Cardio Flashcards
1
Q
What is an accelerated idioventricular rhythm? Management?
A
Benign ectopic rhythm of ventricular origin
Occurs following reperfusion of ischaemic tissue, electrolyte abnormalities or drug toxins –> increased rate of ventricular depolarisation
Management: Self limiting
2
Q
What are the acceptable rise in eGFR/creatinine when starting ACEi?
A
Creatinine - up to 30%
eGFR - up to 25%
K - up to 5.5
3
Q
What is achondroplasia?
A
Autosomal dominant
Short stature
Large heart with frontal bossing
Trident hands
Lumbar lordosis
4
Q
Management of STEMI?
A
Aim saturations >94%
GTN, IV morphine, metoclopramide
Aspirin 300mg
+Clopidogrel/Ticagrelor/Prasurgel
NOTE: Ticagrelor is now preferred over clopidogrel if medically managed. Aspirin and Prasugrel if PCI
PCI within 120 minutes
If not, fibrinolysis. If failure of resolution at 90 minutes on ECG, then transfer for PCI
5
Q
Management of acute pericarditis? Most specific ECG finding? What should all patients have?
A
NSAID + Colchicine
ECG: PR depression most specific. Widespread saddle shaped ST elevation
All should have TTE
6
Q
Causes of pericarditis? (8)
A
viral infections (Coxsackie) tuberculosis uraemia (causes 'fibrinous' pericarditis) trauma post-myocardial infarction, Dressler's syndrome connective tissue disease hypothyroidism malignancy
7
Q
What potentiate the effects of adenosine?
A
Dipyridamole
8
Q
What reduces the effects of adenosine?
A
Theophyllines
9
Q
What condition is a contraindication for adenosine?
A
Asthma
Can enhance conduction down accessory pathways i.e. WPW
10
Q
Examples of ADP (adenosine diphosphate) receptor inhibitors?
A
Clopidogrel
Prasugrel
Ticagrelo
Ticlopidine
11
Q
New recommendations for dual antiplatelet treatment for 12 months as secondary prevention?
A
Aspirin (75mg OD)
Ticagrelor (90mg BD)
12
Q
What is the interaction between clopidogrel and PPIs?
A
Reduced antiplatelet effects
13
Q
What are the four Hs and four Ts in ALS?
A
Hypoxoia
Hypovolaemia
Hyperkalaemia/Hypokalaemia/Hypoglycaemia/Hypocalcaemia
Hypothermia
Thrombosis
Tension Pneumothorax
Tamponade
Toxins
14
Q
When is adrenaline given in VT/VF arrest?
A
After the third shock. The every 3-5 minutes (alternate cycles)
15
Q
When is adrenaline given in asystole/PEA?
A
Immediately
16
Q
What would amyloidosis look like on an ECG?
What might you see on echo?
A
Low voltage complexes
Poor R wave progression
Global speckled pattern on echo
17
Q
What is drug management of angina?
A
- Beta-blocker or Calcium Channel blocker (verapamil or diltiazem if monotherapy. Nifedipine, amlodipine, felodipine if dual)
- Poor response - titrate up
- 1: Add second agent
- 2: If no response and second agent not tolerated, add long acting nitrate, ivabradine, nicorandil, ranolazine
- Assess for PCI or CABG
All patients:
Aspirin
Statin
GTN
18
Q
What should you do i nitrate tolerance develops in angina?
A
Second dose after 8 hours (for IR only)
19
Q
Antiplatelet management (first and second line):
Medically treated ACS
A
Aspirin (life)
Ticagrelor (12 mo)
OR Clopidogrel (life)
20
Q
Antiplatelet management (first and second line):
PCI
A
Aspirin (life)
Ticagrelor/Prasurgrel (12 mo)
OR Clopidogrel (life)
21
Q
Antiplatelet management (first and second line):
TIA
A
Clopidogrel (life)
OR Aspirin (lifelong) & dipyridamole (lifelong)
22
Q
Antiplatelet management (first and second line):
Ischaemic Stroke
A
Clopidogrel (life)
OR Aspirin (lifelong) & dipyridamole (lifelong)
23
Q
Antiplatelet management (first and second line):
Peripheral Arterial Disease
A
Clopidogrel (life)
OR
Aspirin (life)
24
Q
Signs of aortic regurgitation?
A
Early diastolic murmur Collapsing Pulse Wide pulse pressure Quinke's sign De Musset's sign Mid-diastolic Austin Flint murmur if severe
25
Aortic dissection management.
Type A vs Type B
Type A:
Surgical
BP aim 100-120
Type B:
Conservative
IV Labetalol
26
Features of aortic stenosis?
Chest pain
SOB
Syncope
```
Ejection systolic murmur
Narrow pulse pressure
Slow rising pulse Delayed ESM
Soft/absent S2
S4
Thrill
LVH
```
27
Management of aortic stenosis?
What other investigation should be done whilst investigating and why?
Symptomatic - replace
Asmyptomatic with gradient >40mmHg - consider surgery
Often do angiogram at same time - so can have CABG if needed
28
What is arrhythmogenic right venticular cardiomyopathy?
Typical ECG findings?
Management?
Autosomal dominant
Fatty and fibrofatty tissue replaced
Palpitations
Syncope
Sudden cardiac death
```
V1-3 T Wave Inversion
Epsilon Wave (terminal notch in QRS)
```
Management:
Sotalol
ICD
Catheter Ablation
29
How to rate control AF?
Beta-blocker
OR
Rate-limiting calcium channel blocker (Diltiazem)
If this fails, can combine with any 2 of the following:
Beta-blocker
Diltiazem
Digoxin
30
Who can be electively cardioverted in AF?
What extra precaution of high risk of failure?
Only if new onset for 48 hours --> heparinise
Onset >48hrs
Anticoagulated for 3 weeks and then continue for 4 weeks after (or can exclude with TOE and then heparinise and cardiovert immediately)
If high risk of failure (previous failure, AF recurrence) - at least 4 weeks amiodarone or sotalol prior
31
What is CHA2DS2VASc score?
```
CCF (1)
HTN (1)
Age 75 (2)
Age 64-75 (1)
Diabetes (1)
Stroke/TIA (2)
Vascular Disease (1)
Sex - Female (1)
```
If 0 - no treatment
If 1 - male consider, female no treatment
If 2 - offer anticoagulation
32
Where should atrial flutter be ablated?
Radiofrequency ablation of the tricuspid valve isthmus
33
What is an atrial myxoma?
Features?
Primary cardiac tumour
75% in left atrium
```
SOB
Fatigue
Pyrexia
Clubbing
Emboli
AF
Mid diastolic murmur
Tumour plop
```
34
Features of ASD?
ESM
| Fixed split S2
35
What are the features of the two common ASDs?
Ostium Secundum
70%
Higher in location
ECG: RBBB with RAD
Ostium Primum
Abnormal AV valve
Lower in location
ECG: RBBB with LAD, prolonged PR
36
What is Mobitz 1?
Progressive prolongation of PR interval until dropped beat
37
What is Mobitz 2?
PR interval constant
P wave often not followed by a QRS complex
38
What drug must beta blockers never be used with? Why?
Verapamil
Can cause severe bradycardia
39
What is Brugada syndrome? How is it managed?
Autosomal dominant
Mutation in SCN5A gene --> sodium ion channel (20-40%)
Can cause sudden death
Management:
ICD
40
What are characteristic ECG findings of Brugada?
Convex ST elevation >2mm in V1-3 followed by negative T wave
Partial RBBB
May be more apparent with flecainide or ajmaline
41
Which returns lower oxygenation levels. The IVC or SVC?
SVC returns lower oxygenation levels due to the higher consumption of the brain
42
What non-invasive imaging modalities can you use for investigating the heart (i.e. following NSTEMI)
Nucelar Imaging
- assess myocardial perfusion and myocardial viability
Cardiac CT
- calcium score
- contrast CT - visualise coronary artery lumen
Cardiac MRI
- gold standard for structural abnormalities
- perfusion
43
Beck's triad in cardiac tamponade?
Hypotension
Raised JVP
Muffled Heart sounds
```
Also:
SOB
Tachycardia
Absent Y descent
Pulsus paradoxus
Kussmauls
Electrical alternans
```
44
JVP in cardiac tamponade vs constrictive pericarditis?
Cardiac Tamponade
- Absent Y descent
Constrictive pericarditis
X + Y present
45
Common echo findings suggestive of HOCM?
MR
Systolic anterior motion of anterior mitral valve
Asymmetric septal hypertrophy
46
Causes of dilated cardiomyopathy?
Alcohol
Coxsackie B
Wet Beri Beri
Doxorubicin
47
Causes of restrictive cardiomyopathy?
Amyloidosis
Post-radiotherapy
Loeffler's edocarditis
48
What are the three features of typical angina?
1. Constricting discomfort in front of chest, neck, shoulders, jaw or arms
2. Precipitated by physical exertion
3. Relieved by rest or GTN in 5 minutes
49
Investigation of stable angina?
```
How is this order changed according to likely hood of coronary artery disease?
>90%
61-90%
30-60%
10-29%
```
1. CT coronary angiography
2. Non-invasive functional imaging (ie. MPS with SPECT, Stress Echo, MRI)
3. Invasive Coronary Angiography
>90% - no tests
61-90% - Invasive coronary angiography
30-60% - functional imaging
10-29% - CT calcium scoring
50
Features of cholesterol embolisation?
Eosinophilia
Purpura
Renal Failure
Livedo reticularis
51
Features of complete heart block?
```
Syncope
Heart Failure
Regular bradycardia
Wide pulse pressure
JVP - cannon waves
Variable intensity of S1
```
52
Features of constrictive pericarditis?
```
SOB
Right heart failure (elevated JVP< ascites, oedema, hepatomegaly)
Prominant X and Y descent
Pericardial knock
Kussmaul's sign
Pericardial calcification on CXR
```
53
How does dabigatran work?
What is it used for?
Direct thrombin inhibitor
Used for prevention of stroke in patients with non-valvular AF
54
Management of HTN in diabetes:
What is the target BP?
Target BP with end organ damage?
What should first agent be?
Aim <140/80
Aim <130/80 if end organ damage
Begin with ACEi regardless of age or race.
If African, begin with ACEi + Thiazide/CCB
55
What are common cardiac defects found in patients with Down's syndrome?
```
Endocardial cushion defect (40%))
VSD (30%)
2. ASD (10%)
ToF (5%)
PDA (5)
```
56
DVLA Rules for:
```
Elective Angioplasty
CABG
ACS +/- PCI
Angina
PPM
ICD (for arrhythmia, for prophylaxis)
AAA >6.5cm
Catheter ablation for arrhythmia
```
Elective Angioplasty
- 1 week
CABG
- 4 weeks
ACS +/- PCI
- 4 weeks
- 1 week if PCI
Angina
- stop if sx at rest
PPM
- 1 week
ICD
- 6 months (arrhythmia)
- 1 month (prophylaxis)
AAA >6.5cm
- Banned
Catheter ablation for arrhythmia
- 2 days
57
ECG Criteria for electrical hypertrophy?
>40mm the sum of V1 S and V5 or V6 R
58
Bifid P wave?
Left atrial enlargement
59
ECG Bifasicular block?
RBBB + left anterior or posterior hemiblock
i.e. RBBB with LAD
60
ECG Trifasicular block?
RBBB + left anterior or posterior hemiblock
+
1st degree block
61
ECG Territories and Coronary Arteries
Anterior Septal
Inferior
Anterolateral
Lateral
Posterior
Anterior Septal
- V1-V4
- LAD
Inferior
- II, III, aVF
- Right Coronary
Anterolateral
- V4-6, I, aVL
- LAD or Left circumflex
Lateral
- I, aVL +/- V5-6
- Left circumflex
Posterior
- Tall R wave V1-2
- eft circumflex, also right
62
ECG Digoxin signs (4)
Downward sloping ST depression
Flattened/Inverted T wave
Short QT
Arrhythmia
63
ECG Hypokalaemia
```
U waves
Small or absent T waves
Prolong PR
ST depression
Long QT
```
64
ECG Hypothermia
```
Bradycardia
J wave (small hump at end of QRS)
1st degree block
Long QT
Atrial and ventricular arrhythmia
```
65
ECG P Pulmonale?
Cor Pulmonale
66
What is the significance of prolonged PR infective endocarditis?
Abscess secondary to endocarditis --> refer to cardiac surgeons
67
What is Eisenmenger's Syndrome?
Reversal of a left to right shunt in a congenital heart defect due to pulmonary hypertension
ASD
VSD
PDA
68
How should acute heart failure patients be classified?
Four groups
With or without hypoperfusion
With or without fluid congestion
69
Management of heart failure? What cardiac drug class is contraindicated?
ACEi
B-Blocker (bisoprolol, carvedilol, nebivolol)
Spironolactone/Hydralazine with nitrates/ARB
Consider CRT (If NHYA Class III, Wide QRS)/Digoxin (digoxin indicated if co-existant AF)
Consider Ivabradine if HR >75, EF <35% and on maximal medical
Annual influenza Vaccine
One off pneumococcal vaccine
Contraindicated: Rate-limiting CCB
70
What is S3 heart sound?
Rapid diastolic filling of ventricle
Heard in LVH, constrictive pericarditis, mitral regurgitation
71
What is S4 heart sound?
Atrial contraction against a stiff ventricle
Heard in aortic stenosis, HOCM, HTN
72
Cause of widely split S2?
RBBB
Deep inspiration
Pulmonary stenosis
Severe MR
73
Cause of loud S2?
HTN
74
Cause of reversed split S2?
```
LBBB
Severe aortic stenosis
WPW Type B
PDA
RV pacing
```
75
Cause of fixed split S2?
ASD
76
Features of HELLP?
N&V
RUQ pain
Lethargy
Haemolysis
Elevated Liver Enzymes
Low Platelet
Management:
Deliver baby
77
What is homocystinuria?
Autosomal recessive
Defieicny in cystathionine beta synthase
Severe elevations in plasma and urine homocysteine
```
Fine fine hair
Marfan's like
Learning difficulty
Dislocation of lens
Malar flush
```
Positive cyanide-nitroprusside test
Positive cystinuria
Treat: Vitamin B6 (pyridoxine)
78
ECG changes from hypercalcaemia?
Short QT interval
79
Diagnosis of HTN?
Clinic Reading >140/90
Offer ABPM
<135/85 - Nil
>135/85 - Stage 1 HTN
>150/95 - Stage 2 HTN
80
Treatment of Stage 1 HTN
Only if < 80 years and any of the following:
- Target organ damage
- CVS disease
- Renal disease
- Diabetes
- 10 yr score >10%
81
When should immediate HTN be arranged in clinic?
If BP > 180/110
Signs of papilloedema or retinal haemorrhages
82
Management of HTN?
Lifestyle (low salt <6g, low caffeine, stop smoking, less alcohol, Mediterranean diet, exercise, lose weight)
< 55 or T2DM
1) ACEi
2) ACEi + CCB or Thiazide-like
>55 or Afro-caribbean
1) ACEi
2) ACEi + CCB
Common Pathy
3) ACEi + CCB + Thiazide-like
4) If K <4.5 - Spiro. If K >4.5 alpha or beta blocker
83
What is resistant HTN?
HTN requiring step four of treatment algorithm.
You should seek specialist advice if this fails
84
BP Target (in clinic and home)
< 80 years
>80 years
<80
140/90
135/85
>80
150/90
145/85
85
Causes of secondary HTN?
Renal:
- Glomerulonephritis
- Pyelonephritis
- APKD
- Renal Artery Stenosis
Endo:
- Conn's
- Phaeo
- Cushing
- Liddle's
- CAH
- Acromegaly
Drug:
- Steroids
- MAOi
- COC
- NSAIDs
- Leflunomide
Other
- Pregnancy
- Coarctation of aorta
86
Management of Hypertrophic obstructive cardiomyopathy?
```
(ABCDE)
Amiodarone
Beta-blocker/verapamil
Cardioverter Defibrillator
Dual Chamber PPM
Endocarditis Prophylaxis
```
AVOID:
Nitrates
ACEi
Inotropes
87
Infective endocarditis:
Most common organism in Developing world
Streptococcus Viridans
88
Infective endocarditis:
Most common organism in Developed world
Staphylococcus Aureus
89
Infective endocarditis:
Most common organism in indwelling lines (thus first 2 months following prosthetic surgery)
Staphylococcus epidermidis
90
Infective endocarditis:
Most common organism in poor dental hygeine?
Streptococcus viridans (mitis or sanguinis)
91
Infective endocarditis management:
Blind
Native Valve - Amox
Pen Allergy - Vanc, Gent
Prosthetic - Vanc, Rifampicin, Gent
92
Infective endocarditis management:
Native (Staphylococci)
Flucloxacillin
Pen Allergy - Vanc, Rifampicin
93
Infective endocarditis management:
Prosthetic (Staphylococci)
Flucloxacillin, rifampicin, gent
Pen allergy - vanc, rifampicin, gent
94
Infective endocarditis management:
Streptococci (full sensitive)
Benzylpenicillin
Pen Allergy - vanc + gent
95
Infective endocarditis management:
Streptococci (partial sensitive)
Benzylpenicillin + gent
Pen Allergy - vanc + gent
96
Indications for surgery in infective endocarditis?
Severe valve incompetence
Aortic abscess
Resistant to Abx
Cardiac failure refractory to medical managent
Recurrent emboli after Abx
97
Adverse effects of ivabradine? (3)
Visual effect (luminous phenomena)
Headache
Bradycardia/Heart block
98
JVP - list the order of waves
A --> C --> X --> V --> Y
99
JVP: What does the A wave represent?
What do cannon A waves represent?
A = atrial contraction
If large --> Tricuspid stenosis, pulmonary stenosis, pulmonary HTN
Cannon A = atrial contraction against a close tricuspid valve
Seen in complete HB, VT, Ectopics, Nodal Rhythm
100
JVP: What does the c wave represent?
Closure of tricuspid valve
Not normally visible
101
JVP: What does the V wave represent?
What do giant V waves represent?
Passive filling of blood into atrium against closed tricuspid valve
Giant V waves in tricuspid regurgitation
102
JVP: What does the X descent represent?
Fall in atrial pressure during ventricular systole
103
JVP: What does the Y descent represent?
Opening of tricuspid valve
104
Management of Kawasaki disease?
High dose aspirin
IVIG
ECHO
105
What complicaiton of kawasaki disease are you most concerned about?
Coronary artery aneurysm
106
What are the features of kawasaki disease?
```
High grade fever >5 days
Conjunctival injection
Bright red, cracked lips
Strawberry tongue
Cervical lymphadenopathy
Red palms of hands and soles of feet which later peel
```
107
How do LQT 1 patients present?
Exertional syncope
108
How do LQT 2 patients present?
Emotional syncope
109
How do LQT 3 patients present?
Die in sleep or event at night
110
Congenita LQT and Deafness
Jervell-Lange-Nielsen Syndrome
111
Congenital LQT
No deafness
Romano-Ward Syndrome
112
What is Lown-Ganong-Levine Syndrome?
Pre-excitation disorder of heart
Abnormal connection between atria and ventricles which bypassess AV node straight to Bundle of His
Bundle of James
Short PR interval
113
Features of McCune-Albright syndrome?
precocious puberty
cafe-au-lait spots
polyostotic fibrous dysplasia
short stature
114
Causes of mitral stenosis?
Rheumatic Fever - often presents late in pregnancy
(also:
Mucopolysaccharidoses
Carcinoid
Endocardial Fibroelastosis)
115
Features of Mitral stenosis?
```
Mid-late diastolic murmur
Loud S1 (opening snap)
Low volume pulse
Malar flush
AF
```
Left Atrial Enlargement on CXR
116
Continuous machine like murmur
PDA
117
Mid-late diastolic murmur (2)
Mitral stenosis (rumbling)
Austin-Flint (severe AR)
118
Early diastolic murmur (2)
Aortic Regurgitation (blowing, high pitch)
Graham-Steel Murmur (Pulmonary regurgitation)
119
Late Systolic (2)
Mitral Valve prolapse
Coarctation of aorta
120
Holosystolic (2)
Mitral/tricuspid regurgitation (high pitch, blowing)
VSD (harsh)
121
Ejection Systolic (5)
```
Aortic stenosis
Pulmonary Stenosis
HOCM
ASD
ToF
```
122
Complications of MI (10)
1. Cardiac Arrest (VF --> ALS)
2. Cardiogenic Shock (inotropic support/intra-aortic balloon pump)
3. CHF
4. Tachyarrhythmia
5. Bradyarrhythmia
6. Pericarditis (acute, dressler's)
7. LV Aneurysm (persistent ST elevation, LV failure. Anticoagulate)
8. LV Free Wall Rupture (leads to tamponade, pericardiocentesis)
9. VSD (acute HF and pansystolic murmur)
10. Acute MR (infero-osterior infarction. Acute hypotension and pulmonary oedema)
123
Secondary prevention of MI?
```
Dual antiplatelet
ACEi
B-Blocker
Statin
Mediterranean diet
Exercise
```
If signs of HF after acute MI, treat with eplerenone within days 3-14.
124
Glycaemic control in MI patients with diabetes?
Dose adjusted insulin infusion
Aim < 11mmol/l
125
Causes of myocarditis?
```
Viral: Coxsackie B, HIV
Bacteria: Diphtheria, clostridia
Lyme disease
Chagas
Toxoplasmosis
Autoimmune
Doxorubicin
```
126
Treatment of orthostatic hypotension?
How is it defined?
Drop >20/10 mgHg within 3 minutes of standing
Midodrine
Fludrocortisone
Beware other causes i.e. alpha-blockers
127
What is a patent ductus arteriosus?
Management?
Connection between pulmonary trunk and descending aorta
Indomethacin - closes connection
128
Features of PDA?
```
left subclavicular thrill
continuous 'machinery' murmur
large volume, bounding, collapsing pulse
wide pulse pressure
heaving apex beat
```
129
What are the signs for urgent treatment of a bradyarrhythmia/tachyarrhythmia?
BP < 90, pallor, sweating, cold, confused
Syncope
MI
HF
130
What is the management of symptomatic bradyarrhythmia?
1. Atropine (500mcg) IV up to 3x
| 2. Trascutaneous Pacing OR Isoprenaline/Adrenaline
131
What is the management of symptomatic tachyarrhythmia?
DC Shock!
132
What is Phenylketonuria?
Autosomal recessive
Disorder of phenylalanine metabolism
```
Presents as:
Seizures
Developmental delay
Fair hair, blue eyes
Eczema
Musty odour
```
Management:
Strict diet
133
Features of pre-eclampsia?
After 20 weeks gestation
HTN
Proteinuria
```
Headache
Visual distrubance
Papilloedema
RUQ pain
Hyperreflexia
```
134
Risk factors for pre-eclampsia?
```
High risk:
Previous HTN pregnancy
CKD
Autoimmune disease
Diabetes
Chronic HTN
```
```
Moderate Risk:
First pregnancy
Age 40+
BMI >35
Family history
Multiple pregnancy
```
135
Management of pre-eclampsia?
Target BP <160/110
Labetaolol
Nifedipine
Hydralazine
Deliver baby
136
Investigation of DVT/PE in pregnancy?
Why is CTPA bad?
If suspect DVT:
1. Compression duplex USS
If suspect PE:
1. ECG, CXR
2. Compression duplex USS
3. V/Q or CTPA
CTPA carries increased risk of maternal breast cancer
137
What is pulmonary arterial hypertension?
Presentation?
>25mmHg
```
Progressive SOB on exertion
Exertional syncope
Exertional CP
Perioheral oedema
Cyanosis
RV heave
Loud P2
Raised JVP
TR
```
138
Management of pulmonary arterial HTN?
First vasodilator testing
If positive:
- Oral calcium channel blocker
If negative:
prostacyclin analogues: treprostinil, iloprost
endothelin receptor antagonists: bosentan, ambrisentan
phosphodiesterase inhibitors: sildenafil
139
Using the 2-level wells score for PE, what is the cut off point for PE likely ?
More than 4 points
4 or less means PE unlikely
140
Investigation and management of PE with score of 4 on Wells score?
Urgent CTPA
If not possible, treat with LMWH whilst waiting
V/Q if renal impairment
141
What is a pulsus paradoxus?
Fall of 10mmHg systolic BP during inspiration
Severe asthma
Cardiac tamponade
142
What is a slow rising pulse?
Aortic stenosis
143
What is a collapsing pulse?
Aortic regurgitation
PDA
Hyperkinetic state (anaemia, thyrotoxic, fever, exercise)
144
What is a Pulsus alternans?
Regular alternation of force of arterial pulse
Severe LVF
145
What is a Bisferiens pulse?
Double pulse (two systolic peaks)
Mixed aortic valve disease
146
What is a Jerky pulse?
HOCM
147
What is Rheumatic fever?
Develops following umunologicalr eaction to recent (2-6weeks) streptococcus pyogenes infection
148
Diagnosis of Rheumatic fever?
Diagnosis is based on evidence of recent streptococcal infection accompanied by:
2 major criteria
1 major with 2 minor criteria
Evidence of recent streptococcal infection
raised or rising streptococci antibodies,
positive throat swab
positive rapid group A streptococcal antigen test
Major criteria
erythema marginatum
Sydenham's chorea: this is often a late feature
polyarthritis
carditis and valvulitis (eg, pancarditis)*
subcutaneous nodules
```
Minor criteria
raised ESR or CRP
pyrexia
arthralgia (not if arthritis a major criteria)
prolonged PR interval
```
149
What is superficial thrombophlebitis? How should it be investigated and managed?
Inflammation and throbosis of one of the superficial veins
20% have underlying DVT
Investigaiton:
USS to exclude DVT
Management:
Compression Stockings
LMWH for 30 days (fondaparinux for 45 days) OR NSAIDs for 8-12 days
If near the sapheno-femoral junctoin - anticoagulate for 6-12 weeks
150
Management of SVT in asthmatics if vagal manoeuvre fails?
Verapamil
151
Management of Takayasu's arteritis?
Steroids
Associated with renal artery stenosis
152
Features of Takotsubo cardiomyopathy?
Stress induced
Apical ballooning and severe hypokinesis of mid and apical segments of heart
Chest pain
HF features
ST elevation
Normal Coronary angiogram
Supportive management
153
What are the four features of tetraolgy of fallot
VSD
RV Hypertrophy
RV outflow tract obstruction
Overriding aorta
Presents around 1-2 months
154
Features of Tricuspid regurgitation
Pan systolic murmur
Prominent/giant V waves
Pulsatile hepatomegaly
Left parasternal heave
155
Management of haemodynamically stable VT?
Amiodarone
Lidocaine
Procainamide
DO NOT USE VERAPAMIL!
156
INR target for warfarinised VTE:
Initial event
Recurrent
Initial - 2.5
Recurrent - 3.5
157
AF INR target:
2.5
158
Management of Warfarin with high INR:
Major Bleed
Stop warfarin
Give IV Vit K and Prothrombin complex concentrate
159
Management of Warfarin with high INR:
INR >8, minor bleed
Stop warfarin
IV Vit K
Repeat dose if still high at 24 hrs
Restart when INR <5
160
Management of Warfarin with high INR:
INR >8, no bleed
Stop warfarin
Oral vit K
Repeat dose if still high at 24 hrs
Restart when INR <5
161
Management of Warfarin with high INR:
INR 5-8, minor bleed
Stop warfarin
IV vit K
Re-start when <5
162
Management of Warfarin with high INR:
INR 5-8, no bleed
Withhold 1 or 2 doses
163
WPW positive R wave in V1. Which type and where is the accessory pathway?
Type A
Between left atria and ventricle
Causes RAD
164
Which patients benefit from CABG over PCI in uncontrolled angina?
No more than 2 antianginals prior to consideration of reperfusion therapy
When stable coronary artery disease and ischaemia >10% in left ventricle
Patients with:
```
Complex Anatomy
Triple Vessel disease
Proximal left main stem disease
Age 65+
Diabetes
```
165
Side effects/contraindications of the additional anti-anginal drugs:
Long-acting nitrates
Nicorandil
Ivabradine
Ranolazine
Long-acting nitrates
- Hypotension
- Contraindicated with sildenafil
Nicorandil
- Hypotension
- Severe headaches
- Contraindicated with sildenafil
Ivabradine
- Only works in sinus rhythm (thus not used in sick sinus)
- Reduces heart rate (don't use in bradycardia)
- Do not use in moderate to severe angina
- Does not cause hypotension
Ranolazine
- Negative inotrope
- Liver dysfunction
- Severe renal disease
166
What is Wellen's syndrome?
ECG manifestation of critical proximal left anterior descending coronary artery stenosis
Unstable angina
Symmetrical deep >2mm T wave inversion in anterior precordial leads
Treat with urgent angiography and revascularisation
167
When should patients with angina have a third agent?
Only if not candidate for PCI or CABG
168
What is Prinzmetal's angina?
Due to vasospasm
Pain at rest
ECG - ST elevation. This disappears when pain goes
Avoid smoking
Rx:
CCB, Nitrates, Nicorandil
169
When investigating angina, if calcium score is:
0
1-400
>400
0 - Ix for other causes of pain
1-400 - 64 slice CT angiogram
>400 - invasive angiogram
170
When should ivabradine be used for heart failure patients?
```
Ejection fraction 35%
Heart rate >75/min
Sinus rhythm
NYHA class 2-4
Maximally titrated beta blocker therapy.
```
171
Management of resistant hypertension?
Resistant Hypertension
HTN that has not responded to 3 appropriately dosed anti-HTN medications
K+ > 4.5 - alpha or beta-blocker
K+ <4.5 - spironolactone
172
What should not be done / given to patients with WPW in AF?
How should they be managed?
Do not:
Valsalva
AV Blocking Drugs (adenosine, beta-blocker, calcium channel blocker, digoxin [ABCD])
Risk VT or VF
Unstable - urgent syncrhonised DC cardioversion
Stable - procainamide, DC cardioversion, flecainide, amiodarone
Definitive - ablation
173
Differentiate WPW Type A from Type B
Type A
- Left AV connection
- Positive R wave in V1
Type B
- Right AV connection
- Negative delta wave in V1
174
Differentiating spinal stenosis from vascular claudication?
Neurogenic Claudication:
- Sx on exertion that improve with leaning forward, sitting down
Vascular Claudication:
- Sx on exertion that improve with rest
175
Criteria for diagnosis of Takayasu?
3 of 6 below = 90% sensitivity and specificity
1. Age onset <=40 years
2. Claudication of the extremities
3. Decreased pulsation of one or both brachial arteries
4. Difference of at least 10 mm Hg in systolic blood pressure between the arms
5. Bruit over one or both subclavian arteries or the abdominal aorta
6. Arteriographic narrowing or occlusion of the entire aorta, its primary branches, or large arteries in the proximal upper or lower extremities, not due to arteriosclerosis, fibromuscular dysplasia, or other causes
176
What is the pulmonary wedge pressure a surrogate marker for?
Left atrial pressure
177
What commonly occurs with right ventricle infarction? What happens to JVP?
Tricuspid regurgitation
Prominent V Wave
178
What are the HACEK group and what is their significance in infective endocarditis?
Can causes gram negative endocarditis
```
Haemophilus species
Actinobacillus actinomycetemcomitans
Cardiobacterium hominis
Eikenella corrodens
Kingella
```
179
What clue can help distinguish VT from SVT and BBB?
If RBBB and RAD --> more likely to be SVT with BBB
180
Who is Cardiac resyhchronisation therapy offered to?
NYHA III or IV heart failure
Ejection fraction of <35%
The heart is beating regularly with evidence of electrical conduction disease (wide QRS)
They are medication that is most effective for them
181
What do patients with sick sinus syndrome often have before beginning medication therapy? Why?
AAIR pacemaker
Can present with mixture of brady and tachy arrhyhthmias
182
When is starting a beta-blocker in heart failure contra-indicated?
When in acute decompensated heart failure
183
What is cyclizine induced heart failure?
Causes systemic HTN and tachycardia
Not recommended in ACS or severe hF
184
Side effect of ivabradine?
Visual disturbances (phosphenes and green luminescence)
185
Afro-Carribean on optimal first line heart failure medication. What is the next step?
Hydralazine and Nitrate
186
When would Sacubitril-Valsartan be indicated?
What is the washout period?
Heart failure not optimally managed despite medical therapy AND:
- Bradycardic
- Hypotensive
- Slightly raised K+
Washout 36 hours from last ACEi
187
Medical treatment of HOCM? What should not be given?
Betablocker (propranolol)
Or
Rate-limiting CCB (Verapamil)
If not managed:
Disopyramide
Not controlled with two agents:
- Surgical Myectomy
- DDR pacemakers
- Alcohol ablation
DO NOT give ACEi, Nitrates
188
Mainstay in additional treatment of anterior wall MI?
Diuretics to reduce pulmonary congestion
Inotropic support to enhance cardiac output and perfusion
189
In initial phase after PCI for ACS in patients with AF, what should be given to thin the blood?
2 antiplatelets
| 1 anticoagulant
190
What is Bornholm disease?
Viral infection causing pain in lower chest
191
What is pacemaker syndrome?
VVI Pacemaker
Simultaneous atria and ventricle contraction
Causes fatigue, dizziness, hypotension
192
Causes of AKI following angiography?
Contrast induced nephropathy
Cholesterol emboli
- raised eosinophils
- livedo reticularis
193
Management of Pulmonary embolism?
Sub-massive (RV dysfunction, myocardial injury):
- LMWH
Massive (shock or hypotension):
- Thrombolysis
194
Drug management of HTN?
Step 1; Age <55 - ACE inhibitor. Age >55 or of black African or Caribbean origin - calcium channel blocker
Step 2; ACE inhibitor + calcium channel blocker
Step 3; ACE inhibitor + calcium channel blocker + thiazide-like diuretic (Indapamide in preference)
Step 4; consider further diuretic or beta-blockade or alpha blocker and seeking expert advice
195
Complete heart block following MI in:
Anterior MI
Inferior MI
What are the different outlooks?
Anterior MI - significant damage. Will need pacing
Inferior MI - Likely transient (resolves after PCI)
196
Management of P wave systole?
External pacing
197
What can be used for rapid reversal of dabigatran?
Idarucizumab
198
When is Ezetimibe used?
Primary Hypercholesterolaemia
199
Elderly male with syncope on alpha blocker or BPH. What should you do?
Lying standing BP
| Stop the alpha blocker!
200
List causes of secondary hypertension:
```
Endocrine (4)
Adrenal (3)
Renal (4)
Cardiovascular (1)
Drugs (5)
```
Endocrine:
- Cushing
- Acromegaly
- Thyroid
- Hyperparathyroid
Adrenal
- Conns
- Adrenal hyperplasia
- Phaeo
Renal
- Diabetic nephropathy
- Chronic GN/TIN
- Adult polycystic kidney disease
- Renovascular disease
Cardiac
- Aortic dissection
Drugs:
- NSAIDs
- Oral Contraception
- Steroids
- Symphathomimetics
- MAOi
201
What is a MIBG scan used for?
Investigating Phaeo
202
Drugs causing Long QT?
```
TCAs
Quinidine
Erythromycin
Digoxin
Amiodarone
Lithium
```
203
Mobitz 2 or Complete heart block. What type of pacemaker?
DDD or DDDR
| as functioning atria
204
Relevance of cardiac amyloidosis and digoxin?
Digoxin should not be given due to higher risk of digoxin toxicity
205
What should happen to anticoagulation in AF after elective DC cardioversion?
Continue for 1 month
High risk of recurrent AF
206
What is the valve disease associated with ADPKD?
Mitral valve prolapse
207
What is Twiddling?
Refers to pacemaker dysfuntion due to patients interfering with wires
208
What imaging would you use to diagnose myocarditis?
Cardiac MRI
209
What is the risk if start AF patients on flecainide alone?
May turn to Atrial Flutter
Slows AF and then nay increase conduction due to 1:1 conduction and thus HR increases
210
What is peripartum cardiomyopathy?
LV ejection fraction reduced in last month or within 5 months of giving birth
Avoid ACEi if breast feeding/pregnant
211
What imaging would you use to investigate cardiomyopathy?
Cardiac MRI
212
Who is eligible for a pill in the pocket?
Paroxysmal AF (infrequent) with few symptoms
```
No history of IHD, valve or LV dysfunction
Infrequent episodes
BP >100
HR > 70
Understand when to take
```
213
How do you assess risk of LV tract obstruction in cardiomyopathy?
Exercise stress echo
214
Xanthelasma cause?
Hypercholesterolaemia
215
Management of Mitral valve stenosis?
Symptomatic (mitral valve area 1.5cm) and favourable valve morphology in absence of LA thrombus or moderate-to-severe MR
- Mitral valve balloon valvotomy
```
Severely symptomatic (NYHA 3, mitral valve area 1.5cm) who are not high risk for surgery and not candidates or failed previous balloon valvotomy
- Mitral valve surgery
```
216
When should TAVI be offered?
TAVI (transfemoral) for patients with low or intermediate risk surgical aortic valve insertion
For older patients that would usually have bioprosthetic valve
NOTE: Transapical TAVI inferior to surgical
217
Management of patient with severe aortic stenosis and sign of heart failure?
Consider aortic valve replacement
218
BP target?
HTN without comorbidity
Patient with Diabetes
Patient with diabetes and organ damage
HTN without comorbidity
140/90
Patient with Diabetes
140/80
Patient with diabetes and organ damage
130/80
219
Indication for mitral valve replacement?
New AF with MR
symptoms, left ventricular dysfunction, pulmonary hypertension, new atrial fibrillation and dilated left ventricle.
220
Indication for aortic valve replacement in AR?
significant enlargement of the ascending aorta, severe regurgitation with symptoms or if severe with an ejection fraction of less than 50%.
