmia
5. HTN
6. Thyrotoxicosis
7. Migraine
8. Anxiety
56
What are 5 s/es of BBs?
1. Bronchospasm
2. Cold peripheries
3. Fatigue
4. Sleep disturbance
5. Erectile dysfunction
57
What are C/Is for BBs?
1. Uncontrolled HF
2. Asthma
3. SSS
4. Verapamil
58
What are options for tx of angina if a pt doesnt tolerate BBs or CCBs?
Monotherapy with
1. A long acting nitrate
2. Ivabridine
3. Nicorandil
4. Ranolazine
59
What is the management of stable angina?
1. Aspirin and statin
2. Sublingual GTN to abort attacks
3. Either a BB or CCB
60
What are some s/es of ivabridine?
Visual disturbance: Phosphenes and green luminescence
61
What is the MOA of ivabridine?
It acts on the If ('funny') ion current which is highly expressed in the sinoatrial node, reducing cardiac pacemaker activity.
62
What is ivabridine used for?
Symptomatic relief of angina in patients with a heart rate >70, as an alternative to first line therapies
63
What are 4 s/es of warfarin?
1. Haemorrhage
2. Skin necrosis
3. Purple toes
4. Teratogenic
64
What are some factors that may potentiate warfarin?
1. Liver disease
2. PY450 enzyme inhibitors
3. Cranberry juice
4. NSAIDs (displace warfarin from plasma albumin and inhibit platelet function)
65
What is the dose of adrenaline in anaphylaxis in a child aged 6-11 y/o?
300 micrograms
66
What are some ECG findings of hypokalaemia?
1. Prominent u waves
2. T wave is sine wave
3. Prolonged QTc
4. Borderline PR interval
In hypokalaemia, U have no Pot and no T, but a long PR and a long QT
67
What are some associations of coarctation of the aorta?
1. Turner's syndrome
2. Bicuspid aortic valve
3. Berry aneurysms
4. NF
68
What cardiac medication is c/i in aortic stenosis?
Nitrates
69
What can thiazides do to calcium levels?
Cause hypercalcaemia
70
What is the MOA of dipyridamole?
Non-specific phosphodiesterase inhibitor
71
Haemorrhagic stroke in pt on warfarin - whats the management?
1. Stop warfarin
2. IV Vit K 5mg
3. Prothrombin complex concentrate
72
What are some factors favouring rate control of pts with AF?
1. >65 y/o
| 2. IHD
73
What are some factors favouring rhythm control of pts with AF?
1. <65 y/o
2. Symptomatic
3. First presentation
4. Lone AF
5. CCF
74
What medication must be stopped when a macrolide Abx is being started?
Statins (increased risk of rhabdo when combining these 2 drugs)
75
What are 2 C/Is to statins?
1. Macrolides
| 2. Pregnancy
76
What is the atorvastatin dose for primary and secondary prevention?
1. Primary = 20mg OD
| 2. Secondary = 80mg OD
77
What are 3 adverse effects of statins?
1. Myopathy
2. Liver impairment
3. Increased risk of intracerebral haemorrhage
78
Discuss liver monitoring on statins
The 2014 NICE guidelines recommend checking LFTs at baseline, 3 months and 12 months. Treatment should be discontinued if serum transaminase concentrations rise to and persist at 3 times the upper limit of the reference range
79
What does an inferior MI on ECG and an AR murmur suggest?
Proximal aortic dissection
80
What is the Mackler triad for Boerhaave syndrome?
Vomiting, thoracic pain, subcutaneous emphysema
81
How are Stanford type A and B aortic dissections usually treated?
Type A = surgically
| Type B = non-operatively
82
What is the difference between Stanford type A and B aortic dissections?
Type A = commence proximally to left subclavian artery
| Type B = commence distally to left subclavian artery
83
What is S1Q3T3 a sign of, and what is it?
PE
1. S waves in lead I
2. Q waves in lead III
3. Inverted T waves in Lead III
84
What is Boerhaaves syndrome?
Spontaneous rupture of the oesophagus as a result of repeated episodes of vomiting
85
What is the management for Boerhaaves syndrome?
Thoracotomy and lavage
86
What are 4 associations of coarctation of the aorta?
1. Turner's
2. Bicuspid aortic valve
3. Berry aneurysms
4. NF
87
What may you see in coarctation of the aorta on CXR?
Notching of the ribs due to collateral vessels
88
What are some possible ECG features of WPW?
1. Short PR interval
2. Wide QRS complexes with a slurred upstroke
3. LAD if right-sided accessory pathway
4. RAD if left-sided accessory pathway
89
What are 5 associations of WPW?
1. HOCM
2. Mitral valve prolapse
3. Ebstein's anomaly
4. Thyrotoxicosis
5. Secundum ASD
90
Which drugs have been shown to improve mortality in pts with chronic HF?
1. ACEi (SAVE, SOLVD, CONSENSUs)
2. Spironolactone (RALES)
3. BBs (CIBIS)
4. Hydralazine with nitrates (VHEFT-1)
91
What vaccinations should be offered in HF?
1. Annual influenza vaccine
| 2. One-off pneumococcal vaccine
92
What 3 things can be offered if triple therapy for HF is not sufficient?
1. CRT
2. Digoxin
3. Ivabridine
93
What medications have no effect on mortality in HFpEF?
ACEi and BBs
94
What medication is first line for treating HTN in diabetics?
ACEi
95
How long are 'provoked' PEs typically treated for?
3 months
96
How long are 'unprovoked' PEs typically treated for?
6 months
97
When is thrombolysis used for PE?
Massive PE where there is circulatory failure (e.g. hypotension)
98
What is bifascicular and trifasciscular block?
1. Bifascicular block = RBBB w/ LAD or posterior hemiblock
| 1. Trifascicular block = features of bifascicular block + 1st degree heart block
99
What scoring system is used for hypermobility?
Beighton score
100
What can be used to treat dyspnoea and anxiety in acute exacerbation of HF?
Morphine
101
How does one define a pathological Q wave?
Q wave of >0.04s and an amplitude >25% of the R wave in that lead. present in at least 2 contiguous leads
102
In what kind of body habitus may one seed RAD?
Tall and thin individuals
103
In what kind of body habitus may one see LAD?
Short, obese individuals
104
What is pulsus paradoxus? What is it a sign of?
1. Grater than the normal 10mmHg fall in SBP during inspiration
2. Severe asthma, cardiac tamponade
105
What is a slow rising pulse a sign of?
Aortic stenosis
106
What is pulsus alternans and what is it a sign of?
Regular alternation of the force of the arterial force, a sign of LVF
107
What is a bisferiens pulse and what is it a sign of?
A 'double pulse' with two systolic peaks, it is a sign of mixed aortic valve disease/HOCM
108
What is a 'jerky' pulse a sign of?
HOCM
109
What is the management of a haemodynamically stable pt with a regular broad complex tachycardia?
Assume VT --> Loading dose of amiodarone followed by 24 hour infusion
110
What is the management of a haemodynamically stable pt with an irregular broad complex tachycardia?
1. AF w/ BBB --> tx as for narrow complex tachycardia
| 2. Polymorphic VT --> IV magnesium
111
What is the management of a regular narrow complex tachycardia?
1. Vagal manoeuvres followed by IV adenosine (6mg --> 12mg --> 12mg)
2. Electrical cardioversion
112
What are 2 causes of a regular broad complex tachycardia?
1. VT
| 2. SVT w/ BBB
113
What will P450 inducers do to INR?
INR will decrease
114
What will P450 inhibitors do to INR?
INR will increase (inhibit --> increase)
115
What is Kussmaul's sign, and what may it indicate?
A paradoxical rise in JVP with inspiration, may indicate constrictive pericarditis
116
What may you see on CXR with constrictive pericarditis?
Pericardial calcification
117
What is the textbook triad of PE?
1. Pleuritic chest pain
2. Dyspnoea
3. Haemoptysis
118
What is the most common clinical sign of PE?
Tachypnoea
119
If a pt with AF has a stroke/TIA, what is the anticoagulant of choice?
Warfarin or a directin thrombin/factor Xa inhibitor
120
When should anticoagulation therapy be started in acute stroke pts, in the absence of haemorrhage?
After 2 weeks
121
What is the commonest association for aortic dissection?
Hypertension
122
What proportion of aortic dissections are Type A and Type B?
```
A = 2/3rd
B = 1/3rd
```
123
What could cause an irregular narrow complex bradycardia with no discernible P waves?
AF with a slow ventricular response
124
What are the ECG changes in a posterior STEMI?
1. ST depression in leads V1-V3
2. Tall, broad R waves
3. Upright T waves
125
What do hyperacute T waves signify?
That an MI is imminent
126
Below what HR can ivabridine not be used in HF?
75
127
Where should an epipen be injected?
Anterolateral aspect of the middle third of the thigh
128
What is a valsalva manoeuvre?
Forced expiration against a closed glottis
129
What is the target INR if a pt has recurrent VTEs?
3.5
130
What is an important interaction to consider when a pt is receiving a statin?
Macrolides (can lead to statin-induced myopathy)
131
What is the investigation of choice for PE if the pt has renal impairment?
V/Q scan
132
How should one manage IE causing CCF?
Emergency valve replacement surgery
133
What is the most common site of mutation in HOCM?
B-myosin heavy chain or MYBP-C
134
What do you see on biopsy of HOCM?
Myocyte disarray
135
What are 2 associations of HOCM?
Friedrich's ataxia and WPW
136
What are the echo findings of HOCM?
MR SAM ASH
1. MR = mitral regurgitation
2. SAM = systolic anterior motion of the anterior mitral valve leaflet
3. ASH = asymmetric hypertrophy
137
If a pt has 1st degree heart block during/following an MI, which vessel has been affected and why?
RCA, as it supplies the AVN --> ECG changes in II, III, aVF
138
What is the main ECG abnormality seen with hypercalcaemia?
Shortening of the QT interval
139
What are bizarre, wide, inverted T waves in a pt who has presented with collapse associated with?
Stokes-Adams attacks
140
Which coronary artery can be involved in an aortic dissection, causing an MI?
RCA
141
What is the most useful blood test to confirm an anaphylactic reaction?
Serum tryptase
142
What should one add after ACEi and CCB for tx of HTN?
A Thiazide-like diuretic e.g. Indapamide
143
Why are venodilators used in the treatment of pulmonary oedema?
Because in cardiogenic shock, pulmonary pressures are often high
144
What is pulmonary artery occlusion pressure an indirect measure of?
Left atrial pressure
145
What is normal pulmonary artery occlusion pressure?
8-12 mmHg
146
What is a sign of hypokalaemia on ECG?
U waves
147
What are 3 words to describe an atrial myxoma on echo?
Pedunculated heterogeneous mass, attached to the fossa ovalis region of the interatrial septum
148
What is the triad of presentation of an atrial myxoma?
1. Mitral valve obstruction
2. Systemic embolisations
3. Constitutional symptoms
149
What is the most common primary cardiac tumour?
Atrial myxoma
150
What are atrial myxomas typically attached to?
The fossa ovalis
151
Why are statins c/i in pregnancy?
They might disrupt cholesterol synthesis in the developing foetus
152
Can T wave inversion in Lead III be a normal variant?
Yes
153
What is the adult adrenaline dose and route for anaphylaxis?
IM 0.5mg 1:1000 (0.5ml of 1 in 1,000)
154
What ECG change might you see with an aortic dissection?
ST elevation in the inferior leads if it involves the RCA
155
What is the DeBakey classification system for aortic dissections?
1. Type I - originates in ascending aorta, propagates to at least the aortic arch and possibly beyond it distally
2. Type II - originates in and is confined to the ascending aorta
3. Type III - originates in descending aorta, rarely extends proximally but will extend distally
156
What is the management for a Type A aortic dissection?
Surgical management, but blood pressure should be controlled to a target systolic of 100-120 mmHg whilst awaiting intervention
157
What is the management for a Type B aortic dissection?
1. Conservative management
2. Bed rest
3. IV labetalol
158
What are the complications of a backwards aortic dissection tear?
1. Aortic incompetence/regurgitation
| 2. Inferior MI due to RCA involvement
159
What are the complications of a forwards aortic dissection tear?
1. Unequal arm pulses and BP
2. Stroke
3. Renal failure
160
What is the adrenaline dose for anaphylaxis in children 6m -6y/o?
IM adrenaline 150 mcg (0.15ml of 1 in 1,000)
161
What is the recommended dose of adrenaline to give during advanced ALS?
1mg
162
What are Type A and Type B WPW?
1. Type A = left sided pathway
| 2. Type B = right sided pathway
163
How do you differentiate between Type A and Type B WPW?
1. Type A = L sided pathway = dominant R wave in V1
| 2. Type B = R sided pathway = no dominant R wave in V1
164
What is the management for WPW?
1. Medical = Sotalol, amiodarone, fleicanide
| 2. Definitive = RFA of accessory pathway
165
What is the inheritance pattern of HOCM?
Autosomal dominant
166
in the absence of contraindications, what should all pts with MI be given in terms of medications?
1. Aspirin
2. P2Y12 receptor antagonist e.g. Ticagrelor/Clopidogrel
3. UFH if having PCI
167
What kind of anti-anginal medication do pts commonly develops tolerance to?
Standard release isosorbide mononitrate
168
What should you do if pts develop a tolerance to their nitrate?
Take second dose of isosorbide mononitrate after 8 hours rather than after 12 hours
169
What is the management of acute pericarditis?
1. Treat the underlying cause
| 2. Combination of NSAIDs and Colchicine for acute idiopathic/viral pericarditis
170
What is the more formal term for the 'M' seen in V1 in RBBB?
RSR pattern
171
If a pt is in SVT and has asthma, what medication would you use in the acute phase?
Verapamil, as adenosine is c/i in asthmatics
172
What is the prophylaxis for SVT?
1. BBs
| 2. RFA
173
What is the most common cause of death following an MI?
VF
174
When does Dressler's syndrome occur?
2-6 weeks following an MI
175
What is the treatment for Dressler's syndrome?
NSAIDs
176
What is the management for LV free wall rupture after an MI?
Urgent pericardiocentesis and thoracotomy
177
What can be used to differentiate between Cardiac tamponade and constrictive pericarditis?
Kussmaul's sign
178
What is the most specific ECG marker for pericarditis?
PR depression
179
What are 4 s/es of ACEi?
1. Cough (15%)
2. Angioedema
3. Hyperkalaemia
4. First dose hypotension
180
What electrolyte changes are expected after starting ACEi?
Creatinine and potassium
181
What are the acceptable changes in creatinine and potasssium after starting an ACEi?
1. Creatinine up to 30% from baseline/ >310umol/l
| 2. Potassium up to 5.5 mmol/l
182
What does p mitrale represent?
LA hypertrophy/strain e.g. in mitral stenosis
183
What is the ECG finding of p mitrale?
Bifid p wave
184
What is a cause of increased p wave amplitude?
Cor pulmonale
185
What is the management of major bleeding in a pt on Warfarin?
1. Stop warfarin
2. IV Vitamin K 5mg
3. Prothrombin complex concentrate, if not available then FFP
186
When should an ICD be implanted in a pt with prolonged QT?
1. QTC > 500ms
| 2. Previous episodes of cardiac arrest
187
What is the normal QTc in males and females?
1. Males = <430 ms
| 2. Females = <450 ms
188
What is the management of long QT interval?
1. Avoid QT prolonging drugs and precipitants e.g. strenuous exercise
2. Beta blockers
3. ICD in high risk cases
189
Cause of pericardial calcification in a pt from South Africa?
TB
190
In the treatment of anaphylaxis, how frequently can adrenaline be repeated?
Every 5 minutes
191
In the treatment of anaphylaxis, how frequently can salbutamol be repeated?
Back to back
192
How long after anaphylaxis should pts be monitored and why?
6-12 hours from onset of symptoms, as biphasic reactions can occur in up to 20% of pts
193
How long after a case of anaphylaxis do tryptase levels remain elevated?
Up to 12 hours
194
What is the investigation of choice for pts presenting with non-cardiac chest pain but whose ECG shows signs of ischaemia?
Contrast-enhanced CT coronary angiography
195
What heart scan can be done before and after cardiotoxic drugs are used?
MUGA scan (multi gated acquisition scan)
196
What are the 2 main methods of Cardiac CT for assessing suspected IHD?
1. Calcium score
| 2. Contrast enhanced CT
197
Breathing problems with a clear chest is suggestive of?
Pulmonary Embolism
198
What baseline tests are needed before starting a pt on amiodarone?
1. TFT
2. LFT
3. U&E
4. CXR
199
What Vaughn-Williams class is amiodarone, and its MOA?
Class III, is mainly a potassium channel blocker. and thus inhibits repolarisation and hence prolongs the action potential. Also blocks sodium channels.
200
Why is a loading dose needed for amiodarone?
It has a very long half life of 20-100 days
201
Why should amiodarone ideally be given into central veins?
Causes thrombophlebitis
202
What bloods need to be done whilst on amiodarone and how often?
TFT and LFT every 6 months
203
What medication causes a slate-grey appearance?
Amiodarone
204
What artery is affected in a lateral MI?
LCX
205
What is bronchial breathing?
A generic breath sound associated with consolidation. They are louder and higher pitched than normal breathing, with an obvious gap between inspiration and expiration.
206
What is required for the diagnosis of malignant HTN?
1. Systolic BP >180 or diastolic BP >120
| 2. Evidence of acute organ damage
207
What are some features of malignant HTN?
1. Eyes = bilateral retinal haemorrhage, papilloedema
2. Brain = raised ICP --> headache and nausea
3. Heart = CP due to increased strain
4. Kidneys = haematuria
5. Nosebleeds difficult to stop
208
What are 4 medications that should offered to all pts after an MI?
1. DAPT
2. ACEi
3. BB
4. Statin
209
What antiplatelets are now more commonly used instead of clopidogrel?
Ticagrelor and prasugrel
210
When should ticagrelor/prasugrel/clopidogrel be stopped after an MI?
After 12m
211
When should IV glycoprotein IIb/IIIa receptor antagonists be given to patients with MI?
1. Pts with high risk of adverse cardiovascular events
| 2. Scheduled to undergo angio within 96 hours of hospital admission
212
What are 3 examples of glycoprotein IIb/IIIa receptor antagonists?
1. Abciximab
2. Tirofiban
3. Eptifibatide
213
What do you call aortic stenosis if the murmur doesnt radiate to the carotids?
Aortic sclerosis
214
Does PCI provide any prognostic benefit over optimal medical therapy for stable angina?
No
215
What is the ABG finding for a PE and why?
Respiratory alkalosis due to hyperventilation
216
What would you call an ECG with sawtooth waves that are irregular?
Atrial flutter with variable block
217
What is Wellen's syndrome?
Critical stenosis of the LAD, with deeply inverted or biphasic T waves in V2-V3 on ECG
218
What is downsloping ST depression ('tick sign') indicative of?
Digoxin toxicity
219
What are 2 pharmacological options for treatment of orthostatic hypotension?
1. Fludrocortisone
| 2. Midodrine
220
What is the MOA of midodrine?
An alpha-1 receptor agonist
221
What are some ECG findings of HOCM?
1. LVH
2. T wave inversion
3. Nonspecific ST segment and T wave abnormalities
222
What is a saddle embolus?
A large embolus where the pulmonary trunk splits to form the right and left pulmonary arteries
223
What do you do in stable cardiovascular disease with an indication for an anticoagulant?
Anticoagulant monotherapy should be given without the addition of antiplatelets
224
What are 3 agents used to control rate in pts with AF?
1. BB
2. CCB
3. Digoxin (also preferred choice if pt has HF)
225
What are 3 agents used to control rhythm in pts with AF?
1. Sotalol
2. Amiodarone
3. Fleicanide
226
What is the HAS-BLED score?
Scoring system used to assess 1-year risk of major bleeding in pts taking anticoagulants with AF
227
What are the components of the HAS BLED score?
1. HTN
2. Abnormal renal and liver function
3. Stroke
4. Bleeding
5. Labile INR
6. Elderly
7. Drug/alcohol
228
What is first line antiplatelet therapy after an ACS?
Aspirin lifelong and ticagrelor 12m
229
What is first line antiplatelet therapy after a PCI?
Aspirin lifelong and prasugrel/ticagrelor 12m
230
What is first line antiplatelet therapy after a TIA?
Lifelong clopidogrel
231
What is first line antiplatelet therapy after a stroke?
Lifelong clopidogrel
232
What is first line antiplatelet therapy for peripheral arterial disease?
Lifelong clopidogrel
233
What is rheumatic fever?
An immunological reaction to a recent (2-6wks ago) Strep pyogenes infection
234
What is the MOA of thiazides?
Inhibits sodium reabsorption by blocking the Na+-Cl− symporter at the beginning of the distal convoluted tubule
235
What can sometimes present with a pericardial friction rub?
Acute pericarditis
236
What antihypertensive causes both a hyponatraemia and a hypokalaemia?
Bendroflumethiazide
237
What antihypertensive causes hypercalcaemia?
Bendroflumethiazide
238
What is persistent ST elevation after a previous MI very suggestive of?
A LV aneurysm
239
What is a compliction of a LV aneurysm?
Blood stagnates around a left ventricle aneurysm, thereby promoting platelet adherence and thrombus formation. Embolisation of left ventricular thrombi can lead to embolic stroke or other systemic embolisms.
240
Beck's triad for cardiac tamponade?
1. Hypotension
2. Raised JVP
3. Muffled heart sounds
241
What foods are high in Vit K?
Sprouts, spinach, kale and broccoli
242
HOCM heart sound?
S4
243
Why S4 in HOCM?
Causes reduced compliance of the ventricular wall, reducing the rate of diastolic filling. As a consequence, there is a vigorous atrial contraction at the end of diastole to overcome the raised ventricular end-diastolic pressure. This creates a fourth heart sound.
244
HOCM inheritance?
AD
245
HOCM prevalence?
1/500
246
HOCM septum size?
>12mm
247
HOCM death cause?
Ventricular arrhythmia
248
Mx of HOCM
ABCDE
1. Amiodarone
2. BB or verapamil for sx
3. ICD
4. Dual chamber pacemaker
5. Endocarditis prophylaxis
249
Statin for secondary prevention dose?
Atorvastatin 80mg
250
Statin for primary prevention dose?
Atorvastatin 20mg
251
3 myopathies caused by statins?
1. Myalgia
2. Myositis
3. Rhabdomyolysis
252
2 c/is of statins?
1. Macrolides
| 2. Pregnancy
253
Who should receive a statin?
1. Established CVD
2. QRISK2 > 10
3. T1DM Dx >10yrs ago OR >40y/o OR established nephropathy
254
Poorly controlled hypertension, already taking an ACE inhibitor, calcium channel blocker and a standard-dose thiazide diuretic. K+ > 4.5mmol/l, nextstep?
Add alpha or beta blocker
255
Most common cause of IE?
S. aureus
256
IE cause from an indwelling line?
S. epidermidis
257
Strep viridans fuckery?
Technically Streptococcus viridans is a pseudotaxonomic term, referring to viridans streptococci, rather than a particular organism. The two most notable viridans streptococci are Streptococcus mitis and Streptococcus sanguinis. They are both commonly found in the mouth and in particular dental plaque so endocarditis caused by these organisms is linked with poor dental hygiene or following a dental procedure
258
What strep is associated with colorectal cancer?
Strep. bovis
259
Causes of long QT syndrome?
1. Genetic
2. Electrolytes
3. Drugs
260
Genetic causes of LQTS?
1. LQT1/2/3
2. Jervell and Lange-Neilsen syndrome (associated with deafness)
3. Romano-Ward syndrome
261
Electrolyte causes of LQTS?
1. Hypocalcaemia
2. Hypomagnesaemia
3. Hypokalaemia
262
Drug causes of LQTS?
1. Antiarrythmics e.g. amiodarone, sotalol
2. Abx e.g. erythromycin, clarithromcyin, ciprofloxacin
3. Antidepressants e.g. SSRIs, TCA. neuroleptic agents
263
How does HOCM lead to diastolic dysfunction?
1. LVH --> decreased compliance --> decreased CO
264
Complications of VSD?
1. AR
2. IE
3. Eisenmenger's complex
4. RHF
5. Pulmonary HTN
265
Why AR with VSD?
A poorly supported right coronary cusp results in cusp prolapse
266
What is c.i in women with pulmonary HTN?
Pregnancy due to 30-50% risk of mortality
267
Elevated JVP, HTN, tachycardia despite fluid resus in a pt wit chest wall trauma?
Cardiac tamponade
268
What is flail chest?
Detachment of rib cage from the chest wall due to trauma
269
Triad of cardiac tamponade?
Beck's triad
1. Hypotension
2. Raised JVP
3. Muffled HS
270
Max dose of amlodipine?
10mg
271
Any need for DVT prophylaxis whilst travelling?
No
272
BP targets for diabetics?
1. If end-organ damage <130/80
| 2. Otherwise <140/80
273
Young male smoker with sx similar to limb ischaemia?
Buerger's disease
274
Buerger's disease?
Aka thrombangiitis obliterans is a small and medium vessel vasculitis strongly associated with smoking
275
Features of Buerger's disease?
1. Extremity ischaemia
2. Superficial thrombophlebitis
3. Raynaud's phenomenon
276
Features of severe AS on examination?
1. Narrow pulse pressure
2. Slow rising pulse
3. Thrill over apex
4. S4 indicative of LVH
5. Soft/absent S2
277
What valve disease is associated with PCKD?
Mitral valve prolapse
278
1st line mx of SVT?
Vagal manoeuvres e.g. Valsalva/carotid sinus massage
279
Acute mx of SVT?
1. Vagal manoeuvres
2. IV adenosine 6mg --> 12mg --> 12m
3. Electrical cardioversion
280
Mx of atrial flutter?
1. Similar to AF although meds may be less effective
2. More sensitive to cardioversion than AF so lower energy levels may be used
3. RFA of the tricuspid valve isthmus is curative for most pts
281
5 drugs after MI?
1. ACEi
2. BB
3. Statin
4. Aspirin
5. Clopidogrel
282
When may sexual activity resume after an uncomplicated MI?
4 weeks
283
Complete heart block after MI, which vessel affected?
RCA lesion
284
What artery supplies the AVN?
Posterior interventricular artery, which in the majority of pts is a branch of the RCA, but can be supplied by the LCX in some
285
4 most common clinical signs in PE?
1. Tachypnoea (96%)
2. Crackles (58%)
3. Tachycardia (44%)
4. Fever (43%)
286
PE ix of choice if there is renal impairment?
V/Q scan
287
Gold standard ix for PE?
Pulmonary angiography
288
C/Is for BBs?
1. Uncontrolled HF
2. Asthma
3. SSS
4. Concurrent verapamil use - may precipitate severe bradycardia
289
5 s/es of BBs?
1. Bronchospasm
2. Cold peripheries
3. Fatigue
4. Sleep disturbance
5. Erectile dysfunction
290
ACEi, BB, Furosemide, statin, which causes osteoporosis?
Furosemide, due to increased urinary excretion of calcium
291
Mechanism of carotid sinus hypersensitivity?
Carotid sinus pressure/massage --> stimulates the baroreceptors and the parasympathetic nervous system. This increases the vagal tone and affects the SA and AV node, leading to a decrease in BP and HR. If the baroreceptor is hypersensitive, this response is exaggerated.
292
2 possible features of carotid sinus hypersensitivity?
1. Cardioinhibitory = Ventricular pause of >3s
| 2. Vasodepressive = SBP fall >50mmHg
293
What is the HASBLED scoring system/
To assess 1-year risk of major bleeding in patients taking anticoagulants with atrial fibrillation.
294
What CM are alcoholics at risk of?
Dilated CM
295
Most common cause of cardiomyopathy?
Dilated (accounts for 90% cases)
296
2nd line antihypertensive for afrocaribbeans?
ARB NOT ACEi (2019 guideline change)
297
Why are ACEi first line antihypertensive for diabetes?
Due to their renoprotective effect
298
Why can flash pulmonary oedema happen after MI?
Due to acute mitral valve regurgitation, due to rupture of tendinous cords
299
Persistent ST elevation and LV failure after MI?
LV aneurysm
300
Definitive investigation for acute pericarditis?
TTE
301
Mx of acute pericarditis?
1. The cause
| 2. NSAIDs and colchicine if acute idiopathic or viral pericarditis
302
Preferred anti-epileptic in pregnancy?
Lamotrigine
303
4 drugs that improve mortality with chronic HF?
1. ACEi (SAVE, SOLVD, CONSENSUS)
2. Spironolactone (RALES)
3. BB (CIBIS)
4. Hydralazine with nitrates (VHEFT-1)
304
Features of Takayasu's arteritis?
1. Systemic features
2. Unequal BP in limbs
3. Carotid bruit
4. Intermittent claudication
5. Aortic regurgitation (20%)
305
Association of takayasu's arteritis?
Renal Artery Stenosis
306
Mx of Takayasu's arteritis?
Steroids
307
Normal corrected QT interval?
1. <430 ms in males
| 2. <450ms in females
308
How do drugs prolong Qt interval?
Blockage of potassium channels
309
What type of immune response is rheumatic fever?
Type II hypersensitivity reaction
310
Notching of the inferior border of the ribs?
70% of adults with coarctation of the aorta
311
Mechanism of rib notching in coarctation?
Aortic obstruction gives rise to the development of dilated intercostal collateral vessels to allow sufficient blood flow to reach the descending aorta. The pressure of these vessels erodes the inferior margin of the ribs
312
MOA of nitrates?
1. Cause the release of NO in smooth muscle, activating guanylate cyclase which then converts GTP to cGMP, which in turn leads to a fall in intracellular calcium levels
1. In angina they both dilate the coronary arteries and also reduce venous return which in turn reduces left ventricular work, reducing myocardial oxygen demand
313
4 s/es of nitrates?
1. Hypotension
2. Tachycardia
3. Headaches
4. Flushing
314
When to electrically cardiovert acute AF?
If < 48 hours
315
AF onset <48 hours mx?
1. Pt heparinised
2. Electrical DC cardioversion
3. Pharm = amiodarone if structural heart disease, flecainide or amiodarone in those without structural heart disease
316
AF onset >48 hours mx?
1. Anticoagulation for at least 3 weeks prior to electrical cardioversion (alternative = TOE to exclude LAA thrombus, if absent then immediate heparin and cardioversion)
2. BB
317
AF < 48 hours, terminated by cardioversion, further anticoagulation necessary?
No
318
AF > 48 hours, terminated by cardioversion, further anticoagulation necessary?
At least 4 weeks, then review
319
Causes of postural hypotension?
1. Hypovolaemia
2. Autonomic dysfunction = diabetes, Parkinsons
3. Drugs
4. Alcohol
320
Potassium > 6mmol/L in hypertensive pt with CKD mx?
Cessation of ACEi
321
4 s/es pf ACEi?
1. Cough (may occur up to a year after starting)
2. Angioedema (may occur up to a year after starting)
3. Hyperkalaemia
4. First dose hypotension
322
Acceptable changes after starting ACEI?
1. Increase in serum creatinine up to 30% from baseline
| 2. Increase in K up to 5.5mmol/l
323
Which beta blocker is known to cause QT prolongation?
Sotalol
324
Ostium secundum or primum ASD more common?
Ostium secundum
325
Tri-phalangeal thumbs and ostium secundum?
Holt-Oram syndrome
326
AF pharmacological cardioversion agents?
Amiodarone and fleicanide ('pill in pocket')
327
Main complication of Boerhaaves?
Severe sepsis secondary to mediastinitis
328
Dx of boerhaaves?
CT contrast swallow
329
Mx of boerhaaves?
Thoracotomy and lavage
330
Mx of pt on warfarin undergoing emergency surgery?
Give four-factor prothrombin complex concentrate
331
7 causes of ST elevation?
1. MI
2. Pericarditis/myocarditis
3. Normal variant (high take-off)
4. LV aneurysm
5. Prinzmetal's angina
6. Takotsubo's cardiomyopathy
7. Subarachnoid haemorrhage
332
Mx of native valve endocarditis (NVE)?
Amoxicillin + Gentamicin
333
Mx of endocarditis with suspected MRSA?
Vancomycin + Gentamicin
334
What is c/i in ACS in pts with hypotension (<90mmHg)?
Nitrates
335
Eponym of murmur grading scale?
Levine scale
336
What are the 6 Levine grades?
1. Grade 1 - Very faint murmur, frequently overlooked
2. Grade 2 - Slight murmur
3. Grade 3 - Moderate murmur without palpable thrill
4. Grade 4 - Loud murmur with palpable thrill
5. Grade 5 - Very loud murmur with extremely palpable thrill. 6. Can be heard with stethoscope edge
Grade 6 - Extremely loud murmur - can be heard without stethoscope touching the chest wall
337
AF rate control drugs?
1. BB
2. CCBs
3. Digoxin
338
AF rhythm control drugs?
1. Sotalol
2. Amiodarone
3. Fleicanide
339
2 factors favouring rate control for AF?
1. Older than 65 y/o
| 2. Hx of IHD
340
Factors favouring rhythm control for AF?
1. <65 y/o
2. Symptomatic
3. First presentation
4. Lone AF/due to corrected precipitant e.g. alcohol
5. Congestive HF
341
Mx of peri-arrest bradycardia?
1. Atropine 500mg IV
2. Atropine up to max 3mg
3. Transcutaneous pacing
4. Isoprenaline/adrenaline infusion titrated to response
342
How long before surgery is warfarin stopped?
5 days, and once INR is <1.5 surgery can go ahead
343
Definitive mx of proximal aortic dissection?
Surgical aortic root replacement
344
Biomarker for detection of re-infarction 4-10 days after MI?
CK-MB (only remains elevated for 3-4 days post infarction
345
How long does troponin remain elevated after MI?
10 days
346
What is the first cardiac enzyme that rises?
Myoglobin
347
Takotsubo on echo?
Apical ballooning of the myocardium, resembling an octopus pot
348
Why does apical ballooning occur in Takotsubo?
Severe hypokinesis of the mid and apical segments with preservation of activity of the basal segments. In simple terms, the bottom of the heart (the apex) does not contract and therefore appears to balloon out.
349
Features of Takotsubo's cadiomyopathy?
1. Chest pain
2. Features of HF
3. ST elevation on ECG
4. Normal coronary angiogram
350
Mx of Takotsubo's?
Treatment is mainly supportive
351
Most commonly used vein for venous cutdown?
Long saphenous vein
352
Where does the long saphenous vein pass?
Anterior to medial malleolus
353
Where does the short saphenous vein pass?
Posterior to the lateral malleolus
354
Amiodarone dose in ALS?
300mg
355
Mx of pt post-PCI for MI experiencing pain or haemodynamic instability post-PCI?
CABG
356
When is unfractionated heparin given for MI?
For pts who are going to have MI
357
2 main mx strategies for AF?
1. Rate/rhythm control
| 2. Reducing stroke risk
358
IPSS?
International prostate symptom score
359
LAD and RBBB?
Bifascicular block
360
LAD + RBBB + 1st degree HB?
Trifascicular block
361
Ventricular escape rhythm in complete HB?
35-40bpm
362
Adenosine half life?
8-10 seconds
363
Adenosine MOA?
1. Causes transient heart block in the AVN
2. Agonist of the A1 receptor in the atrioventricular node, which inhibits adenylyl cyclase thus reducing cAMP and causing hyperpolarization by increasing outward potassium flux
364
AF post-stroke Mx?
1. Warfarin or direct factor Xa inhibitor
| 2. Should only be commenced after 2 weeks
365
IV amiodarone s/e?
Thrombophlebitis
366
Amiodarone half life?
20-100 days
367
Amiodarone monitoring?
1. TFT, LFT, U&E, CXR prior to tx
| 2. TFT, LFT every 6m
368
Slate grey appearance?
Amiodarone
369
How should adenosine be infused and why?
Via a large calibre cannula e.g. 16G due to its short half life
370
4 adverse effects of adenosine?
1. Chest pain
2. Bronchospasm
3. Transient flushing
371
Fondaparinux MOA?
Activates antithrombin III, just like LMWH
372
Bisferiens pulse?
HOCM or mixed aortic valve disease
373
Subclavian steal syndrome presentation?
Posterior circulation symptoms e.g. dizziness and vertigo, during exertion of an arm
374
Pathophysiology of subclavian steal syndrome?
Subclavian artery steno-occlusive disease proximal to the origin of the vertebral artery and is associated with flow reversal in the vertebral artery
375
Mx of subclavian steal syndrome?
Percutaneous trnasluminal angioplasty/stent
376
5 branches of the subclavian artery?
1. Vertebral artery
2. Internal thoracic artery
3. Thyrocervical trunk
4. Costocervical trunk
5. Dorsal scapular artery
377
Why is a CXR essential when Ix PE?
To rule out any other pathologies causing CP
378
DVLA advice post MI?
Cannot drive for 4 weeks
379
Mx of HF is symptoms persist despite maximal management with triple therapy?
1. CRT
2, Digoxin
3. Ivabridine
380
Raised JVP with inspiration?
Kussmaul's sign, typical of contrictive pericarditis
381
Drop in BP and SV with inspiration?
Pulsus paradoxus, a sign of cardiac tamponade
382
3 examples of thrombolytics?
1. Alteplase
2. Tenecteplase
3. Streptokinase
383
What antihypertensive is C/I in pregnancy?
ACEi, because they cause foetal abnormalities and renal failure
384
How do thiazides cause gout?
Reduce uric acid secretion from the kidney
385
Pulmonary HTN effect on heart sounds?
Loud S2 (due to a loud P2)
386
U waves?
Hypokalaemia
387
What 2 things is GFR dependent upon?
1. Overall blood flow to kidney
| 2. Autoregulation of the afferent and efferent arterioles to fine tune the pressure
388
What mediates afferent renal arteriole dilation?
PGE2, to increase flow
389
What mediated efferent renal arteriole constriction?
Ang II, to increase pressure
390
How do NSAIDs cause AKI?
Blog PGE2 and disrupt possible afferent arteriole dilation (oral aspirin however, does NOT do this)
391
Atypical chest pain defn?
Meets 2/3 of criteria of stable angina
1. Constricting CP
2. Precipitated by physical exertion
3. Relieved by GTN spray within 5 mins
392
First line Ix for stable CP of suspected CAD aetiology?
Contrast-enhanced CT coronary angio
393
QRISK threshold for statin?
>10
394
HTN in DM Mx?
ACEi, regardless of age
395
Orthostatic HTN time measurement?
Within 3 mins of standing
396
Which BBs are used for HF in UK?
Bisoprolol, carvedilol and nebivolol
397
2 types of VT?
1. Monomorphic = most commonly following MI
| 2. Polymorphic = subtype is Torsades
398
What CVS drug can reduce hypoglycaemic awareness?
BBs
399
MOA of BBs causing reduced hypoglycaemic awareness?
Can theoretically suppress all of the adrenergically mediated sx of hypoglycameia and can thus lead to unawareness
400
Where are inhaled foreign objects most likely to be found?
Right main bronchus
