Cardio II

Question 1

Define cardiogenic shock

Answer 1

Inadequeate tissue perfusion primarily due to cardiac dysfunction

Question 2

Causes of cardiogenic shock

Answer 2

MI
Hyperkalaemia 
Endocarditis 
Aortic dissection 
Rhythm disturbance 
Tamponade

Question 3

List three causes of aortic stenosis

Answer 3

1. Senile calcification
2. Congenital
3. Rheumatic fever

Question 4

A patient presents with angina, dyspnoea and syncope. . She also complains of coughing up a white frothy sputum and needing to sleep with three pillows at night.

O/E you note that she has a slow rising pulse with a narrow pulse pressure. The apex beat is forceful and not displaced.

What is a possible dx? What type of murmur is associated with this condition

Answer 4

Aortic Stenosis

Ejection systolic murmur which radiates to the carotids. Heard loudest at the 2nd ICS when the patient is sitting forward.

Question 5

Outline the investigations you would do in a patient with suspected aortic stenosis.
What would you see on an ECG

Answer 5

Bloods: FBC, U&E's, Glucose, Lipids 
ECG: 
- LVH
- LV strain
- Tall R waves 
- ST depression 
- T wave inversion

Question 6

Outline the signs seen in patients presenting with aortic regurgitation

Answer 6

Collapsing pulse pressure, Corrigan’s pulse
Wide pulse pressure
Displaced apex beat
Soft/absent S2
Early diastolic murmur +/- Austin Flint murmur

Question 7

Pathophysiological changes as a result of mitral stenosis

Answer 7

1. Valve narrows, increase in LA pressure, loud S1 and atrial hypertrophy resulting in AF
2. Pulmonary oedema, pulmonary HTN, Loud P2.
3. RVH with a left parasternal heave
4. Raised JVP, oedema and ascites

Question 8

Clinical signs seen in patients presenting with mitral stenosis

Answer 8

Low volume pulse pressure 
Af 
Raised JVP 
Tapping non displaced apex beat 
Rumbling mid diastolic murmur 

**Gratham steel murmur: high pitched decrescendo murmur loudest on inspiration.

Question 9

Causes of mitral regurgitation

Answer 9

Mitral valve prolapse 
LV dilation
Post MI
Rheumatic fever 
Connective tissue disorders

Question 10

Patient presents complaining of fatigue, breathlessness and palpations
O/E you note a loud P2 and a blowing pansystolic murmur which radiates to the axilla.
An ECG shows P mitrale
What is your diagnosis?
What is p mitrale?
What would the CXR findings be in this patient?

Answer 10

Mitral regurgitation

P mitrale is an ECG finding of a P wave shaped like an M. It is indicative of a bulky left atrium, most commonly in left atrial hypertrophy

CXR

• LA and LV hypertrophy
• Mitral valve calcification
• Pulmonary oedema

Question 11

Cardiac side effect of erythromycin

Answer 11

Prolongs the QT interval

Produces Torsades de Pointes

Question 12

What are the contra indications for thrombolysis

Answer 12

Pregnancy 
Bleeding 
Recent stroke 
Severe HTN 
GI malignancy

Question 13

What are the features of tetralogy of fallot

Answer 13

VSD
Pulmonary stenosis
Over riding aorta
Right ventricular hypertrophy

Question 14

List the ECG findings of digoxin toxicity

Answer 14

Results in ECG abnormalities
Reverse tick phenomen
ST segement depression
Accentuated U wave

Question 15

List the causes of cardiomyopathy, classifying them under the following

• dilated
• restrictive
• hypertrophic

Answer 15

Hypertrophic

• Genetic
• Sporadic mutations

Restrictive

• Idiopathic
• Amyloidosis
• Sarcoidosis
• Haemochromatosis

Dilated

• Post viral
• Alcohol
• Pregnancy
• Chagas disease

Question 16

List the treatments for heart failure

Answer 16

1) ACEi, B blocker, diuretic (spiro) watch K+

2) Siagoxin/ ivabarine

Question 17

List the treatments for angina

Answer 17

Aspirin
Statins
ACEi +/- B blockers
+/- GTN spray

Question 18

List potential causes of HTN in young people

Answer 18

Endo

• Cushing’s
• Conn’s
• Acromegaly

Renal

• Renal artery stenosis
• Polycystic kidney disease
• Renal malignant tumours

Question 19

ECG changes of pericarditis

Answer 19

Wide spread ST elevation (saddle shaped)
PR depression
Variable T wave ( flattening and inversion)

Question 20

Causes of 1st degree heart block

Answer 20

Increased vagal tone
Athletes
Inferior MI
Mitral valve disease

Question 21

Name four types of supraventricular tachycardia

Answer 21

Atrial Flutter
Atrial Fibrillation
Atrioventricular Reentry Tachy (AVRT)
Atrioventricular Nodal Reentry Tachy (AVNRT)

Question 22

Causes of atrial fibrillation

Answer 22

Ischaemic heart disease
Hypertension
Valvular heart disease (esp. mitral stenosis / regurgitation)
Acute infections
Electrolyte disturbance (hypokalaemia, hypomagnesaemia)
Thyrotoxicosis
Drugs (e.g. sympathomimetics)
Pulmonary embolus
Pericardial disease
Acid-base disturbance
Pre-excitation syndromes
Cardiomyopathies: dilated, hypertrophic.
Phaeochromocytoma

Question 23

Causes of 1st degree heart block

Answer 23

Increased vagal tone
Athletic training
Inferior MI
Mitral valve surgery
Myocarditis (e.g. Lyme disease)
Electrolyte disturbances (e.g. Hyperkalaemia)
AV nodal blocking drugs (beta-blockers, calcium channel blockers, digoxin, amiodarone)
May be a normal variant

Question 24

Causes of Mobtiz II

Answer 24

Drugs: beta-blockers, calcium channel blockers, digoxin, amiodarone
Increased vagal tone (e.g. athletes)
Inferior MI
Myocarditis
Following cardiac surgery (mitral valve repair, Tetralogy of Fallot repair)

Question 25

Causes of Mobitz II

Answer 25

Anterior MI (due to septal infarction with necrosis of the bundle branches). Idiopathic fibrosis of the conducting system (Lenegre’s or Lev’s disease). Cardiac surgery (especially surgery occurring close to the septum, e.g. mitral valve repair) Inflammatory conditions (rheumatic fever, myocarditis, Lyme disease). Autoimmune (SLE, systemic sclerosis). Infiltrative myocardial disease (amyloidosis, haemochromatosis, sarcoidosis). Hyperkalaemia. Drugs: beta-blockers, calcium channel blockers, digoxin, amiodarone.

Question 26

Causes of complete heart block

Answer 26

Inferior myocardial infarction AV-nodal blocking drugs (e.g. calcium-channel blockers, beta-blockers, digoxin) Idiopathic degeneration of the conducting system (Lenegre’s or Lev’s disease)

Question 27

Causes of aortic regurgitation

Answer 27

ACUTE - Rheumatic fever - Aortic dissection CHRONIC - Congenital - Rheumatic heart disease - Connective tissue disease marfans - Autoimmune (Ank spon)

Question 28

Signs of aortic regurgitation

Answer 28

``` Collapsing pulse Wide pulse pressure Displaced apex beat Early diastolic murmur (+/- Austin Flint murmur) ```

Question 29

Signs of aortic stenosis

Answer 29

Slow rising pulse Narrow pulse pressure Ejection systolic murmur Forceful non dispalced apex beat

Question 30

Management of aortic stenosis

Answer 30

Medical - Monitor with f/up echo - Angina: Beta blockers - Rx HF (ACEi, diuretics) Surgery - Valve replacement - TAVI

Question 31

Management of a HIGH risk NSTEMI

Answer 31

``` Persistent ischaemia (ST depression, DM, +ve trop) GPIIb/IIIa antagonist (tirofiban) Angio within 96hrs Clopidogrel 75mg/d ```

Question 32

Name the medications that are given to prevent clot formation in patients receiving PCI

Answer 32

Antiplatelet agents 1. Ticagrelor: P2Y12 receptor antagonist 2. Low dose aspirin for 12 months post Anticoagulation - Heparin

Question 33

Signs of mitral stenosis

Answer 33

``` AF Low volume pulse Malar flush Increased JVP Non displaced tapping apex beat Rubbing mid diastolic murmur (+/- Gratham steel murmur) ```

Question 34

Causes of mitral regurgitation

Answer 34

``` Mitral valve prolapse LV dilatation Post MI (papillary muscle dysfunction) Rheumatic fever Connective tissue disease ```

Question 35

Signs of mitral regurgitation

Answer 35

Blowing pansystolic murmur Radiates to the axilla Displaced apex beat AF

Question 36

Signs of the tricuspid regurgitation

Answer 36

``` Raised JVP RV Heave Pansystolic murmur Pulsitile HSM Jaundice ```

Question 37

Management of sick sinus syndrome

Answer 37

Permanent atrial/dual chamber pacemaker

Question 38

General management of bradycardia

Answer 38

IV atropine | If poor response transcutaneous pacing

Question 39

Management of sinus tachycardia

Answer 39

Vagal manoeuvres (carotid massage) Beta-blockers Non-dihydropyridine CCB (verapamil)

Question 40

Management of AVNRT

Answer 40

Vagal manoeuvres Adenosine Prophylaxis: Digoxin, diltiazem, felcainide, BB Curative: radiofrequency ablation

Question 41

Management of AVRT

Answer 41

Vagal manoeuvres + adenosine Prophylaxis flecanide or sotalol Curative : radiofrequency ablation If it occurs with AF avoid using drugs that block the AV node

Question 42

Management of atrial flutter

Answer 42

Rhythm control Cardioversion or medications DC cardioversion IV amiodarone, sotalol, flecanide Recurrence Radio frequency catheter ablation

Question 43

Management of broad complex tachycardia

Answer 43

UNSTABLE - synchronised DC up to 3 times - Amiodarone 300mg 10-20 mins, 900ng 24hours STABLE/ IRREGULAR - Magnesium 2g over 10 minutes STABLE/REGULAR - Amiodarone as above Note VT is usually due to damage so will require maintenance anti- arrhythmias (BB/CBB) or consider implantable cardioversion defibrillator

Question 44

Mechanism of action of amiodarone

Answer 44

Blockade of Na/K/Ca channels Antagonist alpha and beta adrenergic receptos Slows conduction and increases refractory period (AV node) Do not give in heart block or in thyroid disease

Question 45

Mechanism of action of adenosine

Answer 45

Adenosine receptor agonists on cell surface Reduces automaticity and increases refractoiness Slows sinus rate Slows conduction and increases AV node refractoriness Breaks the re entry circuit Must monitor with a continuous ECG

Question 46

Mechanism of action of digoxin

Answer 46

Negatively chronotropic Positively ionotropic Reduces conduction at the AV node Increases the contractile force