UKMLA Cardiology Flashcards
1
Q
What is the 2 week referral indication for a patient with a systolic murmur?
A
Systolic murmur AND exertional syncope
2
Q
What is the target INR for a mechanical aortic valve?
A
3.0
3
Q
What is the target INR for a mechanical mitral valve?
A
3.5
4
Q
What is the mean pressure gradient value for severe aortic stenosis?
A
> 40 mmHg
5
Q
What is the valve area value for severe aortic stenosis?
A
- Valve area of <1.0 cm2
6
Q
What is the peak velocity across the aortic valve that is consistent for severe aortic stenosis?
A
- Peak velocity >4 m/sec
7
Q
What is the most common cause of aortic stenosis?
A
Senile age-related calcification
Rheumatic heart disease
8
Q
What type of cardiac hypertrophy is associated with aortic stenosis?
A
Concentric hypertrophy
9
Q
What type of murmur is associated with aortic stenosis?
A
Ejection systolic crescendo-decrescendo murmur - radiating to the carotid arteries
10
Q
On examination what pulse pressure presentation is observed in aortic stenosis?
A
Narrow pulse pressure
Slow-rising pulse
11
Q
What happens to the S2 sound in aortic stenosis?
A
Soft S2
12
Q
What murmur examination finding is associated with severe disease?
A
Murmur progression then regression
13
Q
What is the first line investigation for suspected aortic stenosis?
A
Echocardiography
14
Q
Which type of aortic valve replacement is recommended in younger patients?
A
Metallic valve
15
Q
What type of hypertrophic remodelling is associated with aortic regurgitation?
A
Eccentric hypertrophy
16
Q
Which antihypertensive medication increases uric acid and increases the risk of gout?
A
Thiazide e.g., indapamide
17
Q
What type of murmur is associated with aortic regurgitation?
A
Early diastolic murmur
18
Q
A water hammer pulse is associated with which valvular pathology?
A
Aortic regurgitation
19
Q
What is the mot common cause of aortic regurgitation?
A
Congenital valve abnormalities e.g., bicuspid aortic valve
Rheumatic heart disease
20
Q
Which sign describes head nodding in time with the pulse in AR?
A
De Musset’s sign
21
Q
Which sign describes visible pulsations in the nailbed in AR?
A
Quincke’s sign
22
Q
Which sign describes visible pulsations in the neck in AR?
A
Corrigan’s sign
23
Q
Which specific coronary artery supplies the atrioventricular node?
A
Posterior interventricular artery branching off from the RCA
24
Q
Fixed splitting of the second heart sound suggests which septal defect?
A
Atrial septal defect
25
Which drug is the most effective to reduce triglyceride concentration?
Fibrates
26
What are the first line prophylactic anti-anginal medication indicated in a patient with asthma?
Rate limiting CCB e.g., diltiazem/verapamil
27
What test is used for confirming the diagnosis of rheumatic fever?
Antistreptolysin O test
28
What is the first line management for an aortic dissection?
Intravenous labetalol
29
What is the gold-standard investigation in a patient who is clinically stable?
CT angiography of the chest, abdomen and pelvis
30
What is the first line management of Kawasaki disease?
Intravenous immunoglobulin
31
Which serum blood test is recommended for the diagnosis of heart failure?
Plasma NT-pro-BNP
32
Prior to starting ACE inhibitors, what disorder should be excluded first?
Renal artery stenosis
33
What is the first line management for patients with heart failure without pulmonary oedema?
ACE inhibitors
34
What is the first line of investigation to confirm acute anaphylaxis?
Serum tryptase
35
What is the most common risk factor for aortic dissection?
Hypertension
36
What type of aortic dissection is proximal to the brachiocephalic artery?
Type A
37
What classification system is used for aortic dissection?
DeBakey/Stanford
38
Which genetic syndromes are associated with aortic dissection?
Marfan Syndrome, Ehlers–Danlos Syndrome, Turner syndrome and bicuspid aortic valve.
39
What is the characteristic presentation of an aortic dissection?
Sudden onset tearing chest pain
40
Where does the pain radiate to in a descending aortic dissection?
Interscapular and lower back pain
41
What happens to the pulse in an aortic dissection?
Pulse deficit (>20 mmHg)
42
Which type of aortic dissection is associated with a diastolic? murmur?
Type A (Ascending)
43
What ECG changes are associated with an aortic dissection?
ST-segment depression
44
What chest radiograph sign is observed in an aortic dissection?
Widening of the mediastinum
Aortic knob
45
What is the definitive investigation for an aortic dissection (stable patients)?
CT angiography
46
What is the definitive investigation for unstable patients with an aortic dissection?
Transoesophageal echocardiography
47
What is the first line management for a confirmed type A aortic dissection?
Labetalol and immediate surgical repair (open aortic arch replacement/total endovascular repair)
48
What is the management for a confirmed type B aortic dissection?
Labetalol
49
What is the main complication associated with a type A aortic dissection?
Aortic regurgitation
50
An aortic aneurysm is characterised by a diameter of ?
>3.0cm (x 1.5 normal diameter(
51
When does the AAA screening programme begin in the UK?
65 and over
52
What is the investigation of choice for an AAA?
Abdominal ultrasound scan
53
What is the frequency of investigation for a small AAA (3 - 4.4 cm)?
Repeat scan every 12 months
54
What is the frequency of investigation for a medium AAA (4.5 - 5.4 cm)?
Repeat scan every 3 months
55
What is the cut-off for an urgent AAA (referral for a vascular surgeon within 2 weeks)?
>5.5 cm
56
What are the referral criteria for an AAA?
* Symptomatic
* Asymptomatic, >4.0 cm AND has grown by more >1.0 cm in 1 year (measured inner-to-inner maximum anterior-posterior aortic diameter on ultrasound).
* Asymptomatic and >5.5 cm.
57
Definition of persistent AF?
>7 days
58
Definition of paroxysmal AF?
Episodes that last >30s that terminate spontaneously or with intervention within 7 days of onset
59
What ECG findings are observed in patients with AF?
Absence of distinct repeating P waves, irregular atrial activations, irregularly irregular R-R intervals + narrow QRS complex.
* Consider a 24-hour ambulatory ECG monitor if suspected and not detected on standard ECG.
60
What is the first line management for AF >48 hours of presentation)?
Rate control with a beta-blocker or a rate-limiting calcium channel blocker
61
Provide examples of a rate-limiting calcium channel blocker:
diltiazem
verapamil
62
If the maximum tolerated dose of rate limiting drugs are ineffective what is recommended for AF?
Digoxin
63
What is the management for stable onset AF <48 hours?
Admission for cardioversion
64
What is the management of AF >48 hours with no reversible causes?
CHA2DS2-VASc score: Start DOAC and beta-blocker or rate limiting CCB
65
What scoring system is used to assess stroke risk in patient with AF?
CHA2DS2-VASc score
66
When should a review be scheduled in a patient with AF treated with rate control?
Within 1 week
67
What are the parameters and score of the CHA2DS2—VASc score?
* Congestive heart failure/left ventricular dysfunction = 1
* Hypertension (>140 mmHg systolic/>90 mmHg diastolic) = 1
* Age (>75 year) = 2
* Diabetes mellitus (fasting plasma glucose >7.0 mmol/L) = 1
* Stroke/transient ischaemic attack = 2
* Vascular disease (prior to myocardial infarction, peripheral arterial disease or aortic plaque) = 1
* Age 65-74 years = 1
* Sex category (female) = 1
68
What is the cut off for starting a DOAC in a man and woman with AF?
2 or above - woman
1 - man
69
What is the preferred anticoagulation in patients with AF?
Apixaban, dabigatran, edoxavban and rivaroxaban
70
When is anticoagulation contraindicated in patients with AF?
Left atrial appendage occlusion
71
What is the absolute contraindication for apixaban in the management of AF?
Antiphospholipid syndrome and positive lupus anticoagulant
72
What anticoagulant should be prescribed in patients with AF (with antiphospholipid syndrome)?
Warfarin
73
What score is used to assess the risk of bleeding in AF?
ORBIT bleeding score
74
When should electrical cardioversion be performed in patients with AF?
AF <48 hours of onset
Haemodynamic instability
75
How long should anticoagulation be initiated until cardioversion in persistent AF?
3 weeks
76
Which AF drug is contraindicated in structural heart disease?
Flecainide
77
What is the anticoagulation of choice for patients with valvular AF?
Warfarin
78
QRS duration for narrow complex tachycardia?
QRS <120 ms
79
What is the first line investigation for SVT?
ECG followed by a Holter monitor and EPS
80
What is the first line management for SVT?
Vagal manoeuvres
81
Following Vagal manoeuvres , what is the next step of management for SVT?
Adenosine 6 mg
82
What is the drug of choice for SVT in a patient with asthma?
verapamil
83
If drug management is ineffective in SVT, what is the next step in management?
Synchronised DC cardioversion
84
What are the adverse effects associated with adenosine?
Chest pain
Bronchospasm
Transient flushing
85
What is the definitive management for SVT?
Radiofrequency catheter ablation
86
Which structure is implicated in Wolff–Parkinson–White Syndrome?
Bundle of Kent
87
What characteristic ECG findings are associated with Wolff–Parkinson–White Syndrome?
Delate wave - short PR interval and pre-excitation
88
What is the management of unstable Wolff–Parkinson–White Syndrome?
Synchronised DC shock
89
What is the management of stable Wolff–Parkinson–White Syndrome?
Sotalol, amiodarone, flecainide
90
What is the most common risk factor for ventricular tachycardia?
Ischaemic heart diseae
91
Congenital cause of prolonged QT interval (2)?
- Jervell–Lange–Nielsen Syndrome (includes deafness – abnormal potassium channel).
- Romano–Ward
92
Which drugs are associated with prolonged QT?
- Amiodarone, sotalol, class 1a antiarrhythmic drugs
- Tricyclic antidepressants, fluoxetine
- Chloroquine
- Terfenadine
- Erythromycin, clarithromycin
93
What is the management for pulseless VT?
Immediate unsynchronised cardioversion
CPR 30:2 and 300 mg amiodarone
94
What is the management for VT (unstable)?
Synchronised shock (up to 3) + amiodarone
95
What is an alternative to amiodarone in the management of VT?
Procainamide 50 mg/min, lignocaine
96
What is the first line management for stable VT?
300 mg amiodarone
97
Which drug is contraindicated for VT?
Verapamil
98
What is the ICD criteria for VT?
* Sustained VT causing syncope
* Sustained VT with EF <35%
* Previous cardiac arrest due to VT/VF
* MI complicated by non-sustained VT
99
QTc threshold in men?
450 ms
100
QTc threshold in women?
460 ms
101
What is the management for Torsades des pointes?
IV Magnesium Sulphate
102
QRS duration for wide-complex tachycardia?
>120 ms
103
What is the first line management for VF?
Urgent defibrillation and CPR (30:2) – continue for 2 minutes then pause briefly to check the monitor (non-synchronised DC shock).
104
Maximum number of shocks for VF?
3
105
What drug should be prescribed following the third shock in VF?
1 mg adrenaline and 300 mg amiodarone
106
How frequently should 1 mg of IV adrenaline be prescribed in VF?
every 3-5 minutes
107
What are the two non-shockable rhytmns?
Pulseless electrical activity
Asystole
108
What are the 4H's and 4 T's?
1. Hypovolaemia
2. Hypoxia
3. Hypokalaemia/hyperkalaemia
4. Hypothermia
4 Ts:
1. Tension pneumothorax
2. Trauma
3. Tamponade
4. Thrombosis
109
What is the first step in managing PEA/Asystole?
CPR with a 30:2 ratio AND 1 mg IV adrenaline
110
Which artery is responsible for supplying the AV node?
Right coronary artery
111
What is the normal PR interval?
120-200 ms
112
Which type of AV block is characterised by a constant prolonged PR interval?
Type 1
113
What is the management for Type 1 AV block?
Reassurance - normal physiological variant
114
Which type of AV block is characterised by a progressive prolongation of the PR interval?
2nd degree - Mobitz type I
115
What is the management for symptomatic Mobitz type 1 heart block?
Transcutaneous pacing
116
Which type of heart block is characterised by a constant PR interval with intermittent dropped QRS complexes?
Mobitz type 2
117
What is the management for unstable Mobitz type 2 heart block?
Beta-adrenergic agonist e.g., isoproterenol, dopamine, dobutamine or adrenaline + temporary pacing.
118
What is the management for unstable Complete heart block?
Atropine and temporary cardiac pacing
119
What is the management for stable complete heart block?
Permanent pacemaker insertion
120
What is the most common viral cause of acute pericarditis?
Coxsackie virus A and B, echovirus, adenovirus
121
Which connective tissue disorders are associated with acute pericarditis?
Sarcoidosis, SLE, scleroderma
122
Which drugs can cause acute pericarditis?
Hydralazine, isoniazid
123
How is acute pericarditis relieved?
Sitting forward
124
Which specific ECG finding is associated with acute pericarditis?
PR depression followed by T-wave flattening and inversion
125
What is the characteristic ECG presentation observed in acute pericarditis?
Widespread saddle-shaped (Concave) ST-elevation
126
Which investigation is indicated in acute pericarditis to assess for pericardial effusion?
Echocardiogran
127
What is the first-line management for acute pericarditis?
NSAIDs or aspirin or colchicine
128
What is the management for cardiac tamponade?
Emergency pericardiocentesis
129
What is Beck's triad?
Raised JVP, hypotension, muffled heart sounds
130
Which pulse waveform is characteristic of cardiac tamponade?
pulsus paradoxus
131
Define pulsus paradoxus?
large decrease in SBP >10 mmHg during inspiration
132
What i the most common cause of constrictive pericarditis?
Tuberculosis
133
What characteristic sign is associated with constrictive pericarditis?
Kussmaul's sign
134
What is Kussmaul's sign?
Paradoxical increase in JVP that occurs during inspiration
135
What is the management of constrictive pericarditis?
Pericardiectomy
136
What is the time-frame for acute limb ischaemia?
<2 weeks of symptoms
137
Which artery is most affected in acute limb ischaemia?
Superficial femoral artery
138
What is the classic presentation of Acute limb ischaemia?
* Pallor
* Pain
- Present and persistent
* Paraesthesia
- Reduced sensation or numbness
* Paralysis
* Pulselessness
- Absent ankle pulses
139
What investigation is first line for acute limb ischaemia?
Measure ankle-branchial pressure index
140
What ABPI measurement indicates chronic limb-threatening ischaemia?
<0.5
141
What ABPI measurement indicates peripheral arterial disease?
<0.9
142
Which ABPI measurement indicates arterial calcification secondary to diabetes?
Diabetes
143
What is the confirmatory testing for acute limb ischaemia?
CT angiogram
144
What is the first line of management for ALI?
IV unfractionated heparin and urgent vascular assessment
145
What is the definitive management for ALI?
* Endovascular therapies – percutaneous catheter-directed thrombolytic therapy | percutaneous mechanical thrombus extraction.
146
What is the characteristic presentation of chronic limb ischaemia?
Chronic rest pain - worst at night (decrease in BP due to loss of gravitational effects on lower limb circulation)
147
What is the definitive management of CLI?
Definitive management: revascularisation
148
What three conditions fall under ACS?
1. Unstable angina (no cardiac injury)
2. Non-ST-elevation myocardial infarction (NSTEMI)
3. ST-elevation MI
149
Which biomarker is measured to evaluate for recurrent MI?
CK-MB
150
Which biomarker is initially measured for acute MI?
Troponin-T
151
Which early ECG changes should suspect MI?
New-onset LBB
152
ST elevation in leads: I, aVL, V5, V6 is associated with what coronary artery?
Left circumflex
153
ST elevation in leads: II, III, AvF associated with what coronary artery?
Right coronary artery
154
ST-elevation in which leads is associated with an MI in the LAD?
V1, V2, V3, V4
155
What is the definitive gold-standard investigation for ACS?
Coronary angiography
156
What is the first line drug for unstable angina/NSTEMI?
300 mg aspirin AND fondaparinux
157
When should oxygen be delivered in ACS?
If oxygen is <94%
158
Which risk assessment tool is used for assessing the 6-month mortality in patients with NSTEMI?
Global Registry of Acute Cardiac Events (GRACE)
159
A GRACE score >3%, warrants what next immediate management?
PCI within 72 hours
160
What is the management for NSTEMI with a GRACE score <3%?
Ticagrelor
161
What is the first line management for a STEMI?
300 mg aspirin
162
What is the definitive intervention for STEMI?
Coronary reperfusion therapy (primary PCI or fibrinolysis) – radial artery is preferred.
163
What is the preferred artery for PCI?
Radial artery
164
What is the indications for primary PCI in STEMI?
Within 12 hours of symptom onset
If PPCI can be performed within 120 minutes
165
What additional anticoagulant is prescribed for patients with PCI?
Prasugrel
166
What is the alternative intervention for patients whereby PCI cannot be performed in STEMI?
* Fibrinolysis (Tissue plasminogen activators e.g., streptokinase, and urokinase)
167
What is administered alongside fibrinolytic therapy in the management of STEMI?
Antithrombin - e.g., fondaparinux
168
What is the next line in management if there is residual ST-elevation after 60-90 minutes?
Immediately coronary angiography with follow-on pCI
169
What is the dual antiplatelet therapy for PCI?
Aspirin and prasugrel (if not on DOAC, maintenance dose 75 mg for one year minimum)
170
If a patient is on a DOAC, what is the DAPT of choice?
Aspirin and clopidogrel
171
What antithrombin therapy is delivered during primary PCI?
Unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor (e.g., tirofiban, eptifibatide) – if radial PCI.
172
If femoral access is used for primary PCI, what is the antithrombin therapy of choice?
Bivalirudin with bailout GPI
173
What dose of statin is indicated post MI?
Atorvastatin 80 mg
174
What secondary prevention drugs are prescribed post-MI?
* Angiotensin-converting enzyme inhibitor
* Dual antiplatelet therapy (as aspirin + second antiplatelet) – continue for up to 12 months, and aspirin indefinitely.
* Beta-blocker – Continue for 12 months (assess for left ventricular ejection fraction).
* Atorvastatin – 80 mg OD
175
What investigation and frequently, should be performed once a statin is initiated?
Liver function tests at baseline, 3 months and 12 months
176
For long is driving not advised post MI?
1 month
177
What is Killip Class IV?
Cardiogenic shock
178
Most common cause of death post-MI?
Ventricular fibrillation
179
When does Dressler's syndrome typically arise post-MI?
2-6 weeks
180
Which post-MI complication is associated with persistent ST-elevation and left ventricular failure?
Left ventricular aneurysm
181
Which post-MI complication is associated with cardiac tamponade?
Left ventricular free wall rupture
182
What is the complication associated with a papillary muscle rupture?
Acute mitral regurgitation
183
Coved ST-segment elevation of V1-V3 followed by a negative T wave is associated with what?
Brugada syndrome
184
Brugada syndrome is associated with which gene?
SCN5A
185
Which electrolyte derangement is associated with digoxin toxicity?
Hypokalaemia
186
At what concentration does digoxin toxicity arise?
1.5 to 3 mcg/L
187
What ocular manifestation is associated with digoxin toxicity?
Yellow-green discolouration in vision
188
What is the 1st line management for digoxin toxicity?
Digoxin-specific antibody antigen-binding fragments (DSFab) – ‘digibind’
189
What ejection fraction is associated with HF with reduced EF?
<40%
190
HFrEF is associated with which type of HF?
Systolic failure
191
Which classification system is used to assess for symptomatic severity of HFrEF?
New York Heart Association (NYHA) classification
192
What is Class 2 NYHA?
Slight limitation of physical activity – comfortable at rest, however, ordinary physical activity manifests as undue breathlessness, fatigue or palpitations.
193
What is Class 3 NYHA?
: Marked limitation of physical activity – comfortable at rest, but less than ordinary physical activity results in symptoms.
194
Which NYHA class is associated with symptoms at rest?
Class 4
195
What is the most specific auscultation finding in heart failure?
S3 - ventricular gallop
196
Which imaging investigation is indicated for HFrEF?
Echocardiography
197
Which serum marker is used to investigate HFrEf?
NT-pro-BNP
198
What NT-pro-BNP cut off is used for diagnosis of HF?
>125 pg/mL
199
What is the first line management for chronic HFrEF?
ACE inhibitor AND beta-blocker
200
When is a beta-blocker contraindicated in chronic HFrEF?
Hx of diabetes mellitus or signs of fluid overload
201
What is the second line medical management for chronic HFrEF?
Mineralocorticoid receptor antagonist e.g., spironolactone.
202
Which drug should replace an ACE inhibitor if EF <35%?
sacubitril valsartan
203
What fourth drug should be added to medical management in patients with chronic HFrEF?
SGLT-2 inhibitor
204
What are the adverse effects associated with the use of SGLT-2 inhibitors?
Fournier’s gangrene, necrotising fasciitis, increased UTIs, euglycemic diabetic ketoacidosis.
205
Which medical drugs are recommended in patients of African-Carribbean descent in chronic HFrEF?
* Hydralazine and nitrate
206
Name the two criteria for ICD insertion in chronic heart failure?
LVEF <35%
QRS <130 ms
207
What are the indications for CRT in chronic heart failure?
* Symptomatic patients with HF with a QRS duration >150 ms and LBB QRS morphology and with LVEF <35%
208
What is the 1st line medical management for acute heart failure?
loop diuretics e.g., furosemide or bumetanide
209
What is the EF threshold for HFpEF?
LVEF >50%
210
Diastolic heart failure is associated with which type of HF?
HFpEF?
211
What is the medical management for HFpEF?
SGLT-2 inhibitor
212
Which two vaccinations are indicated for chronic heart failure?
once only pneumococcal vaccination
Annual influenza vaccine
213
What are the contraindications for nitrates in HF?
in SBP <90 mmHg or in aortic stenosis
214
What is the 1st medical management for cardiogenic shock in HF?
inotropes/vasopressors e.g., dobutamine, and noradrenaline.
215
Which circulatory support devices are indicated in cardiogenic shock?
Intra-aortic balloon pump
216
What is the first line medical management for peri-arrest bradycardia?
Atropine (500 mcg IV) – up to a maximum of 3 mg.
217
Following atropine in bradycardia management, what is the next intervention?
Transcutaneous pacing
218
What are the ECG changes associated with LBBB?
* QRS duration > 120 ms
* Dominant S wave in V1 (W in V1)
* Broad monophasic R wave in lateral leads (I, aVL, V5-6)
* Prolonged R wave peak time >60 ms in leads V5-6 (M in V6)
219
What ECG pattern is associated with RBBB?
* QRS duration >120 ms
* V1: RSR’ pattern in V1-3 (M-shaped QRS complex)
* V6: Wide, slurred S wave in lateral leads
220
Which classification system is used for typical angina diagnosis?
Diamond classification
221
What i the gold standard investigation for typical angina?
CT coronary angiography
222
What is the first line symptomatic relief for angina?
Sublingual glyceryl trinitrate
223
What is the first line long-term management for angina?
Beta-blocker or calcium-channel blocker (Rate-limiting is indicated for monotherapy e.g., verapamil or diltiazem – class IV antiarrhythmics).
224
What are the adverse effects associated with beta-blockers?
Tiredness, postural hypotension (in elderly patients), loss of sympathetic response to hypoglycaemia, nightmares (use a fat-soluble agent e.g., atenolol), male impotence.
225
What is the second line management for angina?
Combination dual-therapy – long-acting dihydropyridine CCB (e.g., amlodipine, modified-release nifedipine)
226
What is the consequence of Verapamil + beta-blocker ?
Complete heart block
227
If monotherapy or initial CCB/BB therapy is ineffective in managing angina, what is next?
Long-acting nitrate (e.g., isosorbide mononitrate); nicorandil; ivabradine; ranolazine
228
Where do loop diuretics act?
Na-K-Cl cotransport in the thick ascending limb of the loop of Henle
229
How do loop diuretics affect calcium?
* Hypocalcaemia
230
What electrolyte derangement is associated w/loop diuretics?
* Hyponatraemia
* Hypokalaemia, hypomagnesaemia
* Hypocalcaemia
231
What is the diagnostic investigation for Buerger's disease?
* Contrast angiography
232
What finding is observed in Buerger's disease?
Segmental arterial occlusions with corkscrew appearance
233
Which bacteria is associated with underlying colon cancer (infective endocarditis)?
streptococcus bovis
234
What is the most common cause of infective endocarditis?
Staph. Aureus
235
What are the HACEK organisms?
Haemophilus, Aggregatibacter, Cardiobacterum, Eikenella, and Kingella.
236
Which valve is most affected in IVDU?
Tricuspid
237
What is the most common cause of infective endocarditis following a valve replacement (within the first 2 months)?
streptococcus viridans
238
Where do Janeway lesions typically affect?
Painless flat macules on the palms and soles
239
What are Osler's nodes?
Tender red/purple nodules on the pads of the fingers and toes
240
What ocular manifestation of infective endocarditis is observed?
Roth spots
241
What are the two major Duke's criteria?
* Positive blood cultures growing typical IE organisms or 3 positive cultures>12 hours, taken from 3 different sites at 3 different times.
* Evidence of vegetation on TTE or new regurgitant murmur
242
What are the five minor Duke's criteria?
* Risk factors (e.g., prosthetic valve, IVDU, congenital valve abnormalities).
* Fever >38
* Thromboembolic phenomena
* Immune phenomena – glomerulonephritis, Osler’s nodes, Roth spots
* Positive blood cultures not meeting major criteria.
243
What is the antibiotic of choice for prosthetic valve IE?
Vancomycin + rifampicin + gentamicin.
244
What investigation is required prior to antibiotics in IE?
Blood cultures
245
What is the antibiotic of choice for confirmed staphylococcus aureus IE?
Flucloxacillin
246
What is the most common viral cause of myocarditis?
Coxsackie B virus
247
What is the gold-standard investigation to confirm myocarditis?
Endomyocardial biopsy
248
What is the clinic range for stage 1 hypertension?
140/90 mmHg to 159/99 mmHg
249
What is the daytime or HBPM average for stage 1 hypertension?
135/85 to 149/94 mmHg
250
What is the clinic BP range for stage 2 hypertension?
160/100 to 180/120 mmHg
251
What is the ABPM daytime average for stage 2 hypertension?
>150/95 mmHg
252
Define stage 3 (severe) hypertension?
Clinic blood pressure >180 mmHg or clinic diastolic blood pressure >120 mmHg.
253
What is malignant hypertension?
Malignant hypertension is defined as a blood pressure >180/120 mmHg accompanied by signs of retinal haemorrhage, papilloedema and new or progressive target organ damage.
254
What are the BP target ranges for 'normal' patients (<80 years)?
<140/90
255
What are the BP target ranges for a patient with T1DM/CKD (<80 years)?
<130/90
256
What is the BP target range for patients aged >80 years?
<150/90
257
What is the first line drug for hypertension <55 years non-AC origin?
ACE inhibitors e.g., ramipril
258
What is the first line management for hypertension >55 years or AC origin?
Calcium channel blocker e.g., amlodipine, nifedipine
259
What is the second line medical management for hypertension?
* ACEi/ARB + CCB or thiazide-like diuretic.
* CCB + ACEi/ARB or thiazide-like diuretic (For those on CCB as first-line).
260
What is the third line medical management for hypertension?
* ACEi/ARB + CCB + thiazide-like diuretic.
261
What potassium level indicates low-dose spironolactone for step 4 hypertension management?
<4.5 mmol/L
262
What is the medical management for refractory hypertension and potassium >4.5 mmol/L?
alpha-blocker or beta-blocker.
263
What are the contraindications for alpha-blockers?
Postural hypotension, and micturition syncope
264
What are the adverse effects associated with alpha-blockers?
vertigo, dizziness, arrhythmias, chest pain, constipation and diarrhoea, depression, drowsiness, dry mouth, dyspnoea, first-dose hypotension, headache, oedema, palpitations, syncope, sexual dysfunction, and tinnitus
265
What is the main adverse effect associated with ACE inhibitors?
Dry non-productive cough and angioedema
266
What are the contraindications to ACE inhibitors?
history of recurrent or family angioedema; reduced eGFR <60 mL/minute/1.73m2 and in combination with aliskiren; pregnancy and breastfeeding women
267
Wells score >4, what is the next investigation?
CTPA and interim anticoagulation
268
What is the first line anticoagulation indicated for PE?
DOAC e.g., apixaban
269
If the Wells score is <4, what is the next test?
D-dimer within 4 hours
270
A positive D-dimer in a patient with Well's score <4, indicates what?
CTPA
271
What is the most common ECG finding observed in PE?
Sinus tachycardia
272
What specific rare ECG pattern is associated with PE?
* S1Q3T3
273
What is the management of massive PE or those that are haemodynamically unstable?
Thrombolytic therapy e.g., IV alteplase
274
What is the first line management of orthostatic hypotension?
Fludrocortisone
275
A pansystolic murmur radiating to the axilla, is consistent with what?
Mitral regurgitation
276
Which ECG feature is associated with mitral regurgitation?
P mitrale
277
What is the definitive diagnosis of MR?
Echocardiography
278
Which murmur is heard in mitral stenosis?
Mid-diastolic low-pitched murmur
279
A malar flush is associated with what?
Mitral stenosis
280
Why is there a loud S1 in mitral stenosis?
– thick valves requiring a large systolic force to shut.
281
Which investigation is indicated following a vasovagal syncope?
12-lead ECG
282
Which murmur is heard in hypertrophic cardiomyopathy?
* Crescendo-decrescendo ejection systolic murmur
best auscultated at the apex and lower left sternal border) – increases with Valsalva manoeuvre and decreases on squatting.
283
Which investigation confirms hypertrophic cardiomyopathy?
2D transthoracic echocardiography or cardiovascular magnetic resonance imaging demonstrating a maximal end-diastolic left ventricular wall thickness of ≥15 mm
284
What prophylactic intervention is recommended in HCM?
prophylactic ICD therapy
285
Which drugs are indicated for symptomatic control in HCM?
non-vasodilating beta-blockers or non-dihydropyridine calcium channel blockers
286
Critical stenosis of the LAD is associated with what disorder?
Wellen’s Syndrome
