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1
Q

AFib treatment in a young patient with no TIA or other risk factors (CHA2DS2-VASc =0)?

A

No treatment required

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2
Q

Which cardiac medication can cause angioedema without urticaria?

A

ACE inhibitors ++++
ARBs +

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3
Q

What’s the first line anticoagulant for Atrial Fibrillation?

A

DOAC (Apixaban, Dabigatran, Edoxaban, Rivaroxaban)

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4
Q

Sudden death with prodromal shortness of breath + irregular pulse 140bpm and ECG shows ventricular hypertrophy, deep Q waves and non-specific T-wave inversion. Diagnosis?

A

Hypertrophic obstructive cardiomyopathy (death by ventricular arrythmia)

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5
Q

What’s the inheritance mode of hypertrophic cardiomyopathy?

A

Autosomal dominant

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6
Q

In Hypertrophic obstructive cardiomyopathy, the genetic defect is?

A

A mutation in the gene encoding
- Beta-myosin heavy chain protein
- Myosin-binding protein C

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7
Q

Why is there syncope in HOCM?

A

By functional aortic stenosis due to subaortic hypertrophy of the ventricular septum

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8
Q

What’s the histology of HOCM?

A

Widespread interstitial fibrosis with disorganised myocytes and myofibrillar hypertrophy (disarray)
Might have intimal coronary artery thickening with luminal narrowing

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9
Q

What are the murmurs in HOCM?

A

Systolic murmurs:
- Ejection systolic murmur due to left ventricular outflow tract obstruction
- Pansystolic murmur due to systolic anterior motion of the mitral valve => Mitral regurgitation

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10
Q

Echo findings in HOCM?

A

Mnemonic : MR SAM ASH
- Mitral regurgitation (MR)
- Systolic anterior motion of anterior mitral valve leaflet (SAM)
- Asymmetric hypertrophy (ASH)

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11
Q

ECG findings in HOCM?

A
  • Left ventricular hypertrophy
  • Non-specific ST segment and T-wave abnormalities
  • Deep Q waves
  • Atrial Fibrillation
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12
Q

HOCM can be associated with?

A
  • Friedrich’s ataxia
  • Wolff-Parkinson-White
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13
Q

What is the treatment for acute pericarditis?

A

1st line : NSAID + colchicine
2nd line : NSAID+colchicine+steroid
3rd line : azathioprine - IV immunoglobulin and anakinra (an interleukin 1B antagonist)

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14
Q

Post-MI pleuritic chest pain?

A

1-3 days : fibrinous pericarditis
Late (weeks to months) : autoimmune pericarditis (Dressler’s syndrome)

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15
Q

What’s the most specific ECG finding for pericarditis?

A

PR depression

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16
Q

What are the ECG changes in pericarditis?

A

Widespread saddle-shaped ST elevation and depressed PR segment

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17
Q

What’s the treatment duration in acute pericarditis?

A

3 months (1-2 weeks at full dose until resolution of symptoms, then tapering of dose)

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18
Q

Childhood history of rheumatic fever, SOB and fatigue over 6 months, low-volume pulse, raised JVP, diastolic murmur heard best at apex with patient in left lateral position. What’s the condition and treatment?

A

Mitral stenosis. Treatment is percutaneous mitral commissurotomy in younger patients (minimally invasive) or mitral valve replacement (invasive)

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19
Q

Features of mitral stenosis?

A

Dyspnoea
Haemoptysis
Mid-late diastolic murmur best heard at the apex in expiration
Loud S1
Opening snap
Low volume pulse
Malar flush
Atrial fibrillation due to left atrial enlargment

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20
Q

What are the manifestations of cholesterol embolus?

A

Livedo reticularis, purpura, cold blue toe, eosinophilia, gastrointestinal symptoms if embolus in gastro tract, acute kidney injury if in renal vasculature

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21
Q

What precipitates cholesterol embolism?

A

Vascular surgery and angiography

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22
Q

History of TIA + AFib, what anticoagulation and when?

A

DOAC because according to CHA2DS2-VASc, TIA is 2 points. Start anticoagulation immediately?

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23
Q

Stroke + A Fib, when to anticoagulate?

A

Wait two weeks to rule out haemorrhagic stroke, then start DOAC

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24
Q

Aortic stenosis - most common cause?

A
  • Younger patients < 65 years: bicuspid aortic valve
  • Older patients > 65 years: calcification
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25
Features of aortic stenosis?
- chest pain - dyspnoea - syncope / presyncope (e.g. exertional dizziness) - murmur: ejection systolic murmur (ESM) classically radiates to the carotids, decreased following the Valsalva manoeuvre
26
Causes of aortic stenosis?
- Degenerative calcification (patients > 65 years) - Bicuspid aortic valve (patients < 65 years) - William's syndrome (supravalvular aortic stenosis) - Post-rheumatic disease - Subvalvular: HOCM
27
Causes of a loud S2?
- Hypertension: systemic (loud A2) or pulmonary (loud P2) - Hyperdynamic states - Atrial septal defect without pulmonary hypertension
28
What causes splitting of first heart sound?
Mitral valve closes before tricuspid valve, producing two separate sounds. Inspiration is a common cause of this as it delays the closure of the tricuspid valve due to increased venous return
29
What causes a soft second heart sound?
Aortic stenosis
30
What causes a loud first heart sound?
Mild to moderate mitral stenosis
31
What causes a soft first heart sound?
Severe mitral stenosis
32
What causes a widely split S2?
- Deep inspiration - RBBB - Pulmonary stenosis - Severe mitral regurgitation
33
What causes a reversed (paradoxical) split S2 (P2 occurs before A2)?
- LBBB - Severe aortic stenosis - Right ventricular pacing - WPW type B (causes early P2) - Patent ductus arteriosus
34
Nicorandil's gastrointestinal side-effects?
Ulcerations anywhere in the GI tract
35
What is Nicorandil mechanism of action?
It's a vasodilatory drug used to treat angina. It is a potassium-channel activator with vasodilation is through activation of guanylyl cyclase which results in increase cGMP
36
Side-effects of Nicorandil?
Headache Flushing Skin, mucosal, ocular and gastrointestinal ulcers (anywhere from mouth to anus)
37
HOCM - poor prognostic factor on echo?
Septal wall thickness >3cm (most important prognostic factor)
38
What anticoagulation for severe mitral regurgitation + mitral mechanical valvular replacement?
- Warfarin with an INR target of 3.5 (because mitral mechanical valves are more prone to thrombus) - Aortic valve, the target INR would be 3.0
39
In a patient with valvular replacement, what antibiotic should be given for prophylaxy of endocarditis after dental work?
No antibiotic required anymore.
40
Rheumatic fever treatment?
- Antibiotics: oral penicillin V - Anti-inflammatories: NSAIDs are first-line - Treatment of any complications e.g. heart failure
40
What's the histological finding in rheumatic heart disease?
Aschoff bodies: granulomatous nodules found in rheumatic heart fever + Anitschkow cells (enlarged macrophages with ovoid, wavy, rod-like nucleus)
41
Rheumatic fever diagnosis?
Evidence of Streptococcus pyogenes infection + 2 major critera or 1 major and 2 minor
42
What is Brugada syndrome?
Sodium ion channelopathy caused by mutation in SCN5A gene encoding the alpha subunit of the myocardiocytes sodium channels (loss of function). Predisposes to fatal VFib/ VTach
43
What is Brugada Syndrome's mode of inheritance?
Autosomal dominant with incomplete penetrance
44
What are the ECG findings in Brugada Syndrome?
Type 1 : Coved ST-elevation of 2mm or greater, followed by inverted T-wave + J point elevation in any lead from V1 to V3 Type 2 : Saddleback ST-elevation with J point elevation of 2 mm or more
45
What is the management of Brugada syndrome?
Implantable Cardioverter-defibrillator
46
What ECG findings are associated with hypothermia?
J waves
47
Cardiorespiratory arrest in post-orthopaedic surgery, what should we think of?
Suspect pulmonary embolism (especially if signs of massive PE like prior dyspnea, hypoxia and right ventricular hypertrophy) => Give thrombolytic (Alteplase) with ALS protocol.
48
What are ECG findings of Digoxin toxicity?
- Down-sloping ST depression ('reverse tick', 'scooped out') - Flattened/inverted T waves - Short QT interval - Arrhythmias e.g. AV block, bradycardia
49
Indications of implantable cardiac defibrillators?
- Long QT syndrome - Hypertrophic obstructive cardiomyopathy - Previous cardiac arrest due to VT/VF - Previous myocardial infarction with non-sustained VT on 24 hr monitoring, inducible VT on electrophysiology testing and ejection fraction < 35% - Brugada syndrome
50
Most common chest X-ray finding in pulmonary embolism?
No change.
51
What's the most common cause of paradoxical embolus? (e.g Woman with DVT develops a stroke)
Patent Foramen Ovale is most common (Atrial septal defects can also be the cause but not the most likely if PFO is in the options)
52
Definitive management of Eisenmenger's syndrome?
Heart-lung transplant
53
Best next management for Eisenmenger's syndrome?
Medical therapy trial before surgery with pulmonary vasodilator therapy: - Endothelin receptor antagonist (Bosentan) - Phosphodiesterase-5 inhibitors (Sildenafil) - Prostacycline analogues (Epoprostenol)
54
MI ECG changes in leads II, III and aVF correspond to which MI and artery?
Inferior MI - Right coronary artery
55
MI ECG changes in leads V1-V4 correspond to which territory and artery?
Anteroseptal MI - LAD artery (left anterior descending)
56
MI ECG changes in leads I, aVL and V5-6?
Lateral MI - Left circumflex
57
MI ECG changes in leads V1-6, I and aVL correspond to which territory and artery?
Anterolateral - Proximal left anterior descending
58
MI ECG changes in leads V1-3 correspond to which territory and artery?
Posterior - Left circumflex usually or right coronary artery
59
Mechanism of action of Furosemide? (loop diuretics)
Inhibits the Na/K/2Cl co-transporter in the thick ascending limb of the loop of Henle
60
Mechanism of action of thiazide diuretics?
Inhibition of Na+Cl- transporter in the distal convoluted tubule
61
Mechanism of action of Clopidogrel?
Inhibits ADP binding to platelet receptors
62
Long QT sd + sensorineural deafness = ?
Jervell-Lange-Nielsen syndrome.
63
How to treat prosthetic valve endocarditis caused by staphylococci?
Flucloxacillin + low-dose gentamycin + rifampicin
64
Treatment for severe sepsis from infective endocarditis if it is a native valve and there is a penicillin allergy?
Vancomycin + gentamycin
65
Treatment for infective endocarditis from a native valve with no penicillin allergy (before culture results are available)?
Amoxicillin + low-dose gentamicin
66
Treatment for infective endocarditis with intra-cardiac prosthesis of unknown cause?
Vancomycin, gentamicin + rifampicin
67
Most common cause of endocarditis within 2 months of prosthetic valve surgery?
Staphylococcus epidermidis
68
Most common cause of endocarditis in general population?
Staphylococcus aureus
69
Normal coronary angiograms despite ECG changes on exercise stress testing = ?
Cardiac syndrome X
70
Mode of action of Amiodarone?
Block potassium K+ channels
71
Pulmonary pressure measurement with Swan-Ganz balloon measure pressure of?
Left atrium
72
Why is Amiodarone administered as a loading dose followed by infusion?
Because it's has a long-half life and is highly lipophilic and easily absorbed by tissues which reduces its bioavailability.
73
INR target for mechanical aortic valve? and mitral valve?
Aortic : 3.0 Mitral : 3.5
74
What clinical finding suggest that mitral valve still have some mobility?
An opening snap (Opening snap = pathognomonic of mitral valve stenosis. It's a high-pitched early diastolic sound (just after S2) due to the sudden contraction of the valve leaflets after their initial opening. Opening snap = valve = suitable for balloon mitral valvuloplasty.)
75
What's the mechanism of action of statins?
HMG-CoA reductase inhibitor, decreases intrinsic LDL cholesterol synthesis by the liver
76
Complete heart block (bradycardia, low BP) following a MI, which artery is concerned?
Right coronary artery lesion
77
Patients on warfarin undergoing emergency surgery, what to give before surgery?
Four-factor prothrombin complex concentrate
78
Massive pulmonary embolism + hypotension, what to do?
Thrombolyse
79
Ischaemic heart disease + presence of fusion and capture beats on ECG + broad complext tachycardia, how to treat?
It's most likely ventricular tachycardio, treat with : - Amiodarone (safe to use in impaired LVF) - Lidocaine (use with caution in impaired LVF) - Procainamide
80
Heart failure + atrial fibrillation, how to control rate?
Digoxin is the best choice Rate control drugs : Betablockers (sotalol) - Dronedarone (2nd line in patients following cardioversion) - Digoxin
81
Rythm control drugs in Afib?
If patients rythm is high AF, give him AFs = Amiodarone - Flecainide - Sotalol

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