cardio Flashcards
(499 cards)
1
Q
acei are also extensively used to treat
A
HF
2
Q
mechanism of action of ace i
A
inhibit the conversion from angiotensin I to angiontesnin II
3
Q
angiotensin II constricts the
A
efferent arterioles
4
Q
other side effects of acei
A
angioedema
hyperkalaemia
first dose hypotension (more common in people taking diuretics)
5
Q
contraindication to acei i
A
moderate - severe aortic stenosis
6
Q
should you give acei if breastfeeding
A
no
7
Q
what blood should be checked before and after taking acei
A
U&Es
8
Q
what is an acceptable range of increased in serum creatinine or potassium after starting Acei
A
rise in serum creatinine of up to 30% from baseline and increase in potassium up to 5.5
9
Q
getting significant renal impairment after starting an acei may mean you have
A
bilateral renal artery stenosis
10
Q
no rise in troponin is
A
unstable angina
11
Q
why might unstable angina be treated as NSTEMI initially
A
as troponin results can take some hours
12
Q
Nstemi can have
A
st depression
13
Q
v1-v4 what artery
A
LAD
14
Q
treatment of acs
A
MONA
15
Q
when do you give oxygen in ACS
A
ox sats <94%
16
Q
if had STEMI what should be given in addition to MONA
A
second antiplatelet
17
Q
PCI involves
A
balloon then stent
18
Q
risk stratification for NSTEMI
A
GRACE
19
Q
DABS for secondary prevention of MI
A
Dual antiplatelet
acei
beta blocker
statin
20
Q
how much aspirin in acs
A
300mg
21
Q
acs symptoms generally last at least
A
20mins
22
Q
STEMI criteria > 2 cocntingious leads of
A
2.5mm ST elevation in v2-3 in men under 40
>2mm in v2-3 in men over 40
1.5mm in v2-3 in women
1mm st elevation in other leads
new LBBB
23
Q
what happens if semi identified
A
300mg aspirin then is PCI possible within 120mins
24
Q
if PCI possible then what do
A
give praugrel
then give unfractionated heparin and bailout glycoprotein 2b/3a inhibitor
(drug eluting stents should be used in preference)
25
If PCI not possible so fibrinolysis then what.
give antithrombin at same time. then following procedure give ticagrelor
26
after fibrinolysis is there is ongoing myocardial ischaemia consider
PCI
27
if pt has high bleeding risk in PCI what do you swap prasugrel for
ticagrelor
28
if pt got high bleeding risk in fibrinolysis what do you swap ticagrelor for
clopidogrel
29
for PCI and pt is taking oral anticoagulants what do you swap prasugrel for
clopidogrel
30
what is the preferred stent type for PCI
drug eluting
31
what access is preferred for PCI
radial
32
fibrinolysis should also be done within 12hrs but if PCI
cannot be delivered within 120 mins
33
further anti platelet prior to PCI
not taking an oral anticoagulant - prasugrel
if taking an oral anticoagulant - clopidogrel
34
drugs used during PCI with radial access
unfractionated heparin with bailout glycoprotein 2b/3a inhibitor
35
drugs for PCI with femoral access
bivalirudin with bailout GPI
36
patients undergoing fibrinolysis should also be given an
antithrombin drug
37
when should ECG be repeated
after 60-90misn
38
in NSTEMI/ unstable angina. in addition to aspirin what should be given if no immediate PCI planned
fondaparinux
39
In an Nstemi/ unstable angina when should. you give unfractionated heparin as opposed to fondaparinux
if immediate angiography is planned to creatinine >265
40
what pts should have immediate coronary angiography in nstemi/ unstable angina
if unstable eg hypotensive
41
what its with nstemi/unstable angina should have coronary angio with 72hrs
if grace score>3%
42
further drug therapy for PCI in nstemi/unstbale angina
unfractioned herparin
dual antiplatelet therapy prior to PCI ( if not taken an oral anticoagulant - prasugrel or ticagrelor) if taking oral anticoagulant (clopidogrel)
43
further drug treatment in NSTEMI/ unusable angina if conservate ie no PCI
dual anti platelet - if high risk of bleeding - ticargrelor, if not at high risk of bleeding clopidogrel
44
Killip class stratifies
risk post MI
45
what is a poor prognostic indicator post mI
cardiogenic chock
46
acute pericarditis lasts less than
4-6 weeks
47
acute pericarditis 1-3 days post MI
fibrinous pericarditis
48
pericarditis can arise secondary to
malignancy eg lung or breast
49
pericarditis can sometimes present with
pericardial rub
50
what is the most specific marker for pericarditis
PR depression
51
all pts with suspected acute pericarditis should have
transthoracic echo
52
when should pericarditis be treated as an inpatient
fever over 38 or elevated troponin
53
what should be avoided until symptom reiltuon and normalisation of inflammatory markers in pericarditis. athletes should avoid strenuous exercise for at least 3 months
exercise
54
first lune for acute idiopathic or viral pericarditis
NSAIDS and colchicine- continued until symptom resolution and normalisation of inflammatory markers (1-2 weeks) followed by a taper of the dose over a further 2-4 weeks
55
adenosine used to terminate
SVT
56
effects of adenosine are enhanced by
dipyridamole
57
effects of adenosine are blocked by
theophylline
58
when should adenosine be avoided
asthmatics due to bronchospasm
59
what is an agonist of A1 rector in AV node and causes transient heart block in AV node
adenosine
60
why is adenosine infused via a large calibre cannula
due to its short half life of about 8-10 seconds
61
adenosine effects
chest pain
bronchospasm
transient flushing
can result in WPW
62
if cpr is in monitored unit eg CCU can give how many shocks
up to 3
63
what should be delivered asap for non shockable rhythms
adrenaline
64
in VF/pulseless VT when is adrenaline given
after 3 shocks
65
repeat adrenaline how often
1mg every 3- 5mins
66
what is an alternative to amiodarone that can be given
lidocaine
67
if thrombolytic drugs are given for suspected PE then CPR should be continued for how long
60-90misn
68
is atropine used for systole or PEA
no
69
following resus in ALS what should the oxygen be
94-98 _ don't want to over hyper- oxaemia
70
other H in reversible causes
hypothermia
71
amiodarone is used in
ventricular tachycardias
72
amiodarone mechanism of action
blocking K channels
73
why should amiodarone be given in central veins
causes thrombophlebitis
74
what is the half life for amiodarone
very long - 20-100 days
75
amiodarone is a p450 inhibitor so does what to warfarin
decreases metabolism of warfarin
76
hypo&hyper thyroids
corneal deposits
pulmonary fibrosis/pmneumonitis
liver fibrosis/ hepatitis
peripheral neuropathy
photosensitivity
slate grey appearance
bradycardia
lengthens QT interval
amiodarone
77
imaging you need to get before starting amiodarone
CXR
78
all its with angina should get
aspirina and statin (unless contraindicated)
79
what is given to abort attacks in stable angina
GTN sublingual
80
what is given first line to prevent angina attacks
Beta blocker or ccb
81
if a CCB mono therapy is given for angina which one
rate limiting so verapamil or diltiazem
82
if CCB for prevention of attacks in angina is given with a beta blocker a long acting dyhydropyridine should be given eg
amlodipine
83
why should beta blockers not be prescribed with verapamil
risk of complete heart block
84
if still symptomatic after mono therapy with beta blocker of CCB for angina add what
the other
85
other drugs to consider
long acting nitrate
ivabradine
nicorandil
ranolazine
86
if taking a beta blocker and a CCB for angina then only add a 3rd if awaiting PCI or CABG
87
annoying thing about nitrates
develop tolerance
88
if taking standard release isosorbide mononitrate should have asymmetric dosing regime so has nitrate free time of 10-14hrs to minimise development of tolerance
89
what drug blocks agiontensi II
arbs
90
pain is typically maximal at onset
aortic dissection
91
pain more common in type A
chest pain. upper back in B
92
pulse deficit so variation between arms
aortic dissection
93
aortic regurgitation may be seen in
aortic dissection
94
if spinal arteries are affected may cause
paraplegia- weakens of lower limbs and loss of bladder/bowel
95
type 1,2,3
1- ascending aorta to at least aortic arch
2- confined to ascending
3- descending
96
widened mediastinum
aortic dissection
97
ix of choice in aortic dissection
CT angio
98
what might CT angio show in aortic dissection
false lumen
99
what may be used in aortic dissection if cannot do CT
transoesosphageal echo (tOE)
100
mx of type a
surgery - & bp systolic should be between 100-120
101
type B mx
bed rest & reduce BP IV labetalol
102
forward tear complications
unequal arm pulses and BP and stroke
103
complication of backwards tear
aortic regal
inferior MI
104
signs of aortic regurgitation
collapsing pulse
wide pulse pressure
quince sign (nailed pulsation)
de musset sign (head bobbing)
105
intensity of murmur of aortic regurgitation can be increased by
handgrip maneovre
106
severe aortic regurgitation may have
mid diastolic Austin flint murmur - due to partial close os anterior mitral valve
107
aortic regurgitation imaging
echo
108
manage aortic regurgitation
medial mx of heart failure
109
most common cause of aortic regurgitation in developing world
rheumatic fever
110
marinas associated with
aortic regurgitation
111
acute presentations of aortic regurgitation
infective endocarditis
aortic dissection
112
aortic stenosis can present with
syncope
113
ejection systolic murmur seen in aortic stenosis can be decreased by
Valsalva manoeuvre
114
narrow pulse pressure
slow rising pulse
soft/absentS2
S4
aortic stenosis
115
most common cause of aortic stenosis if under 65
bicuspid aortic valve
116
most common cause of aortic stenosis if over 65
degenerative calcification
117
what is supravalvualr aortic stenosis cause
williams syndrome
118
symptomatic aortic stenos
valve replacement if asymptomatic then observe
119
in aortic stenosis if asymptomatic but valvular gradient is over 40 then
surgery for valve repalcemtn
120
what may be given to kids with aortic stenosis or adults who are not fit for valve replacement
balloon valvuloplasty
121
arrhythomegic right ventricular cardiomyopathy
second most common cause of sudden cardiac death in young people after hypertrophic cardiomyopathy
122
ARVC inherited via
auto dom
123
right ventricular myocardium is replaced by fatty and fibrofatty tissue
ARVC
124
epsilon wave and T wave inversion in V1-3
ARVC
125
mx of ARVC
sotalol
126
subtype of ARVC that has woolly hair and palmoplantar keratosis
Naxos disease
127
paroxysmal vs persistent af
episode lasts less or greater than 7 days
128
when would you use rhythm control over rate
coexistent HF
first onset AF
obvious reversible causes
129
first line rate control
beta blocker or rate limiting ccb eg diltiazem
130
if rate is not controlled by one drug then combination of 2 drugs can be used
beta blocker
diltiazem
digoxin
131
when is the greatest risk of stroke in af
when switches from AF to sinus rhythm
132
prior to cardio version need to
symtoms present for less than 48hrs or be anti coagulated for a period of time prior to cardio version
133
what scores you 2 points in chadvasc
age >75
s- stroke, TIA or thromboembolism prior
134
shdvasc when give anticoagulation
1 in males and 2 in females
135
if chadsvasc score indicates no need for anticoagulation important to to what imaging to exclude a valvular heart disease
transthoracic echo
136
risk of bleeding on anticoagulants
ORBIT
137
anaemia and renal impairment are on orbit score and suggest
an increased risk of bleeding
138
if previous yon warfarin for anticoagulant for af should you switch to a doac
yes
139
dabigtran is a DOAC
yep
140
electrical cardio version is synchronised to what wave
r
141
if arrthymia is less than 48hrs can start rate or rhythm control but if after 48hrs must start
rate - also if start of symptoms is uncertain then rate
142
if onset is less than 48hrs its should be
heparinised
143
what are the pharmacological carioversion
amiodarone or flecainide
144
what pharmacological conversion cannot be sued in structural heart disease
flecainide
145
Following electrical cardioversion if AF is confirmed as being less than -- hours duration then further anticoagulation is unnecessary
48
146
If the patient has been in AF for more than 48 hours then anticoagulation should be given for at least --- weeks prior to cardioversion.
3
147
if don't want to anticoagulant for 3 weeks prior to cardio version in onset>48hrs then can
do a transoesophageal echo (TOE) to exclude a left atrial appendage thrombus. if excluded its can be heparinised and cardioverted immediately
148
is onset >4hrs for carfivoersion nice recommend
electrical rather than pharmacological
149
if there is a high risk of cardioversion failure (e.g. Previous failure or AF recurrence) then it is recommend to have at least -- weeks amiodarone or sotalol prior to electrical cardioversion
4
150
Following electrical cardioversion patients should be anticoagulated for at least -- weeks. After this time decisions about anticoagulation should be taken on an individual basis depending on the risk of recurrence
4
151
if a patient with AF has had a stroke or a TIA, the log term anticoagulant for prevention should be
warfarin or a direct thrombin(dabigatran) or factor Xa inhibitor(rivaroxaban)
152
anticoagulant post stroke should be started
in absence of haemorrhage - 2 weeks after. antiplateelts should be given in the intervening period
in absence of haemorrhage - TIA- immediately
153
if >48hrs or pt not sure when symptoms started what control
RATE
154
if considered for long-term rhythm control, delay cardioversion until they have been maintained on therapeutic anticoagulation for a minimum of -- weeks
3
155
all patients with new-onset AF require anticoagulation, regardless of onset.
long-term anticoagulation is based on the CHA2DS2-VASc score
156
drug used to maintain sinus rhythm in its with history of fib
beta blockers ? (don't get)
amidoarone - particularly if coexisting heart failure
157
catheter ablation targets where
between pulmonary veins and left atrium
158
what should be done 4 weeks prior to catheter ablation
4 weeks anticoagulant
159
it should be remember that catheter ablation controls the rhythm but does not reduce the -- risk, even if patients remain in sinus rhythm. Therefore, patients still require anticoagulation as per their CHA2DS2-VASc score
stroke
160
complication of catheter ablation
cardiac tamponade
161
atrial flutter is a form of
SVT
162
rapid atrial depolarisation waves
atrial flutter
163
as the underlying atrial rate is often around 300/min the ventricular or heart rate is dependent on the degree of AV block. For example if there is 2:1 block the ventricular rate will be ----/min
150
164
what is curative for most its in atrial flutter
radio frequency ablation off the tricuspid valve isthmus
165
atrial flutter may be given meds as for
a fib
166
75% of atrial myxoma are in
left atrium, most commonly attached to the fossa ovalis
167
most common congenital heart defect to be found in adulthood
Atrial septal defect
168
most common ASD
osmium secundum
169
features of ASD
ejection systolic murmur and fixed splitting of S2
170
extra pharynx in thumb (holt oram syndrome ) associated with
osmium secundum
171
BNP is produced by what ventricle
left
172
raised BNP may be seen in
CKD
173
drugs which reduce BNP
antihypertensives
174
what beta blocker can cross the blood brain barrier
propanolol
175
bronchospasm
cold peripheries
fatigue
sleep disturbances, including nightmares
erectile dysfunction
side effects of beta blockers
176
Contraindications
uncontrolled heart failure
asthma
sick sinus syndrome
concurrent verapamil use: may precipitate severe bradycardia
beta blockers
177
bivalirudin is a
direct thrombin inhibitor
178
features suggests of Vt rather than SVT
QRS>160
lack of response to adenosine or carotid sinus massage
Av dissociation
179
brigade syndrome is auto
dom
180
SCN5a gene
brugada
181
ecg Changes in brugada
St elevation in v1-v3 followed by T wave inversion
RBBB
182
ix of choice in brugada
give flecainide or ajmaline and do ecg
183
mx of brugada
implantable cardioverter defibrillator
184
buergers disease presents as
intermittent claudication, ischaemic ulcers
superficial thrombophlebitis
raynauds
strongly associated with smoking
185
oxygen in right side of heart
70%
186
oxygen in left side of heart
98-100%
187
first cardiac enzyme to rise
myoglobin
188
what is a good cardiac enzyme to look for reinfarction
CK-MB as it returns to normal after 2-3 days whereas troponin T ermines elevated for up to 10 days
189
MUGA scan - multi gated acquistion scan used
typically used before and after cardio toxic drugs
190
cardiac MRI is the gold standing for
structural images of heart
191
pulsus paradoxus in cardiac tamponade
abnormal large drop in BP during inspiration
192
electrical alternans
cardiac tamponade
193
absent Y descent on JVP
cardiac tamponade 0 due to limitied right ventricular filling
194
kussmaul sign and pericardial calcification on cXR suggests
constrictive pericarditis
195
A commonly used mnemonic to remember the absent Y descent in cardiac tamponade is TAMponade = TAMpaX
- as one has X descent
196
Echo findings include MR, systolic anterior motion (SAM) of the anterior mitral valve and asymmetric septal hypertrophy
HOCM
197
what may cause dilated cardiomyopathy
chronic alcohol
198
takotsubo cardiomyopathy
stress induced cardiomyopathy - transient apical ballooning of the myocardium
199
pneumothorax
marfans
200
MSK chest pain
pain worse on movement or palpation
201
chest pain prices rash
shingles
202
perforated peptic ulcer
erect cxr- gas
203
boeerhaaves syndrome - severe chest pain after vomiting. ix
CT contrast swallow
204
Treatment is with thoracotomy and lavage, if less than 12 hours after onset then primary repair is usually feasible, surgery delayed beyond 12 hours is best managed by insertion of a T tube to create a controlled fistula between oesophagus and skin.
boerhaaves syndrome
205
do not given another -- for ACS If outside of hospital
antiplatelt
206
present to you with chest
GTN, aspirin and ECG
207
chest pain 12-72 hours ago
same day assessment
208
chest pain presenting >72hrs ago
ECG and troponin
209
copd oxygen sats 88-92% until
blood gas analysis available
210
1. constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms
2. precipitated by physical exertion
3. relieved by rest or GTN in about 5 minute
if meets 2/3 of these is called
atypical angina
211
in choking ask first - are you choking.
eencourage to cough
5 back blows
then 5 abdomen thrusts
then ambulance and CPR
212
hf blood test first line
NT- proBNP
213
if NT-proBNP high
transthoracic echo within 2 weeks
214
if NT-proBNP is raised then arrange echo within
6 weeks
215
high levels
BNP >400, NTproBNP >2000
216
raised levels of
BNP>100-400,NTproBNP 400-2000
217
Obesity
Diuretics
ACE inhibitors
Beta-blockers
Angiotensin 2 receptor blockers
Aldosterone antagonists
these can
decrease BNP levels
218
do loop diuretics have effect on mortality in HF
nope
219
first line for HF
acei and beta blcoker- one should be started at a time
220
beta-blockers licensed to treat heart failure in the UK include --, carvedilol, and nebivolol.
bisoprolol
221
ACE-inhibitors and beta-blockers have no effect on mortality in heart failure with--- ejection fraction
preserved
222
2nd line for HF
aldosterone antagonist
223
important to remember if on second line therapy for HF
acei and aldosterone antagonists both cause hyperkalaemia therefore this should be monitored
224
what diabetes med is goof for HF with reduced ejection fraction
SGLT2i
225
3rd line therapy for HF and can only be started by specialist
ibabradine (criteria sinus rhythm >745 and left ventricular fraction <35%)
sacubitril valsartan _ should be initiated following an acei or arb washout period
digoxin - if coexistent fib
hydralazine particularly indicated in Afro caribeans
cardiac resynchronisation therapy - widened QRS
226
vaccines in HF
annual flu and one of penumcocoal (may need every 5 years if got asplenia, splenic dysfunction, CKD)
227
New York hf classification
1- no symptoms
2- mild
2- moderate
4- severe
228
clopidogrel is first line
ischaemic stroke and peripheral arterial disease
229
clopidogrel drug class
thienopyridinies
230
antagonist of P2Y12 adenosine diphosphate(ADP) rector
clopidogrel
231
what can make clopidogrel less effective
PPI. lansoprazole should be ok
232
coarction of aortic is narrowing of
descending aorta
233
young adult with hypertension and systolic murmur may be
coarction of aorta
234
systolic murmur maximal over the back. apical click from aortic valve, radio femoral delay
coarction of aorta
235
in secondary prevention of stable cardio disease and antiplatetla and coag idnciatef which one you give
anticoagulant
236
if post ACS/ PCI
2 antiplatelens and 1 anticoag for 4 weeks - 6 motnthsn then 1 of each to complete 12months
237
in VTE do orbit and if low risk of bleeding
may continue antiplatelts
238
complete heart block
regular bradycardia
wide pulse pressure
JVP - cannon waves in neck
syncope, HF
239
particular cause of constrictive pericarditis
tb
240
constrive pericarditis typically causes what sided hf
right. elevated JVP, ascites, oedema, hepatomegaly
241
pericardial knock - loud S3 , jvp has X and Y descent, kussmaul sign is pos
constrive pericarditis
242
kussmaul sign in constrive pericarditis
failure of the JVP to fall during inspiration
243
direct thrombin inhibitor
dabigatran
244
when should dabigatran not be prescribed if
creatinine clearance <30
245
what can rapidly reverse dabigatran
idarucizumab
246
dabigatran contraindicated in
prosthetic heart valves
247
Firstly it is an option in the prophylaxis of venous thromboembolism following hip or knee replacement surgery.
Secondly, it is also licensed in the UK for prevention of stroke in patients with non-valvular atrial fibrillation who have one or more of the following risk factors present:
dabigatran
248
when are arbs preferred to acei
black African or African carribean diabetic pts
249
what should be avoided in uncomplicated diabetes hypertension particular when given in combo with thiazides as they may cause insulin resistance
beta blockers
250
duchennes can cause
dilated cardiomyopathy
251
wet beriberi (thiamine def) can cause
restrictive cardiomuypoathy
252
signs of HF
systolic murmur
S3
balloon appearance on CXR
dilated cardiomyopathy
253
in dilated cardiomyopathy predominately leads to what dysfunction
systolic
254
eccentric hypertrophy is seen in
dilated cardiomyopathy
255
acute coronary syndrome- 4 weeks off driving
1 week if successfully treated by angioplasty
implantable cardioverter-defibrillator (ICD)
if implanted for sustained ventricular arrhythmia: cease driving for 6 months
if implanted prophylactically then cease driving for 1 month. Having an ICD results in a permanent bar for Group 2 drivers
256
an aortic diameter of -- cm or more disqualifies patients from driving
6.5cm
257
heart transplant don't drive for
6 weeks
258
--
sum of S wave in V1 and R wave in V5 or V6 exceeds 40 mm
left ventricular hypertrophy
259
bifid p wave in lead II
left atrial enlargement
260
right atrial enlargement
tall p waves in both II and V1
261
right axis deviation causes
right ventricular hypertrophy
cor pulmonale
PE
usually WPW
262
left axis deviation
left anterior hemlock, osmium prime ASD
263
e.g. RBBB with left axis deviation
bifascicular block
264
features of bifascicular block as above + 1st-degree heart block
trifascicular block
265
Lead I: Positive deflection
Lead aVF: Negative deflection
left axis deviation
266
changes in v1-3
usually left circumflex
267
posterior MIs cause reciprocal changes of STEMI
horizontal depression, tall borad R wvaes
268
posterior infarction if confirmed by
ST elevation and Q waves in V7-9
269
digoxin ecg changes
down sloping st depression (reverse tick, scooped out)
270
U waves
small or absent T waves (occasionally inversion)
prolong PR interval
ST depression
long QT
hypokalaemia
271
u wave
small positive deflection following T wave
272
In Hypokalaemia, U have no Pot and no T, but a long PR and a long QT
273
hypothermia ECG
J wave (Osborne wave ) small hump at end of QRS
first degree heart block
274
New LBBB is always
pathological
275
branch block look at
V1 and V6
276
what criteria is used to diagnose a MI if got existing LBBB
Sgarbossa criteria
277
first sign of MI but often only persists for a few mins
Hyperacture T wave
278
T waves in MI become inverted within
24hrs
279
can get pathological Q waves in
MI
280
A posterior MI causes ST --- not elevation on a 12-lead ECG.
depression
281
what do heart blocks are considered normal
first degree and mobitz 1
282
normal variants
sinus bradycardia or junctional rhythm
283
what causes increased P wave amplitude
cor pulmoamle
284
bifid P wave is a sign of
left atrial enlargement classicaly due to mitral stenosis- often most pronounced in lead II
285
there is an absence of P waves
afib
286
short PR interval is seen in
WPW
287
what K disturbance is associated with prolonged PR
Hypo
288
RBBB can be a normal variant as more common with
increasing age
289
PE can be associated with a
RBBB
290
prinzmetals angina refers to
coronary artery spasm
291
peaked T waves can be
hyperkalaemia or MI
292
inverted T waves can bet
MI, digoxin toxicity, SAH, PE
293
wellen Syndrom has high grade stenosis in
LAD
294
biphasic or deep t wave inversion in v2-3
wellens syndrome
295
what refers to reversal of a left to right shunt in a congenital heart defect due to pulmonary hypertension
Eisemengers syndrome
296
original murmur in eisenmengers syndrome may disappear what is the m x
heart- lung transplantation
297
symptoms of HF
breathlessness, reduced exercise tolerance, oedema, fatigue
298
signs of HF
cyanosis, tachycardia, elevated JVO, displaced apex beat, bibasal crackles may cause a wheeze
S3 heart sound
299
S3 heart sound is a sign of what sided
left HF
300
Over---% of patients with AHF have a normal or increased blood pressure (mmHg).
90
301
heart failure ix
bloods , corm echo, BNP
302
pulmonary oedema in HF can cause a
wheeze
303
signs of right sided hf
raised JVP, ankle oedema, hepatomegaly
304
if giving ox for HF what sats should be between
94-98
305
acute heart failure with respiratory failure give
CPAP
306
agent can use in HF if got hypotension
dobutamine
307
if dobutamine not sufficient what can be used
norepinephrine
308
don't give HF pts
opiates - increased morbidity
309
in acute HF regular meds for HF eg acei and beta blockers should be
continued
310
recommend for all pts with acute HF
IV loop
311
reduced LVEF
<35/40%
312
What determines left ventricular ejection fraction
echo
313
generally speaking reduced ejection fraction tend to have
systolic dysfunction and preserved tend to have diastolic dysfunction
314
HOCM has dysfunction
diastolic
315
most urgen symptoms of acute HF are due to
Left ventricular failure resulting in puomary oedema
316
afterload
stenosis
317
preload
regurgitation
318
left ventricular after load and pre land refer to right sided eg
aortic
319
Left ventricular failure typically results in:
pulmonary oedema
dyspnoea
orthopnoea
paroxysmal nocturnal dyspnoea
bibasal fine crackles
Right ventricular failure typically results in:
peripheral oedema
ankle/sacral oedema
raised jugular venous pressure
hepatomegaly
weight gain due to fluid retention
anorexia ('cardiac cachexia')
320
what is an example of high output heart failure
anaemia
321
preload think as
volume load on heart and think after load as pressure load on heart
322
first hear sound is closure of
mitral and tricuspid
323
second heart sound is due to closure of
aortic and pulmonary
324
loud S1
mitral stenosis
325
S2 splitting during inspiration is
normal
326
S2 is wha in aortic stenosis
soft - not what I would have thought
327
3rd heart sound is normal if under 30 or may persist in women to under
50
328
3rd heart sounds also heard in
left ventricular failure
constrictive pericardia
mitral regurgitation
329
3rd heart sound in constrive pericarditis referred to
pericardial knock
330
4th heart sound may be seen in
aortic stenosis, HOCM, hypetesnoon
331
3rd heart sound cuased by
diastolic filling of ventricle
332
4th heart sound caused by
atrial contraction against a stiff ventricle
333
4th heart sound coincides with what wave on ECG
P
334
in HOCM a double apical impulse may be felt as a result of a palpable --
s4
335
where is tricuspid valve
left 4th intercostal space at lower left sternal border
336
shorten QT
hypercalcaemia
337
hypercalcaemia can present as
hypertension
338
eruptive xanthoma are seen where
extensive surfaces
339
eruptive xanthoma are due to high
triglyceride levels
340
tendon xanthoma think
familial hypercholesterolaemia
341
xanthlasma are seenwherc
eyelids- also seen in pts without lipid abnormalities
342
what topcial therapy can be used in xanthelasma
trichloroacetic acid
343
other tests to do in hypertension
fundoscopy, urine dip, ECG, U&e (renal disease) , hba1c, lipids
344
ix for blood pressure
24hr blood pressure - ambulatory blood pressure
345
thiazides inhibit where
beginning of distal convoluted tube
346
side effects of CCB
flushing, ankle swelling, headache
347
side effects of thiazides
low na, K , dehydration
348
arbs s/e
hyperakalaemai
349
acei s/e
cough/angioedema, hyperakalemai
350
stage 2 BP
clinic - 160/100 or ambulatory 150/95
351
stage 3 hypertension
180 or 120
352
bp in both arms use readings from
higher arm
353
unequal blood pressure from arms eg
supravavualr aortic stenosis
354
admit to hospital if BP over
180/120/ phaechromocytoma suspected
355
if bp>180/120 but no worrying signs then first step to to urgently investigation end organ damage
356
if end organ damage present in hypertension don't wait fro results of ABPM just start
meds
357
ABPM 150/95 = stage 2
offer drub treatment regardless
358
low salt diet in
hypertension - less than 6g ideally less than 3g
359
a bpm for under 80 and over
135/85
145/85
360
most common cause of secondary hypertension
Conns
361
hocm is
auto dom
362
characterized by myofibrillar hypertrophy with chaotic and disorganized fashion myocytes ('disarray') and fibrosis on biopsy
HOCM
363
sudden death in HOCM is most commonly due to
ventricular arrthymias
364
double apex beat can be seen in
HOCM
365
how is the ejection systolic murmur of HOCM affected
increases with valsalva and decrease on squatting
366
Hocm is associated with
friedrichs ataxia and WPW
367
Echo findings - mnemonic - MR SAM ASH
mitral regurgitation (MR)
systolic anterior motion (SAM) of the anterior mitral valve leaflet
asymmetric hypertrophy (ASH
HOCM
368
mx of HOCM
Amiodarone
B eta blocker or verapamil for symptoms
Cardioverter defibrillator
Dual chamber pacemaker
Endocarditis prophylaxis
369
drugs to avoid in HOCM
nitrates, acei, inotropes
370
what is released in response to hypothermia
TSH and ACTH
371
best for checking core body temp
rectal or thermistor probes
372
ecg of hypothermia may show
acute st elevation and J waves or Osborn waves
373
what may be elevated in bloods in hypothermia
HB and haematcrit
374
in hypothermia need to monitor K as can become
hypokalaemia
375
don't rewarm to quick
376
IV drugs should be avoided in hypothermia where possible as they are more likely to have a drastic response to drug
377
what not to do if hypothermic
massage limbs
378
strongest rf for infective endocarditis
previous episode
379
most common valve affect in infective endocarditis
mitral
380
most common valve affect in IV drug users
tricuspid
381
organism in IVDU
aureus
382
virdans
poor dental hygiene or following dental procedure
383
epidermis is most common organism when
following prosthetic heart valve however after 2 months staph aureus is most common
384
strep bovis and gallolyticus
colorectal cancer
385
SLE associated with
Libman sacks
386
malignancy causing IE
marantic
387
prior antibiotic therapy
Coxiella burnetii
Bartonella
Brucella
HACEK: Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella)
culture neg causes of IE
388
duke criteria for IE
2 major
1 major and 3 minor
5 minot
389
only need 2 pos blood cultures for strep viridian or HACEK but need 3 for
sueurs and epidermis as they are less specific
390
other minor features of IE
fever, slinter haemorrhages, petechia, predisposing heart condition
391
poor prognosis os IE if
staph aureus infection
392
only give IE prophylaxis if getting surgery done at a site
that is currently receiving therapy for suspected infection
393
foraging body more likely in
right main bronchus
394
low K can cause
palpations
395
after bloods and ECG for arrhtymias what next
Holter monitoring
396
if halter not showing anything for palapatations can do
loop recorder
397
ivabradien reduces heart rate and act on
funny ion current which is expressing in SA node
398
luminous phenomena is common in ivadbradine
seeing flashes of light in dim lighting
399
non pulsatile JVP
superior vena caval obstruction
400
kussmaul sign is a paradoxical rise in JVP during inspiration seen in
constrictive pericarditis
401
Long QT associate with delayed
repolarisation of ventricles
402
Long QT can turn into
VT/torsades de pointes
403
long QT sects in
K channel
404
congenital causes of prolonged QT
Jervell lange nielsen
romano ward
405
electrolytes disturbances thatch prolong QT
Hypos
406
drugs that can prolong QT
amiodarone, sotalol, citalopram, erythromycin, haloperidol
407
exerc=tional syncope or syncope as coated with stress can be
long QT
408
beta blocker used to treat long QT except don't use
sotalol as can make it worse
409
terfinadine can cause long
QT
410
what works on thick ascending loop of Henle
loop - reduces absorption of NAcl
411
pts with renal function may need increased doses of
loop
412
loops can cause
hypocholraemic alkalosis
413
collagen disorders can predispose you to mitral regurgitation eg
marfans and ehlers danlos
414
mitral regurgitation can occur
POSt mI
415
pansystolic murmur seen mitral regurgitation can be described as
blowing
416
features of mid regurgitation
best heard at apex and radiating to axilla
s1 may be quiet and sever MR may cause a widely split ST 2
417
ecg of mitral regurg may show
Borad P wave
418
cardiomegaly may bee seen in mitral regurgitation
419
medical mx in acute cases of mitral regurgitation
nitrates, diuretics, pos inortopes, inta aortic ballon pump
420
causes of mitral stenosis are
rheumatic fever, rheuamtic fever and rheumatic fever
421
signs of mitral stenosis
haemolytic , loud S1, opening snap, low volume pulse, molar rash
422
if mitral stenosis no symptoms
monitor
423
mitral stenosis symptomatic
percutanosu mitral balloon valvotomy
424
double right border on car suggest
left atrial enlargement - maybe seen in MStenois
425
mitral valve prolapse may have
mid systolic click
426
meds shown to improve the long term prognosis fo pts with chronic heart failure
acei and beta blockers
427
most common cause of death following an MI
ventricular fibrillation
428
AV block is more common following
inferior MIs
429
10% of pts following MI get
pericarditis in first 48hrs
430
fever pleuritic pai and pericardial effusion and raised ESR post MI is dressers treated with
NSAIDs
431
left ventricular aneurysm post MI can be associated with
Persistent ST elevation
432
in 3% of post MIs seen 1-2 weeks after
left ventricular free wall rupture and present with HF secondary to cardiac tamponade ( raised JVP, pulsus paradoxes, diminished heart sounds) - urgent pericardiocentesis
433
pansystolic murmur post MI
ventricular septal defect
434
acute mitral regurgitation can occur post MI and due to
ischaemia or rupture of papillary muscle - early to mid systolic murmur is heard
435
don't advise omega 3 supplements and oily fish
post MI
436
post MI how much exercise
20-30mins until slightly breathless
437
sexual activity can resume when after uncomplicated MI
4 weeks
438
sildenafil can be used how long after MI
6 months
439
should not use sildenafil if also on
nitrates or nicorandil
440
P2y12 receptor antagonist
ticagrelor and clopidogrel
441
what is usually given for pts who are going to have a PCI
unfractionated heparin
442
after fibrinolysis ecg should be dome
90mins after - to see if 50% resolution if not may consider PCI
443
young pt with acute history of chest pain
myocarditis - raised inflammatory markers, BNP and cardiac enzymes
444
side effects of nicorandil
flushing and GI ulcers
445
nicorandil is a K channel activator that works through activation of
guanylyl cyclase
446
nicotinic acid is used in treatment of
hyperlipdaemia
447
nitrates cause the release of --- in smooth muscle, activating guanylate cyclase which then converts GTP to cGMP, which in turn leads to a fall in intracellular calcium levels
nitrous oxide
448
hypotension
tachycardia
headaches
flushing
nitrates
449
the BNF advises that patients who develop tolerance should take the second dose of isosorbide mononitrate after 8 hours, rather than after -- hours.
12
450
nitrate tolerance not seen in
isosorbide mononitrate
451
orthostatic hypotension more common in
Parkinson
452
drug causes of orthostatic hypotension
alpha blockers eg used in BPH
453
mx of orthostatic hypotension
midodrine and fludrocortisone
454
post what MI with type 2 or complete heart block is an indicator for temporary pacemaker
ANterior
455
another indication for temp pacemaker is
symptomatic/ unstable bradycardia not responding to atropine
trifascular block prior to surgery
456
fondaparinux actuates
antithrombin III- given subcut
457
direct thrombin inhibitors
bivalirudin or dabigatran (later often referred as doac too)
458
shock presents as
hypotension , pallor, sweating, cold, clammy
459
first line for bradycardia
atropine
460
up to how much atropine can be used
3mg
461
if atropine fails then what
external pacing then isoprenaline/adrenaline
462
in VT if pt unstable then
DC shocks - up to 3
463
narrow complex tachy
vagal manoeuvres then iv adenosine
464
iv vagal manoeuvres and adenosine not working for narrow complex VT then consider atrial flutter and give beta blockers to control rate
465
a narrow complex tachy that is irregular is probs af
466
broad complex tachy mx
AMIODARONE !!!!
467
broad complex tachy that is irregular seek expert help as could be fib with bundle branch block or could be
torsade de pointes
468
other cause of postural hypotension
diabetes, diuretics
469
premature ventricular complexes
sensation of heart skipped a beat - pulse feel irregular - wide QRS ad beats originate in ventricle. if asymptotic no mx
470
biological heart valves given if
old - no long term anticoagulant needed. aspirin long term
471
pulmonary artery occlusion pressure monitoring measures
left atrial pressure- indirect
472
high response rate best sign of
PE
473
PE rule out criteria low probability if less than
15%
474
PE likely if wells score is greater than
4
475
if delay in CTPA give
anticoagulant in meantime
476
if CTPA neg then do
leg US
477
If wells score below 4 then do
d-dimer
478
scan for PE if there is renal impairment - first line
V/Q scan
479
right bundle branch BLOCK AND RIGHT AXIS DEVIATION ARE ALSO ASSCOAITED WITH
PE
480
most common ecg change in PE
sinus tachycardia
481
cxr for all pts who suspect PE to exclude other pathology it is normal normal in PE but may show
wedge shaped opacification
482
is severe renal impairment <15 then what for PE
LMWH
483
PE in antiphospholipid syndrome
LMWH followed by Vit K antagonist
484
PE with instability
thrombolysis - ie if hypotensive
485
recurrent PE
IVC filter
486
rheumatic fever
strep progenies
487
bodies describing the granulomatous nodules found in rheumatic heart fever
Aschoff
488
major criteria for rheumatic fever
erythema marginatum, syndehams chorea, polyarthritis, regurg murmur
489
mx of rheumatic fever
Nsaids first line and antibiotics - Pen V if needed
489
ix for rheumatic fever
evidence of recent strep infection
490
vein may be harvested for bypass or for tx for varicose
long saphenous
491
what passes anterior to medial malleolus
long saphenous vein- originates big toe
492
short saphenous vein
run lateral of foot and post of leg and drains into popliteal vein
493
statins effect
myopathy, liver imapitemetn and may increase risk of intracerebral haemorrhage
494
when are statins contraidacte
macrolides and preg
495
when should statins be taken
night especially simvastatin
496
atorvastatin 20mg for primary prevention
increase the dose if non-HDL has not reduced for >= %
40%
497
statin dose for secondary prevention
80mg atorvastatin
498
