Cardio Flashcards
(108 cards)
1
Q
What investigation is used to diagnose coarctation of aorta?
What is the initial management of coarctation of aorta? What does this do physiologically to help?
What are the 2 definitive managements of coarctation of aorta?
A
ECHO
Give prostaglandin E - this reopens the ductus arteriosis which increases cardiac ouput & relieves the strain on the L ventricle
Surgical repair (narrowed part is resected and the 2 ends are anastamosed together) or stent insertion
2
Q
You are working in A&E and a patient is hypotensive. What do you do to increase the BP?
How much of this would you give and over what time?
A
IV fluid resuscitation
500ml saline or plasmalyte bolus over 15 mins
3
Q
When would the ventricles release BNP?
A high BNP suggests what condition?
A
BNP is secreted in response to ventricular stretching
A high BNP suggests heart failure
4
Q
What murmur is heard in aortic stenosis & where would you heart it?
What murmur is heard in pulmonary stenosis & where would you hear it?
A
Ejection systolic murmur heard over right sternal border - radiates to carotids
Ejection systolic murmur heard over left sternal border - radiates to back
5
Q
What is the classical presentation of an aortic dissection?
A
Sudden onset ‘tearing’ chest pain (or interscapular pain) that radiates to the back
6
Q
What conditions can cause a rise in troponin? (8)
A
Myocardial infarction
Pulmonary embolism
Myocarditis
Arrythmia’s
Heart failure
Sepsis
Renal failure
Aortic dissection
7
Q
An ejection systolic murmur in the upper left sternal border & radiates to the back indicates what type of valvular condition?
An ejection systolic murmur in the upper right sternal border & radiates to the carotids indicates what type of valvular condition?
A
Pulmonary stenosis
Aortic stenosis
8
Q
What treatment (if any) is required for 3rd degree heart block?
A
Permanent pacemaker
9
Q
What does AVPU stand for?
What is it used for?
A
A - is the patient alert?
V - does the patient respond to voice?
P - does the patient respond to pain?
U - is the patient unconscious?
AVPU: used to quickly assess the consciousness & response of a patient (instead of doing a full GCS)
10
Q
Which areas of the heart do the leads of an ECG correspond to:
→ Anterior
→ Inferior
→ Lateral
→ Septal
Which artery is involved in each of the above 3 areas of the heart?
A
Coronary arteries:
- Anterior*: left anterior descending artery
- Inferior*: right coronary artery
- Lateral*: circumflex artery
11
Q
Which areas of the heart do the leads of an ECG correspond to:
→ Anterior
→ Inferior
→ Lateral
→ Septal
Which artery is involved in each of the above 3 areas of the heart?
A
Coronary arteries:
- Anterior*: left anterior descending artery
- Inferior*: right coronary artery
- Lateral*: circumflex artery
12
Q
What valvular disease is indicated by a slow rising carotid pulse?
A
Aortic stenosis
13
Q
If you see a regular rhythm tachycardic ECG with very narrow QRS complexes, which arrhythmia would this indicate?
What is the underlying physiology causing this?
A
Supraventricular tachycardia
There is a self-continuing loop going from the ventricles to the AVN and back to the ventricles!
14
Q
What is the management of Stanford type B aortic dissections?
A
Conservative management with BP control
15
Q
What is the 1st line treatment of non-bacterial pericarditis?
What is the treatment of bacterial pericarditis?
A
NSAIDs (reduces the inflammation of the pericardium)
IV antibiotics
16
Q
What is the commonest
1. ACEi
2. Beta blocker
used in the treatment of heart failure?
A
ACEi: Ramipril
Beta blocker: Bisoprolol
17
Q
What is the management of a baby with symptomatic patent ductus arteriosus? - what is the mechanism behind this?
When would this management not be used and why?
In these babies, what would the management be? - what is the timeframe for this?
A
Indomethacin (an NSAID) - it is a prostagland inhibitor so causes closure of ductus arteriosus
Not used in term babies as their patent ductus arteriosus isnt prostaglandin sensitive!
Watch & wait - most will close spontaneously within 1y. IF symptomatic, can be surgically ligated
18
Q
There are 2 types of 2nd degree heart block. What are they called?
What is the common pathology in a 2nd degree block?
A
Morbitz I & Morbitz II
In each type, a beat is dropped occasionally (missing QRS complex)
19
Q
What medication is associated with causing Gout as a S/E?
A
Thiazides
20
Q
What are 2 common complications of pericarditis?
Recurrent episodes of pericarditis can cause what?
A
Cardiac tamponade & pericardial effusion (fluid inbetween the 2 layers of pericardium)
Constrictive pericarditis
21
Q
What happens in Morbitz I (2nd degree heart block)?
A
Progressive lengthening of the PR interval until a beat is dropped (there is no QRS complex following 1 P wave)
22
Q
What clinical signs would be seen in someone with an aortic dissection?
A
Radio-radial delay
Radio-femoral delay
BP is different between L & R arms
23
Q
What is the main action of a statin?
A
To lower cholesterol
24
Q
What route is Dalteparin administered?
A
Subcutaneous injection
25
Describe what coarctation of the aorta is:
List the clinical signs/ symptoms of coarctation of aorta: (3)
How would a child with coarctation of aorta usually present?
Narrowing of the descending aorta
1) Weak/ absent femoral pulse
2) Radio-femoral delay
3) Systolic murmur that's loudest at the back
Presentation: sudden deterioration & collapse
26
What is the most appropriate 1st line treatment for a patient with a STEMI in the following settings:
~ Remote and rural (*more than 120 mins away from a big hospital)*
~ Urban setting
**Remote and rural:** thrombolysis (this is because PCI needs to be done within 120 mins, so if this isn't possible, start with thrombolysis and follow this with PCI when available)
**Urban setting:** PCI (if patient has presented within 12h of symptom onset)
27
Ventricular-septal defects are associated with which 2 genetic conditions?
What type of murmur is heard when there is a ventricular-septal defect?
Down syndrome, Turner's syndrome
Pan-systolic murmur
28
What is lactate a marker of?
Is a high or low lactate good?
Hypoperfusion (reduced O2 reaching the tissues)
LOW lactate - the higher the lactate, the more tissues are without O2!
29
What direction is blood shunted in a ventricular-septal defect?
What pathology can occur over time if a ventricular-septal defect isnt corrected? What causes this?
What condition does this result in and why?
What clinical sign will be seen when this happens?
L→R ventricle
Increased blood in R ventricle → increased blood (and thus pressure) in pulmonary circulation → **pulmonary hypertension**
Pulmonary hypertension causes **Eisenmenger syndrome:** pressure in R ventricle is higher than L which causes blood to be shunted from R→L
Central cyanosis (more blood is bypassing the lungs)
30
If an ECG shows a **new LBBB,** what cardiac condition should *always* be suspected and treated for immediately?
STEMI
31
What xray findings are seen in heart failure? (**ABCDEF**)
* *A**: **_A_**lveolar oedema
* *B:** Kerley **_B_** lines (caused by interstitial oedema)
* *C:** **_C_**ardiomegaly
* *D:** Upper lobe **_d_**iversion (increased blood through the smaller blood vessels in the upper lobes - looks like cloudiness on xray)
* *E**: Pleural **_E_**ffusions
* *F:** **_F_**luid in the horizontal fissure
32
What is the management of Stanford type A aortic dissections?
Surgical management (aortic graft)
33
What is aortic dissection?
A tear in the tunica intima of the aorta allows blood to flow between the inner & outer layers of the walls of the aorta
34
A patient with a DVT that suddenly has a large stroke is indicitive of what pathology?
An atrial septal defect - the clot from the leg passed through the septum and into the brain!
35
What **blood test** would you do if you suspect someone has **heart failure**?
What **other investigations** would you want to request? (2)
**BNP**
Chest xray
ECHO (*gold standard*)
36
What traid of symptoms are associated with aortic stenosis?
1. Heart failure
2. Syncope
3. Angina
37
What is a 3rd degree heart block in relation to the electical activity?
What would you see on an ECG?
No impulses are conducted between the atria & ventricles but both still contract independently at different rates
On the ECG: P waves & QRS complexes are out of sync & not related to each other at all
38
What are the main risk factors associated with aortic dissection? (4)
Hypertension
Connective tissue diseases (eg, Marfans)
Cocaine use
Valvular heart disease
39
What are the 6 components of sepsis 6?
| (take 3, give 3)
→ Take blood cultures
→ Measure blood lactate
→ Measure urine output
→ Give O2 if sats are below 94%
→ Give IV antibiotics
→ Fluid challenge (give IV fluids)
40
What is a stanford type A and stanford type B aortic dissection?
Stanford type A: tear is within the ascending aorta or the arch of the aorta
Stanford type B: tear is within the descending aorta
41
What are some common triggers of trigeminal neuralgia? (5)
Cold
Wind
Chewing
Talking
Touching face
42
What **4** medications are used as part of **thrombolysis** for initial management of a STEMI?
1. **Tenecteplase** IV - 50mg
2. **Heparin** IV - 5000 units loading dose
3. **Enoxaparin** 1mg/kg subcutaneous
4. **Clopidogrel** 300mg loading dose
43
What drug class is the 1st line treatment of hypertension in:
1. Caucasian people under 55y
2. People over 55y OR black/Caribbean people of any age
* Give an example of a drug that may be used in each.*
What is a contraindictation to the drug class used in 1. & what would be used instead?
1. ACEi - ramipril
2. Calcium channel blocker - amlodipine
Contraindictation to ACEi = pregnancy! Use an ARB instead
44
Does 1st degree heart block need to be treated?
No
45
What is a common **side effect** of **ACE inhibitors** that patients should be told about?
What **organ function** need's to be **monitored** when taking an **ACEi?**
**DRY COUGH!**
**Kidneys!** ACEi can affect the kidneys
46
What ECG finding is seen in hyperkalaemia?
Peaked T waves
47
What might be seen on an ECG in **hypo**kalaemia?
What might be seen on an ECG in **hyper**kalaemia?
Flattened T waves
Tall-tented T waves
48
What condition is indicated if a woman presents with **recurrent miscarriages** & a history of **VTE** events?
What is the treatment of this condition? (2)
**Antiphospholipid syndrome**
Aspirin & LMWH
49
What is lactate a marker of?
Is a high or low lactate good?
Hypoperfusion (reduced O2 reaching the tissues)
LOW lactate - the higher the lactate, the more tissues are without O2!
50
A collapsing pulse is indicative of which valvular disease?
Aortic regurgitation
51
Asymptomatic atrial fibrillation should be treated with what medication?
**None!** AF isnt treated unless it is symptomatic!
52
In terms of mm, how big does ST elevation on an ECG need to be, to be classed as a STEMI in:
* 1.* Chest leads
* 2.* Limb leads
**Chest leads:** more than 2mm
**Limb leads:** more than 1mm
53
In bundle branch blocks, are the QRS complexes wider or narrower than usual?
What is the normal time/num. of boxes of a QRS complex?
Wider than usual
Normally, QRS complexes are no wider than: 120ms = 3 small boxes
54
What criteria is used to diagnose infective endocarditis?
Modified dukes criteria
55
How long does it take for troponin to fall after a myocardial infarction?
If the patient presents within this timeframe with chest pain (suspected re-infarction), what test should be done to confirm this?
7-10 days
CK-MB
56
What happens in Morbitz II (2nd degree heart block)?
Each PR interval is normal lenght but occasionally the P wave isn't followed by a QRS complex - dropped beat
57
What score do GPs use to calculate someones risk of cardiovascular disease?
**ASSIGN** score
58
A patient younger than 55y *or* who has T2DM should be started initially on which class of antihypertensives?
A patient older than 55y *or* of africo-caribbean origin shoule be staretd initially on which class of antihyperternsives?
ACE inhibitors
Ca channel blockers
59
What would you hear when ascultating someone with an atrial septal defect? (2)
Explain why you would hear these things!
**Fixed, split 2nd heart sound** → as blood is being shunted from L→R atria, there is more blood to flow through the pulmonary valve. This causes a delay in the valve closing compared to closing of aortic valve = split 2nd heart sound
Pulmonary flow murmur (ejection systolic murmur) → due to increased blood flowing through the valve
60
List some common symptoms/signs seen in pericarditis: (5)
Chest pain (pleuritic)
→ Worse when lying down / deep breaths
→ Better sitting forwards
Fever
Pericardial rub
Raised troponin
ECG changes: widespread, saddleshaped ST elevation
61
What is PCI (percutaneous coronary intervention)?
When would it be offered to a patient? (For what condition and within what timeframe?)
~ If the timeframe isn't met, what is offered in the meantime?
**PCI:** stent insertion into a blocked coronary artery to resume it's blood flow. (Access is via femoral or radial artery)
PCI is offered for patients with a **STEMI** that have presented within **12h of symptom onset**
*\*\*\*\* Has to be performed within 120 minutes of patient presentation to health care (if this isn't possible then thrombolysis is started, followed by PCI)*
62
What condition is most likely if a patient has chest pain but there is *no* rise in troponin?
**Unstable angina**
63
What medication is given in ARI as post-surgical prophylaxis of VTE & what drug class is it?
How long is it given for post-surgery?
Dalteparin - LMWH
30 days
64
What 2 common features would you see on an ECG to indicate AF?
Absent P waves
Irregularly irregular rhytm
65
What **2** classess of **medications** are used **1st line** in the management of **heart failure**?
What additional medication can be added for symptomatic relief of fluid overload?
**ACE inhibitors**
**Beta blockers**
Furosemide ~ *\*no effect on mortality\**
66
What symptoms would be seen in moderate/severe aortic stenosis in children? (3)
What symptoms would be seen in moderate/severe pulmonary stenosis in children? (2)
Reduced exercise tolerance, exertional chest pain & syncope
Exertional SOB & fatigue
67
How long does it take **troponin** to rise after a cardiac event?
Why is this important to know for investigating a patient?
**10-12 hours**
Important as you need a repeat troponin 10-12h after the initial one to see whether there has been a rise or not. - *A significant rise in troponin indicates a cardiac event.*
68
On an ECG, what is the normal lenght of the PR interval?
120 - 200ms
69
What investigation is used to diagnose coarctation of aorta?
What is the initial management of coarctation of aorta? What does this do physiologically to help?
What are the 2 definitive managements of coarctation of aorta?
ECHO
**Give prostaglandin E** - this reopens the ductus arteriosis which increases cardiac ouput & relieves the strain on the L ventricle
Surgical repair (narrowed part is resected and the 2 ends are anastamosed together) *or* stent insertion
70
What classification system is used for aortic dissections?
Stanford classification
71
What is 1st degree heart block?
A continually prolonged PR interval of more than 200ms
72
Which heart valve is most commonly affected in infective endocarditis?
If the cause of infective endocarditis is due to the patient being an IVDU, what valve is then most commonly affected?
Mitral valve
Tricuspid valve
73
What investigation is used to diagnose an aortic dissection?
CT angiogram
74
What arrhthymia does this ECG show?
**Supraventricular tachycardia**
75
What is **pericarditis**?
What are the **4** main **symptoms**/**signs** of pericarditis?
Inflammation of the pericardium (the sace surrounding the heart)
1. **Chest pain**, relieved by sitting forwards
2. **Fever**
3. **Pericardial friction rub**
4. ECG changes (***wide spread, saddle-shaped ST elevation*)**
76
What ECG changes would you expect to see in **pericarditis?**
Widespread, **saddle-shaped ST elevation** + PR depression
77
If there is *new* LBBB seen on an ECG, what condition is this highly suggestive of?
STEMI
78
What time of day should **statins** be prescribed at?
~ *why?*
Statins should be taken at **night**
~ the majority of cholesterol synthesis in the liver occurs at **night!**
79
After a VTE, how long should anticoagulation continue for in:
~ *un*provoked VTE
~ provoked VTE
**Unprovoked VTE:** 6 months
**Provoked VTE:** 3 months
80
Name the 2 most commonly used DOACs:
Apixaban & Rivaroxaban
81
**ACS** is a spectrum of (3) disorders. Name the ACS associated with the features below:
1. Cardiac **chest** **pain** + abnormal/normal ECG (*no ST elevation*) + **raised** troponin
2. Cardiac **chest pain** + abnormal/normal ECG + **normal** troponin
3. Cardiac **chest pain** + persistent **ST-elevation**/**new LBBB** (*don't need to do a troponin in this case)*
* ~* if a troponin was done, would you expect it to be normal/raised?
1. **NSTEMI**
2. **Unstable angina**
3. **STEMI**
~ raised
82
Which areas of the heart do the leads of an ECG correspond to:
→ Anterior
→ Inferior
→ Lateral
*→ Septal*
Which artery is involved in each of the above 3 areas of the heart?
**Coronary arteries:**
* Anterior*: left anterior descending artery
* Inferior*: right coronary artery
* Lateral*: circumflex artery
83
State the initial **medical** management of a **STEMI**: (4)
PCI is given to patients with a STEMI that fulfil 2 criteria upon presentation. State what these criteria are:
**M -** morphine
**O -** oxygen (*only if SATs are below 94%*)
**N -** nitrates, eg GTN spray for symptom relief
**A -** ASPIRIN ~ *oral loading dose of _300mg_*
**PCI criteria**:
~ patient presents within **12h of onset** of chest pain
~ PCI is available within **\<2 hours** of patient **presenting** to **healthcare** setting
84
State the initial management of an **NSTEMI**:
What **classification** system is used to calculate patients **6 month mortality risk**?
What **imaging** would patients with a high 6 month risk of mortality be offered?
~ what is the purpose of doing this imaging?
**M -** morphine
**O -** oxygen (*only if SATs are below 94%*)
**N -** nitrates, eg GTN spray for symptom relief
**A -** ASPIRIN ~ *oral loading dose of _300mg_*
~ CALCULATE PATIENTS 6 MONTHLY MORTALITY RISK USING **_GRACE SCORE_**
~ any patient that is above *low* risk of mortality should be started on either **300mg clopidogrel** OR **180mg ticagrelor**
**+**
**Antithrombin therapy** (*eg using LMWH or fondaparinux*)
**Angiogram** within 96h of symptom onset - *for patients with high mortality risk*
*~* to see whether the patient should be stented or not!
85
ALL post-MI patients (STEMI + NSTEMI) should be started on which **5** **medications** longterm?
What **imaging** should ALL post-MI patients have as routine follow-up?
~ what is this assessing?
1. **Aspirin 75mg** + *second* anti-platelet (**clopidogrel 75mg** or **ticagrelor 90mg**)
2. **Beta blocker (**eg, **bisoprolol)**
3. **ACE-inhibitor (**eg, **ramipril)**
4. **High dose statin (**eg, **Atorvastatin 80mg)**
**ECHO** ~ to assess **systolic** function
86
In terms of **%,** what is the **normal** left ventricular ejection fraction?
**65%**
87
Supraventricular tachycardia causes a **regular** rhythm, **narrow complex QRS**. Name the initial management that should be done to restore sinus rhythm:
If this doesn't work, what would the next management option be?
If *this* still doesn't work, what would the next management option be?
1. **Vagal manoeuvres** (eg, ask patient to blow into a syringe OR a carotid sinus massage)
2. Give a rapid bolus of **adenosine 6mg**
3. Give another bolus of **adenosine 12mg**
88
A 62y/o male is recovering on the ward from a recent MI. Whilst sitting in bed he notes sudden onset palpitations & dizziness. 30 seconds later he turns grey and loses consciousness.
There are no signs of life, so CPR is commences for 2 minutes. The ECG shows **irregular broad complex tachycardia**.
What arrhythmia is likely occurring in this situation?
What would be the next step in management of this patient?
**IF** the rhythm was **regular** (instead of irregular), what would the management be instead of the above?
**Ventricular fibrillation** (due to the irregular broad complex tachycardia _&_ cardiac arrest!)
**Unsynchronised DC cardioversion**
~ there isn't a rhythm to synchronise the shock to hence why it's not synchronised!
~ there is **still a** ***rhythm*** so you would want to fibrillate the heart (shock it) back into a normal rhythm
**Synchronised DC cardioversion** *as the shock can now be given at a certain point!*
89
What effect does **amitriptyline** have on an **ECG**?
Increased QT interval
90
A 30y/o man is brought into A&E after being stabbed in the chest. The chest is clear bilaterally with **quiet heart sounds**.
BP is **90/60** and he is tachycardic with a **raised JVP**.
What is the likely diagnosis?
What is the management of this condition?
**Cardiac tamponade**
**Pericardiocentesis**
~ a needle is placed into the pericardium which drains the excess fluid
91
An **ejection systolic** murmur that radiates to the **carotid's** should make you think of what valvular condition?
An **ejection systolic** murmur that DOES NOT radiate to the carotid's should make you think of what valvular condition?
**Aortic stenosis**
Aortic **sclerosis**
\*\*\* Stenosis = when the valve is thickened & has an impact on the hearts ability to pump blood
\*\*\* Sclerosis = when the valve is thickened but does NOT impact the heart's ability to pump blood!
92
A **pansystolic murmur** should make you think of what valvular condition?
**Mitral regurgitation**
93
What is the commonest organism to cause **infective endocarditis**?
If a patient with infective endocarditis has **PR interval prolongation** on their ECG:
1. in regards to endocarditis, what does this **suggest**?
2. what would the **management** be?
Staph aureus
1. An **aortic root abscess**
2. **SURGERY** asap**!**
94
A 46 year old female patient is reviewed on the ward due to palpitations. She was admitted due to a community acquired pneumonia and has been taking amoxicillin and clarithromycin for this.
She has a past medical history of depression and anxiety for which she takes fluoxetine once daily but is on no other medications.
On examination she complains of feeling very faint and lightheaded. She is saturating 96% on room air and her respiratory rate is 24 breaths/min. Her blood pressure is 90/50 mmHg and her heart rate is 180bpm.
Her ECG is shown below:
What is the most likely cause of her symptoms?
What features from her above history are risk factors for developing this arrhythmia?
~ how do they increase the risk of this arrhythmia?
**Torsades des pointes** (a *type* of ventricular tachycardia)
Clarithromycin (*macrolide*) & Fluoxetine (*SSRI*)
~ they *both* **increase** the **QT** **interval**!
95
What does this ECG show?
What would the management be?
**1st degree heart block**
NO management needed *if* patient is asymptomatic
96
A 65y/o man with a history of hypertension and AF presents to the ED with **palpitations** and **dizziness**. His vital signs are stable, and he reports no chest pain or shortness of breath. A 12-lead ECG is obtained, which shows a **regular tachycardia** with a rate of approximately 150 beats per minute. The ECG also shows a **sawtooth pattern** in the inferior leads.
What is the most likely diagnosis based on the ECG findings?
Atrial flutter
~ *sawtooth pattern + tachycardia!*
*\*\*\* atrial flutter is a type of supraventricular tachycardia*
97
What does this ECG show?
**RBBB** *~ in V1*
98
What condition is the commonest cause of **sudden cardiac death** in the **young**?
What type of inheritance pattern does it have?
Which 2 parts of the heart are usually hypertrophied?
**Hypertrophic obstructive cardiomyopathy (HOCM)**
Autosomal **dominant**
~ Interventricular septum (which causes outflow tract obstruction)
~ Left ventricle
99
What medication can be used in the treatment of **orthostatic hypotension**?
Fludrocortisone
100
EVERYONE who has had an episode of AF needs to have an assessment for whether anticoagulation is needed.
What system is used to calculate this risk?
A score of what indicates the need for anticoagulation?
~ If the patient scores less than this and thus doesn't need anticoagulation, what is the next step in managing the patient? *- why is this done?*
**CHA2DVAS2c Score**
~ scoring **_2_** or more indicates the need for anticoagulation
No anticoagulation: **ECHO** to exclude valvular heart disease
~ *if the ECHO shows valvular heart disease then the patient would be started on anticoagulation!*
101
How long are 1. **provoked** and 2. **unprovoked** PE's/DVT's treated for?
**Provoked:** 3 months
**Unprovoked:** 6 months
102
A patient attends ED with mild chest pain that started 11 hours ago and isn't improving with paracetamol.
What does this ECG show?
How would you manage this?
ST elevation in V1-V4 = **anterior STEMI** due to **LAD occlusion**!
Management:
**Paracetamol** (usually morphine, however the pain is only mild), **oxygen** (if SATs are below 94%), **nitrates** (eg GTN), **aspirin 300mg**
**+**
**PCI** (*if available within 2 hours*)
**Fibrinolysis** *(if PCI not available within 2 hours!)*
*\*\*\* PCI is only done if patient presents within 12h of symptom onset! \*\*\**
103
What electrolyte disturbance may **thiazides** cause?
What ECG changes would you expect to see in this electrolyte disturbance?
**Hypokalaemia**
* small/ absent T waves (occasionally inversion)
* prolonged PR interval
* ST depression
* long QT
104
What type of **murmur** would you hear in **aortic regurgitation?**
Early **diastolic murmur**
105
An **early diastolic murmur** would indicate which valvular pathology?
Aortic **regurgitation**
106
After lifestyle modifications, what is the 1st line management of **stable angina**? (2)
~ if one of these medications isn't tolerated, what is used instead?
**GTN** spray + **beta blocker** (eg, bisoprolol)
~ calcium channel blocker
107
What complication of infective endocarditis requires surgical repair?
What ECG change would be seen in someone with this complication?
**Aortic root abscess**
Prolonged PR interval (ECHO would show involvement of the aortic valve)
108
A homeless man in his early 40s is brought to ED by the police after they find him barely responsive on the street. He smells of *vodka* and has an *empty bottle* beside him on the pavement. During the physical examination, the patient exhibits *psychomotor slowing* and *decreased mental function*, and no further medical history can be obtained. The ECG shows an *abnormal heart rhythm*.
What is the most likely *ECG finding*?
~ how does alcohol cause this?
**Atrial fibrillation**
~ alcohol excess can cause **myocarditis** (inflammation of heart tissue) which damages the electrical conduction of the heart, resulting in AF!
