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Cardiology Flashcards

1
Q

Describe the coronary dominance proportions

A

Right coronary: 60%
Left coronary: 20%
Equal: 20%

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2
Q

What does the RCA supply?

A

Right atrium, SA node, AV node, right ventricle, posterior part of the interventricular septum

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3
Q

From where does the RCA arise?

A

Anterior aortic sinus

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4
Q

What are the main branches of the RCA?

A

Posterior descending branch - runs in the posterior interventricular groove
Marginal branch - runs along inferior border

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5
Q

From where does the LCA arise?

A

Posterior aortic cusp

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6
Q

What does the LCA supply?

A

Anterior part of left and right ventricle, anterior interventricular septum, atrioventricular groove, lateral wall of left ventricle

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7
Q

Outline the venous drainage of the heart

A

90% of the drainage is into the right atrium through the coronary sinus via the great, middle and small cardiac veins
10% drains into other chambers via the venae cordis minimae

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8
Q

Where is BNP mainly produced?

A

Left ventricular myocardium

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9
Q

What are the effects of BNP?

A

Diuretic
Natriuretic
Suppresses sympathetic tone and RAS

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10
Q

In which condition can BNP also be elevated?

A

CKD (due to reduced excretion)

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11
Q

Name some causes of infective endocarditis

A

Staph. aureus
Strep. viridans (actually refers to Strep. mitis and Strep. sanguinis, usually acquired through poor dental hygiene)
Staph. epidermidis (coagulase negative, usually on prosthetic valves)
HACEK
Bartonella
Brucella
Coxiella burnetti (Q fever)

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12
Q

What is the most common primary cardiac tumour?

A

Atrial myxoma

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13
Q

Where is atrial myxoma commonly found?

A

75% in left atrium, commonly attached to the fossa ovalis

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14
Q

What is the definitive treatment for atrial flutter?

A

Radiofrequency ablation of the tricuspid valve isthmus

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15
Q

What is the MOA of Ivabradine?

A

Inhibition of If channels - mixed sodium and potassium channels - inhibition delays spontaneous depolarisation

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16
Q

Name a key side effect of ivabradine

A

Transient luminous phenomenon

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17
Q

Name some causes of restrictive cardiomyopathy

A

Amyloidosis (e.g. secondary to myeloma) - most common cause in UK
Haemochromatosis
Post-radiation fibrosis
Loffler’s syndrome: endomyocardial fibrosis with a prominent eosinophilic infiltrate
Endocardial fibroelastosis: thick fibroelastic tissue forms in the endocardium; most commonly seen in young children
Sarcoidosis
Scleroderma

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18
Q

What type of dysfunction does restrictive cardiomyopathy cause?

A

Diastolic

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19
Q

What is the MOA of ticagrelor?

A

PY212 ADP receptor antagonist, however in comparison to clopidogrel, it is reversible as it is an allosteric antagonist

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20
Q

What is the MOA of sacubitril?

A

Neprilysin inhibitor - prevents breakdown of endogenous BNP and ANP - it is a membrane bound endopeptidase found in high concentrations in the kidney

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21
Q

What is a MUGA scan?

A

Muti gated acquisition scan - radionuclide angiography technique used to accurately asses left ventricular function

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22
Q

Which drugs should be avoided in HOCM?

A

Nitrates
ACE-inhibitors
Inotropes

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23
Q

Name some indications for a temporary pacemaker

A

Symptomatic/haemodynamically unstable bradycardia, not responding to atropine
Post-ANTERIOR MI: type 2 or complete heart block*
Trifascicular block prior to surgery

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24
Q

Name some associations of mitral valve prolapse

A 
Congenital heart disease: PDA, ASD
Cardiomyopathy
Turner's syndrome
Marfan's syndrome, Fragile X
Osteogenesis imperfecta
Pseudoxanthoma elasticum
Wolff-Parkinson White syndrome
Long-QT syndrome
Ehlers-Danlos Syndrome
Polycystic kidney disease
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25
Q

What are the main complications following stent insertion?

A

Stent thrombosis: due to platelet aggregation as above. Occurs in 1-2% of patients, most commonly in the first month. Usually presents with acute myocardial infarction

Restenosis: due to excessive tissue proliferation around stent. Occurs in around 5-20% of patients, most commonly in the first 3-6 months. Usually presents with the recurrence of angina symptoms. Risk factors include diabetes, renal impairment and stents in venous bypass grafts

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26
Q

Name some features of complete heart block

A 
Syncope
Heart failure
Regular bradycardia (30-50 bpm)
Wide pulse pressure
JVP: cannon waves in neck
Variable intensity of S1
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27
Q

What are the types of second degree heart block?

A 
Type 1 (Mobitz I, Wenckebach): progressive prolongation of the PR interval until a dropped beat occurs
Type 2 (Mobitz II): PR interval is constant but the P wave is often not followed by a QRS complex
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28
Q

What is the cause of catecholaminergic polymorphic ventricular tachycardia?

A

AD inheritance, caused by a defect in the ryanodine receptor (RYR2), found in the sarcoplasmic reticulum

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29
Q

Which drug is contraindicated in ventricular tachycardia?

A

Verapamil

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30
Q

What is important to monitor during magnesium infusion?

A

Urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment
respiratory depression can occur.
Calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression

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31
Q

Name some poor prognostic factors in HOCM

A

Syncope
Family history of sudden death
Young age at presentation
Non-sustained ventricular tachycardia on 24 or 48-hour Holter monitoring
Abnormal blood pressure changes on exercise

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32
Q

What defines pulmonary artery hypertension?

A

Resting mean pulmonary artery pressure of >= 25 mmHg

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33
Q

Name some clinical signs of PAH

A

Right ventricular heave, loud P2, raised JVP with prominent ‘a’ waves, tricuspid regurgitation

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34
Q

What is the MOA of warfarin?

A

Inhibits epoxide reductase preventing the reduction of vitamin K to its active hydroquinone form
This in turn acts as a cofactor in the carboxylation of clotting factor II, VII, IX and X (mnemonic = 1972) and protein C

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35
Q

Name some side effects of warfarin

A

Haemorrhage
Teratogenic, although can be used in breastfeeding mothers
Skin necrosis
When warfarin is first started biosynthesis of protein C is reduced
Thrombosis may occur in venules leading to skin necrosis
Purple toes

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36
Q

Which factors may potentiate warfarin?

A

Liver disease
P450 enzyme inhibitors, e.g.: amiodarone, ciprofloxacin
Cranberry juice
Drugs which displace warfarin from plasma albumin, e.g. NSAIDs
Inhibit platelet function: NSAIDs

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37
Q

Indications for warfarin use

A

Mechanical heart valves
Target INR depends on the valve type and location
mitral valves generally require a higher INR than aortic valves.
Second-line after DOACs:
Venous thromboembolism: target INR = 2.5, if recurrent 3.5
Atrial fibrillation, target INR = 2.5

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38
Q

Which drug is contraindicated in VT?

A

Verapamil

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39
Q

Which drugs can be used in broad complex tachycardia?

A

Amiodarone: ideally administered through a central line
Lidocaine: use with caution in severe left ventricular impairment
Procainamide

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40
Q

Name some features of PAH

A

Progressive exertional dyspnoea is the classical presentation
Other possible features include exertional syncope, exertional chest pain and peripheral oedema
Cyanosis
Right ventricular heave, loud P2, raised JVP with prominent ‘a’ waves, tricuspid regurgitation

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41
Q

How do you manage PAH?

A

Acute vasodilator testing:
Administer epoprostenol or inhaled nitric oxide, if there is a fall in pressure then calcium channel blocker is indicated (minority of patients)
If no fall, prostacyclin analogues, endothelin receptor antagonists and phosphodiesterase inhibitors can be used

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42
Q

How long do you need off driving with an elective angioplasty?

A

1 week

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43
Q

How long do you need off driving following a CABG?

A

4 weeks

44
Q

How long do you need off driving following ICD insertion?

A

If implanted for sustained ventricular arrhythmia: cease driving for 6 months
If implanted prophylactically then cease driving for 1 month. Having an ICD results in a permanent bar for Group 2 drivers

45
Q

How long do you need off driving following a heart transplant?

A

6 weeks

46
Q

What is Eisenmenger’s syndrome?

A

The reversal of a left to right shunt in the context of an underlying congenital cardiac condition due to pulmonary hypertension

47
Q

Which drug should not be prescribed concurrently with beta blockers?

A

Verapamil - risk of complete heart block

48
Q

What is the MOA of aliskiren?

A

Direct renin inhibitor

49
Q

Name some causes of eruptive xanthoma

A

Familial hypertriglyceridaemia

Lipoprotein lipase deficiency

50
Q

Name an adverse effect of ticagrelor

A

Dyspnoea due to impaired clearance of adenosine

51
Q

Name some drugs that can cause long QT syndrome

A 
Amiodarone, sotalol, class 1a antiarrhythmic drugs
tricyclic antidepressants, selective serotonin reuptake inhibitors (especially citalopram)
Methadone
Chloroquine
Terfenadine**
Erythromycin
Haloperidol
Ondanestron
52
Q

Name some features of mitral stenosis

A

Dyspnoea
↑ left atrail pressure → pulmonary venous hypertension
Haemoptysis
Due to pulmonary pressures and vascular congestion
May range from pink frothy sputum to sudden haemorrhage secondary to rupture of thin walled and dilated bronchial veins
Mid-late diastolic murmur (best heard in expiration)
Loud S1, opening snap
Low volume pulse
Malar flush
Atrial fibrillation
Secondary to ↑ left atrial pressure → left atrial enlargement

53
Q

Which condition is associated with a left dominant coronary circulation?

A

Bicuspid aortic valve

54
Q

In which conditions may S3 be heard?

A

Heard in left ventricular failure (e.g. dilated cardiomyopathy), constrictive pericarditis (called a pericardial knock) and mitral regurgitation

55
Q

Name some signs of tricuspid regurgitation

A

Pan-systolic murmur
Prominent/giant V waves in JVP
Pulsatile hepatomegaly
Left parasternal heave

56
Q

Name some causes of tricuspid regurgitation

A 
Right ventricular infarction
Pulmonary hypertension e.g. COPD
Rheumatic heart disease
Infective endocarditis (especially intravenous drug users)
Ebstein's anomaly
Carcinoid syndrome
57
Q

Name some congenital causes of long QT syndrome

A

Jervell-Lange-Nielsen syndrome (includes deafness and is due to an abnormal potassium channel)
Romano-Ward syndrome (no deafness)

58
Q

Name some indications for a temporary pacemaker

A

Symptomatic/haemodynamically unstable bradycardia, not responding to atropine
Post-ANTERIOR MI: type 2 or complete heart block*
Trifascicular block prior to surgery

59
Q

Name some indications for an ICD

A 
Long QT syndrome
Hypertrophic obstructive cardiomyopathy
Previous cardiac arrest due to VT/VF
Previous myocardial infarction with non-sustained VT on 24 hr monitoring, inducible VT on electrophysiology testing and ejection fraction < 35%
Brugada syndrome
60
Q

Name some ECG changes seen in hypothermia

A 
Bradycardia
'J' wave (Osborne waves) - small hump at the end of the QRS complex
First degree heart block
Long QT interval
Atrial and ventricular arrhythmias
61
Q

What is the MOA of nicorandil?

A

Nicorandil is a vasodilatory drug used to treat angina. It is a potassium-channel activator with vasodilation is through activation of guanylyl cyclase which results in increase cGMP

62
Q

What is the pathophysiology of Brugada syndrome?

A

Around 20-40% of cases are caused by a mutation in the SCN5A gene which encodes the myocardial sodium ion channel protein

63
Q

Name some features of severe aortic stenosis

A 
Narrow pulse pressure
Slow rising pulse
Delayed ESM
Soft/absent S2
S4
Thrill
Duration of murmur
Left ventricular hypertrophy or failure
64
Q

Name some investigations to exclude angina

A

1st line: CT coronary angiography
2nd line: non-invasive functional imaging (looking for reversible myocardial ischaemia)
3rd line: invasive coronary angiography

65
Q

What is multifocal atrial tachycardia?

A

Multifocal atrial tachycardia (MAT) may be defined as a irregular cardiac rhythm caused by at least three different sites in the atria, which may be demonstrated by morphologically distinctive P waves. It is more common in elderly patients with chronic lung disease, for example COPD

66
Q

How do you manage multifocal atrial tachycardia?

A

correction of hypoxia and electrolyte disturbances
rate-limiting calcium channel blockers are often used first-line
cardioversion and digoxin are not useful in the management of MAT

67
Q

Name some features of amiodarone

A

very long half-life (20-100 days). For this reason, loading doses are frequently used
should ideally be given into central veins (causes thrombophlebitis)
has proarrhythmic effects due to lengthening of the QT interval
interacts with drugs commonly used concurrently (p450 inhibitor) e.g. Decreases metabolism of warfarin
numerous long-term adverse effects (see below)

68
Q

Name some SEs of amiodarone

A

thyroid dysfunction: both hypothyroidism and hyper-thyroidism
corneal deposits
pulmonary fibrosis/pneumonitis
liver fibrosis/hepatitis
peripheral neuropathy, myopathy
photosensitivity
‘slate-grey’ appearance
thrombophlebitis and injection site reactions
bradycardia
lengths QT interval

69
Q

What monitoring do you require with amiodarone treatment?

A

TFT, LFT, U&E, CXR prior to treatment
TFT, LFT every 6 months

70
Q

Name some indications for surgery in IE

A

severe valvular incompetence
aortic abscess (often indicated by a lengthening PR interval)
infections resistant to antibiotics/fungal infections
cardiac failure refractory to standard medical treatment
recurrent emboli after antibiotic therapy

71
Q

Name some risk factors for asystole in heart block

A

complete heart block with broad complex QRS
recent asystole
Mobitz type II AV block
ventricular pause > 3 seconds

72
Q

What subtype of S. bovis is associated with colorectal cancer?

A

Streptococcus gallolyticus

73
Q

What are the associations of aortic dissection?

A

hypertension: the most important risk factor
trauma
bicuspid aortic valve
collagens: Marfan’s syndrome, Ehlers-Danlos syndrome
Turner’s and Noonan’s syndrome
pregnancy
syphilis

74
Q

Name some additional features of cardiac tamponade other than Beck’s triad

A

dyspnoea
tachycardia
an absent Y descent on the JVP - this is due to the limited right ventricular filling
pulsus paradoxus - an abnormally large drop in BP during inspiration
Kussmaul’s sign - much debate about this
ECG: electrical alternans

75
Q

Name some features of broad complex tachycardia suggesting VT rather than SVT

A

AV dissociation
fusion or capture beats
positive QRS concordance in chest leads
marked left axis deviation
history of IHD
lack of response to adenosine or carotid sinus massage
QRS > 160 ms

76
Q

What are some causes of cannon waves?

A

Regular cannon waves
ventricular tachycardia (with 1:1 ventricular-atrial conduction)
atrio-ventricular nodal re-entry tachycardia (AVNRT)

Irregular cannon waves
complete heart block

77
Q

Which drug should never be given in VT?

A

Verapamil should NOT be used in VT.

78
Q

Name some ECG features of digoxin use

A

down-sloping ST depression (‘reverse tick’, ‘scooped out’)
flattened/inverted T waves
short QT interval
arrhythmias e.g. AV block, bradycardia

79
Q

Describe the MOA of thiazide diuretics

A

Thiazide diuretics work by inhibiting sodium reabsorption at the beginning of the distal convoluted tubule (DCT) by blocking the thiazide-sensitive NaCl symporter

80
Q

What is the pathophysiology of ARVC?

A

inherited in an autosomal dominant pattern with variable expression
the right ventricular myocardium is replaced by fatty and fibrofatty tissue
around 50% of patients have a mutation of one of the several genes which encode components of desmosome

81
Q

Name some features of a PDA

A

left subclavicular thrill
continuous ‘machinery’ murmur
large volume, bounding, collapsing pulse
wide pulse pressure
heaving apex beat

82
Q

What is the management for PDA?

A

indomethacin or ibuprofen
given to the neonate
inhibits prostaglandin synthesis
closes the connection in the majority of cases
if associated with another congenital heart defect amenable to surgery then prostaglandin E1 is useful to keep the duct open until after surgical repair

83
Q

Name some ECG changes in pericarditis

A

the changes in pericarditis are often global/widespread, as opposed to the ‘territories’ seen in ischaemic events
‘saddle-shaped’ ST elevation
PR depression: most specific ECG marker for pericarditis

84
Q

Describe some signs of tricuspid regurgitation

A

pan-systolic murmur
prominent/giant V waves in JVP
pulsatile hepatomegaly
left parasternal heave

85
Q

Describe some causes of tricuspid regurgitation

A

right ventricular infarction
pulmonary hypertension e.g. COPD
rheumatic heart disease
infective endocarditis (especially intravenous drug users)
Ebstein’s anomaly
carcinoid syndrome

86
Q

Describe some ECG findings of digoxin use

A

down-sloping ST depression (‘reverse tick’, ‘scooped out’)
flattened/inverted T waves
short QT interval
arrhythmias e.g. AV block, bradycardia

87
Q

Describe some ECG features of hypokalaemia

A

U waves
small or absent T waves (occasionally inversion)
prolong PR interval
ST depression
long QT

88
Q

What ECG finding is associated with hypocalcaemia?

A

shortened QT interval on ECG

89
Q

What is the MOA of nicorandil?

A

Nicorandil is a vasodilatory drug used to treat angina. It is a potassium-channel activator with vasodilation is through activation of guanylyl cyclase which results in increase cGMP.

90
Q

Describe some adverse effects of nicorandil use

A

headache
flushing
skin, mucosal and eye ulceration
gastrointestinal ulcers including anal ulceration

Contraindications
left ventricular failure

91
Q

How often should LFTs be checked with statin use?

A

baseline, 3 months and 12 months

92
Q

Name some causes of a loud S2

A

hypertension: systemic (loud A2) or pulmonary (loud P2)
hyperdynamic states
atrial septal defect without pulmonary hypertension

93
Q

Name some thienopyridines

A

prasugrel
ticagrelor
ticlopidine
clopidogrel

94
Q

Name some drugs that can cause long QT syndrome

A

Sotalol
TCAs
SSRIs
Methadone
Chloroquine
Terfenadine
Erythromycin
Haloperidol
Ondansetron

95
Q

How long do you need off driving following elective angioplasty?

A

1 week

96
Q

How long do you need off driving following pacemaker insertion?

A

1 week

97
Q

How long do you need off driving following CABG?

A

4 weeks

98
Q

Which cardiac biomarker is first to rise following MI?

A

Myoglobin

99
Q

Name some indications for surgery in IE

A

severe valvular incompetence
aortic abscess (often indicated by a lengthening PR interval)
infections resistant to antibiotics/fungal infections
cardiac failure refractory to standard medical treatment
recurrent emboli after antibiotic therapy

100
Q

Name some causes of a prolonged PR interval

A

idiopathic
ischaemic heart disease
digoxin toxicity
hypokalaemia*
rheumatic fever
aortic root pathology e.g. abscess secondary to endocarditis
Lyme disease
sarcoidosis
myotonic dystrophy

101
Q

Which radiotracer is used for cardiac PET?

A

fluorodeoxyglucose (FDG)

102
Q

Name some secondary drug causes of hypertension

A

steroids
monoamine oxidase inhibitors
the combined oral contraceptive pill
NSAIDs
leflunomide

103
Q

Name some features of cholesterol emobolism

A

eosinophilia
purpura
renal failure
livedo reticularis

104
Q

Name some causes of ejection systolic murmurs

A

louder on expiration
aortic stenosis
hypertrophic obstructive cardiomyopathy
louder on inspiration
pulmonary stenosis
atrial septal defect
also: tetralogy of Fallot

105
Q

Name some associations of WPW syndrome

A

HOCM
mitral valve prolapse
Ebstein’s anomaly
thyrotoxicosis
secundum ASD

MRCP (13 decks)

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