What is a side effect of ACEi and when are they contraindicated?
Dry cough
Contraindicated in Renal artery stenosis
What is an irregularly irregular pulse associated with?
AF
Dry cough and hyperkalaemia are associated with which drug?
ACEi
On an ECG what is associated with tall tented T waves and wide QRS complex?
VT
What is associated with a saw tooth ECG?
Atrial flutter
What causes rib-notching on a CXR?
Coarctation of the aorta
What can be associated with a radial-radial delay?
Aortic dissection/coarctation of aorta
What is a collapsing pulse caused by?
Aortic regurgitation
What causes a slow rising pulse?
Aortic stenosis
Splinter haemorrhages are a sign of what?
Infective endocarditis
What is associated with descend-decrescendo murmur?
Aortic stenosis
What are the two organisms causing infective endocarditis?
Staph. Aureus (main cause)
Step. Viridans (a haemolytic)
What causes a staph aureus infection in infective endocarditis?
Prosthetic valves or IV drug users
What causes a strep viridans infection in infective endocarditis?
Present in the mouth after dental surgery
What are the steps in the treatments of acute AF?
Treat underlying cause (MI, Pneumonia, PE, HF etc.)
Control ventricular rate
What is the 1st line treatment in controlling ventricular rate in AF?
Beta blocker or Ca2+ blocker (using both is contraindicated)
What is the 2nd line treatment in acute AF?
Same as 1st line but add Digoxin or Amiodarone
What other treatment is given alongside 1st and 2nd line in acute AF?
Anticoagulate with Heparin
Consider cardioversion if acutely ill
How is Chronic AF treated differently from acute AF?
Anticoagulate with Warfarin (long term therapy compared to verapamil)
Ventricular rate controlled the same
What is paroxysmal AF?
Short spells of AF that come and go
How is paroxysmal AF treated?
1st line - Beta-blocker (verapamil in young patients)
2nd Line - Amiodarone
3rd Line - Digoxin
What is a complication of AF?
STROKE
How is the risk of stroke assessed?
CHA2DS2 score
High risk give Warfarin!
What type of drug is Warfarin?
Vitamin K antagonist
Anticoagulant
What factors does Warfarin render inactive?
II, VII, IX, X
What process does factors II, XII, IX and X undergo to become active and what enzyme is involved?
Gamma carboxylation
Gamma Carboxylase
What does Heparin bind to and how does it prevent coagulation?
Anti-thrombin III
Increases its affinity for clotting factors to increase their rate of inactivation
What does LMWH inhibit?
Xa
What is ductus arteriosus?
Connection between pulmonary artery and descending aorta in foetal development to bypass the lungs
What is indicative of a continuous machine like murmur?
Patent Ductus arteriosus
Connection between aorta and pulmonary artery that remains open
What is associated with strawberry milkshake coloured blood?
Hyperlipidaemia
At what dermatome level does Herpes zoster virus occur?
T4/T5
What is the rate limiting enzyme in cholesterol synthesis?
HMG-CoA reductase
What is the drug target for cholesterol lowering drugs?
HMG-CoA reductase
What are statins competitive inhibitors of?
HMG-CoA reductase
What are side effects of statins?
Rhabdomyolysis
Myositis
What is associated with central abdominal pain and an expansile pulsatile mass?
AAA
What investigations are done for AAA?
1st line USS
CT more accurate - shows anatomical relationship to renal and visceral vessels
What medical management is taken for AAA?
Careful control of Hypertension
Stop smoking
Lipid lowering medication
AAA>5.5cm follow up regular USS
How can AAA be surgically repaired?
Dacron or Gore-Tex graft
What non-surgical approach can be taken to repair AAA?
Endovascular stent (via femoral or iliac arteries)
What alternative approach can be taken for AAA repair?
Laparoscopic
How is mean arterial blood pressure calculated?
Systolic + (2 x Diastolic) / 3
What drug classes are used in anti-hypertensive treatment?
Diuretics Beta-blockers Calcium channel antagonists Vasodilators ARB
Give examples of diuretics used in anti-hypertensive treatment
Thiazide diuretics - mild - Bendrofluazide
Loop diuretics - Stronger - Furosemide
What is the mechanism of Diuretics?
Promote Na+ and water secretion from the kidneys by inhibiting reabsorption in the loop of henle or distal tubule
List some side effects of diuretics
Hypokalaemia Arrhythmias Hyperglycaemia Increased uric acid - Gout Impotence
Give examples of beta-blockers used in anti-hypertensive treatment
Cardioselective - Atenolol
Non-selective Propanolol
Give examples of calcium channel antagonists used in anti-hypertensive treatment
Dihydropyridines - Amlodipine
Rate limiting - Verapamil, diltiazem
List some side effects of Calcium channel antagonists
Ankle oedema
Hypotension
Dizziness
Amlodipine better as less unwanted effects on cardiac muscle
Give examples of vasodilator drugs used in anti-hypertensive treatment
Alpha blockers - Prazosin
ACEi - Lisinopril
Give an example of an ARB used in anti-hypertensive treatment
Losartan
How many classes of anti-arrhythmic drugs?
4
What is the mechanism of ALL class I anti-arrhythmic drugs?
Block voltage-gated Na+ channels with preference to the most active ones (tachyarrhythmic areas)
Give an example of a Class Ia drug and its mechanism
Disopyramide
Moderate rate of dissociation, slow rise of AP, prolonged refractory period
Give an example of a class Ib drug and its mechanism
Lignocaine
Fast rate of dissociation, prevents premature beats
Give an example of a Class Ic drug and its mechanism
Flecainide
Slow rate of dissociation, depress conduction
Give an example of a class II drug and its mechanism
Metaprolol
Beta adrenoceptor as antagonists, decrease rate of depolarization in SA and AV nodes
Give an example of a Class III drug and its mechanism
Amiodarone Target voltage-activated K+ channels, prolong AP duration, increase refractory period
Give an example of a class IV drug and its mechanism
Verapamil
Target voltage-activated Ca+ channels, decrease force of contraction
What do ALL patients with acute heart failure require?
Prophylactic anticoagulation with Heparin
What is the investigation for heart failure?
B-type natriuretic peptides
What is the 1st line drug management for heart failure?
ACEi and Beta-blocker
What is the 2nd line drug treatment for heart failure?
Aldosterone antagonist
Angiotensin II receptor blocker or Hydralazine (vasodilator) in combination with a nitrate
If symptoms of heart failure persist what treatment should be considered?
Cardiac resynchronization therapy or digoxin
What drug treatment should be given for fluid overload in heart failure?
Diuretics
When does acute HF normally occur?
Secondary to abnormal cardiac function
How is acute HF diagnosed?
12 ECG
CXR
Bloods
Transthoracic echo to confirm diagnosis and possibly identify the cause
What is the initial therapy for acute heart failure?
Oxygen
Diuretics (Furosemide)
Vasodilator therapy (GTN infusion)
What support can be added if an additional response is needed in acute heat failure?
Inotropic support (dobutamine, phosphodiesterase inhibitors)
What is given if the BP is low in HF?
Noradrenaline
What is the drug treatment for clinical endocarditis, awaiting culture results with no suspicion of staph?
Penicillin + Gentamicin
What endocarditis is associated with IV drug users, recent intravascular devices or cardiac surgery)?
Staphylococcal endocarditis
How is a suspected staphylococcal endocarditis (IV drug user, recent intravascular devices or cardiac surgery) treated?
Vancomycin + Gentamicin
How is Streptococcal endocarditis treated?
Penicillin + Gentamicin
How is Enterococcal endocarditis treated?
Ampicillin/Amoxicillin + Gentamicin
How is Staphylococcal endocarditis treated?
Vancomycin OR Flucloxacillin OR Benzylpenicillin + Gentamicin
What effect does the parasympathetic nervous system have on the heart?
Negative chronotropic effect via the vagus nerve - Decreases heart rate (main innervation at rest too keep HR low)
What is the receptor and target for the parasympathetic nervous system?
Acetylcholine Muscarinic M2 receptors in the SA node
What effect does the parasympathetic nervous system have on the heart?
Negative inotropic
Reduces slope of pacemaker potential
What is the target an receptor for the sympathetic nervous system?
Noradrenaline
B1 receptors
What effect does the sympathetic nervous system have on the heart?
Increase the slope of the pacemaker potential
Increase rate of conduction through AV node
increase rate of myocardial relaxation
What supplies the SA node?
Right Coronary Artery
What causes the first heart sound and when does it occur?
Mitral + Tricuspid valve closure Phase 3 (isometric ventricular contraction)
What causes the second heart sound and when does it occur?
Aortic + Pulmonary valve closure Phase 4 (ventricular ejection)
What are the side effects of spironolactone?
Gynaecomastia and hyperkalaemia
What is contained in the tetralogy of fallot?
Ventricular septal defect
Overriding aorta
Pulmonary stenosis
Right ventricular hypertrophy
What is contained in the anterior branches of the thoracic aorta?
Bronchial Oesophageal Mediastinal Pericardial & Phrenic Arteries
What is a counter regulatory mechanism to the RAAS system?
ANP
When is ANP released?
In response to atrial distension/hypervolemia
What does ANP do?
Acts as a vasodilator and decreases renin release
Where is the carotid sinus found?
Proximal part of internal carotid artery
What is the carotid sinus innervated by?
Glossopharyngeal nerve
What is the role of the carotid sinus?
Detects stretching of the walls for BP changes
Monitors blood gas and pH
What is the 3rd heart sound and when can it be heard?
Passive filling of ventricle (phase 1)
Early diastole
Physiological or HF in elderly
What is the 4th heart sound and when can it be heard?
Late diastole
Active filling of stiff ventricle by atrial contraction
Pathological (usually LV hypertrophy)
What causes normal splitting of the 2nd heart sound?
Inspiration (closing of the aortic and pulmonary valves)
Give examples of orally given anticoagulants
Warfarin
Dabigatran
Rivaroxaban
What type of tachycardia is broad complex?
Ventricular
What type of tachycardia is Narrow complex?
Atrial
How is sinus tachycardia treated?
Rate control with Beta-blocker
How is stable VT treated?
Amiodarone
How is unstable VT with a pulse treated?
Cardioversion
Anti-arrhythmic medication - Amiodarone
How is acute VT treated?
Adenosine OR Calcium antagonist OR Beta-blocker
How is Torsades de pointes treated?
magnesium sulphate
isoprenaline
Temporary or permanent pacing
How is catecholaminergic polymorphic VT treated?
Beta-blocker then implantable defib
What rhythms are shockable?
VF and pulseless VT
What is atropine an antagonist of and when is it used?
Competitive antagonist of muscarinic ACh receptors (M1, M2, M3) blocks parasympathetic
Reverses bradycardia following MI
Where is the azygous vein found?
Right side of the thoracic vertebra
What causes a slate grey rash side effect?
Amiodarone
Antiemetic given for gastroparesis and following an MI?
Metoclopramide
What is used for immediate symptomatic relief of stable angina?
GTN Spray
What dug is used in long term therapy for stable angina?
Isosorbide mononitrate
What other drugs can be used in the treatment of stable angina?
Ivabradine
Nicorandil
Ranolazine
Statin, aspirin, ACEi
What is the treatment of an MI (STEMI)?
MONA+C Diamorphine + Anti-emetic (Metoclopramide) Oxygen Nitrates Aspirin Clopidogrel Immediate PCI
When should thrombolysis (streptokinase) be administered?
If PCI is not possible within 120 mins
What drug therapy is given after acute care has been administered in an MI?
BADS Beta-blocker (12 months) ACEi (life long) Dual anti-platelet therapy (Aspirin (lifelong) and clopidogrel (4 weeks post MI) Statin (life long)
What life style factors should be changed post MI?
Stop smoking
Healthier diet - less salt, reduce cholesterol
Exercise 20-30 mins a day
What is the treatment for an NSTEMI or unstable angina?
MONA+C
LMWH
PCI/CABG if necessary
