cardio r/v

Question 1

What does the ECG show?

Answer 1

• HR is 100 and regular
• vary tall R waves in V1-V3
• ST depression V1-V4
• very small R wave in V6
• R axis deviation

Question 2

What’s normal range of D-dimer?

Answer 2

208-318 ng/ml

Question 3

Possible causes of increased D-dimmer

Answer 3

• liver disease
• pregnancy
• trauma
• recent surgery
• advanced age
• acute MI

Question 4

Treatment options for PE

Answer 4

• LMWH or fondaparinux →initially after a PE diagnosis

*an exception to this is for patients with a massive PE where thrombolysis is being considered. In such a situation unfractionated heparin should be used.

• a vitamin K antagonist (i.e. warfarin) should be given within 24 hours of the diagnosis

*LMWH or fondaparinux should be continued for at least 5 days or until the international normalised ratio (INR) is 2.0 or above for at least 24 hours, whichever is longer, i.e. LMWH or fondaparinux is given at the same time as warfarin until the INR is in the therapeutic range

*warfarin should be continued for at least 3 months. At 3 months, clinicians should ‘assess the risks and benefits of extending treatment’

*extending warfarin beyond 3 months for patients with unprovoked PE

*for patients with active cancer → LMWH for 6 months

• thrombolysis → first-line treatment for massive PE where there is circulatory failure (e.g. hypotension)
• IVC filters→ if repeat PEs, despite adequate anticoagulation

Question 5

MoA of:

• Heparin
• Warfarin
• Rivaroxaban
• Fondaparinux

Answer 5

Question 6

Signs of PE on ECHO

Answer 6

Question 7

Treatment for a haemodynamically unstable patient with PE

Answer 7

Question 8

Interpret this ECG

Answer 8

Question 9

Biphasic P wave in V1

Normal or abnormal?

Answer 9

P wave in V1 is often biphasic, due to:

• early R atrial forces are directed anteriorly
• followed by L atrial forces travelling posteriorly (producing negative deflection)

*if pathological is usually more generalised

Question 10

Interpret ECG

Answer 10

AF with a rapid ventricular rate

Question 11

6 seconds rule to calculate HR

Answer 11

Question 12

Management of AF

Answer 12

• Verapamil or Diltiazem → first-line

*Metoprolol or Diltiazem → if IV agent needs to be used

• Cardioversion → if symptoms continue
• CHA2DS2VASc + anticoagulation if necessary

Question 13

Causes of AF

Answer 13

• HTN
• valvular heart disease
• HF
• IHD
• chest infection
• lung ca
• excessive alcohol intake
• hyperthyroidism
• electrolyte depletion
• infection
• diabetes

Question 14

Ix in AF

Answer 14

• ECG
• bloods (including TFTs)
• ECHO

Question 15

What else do we need to do with CHA2DS2VASc?

Answer 15

Calculate HAS-BLED score → risk of bleeding

Question 16

How do we measure JVP?

Answer 16

From pulsation from internal jugular vein

Question 17

How to differentiate JVP from carotid pulse?

Answer 17

JVP is:

• multiphasic
• non-palpable
• occludable

Question 18

What does Kausmall’s sign mean?

Answer 18

Kussmaul’s sign describes a paradoxical rise in JVP during inspiration seen in constrictive pericarditis.

Question 19

What’s cause of non-pulsatile JVP?

Answer 19

A non-pulsatile JVP is seen in superior vena caval obstruction

Question 20

What’s ‘a’?

Answer 20

‘a’ wave = atrial contraction

• large if atrial pressure e.g. tricuspid stenosis, pulmonary stenosis, pulmonary hypertension
• absent if in atrial fibrillation

Cannon ‘a’ waves

• caused by atrial contractions against a closed tricuspid valve
• are seen in complete heart block, ventricular tachycardia/ectopics, nodal rhythm, single chamber ventricular pacing

Question 21

What’s ‘C’?

Answer 21

‘c’ wave

• closure of tricuspid valve
• not normally visible

Question 22

What’s ‘v’?

Answer 22

‘v’ wave

• due to passive filling of blood into the atrium against a closed tricuspid valve
• giant v waves in tricuspid regurgitation

Question 23

What’s ‘x’ and ‘y’?

Answer 23

• ‘x’ descent = fall in atrial pressure during ventricular systole
• ‘y’ descent = opening of tricuspid valve

Question 24

What do we use JVP for?

Answer 24

To measure (indirectly) pressure in R atrium and venous system

Question 25

Causes of raised JVP

Answer 25

* HF * cardiac tamponade * constrictive pericarditis * fluid overload

Question 26

Cause of absent A waves

Answer 26

* AF →as atria contract in uncoordinated way

Question 27

Causes of large A wave

Answer 27

A wave → R atrial contraction Large A wave: (anything that will increase pressure in R atrium/R atrial contraction) * R vent hypertrophy * tricuspid stenosis

Question 28

Cause of large V wave

Answer 28

V wave = atrial filling (venous return) Cause of large V wave: * tricuspid regurgitation (as more blood into R atrium due to backflow)

Question 29

Meaning of all points of JVP wave

Answer 29

Question 31

Interpret ECG

Answer 31

Pathologies: * infract * pace maker in situ

Question 32

Vicious cycle of HF

Answer 32

Question 33

Can patients with COPD/asthma be managed with CPAP (e.g. during pulmonary oedema)?

Answer 33

Question 34

Inotropic agents used in IHD with impaired output and haemodynamic instability (e.g. low BP, urinary retention)

Answer 34

Question 35

Name the drugs and when to initiate them in post-MI HF?

Answer 35

Question 36

Answer 36

Question 37

Normal ranges of cQT (corrected QT) for men and women

Answer 37

Question 38

Channels and ion movement during cardiac cycle

Answer 38

Question 39

How long QT can lead to arrhythmias?

Answer 39

Question 40

What's that?

Answer 40

Question 41

Drugs prolonging QT

Answer 41

Question 42

Ix (other than ECG) and Mx for long-QT

Answer 42

Question 43

Interpret ECG + treatment options BP is 120/80

Answer 43

Question 44

What does ECG show?

Answer 44

Question 45

Algorithm for NSTEMI-ACS management

Answer 45

If a patient presents with an NSTEMI then a risk stratification too (such as GRACE) is used to decide upon further management. If a patient is considered high-risk or is clinically unstable then coronary angiography will be performed during the admission. Lower risk patients may have a coronary angiogram at a later date. Secondary prevention * aspirin * a second antiplatelet if appropriate (e.g. clopidogrel) * a beta-blocker * an ACE inhibitor * a statin

Question 46

Calcified aortic valve - aortic valve stenosis * **What (apart from the murmur) would you look for O/E?** * **Further Ix (apart from ECHO)**

Answer 46

Question 47

Treatment options for aortic stenosis

Answer 47

* if asymptomatic then observe the patient is general rule * if symptomatic then valve replacement * if asymptomatic but valvular gradient \> 40 mmHg and with features such as left ventricular systolic dysfunction then consider surgery * cardiovascular disease may coexist. For this reason an angiogram is often done prior to surgery so that the procedures can be combined * balloon valvuloplasty is limited to patients with critical aortic stenosis who are not fit for valve replacement

Question 48

Interpret the ECG

Answer 48

Global ST elevation in all leads apart from I and AVL

Question 49

What do these images show?

Answer 49

Normal coronary angiogram

Question 50

What's the abnormality?

Answer 50

Question 51

Classification of aortic dissection

Answer 51

Stanford classification * type A - ascending aorta, 2/3 of cases * type B - descending aorta, distal to left subclavian origin, 1/3 of cases **DeBakey classification** * type I - originates in ascending aorta, propagates to at least the aortic arch and possibly beyond it distally * type II - originates in and is confined to the ascending aorta * type III - originates in descending aorta, rarely extends proximally but will extend distally

Question 52

Management of aortic dissection

Answer 52

Type A * surgical management, but blood pressure should be controlled to a target systolic of 100-120 mmHg whilst awaiting intervention Type B * conservative management * bed rest * reduce blood pressure IV labetalol to prevent progression

Question 53

Comment on this ECG and ECHO

Answer 53

Question 54

Signs on auscultation of atrial septal defect (ASD)

Answer 54