Passmedicine Questions COPY Flashcards
What is the most common valvular disease after infective endocarditis?
Aortic regurgitation
What sort of murmur is aortic regurgitation?
High pitched, early diastolic murmur
What signs are seen in aortic regurgitation?
Murmur increased by hand gripping manoeuvre
Collapsing pulse
wide pulse pressure
quinckes sign (nailed pulsation)
What is the management of aortic regurgitation?
medical management of associated heart failure
Aortic valve surgery if:
Symptomatic patients with severe AR
Asymptomatic patients with severe AR and LV systolic dysfunction
What are examples of ACE inhibitors?
Rampril
What are examples of calcium channel blockers?
Amlodipine
Verapamil
Diltiazem
Nifedipine
What are examples of thiazide-like diuretics?
Indapamine
What is step 4 of treating hypertension?
Potassium <4.5 - add low dose spironolactone
Potassium >4.5 - add alpha or beta blocker
what does an atrial septal defect sound like?
Ejection systolic murmur louder on inspiration
What does aorta stenosis sound like?
High pitched ejection systolic murmur (louder on expiration)
What does pulmonary stenosis sound like?
Ejection systolic murmur (louder on inspiration)
What does mitral regurgitation sound like?
High pitched pansystolic murmur (louder on expiration)
What does mitral stenosis sound like?
Low pitched rumbling mid diastolic murmur
What does tricuspid regurgitation should like?
High pitched pan systolic murmur (louder on inspiration)
What is the medical management of stable angina?
- CCB or Beta-blocker
- Use in combination ^
- If patient is on mono therapy and can’t tolerate the addition of the other: Long acting nitrate, ivabradine, nicorandil or ranolazine
CCB:
- mono therapy: Use rate limiting eg verapamil or diltiazem
- if used in combination with beta-blocker: Use amlodipine or modified released nifedipine
- DONT USE BETA BLOCKER WITH VERAPAMIL (complete heart block)
What should be done for standard release isosorbide mononitrate?
Asymmetric dosing to maintain nitrate free time of 10-14 hours
(not needed for once daily modified release isosorbide mononitrate)
What is the STEMI Criteria?
- Clinical symptoms of ACS (>20 mins duration and >20 mins persistent ECG leads).
- ECG changes must be in > or equal to 2 continuous leads
What should the elevation be of V2 and V3 in women?
1.5 mm
What should the elevation be of V2 and V3 in men under 40 years?
2.5mm
What should the elevation be of V2 and V3 in men over 40?
2mm
What should the ST elevation be in any other leads?
1mm
What else is classed as a STEMI?
A new LBBB
What are the components of the CHA2DS2-VASc score?
Congestive heart failure - 1
Hypertension - 1
Age >75 - 2
Diabetes - 1
Stroke TIA or thromboembolism - 2
Vascular disease (IHD, PAD) - 1
Age 65-74 - 1
Sex (female) - 1
How is the CHADVASc scores interpreted?
0 - no anticoagulation
1- consider anticoagulation in males, note females
2 or more - offer anticoagulation
What are the components of the ORBIT score?
Haemoglobin <130 in males and <120 in females OR Haemaocrit <40% in males and <36% in females - 2
Age >74 years - 1
Bleeding history (GI, intracranial or haemorrhage stroke) - 2
Renal impairment (GFR <60ml) - 1
Treatment with anti platelets - 1
How is the ORBIT score interpreted?
0-2 LOW RISK (2.4 bleeds per 100 patient years)
3 MEDIUM RISK (4.7 bleeds per 100 patient years)
4-7 HIGH RISK (8.1 bleeds per 100 patient years)
Which anticoagulant is used in AF?
1st line: DOAC
2nd line: Warfarin (Not LMWH)
What are the side effects of ACE inhibitors?
Cough (may occur up to 1 year after starting treatment)
Angioedema (may occur up to 1 year after starting treatment)
Hyperkalaemia
First dose hypotension
Renal impairment (if undiagnosed renal artery stenosis)
What are the causes of RBBB?
Normal variant (more common with increasing age)
Right ventricular hypertrophy
Cor pulmonale
Pulmonary embolism
MI
Atrial septal defect
cardiomyopathy
myocarditis
What is important to remember about ACE inhibitors?
They are BAD in AKI
They are GOOD (renoprotective) in CKD
What are examples or Angiotensin Receptor Blockers?
Candersartan
Losartan
What is the management for hypertrophic obstructive cardiomyopathy?
ABCDE
Amiodarone
Beta blocker (or verapamil) for symptoms
Cardioverter defibrillator
Dial chamber pacemaker
Endocarditis prophylaxis
What is stage 1 hypertension?
Clinic BP >140/90
ABPM >135/85
Treat ONLY if <80 yrs
What is stage 2 hypertension?
Clinic >160/100
ABPM >150/95
Treat at any age
Severe hypertension?
Clinic systolic BP >180
Clinic diastolic BP >120
What is the cause of mitral stenosis?
Rheumatic fever
What are examples of thiazides?
Bendroflumethiazide
What are the indications for urgent valvular surgery in infective endocarditis?
Severe congestive heart failure
Infections resistant to antibiotics
Recurrent emboli after antibiotic therapy
severe valvular incompetence
aortic abscess
What is the major criteria for Dukes Criteria?
Persistently positive blood cultures
Specific imaging findings (like vegetation seen on ECHO)
What is the minor Dukes criteria
Predisposition (heart pathology or IVDU)
Fever above 38 degrees
Vascular phenomena (laneway lesions, splenic infarction or intracranial haemorrhage)
Immunological phenomena (oilers nodes, Roth spots, glomerulonephritis)
Microbiological phenomena (Positive cultures not qualifying as major criteria)
What is the Dukes criteria for?
To diagnose infective endocarditis
How many of the dukes criteria is required for a diagnosis?
One major + 3 minor criteria
OR
5 Minor criteria
What is the treatment for infective endocarditis?
IV broad spectrum antibiotics: amoxicillin or gentamicin
4 weeks for own heart valves
6 weeks for prosthetic heart valves
What is the treatment for infective endocarditis?
IV broad spectrum antibiotics: amoxicillin or gentamicin
4 weeks for own heart valves
6 weeks for prosthetic heart valves
When should you offer anticoagulation in AF?
Women CHADSVASc score >2
Males CHADSVASc score >1
What is a common cause of hypertension in young adults?
Coarctation of the aorta
Renal artery stenosis - no murmur- late systolic murmur
What is the WELLS score for PE?
Clinical signs of DVT (leg swelling and pain on palpation of deep veins) - 3
An alternative diagnosis is less likely than PE - 3
Heart rate >100BPM - 1.5
Immobilisation >3 days or surgery in the last 4 weeks - 1.5
Previous DVT/PE - 1.5
Haemoptysis - 1
Malignancy (on treatment, treatment in the last 6 months or palliative) - 1
What are the investigations for PE?
Likely >4 points:
- Immediate CTPA (ONLY give anticoagulation if there will be a delay in the scan)
- If this is negative do a proximal leg vein ultrasound if DVT is still suspected
PE Unlikely <4 points:
- Arrange a D-Dimer
- If this is positive, arrange an immediate CTPA (only give anticoagulation if theres a delay)
- If negative, PE unlikely, stop anticoagulation and consider alternative diagnosis
What is the treatment for Heart failure with reduced LVEF?
ABAL
1st line:
- ACE Inhibitor and Beta blocker (start one at a time)
2nd line:
- Aldosterone antagonist (spironolactone or eplerenone)
- Consider SGLT2 Inhibitor (gliflozin)
3rd line:
- Loop diuretic (symptomatic control only)
Other”
Annual flu vaccine
One off pneumococcal vaccine
What is normal left ventricular ejection fraction?
45-60%
What is allowed when starting an ACE inhibitor?
Increase in creatinine of 30% from baseline
Increase in potassium up to 5.5
What ECG Changes are seen in acute pericarditis?
Most commonly - Widespread ST elevation
Most specifically - PR depression
What test should all patients with suspected pericarditis have?
Transthoracic echocardiography
What is the management of acute pericarditis?
NSAIDs and Colchicine
what is the treatment for tornadoes des pointes?
Magnesium sulphate
What are common side effects of beta blockers?
Bronchospasm
Cold peripheries
Fatigue
Sleep disturbances, insomnia, nightmares
Erectile dysfunction
Which medication cannot be prescribed with a beta-blocker?
Verapamil - can cause severe bradycardia (complete heart block)
Which medication cannot be prescribed with a beta-blocker?
Verapamil - can cause severe bradycardia (complete heart block)
Where do the loop diuretics target?
Ascending loop of Henle
What is the most important risk factor for aortic dissection?
Hypertension
What is the most important risk factor for abdominal aortic aneurysm?
Smoking
What is the classic triad of symptoms that are seen in a ruptured abdominal aortic aneurysm?
Epigastric pain
Hypotension
Pulsatile mass in the abdomen
