Revision Flashcards
What is Buerger’s disease AKA?
Thromboangiitis obliterans
What is Buerger’s disease?
A small and medium vessel vasculitis strongly associated with smoking.
Features of Buerger’s disease?
1) Raynaud’s phenomenon (discolouration of extremities with cold exposure)
2) Extremity ischemia leading to intermittent claudication (pain in legs which occurs during exercise and is relieved by rest).
What is the most specific ECG marker for pericarditis?
PR depression
There is also saddle shaped ST elevation
What is indicated in patients with clinical signs of heart failure and raised BNP greater than 400 pg/ml?
Urgent (within 2 weeks) specialist review & echo
Give some symptoms of acute mitral regurgitation
Flash pulmonary oedema:
- acute onset shortness of breath
- bibasal crackles
- hypotension
- systolic murmur
What 2 things should be measured when starting an ACEi?
Potassium levels & serum creatinine
What rise in creatinine and potassium is acceptable after starting an ACEi?
1) rise in creatinine up to 30% from baseline
2) rise in K+ up to 5.5 mmol/L
At what K+ level should treatment be immediately offered?
≥6.5 mmol/l
What electrolyte abnormalities can cause a long QT interval?
Hypokalaemia
Hypocalcaemia
Hypomagnesaemia
Describe the murmur in mitral stenosis
Mid-late diastolic (‘rumbling’)
Most likely infective organism in infective endocarditis in patients with no medical history?
S. aureus
Mechanism of thiazide diuretics?
Inhibit sodium reabsorption by blocking the Na+Cl- symporter at the beginning of the distal convulted tubule.
Hence why thiazide diuretics can cause HYPERcalcaemia.
Adverse effects of PPIs?
1) hyponatraemia, hypomagnesaemia
2) osteoporosis
3) microscopic colitis
4) increased risk of C. diff infection
If a patient has a BP of >/= 180/120 mmHg and no worrying signs, what is next step?
urgent investigation for end organ damage
How does a posterior MI typically present on an ECG?
Tall R waves V1-2
In what trimester are ACEi contraindicated?
2nd & 3rd
Threshold for transfusion of RBCs in patients with ACS?
Hb <80 g/L
What is most common cause of acute pericarditis?
Viral infection (patient may have had flu-like symptoms)
In AF, there is a subgroup of patients for whom a rhythm control strategy should be tried first (before rate control).
What are these exceptions?
1) First onset AF
2) Co-existent HF
3) Where there is an obvious reversible cause
If a patient has been in AF for more than 48 hours then anticoagulation should be given for at least 3 weeks prior to cardioversion.
What is an alternative?
An alternative strategy is to perform a transoesophageal echo (TOE) to exclude a left atrial appendage (LAA) thrombus
If a patient has a new BP >= 180/120 mmHg AND retinal haemorrhage or papilloedema, what is next step?
Admit for specialist assessment
ECG changes seen in TCA overdose?
- sinus tachy
- QRS widening
- QT prolongation
Why is amiodarone contraindicated in TCA overdose?
As it prolongs the QT interval
Major risk factor for spontaneous intracranial hypotension?
Connective tissue disorders e.g. Marfan’s
Describe HR and BP in increased ICP?
1) HTN with wide pulse pressure
2) Bradycardia
Adverse effects of adenosine?
- Feeling of doom
- Chest pain
- Bronchospasm
- Transient flushing
Inheritance of HOCM?
Autosomal dominant
Pathophysiology of HOCM?
1) mutation in the gene encoding β-myosin heavy chain protein or myosin-binding protein C
2) results in predominantly diastolic dysfunction: left ventricle hypertrophy –> decreased compliance –> decreased cardiac output
Most common cause of sudden death in HOCM?
Ventricular arrhythmia
If a patient’s AF has been going on for >48 hours, what is most appropriate action?
1) control rate with bisoprolol
2) anticoagulate for 3 weeks
3) then safe to electrically cardiovert
What is the indication for immediate electrical cardioversion in AF?
Acute presentation of AF plus signs of haemodynamic instability (e.g. hypotension, HF)
What ECG sign is considered pathognomic for cardiac tamponade?
Electrical alterans
Triad of symptoms in cardiac tamponade?
1) raised JVP
2) muffled heart sounds
3) hypotension
What abx can cause idiopathic intracranial HTN?
Tetracyclines
Which CCB is used in rate control AF (e.g. if beta blocker is contraindicated)?
Verapamil
What is considered as 3rd line therapy for HF management in Afro-Caribbean patients (i.e. not responding to ACE-inhibitor, beta-blocker and aldosterone antagonist therapy)?
Hydralazine & nitrate
What is a systemic complication of acute pancreatitis?
ARDS
Which drug is indicated as 3rd line therapy in management of HF if there is coexistent atrial fibrillation?
Digoxin
What is rapid drainage of a pneumothorax a risk factor for?
Re-expansion pulmonary oedema
How can 1ary and 2ary aldosteronism be differentiated?
Look at renin levels:
If renin low: 1ary cause more likely
If renin high: 2ary cause more likely
2nd line therapy in HF?
1) aldosterone antagonist
2) SGLT-2 inhibitors e.g. dapagliflozin
In patients with acute HF and respiratory failure, management option?
CPAP
How does liver feel in RHF?
Firm, smooth, tender and pulsatile liver edge
With an irregularly irregular pulse, what does a regular heart rate during exercise suggest a diagnosis of ?
Ventricular ectopics
When would rhythm control be offered to patients with AF (instead of rate control)?
1) reversible cause
2) new onset AF (<48h)
3) HF caused by AF
4) symptoms despite being effectively controlled
What are 3 options for rate control in AF?
1) beta blockers (cardio-specific)
2) CCBs (diltiazem or verapamil - not indicated in HF)
3) digoxin
What are 2 options for rhythm control in AF?
1) cardioversion
2) long-term rhythm control using medications
When is immediate cardioversion used in AF?
1) Present <48h
2) Causing life-threatening haemodynamic instability
What are the 2 options for immediate cardioversion in AF?
1) electrical
2) pharmacological
What is the drug of choice for pharmacological cardioversion in patients with structural heart disease?
Amiodarone
What can be considered before and after electrical cardioversion to prevent AF from recurring?
Amiodarone
What is first line option for long-term rhythm control in AF?
Beta blockers
What are 3 pharmacological options for long term rhythm control?
1) beta blockers
2) amiodarone
3) dronedarone
Management of paroxysmal AF?
Patients may be appropriate for a “pill-in-the-pocket” approach –> they take a pill to terminate their AF only when they feel the symptoms starting.
Anticoagulation based on CHA2DS2-VASc score
What is reversing agent for apixaban and rivaroxaban?
Andexanet alfa
What is the reversal agent for dabigatran?
idarucizumab
Mechanism of warfarin?
Vitamin K antagonist - prolongs prothrombin time (PT)
What does the INR measure?
Prothrombin time
What does an INR of 2 mean?
An INR of 2 means the patient has a prothrombin time twice that of an average healthy adult (it takes them twice as long to form a blood clot).
Target INR for AF?
2-3
Describe CHA2DS2-VASc
C - CHF
H - HTN
A - Age ≥75 (2)
D - Diabetes
S - Stroke/TIA (2)
V - Vascular disease
A - Age 65-74
Sc - Sex (female)
What is an option for patients with contraindications to anticoagulation and a high stroke risk in AF?
Left atrial appendage occlusion
Which part of the QRS complex is used for synchronisation in cardioversion?
R wave
Do patients who have had catheter ablation in AF still require long-term anticoagulation?
yes (as per CHA2DS2-VASc score)
In hypothermia, what can rapid re-warming result in?
Peripheral vasodilation and distributive shock
What is HF with preserved ejection fraction a result of?
Diastolic dysfunction
i.e. issue with filling of LV
What type of valve defect typically causes chronic HF?
Aortic stenosis (LV straining against narrowed aortic valve)
1st line investigation in HF?
NT-proBNP
(N.B. BNP and NT-proBNP can be used in HF diagnosis)
Mx of raised vs high BNP results?
Raised –> arrange specialist assessment (including transthoracic echocardiography) within 2 weeks
High –> arrange specialist assessment (including transthoracic echocardiography) echocardiogram within 6 weeks
Vaccinations in HF?
Annual influenza & one-off pneumococcal
COVID vaccine
1st line medical management of chronic HF?
1) ACEi (as high as tolerated) / or ARB if ACEi not tolerated
+
2) Beta blocker (as high as tolerated)
+
3) Loop diuretic (for symptoms)
What can be added in the management of chronic HF if symptoms are not controlled with ACEi and beta blocker?
Aldosterone antagonist e.g. spironolactone or eplerenone
When are aldosterone antagonists used in chronic HF?
When there is a reduced EF and symptoms not controlled by beta blocker & ACEi
What surgical procedure may be done in severe HF?
1) CRT
2) Heart transplant
At what EF is CRT considered?
<35%
What does Cardiac resynchronisation therapy (CRT) involve?
CRT involves biventricular (triple chamber) pacemakers, with leads in the right atrium, right ventricle and left ventricle.
The objective is to synchronise the contractions in these chambers to optimise heart function
Define cardiac output
Volume of blood pumped out of heart per minut
CO = SV x HR
Define stroke volume
Volume of blood pumped out of heart with each beat
Does raised JVP indicate RHF or LHF?
RHF
Action of BNP?
1) Vasodilator
2) Diuretic action on kidneys
What defines cardiomegaly on a CXR?
Cardiothoracic ratio >0.5
I.e. when the diameter of the widest part of the heart (the widest part of the cardiac silhouette) is more than half the diameter of the widest part of the lung fields.
What are ionotropes?
Medications that alter contractility of heart
What is the most common cause of an exudative pleural effusion?
Pneumonia
What is ARDS?
caused by the increased permeability of alveolar capillaries leading to fluid accumulation in the alveoli i.e. non-cardiogenic pulmonary oedema
Prognosis of ARDS?
mortality of around 40% and is associated with significant morbidity in those who survive.
Causes of ARDS?
1) infection: sepsis, pneumonia
2) massive blood transfusion
3) trauma
4) smoke inhalation
5) acute pancreatitis
6) COVID
7) cardio-pulmonary bypass
Clinical features of ARDS?
Typically of an acute onset and severe:
- dyspnoea
- elevated RR
- bilateral lung crackles
- low O2 sats
What are the 2 key investigations in ARDS?
1) CXR
2) ABG
What type of pleural effusion does hepatitis cause?
Transudative (as causes hypoalbuminaemia)
What type of pleural effusion does a PE cause?
Exudative
Role of CPAP in acute HF?
1) it increases intrathoracic pressure
2) reduces venous return to the heart
3) ultimately reduces preload and pulmonary venous pressure
4) this reduction in hydrostatic pressure promotes the movement of fluid from the interstitial compartment into the vascular compartment, reducing oedema
Max dose of ramipril?
10mg daily
Max dose of bisoprolol?
10mg daily
Stage II vs III of NYHA classification for HF
II - Normal at rest. Ordinary physical activity causes breathlessness
III - Normal at rest. Less-than-ordinary activity causes breathlessness
What class of medication is carvedilol?
beta blocker (cardio specific)
What heart valve pathology is best heard with the patient sat up, leaning forward and holding exhalation? (1)
Aortic regurgitation
What examination findings suggest accelerated (or malignant) hypertension in a patient with a blood pressure above 180/120? (2)
1) retinal haemorrhages
2) papilloedema
What criteria are used for diagnosing infective endocarditis? (1)
Modified Duke criteria
What valve pathology can cause left ventricular dilatation? (1)
Aortic regurgitation
What does the term bigeminy describe on an ECG? (1)
When every other beat is a ventricular ectopic
What medical emergency may occur as a complication of pericarditis? (1)
What is the initial treatment? (1)
Cardiac tamponade
Pericardiocentesis
How should cultures be performed before starting antibiotics in patients with infective endocarditis? (3)
1) 3 blood culture samples
2) Separated by at least 6h
3) Taken from different sites
Which patients are offered statins for primary prevention without calculating the QRISK3 score? (2)
1) CKD
2) T1DM for >10 years or >40 y/o
What murmur may be heard in hypertrophic obstructive cardiomyopathy? (1)
Where is it heard loudest? (1)
Ejection systolic
LLSB
What scoring system is used to assess the severity of liver cirrhosis?
Child-pugh
What scoring system is used in the assessment of suspected obstructive sleep apnoea?
Epworth sleepiness scale
What is the commonest cause of P mitrale on an ECG?
Mitral stenosis (indicates enlarged LA)
What cardiac defect is Quincke’s sign a clinical sign of?
(nailbed pulsation) –> aortic regurgitation
Management of warfarin with INR 5-8 but no bleeding?
Withold 1 or 2 doses, reduce subsequent maintenance dose.
What is the most common cause of mitral stenosis?
Rheumatic fever
What does 1st line management of acute pericarditis involve?
NSAIDs + colchicine
When would clopidogrel be the first-line antiplatelet for secondary prevention? (2)
1) PAD
2) Ischaemic stroke
What valve pathology can cause left atrial dilatation? (1)
Mitral regurg
What medications are avoided with hypertrophic obstructive cardiomyopathy? (2)
1) ACEi
2) Nitrates
What medication may be used longer-term (e.g., 3 months) in patients with pericarditis to reduce the risk of recurrence? (1)
Colchicine
What is the only CCB licensed for use in HF?
Amlodipine
What drugs used in IBD are associated with acute pancreatitis?
5-ASAs
Mesalazine is worse than sulfasalazine
When is cardiac resynchronisation therapy (CRT) indicated in HF?
If not responding to triple therapy –> ACEi + beta blocker + aldosterone antagonist
