Cardio Flashcards
(309 cards)
1
Q
What are the initial divisions of the heart layers?
A
The myocardium and pericardium
2
Q
What is the outermost layer of the heart called?
A
Epicardium
3
Q
What is the thick middle layer of muscular tissue in the heart?
A
Myocardium
4
Q
What is the innermost layer of the heart that sits within the cavity of atria or ventricles?
A
Endocardium
5
Q
Which chambers of the heart are under higher pressure?
A
Left side
6
Q
What are the two types of atrial septal defects (ASD)?
A
- Ostium Secundum * Ostium Primum
7
Q
What syndrome occurs when right-sided pressures overcome left-sided pressures due to a shunt?
A
Eisenmenger Syndrome
8
Q
What type of blood does the left atrium receive?
A
Highly oxygenated blood from the pulmonary veins
9
Q
What is the role of the mitral valve during ventricular diastole?
A
Closes to hold blood in the left atrium
10
Q
What are the two atrioventricular valves?
A
- Mitral valve * Tricuspid valve
11
Q
What is the main function of the subvalvular apparatus in the heart?
A
Prevent cusps from prolapsing and allowing regurgitation
12
Q
What are the two semilunar valves located at the base of the heart?
A
- Aortic valve * Pulmonary valve
13
Q
What is the most common type of Atrial Septal Defect (ASD)?
A
Ostium Secundum
14
Q
What is the main feature of Ventricular Septal Defects (VSD)?
A
Defects arise in the ventricular septum separating the left and right ventricles
15
Q
What is a Bicuspid Aortic Valve (BAV) associated with?
A
Aortic stenosis and regurgitation
16
Q
What are the four components of Tetralogy of Fallot (TOF)?
A
- Pulmonary stenosis * Ventricular septal defect * Right ventricular hypertrophy * Overriding aorta
17
Q
What is the function of the left anterior descending artery?
A
Supplies oxygenated blood to the interventricular septum, anterior left ventricle, and apex
18
Q
What is the resting membrane potential of a cardiac myocyte?
A
-100mV
19
Q
What phase involves rapid sodium influx causing depolarization?
A
Phase 0
20
Q
What occurs during Phase 2 of the action potential?
A
Massive calcium influx
21
Q
What is the role of calcium in cardiac contraction?
A
Calcium binds to troponin proteins and exposes myosin binding sites
22
Q
What happens during ventricular diastole?
A
Atria are low-pressure chambers that fill with blood
23
Q
What is the prevalence of Patent Foramen Ovale (PFO) in autopsy studies?
A
1 in 4 people
24
Q
What is a key feature of Ostium Primum ASD?
A
Strong association with Down’s Syndrome
25
What is the most common location for a congenital Ventricular Septal Defect (VSD)?
Membranous region of the ventricle near the atrioventricular valves/outflow tracts
26
True or False: The right and left sides of the heart communicate under normal circumstances.
False
27
What is a myocardial bridge?
A short segment of the epicardial artery that dives and follows a myocardial route
28
What causes contraction in muscle fibers?
The myosin moves along the actin filaments
## Footnote
This process is coupled with the release of ADP * P and myosin from actin.
29
What allows the contraction process to continue in muscle fibers?
Binding of ATP to myosin
30
What governs blood flow and velocity during the cardiac cycle?
Changes in pressure and some myocardial contractility
31
What occurs during ventricular diastole?
Atria are low-pressure chambers and undergo slight pressure changes
## Footnote
Atrial systole occurs towards the end, pushing blood into the ventricle.
32
What happens to ventricular volume during diastole?
Ventricular volume rises significantly as the ventricular wall relaxes
33
What is the normal left atrial pressure?
5-10mmHg
34
What is the normal right atrial pressure?
<5mmHg
35
What is the first heart sound (S1) associated with?
Closure of the atrioventricular valves
36
What is the normal left ventricular pressure during systole?
<140mmHg
37
What is the second heart sound (S2) associated with?
Closure of the semilunar valves
38
What indicates a normal split of the second heart sound?
Aortic valve closure (A2) is heard first, followed by pulmonary valve closure (P2)
39
What does a loud P2 indicate?
Pulmonary hypertension
40
What does a soft A2 indicate?
Severe calcific aortic stenosis or aortic regurgitation
41
What does a third heart sound (S3) indicate?
Occurs only in disease states, associated with blood oscillation within the left ventricle
42
What characterizes a fourth heart sound (S4)?
Occurs late in diastole, just prior to S1
## Footnote
It is caused by atrial contraction against a stiff ventricle.
43
What is the normal jugular venous pressure (JVP) measurement position?
Patient sat at 45°
44
What are the components of the JVP?
* a-wave: atrial contraction
* c-wave: ventricular contraction
* x-descent: atrial relaxation
* v-wave: tricuspid valve closure and atrial filling
* y-descent: ventricular diastolic filling as tricuspid valve opens
45
What is the largest cause of worldwide mortality?
Cardiovascular disease
46
What are the traditional non-modifiable cardiovascular risk factors?
* Family history
47
What are the traditional modifiable cardiovascular risk factors?
* Smoking
* Hypertension
* Hypercholesterolaemia
* Type 2 Diabetes Mellitus
* Obesity/Waist circumference
48
Which populations have the highest incidence of ischaemic heart disease?
Asian populations
49
What is the Framingham Heart Study known for?
It is the largest cardiovascular risk factor study in history
50
What is the Framingham 10-year cardiovascular risk score used for?
Estimating the 10-year risk of a cardiovascular event
51
What is the LDL target for high-risk patients according to European guidelines?
<1.5mmol/L
52
What is the first-line drug treatment for hyperlipidaemia?
HMG-CoA Reductase Inhibitors (Statins)
53
What do statins do?
Block the rate-limiting step of endogenous cholesterol synthesis
54
What is the expected reduction in LDL from high-intensity statin therapy?
50-60% within 6 weeks
55
What is the role of PCSK9 inhibitors?
They increase the number of LDL receptors on the cell surface
56
What are the monoclonal antibodies to PCSK9?
* Alirocumab
* Evolocumab
57
What does a score of 8+ on the Dutch Lipid Score indicate?
Definite familial hypercholesterolaemia (FH)
58
What is the most potent statin drug?
Rosuvastatin
59
What is the most common adverse effect associated with statins?
Myalgia
60
What is the mechanism of action for cholesterol absorption inhibitors like Ezetimibe?
Block NPC1L1 enterocyte cholesterol absorption channel
61
What is the typical LDL reduction expected from Ezetimibe?
15-20%
62
What is the evidence for bile acid sequestrants in cardiovascular risk modification?
There is no evidence for routine use
63
What is the primary indication for fibrates?
Use in triglyceride lowering
64
What is the LDL reduction percentage achieved by ODYSSEY Trio! despite statin treatment?
>60%
65
What did the FOU.>.UP Trial show regarding high-risk patients for primary prevention?
Minimal benefit and no mortality benefit
66
What was the finding of the ODYSSEY OUTCOMES Trial regarding CV mortality?
Benefit only in those not reaching an LDL target of 1.8mmol/L despite high intensity statin therapy
67
What is the estimated annual cost for PCSK9 inhibitor therapy?
Approximately AU$3,000-5,000
68
What type of molecule is Inclisiran?
Small interfering RNA (siRNA)
69
How does Inclisiran work?
Blocks the PCSK9 pathway by interfering with PCSK9 protein RNA molecules
70
Who are the candidates for PCSK9 therapies in Australia?
Those with familial hypercholesterolaemia or symptomatic atherosclerotic cardiovascular disease not reaching treatment goals despite high intensity statin and ezetimibe therapy
71
What is the general target for HbA1c in diabetes management?
<7%
72
What is an independent risk factor for cardiovascular events in diabetes?
Microalbuminuria
73
What is essential in all patients with diabetes?
Intensive blood pressure, lipid, and smoking control
74
What does the F¢/PA P,+C Trial suggest about SGLT-2 Inhibitor therapy with Empagliflozin?
Reduces heart failure admissions and cardiovascular and all-cause mortality in patients with pre-existing CVD
75
What is the blood pressure target for the general population?
<140/90 mmHg
76
What is the blood pressure target for diabetic patients and those with established CVD?
<130/80 mmHg
77
What is indicated to reduce the risk of 'white coat hypertension'?
Ambulatory blood pressure monitoring
78
When should screening for secondary causes of hypertension be indicated?
With drug-resistant hypertension, severe systolic hypertension on therapy, and other signs indicating secondary causes
79
What is indicated for patients with Grade 3 Hypertension?
Treatment
80
What should be commenced if lifestyle modification is ineffective in low-risk patients?
Drug treatment
81
What are ACE-inhibitors indicated for in diabetic patients?
Treating/preventing microalbuminuria
82
What is the classical presenting symptom of CAD?
Chest pain/angina
83
What occurs in stable CAD due to established coronary artery luminal narrowing?
Angina symptoms due to perfusion deficits at increased metabolic workloads
84
What is the annualized risk of stable CAD leading to ACS?
Approximately 3%
85
What did the ISCHEMIA Trial suggest about revascularization in patients with inducible ischemia?
Limited benefit compared to medical therapy
86
What is the most widely utilized diagnostic test in chest pain assessment?
Exercise ECG Testing
87
What indicates a positive exercise ECG test?
* Chest pain/angina
* ST depression
* Inadequate rise in blood pressure
88
What is the limitation of exercise stress testing?
Low sensitivity (50-60%)
89
What does Exercise Echocardiography provide compared to Stress ECG?
Additional sensitivity
90
What is a key feature of Dobutamine Stress Echocardiography?
Simulates stress without exercise
91
What is the purpose of a Nuclear Myocardial Perfusion Scan?
Detect perfusion defects without the need for exercise
92
What is a limitation of Nuclear Myocardial Perfusion Scan?
High radiation dose (>10mSv)
93
What is the role of Magnetic Resonance Imaging (MRI) in CAD investigation?
Assessment of regional wall motion abnormalities or scar tissue
94
What is required for CT Coronary Angiography?
Contrast media injection
95
What is the sensitivity of CT Coronary Angiography?
>95%
96
What does calcium scoring assess?
Amount of calcium within the coronary arteries
97
What is the main role of calcium scoring?
Guide commencement of statin therapy and risk factor control in intermediate risk asymptomatic patients
98
What is the cut-off point of stenosis rated as severe in invasive coronary angiography?
70%
99
What study showed that medical therapy outweighs the benefit of PCI in stable CAD?
The COURAGE Study
100
What is the sensitivity of Exercise ECG Testing?
85%
101
What is the diagnosis of STEMI based on?
ST elevation and a positive troponin assay
102
What is indicated for patients with low-intermediate pretest probability of significant CAD?
CT Coronary Angiography to exclude significant coronary artery calcification and stenosis
103
What investigation may be warranted for low-intermediate pretest probability with limited coronary artery disease risk factors?
CT Coronary Angiography to exclude significant coronary artery calcification and stenosis.
104
For high pretest probability with significant coronary artery disease risk factors, what may be required instead of CT Coronary Angiography?
Functional investigation (MPS, Stress Echocardiography) or invasive coronary angiography.
105
What factors influence the choice of functional testing?
* Patient's functional ability
* Contraindications to specific testing
* Testing availability in each centre.
106
What should be done for patients with CT Coronary Angiography showing luminal narrowing?
Further investigation with invasive coronary angiography may be required.
107
Invasive angiography should be reserved for patients who are amenable to what?
Revascularisation.
108
What is the role of primary prevention aspirin in asymptomatic people with no cardiovascular disease who are low-intermediate risk?
There is no role for primary prevention aspirin.
109
What is the first line treatment for patients with angina and suspected coronary artery disease?
Optimal medical therapy.
110
What are the key components of optimal medical therapy for angina?
* Antiplatelet - aspirin
* Statin
* Beta-blockers
* Treatment of risk factors.
111
Indications for invasive angiography include which of the following?
* Severe or unstable angina despite optimal medical therapy
* Large burden of ischaemia on stress imaging
* Acute coronary syndrome.
112
What is the definition of a Myocardial Infarction (MI)?
Positive troponin assay plus 1+ symptoms of ischaemia or ECG changes.
113
What characterizes Type 1 Myocardial Infarction?
Atherosclerotic plaque rupture or coronary artery dissection causing thrombus formation.
114
What causes Type 2 Myocardial Infarction?
Myocardial necrosis due to a mismatch of oxygen supply and demand, not caused by acute coronary artery thrombosis.
115
What characterizes Type 3 Myocardial Infarction?
Myocardial necrosis resulting in death, without biomarker evidence.
116
What is the first line bedside investigation to assess for MI?
Electrocardiogram (ECG).
117
What are common ECG findings in NSTEMI?
* ST segment depression
* T-wave inversion.
118
What is the most sensitive method of measuring myocardial necrosis?
Cardiac troponins.
119
What can cause false positive elevations in troponin assays?
* Cardiac conditions (e.g., heart failure)
* Aortic dissection
* Pulmonary embolism
* Neurological conditions.
* Renal failure.
120
What role does chest X-Ray play in the investigation of chest pain?
Essential initial investigation regardless of ECG or biomarker results.
121
What is the role of echocardiography in evaluating chest pain and ACS?
Identifying regional wall abnormalities and excluding severe valvular lesions.
122
What is the sensitivity of CT Coronary Angiography for significant coronary artery stenoses?
Approaching 95%.
123
What monitoring is indicated for NSTEMI and STEMI patients?
Telemetry monitoring.
124
What is the aim of treatment for NSTEMI?
Restore myocardial oxygen supply and reduce myocardial oxygen consumption.
125
What is the only indication for nitrates in acute coronary syndrome?
Symptom control - angina.
126
What are the benefits of beta-blockers during ACS presentations?
Provides a 13% relative risk reduction in mortality in the first week following MI.
127
What is the loading dose of aspirin recommended in the acute setting?
300mg.
128
What is the function of P2Y12 inhibitors in dual antiplatelet therapy?
Inhibit ADP-induced platelet aggregation.
129
What is the loading dose and daily dosing for clopidogrel?
300-600mg loading dose, 75mg daily.
130
What is the loading dose and daily dosing for prasugrel?
60mg loading dose, 10mg daily.
131
What is the main side effect of ticagrelor?
Dyspnoea and bradycardia in 10% of patients.
132
What is the main role of anticoagulation in NSTEMI and STEMI management?
To inhibit thrombin generation or activity.
133
What is the mechanism of action of Unfractionated Heparin?
Inactivates Factor II (thrombin) and Factor Xa.
134
What are the side effects of Unfractionated Heparin?
* Bleeding risk
* Heparin induced thrombocytopenia (HIT).
135
What is the purpose of initial bolus administration in intravenous infusion?
Early establishment of steady state concentration
136
When should anticoagulation be ceased prior to angiography?
Before angiography and not generally recommenced after PCI unless thrombotic complications occur
137
What is a key feature of the half-life of certain anticoagulants?
Short half-life allows for late cessation prior to angiography
138
What are the side effects of anticoagulation?
*Periods of under or over dosing outside of the narrow therapeutic window
*Bleeding risk with supratherapeutic APTT levels
*Heparin induced thrombocytopenia (HITs)
139
What is the mechanism of action of Low Molecular Weight Heparin (LMWH)?
Inactivates Factor Xa but not Factor II (Thrombin)
140
What is the most common form of LMWH?
Enoxaparin, delivered subcutaneously, twice daily
141
What is the bioavailability of Fondaparinux?
100% bioavailability
142
How does Fondaparinux compare to Enoxaparin in clinical trials?
Non-inferior and significantly reduces bleeding and mortality
143
What is the primary action of Bivalirudin?
Binds directly to Factor II (thrombin) to inhibit its action
144
What is the risk of Heparin Induced Thrombocytopenia (HITs) associated with LMWH?
Lower risk compared to unfractionated heparin (UFH)
145
What is the gold standard assessment tool in NSTEMI/STEMI presentations?
Invasive coronary angiography
146
What factors should be considered when deciding to perform invasive angiography?
*Benefit:risk of performing angiography
*Long term morbidity and mortality associated with the procedure
*Patient's functional status and medical comorbidities
147
What is the significance of the Left main coronary artery disease?
Carries a worse prognosis and generally requires CABG
148
What does a fractional flow reserve (FFR) <0.80 indicate?
Flow significant and an indication for PCI
149
What high-risk criteria necessitate urgent invasive therapy?
*Haemodynamic instability
*Cardiogenic shock
*Cardiac arrest
*Life threatening arrhythmia
*Recurrent, dynamic ST changes
150
What is the recommended access approach for coronary angiography based on recent trials?
Radial approach shows significant mortality benefit
151
What is the importance of identifying the 'culprit lesion' in NSTEMI/STEMI?
Prognostically important for treatment strategies
152
What does the Syntax Score help to determine?
Prognostication based on angiographic findings
153
What is the typical duration of dual antiplatelet therapy (DAPT) after PCI?
Minimum of 12 months
154
What is the role of the intra-aortic balloon pump in cardiogenic shock?
May be indicated for management
155
What is the recommended management for patients with heart failure?
*Assessment of symptoms
*Management of comorbidities
*Use of medications like ACE inhibitors, beta-blockers, and diuretics
156
What are the classifications of heart failure based on ejection fraction?
*HFpEF (LVEF >50%)
*HFmrEF (LVEF 40-49%)
*HFrEF (LVEF <40%)
157
What are common causes of heart failure?
*Ischaemic heart disease
*Hypertensive heart disease
*Valvular heart disease
*Arrhythmic heart disease
*Toxic damage
*Infiltrative diseases
*Immune-mediated causes
*Metabolic disorders
*Genetic causes
158
What is the significance of natriuretic peptides in heart failure diagnosis?
Elevated levels can indicate heart failure, but normal results have high negative predictive value
159
What is the New York Heart Association (NYHA) Class I definition?
No limitation in ordinary physical activity
160
What should be done for patients with a strong family history of heart failure?
Consider genetic testing
161
What is the recommended oxygen therapy in heart failure management?
Only indicated in hypoxaemia
162
What are the contraindications for thrombolysis?
*Absolute: Active bleeding, aortic dissection, previous intracranial hemorrhage, closed head trauma within 3 months, ischemic stroke within 3 months, malignant brain lesion
*Relative: Anticoagulation prior to presentation, recent surgery, recent peptic ulcer disease, poorly controlled hypertension, pregnancy, liver disease, prolonged CPR
163
What is the recommended management post-PCI?
*Management in a specialist Coronary Care Unit
*Continuous cardiac monitoring for at least 48 hours
*Assessment and management of cardiovascular risk factors
164
What is the symptom indicating dyspnoea at rest?
Dyspnoea at rest indicates severe limitation in physical activity
## Footnote
Symptoms include orthopnoea, paroxysmal nocturnal dyspnoea, and reduced exercise capacity.
165
What are natriuretic peptides used for in heart failure?
Natriuretic peptides are validated biomarkers for heart failure
## Footnote
An elevated level is not diagnostic, but a normal result has a high negative predictive value.
166
What does an abnormal ECG indicate in heart failure?
An abnormal ECG can indicate the aetiology of heart failure
## Footnote
Q waves suggest previous myocardial infarction; electrical criteria for left ventricular hypertrophy may indicate several conditions.
167
What is the initial test of choice in heart failure?
Echocardiography is the initial test of choice
## Footnote
It measures chamber volumes, pressures, and function without radiation.
168
What does the presence of pulmonary venous congestion suggest?
Pulmonary venous congestion suggests a cardiac cause for dyspnoea
## Footnote
Chest X-ray is used to assess this condition.
169
What is the significance of left ventricular ejection fraction (LVEF)?
LVEF is crucial for diagnosing heart failure types
## Footnote
HFpEF requires LVEF >50%, HFrEF requires LVEF <40%.
170
What is the role of stress echocardiography?
Stress echocardiography identifies inducible ischaemia in exertional symptoms
## Footnote
It can reveal new regional wall motion abnormalities.
171
What is the gold standard for assessing chamber volumes and function?
Cardiac magnetic resonance imaging (CMR) is the gold standard
## Footnote
It is particularly good for assessing right heart size and function.
172
What does a normal coronary angiogram indicate?
A normal coronary angiogram does not exclude ischaemic heart disease
## Footnote
It has a high negative predictive value.
173
What are the diagnostic criteria for HFpEF?
Diagnostic criteria involve:
* Heart failure symptoms
* Normal LVEF (>50%)
* Elevated natriuretic peptide levels
* Evidence of structural cardiac disease
## Footnote
Further echocardiographic features are also required.
174
What is the significance of right heart catheterization in HFpEF?
Right heart catheterization measures pulmonary capillary wedge pressure
## Footnote
A value >15mmHg suggests left heart disease.
175
What is the role of ACE-Inhibitors in HFrEF?
ACE-Inhibitors improve cardiac haemodynamics and prognosis
## Footnote
They reduce hospitalisation, morbidity, and mortality.
176
What are the proposed mechanisms of action for Beta-Blockers?
Beta-Blockers reduce myocardial oxygen demand and increase supply
## Footnote
They improve heart failure symptoms and outcomes.
177
What class of drugs is indicated in all symptomatic patients with LVEF <40%?
Mineralocorticoid Receptor Antagonists (MRAs) are indicated
## Footnote
They should be used with ACE-I and BB.
178
What is the role of Angiotensin Receptor Neprilysin Inhibitors (ARNI)?
ARNIs are superior to ACE-I in managing heart failure
## Footnote
They improve hospitalisations and mortality.
179
What is the mechanism of SGLT2 Inhibitors in heart failure?
SGLT2 Inhibitors reduce glucose reabsorption and encourage diuresis
## Footnote
Their benefit appears independent of diabetes status.
180
What should be avoided in HFrEF treatment?
NSAIDs, non-dihydropyridine calcium channel blockers, and glitazones should be avoided
## Footnote
These can exacerbate heart failure symptoms or worsen mortality.
181
What is the indication for Implantable Cardiac Defibrillators (ICD)?
ICDs are indicated for patients with NYHA II-III and LVEF <35%
## Footnote
They reduce risk of sudden arrhythmic death.
182
What is the evidence for the benefit of Ivabradine?
Ivabradine may provide hospitalisation benefit in selected patients
## Footnote
Criteria include symptomatic patients with specific LVEF and heart rate.
183
What are the effects of diuretics in heart failure?
Diuretics improve symptoms but have no effect on survival
## Footnote
They are used for fluid overload symptoms.
184
What is the mortality benefit of Digoxin in heart failure?
Digoxin has no proven mortality benefit
## Footnote
Emerging evidence suggests harm in some cases.
185
What is the primary indication for an ICD?
To reduce the risk of sudden arhythmic cardiac death in patients with life-threatening ventricular arrhythmia causing haemodynamic instability
## Footnote
Prognosis >1 year, good functional status, and at least 40 days after a myocardial infarction are required.
186
How much does ICD implantation reduce mortality?
25%
## Footnote
This statistic highlights the effectiveness of ICDs in improving patient outcomes.
187
What is the most effective method of preventing Ventricular Tachycardia (VT)?
Beta blockade
## Footnote
Beta blockers are commonly used in managing ventricular arrhythmias.
188
What effect does Amiodarone have on ventricular arrhythmias?
Reduces the number of shocks but does not improve mortality
## Footnote
Amiodarone is often used in the management of arrhythmias.
189
What does Cardiac Resynchronisation Therapy (CRT) involve?
Resynchronisation of ventricular contraction during systole
## Footnote
CRT is particularly beneficial in patients with heart failure and left bundle branch block.
190
What is the aim of CRT?
To resynchronise the ventricles to normal contraction timing
## Footnote
This is achieved through biventricular pacing.
191
What are the criteria for CRT to be effective?
NYHA II-III, LVEF <35%, QRS duration >130msec with left bundle branch block morphology
## Footnote
Reduced benefit is seen with right bundle branch block.
192
What study showed additional benefit in mortality for CRT?
PARE-HF, NEJM, 200ñ
## Footnote
This trial highlighted the mortality benefits of CRT.
193
What is the benefit of combining CRT with an ICD?
Patients fulfill criteria for both CRT and ICD, showing improved mortality
## Footnote
This combination is referred to as CRT-D.
194
What was demonstrated by the COMPANION study?
Benefit in mortality with CRT-D
## Footnote
This study supports the use of combined therapy in specific patient populations.
195
What is the indication for catheter ablation in patients with heart failure and chronic atrial fibrillation?
Improved outcomes to maintain sinus rhythm
## Footnote
CASTLE-AF showed reductions in mortality and hospitalizations.
196
What are the indications for heart transplant?
Severe heart failure with LVEF <35%, refractory life-threatening ventricular arrhythmia, combined heart-lung transplant
## Footnote
Patients must have persistent issues despite optimal therapy.
197
What are contraindications for heart transplant?
Pulmonary hypertension, alcohol excess, smoking, chronic liver disease, malignancy
## Footnote
These conditions can complicate or preclude transplantation.
198
What evaluations are required for heart transplant candidates?
Voltage gated blood pool scans, echocardiography, Holter monitoring, cardiac MRI, coronary angiography, right heart catheterization, potential ventricular biopsy
## Footnote
Comprehensive assessment is crucial for transplant eligibility.
199
What additional screenings are recommended for heart transplant candidates?
Autoimmunity, vasculitides, hepatitis viruses, HIV, cardiac risk factor screening, HLA tissue typing
## Footnote
These screenings help ensure candidate safety and compatibility.
200
What is a recommended pre-transplant assessment?
Dental review due to risk of endocarditis under immunosuppression
## Footnote
Patients are at higher risk for infections post-transplant.
201
What is a common requirement for patients prior to heart transplant?
Left ventricular assist devices and inotropic support
## Footnote
Many patients remain critically unwell while waiting for a transplant.
202
What are some complications associated with heart transplant?
Hyper acute rejection, acute rejection, chronic rejection, infections, malignancy, renal dysfunction, cardiovascular risk
## Footnote
Each complication poses unique challenges in post-transplant care.
203
What is the prognosis for patients with luminal stenosis >40% post-transplant?
Poor prognosis with 50% 2-year survival
## Footnote
Regular monitoring via angiography is essential.
204
What is the definition of Bradyarrhythmias?
Bradyarrhythmias are heart rhythms that are slower than normal.
205
What are normal ECG characteristics of the PR interval?
Normal PR interval is 120-200 msec.
206
What does a prolonged QTc interval indicate?
Prolonged QTc < 440 msec can indicate drug side effects or Long QT Syndrome.
207
What is sinus bradycardia?
Sinus bradycardia can be a normal finding, especially in young athletes or those with high vagal tone.
208
What is the main treatment for symptomatic bradycardias?
Permanent pacemaker is often indicated for symptomatic bradycardias.
209
What is Sick Sinus Syndrome (SSS)?
SSS encompasses a group of arrhythmias primarily affecting the SA Node, causing both bradycardic and tachycardic rhythms.
210
What type of heart block is characterized by fixed prolongation of the PR interval?
First Degree Atrioventricular Block.
211
What distinguishes Mobitz Type I from Mobitz Type II second degree AV block?
Mobitz Type I (Wenckebach) shows progressive PR interval prolongation, while Mobitz Type II has non-conducted P-waves with a fixed number of conducted beats.
212
What is the typical treatment for Mobitz Type II second degree AV block?
A permanent pacemaker is generally indicated due to higher risk of progression to complete heart block.
213
What is a characteristic feature of third degree Atrioventricular Block?
Complete dissociation of atrial P-wave activity from the AV Nodal system and QRS complexes.
214
What is the potential outcome of complete heart block without treatment?
It can lead to cardiac arrest and sudden cardiac death.
215
What is Neurocardiogenic Syncope?
It is complete asystole due to enhanced vagal tone, confirmed by excluding other causes.
216
What are the immediate risks associated with installing a permanent pacemaker?
Infection, bleeding, pneumothorax, ventricular rupture.
217
What long-term risks are associated with permanent pacemakers?
Infection risk, pacemaker induced cardiomyopathy, valvular heart disease, lead failure.
218
What is the most common cardiac tachyarrhythmia?
Atrial Fibrillation (AF).
219
What are common risk factors for Atrial Fibrillation?
* Age
* Hypertension
* Valvular heart disease
* Pulmonary hypertension
* Obesity
* Obstructive sleep apnoea
* Heart failure
220
What is the CHADS2-VASc scoring system used for?
It is used to assess the risk of thromboembolism in patients with AF.
221
What is the significance of a CHADS2-VASc Score of 2 or more?
Anticoagulation is generally indicated.
222
What are some options for anticoagulation in AF?
* Warfarin
* Dabigatran
* Rivaroxaban
* Apixaban
223
What is the role of rhythm control in Atrial Fibrillation management?
It is reserved for patients with new persistent AF or those intolerant of AF despite adequate rate control.
224
What is the most effective drug for inducing and maintaining sinus rhythm?
Amiodarone.
225
What does the term 'electrical cardioversion' refer to?
It refers to the process of restoring normal heart rhythm using electric shocks.
226
What is chemical cardioversion?
Chemical cardioversion can be performed using some antiarrhythmic agents
## Footnote
Common agents include amiodarone and sotalol.
227
Which drug is considered the most effective for inducing and maintaining sinus rhythm?
Amiodarone (60% effectiveness)
## Footnote
It is widely used in clinical practice for this purpose.
228
What is the effectiveness of sotalol in maintaining sinus rhythm after elective DC Cardioversion?
30% of cases
## Footnote
This indicates a lower efficacy compared to amiodarone.
229
Which drugs are less effective for rate control and not considered antiarrhythmic agents?
* Metoprolol
* Atenolol
## Footnote
These are primarily used for rate control in atrial fibrillation.
230
What is electrical cardioversion?
Elective DC Cardioversion performed under anaesthesia
## Footnote
It is a procedure to restore normal heart rhythm.
231
What must be proven before performing chemical or electrical cardioversion?
The absence of a left atrial thrombus
## Footnote
This is crucial to reduce the risk of embolic events.
232
What is the role of therapeutic anticoagulation prior to cardioversion?
For four weeks or a normal Transoesophageal Echocardiogram excluding left atrial thrombus
## Footnote
This reduces the risk of thromboembolic complications.
233
What is Atrial Flutter caused by?
A re-entrant circuit within the atria
## Footnote
This leads to rapid electrical impulses and subsequent atrial contractions.
234
What is the typical atrial rate of contraction in Atrial Flutter?
250-300 beats per minute
## Footnote
The ventricular rate can vary depending on the block type.
235
How is Atrial Flutter managed?
In the same manner as atrial fibrillation
## Footnote
This includes consideration for anticoagulation and cardioversion.
236
What is the most common form of Supraventricular Tachycardia (SVT)?
AV Nodal Re-entrant Tachycardia (AVNRT)
## Footnote
It involves depolarisation between slow and fast pathways around the AV Node.
237
What is a key treatment for AVNRT?
* Vagal manoeuvres
* AV Nodal Blockers (Adenosine)
* DC Cardioversion
## Footnote
Adenosine is contraindicated in severe asthma and with accessory pathways.
238
What is the ECG appearance of Atrioventricular Re-entrant Tachycardia (AVRT)?
Similar to AVNRT, without retrograde P-waves after the QRS complex
## Footnote
This indicates a different conduction pathway.
239
What syndrome is associated with a delta wave on ECG?
Wolff-Parkinson-White (WPW) Syndrome
## Footnote
It can lead to serious complications when combined with AF.
240
What is the risk associated with AF and WPW?
Can degenerate quickly into Ventricular Fibrillation (VF)
## Footnote
This is a life-threatening situation that requires urgent intervention.
241
What is the treatment for Atrial Tachycardia (MAT)?
Beta-blockade and management of pulmonary disease
## Footnote
MAT is often associated with advanced pulmonary conditions.
242
What is Ventricular Tachycardia (VT) typically associated with?
A structurally abnormal heart
## Footnote
Previous myocardial infarction is a major risk factor.
243
What are typical ECG features of VT?
* AV dissociation
* Distinct change in axis
* Capture beats
* Fusion beats
## Footnote
These features help in diagnosing VT.
244
What is the emergency management for hemodynamically compromised VT?
Emergency DC Cardioversion
## Footnote
This is critical for patients with altered levels of consciousness.
245
What is Torsades de Pointes?
A distinct form of polymorphic VT
## Footnote
It results from prolonged repolarisation typically due to electrolyte abnormalities.
246
What is the treatment for Ventricular Fibrillation (VF)?
* Cardiopulmonary resuscitation (CPR)
* Early defibrillation
* Amiodarone intravenous boluses
## Footnote
VF is always life-threatening and requires immediate action.
247
What genetic condition is associated with Long QT Syndrome?
Channelopathy affecting ion transport across myocardial membranes
## Footnote
It has an autosomal dominant inheritance pattern.
248
What is Brugada Syndrome characterized by?
ST segment variations in the anterior leads with a right bundle branch block pattern
## Footnote
It has a significant risk of sudden cardiac death.
249
What is Arrhythmogenic Right Ventricular Dysplasia (ARVD)?
A progressive heart muscle disorder predominantly affecting the right ventricle
## Footnote
It has an autosomal dominant inheritance pattern.
250
What is the classical feature of Hypertrophic Cardiomyopathy (HCM)?
Increased left ventricular wall thickness with hypertrophy (LVH)
## Footnote
It is the leading cause of sudden cardiac death in young individuals.
251
What treatments are indicated for high-risk patients with HCM?
* Avoidance of competitive sports
* Beta blockers
* ICD for proven VT episode
## Footnote
Other interventions include septal myectomy or alcohol septal ablation.
252
What are the three classifications of abnormal function of heart valves?
Stenotic, regurgitant, or combined
253
What is the consequence of stenotic lesions?
Pressure-loaded conditions in the chamber proximal to the valve
254
What is the consequence of regurgitant lesions?
Volume-loaded conditions proximal to the valve
255
What is a common presenting complaint in valve disease?
Exertional dyspnoea
256
What are other common complaints associated with aortic stenosis?
Angina and syncope
257
What does ECG assess in valvular heart disease?
Atrial enlargement, ventricular hypertrophy, arrhythmia, pulmonary hypertension
258
What can chest X-rays show in valvular heart disease?
Valvular calcification or previous valvular replacement
259
What is the first choice investigation for a heart murmur?
Transthoracic Echocardiography (TTE)
260
What does transthoracic echocardiography allow for?
Characterisation of the valvular lesion, severity, valvular anatomy, and consequences of remodelling
261
What is the purpose of transoesophageal echocardiography (TOE)?
Better definition of valve anatomy and assessment of flow across the valve
262
What are the indications for TOE?
High suspicion of endocarditis, exclusion of paravalvular abscess, closer assessment of prosthetic valve disease
263
What is the most common cause of mitral regurgitation?
Primary degeneration - leaflet prolapse or flail leaflet
264
What are symptoms of acute severe mitral regurgitation due to papillary muscle rupture?
Acute pulmonary oedema
265
What is the management option for acute severe MR?
Urgent surgical repair
266
What are the indications for surgical management of severe MR?
* Symptomatic patients
* Asymptomatic patients with dilated LV or LVEF <50%
* Asymptomatic patients with secondary pulmonary hypertension or new AF
* Asymptomatic severe MR undergoing CABG
267
What is the preferred surgical option for mitral regurgitation?
Valve repair over valve replacement
268
What is a common cause of mitral stenosis in Australia?
Rheumatic heart disease
269
What symptoms are commonly reported in mitral stenosis?
Exertional dyspnoea
270
What are the echocardiographic indications for surgical intervention in mitral stenosis?
* Valve area <1.0cm²
* Mean gradient >10mmHg
271
What is the main management option for aortic regurgitation?
Aortic valve replacement
272
What are the indications for aortic valve replacement?
* Symptomatic patients
* Asymptomatic patients with LVEF <50%
* Progressive severe left ventricular dilatation
* Patients undergoing CABG
273
What is the primary cause of aortic stenosis?
Degenerative and calcific changes, congenital bicuspid valve, rheumatic heart disease
274
What are the symptoms of aortic stenosis?
Angina, exertional dyspnoea, syncope
275
What defines severe aortic stenosis by TTE?
* Mean gradient >40mmHg
* Velocity >4m/sec
* Valve area <1.0cm²
* DSI <0.25
276
What are the consequences of aortic stenosis?
Concentric left ventricular hypertrophy, impaired diastolic relaxation, pulmonary hypertension
277
What is the management option for severe aortic stenosis?
Surgical intervention with valve replacement
278
What is the role of TAVI in aortic stenosis management?
Used in high-risk patients with contraindications to surgical valve replacement
279
What complications can arise from TAVI?
* Paravalvular leak
* Stroke
* Valve thrombosis
* Valve displacement
* New AV block requiring pacemaker
280
What is the common outcome for right-sided valve lesions compared to left-sided?
Right-sided valve lesions are much less symptomatic
281
What is a rare indication for tricuspid valve replacement?
Tricuspid stenosis
282
What is the typical cause of pulmonary valve lesions?
Congenital heart disease
283
What is the controversy surrounding the use of NOACs in valvular heart disease?
Mitral valve lesions being a common precipitant of atrial fibrillation
284
What is the only validated safe treatment option for anticoagulation in significant valvular heart disease?
Warfarin
285
What is the only tested and validated safe treatment option for patients with prosthetic valves requiring anticoagulation?
Warfarin
## Footnote
Warfarin is the only anticoagulant recommended for patients with prosthetic heart valves.
286
Which anticoagulants are contraindicated in patients with prosthetic heart valves?
NOACs
## Footnote
NOACs (Novel Oral Anticoagulants) have been shown to be harmful in patients with prosthetic heart valves.
287
What cardiovascular changes occur during pregnancy?
* Increased plasma volume
* Increased heart rate and cardiac output
* Decrease in systemic vascular resistance
288
What cardiac conditions are considered high risk during pregnancy?
* Left sided obstructive valve defects
* Pulmonary arterial hypertension
* Preexisting left ventricular systolic dysfunction
289
Which valvular lesion carries the worst prognosis in pregnancy?
Moderate to severe mitral stenosis
## Footnote
Especially when complicated by pulmonary hypertension.
290
What is infective endocarditis (IE)?
Presence of pathogenic organisms within the endocardium, typically attached to valve leaflets.
291
What is the most common initial complaint in patients with infective endocarditis?
Fever
## Footnote
Fever occurs in 90-96% of cases.
292
What are common embolic phenomena seen in infective endocarditis?
* Brain emboli
* Renal emboli
* Pulmonary emboli
* Splenic emboli
293
Which patients are at particularly high risk for infective endocarditis?
Patients using intravenous drugs (IVDU)
## Footnote
They are at risk of right sided valve lesions and skin organisms.
294
What pre-existing cardiac conditions predispose to infective endocarditis?
* Prosthetic valve replacement
* Congenital cyanotic heart disease
* Previous episodes of infective endocarditis
295
What antibiotic regimen is recommended for dental procedures to prevent infective endocarditis?
Amoxicillin IV or Oral, 2g once only, 60 minutes prior to procedure.
296
What are the Modified Duke Criteria used for?
To determine the likelihood of infective endocarditis.
297
What is the typical duration of antibiotic treatment for infective endocarditis?
Typically 6 weeks or longer.
298
What is the most common organism identified in infective endocarditis?
Staphylococcus aureus.
299
What is the first line treatment for Enterococcus in infective endocarditis?
Combination of Amoxicillin and Gentamicin for six weeks.
300
What are indications for surgical intervention in infective endocarditis?
* Acute heart failure
* Persistent infection despite adequate antibiotics
* Extension of infection into perivalvular tissue
301
What is the prognosis for fungal infections in infective endocarditis?
Worse than most bacterial pathogens.
302
What are common causes of pericarditis?
* Viral infections (e.g., Coxsackie)
* Drug-related
* Malignant
* Traumatic
303
What typical ECG findings support a diagnosis of pericarditis?
* Widespread PR depression
* Saddle-shaped ST elevation
304
What is the treatment for aseptic, low-risk pericarditis?
Colchicine +/- NSAID as an outpatient.
305
How is myocarditis diagnosed?
Chest pain and elevated troponin assay without coronary artery disease.
306
What is a common complication associated with myocarditis?
Ventricular arrhythmia.
307
What are the signs indicating cardiac tamponade?
* Haemodynamic compromise
* Raised jugular venous pressure
* Muffled heart sounds
* Pulsus paradoxus
308
What is the urgent treatment for cardiac tamponade?
Pericardiocentesis under image-guidance.
309
What complications can arise from pericardial effusion?
* Fluid reaccumulation
* Repeated pericardiocentesis
* Constrictive pericarditis
