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Medicine > Cardiology > Flashcards

Cardiology Flashcards

1
Q

When should oxygen be given to STEMI patients? (1)

A

if the oxygen saturations are < 94%

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2
Q

Name 4 drugs that can be used in the acute management of STEMI patients (4)

A
  • GTN
  • morphine (+ metoclopramide)
  • aspirin
  • clopidogrel, ticagrelor, prasurgel
  • bivalirudin
  • heparin (LMW or unfractionated)
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3
Q

What is the MoA of bivalirudin? (1)

A

reversible direct thrombin inhibitor

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4
Q

Name 4 drugs that can be used in the acute management of NSTEMI patients (4)

A
  • morphine (+ metoclopramide)
  • aspirin 300mg
  • fondaparinux
  • clopidogrel
  • tirofiban, eptifibatide
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5
Q

What is the MoA of enoxaparin? (1)

A

activates antithrombin III, which in turn potentiates the inhibition of coagulation factors Xa

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6
Q

What is the MoA of fondaparinux? (1)

A

activates antithrombin III, which in turn potentiates the inhibition of coagulation factors Xa

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7
Q

What is the MoA of tirofiban? (1)

A

glycoprotein IIb/IIIa receptor antagonist

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8
Q

Give 4 clinical features of acute pericarditis (4)

A
  • chest pain (pleuritic)
  • pericardial rub
  • tachypnoea
  • tachycardia
  • non-productive cough
  • dyspnoea
  • flu-like symptoms
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9
Q

Give 4 causes of acute pericarditis (4)

A
  • viral infection (e.g. Coxsackie)
  • TB
  • uraemia
  • trauma
  • post-MI (Dressler’s syndrome)
  • connective tissue disease
  • hypothyroidism
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10
Q

Give 2 ECG changes indicative of acute pericarditis (2)

A
  • widespread ST-elevation (saddle-shaped)

- PR depression

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11
Q

In which patient group is the use of adenosine contraindicated?

A

Asthmatics

action of adenosine is blocked by theophyllines

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12
Q

What is the MoA of adenosine? (3)

A

agonist of the A1 receptor which inhibits adenylyl cyclase (1) thus reducing cAMP and causing hyperpolarization by increasing outward potassium flux (2), resulting in a transient heart block in the AV node (3)

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13
Q

Give 3 side effects of adenosine

A
  • chest pain
  • bronchospasm
  • arrhythmias (e.g. WPW syndrome)
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14
Q

When can adrenaline be given during a cardiac arrest? (2)

A
  • once chest compressions have restarted after the third shock
  • then every 3-5 minutes (during alternate cycles of CPR)
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15
Q

What class of anti-arrhythmic agent is amiodarone?

A

Class III

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16
Q

What is the MoA of amiodarone? (3)

A

Blocks potassium channels which inhibits repolarisation (1) and hence prolongs the action potential (2)

Amiodarone also has other actions such as blocking sodium channels (3)

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17
Q

Name 4 investigations that should be performed prior to amiodarone treatment (4)

A
  • TFT
  • U&E
  • LFT
  • CXR
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18
Q

Name 2 investigations that must be performed every 6 months in patients taking amiodarone (2)

A
  • TFT

- LFT

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19
Q

Give 5 side effects of amiodarone

A
  • thyroid dysfunction
  • corneal deposits
  • pneumonitis/pulmonary fibrosis
  • hepatitis/liver fibrosis
  • peripheral neuropathy
  • myopathy
  • photosensitivity
  • ‘slate-grey’ appearance
  • thrombophlebitis (at injection site)
  • bradycardia (QT prolongation)
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20
Q

Give 3 drugs that can be used in management of anaphylaxis (3)

A
  • adrenaline
  • hydrocortisone
  • chlorphenamine
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21
Q

What is the best site for the administration of adrenaline in anaphylactic patients?

A

anterolateral aspect of the middle third of the thigh

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22
Q

What blood test can be performed in patients following an episode of anaphylaxis?

A

serum tryptase

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23
Q

What is the dose of adrenaline used in management of anaphylaxis in an adult?

A

500 micrograms (0.5ml 1 in 1,000)

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24
Q

What is the dose of adrenaline used in management of anaphylaxis in a child aged 6-12 years?

A

300 micrograms (0.3ml 1 in 1,000)

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25
Q

What is the dose of adrenaline used in management of anaphylaxis in a child aged <6 years?

A

150 micrograms (0.15ml 1 in 1,000)

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26
Q

Name 5 drugs used in the management of angina pectoris (5)

A
  • statin
  • aspirin
  • GTN
  • beta-blocker/calcium channel blocker
    (either monotherapy or combined)
  • long-acting nitrates
    (e.g. ivabradine, nicorandil, ranolazine)
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27
Q

What type of calcium channel blocker should be considered for monotherapy in patients with angina pectoris?

A

Rate-limiting

e.g. verapamil, diltiazem

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28
Q

What type of calcium channel blocker should be considered when prescribed in combination with beta blockers for patients with angina pectoris?

A

long-acting dihydropyridine calcium-channel blocker

e.g. nifedipine

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29
Q

Why is verapamil contraindicated in patients taking beta blockers? (1)

A

Risk of complete heart block

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30
Q

What is the MoA of ivabradine? (2)

A

acts on the If (‘funny’) ion current which is highly expressed in the sinoatrial node (1), reducing cardiac pacemaker activity and decreasing heart rate (2)

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31
Q

Give 3 side effects of ivabradine (3)

A
  • visual disturbance
  • headache
  • bradycardia
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32
Q

Give 3 uses of ACEi (3)

A
  • management of hypertension (in <55 years)
  • management of heart failure
  • management of diabetic nephropathy
  • secondary prevention of IHD
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33
Q

What is the MoA of ACEi (1)

A

inhibit the conversion angiotensin I to angiotensin II

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34
Q

Give 3 side effects of ACEi (3)

A
  • dry cough
  • first dose hypotension
  • hyperkalaemia
  • angioedema
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35
Q

Give 3 contraindications of ACEi (3)

A
  • pregnancy/breastfeeding
  • renovascular disease (e.g. renal artery stenosis)
  • aortic stenosis
  • patients receiving high-dose diuretic therapy
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36
Q

Which investigation should be performed prior to ACEi treatment?

A

U&E

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37
Q

Name 2 changes in renal function that may be seen after starting ACEi treatment (2)

A
  • increase in serum creatinine (up to 30% of baseline)

- increase in potassium (up to 5.5 mmol/l)

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38
Q

Name 2 angiotensin II receptor blockers (2)

A
  • candesartan
  • losartan
  • irbesartan
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39
Q

Which class of drug can be used in patients that do not tolerate ACEi?

A

angiotensin II receptor blockers

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40
Q

Give 2 side effects of angiotensin II receptor blockers (2)

A
  • hypotension

- hyperkalaemia

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41
Q

What is the MoA of angiotensin II receptor blockers (1)

A

block effects of angiotensin II at the AT1 receptor

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42
Q

Name the 2 types of aortic dissection, according to the Stanford classification system (2)

A
  • Type A (ascending aorta)

- Type B (descending aorta)

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43
Q

Name the 3 types of aortic dissection, according to the Debakey classification system (3)

A
  • Type I (originates in the ascending aorta and propagates to at least the the aortic arch)
  • Type II (originates in and is confined to the ascending aorta)
  • Type II (originates in the descending aorta)
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44
Q

Give 4 risk factors for aortic dissection (4)

A
  • hypertension
  • trauma
  • biscupid aortic valve
  • connective tissue disorders
    (e. g. Marfan’s syndrome, Ehlers-Danlos syndrome)
  • Turner’s syndrome
  • Noonan’s syndrome
  • pregnancy
  • syphilis
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45
Q

Give 2 complications of a backward aortic dissection (2)

A
  • aortic incompetence/regurgitation

- inferior MI

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46
Q

Give 2 complications of a forward aortic dissection (2)

A
  • unequal arm pulses and pressures
  • stroke
  • renal failure
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47
Q

How should a Type A aortic dissection be managed? (1)

A

surgically

blood pressure should be controlled to 100-120 mmHg whilst awaiting intervention

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48
Q

How should a Type B aortic dissection be managed? (1)

A

conservatively

bed rest and IV labetalol to reduce blood pressure and prevent progression

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49
Q

Give 5 clinical features of aortic stenosis (5)

A
  • narrow pulse pressure
  • slow rising pulse
  • late ejection systolic murmur
  • soft/absent S2
  • S4
  • thrill
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50
Q

Give 3 causes of aortic stenosis (3)

A
  • degenerative calcification (patients <65 years)
  • bicuspid aortic value (patients <65 years)
  • William’s syndrome (supravalvular aortic stenosis)
  • post-rheumatic disease
  • subvalvular disease (e.g. HOCM)
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51
Q

What is the approach to management in patients with asymptomatic aortic stenosis? (1)

A
  • observation
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52
Q

What is the approach to management in patients with symptomatic aortic stenosis? (2)

A
  • valve replacement

- balloon valvuloplasty (e.g. TAVI)

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53
Q

Name 3 classes of drug used for rate control in patients with AF (3)

A
  • beta blockers
  • calcium channel blockers
  • digoxin
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54
Q

Name 3 drugs used to maintain sinus rhythm in patients with a history of AF (3)

A
  • sotalol
  • amiodarone
  • flecainide
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55
Q

Give 2 factors that indicate rate control management of AF (2)

A
  • > 65 years

- history of IHD

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56
Q

Give 2 factors that indicate rhythm control management of AF (2)

A
  • <65 years
  • symptomatic
  • first presentation
  • lone AF
  • congestive heart failure
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57
Q

Name 2 drugs used in the pharmacological cardioversion of AF (2)

A
  • amiodarone

- flecainide

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58
Q

Which scoring system is used to determine the most appropriate anticogaulation strategy for patients with AF

A

CHA2DS2-VASc

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59
Q

Outline the CHA2DS2-VASc scoring system

A 
C: Cogestive Heart Failure (1)
H: Hypertension (1)
A: >65 years (1), >75 years (2)
D: Diabetes Mellitus
S: Stroke or TIA (2)
V: Vascular Disease (1)
Sc: Sexual characteristics (1 for females)
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60
Q

How should results of the CHA2DS2-VASc scoring system be interpreted? (3)

A

0: No treatment
1: Consider treatment (males). No treatment (females)
2: Offer anticoagulation

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61
Q

Name 2 types of anticoagulants for patient with AF

A
  • warfarin

- NOACs

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62
Q

Which scoring system is used to determine the risk of bleeding in patients receiving anticoagulation therapy

A

HASBLED

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63
Q

Outline the HASBLED scoring system

A 
H: Hypertension 
A: Abnormal renal/liver function 
S: previous Stroke
B: previous Bleed
L: Labile INRs (unstable/high)
E: Elderly >65 years 
D: Drugs (e.g. NSAIDs, antiplatelets), Drink (alcohol)
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64
Q

How should results of the HASBLED scoring system be interpreted? (1)

A

No formal rules but a score of >= 3 indicates a ‘high risk’ of bleeding

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65
Q

What is atrial flutter? (1)

A

A form of supraventricular tachycardia characterised by a succession of rapid atrial depolarisation waves

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66
Q

Name the classic ECG feature of atrial flutter (2)

A

‘sawtooth appearance’

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67
Q

Outline the management of atrial flutter (3)

A
  • similar to that of atrial fibrillation
    (medication may be less effective)
  • DC cardioversion
  • radiofrequency ablation of the tricuspid valve isthmus
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68
Q

What is the most common congenital heart defect in adults?

A

ASD

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69
Q

Name the 2 types of ASD (2)

A
  • ostium secundum (most common)

- ostium primum

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70
Q

Give 2 clinical features of ASD (2)

A
  • ejection systolic murmur

- fixed splitting of S2

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71
Q

Give 2 ECG features of an ostium secundum ASD (2)

A
  • RBBB

- RAD

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72
Q

Give 2 ECG features of an ostium primum ASD (2)

A
  • RBBB
  • LAD
  • prolonged PR interval
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73
Q

Where is B-type natriuretic peptide produced?

A

left ventricular myocardium in response to strain

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74
Q

Give 3 effects of B-type natriuretic peptide (3)

A
  • vasodilation
  • diuretic and natriuretic
  • suppresses sympathetic tone
  • suppresses RAAS
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75
Q

Give 3 clinical uses of B-type natriuretic peptide (3)

A
  • diagnosis of patients with acute dyspnoea
    (a low concentration rules out a diagnosis of heart failure)
  • prognosis in chronic heart failure
  • responses to treatment in chronic heart failure
  • screening for cardiac dysfunction
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76
Q

What is Boerhaaves syndrome?

A

spontaneous rupture of the oesophagus that occurs as a result of repeated episodes of vomiting

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77
Q

What time of referral should be made for patients with current chest pain or chest pain in the last 12 hours with an abnormal ECG?

A

emergency referral

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78
Q

What time of referral should be made for patients with chest pain 12-72 hours ago?

A

same-day referral to hospital for assessment

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79
Q

What time of referral should be made for patients with chest pain > 72 hours ago?

A

perform full assessment with ECG and troponin measurement before deciding upon referral

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80
Q

What are the 3 features of anginal pain? (3)

A
  • constricting discomfort in the front of the chest, neck, shoulders, jaw or arms
  • pain precipitated by physical exertion
  • pain relieved by rest or GTN in about 5 minutes
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81
Q

How are the features of anginal pain used for diagnosis? (3)

A
  • patients with all 3 features have typical angina
  • patients with 2 features have atypical angina
  • patients with 1 or no features have non-anginal chest pain
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82
Q

According to NICE Guidelines, how should patients with anginal symptoms be investigated? (3)

A

CAD risk 61-90%: coronary angiography

CAD risk 30-60%: functional imaging (e.g. myocardial perfusion scan, stress echocardiogram, etc)

CAD risk 10-29%: CT calcium scoring

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83
Q

What is MoA of clopidogrel? (2)

A

antagonist of the P2Y12 adenosine diphosphate (ADP) receptor (1), inhibiting the activation of platelets (2)

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84
Q

Define coarctation of the aorta (1)

A

a congenital narrowing of the descending aorta

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85
Q

Give 4 clinical features of coarctation of the aorta (4)

A
  • hypertension (adults)
  • radio-femoral delay
  • mid diastolic murmur (maximal at the back)
  • apical click from the aortic valve
  • notching of the inferior border of the ribs
  • heart failure (infancy)
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86
Q

Name 3 conditions that are associated with coarctation of the aorta (3)

A
  • Turner’s syndrome
  • bicuspid aortic valve
  • berry aneurysms
  • neurofibromatosis
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87
Q

Give 4 clinical features of complete heart block (4)

A
  • syncope
  • heart failure
  • regular bradycardia (<50bpm)
  • wide pulse pressure
  • cannon waves in the jugular vein
  • variable intensity of S1
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88
Q

Define 1st degree heart block (1)

A

prolongation of the PR interval (>0.2s)

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89
Q

Define 2nd degree heart block (2)

A

Mobitz Type 1: progressive prolongation of the PR interval until a dropped beat occurs

Mobitz Type 2: PR interval is constant but the P wave is often not followed by a QRS complex

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90
Q

Define 3rd degree (complete) heart block (1)

A

there is no association between the P waves and QRS complexes

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91
Q

Give 3 clinical features of constrictive pericarditis (3)

A
  • dyspnoea
  • right heart failure
    (elevated JVP, ascites, oedema, hepatomegaly)
  • JVP show prominent x and y descent
  • pericardial knock (loud S3)
  • Kussmaul’s sign is positive
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92
Q

What is Kussmaul’s sign?

A

a paradoxical rise in jugular venous pressure (JVP) on inspiration

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93
Q

What are the blood pressure targets for patients with diabetes? (2)

A

no organ damage: <140/80 mmHg

end-organ damage: <130/80 mmHg

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94
Q

Which class of drug is the first line antihypertensive in diabetic patients?

A

ACEi

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95
Q

What is the MoA of dipyridamole? (4)

A

inhibits phosphodiesterase, elevating platelet cAMP (1) levels which in turn reduce intracellular calcium levels (2)

also reduces cellular uptake of adenosine (3) and inhibits thromboxane synthase (4)

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96
Q

What are the specific DVLA rules for patients with hypertension? (2)

A

can drive unless treatment causes unacceptable side effects

no need to notify DVLA

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97
Q

What are the specific DVLA rules for patients that have undergone angioplasty? (1)

A

1 week off driving

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98
Q

What are the specific DVLA rules for patients that have undergone CABG? (1)

A

4 weeks off driving

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99
Q

What are the specific DVLA rules for patients with acute coronary syndrome? (2)

A

4 weeks off driving

1 week if successfully treated by angioplasty

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100
Q

What are the specific DVLA rules for patients with angina? (1)

A

driving must cease if symptoms occur at rest/at the wheel

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101
Q

What are the specific DVLA rules for patients that have undergone pacemaker insertion? (1)

A

1 week off driving

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102
Q

What are the specific DVLA rules for patients with implantable cardioverter-defibrillators? (2)

A

if implanted for sustained ventricular arrhythmia: cease driving for 6 months

if implanted prophylatically then cease driving for 1 month

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103
Q

What are the specific DVLA rules for patients that have undergone catheter ablation for an arrhythmia? (1)

A

2 days off driving

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104
Q

What are the specific DVLA rules for patients with an aortic aneurysm of 6cm or more? (3)

A

notify DVLA

licensing will be permitted subject to annual review

an aortic diameter of 6.5 cm or more disqualifies patients from driving

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105
Q

What are the specific DVLA rules for patients that have undergone a heart transplant? (1)

A

DVLA do not need to be notified

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106
Q

What is Ebstein’s anomaly? (2)

A

a congenital heart defect characterised by low insertion of the tricuspid valve resulting in a large atrium and small ventricle

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107
Q

Name 2 conditions that are associated with Ebstein’s anomaly (2)

A
  • tricuspid incompetence

- WPW syndrome

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108
Q

Give a cause of Ebstein’s anomaly

A

exposure to lithium in-utero

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109
Q

Give 4 examples of normal variants on an ECG of an athlete (4)

A
  • sinus bradycardia
  • junctional rhythm
  • first degree heart block
  • second degree (Mobitz type I) heart block
110
Q

Give 3 ECG features that indicate a myocardial infarction (3)

A
  • ST elevation
  • ST depression
  • pathological Q waves
111
Q

Give 3 causes of ST elevation on an ECG (3)

A
  • MI
  • pericarditis
  • left ventricular aneurysm
  • normal variant (high take-off)
  • Prinzmetal’s angina (coronary artery spasm)
112
Q

Give 2 ECG features that indicate a LBBB (2)

A
  • ‘W’ in V1

- ‘M’ in V6

113
Q

Give 2 ECG features that indicate a RBBB (2)

A
  • ‘M’ in V1

- ‘W’ in V6

114
Q

Give 4 causes of RBBB (4)

A
  • normal variant (common in elderly)
  • right ventricular hypertrophy
  • right ventricular hypertension (e.g. cor pulmonale)
  • PE
  • MI
  • ASD (ostium secundum)
  • myocarditis/cardiomyopathy
115
Q

Give 4 causes of LBBB (4)

A
  • IHD
  • hypertension
  • aortic stenosis
  • cardiomyopathy
  • idiopathic fibrosis
  • digoxin toxicity
  • hyperkalaemia
116
Q

Define bifascicular block (2)

A
  • RBBB

- LAFB or LPFB

117
Q

Define trifascicular block (3)

A
  • RBBB
  • LAFB or LPFB
  • first degree heart block
118
Q

Give 3 ECG features that indicate hypothermia (3)

A
  • bradycardia
  • J wave
  • first degree heart block
  • long QT interval
119
Q

What is a J wave?

A

small hump at the end of the QRS complex

120
Q

Give 3 ECG features that indicate hypokalaemia (3)

A
  • U waves
  • small or absent T waves (occasionally inversion)
  • prolong PR interval
  • ST depression
  • long QT
121
Q

What is a U wave?

A

a small deflection immediately following the T wave

122
Q

What does S1 represent?

A

closure of the mitral and tricuspid valves

123
Q

What does S2 represent?

A

aortic and pulmonary valve closure

124
Q

What does a soft S1 represent? (2)

A
  • long PR

- mitral regurgitation

125
Q

What does a loud S1 represent? (1)

A
  • mitral stenosis
126
Q

What does a soft S2 represent? (1)

A
  • aortic stenosis
127
Q

Give 3 causes of S3 (3)

A
  • left ventricular failure (e.g. dilated cardiomyopathy)
  • constrictive pericarditis
  • mitral regurgitation
128
Q

Give 3 causes of S4 (3)

A
  • aortic stenosis
  • HOCM
  • hypertension
129
Q

What investigation should be performed to investigate a diagnosis of heart failure in patients that have previously had an MI? (1)

A

echocardiogram within 2 weeks

130
Q

What investigation should be performed to investigate a diagnosis of heart failure in patients with no history of MI? (3)

A
  • measure serum natriuretic peptides (BNP)
  • if levels are ‘high’ (>400 pg/ml) arrange echocardiogram within 2 weeks
  • if levels are ‘raised’ (100-400 pg/ml) arrange echocardiogram within 6 weeks
131
Q

Give 5 indications for beta blocker use (5)

A
  • angina
  • post-MI
  • heart failure
  • arrhythmias
  • hypertension
  • thyrotoxicosis
  • migraine prophylaxis
  • anxiety
132
Q

Give 3 side effects of beta blockers (3)

A
  • bronchospasm
  • cold peripheries
  • fatigue
  • sleep disturbances (including nightmares)
133
Q

Give 3 contraindications of beta blockers (3)

A
  • uncontrolled heart failure
  • asthma
  • sick sinus use
  • concurrent verapamil use (causes bradycardia)
134
Q

Give 3 factors that increase levels of B-type natriuretic peptide (3)

A
  • left ventricular hypertrophy
  • ischaemia
  • tachycardia
  • right ventricular overload
  • hypoxaemia
  • GFR <60 ml/min
  • sepsis
  • COPD
  • diabetes
  • age >70
  • cirrhosis
135
Q

Give 3 factors that decrease levels of B-type natriuretic peptide (3)

A
  • obesity
  • diuretics
  • ACEi
  • beta blockers
  • angiontensin II receptor blockers
  • aldosterone antagonists
136
Q

Which classification system is used to classify the severity of heart failure?

A

New York Heart Association (NYHA) classification

137
Q

Outline the NYHA classification system (8)

A

NYHA Class I
Symptoms: None
Limitations: None (ordinary physical exercise does not cause undue fatigue, dyspnoea or palpitations)

NYHA Class II
Symptoms: Mild
Limitations: Slight limitation of physical activity (comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea)

NYHA Class III
Symptoms: Moderate
Limitations: Marked limitation of physical activity
(comfortable at rest but less than ordinary activity results in symptoms)

NYHA Class IV
Symptoms: Severe
Limitations: unable to carry out any physical activity without discomfort (symptoms of heart failure are present even at rest with increased discomfort with any physical activity)

138
Q

Give 4 options for the management of acute heart failure

A
  • oxygen
  • diuretics
  • opiates
  • vasodilators
  • inotropic agents
  • CPAP
  • ultrafiltration
  • mechanical circulatory assistance (e.g. IABP, VAD)
139
Q

Name 3 classes of drug that have been shown to improve mortality in patients with chronic heart failure (3)

A
  • ACEi
  • spironolactone
  • beta blockers
  • hydralazine with nitrates
140
Q

What are the first line treatments for patients with chronic heart failure? (2)

A

ACEiandbeta-blocker

141
Q

What are the second line treatment options for patients with chronic heart failure? (3)

A
  • aldosterone antagonist (e.g. spironolactone)
  • angiotensin II receptor blocker
  • hydralazine with nitrates
142
Q

What are the additional treatment options for patients with persistent symptomatic chronic heart failure?

A
  • cardiac resynchronisation therapy

- digoxin

143
Q

Which 2 vaccinations should be offered to patients with chronic heart failure?

A
  • annual influenza vaccine

- one-off pneumococcal vaccine

144
Q

When would digoxin be strongly indicated in patients with chronic heart failure?

A

when there is nonexistent AF

145
Q

Name 2 beta blockers used for the treatment of chronic heart failure (2)

A
  • bisoprolol
  • carvedilol
  • nebivolol
146
Q

What is HOCM?

A

an autosomal dominant disorder of muscle tissue caused by defects in the genes encoding contractile proteins

147
Q

What is the prevalence of HOCM?

A

1 in 500

148
Q

What is the pattern of inheritance for HOCM?

A

autosomal dominant

149
Q

Give 5 clinical features of HOCM

A
  • often asymptomatic
  • dyspnoea
  • angina
  • syncope
  • arrhythmias
  • heart failure
  • sudden death (due to ventricular arrhythmias)
  • jerky pulse
  • large ‘a’ waves
  • double apex beat
  • ejection systolic murmur
    (increases with Valsalva, decreases on squatting)
150
Q

Name 2 conditions associated with HOCM (2)

A
  • Friedreich’s ataxia

- Wolff-Parkison White

151
Q

Give 3 features on an echocardiogram that indicate HOCM (3)

A

MR SAM ASH

  • mitral regurgitation
  • systolic anterior motion of the anterior mitral valve leaflet
  • asymmetric hypertrophy
152
Q

Give 3 ECG features that indicate HOCM (3)

A
  • left ventricular hypertrophy
  • progressive T wave inversion
  • deep Q waves
  • atrial fibrillation (occasionally)
153
Q

Give 3 options for the management of xanthelasma

A
  • surgical excision
  • topical trichloroacetic acid
  • laser therapy
  • electrodesiccation
154
Q

Define Stage 1 hypertension (2)

A

Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg

155
Q

Define Stage 2 hypertension (2)

A

Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg

156
Q

Define severe hypertension (2)

A

Clinic systolic BP >= 180 mmHg

or clinic diastolic BP >= 110 mmHg

157
Q

How is ambulatory blood pressure monitoring (ABPM) performed? (2)

A
  • at least 2 measurements per hour during the person’s usual waking hours
  • use the average value of at least 14 measurements
158
Q

How is home blood pressure monitoring (HBPM) performed? (4)

A
  • for each BP recording, two consecutive measurements need to be taken, at least 1 minute apart and with the person seated
  • BP should be recorded twice daily, ideally in the morning and evening
  • BP should be recorded for at least 4 days, ideally for 7 days
  • discard the measurements taken on the first day and use the average value of all the remaining measurements
159
Q

When should stage 1 hypertension be treated?

A

if <80 years of age AND any of the following apply:

  • target organ damage
  • established cardiovascular disease
  • renal disease
  • diabetes
  • 10-year cardiovascular risk equivalent to 20% or greater
160
Q

Give 4 lifestyle changes that should be recommended to reduce blood pressure

A
  • low salt intake (<6g/day)
  • reduce caffeine intake
  • stop smoking
  • reduce alcohol consumption
  • lose weight
  • exercise more frequently
  • increase consumption of fruit and vegetables
161
Q

What are the first line treatments for hypertension? (2)

A

<55-years: ACEi

> 55-years or of Afro-Caribbean origin: calcium channel blocker

162
Q

What are the second line treatments for hypertension?(2)

A

ACEi + calcium channel blocker

163
Q

What are the third line treatments for hypertension? (3)

A

ACEi + calcium channel blocker + thiazide diuretic (e.g. chlorthalidone or idapamide)

164
Q

Outline the management options for patients with resistant hypertension (4)

A

further diuretic treatment

  • potassium <4.5 mmol/l add spironolactone
  • potassium >4.5 mmol/l add higher dose thiazide diuretic

if further diuretic therapy is not tolerated, contraindicated or ineffective, consider an alpha- or beta-blocker

165
Q

What is the blood pressure target for patients aged <80 years

A

140/90

166
Q

What is the blood pressure target for patients aged >80 years

A

150/90

167
Q

Give 6 secondary causes of high blood pressure (6)

A
  • renal disease
    (e. g. glomerulonephritis, pyelonephritis, polycystic kidney disease, renal artery stenosis)
  • endocrine disorders
    (e. g. primary hyperaldosteronism, phaechromocytoma, Cushing’s syndrome, acromegaly, congenital adrenal hyperplasia)
  • drugs
    (e. g. steroids, MOAIs, cOCP, NSAIDs)
  • pregnancy
  • coarctation of the aorta
168
Q

What is the strongest risk factor for developing endocarditis?

A

a previous episode of endocarditis

169
Q

Name 3 groups of patients that can develop infective endocarditis

A
  • rheumatic heart disease
  • prosthetic heart valves
  • congenital heart defects
  • IVDUs
170
Q

What is the most common cause of infective endocarditis?

A

Staphylococcus aureus

171
Q

What is the most common cause of infective endocarditis in patients following prosthetic heart valve surgery?

A

coagulase-negative Staphylococci

e.g. Staphylococcus epidermidis

172
Q

Infective endocarditis caused by Streptococcus bovisis commonly associated with which condition?

A

colorectal cancer

173
Q

What is the most common cause of infective endocarditis in patients with poor dental hygiene?

A

Streptococcus viridans

174
Q

Which criteria are used to diagnosis infective endocarditis?

A

Modified Duke criteria

175
Q

What is long QT syndrome?

A

an inherited condition associated with delayed repolarization of the ventricles

176
Q

Give 4 causes of long QT syndrome

A
  • congenital conditions
    (e. g. Jervell-Lange-Nielson symdrome, Romano-Ward syndrome)
  • drugs
    (e. g. TCAs, SSRIs, anti-psychotics, anti-arrhythmics)
  • electrolyte imbalance
    (e. g. hypocalcaemia, hypokalaemia, hypomagnesaemia)
  • acute MI
  • myocarditis
  • hypothermia
  • SAH
177
Q

Name 4 drugs that can cause long QT syndrome

A
  • amiodarone
  • sotalol
  • citalopram
  • methadone
  • chloroquine
  • erythromycin
  • haloperidol
178
Q

What is the first line treatment for long QT syndrome?

A

beta blockers

179
Q

What may be required for high risk patients with long QT syndrome?

A

ICD

180
Q

What is the MoA of loop diuretics? (3)

A

act by inhibiting the Na-K-Cl cotransporter (1) in the thick ascending limb of the loop of Henle (2), reducing the absorption of NaCl (3)

181
Q

Name 2 loop diuretics

A
  • furosemide

- bumetanide

182
Q

Give 4 side effects of loop diuretics

A
  • hypotension
  • hyponatraemia
  • hypokalaemia
  • hypochloric alkalosis
  • ototoxicity
  • hypocalcaemia
  • renal impairment
  • hyperglycaemia
  • gout
183
Q

Give 3 causes of ejection (early) systolic murmurs

A
  • aortic stenosis
  • pulmonary stenosis
  • HOCM
  • ASD
  • Tetrology of Fallot
184
Q

Give 2 causes of pansystolic murmurs

A
  • mitral regurgitation
    (high-pitched and ‘blowing’ in character)
  • tricuspid regurgitation
    (high-pitched and ‘blowing’ in character)
  • VSD
    (‘harsh’ in character)
185
Q

Give 2 causes of late systolic murmurs

A
  • mitral valve prolapse

- coarctation of the aorta

186
Q

Give 2 causes of early diastolic murmurs

A
  • aortic regurgitation
    (high-pitched and ‘blowing’ in character)
  • pulmonary regurgitation (Graham-Steel)
    (high-pitched and ‘blowing’ in character)
187
Q

Give 2 causes of mid-late diastolic murmurs

A
  • mitral stenosis
    (‘rumbling’ in character)
  • severe aortic regurgitation (Austin-Flint)
    (‘rumbling’ in character)
188
Q

Which congenital heart defect causes a continuous machine-like murmur?

A

PDA

189
Q

Name the 4 drugs that should be offered to all patients following a MI

A
  • dual antiplatelet therapy (aspirin + clopidogrel)
  • ACEi
  • beta blocker
  • statin
190
Q

Give 5 complications following a MI

A
  • cardiac arrest
  • cardiogenic shock
  • chronic heart failure
  • tachyarrhythmias
  • bradyarrhythmias
  • pericarditis
  • left ventricular aneurysm
  • left ventricular free wall rupture
  • VSD
  • mitral regurgitation
191
Q

What is Dressler’s syndrome

A

an autoimmune reaction against antigenic proteins formed as the myocardium recovers

192
Q

Give 3 clinical features of Dressler’s syndrome

A
  • fever
  • pleuritic chest pain
  • pericardial effusion
  • raised ESR
193
Q

When does Dressler’s syndrome typically occur?

A

2-6 weeks following a MI

194
Q

What is the treatment for Dressler’s syndrome?

A

NSAIDs

195
Q

What is the MoA of nitrates?

A

cause release of nitric oxide in smooth muscle (1), increasing cGMP (2) which leads to a fall in intracellular calcium levels, resulting in vasodilation (3)

196
Q

Give 3 side effects of nitrates

A
  • hypotension
  • headache
  • tachycardia
  • flushing
197
Q

What is a patent ductus arteriosus?

A

a congenital heart defect in which the connection between the pulmonary trunk and descending aorta remains patent

198
Q

Give 3 clinical features of a patent ductus arteriosus

A
  • left subclavicular thrill
  • continuous machine-like murmur
  • bounding pulse
  • collapsing pulse
  • wide pulse pressure
  • heaving apex beat
199
Q

Which drug is used to close a patent ductus arteriosus?

A

Indomethacin

200
Q

Which drug is used to maintain the maintain the patency of a patent ductus arteriosus

A

prostaglandin E1

201
Q

What is the first line treatment for bradycardia in patients with haemodynamic compromise?

A

atropine

202
Q

Give 3 indications of haemodynamic compromise in patients that are either bradycardic or tachycardia

A
  • hypotension (SBP <90 mmHg)
  • pallor
  • sweating
  • cold, clammy peripheries
  • confusion/impaired consciousness
  • syncope
  • MI
  • heart failure
203
Q

What is the first line treatment for bradycardia in patients with a potential risk of asystole?

A

transvenous pacing

204
Q

Give 3 indications of a potential risk of asystole in bradycardic patients

A
  • complete heart block with broad QRS
  • recent asystole
  • Mobitz type II AV block
  • ventricular pause >3s
205
Q

What is the first line treatment for tachycardia in patients with haemodynamic compromise?

A

DC cardioversion

206
Q

What is the first line treatment for a regular broad-complex tachycardia?

A

amiodarone

207
Q

Name 2 causes of irregular broad-complex tachycardia

A
  • AF with bundle branch block

- polymorphic VT (e.g. Torsade de pointes)

208
Q

Outline the management of a regular narrow-complex tachycardia (2)

A
  • vagal manoeuvres

- IV adenosine

209
Q

Outline the management of an irregular narrow-complex tachycardia (3)

A
  • if onset <48 hr consider electrical or pharmacological cardioversion
  • rate control
  • anticoagulation
210
Q

What is a phaechromocytoma?

A

a rare catecholamine secreting tumour

211
Q

Name 3 conditions associated with a phaechromocytoma (3)

A
  • MEN type II
  • neurofibromatosis
  • von Hippel-Lindau syndrome
212
Q

Give 3 clinical features of a phaechromocytoma

A
  • hypertension
  • headaches
  • palpitations
  • sweating
  • anxiety
213
Q

What test is used to diagnose a phaechromocytoma

A

24hr urinary collection of metanephrines/catcholamines

214
Q

Outline the management of a phaechromocytoma (3)

A
  • stabilisation with an alpha-blocker (e.g. phenoxybenzamine), given before a beta-blocker (e.g. propranolol)
  • surgery
215
Q

What is pulsus paradoxus?

A

a greater than the normal fall in SBP during inspiration (faint or absent pulse in inspiration)

216
Q

Give 2 causes of pulsus paradoxus

A
  • cardiac tamponade

- severe asthma

217
Q

What causes a slow-rising pulse?

A

aortic stenosis

218
Q

Give 2 causes of a collapsing pulse

A
  • aortic regurgitation

- PDA

219
Q

What is pulsus alternans?

A

a regular alternation of the force of the arterial pulse

220
Q

What causes pulsus alternans?

A

severe LVF

221
Q

What is a bisferiens pulse?

A

a ‘double pulse’ (two systolic peaks)

222
Q

What causes a bisferiens pulse?

A

mixed aortic valve disease

223
Q

What causes a ‘jerky’ pulse?

A

HOCM

224
Q

What is the major disadvantage of bioprosthetic heart valves?

A

structural deterioration and calcification over time

225
Q

What is the major disadvantage of mechanical heart valves?

A

the increased risk of thrombosis meaning long-term anticoagulation is needed

226
Q

What is the target INR for a patient with a mechanical aortic valve?

A

3.0

227
Q

What is the target INR for a patient with a mechanical mitral valve?

A

3.5

228
Q

What is Rheumatic fever?

A

A condition that develops following an immunological reaction to recent (2-6 weeks)Streptococcus pyogenesinfection

229
Q

Give 2 examples of evidence for a recent streptococcal infection

A
  • antistreptolysin O titre (ASOT) >200iu/mL
  • history of scarlet fever
  • positive throat swab
  • increase in DNase B titre
230
Q

Give 3 clinical features of Rheumatic fever

A
  • erythema marginatum
  • Sydenham’s chorea
  • polyarteritis
  • endocarditis/mycarditis/pericarditis
  • subcutaneous nodules
  • raised CRP/ESR
  • pyrexia
  • arthralgia
  • prolonged PR interval
231
Q

Name the rash that is occasionally seen in cases of Rheumatic fever in children

A

erythema marginatum

232
Q

How is systemic inflammatory response syndrome (SIRS)

diagnosed? (4)

A

At least 2 of the following

  • body temperature <36°C or >38.3°C
  • HR >90/min
  • RR >20 breaths per minute
  • white cell count <4 or >12
233
Q

Give 3 causes of systemic inflammatory response syndrome (SIRS)

A
  • infection
  • burns
  • pancreatitis
234
Q

Define sepsis

A

systemic inflammatory response syndrome (SIRS) to a proven or presumed infection

235
Q

Define severe sepsis

A

sepsis with end organ dysfunction or hypoperfusion (indicated by hypotension, lactic acidosis or decreased urine output or others)

236
Q

Define septic shock

A

severe sepsis with hypotension that is unresponsive to fluid resuscitation

237
Q

What is the MoA of statins? (2)

A

inhibit the action of HMG-CoA reductase (1), the rate-limiting enzyme in hepatic cholesterol synthesis (2)

238
Q

Give 2 side effects of statins

A
  • myopathy (e.g. myalgia, myositis)

- liver impairment

239
Q

When should LFTs be checked in patients taking statins?

A

at baseline, 3 months and 12 months

240
Q

Give 2 indications for the use of stations

A
  • established cardiovascular disease
    (e. g. stroke, TIA, IHD, PVD)
  • any patient with a 10-year cardiovascular risk >=10%
  • T1DM for >10 years, aged >40 years or with established nephropathy
241
Q

When should statins be taken?

A

at night as this is when the majority of cholesterol synthesis takes place

242
Q

What does of statin is used for primary prevention?

A

20mg

243
Q

What does of statin is used for secondary prevention?

A

80mg

244
Q

Outline the acute management of supraventricular tachycardia (3)

A
  • vagal manoeuvres
  • IV adenosine (6mg, 12mg, 6mg)
  • DC cardioversion
245
Q

What 2 treatments can be used to prevent episodes of supraventricular tachycardia?

A
  • beta blockers

- radio-frequency ablation

246
Q

What is the MoA of thiazide diuretics? (2)

A

inhibit sodium absorption (1) at the proximal part of the distal convoluted tubule (2)

247
Q

Give 3 side effects of thiazide diuretics

A
  • dehydration
  • postural hypotension
  • hyponatraemia
  • hypokalaemia
  • hypercalcaemia
  • gout
  • impaired glucose tolerance
  • impotence
  • thrombocytopaenia
  • agranulocytosis
  • photosensitivity rash
  • pancreatitis
248
Q

What is the mechanism of action of thrombolytic drugs? (2)

A

activate plasminogen to form plasmin (1), which in turn degrades fibrin and help breaks up thrombi (2)

249
Q

Give 2 examples of thrombolytic drugs

A
  • alteplase
  • tenecteplase
  • streptokinase
250
Q

Give 3 indications to thrombolysis

A
  • active internal bleeding
  • recent haemorrhage, trauma or surgery
  • coagulation/bleeding disorders
  • intracranial neoplasms
  • stroke <3 months
  • aortic dissection
  • recent head injury
  • pregnancy
  • severe hypertension
251
Q

What is the treatment for long QT syndrome?

A

IV magnesium sulphate

252
Q

When should antiplatelet therapy be stopped before surgery?

A

1 week

253
Q

When should the cOCP be stopped before surgery?

A

4 weeks

254
Q

Give 5 risk factors for venous thromboembolism

A
  • active cancer or cancer treatment
  • age >60 years
  • critical care admission
  • dehydration
  • known thrombophilias
  • obesity (>30)
  • significant comorbities
  • previous history of VTE
  • first degree relative with a history of VTE
  • HRT
  • oestrogen-containing contraceptive therapy
  • varicose veins with phlebitis
255
Q

Give 2 examples of in-patient pharmacological VTE prophylaxis

A
  • fondaparinux
  • LMWH
  • unfractionated heparin
256
Q

Give 2 examples of in-patient mechanical VTE prophylaxis

A
  • anti-embolism stockings
  • foot impulse devices
  • intermittent pneumatic compression devices
257
Q

Give 2 examples of post-procedure VTE prophylaxis

A
  • dabigatran (14 hours post-procedure)
  • fondaparinux (6 hours post-procedure)
  • LMWH (6-12 hours post-procedure)
  • rivaroxaban (6-10 hours post-procedure)
  • apixaban
258
Q

What is the management of ventricular tachycardia in patients with adverse signs? (1)

A

immediate cardioversion

259
Q

Give 3 examples of adverse signs in patients with ventricular tachycardia

A
  • SBP <90 mmHg
  • chest pain
  • heart failure
  • HR >150bpm
260
Q

Give 2 examples of anti arrhythmic drugs that are used in the management of ventricular tachycardia in the absence of adverse signs

A
  • amiodarone
  • lidocaine
  • procainamide
261
Q

What is the MoA of warfarin? (2)

A

inhibits the reduction of vitamin K to its active hydroquinone form (1), which in turn acts as a cofactor in the carboxylation of clotting factor II, VII, IX and X and protein C (2)

262
Q

Give 2 indications for the use of warfarin

A
  • VTE
  • atrial fibrillation
  • mechanical heart valves
263
Q

What is an INR?

A

International Normalised Ratio

the ratio of the prothrombin time for the patient over the normal prothrombin time

264
Q

Give 2 factors that potentiate the effects of warfarin

A
  • liver disease
  • P450 enzyme inhibitors
    (e. g. amiodarone, ciprofloxacin)
  • cranberry juice
  • drugs that displace warfarin from plasma albumin
  • drugs that inhibit platelet function
265
Q

Give 2 side effects of warfarin

A
  • haemorrhage
  • teratogenic
  • skin necrosis
  • purple toes
266
Q

Outline the management of a major bleed in a patient that takes warfarin (3)

A
  • stop warfarin
  • give IV vitamin K (5mg)
  • give prothrombin complex concentrate
    (if not available, then FFP)
267
Q

What is Wolff-Parkinson White syndrome?

A

a condition characterised by a congenital accessory conducting pathway between the atria and ventricles leading to an atrioventricular re-entry tachycardia

268
Q

Give 2 ECG features of Wolff-Parkinson White syndrome

A
  • short PR interval
  • wide QRS with slurred upstroke (delta wave)
  • LAD if right-sided accessory pathway (type B)
  • RAD if left-sided accessory pathway (type A)
269
Q

How is it possible to differentiate between a type A and type B accessory pathway on an ECG?

A
  • type A (left-sided pathway): dominant R wave in V1

- type B (right-sided pathway): no dominant R wave in V1

270
Q

Name 3 conditions associated with Wolff-Parkinson White syndrome (3)

A
  • HOCM
  • mitral valve prolapse
  • Ebstein’s anomaly
  • thyrotoxicosis
  • ostio secundum ASD
271
Q

Outline the management of Wolff-Parkinson White syndrome (2)

A
  • anti-arrhythmics (e.g. amiodarone, flecainide, sotalol)

- radio-frequency ablation of accessory pathway

Medicine (9 decks)

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