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Cardio Flashcards

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1
Q

What occurs to blood pressure during exercise?

A

Systolic increases, diastolic decreases - leads to increased pulse pressure

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2
Q

Why does cardiac output increase during exercise?

A

Venous constriction, increased venous return, increased myocardial contractibility

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3
Q

Why does systemic vascular resistance fall during exercise?

A

Vasodilation in skeletal muscles

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4
Q

What are the stages of Valsalva maneouvre?

A
  1. Increased intra-thoracic pressure
  2. Resultant increases in venous and right atrial pressures reduces venous return
  3. Reduced preload leads to a fall in cardiac output (Frank Starling mechanism)
  4. When the pressure is released there is a further slight fall in cardiac output due to increased aortic volume
  5. Return of normal cardiac output
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5
Q

In what conditions are S1 and S2 soft?

A

S1: soft in MS
S2: soft in AS

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6
Q

When is S3 normal

A

<30 years or women <50 years

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7
Q

What is a pathological cause of S3?

A

Left ventricular failure
MR
Constrictive pericarditis

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8
Q

What causes S4?

A

Atrial contraction against a stiff ventricle

AS, HOCM, Hypertension

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9
Q

What does the left coronary artery turn into?

A

LAD and circumflex

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10
Q

What does the right coronary artery turn into?

A

Posterior descending

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11
Q

Which artery supplies the SA node in 60% and AV node in 90%?

A

Right coronary

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12
Q

What is bicuspid aortic valve associated with?

A

Left dominant coronary circulation, where the posterior descending artery arises from the circumflex instead of the right coronary

+ Turner’s syndrome, coarctation of the aorta

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13
Q

Which cardiac abnormality is most common in Down’s syndrome?

A

AVSD

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14
Q

What murmur is heard in ASD?

A

Ejection systolic, louder on inspiration, fixed split S2

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15
Q

What is ASD associated with?

A

Ebstein’s anomaly, foetal alcohol syndrome

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16
Q

What is Ebstein’s anomaly?

A

Tricuspid leaflet dysplasia, apical displacement of the tricuspid annulus, abnormalities of RA and RV

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17
Q

What are the signs of tricuspid regurgitation?

A

Pansystolic murmur
Prominent V waves in JVP
Pulsatile hepatomegaly
Left parasternal heave

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18
Q

What is a risk factor for Ebstein’s anomaly?

A

Exposure to lithium in utero

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19
Q

What is Ebstein’s anomaly associated with?

A

PFO/ASD

WPW

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20
Q

What are the signs of Ebstein’s anomaly?

A 
Cyanosis
Prominent a wave in JVP
Hepatomegaly
TR
RBBB --> widely split S1 and S2
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21
Q

What type of coarctation of the aorta is more common in adults?

A

Postductal (distal to the ductus arteriosus) which occurs after the left subclavian artery branches from the aorta

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22
Q

What are the signs of coarctation of the aorta?

A

Infancy - heart failure
Adults - HTN

Radiofemoral delay
Midsystolic murmur, maximal over back
Apical click
Notching of inferior border of ribs

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23
Q

Which cardiac enzyme is the first to rise in cardiac damage?

A

Myoglobin

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24
Q

What is the first line investigation in stable cardiac chest pain?

A

CT coronary angiography

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25
What 3 other imaging modalities are 2nd line in investigating stable cardiac chest pain, looking for reversible myocardial ischaemia?
MPS with SPECT Stress echo MR perfusion
26
What is the 3rd line investigation in stable cardiac chest pain?
Invasive coronary angiography
27
What are the indications for exercise tolerance tests?
Assessing patients with suspected angina | Risk stratifying post MI/HOCM
28
When is exercise tolerance contraindicated?
``` MI<7 days Unstable angina Systolic BP>180bpm or <90bpm AS LBBB ```
29
What artery supplies the lateral aspect of the heart and which leads does this correspond to?
Circumflex V5, V6, I
30
What artery supplies the anterior of the heart and which leads does this correspond to?
LAD V1-V4
31
Which artery supplies the inferior aspect of the heart and which leads does this correspond to?
Right coronary II, III, aVF
32
What is the ECG criteria for STEMI?
ECG changes in 2 or more contiguous leads and persist for >20 minutes: V2-V3: Women: 1.5mm STE Men>40: 2mm STE Men<40: 2.5mm STE All other leads: 1mm STE New LBBB
33
What is the management of blood glucose in T2DM post MI?
IV insulin
34
What is the general management of STEMI?
300mg aspirin Oxygen if SpO2 <94% Morphine/nitrates PCI within 120 minutes OR fibrinolysis
35
What medications are given prior/during PCI?
Prasugrel Radial access: Unfractionated heparin + bailout GPIIb/IIIa inhibitor Femoral access: bivalirudin + bailout GPI
36
What medications are given prior/during fibrinolysis?
Antithrombin | Ticagrelor post procedure
37
What measures are taken if patient is high bleeding risk?
If having PCI: swap prasugrel to ticagrelor | If being thrombolysed: swap ticagrelor for clopidogrel
38
What type of stent is used in PCI?
Drug eluting to reduce the risk of restenosis
39
What type of access if preferred in PCI?
Radial
40
In the PCI pathway, if a patient is already taking anticoagulation, what changes are made to the drugs?
Aspirin 300mg as normal | Instead of prasugrel, give clopidogrel
41
What other procedure are performed during PCI?
Thrombus aspiration | Complete revascularisation
42
What is the general management of NSTEMI?
Aspirin 300mg Estimate 6 month mortality: Low risk - ticagrelor, fondaparinux High risk - PCI
43
Why are nitrates avoided in RV infarct?
Reduces preload
44
How is 6 month mortality estimated in NSTEMI?
GRACE Uses age, HR, BP, cardiac (Killip class), renal function, cardiac arrest of presentation, ECG findings, trop levels
45
What are 5 differentials for ST elevation?
``` Pericarditis/myocarditis Normal variant - high take off Left ventricular aneurysm Prinzmetal's angina Takotsubo cardiomyopathy ```
46
What is the general management of angina?
Aspirin Statin SL GTN spray PRN
47
What is the first line treatment of angina?
BB or CCB If CCB monotherapy - rate limiting e.g. verapamil/diltiazem Increase to max tolerated dose
48
What is the second line treatment of angina?
BB and CCB CCB must be dihydropyridine e.g. nifedipine, if combining with BB
49
What is the third line treatment of angina?
Long acting nitrate Ivabradine Nicorandil Ranolazine
50
What is the treatment of Prinzmetal's angina?
Dihydropyridine CCB
51
What is the most common cause of arrest in MI?
VF
52
What 2 types of pericarditis occur post MI?
Post 48h | Post 2-6w (Dressler's syndrome, autoimmune)
53
What are the signs of LV aneurysm?
Persistent STE and LV failure | No chest pain
54
How does LV free wall rupture present?
Acute heart failure secondary to cardiac tamponade
55
Which 2 post MI complications present with acute heart failure and pansystolic murmur?
Acute MR | VSD
56
Which type of infarction is acute MR more common with?
Infero-posterior infarction
57
What is the most common cause of secondary hypertension?
Primary hyperaldosteronism
58
Which drugs cause secondary hypertension?
``` Steroids MAOs COCP NSAIDs Leflunomide ```
59
Define PAH.
Resting mean pulmonary artery pressure >25mmHg
60
What are the features of pulmonary hypertension?
Progressive exertional dyspnoea | Exertional syncope, chest pain, peripheral oedema
61
What are the signs of pulmonary hypertension?
RV heave Loud P2 Raised JVP with prominent a waves TR
62
What is the management of PAH?
Acute vasodilator testing (administration of IV epoprostenol/inhaled NO) +ve (minority): PO CCB -ve (majority): prostacyclin analogues (iloprost), endothelin receptor antagonists (bosentan), PDE inhibitors (sildenafil)
63
What are the 8 reversible causes of cardiac arrest?
Hypoxia Hypovolaemia HyperK, hypoK, hypoBM, hypoCa Hypothermia Thrombosis Tension pneumo Tamponade Toxins
64
What is the first line treatment of heart failure?
ACEI and BB One drug started at a time
65
Which beta blockers are licensed for use in heart failure?
Bisoprolol Carvedilol Nebivolol
66
What is the 2nd line treatment of heart failure?
Aldosterone antagonist
67
What is the 3rd line treatment of heart failure?
``` Ivabradine Sacubitril-valsartan Digoxin Hydralazine + nitrate Cardiac resynchronisation therapy ```
68
What is the mechanism of sacubitril valsartan?
Prevents degradation of natriuretic peptides such as BNP and ANP
69
Why is digoxin used in heart failure if it has no affect on mortality?
May improve symptoms due to inotropic properties
70
What are the indications for CRT?
Wide QRS/LBBB | Ejection fraction<35%
71
What are 6 causes of increased BNP, except LV failure?
``` Tachycardia Hypoxaemia Sepsis COPD Diabetes Cirrhosis ```
72
What are 6 causes of decreased BNP?
Obesity Diuretics ACEI, BB, AA, ARB
73
What valvular abnormality is seen in William's syndrome?
Supravalvular aortic stenosis
74
What are the 2 causes of aortic stenosis?
<65: bicuspid valve | >65: calcification
75
What are the features of severe AS?
``` Narrow pulse pressure Slow rising pulse Delayed ESM Soft S2 S4 Thrill LV failure ```
76
When is aortic valve replacement indicate?
Symptomatic Valvular gradient >40 LVSD
77
What are the signs of mitral stenosis?
``` Mid-late diastolic murmur, loudest in expiration Loud S1, opening snap Low volume pulse Malar flush AF ```
78
What is the management of mitral stenosis?
Severe: percutaneous mitral commissurotomy --> mitral valve replacement If unsuitable for open surgery - transcatheter mitral valve replacement
79
What is the treatment of mitral regurgitation?
MV repair
80
What drugs are used in pharmacological cardioversion in AF?
``` Amiodarone Flecainide (if no structural heart disease) ```
81
To what is electrical cardioversion synchronised to in AF?
The R wave
82
What happens if shock is delivered during T wave during AF?
This is ventricular repolarisation | Can trigger T on T phenomenon which leads to VF
83
In non emergency situations, how long duration of anticoagulation is needed before electrical cardioversion for AF?
4 weeks
84
Why is conservative management recommended in complete heart block following inferior MI?
Ischaemic AV conduction block | Tends to resolve upon successful revascularisation of the infarcted AV nodal tissue
85
What is the management of 2nd degree/complete heart block following anterior MI?
Temporary pacing wire May also be a bridging measure to insert PPM
86
What are the indications for a temporary pacemaker?
Symptomatic/heamodynamically unstable bradycardia, not responding to atropine Post anterior MI Trifascicular block prior to surgery
87
In what condition is variable intensity of S1 seen?
Complete heart block
88
When are 3 successive shocks prior to CPR indicated?
Witnessed cardiac arrest whilst on monitor
89
What are the ECG changes of hypokalaemia?
``` U waves Small/inverted T waves Prolonged PR interval ST depression Long QT ```
90
What are the ECG changes of hypothermia?
Bradycardia J waves First deg heart block Long QT
91
What is the name of the condition where there is a congenital accessory conducting pathway between the atria and ventricles leading to AVRT?
Wolff-Parkinson White syndrome
92
In WPW, Why can AF degenerate rapidly to VF?
The accessory pathway does not slow conduction
93
What are the ECG features of WPW?
Short PR Wide QRS with slurred upstroke (delta wave) Type B: LAD, no dominant R wave in V1 Type A: RAD, dominant R wave in V1
94
What is type A and B WPW?
Type A: left sided accessory pathway Type B: right sided accessory pathway
95
What are 5 associations of WPW?
``` HOCM MV prolapse Ebstein's anomaly Thyrotoxicosis Secundum ASD ```
96
What is the treatment of WPW?
Amiodarone/flecainide Sotalol if not AF Radiofrequency ablation of accessory pathway
97
What is the atrial rate in atrial flutter?
300bpm
98
What is the treatment of atrial flutter?
Similar to AF Medications less effective, cardioversion more effective - lower energy levels Radiofrequency ablation of the tricuspid valve isthmus
99
What is the mechanism of action of nicorandil?
Potassium channel activator | Activates guanylyl cyclase with increases cGMP --> vasodilation
100
What are 3 side effects of nicorandil?
Headache, flushing, ulceration
101
How does atropine treat bradycardia?
Inhibits vagal tone by modulating the SA node
102
What is the mechanism of action of amiodarone?
Blocks K channels - inhibits repolarisation and prolongs the AP Also blocks Na channels
103
Name 6 side effects of amiodarone
``` Thyroid dysfunction Corneal deposits Pulm/liver fibrosis Slate grey appearance Prolonged QT Bradycardia ```
104
How do ADP receptor inhibitors, such as clopidogrel and ticagrelor work?
Inhibition of P2Y12 receptor which reduces platelet aggregation ADP is one of the main platelet activation factors
105
Why does ticagrelor cause dyspnoea?
Impaired clearance of adenosine
106
How does dipyridamole work?
Inhibits phosphodiesterase, which elevates platelet cAMP which reduces intracellular calcium
107
How does adenosine work?
Blocks AV node - agonist of A1 receptor in AV node which inhibits adenylyl cyclase --> reducing cAMP --> hyperpolarization by increased K efflux
108
What are the ECG signs of digoxin toxicity?
Downsloping ST depression Flattened/inverted T waves Short QT AV block/bradycardia
109
What is the mechanism of action of statins?
Inhibits HMG-CoA reductase which is the rate limiting enzyme in hepatic cholesterol synthesis
110
What are the risk factors for myopathy in patients who take statins?
``` Female Older age Low BMI Diabetes Lipophilic statins ```
111
What are the indications for statins?
Q risk >10% Established CV disease T1DM: diagnosed >10 years, aged >40, or established nephropathy
112
Why are statins taken at night?
This is when the majority of cholesterol synthesis takes place
113
What is the pathophysiology of Takotsubo cardiomyopathy?
Apical ballooning like octopus pot due to severe hypokinesis of mid and apical segments, preservation of basal segments
114
What are the genetics of HCOM?
Mutation in gene encoding beta-myosin heavy chain protein or myosin binding protein C
115
What is the pathophysiology of HCOM?
LV hypertrophy --> decreased compliance --> decreased cardiac output Mainly diastolic dysfunction Myofibrillar hypertrophy + disarray and fibrosis of myocytes
116
What are the signs of HCOM?
Jerky pulse Large a waves of JVP Double apex beat ESM, increases with Valsalva and decreases on squatting
117
What is seen on echo and ECG in HCOM?
Echo: asymmetric septal hypertrophy with systolic anterior movement of anterior leaflet of mitral valve ECG: LV hypertrophy, progressive TWI, deep Q waves
118
What are 5 poor prognostic features of HCOM?
``` Syncope FH SCD Young age at presentation Increased septal wall thickness >30mm Abnormal BP change on exercise ```
119
What is the management of HCOM?
ABCDE ``` Amiodarone Betablockers/verapamil for symptoms Cardioverter defibrillator Dual chamber pacemaker Endocarditis prophylaxis ```
120
Which drugs should be avoided in HCOM?
Nitrates ACEIs Inotropes
121
Why are nitrates avoided in heart failure?
Vasodilation reduces preload
122
What are the causes of restrictive cardiomyopathy?
``` Amyloid Haemochromatosis Loffler's syndrome Sarcoid Scleroderma ```
123
How can restrictive cardiomyopathy be differentiated from constrictive pericarditis?
Prominent apical pulse No pericardial calcification Enlarged heart Bundle branch block and Q waves
124
What is the inheritance of arrhythmogenic right ventricular cardiomyopathy?
Autosomal dominant
125
What are the ECG changes of arrhythmogenic right ventricular cardiomyopathy?
TWI V1-V3 | Epsilon wave in 50% (terminal notch in QRS)
126
What is the treatment of ARVC?
Sotalol Catheter ablation to prevent VT ICD
127
What is the triad of Naxos disease?
ARVC (AR variant) Palmoplantar keratosis Woolly hair
128
What is the pathophysiology of LQTS?
Defects in alpha subunit of slow delayed rectifier K channel
129
What are the congenital causes of LQTS?
Jervell-Lange Nielsen (deafness) | Romano-Ward (no deafness)
130
What are the acquired causes of LQTS?
Drugs: amiodarone, sotalol, SSRIs, TCAs, chloroquine, macrolides, ondansetron, methadone Low K, Ca, Mg
131
What is the management of LQTS?
BB | ICD
132
What is the genetics of Brugada syndrome?
Autosomal dominant SCN5A gene - encodes myocardial sodium ion channel
133
What are the ECG changes of Brugada syndrome?
Convex ST elevation >2mm in >V1-V3, followed by TWI Partial RBBB Changes more apparent following administration of flecainide or ajmaline
134
Name 6 causes of pericarditis
``` Coxsackie virus TB Uraemia Dressler's CTD Malignancy ```
135
What are the ECG changes of pericarditis?
Diffuse saddle shaped ST elevation | PR depression
136
What is the pathophysiology of rheumatic fever?
Strep pyogenes infection (cell wall includes M protein which is highly antigenic) Activation of innate immune system leading to antigen presentation to T cells Molecular mimicry (form of T2 hypersensitivity) Antibodies against M protein cross-react with myosin
137
What are the major criteria of rheumatic fever?
``` Erythema marginatum Sydenham's chorea Polyarthritis Carditis/valvulitis SC nodules ```
138
What is the treatment of rheumatic fever?
PO penicillin V
139
Which cause of infective endocarditis is linked to dental work?
Strep viridans (includes strep mitis, strep sanguinis)
140
Infective endocarditis caused by staph epidermis is most common in what scenario?
Indwelling lines | Prosthetic valve surgery
141
Strep bovis/gallolyticus endocarditis is associated with what?
Colorectal Ca
142
Name 4 culture negative causes of endocarditis.
Coxiella burnetti Bartonella Brucella HACEK
143
What are 4 poor prognostic features of IE?
S.aureus Prosthetic valve Culture -ve Low complement
144
What is the treatment of IE of prosthetic valves?
Rifampicin + gentamicin + fluclox/vancomycin
145
What is Eisenmenger's syndrome?
The reversal of left to right shunt in congenital heart defect due to pulmonary hypertension
146
What are the signs of Eisenmenger's syndrome?
``` Original murmur may disappear Cyanosis Clubbing RV failure Loud S2 Large a waves in JVP ```
147
What is the function of BNP?
Vasodilator Diuretic, natriuretic Suppresses sympathetic tone and RAAS
148
Name 2 causes of reduced BNP
ACEIs/ARBs | Digoxin
149
Which scan measures LVEF accurately and is used before and after use of cardiotoxic drugs?
Multi-gated acquisition scan (MUGA)
150
What can SPECT imaging do?
Assess myocardial perfusion and viability
151
What are the 2 methods of assessing IHD in cardiac CT?
Calcium score | Contrast enhanced - visualisation of coronary artery lumen
152
What is a risk factor for multi-focal atrial tachycardia?
Chronic lung disease
153
What are the pathways in AVNRT?
Slow (alpha) with short refractory period | Fast (beta) with long refractory period
154
What is the management of AVNRT?
Vagal maneouvres IV adenosine 6 --> 12 --> 12 Cardioversion
155
What is the treatment of AVNRT in asthmatics?
Substitute adenosine for verapamil
156
Which features suggest VT rather than SVT with aberrant conduction?
``` QRS>160 Capture and fusion beats AV dissociation Marked LAD History of IHD Lack of response to adenosine/carotid sinus massage Positive QRS concordance in chest leads ```
157
What is the treatment of sustained (>30s) VT?
Shock etc: synchronised DC cardioversion Amiodarone, lidocaine
158
What are the causes of polymorphic VT?
If prolonged QT: TDP | If bidirectional: digoxin toxicity
159
What is the pathophysiology of VT caused by digoxin toxicity?
Triggered activity - due to early or late after-depolarisations
160
What is the pathophysiology of monomorphic VT?
Re-entry | Abnormal automaticity
161
What is the treatment of TDP?
IV magnesium sulphate

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