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Akt 6 Flashcards

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1
Q

What are significant risk factors for osteoporosis?

A

Advancing age and female sex

The prevalence of osteoporosis increases from 2% at 50 years to more than 25% at 80 years in women.

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2
Q

What are the most important risk factors used by major risk assessment tools such as FRAX?

A
  • History of glucocorticoid use
  • Rheumatoid arthritis
  • Alcohol excess
  • History of parental hip fracture
  • Low body mass index
  • Current smoking
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3
Q

List some other risk factors for osteoporosis.

A
  • Sedentary lifestyle
  • Premature menopause
  • Caucasians and Asians
  • Endocrine disorders
  • Multiple myeloma, lymphoma
  • Gastrointestinal disorders
  • Chronic kidney disease
  • Osteogenesis imperfecta, homocystinuria
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4
Q

Which medications may worsen osteoporosis?

A
  • SSRIs
  • Antiepileptics
  • Proton pump inhibitors
  • Glitazones
  • Long term heparin therapy
  • Aromatase inhibitors (e.g. anastrozole)
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5
Q

What are the reasons for further investigations in patients diagnosed with osteoporosis?

A
  • Exclude diseases that mimic osteoporosis
  • Identify the cause of osteoporosis and contributory factors
  • Assess the risk of subsequent fractures
  • Select the most appropriate form of treatment
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6
Q

What investigations are recommended by NOGG for osteoporosis?

A
  • History and physical examination
  • Blood cell count
  • Sedimentation rate or C-reactive protein
  • Serum calcium
  • Albumin
  • Creatinine
  • Phosphate
  • Alkaline phosphatase
  • Liver transaminases
  • Thyroid function tests
  • Bone densitometry (DXA)
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7
Q

Fill in the blank: The minimum blood tests for all patients with osteoporosis include full blood count, urea and electrolytes, ______, CRP, and thyroid function tests.

A

liver function tests

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8
Q

What are some additional procedures that may be indicated for osteoporosis investigations?

A
  • Lateral radiographs of lumbar and thoracic spine/DXA-based vertebral imaging
  • Protein immunoelectrophoresis and urinary Bence-Jones proteins
  • 25OHD
  • PTH
  • Serum testosterone, SHBG, FSH, LH (in men)
  • Serum prolactin
  • 24 hour urinary cortisol/dexamethasone suppression test
  • Endomysial and/or tissue transglutaminase antibodies (coeliac disease)
  • Isotope bone scan
  • Markers of bone turnover, when available
  • Urinary calcium excretion
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9
Q

What is a DEXA scan used for?

A

To assess bone density and diagnose conditions like osteoporosis

DEXA stands for Dual-Energy X-ray Absorptiometry.

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10
Q

What does the T score represent?

A

Bone mass compared to a young reference population

A T score indicates how much an individual’s bone density deviates from the average bone density of a healthy young adult.

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11
Q

What does a T score of -1.0 indicate?

A

Bone mass is one standard deviation below that of the young reference population

This is considered the threshold for normal bone density.

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12
Q

What is the Z score adjusted for?

A

Age, gender, and ethnic factors

The Z score provides a comparison of an individual’s bone density to that of others of the same age and demographic.

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13
Q

What does a T score greater than -1.0 indicate?

A

Normal bone density

This is a sign that the bone density is within the healthy range.

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14
Q

What T score range indicates osteopaenia?

A

-1.0 to -2.5

Osteopaenia is a condition where bone density is lower than normal but not low enough to be classified as osteoporosis.

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15
Q

What T score value indicates osteoporosis?

A

< -2.5

Osteoporosis signifies significantly reduced bone density, increasing fracture risk.

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16
Q

What is a QFracture or FRAX score used for?

A

To identify patients at high risk of fragility fractures

These scores help assess the risk of osteoporosis-related fractures.

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17
Q

What lifestyle changes should patients at risk of osteoporosis be advised to make?

A
  • Healthy, balanced diet
  • Moderate alcohol consumption
  • Avoid smoking

These changes can help reduce the risk of osteoporosis.

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18
Q

What dietary supplementation should be offered to women at risk of osteoporosis?

A

Calcium and vitamin D supplementation

Supplementation is recommended unless the clinician is confident of adequate intake.

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19
Q

What type of exercise is encouraged for patients at risk of osteoporosis?

A

Regular weight-bearing and muscle strengthening exercise

Exercise is crucial for maintaining bone health.

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20
Q

What are the first-line drug treatments for patients at risk of fragility fractures?

A

Bisphosphonates

Oral bisphosphonates like alendronate and risedronate are typically used first.

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21
Q

What is the recommended treatment following a hip fracture according to NOGG?

A

IV zoledronate as the first-line treatment

This is given yearly after a hip fracture.

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22
Q

What is the BMD threshold for defining osteoporosis?

A

A T-score of -2.5 SD or below

This measure is used to assess bone mineral density.

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23
Q

What should be done if a postmenopausal woman begins glucocorticoid treatment?

A

Start bone protective treatment simultaneously

Do not wait for a DEXA scan before starting treatment.

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24
Q

What is a common side effect of oral bisphosphonates?

A
  • Gastrointestinal discomfort
  • Oesophagitis
  • Hypocalcaemia

These side effects are important to monitor in patients.

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25
How should oral bisphosphonates be taken?
With a full glass of water, on an empty stomach, and remain upright for at least 30 minutes ## Footnote This helps minimize the risk of oesophageal side effects.
26
What is denosumab?
A human monoclonal antibody that inhibits RANK ligand ## Footnote It helps in reducing the maturation of osteoclasts.
27
What is the role of strontium ranelate in osteoporosis treatment?
It increases deposition of new bone and reduces bone resorption ## Footnote It should only be prescribed by a specialist due to safety concerns.
28
What is teriparatide?
A recombinant form of parathyroid hormone ## Footnote It is effective at increasing bone mineral density.
29
What dual action does romosozumab have?
Inhibits sclerostin, increasing bone formation and decreasing bone resorption ## Footnote This significantly improves bone density and reduces fracture risk.
30
True or False: Raloxifene has been shown to reduce the risk of non-vertebral fractures.
False ## Footnote Raloxifene has not yet been shown to reduce the risk of non-vertebral fractures.
31
What is the follow-up plan for prescribing bisphosphonates?
Prescribe for at least 5 years for oral bisphosphonates and 3 years for intravenous bisphosphonates, then re-assess fracture risk ## Footnote Regular reassessment is crucial for ongoing management.
32
What is a common tool used to assess fracture risk in patients?
QFracture or FRAX score ## Footnote These tools help identify patients at high risk of fragility fractures.
33
What is the BMD threshold for defining osteoporosis?
T-score of -2.5 SD or below ## Footnote This threshold is used to determine the presence of osteoporosis based on bone mineral density.
34
What is the first-line treatment for osteoporosis management?
Oral bisphosphonates such as alendronate or risedronate ## Footnote These medications are commonly prescribed to manage osteoporosis.
35
When should bone protective treatment be started for patients on glucocorticoids?
If >65 with previous fragility fracture then start protection If <65 then arrange DEXA scan (if between 0 to -1.5 repeat scan in 3 years, if less than -1.5 offer protection) If postmenopausal or men aged 50 and above - starting ≥7.5 mg/day prednisolone or equivalent for the next 3 months ## Footnote Treatment should begin concurrently with glucocorticoid therapy. No, don't wait for a DEXA scan before starting treatment
36
When should you start bone protection for someone with a symptomatic osteoporotic vertebral fracture?
postmenopausal woman or a man age ≥50 with Start treatment straight away with oral bisphosphonates ## Footnote Immediate management is crucial for symptomatic fractures.
37
How is a hip fracture in older adults related to osteoporosis?
It is a manifestation of osteoporosis ## Footnote Hip fractures are significant indicators of underlying osteoporosis.
38
Is a DEXA scan necessary to diagnose osteoporosis following a fragility fracture in women ≥75 years?
No, a DEXA scan is not necessary ## Footnote Treatment can commence based on clinical findings alone.
39
What role does BMD measurement have after a fragility fracture?
Acts as a baseline rather than determining treatment ## Footnote It helps in monitoring but does not dictate the need for treatment.
40
What does NOGG recommend for first-line treatment in osteoporosis management?
IV zoledronate ## Footnote Local guidelines may vary, and oral bisphosphonates are often used.
41
Fill in the blank: Oral bisphosphonates are used first-line, e.g., _______ or _______.
alendronate or risedronate ## Footnote These are the most commonly prescribed oral bisphosphonates.
42
What factors might make a patient unsuitable for BMD assessment?
Frailty etc. ## Footnote Some patients may not be able to undergo BMD testing due to their condition.
43
What is the recommended first-line treatment for osteoporosis?
Oral alendronate, taken once weekly at a dose of 70mg ## Footnote It is tolerated in around 75% of patients.
44
What should be assessed if oral alendronate is not tolerated?
Risk tables based on minimum T scores ## Footnote These tables help determine if trying another treatment is 'worth' it.
45
What are the recommended second-line treatments if alendronate is not tolerated?
Oral bisphosphonates: risedronate or etidronate ## Footnote These are suitable for both primary and secondary prevention of fragility fractures.
46
What does NICE recommend if bisphosphonates are not tolerated?
Review risk tables based on minimum T scores for further treatment options ## Footnote If indicated, strontium ranelate or raloxifene are recommended.
47
What is strontium ranelate known as?
'Dual action bone agent' ## Footnote It increases deposition of new bone by osteoblasts and reduces bone resorption by inhibiting osteoclasts.
48
What concerns have been raised regarding strontium ranelate?
Safety profile concerns, including increased risk of cardiovascular events ## Footnote It should only be prescribed by a specialist in secondary care.
49
What contraindication exists for strontium ranelate?
Any history of cardiovascular disease or significant risk of cardiovascular disease ## Footnote Increased risk of thromboembolic events also contraindicates its use.
50
What serious skin reaction may strontium ranelate cause?
Stevens Johnson syndrome ## Footnote This is a serious skin reaction associated with the drug.
51
What type of drug is raloxifene?
Selective oestrogen receptor modulator (SERM) ## Footnote It is used to prevent bone loss and reduce the risk of vertebral fractures.
52
What has raloxifene been shown to do?
Increase bone density in the spine and proximal femur ## Footnote However, it has not been shown to reduce the risk of non-vertebral fractures.
53
What are some potential side effects of raloxifene?
May worsen menopausal symptoms and increase risk of thromboembolic events ## Footnote It may also decrease the risk of breast cancer.
54
What is Metformin primarily used for?
Treatment of type 2 diabetes mellitus ## Footnote Metformin is also used in polycystic ovarian syndrome and non-alcoholic fatty liver disease.
55
What class of medication is Metformin?
Biguanide
56
What are some actions of Metformin that improve glucose tolerance?
* Increases insulin sensitivity * Decreases hepatic gluconeogenesis * May reduce gastrointestinal absorption of carbohydrates
57
True or False: Metformin causes hypoglycaemia and weight gain.
False
58
What are common gastrointestinal adverse effects of Metformin?
* Nausea * Anorexia * Diarrhoea
59
What percentage of patients find gastrointestinal side effects intolerable?
20%
60
What serious condition can occur with Metformin in severe liver disease or renal failure?
Lactic acidosis
61
What is the recommendation regarding Metformin dose in chronic kidney disease?
* Review if creatinine > 130 µmol/l (or eGFR < 45 ml/min) * Stop if creatinine > 150 µmol/l (or eGFR < 30 ml/min)
62
What conditions increase the risk of lactic acidosis when taking Metformin?
* Recent myocardial infarction * Sepsis * Acute kidney injury * Severe dehydration
63
What should be done with Metformin before iodine-containing x-ray contrast media procedures?
Discontinue on the day of the procedure and for 48 hours thereafter
64
What is a relative contraindication for Metformin use?
Alcohol abuse
65
How should Metformin be initiated in patients?
Titrated up slowly to reduce gastrointestinal side-effects
66
What should be considered if patients develop unacceptable side effects from Metformin?
Modified-release Metformin
67
What is the mechanism of action of Metformin?
* Activation of the AMP-activated protein kinase (AMPK) * Increases insulin sensitivity * Decreases hepatic gluconeogenesis * May reduce gastrointestinal absorption of carbohydrates
68
Fill in the blank: Metformin acts by activating the _______.
AMP-activated protein kinase (AMPK)
69
What are sulfonylureas?
Oral hypoglycaemic drugs used in the management of type 2 diabetes mellitus
70
How do sulfonylureas work?
By increasing pancreatic insulin secretion
71
When are sulfonylureas effective?
Only if functional B-cells are present
72
To which channel do sulfonylureas bind on pancreatic beta cells?
ATP-dependent K+(KATP) channel
73
What is a common adverse effect of sulfonylureas?
Hypoglycaemic episodes
74
Which sulfonylurea is more likely to cause hypoglycaemic episodes?
Long-acting preparations such as chlorpropamide
75
What is another common adverse effect associated with sulfonylureas?
Weight gain
76
What is a rarer adverse effect of sulfonylureas related to sodium levels?
Hyponatraemia secondary to syndrome of inappropriate ADH secretion
77
What is a rare but serious adverse effect of sulfonylureas affecting blood cells?
Bone marrow suppression
78
What type of hepatotoxicity is associated with sulfonylureas?
Typically cholestatic
79
What is a rare neurological adverse effect of sulfonylureas?
Peripheral neuropathy
80
In which conditions should sulfonylureas be avoided?
Breastfeeding and pregnancy
81
What are thiazolidinediones used to treat?
Type 2 diabetes mellitus ## Footnote Thiazolidinediones are a class of agents aimed at managing blood sugar levels in type 2 diabetes patients.
82
What receptor do thiazolidinediones act as agonists to?
PPAR-gamma receptor ## Footnote PPAR-gamma receptor plays a crucial role in regulating glucose and lipid metabolism.
83
What effect do thiazolidinediones have on insulin resistance?
Reduce peripheral insulin resistance ## Footnote This mechanism helps improve insulin sensitivity in patients with type 2 diabetes.
84
What happened to Rosiglitazone in 2010?
Withdrawn due to cardiovascular side-effect concerns ## Footnote The withdrawal was prompted by evidence linking Rosiglitazone to an increased risk of heart issues.
85
What type of receptor is the PPAR-gamma receptor?
Intracellular nuclear receptor ## Footnote This receptor is involved in the regulation of gene expression related to glucose and lipid metabolism.
86
What are the natural ligands of the PPAR-gamma receptor?
Free fatty acids ## Footnote These ligands are vital for the receptor's activation and subsequent biological effects.
87
List some adverse effects of thiazolidinediones.
* Weight gain * Liver impairment (monitor LFTs) * Fluid retention * Increased risk of fractures * Increased risk of bladder cancer ## Footnote These adverse effects necessitate careful patient monitoring and consideration of contraindications.
88
Why are thiazolidinediones contraindicated in heart failure?
Due to the risk of fluid retention ## Footnote Fluid retention can exacerbate heart failure symptoms and lead to serious complications.
89
What increases the risk of fluid retention in patients taking thiazolidinediones?
Concurrent insulin use ## Footnote The combination of insulin and thiazolidinediones can significantly heighten the risk of fluid retention.
90
What is the hazard ratio for bladder cancer in patients taking pioglitazone?
2.64 ## Footnote This indicates a significantly increased risk of developing bladder cancer among pioglitazone users.
91
What do SGLT-2 inhibitors do?
Reversibly inhibit sodium-glucose co-transporter 2 (SGLT-2) in the renal proximal convoluted tubule to reduce glucose reabsorption and increase urinary glucose excretion.
92
Name three examples of SGLT-2 inhibitors.
* Canagliflozin * Dapagliflozin * Empagliflozin
93
What is a common adverse effect of SGLT-2 inhibitors?
Urinary and genital infection (secondary to glycosuria)
94
What serious condition has been reported as an adverse effect of SGLT-2 inhibitors?
Fournier's gangrene
95
What metabolic condition can occur with SGLT-2 inhibitors despite normal blood glucose levels?
Normoglycaemic ketoacidosis
96
What risk is increased for patients taking SGLT-2 inhibitors regarding limb health?
Increased risk of lower-limb amputation
97
What should be closely monitored in patients taking SGLT-2 inhibitors?
Feet
98
How do SGLT-2 inhibitors affect weight in patients with type 2 diabetes mellitus?
Patients often lose weight
99
What hormone is released by the small intestine in response to an oral glucose load?
Glucagon-like peptide-1 (GLP-1) ## Footnote GLP-1 plays a crucial role in insulin secretion and glucose metabolism.
100
What is the incretin effect?
The phenomenon where an oral glucose load results in greater insulin release than an intravenous load ## Footnote This effect is primarily mediated by GLP-1 and is diminished in type 2 diabetes mellitus (T2DM).
101
What are the two recent classes of drugs targeting GLP-1?
1. GLP-1 mimetics (e.g. exenatide) 2. Dipeptidyl peptidase-4 (DPP-4) inhibitors ## Footnote DPP-4 inhibitors, also known as gliptins, work by inhibiting the breakdown of GLP-1.
102
What is an example of a GLP-1 mimetic?
Exenatide ## Footnote Exenatide is administered by subcutaneous injection and increases insulin secretion.
103
What is a major benefit of GLP-1 mimetics compared to other diabetes medications?
They typically result in weight loss ## Footnote This contrasts with medications like insulin, sulfonylureas, and thiazolidinediones, which may cause weight gain.
104
How must exenatide be administered?
By subcutaneous injection within 60 minutes before morning and evening meals ## Footnote It should not be given after a meal.
105
What is an advantage of liraglutide over exenatide?
Liraglutide only needs to be given once a day ## Footnote This makes it more convenient for patients compared to exenatide.
106
What are the NICE criteria for adding exenatide to metformin and a sulfonylurea?
1. BMI >= 35 kg/m² with associated problems 2. BMI < 35 kg/m² with unacceptable insulin use or weight loss benefits for comorbidities ## Footnote These criteria help guide treatment decisions in type 2 diabetes mellitus.
107
What is the major adverse effect of GLP-1 mimetics?
Nausea and vomiting ## Footnote Severe pancreatitis has also been linked to exenatide use in certain patients.
108
What do DPP-4 inhibitors do?
They increase levels of incretins (GLP-1 and GIP) by decreasing their peripheral breakdown ## Footnote This action helps regulate blood sugar levels.
109
How are DPP-4 inhibitors administered?
Oral preparation ## Footnote This allows for easier administration compared to injectable GLP-1 mimetics.
110
What is the tolerance level of DPP-4 inhibitors based on trials?
They are relatively well tolerated with no increased incidence of hypoglycaemia ## Footnote DPP-4 inhibitors do not cause weight gain.
111
When might a DPP-4 inhibitor be preferred over a thiazolidinedione?
If further weight gain would cause significant problems, thiazolidinedione is contraindicated, or there has been a poor response to a thiazolidinedione ## Footnote This recommendation is based on NICE guidelines.
112
What are conditions where HbA1c may not be used for diagnosis?
Haemoglobinopathies, haemolytic anaemia, untreated iron deficiency anaemia, suspected gestational diabetes, children, HIV, chronic kidney disease, people taking medication that may cause hyperglycaemia (for example corticosteroids) ## Footnote These conditions can affect the accuracy of HbA1c measurements.
113
What is Orlistat?
A pancreatic lipase inhibitor used in the management of obesity ## Footnote Orlistat works by inhibiting the enzyme that breaks down fats in the diet.
114
What are the adverse effects of Orlistat?
Faecal urgency/incontinence and flatulence ## Footnote These side effects can affect compliance with the treatment.
115
What is the lower dose version of Orlistat available without prescription?
'Alli' ## Footnote 'Alli' is a lower strength formulation of Orlistat meant for over-the-counter use.
116
What criteria has NICE defined for the use of Orlistat?
BMI of 28 kg/m² or more with associated risk factors, or BMI of 30 kg/m² ## Footnote NICE guidelines ensure that Orlistat is prescribed appropriately based on the patient's obesity and health risks.
117
What is the recommended weight loss percentage at 3 months for Orlistat to be continued?
5% ## Footnote Achieving this target indicates effectiveness and justifies the continuation of therapy.
118
For how long is Orlistat normally used?
< 1 year ## Footnote Long-term use beyond a year is typically not recommended.
119
What is Liraglutide?
A glucagon-like peptide-1 (GLP-1) mimetic used in the management of type 2 diabetes mellitus (T2DM) ## Footnote Liraglutide mimics the effects of the GLP-1 hormone, which helps to regulate blood sugar levels.
120
How is Liraglutide administered?
Once daily subcutaneous injection ## Footnote This method of administration is common for medications that require steady levels in the bloodstream.
121
What additional benefit has been noted with Liraglutide when used for T2DM management?
Weight loss in a significant proportion of patients ## Footnote This side effect led to research on its potential use in obesity management.
122
What are the current NICE criteria for the use of Liraglutide?
BMI of at least 35 kg/m² and prediabetic hyperglycaemia (HbA1c 42 - 47 mmol/mol) ## Footnote These criteria ensure that Liraglutide is used effectively in patients who may benefit from it.
123
124
What is the most common cause of death following a myocardial infarction?
Ventricular fibrillation ## Footnote Cardiac arrest due to ventricular fibrillation is a critical complication after MI.
125
What management protocol is followed for patients experiencing cardiac arrest after a myocardial infarction?
ALS protocol with defibrillation ## Footnote Advanced Life Support (ALS) protocols are essential for managing cardiac arrest.
126
What condition may develop if a large part of the ventricular myocardium is damaged during a myocardial infarction?
Cardiogenic shock ## Footnote Cardiogenic shock results from decreased ejection fraction and is challenging to treat.
127
What treatments may be required for patients with cardiogenic shock?
* Inotropic support * Intra-aortic balloon pump ## Footnote These interventions help support cardiac function in cardiogenic shock.
128
What is a possible long-term complication of myocardial infarction if the patient survives the acute phase?
Chronic heart failure ## Footnote Chronic heart failure can result from dysfunctional ventricular myocardium post-MI.
129
Which medications can improve the long-term prognosis of patients with chronic heart failure?
* Loop diuretics (e.g., furosemide) * ACE-inhibitors * Beta-blockers ## Footnote These medications help manage fluid overload and improve heart function.
130
What is the most common arrhythmia occurring after a myocardial infarction?
Ventricular fibrillation ## Footnote Ventricular fibrillation is critical and often leads to sudden death.
131
What type of arrhythmia is more common following inferior myocardial infarctions?
Atrioventricular block ## Footnote Atrioventricular block can complicate recovery from inferior MIs.
132
What complication occurs in approximately 10% of patients within the first 48 hours following a transmural myocardial infarction?
Pericarditis ## Footnote Pericarditis presents with typical symptoms like pain worse when lying flat.
133
What syndrome may occur 2-6 weeks after a myocardial infarction and is characterized by fever and pleuritic pain?
Dressler's syndrome ## Footnote Dressler's syndrome is believed to be an autoimmune reaction following MI.
134
What is a potential late complication of myocardial infarction characterized by aneurysm formation?
Left ventricular aneurysm ## Footnote Aneurysms can lead to thrombus formation and increased stroke risk.
135
What urgent treatments are required for left ventricular free wall rupture following a myocardial infarction?
* Pericardiocentesis * Thoracotomy ## Footnote These interventions are necessary to manage cardiac tamponade resulting from rupture.
136
What complication involves rupture of the interventricular septum and usually occurs in the first week after a myocardial infarction?
Ventricular septal defect ## Footnote This condition requires urgent surgical correction and presents with acute heart failure.
137
What is a common cause of acute mitral regurgitation following an infero-posterior myocardial infarction?
Ischaemia or rupture of the papillary muscle ## Footnote This complication can lead to acute hypotension and pulmonary edema.
138
Patients with acute mitral regurgitation may experience which physical examination finding?
Early-to-mid systolic murmur ## Footnote This murmur is a key sign of acute mitral regurgitation.
139
Fill in the blank: Patients with acute mitral regurgitation are typically treated with _______.
Vasodilator therapy ## Footnote Emergency surgical repair may also be required for severe cases.
140
What is the focus of NICE guidelines produced in 2013?
Management of patients following a myocardial infarction (MI) ## Footnote Guidelines emphasize secondary prevention strategies.
141
What drugs should all patients be offered after a myocardial infarction?
* Dual antiplatelet therapy (aspirin plus a second antiplatelet agent) * ACE inhibitor * Beta-blocker * Statin ## Footnote These medications are essential for secondary prevention.
142
What dietary changes are recommended for patients following a myocardial infarction?
Advise a Mediterranean style diet and switch butter and cheese for plant oil based products ## Footnote Omega-3 supplements or eating oily fish are not recommended.
143
How much exercise should patients engage in after a myocardial infarction?
20-30 minutes a day until patients are 'slightly breathless' ## Footnote Regular exercise is crucial for recovery.
144
When may sexual activity resume after an uncomplicated myocardial infarction?
4 weeks after an uncomplicated MI ## Footnote Patients should be reassured that sex does not increase the likelihood of a further MI.
145
What are PDE5 inhibitors, and when can they be used after a myocardial infarction?
PDE5 inhibitors (e.g., sildenafil) may be used 6 months after a MI ## Footnote They should be avoided in patients prescribed nitrates or nicorandil.
146
What was previously the second antiplatelet of choice before ticagrelor and prasugrel?
Clopidogrel ## Footnote Clopidogrel has been largely replaced by newer agents.
147
What does NICE recommend for post-acute coronary syndrome management?
Add ticagrelor to aspirin, stop ticagrelor after 12 months ## Footnote This is for patients who are medically managed.
148
What should be done for patients post-percutaneous coronary intervention?
Add prasugrel or ticagrelor to aspirin, stop the second antiplatelet after 12 months ## Footnote Adjustments may be made for high-risk patients.
149
What is the treatment recommendation for patients with acute MI and heart failure signs?
Initiate treatment with an aldosterone antagonist (e.g., eplerenone) within 3-14 days of the MI ## Footnote This should preferably occur after ACE inhibitor therapy.
150
True or False: Dual antiplatelet therapy is now standard for most patients who've had an acute coronary syndrome.
True ## Footnote DAPT is a critical component of post-MI management.
151
Fill in the blank: Patients should be reassured that _______ does not increase their likelihood of a further MI.
sexual activity ## Footnote This reassurance is important for patient confidence.
152
What does the jugular venous pulse (JVP) provide information about?
Right atrial pressure and underlying valvular disease
153
What is a non-pulsatile JVP indicative of?
Superior vena caval obstruction
154
What does Kussmaul's sign describe?
A paradoxical rise in JVP during inspiration seen in constrictive pericarditis
155
What does the 'a' wave represent in the JVP waveform?
Atrial contraction
156
When is the 'a' wave large?
If atrial pressure is high, e.g., tricuspid stenosis, pulmonary stenosis, pulmonary hypertension
157
When is the 'a' wave absent?
In atrial fibrillation
158
What are cannon 'a' waves caused by?
Atrial contractions against a closed tricuspid valve
159
In which conditions are cannon 'a' waves seen?
* Complete heart block * Ventricular tachycardia/ectopics * Nodal rhythm * Single chamber ventricular pacing
160
What does the 'c' wave represent in the JVP waveform?
Closure of the tricuspid valve
161
Is the 'c' wave normally visible?
No
162
What does the 'v' wave represent in the JVP waveform?
Passive filling of blood into the atrium against a closed tricuspid valve
163
What condition is associated with giant 'v' waves?
Tricuspid regurgitation
164
What does the 'x' descent represent?
Fall in atrial pressure during ventricular systole
165
What does the 'y' descent represent?
Opening of the tricuspid valve
166
What is the criterion for diagnosing left ventricular hypertrophy?
Sum of S wave in V1 and R wave in V5 or V6 exceeds 40 mm ## Footnote This measurement indicates increased muscle mass of the left ventricle.
167
What indicates right ventricular hypertrophy on an ECG?
Criteria not specified in the provided text ## Footnote The specific criteria for right ventricular hypertrophy were not included in the content.
168
How is left atrial enlargement identified on an ECG?
Bifid P wave in lead II with a duration > 120 ms and negative terminal portion in V1 ## Footnote The bifid appearance suggests delayed conduction in the left atrium.
169
What are the characteristics of right atrial enlargement on an ECG?
Tall P waves in both II and V1 which exceed 0.25 mV ## Footnote This indicates increased right atrial pressure or volume.
170
What is left axis deviation (LAD)?
A condition in ECG where the electrical axis of the heart shifts to the left.
171
Name one cause of left axis deviation (LAD).
left anterior hemiblock
172
What is a significant cause of left axis deviation related to heart block?
left bundle branch block
173
What type of myocardial infarction can cause left axis deviation?
inferior myocardial infarction
174
Which syndrome, associated with an accessory pathway, can cause left axis deviation?
Wolff-Parkinson-White syndrome - right-sided accessory pathway
175
What electrolyte imbalance can lead to left axis deviation?
hyperkalaemia
176
Name a congenital condition that can cause left axis deviation.
ostium primum ASD
177
What is another congenital condition associated with left axis deviation?
tricuspid atresia
178
In which demographic might minor left axis deviation be observed?
obese people
179
What is right axis deviation (RAD)?
A condition in ECG where the electrical axis of the heart shifts to the right.
180
Name one cause of right axis deviation (RAD).
right ventricular hypertrophy
181
What heart block condition can lead to right axis deviation?
left posterior hemiblock
182
What type of myocardial infarction can cause right axis deviation?
lateral myocardial infarction
183
What chronic condition can lead to right axis deviation?
chronic lung disease → cor pulmonale
184
What acute condition can cause right axis deviation?
pulmonary embolism
185
Which congenital defect can lead to right axis deviation?
ostium secundum ASD
186
What syndrome related to an accessory pathway can cause right axis deviation?
Wolff-Parkinson-White syndrome - left-sided accessory pathway
187
Is right axis deviation normal in infants under 1 year old? True or False?
True
188
In which demographic might minor right axis deviation be observed?
tall people
189
What ECG changes are associated with the Left anterior descending artery?
Anteroseptal: V1-V4 ## Footnote The Left anterior descending artery supplies the anterior wall of the heart.
190
Which ECG leads indicate an inferior myocardial infarction?
II, III, aVF ## Footnote The Right coronary artery is typically responsible for inferior wall infarctions.
191
What are the ECG changes for anterolateral myocardial infarction?
V1-6, I, aVL ## Footnote The proximal left anterior descending artery is involved in anterolateral infarctions.
192
Which leads are associated with lateral myocardial infarction?
I, aVL +/- V5-6 ## Footnote The Left circumflex artery supplies the lateral wall of the heart.
193
What indicates posterior myocardial infarction on an ECG?
Changes in V1-3 ## Footnote Posterior infarction can be further confirmed by ST elevation and Q waves in posterior leads V7-9.
194
What are typical reciprocal changes of STEMI?
* Horizontal ST depression * Tall, broad R waves * Upright T waves * Dominant R wave in V2 ## Footnote These changes often indicate the presence of a STEMI in adjacent leads.
195
True or False: ST elevation and Q waves in leads V7-9 confirm posterior infarction.
True ## Footnote These findings are critical for diagnosing posterior myocardial infarction.
196
What is a common ECG feature associated with digoxin?
Down-sloping ST depression ('reverse tick', 'scooped out') ## Footnote This feature is indicative of digoxin effect on the heart's electrical activity.
197
What type of T wave changes are observed in digoxin effect?
Flattened/inverted T waves ## Footnote These changes can signify alterations in myocardial repolarization due to digoxin.
198
What is a characteristic QT interval change noted with digoxin?
Short QT interval ## Footnote A shortened QT interval can be a sign of digoxin toxicity.
199
Which arrhythmias can be caused by digoxin?
AV block, bradycardia ## Footnote These arrhythmias are potential side effects of digoxin, affecting heart rhythm.
200
What are the ECG features of hypokalaemia?
U waves, small or absent T waves, prolonged PR interval, ST depression, long QT ## Footnote Each of these features indicates disturbances in cardiac repolarization associated with low potassium levels.
201
What is a characteristic feature of hypokalaemia on an ECG?
U waves ## Footnote U waves are additional waves that appear after the T wave and can indicate hypokalaemia.
202
What may occur to T waves in hypokalaemia?
Small or absent T waves, occasionally inversion ## Footnote T wave abnormalities can reflect altered myocardial repolarization due to electrolyte imbalances.
203
What is the effect of hypokalaemia on the PR interval?
Prolonged PR interval ## Footnote A prolonged PR interval can indicate delayed conduction through the atrioventricular node.
204
What type of ST segment change is associated with hypokalaemia?
ST depression ## Footnote ST segment changes can signal ischemic changes or electrolyte disturbances.
205
What is a common QT interval finding in hypokalaemia?
Long QT ## Footnote A prolonged QT interval increases the risk of arrhythmias.
206
What ECG change is characterized by a slow heart rate in hypothermia?
bradycardia ## Footnote Bradycardia is defined as a heart rate of less than 60 beats per minute.
207
What is the 'J' wave also known as?
'J' wave (Osborne waves) ## Footnote The 'J' wave appears as a small hump at the end of the QRS complex on an ECG.
208
What type of heart block may occur in cases of hypothermia?
first degree heart block ## Footnote First degree heart block is characterized by a prolonged PR interval.
209
What ECG interval may be prolonged due to hypothermia?
long QT interval ## Footnote A long QT interval can increase the risk of arrhythmias.
210
What types of arrhythmias can occur in hypothermia?
atrial and ventricular arrhythmias ## Footnote Arrhythmias can significantly affect cardiac output and overall heart function.
211
What does LBBB stand for?
Left Bundle Branch Block ## Footnote LBBB refers to a specific type of heart block affecting the electrical conduction system.
212
What mnemonic helps differentiate between LBBB and RBBB?
WiLLiaM MaRRoW ## Footnote This mnemonic highlights the characteristic patterns seen in the ECG for both blocks.
213
In which leads does LBBB show a 'W' and an 'M'?
A 'W' in V1 and an 'M' in V6 ## Footnote This pattern is crucial for identifying LBBB on an ECG.
214
In which leads does RBBB show a 'M' and a 'W'?
An 'M' in V1 and a 'W' in V6 ## Footnote This pattern is critical for identifying RBBB on an ECG.
215
Is new LBBB always pathological?
Yes ## Footnote New LBBB indicates an underlying health issue that requires further investigation.
216
List some common causes of LBBB.
* Myocardial infarction * Hypertension * Aortic stenosis * Cardiomyopathy * Rare: idiopathic fibrosis, digoxin toxicity, hyperkalaemia ## Footnote Each of these conditions can lead to the development of LBBB.
217
What is a challenge in diagnosing myocardial infarction in patients with existing LBBB?
It is difficult ## Footnote The presence of LBBB can obscure the classic signs of a myocardial infarction on an ECG.
218
What criteria can help diagnose myocardial infarction in the presence of LBBB?
Sgarbossa criteria ## Footnote These criteria provide specific ECG findings that can indicate a myocardial infarction despite the presence of LBBB.
219
What does LBBB stand for?
Left Bundle Branch Block ## Footnote LBBB refers to a specific type of heart block affecting the electrical conduction system.
220
What mnemonic helps differentiate between LBBB and RBBB?
WiLLiaM MaRRoW ## Footnote This mnemonic highlights the characteristic patterns seen in the ECG for both blocks.
221
In which leads does LBBB show a 'W' and an 'M'?
A 'W' in V1 and an 'M' in V6 ## Footnote This pattern is crucial for identifying LBBB on an ECG.
222
In which leads does RBBB show a 'M' and a 'W'?
An 'M' in V1 and a 'W' in V6 ## Footnote This pattern is critical for identifying RBBB on an ECG.
223
Is new LBBB always pathological?
Yes ## Footnote New LBBB indicates an underlying health issue that requires further investigation.
224
List some common causes of LBBB.
* Myocardial infarction * Hypertension * Aortic stenosis * Cardiomyopathy * Rare: idiopathic fibrosis, digoxin toxicity, hyperkalaemia ## Footnote Each of these conditions can lead to the development of LBBB.
225
What is a challenge in diagnosing myocardial infarction in patients with existing LBBB?
It is difficult ## Footnote The presence of LBBB can obscure the classic signs of a myocardial infarction on an ECG.
226
What criteria can help diagnose myocardial infarction in the presence of LBBB?
Sgarbossa criteria ## Footnote These criteria provide specific ECG findings that can indicate a myocardial infarction despite the presence of LBBB.
227
What is one of the main uses of the ECG?
To determine whether a patient is having a cardiac event in the context of chest pain ## Footnote The ECG can show a variety of changes depending on the type, location, and timing of the ischaemic event.
228
What are hyperacute T waves in the context of myocardial infarction?
Often the first sign of MI but only persists for a few minutes ## Footnote Hyperacute T waves are an early indicator of an acute myocardial infarction.
229
What ECG change typically develops after hyperacute T waves?
ST elevation may then develop ## Footnote This change indicates a progression of the myocardial infarction.
230
What happens to T waves within the first 24 hours after an MI?
T waves typically become inverted ## Footnote The inversion can last for days to months.
231
When do pathological Q waves develop after an MI?
After several hours to days ## Footnote This change usually persists indefinitely.
232
What are the clinical symptoms consistent with STEMI?
Symptoms of acute coronary syndrome (ACS) generally of ≥ 20 minutes duration ## Footnote STEMI is characterized by persistent ECG features.
233
What is the ST elevation criteria for men under 40 years in leads V2-3 for STEMI?
≥ 2.5 mm (i.e ≥ 2.5 small squares) ## Footnote This is a specific measurement for diagnosing STEMI in younger men.
234
What is the ST elevation criteria for men over 40 years in leads V2-3 for STEMI?
≥ 2.0 mm (i.e ≥ 2 small squares) ## Footnote This indicates a higher threshold for older men.
235
What is the ST elevation criteria for women in leads V2-3 for STEMI?
1.5 mm ## Footnote This reflects gender differences in ECG criteria for STEMI.
236
What is the ST elevation criteria for other leads in STEMI?
1 mm ## Footnote This applies to leads outside of V2-3.
237
How should new LBBB be interpreted in the context of STEMI?
Considered new unless there is evidence otherwise ## Footnote New left bundle branch block (LBBB) can be a significant finding in acute myocardial infarction.
238
What does a posterior MI cause on a 12-lead ECG?
ST depression, not elevation ## Footnote This is an important distinction in diagnosing myocardial infarction.
239
What is a common ECG change considered a normal variant in an athlete?
Sinus bradycardia ## Footnote Sinus bradycardia is a slower than normal heart rate often seen in athletes due to increased vagal tone.
240
What ECG change refers to a rhythm originating from the junction of the atria and ventricles?
Junctional rhythm ## Footnote Junctional rhythm can occur in athletes and indicates a different pacemaker site in the heart.
241
Which ECG change involves a prolonged PR interval without dropped beats?
First degree heart block ## Footnote First degree heart block is common in athletes and generally considered benign.
242
What is the name of the phenomenon characterized by progressively lengthening PR intervals followed by a dropped beat?
Mobitz type 1 (Wenckebach phenomenon) ## Footnote This phenomenon can be seen in athletes and is often not clinically significant.
243
What is indicated by increased P wave amplitude?
cor pulmonale ## Footnote Cor pulmonale refers to right heart failure due to lung disease.
244
What do broad, notched (bifid) P waves signify?
left atrial enlargement, classically due to mitral stenosis ## Footnote These waves are often most pronounced in lead II.
245
What is the characteristic of P waves in atrial fibrillation?
absence of P waves
246
What is the PR interval in ECG?
The PR interval is the time between the onset of atrial depolarization and the onset of ventricular depolarization. ## Footnote It is measured from the beginning of the P wave to the beginning of the QRS complex.
247
List the causes of a prolonged PR interval.
* Idiopathic * Ischaemic heart disease * Digoxin toxicity * Hypokalaemia * Rheumatic fever * Aortic root pathology (e.g. abscess secondary to endocarditis) * Lyme disease * Sarcoidosis * Myotonic dystrophy ## Footnote A prolonged PR interval indicates delayed conduction through the AV node.
248
In which population might a prolonged PR interval also be seen?
Athletes ## Footnote Athletes may exhibit a prolonged PR interval due to increased vagal tone.
249
What condition is associated with a short PR interval?
Wolff-Parkinson-White syndrome ## Footnote This syndrome is characterized by an accessory conduction pathway that can lead to tachycardia.
250
True or False: Hyperkalaemia is a common cause of a prolonged PR interval.
False ## Footnote Hyperkalaemia can rarely cause a prolonged PR interval, but hypokalaemia is a much more common association.
251
What is right bundle branch block commonly seen on?
ECGs ## Footnote Right bundle branch block is a common feature observed in electrocardiograms.
252
How can you remember the difference between LBBB and RBBB?
WiLLiaM MaRRoW ## Footnote This mnemonic helps differentiate the patterns seen in left bundle branch block and right bundle branch block.
253
What is seen in V1 and V6 for LBBB?
'W' in V1 and 'M' in V6 ## Footnote These letters represent the characteristic shapes of the ECG waveforms in left bundle branch block.
254
What is seen in V1 and V6 for RBBB?
'M' in V1 and 'W' in V6 ## Footnote These letters represent the characteristic shapes of the ECG waveforms in right bundle branch block.
255
What are common causes of RBBB?
* Normal variant * Right ventricular hypertrophy * Chronically increased right ventricular pressure * Pulmonary embolism * Myocardial infarction * Atrial septal defect (ostium secundum) * Cardiomyopathy or myocarditis ## Footnote These conditions can lead to the development of right bundle branch block in patients.
256
True or False: RBBB is more common with increasing age.
True ## Footnote Right bundle branch block can be a normal variant that occurs more frequently as individuals age.
257
What are the causes of ST depression?
* secondary to abnormal QRS (LVH, LBBB, RBBB) * ischaemia * digoxin * hypokalaemia * syndrome X ## Footnote ST depression can indicate underlying cardiac issues and requires further evaluation.
258
What are the causes of ST elevation?
* myocardial infarction * pericarditis/myocarditis * normal variant - 'high take-off' * left ventricular aneurysm * Prinzmetal's angina (coronary artery spasm) * Takotsubo cardiomyopathy * rare: subarachnoid haemorrhage ## Footnote ST elevation is often associated with acute coronary syndromes and other cardiac conditions.
259
What does peaked T waves indicate?
hyperkalaemia and myocardial ischaemia ## Footnote Peaked T waves are often seen in cases of elevated potassium levels or myocardial ischemia.
260
What conditions can cause inverted T waves?
* myocardial ischaemia * digoxin toxicity * subarachnoid haemorrhage * arrhythmogenic right ventricular cardiomyopathy * pulmonary embolism ('S1Q3T3') * Brugada syndrome ## Footnote Inverted T waves can suggest various cardiac and neurological conditions and may require further diagnostic workup.
261
Fill in the blank: ST depression can be secondary to _______.
abnormal QRS (LVH, LBBB, RBBB) ## Footnote Abnormal QRS complexes can lead to misinterpretation of ST segment changes.
262
True or False: ST elevation is only caused by myocardial infarction.
False ## Footnote ST elevation can be caused by multiple conditions, not just myocardial infarction.
263
What is a normal variant of ST elevation?
'high take-off' ## Footnote 'High take-off' refers to a benign variant that can mimic pathological ST elevation.
264
What is a rare cause of ST elevation?
subarachnoid haemorrhage ## Footnote While not common, ST elevation can indicate serious conditions like subarachnoid haemorrhage.
265
What causes the first heart sound (S1)?
Closure of the mitral and tricuspid valves ## Footnote S1 can be soft if there is a long PR interval or mitral regurgitation, and loud in mitral stenosis.
266
What is the cause of the second heart sound (S2)?
Closure of the aortic and pulmonary valves ## Footnote S2 is soft in aortic stenosis and may have splitting during inspiration, which is considered normal.
267
What is the third heart sound (S3) caused by?
Diastolic filling of the ventricle ## Footnote S3 is considered normal if the patient is less than 30 years old and may persist in women up to 50 years old. It is heard in left ventricular failure, constrictive pericarditis (known as a pericardial knock), and mitral regurgitation.
268
What is the fourth heart sound (S4) associated with?
Atrial contraction against a stiff ventricle ## Footnote S4 may be heard in aortic stenosis, hypertrophic obstructive cardiomyopathy (HOCM), and hypertension. It coincides with the P wave on ECG and may be felt as a double apical impulse in HOCM.
269
Where is the pulmonary valve auscultated?
Left second intercostal space, at the upper sternal border ## Footnote This location is critical for identifying heart sounds effectively.
270
Where is the aortic valve auscultated?
Right second intercostal space, at the upper sternal border ## Footnote Correct identification of this site is important for auscultation.
271
Where is the mitral valve auscultated?
Left fifth intercostal space, just medial to mid clavicular line ## Footnote This site is essential for assessing mitral valve function.
272
Where is the tricuspid valve auscultated?
Left fourth intercostal space, at the lower left sternal border ## Footnote Accurate auscultation at this location can help in diagnosing tricuspid valve issues.
273
True or False: S2 heart sound may split during inspiration.
True ## Footnote Splitting of S2 during inspiration is a normal physiological finding.
274
Fill in the blank: S3 is considered normal if the patient is _______.
< 30 years old ## Footnote S3 may persist in women up to 50 years old.
275
What may cause a loud S1 heart sound?
Mitral stenosis ## Footnote A loud S1 can be indicative of certain heart conditions.
276
What condition is associated with a pericardial knock?
Constrictive pericarditis ## Footnote This phenomenon is important in the evaluation of heart sounds.
277
What is the QTC range for men?
Less than 450 milliseconds (ms) ## Footnote QTC refers to the corrected QT interval, an important measure in cardiology.
278
What is the QTC range for women?
Less than 460 milliseconds (ms) ## Footnote The QTC range varies between genders, indicating different thresholds for normalcy.
279
What are the features of complete heart block?
* syncope * heart failure * regular bradycardia (30-50 bpm) * wide pulse pressure * JVP: cannon waves in neck * variable intensity of S1 ## Footnote These features indicate severe impairment in heart conduction.
280
What is the PR interval duration in first degree heart block?
PR interval > 0.2 seconds ## Footnote This indicates a delay in the conduction through the AV node.
281
What characterizes second degree heart block type 1 (Mobitz I, Wenckebach)?
Progressive prolongation of the PR interval until a dropped beat occurs ## Footnote This type is often associated with a benign prognosis.
282
What characterizes second degree heart block type 2 (Mobitz II)?
PR interval is constant but the P wave is often not followed by a QRS complex ## Footnote This type carries a higher risk of progression to complete heart block.
283
What is the defining feature of third degree (complete) heart block?
There is no association between the P waves and QRS complexes ## Footnote This indicates a total failure of conduction between atria and ventricles.

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