Cardiology 1 Flashcards
(500 cards)
1
Q
MOA of fondaparinux?
A
Activates antithrombin III, which in turn potentiates the inhibition of coagulation factors Xa
2
Q
MOA of bivalirudin?
A
Reversible direct thrombin inhibitor, given IV
3
Q
MOA of indapamide?
A
Thiazide like diuretic
4
Q
Stage 1 Hypertension?
A
Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg
5
Q
Stage 2 Hypertension?
A
Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg
6
Q
Severe Hypertension?
A
Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 110 mmHg
7
Q
When should you treat stage 1 hypertension?
A
If <80 y/o and ANY of the following
- Target organ damage
- Established cardiovascular disease
- Renal disease
- Diabetes
- 10 year cardiovascular risk >=10%
8
Q
When should you treat stage 2 hypertension?
A
Treat all patients, regardless of age
9
Q
Lifestyle advice for hypertension?
A
- A low salt diet is recommended, aiming for less than 6g/day, ideally 3g/day. The average adult in the UK consumes around 8-12g/day of salt. A recent BMJ paper* showed that lowering salt intake can have a significant effect on blood pressure. For example, reducing salt intake by 6g/day can lower systolic blood pressure by 10mmHg
- Caffeine intake should be reduced
- The other general bits of advice remain: stop smoking, drink less alcohol, eat a balanced diet rich in fruit and vegetables, exercise more, lose weight
10
Q
NICE 2019 addition to guidelines?
A
Consider antihypertensive drug treatment in addition to lifestyle advice for adults aged under 60 with stage 1 hypertension and an estimated 10-year risk below 10%
11
Q
When should you get specialist review for HTN?
A
BP not controlled on 4 drugs (resistant hypertension)
12
Q
BP not controlled on A+C+D management?
A
- K < 4.5 = low dose spironolactone
2. K > 4.5 = alpha or beta blocker
13
Q
BP target for <80y/o?
A
- Clinic = 140/90
2. ABPM/HBPM = 135/80
14
Q
BP target for >80 y/o?
A
- Clinic = 150/90
2. ABPM/HBPM = 145/85
15
Q
New anti-hypertensive drug?
A
Direct renin inhibitor
16
Q
Example of direct renin inhibitor?
A
Aliskiren
17
Q
Discussion of aliskiren?
A
- No trials have looked at mortality data yet. Trials have only investigated fall in blood pressure.
- Initial trials suggest aliskiren reduces blood pressure to a similar extent as angiotensin converting enzyme (ACE) inhibitors or angiotensin-II receptor antagonists
- Adverse effects were uncommon in trials although diarrhoea was occasionally seen
- Only current role would seem to be in patients who are intolerant of more established antihypertensive drugs
18
Q
What endocarditis is associated with colorectal cancer?
A
Streptococcus bovis (streptococcus gallolyticus subtype)
19
Q
Greatest risk factor for developing IE?
A
Previous IE
20
Q
Types of pts affected by IE?
A
- Previously normal valve (50%, usually mitral)
- Rheumatic (30%)
- Prosthetic valves
- Congenital heart defects
- IVDU (tricuspid)
- Recent piercings
21
Q
Most common cause of IE?
A
- Staph Aureus in UK
2. Historically, it was Strep Viridans (most common in developing countries)
22
Q
Cause of IE in pt with indwelling line?
A
CoNS e.g. Staphylococcus Epidermidis
23
Q
Cause of IE in prosthetic valve pt after surgery?
A
CoNS e.g. Staphylococcus Epidermidis
24
Q
Cause of IE in prosthetic valve pt >2 months after surgery?
A
Staph aureus
25
Streptococcus Viridans mushkie?
1. Technically S. Viridans is a pseudotaxonomic term, referring to viridans streptococci rather than a particular organism
2. 2 most notable viridans streptococci are: S. mitis and S. sanguinis
3. They are both commonly found in the mouth and in particular dental plaque so endocarditis caused by these organisms is linked with poor dental hygiene or following a dental procedure
26
Non-infective cause of IE?
SLE --> Libman-Sacks endocarditis
27
Malignancy cause of IE?
Marantic IE
28
Culture negative causes of IE?
1. Prior Abx therapy
2. Coxiella burnetii
3. Bartonella
4. Brucella
5. HACEK
29
What are the HACEK organisms?
Small, fastidious gram-negative bacilli
1. Haemophilus species
2. Aggregatibacter actinomycetemcomitans
3. Cardiobacterium hominis 4. Eikenella corrodens
5. Kingella kingae
30
First line management of acute pericarditis?
Combination of NSAID and Colchicine for 3 months
31
Features of acute pericarditis?
1. Chest pain, pleuritic, relieved by sitting forwards
2. Non-productive cough, dyspnoea, flu-like symptoms
3. Pericardial rub
4. Tachypnoea
5. tachycardia
32
Causes of acute pericarditis?
1. Infection = Viral (Coxsackie), TB
2. Inflammation = CTD
3. Malignancy
4. Metabolic = uraemia (causes fibrinous pericarditis), hypothyroidism
5. Post-MI (Dressler's syndrome)
6. Trauma
33
ECG changes in pericarditis?
1. Global saddle-shaped ST elevation
| 2. PR depression
34
Most specific ECG marker for pericarditis?
PR Depression
35
Ix for all patients with acute pericarditis?
TTE
36
What drugs should be avoided in pts with HOCM?
ACE inhibitors, Nitrates, Inotropes
37
Why are ACE inhibitors C/I in HOCM with LVOT?
They can reduce afterload which may worsen the LVOT gradient
38
HOCM definition?
An autosomal dominant of muscle tissue caused by defects in the genes encoding contractile proteins
39
HOCM prevalence?
1 in 500
40
Management of HOCM?
1. Amiodarone
2. Beta blockers or verapamil for symptoms
3. Cardioverter defebrillator
4. Dual chamber pacemaker
5. Endocarditis prophylaxis
41
Is antibiotic prophylaxis to prevent IE routinely recommended for dental procedures?
No
42
If person at risk of IE is given Abx for a GI/GU procedure, what should you take into account?
They should be given an antibiotic that covers organisms that cause IE
43
NYHA I?
No symptoms or limitation
44
NYHA II?
1. Mild symptoms
2. Slight limitation of physical activities = comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea
45
NYHA III?
1. Moderate symptoms
| 2. Marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms
46
NYHA IV?
1. Severe symptoms
| 2. Unable to carry out any physical activity without discomfort, symptoms present at rest
47
What may a VT turn out to be?
SVT with aberrant conduction
48
VT with adverse signs (SBP <90, chest pain, HF, syncope) management?
Immediate Synchronised D/C Cardioversion
49
VT with no adverse signs?
Anti-arrhythmics
1. Amiodarone ideally administered through a central line
2. Lidocaine = use with caution in severe LV impairment
3. Procainamide
50
What drug should NOT be used in VT?
Verapamil
51
VT with no adverse signs and drugs have failed?
1. Electrophysiology study (EPS)
| 2. ICD = particularly indicated in pts with significantly impaired LV function
52
Murmur at LLSE?
1. Tricuspid valve pathology
2. VSD
3. HOCM
53
Ejection systolic murmur louder on expiration?
AS and HOCM
54
Ejection systolic murmur louder on inspiration?
PS and ASD
55
Pansystolic murmur?
1. Mitral/tricuspid regurgitation
| 2. VSD (harsh in nature)
56
Late systolic murmur?
1. Mitral valve prolapse
| 2. Coarctation of the aorta
57
Early diastolic murmur?
1. AR (high pitched and blowing)
| 2. Graham-Steel murmur (pulmonary regurgitation, also high pitched and blowing)
58
Mid-late diastolic murmur?
1. Mitral stenosis (rumbling)
| 2. Austin-flint murmur (severe AR, also rumbling)
59
Continuous machine like murmur?
PDA
60
Secondary prevention of MI?
1. DAPT (Aspirin + Ticagrelor/Prasugrel)
2. ACEi
3. Beta Blocker
4. Statin
61
When may sexual activity resume after uncomplicated MI?
4 weeks
62
When can PDE5 inhibitors be used after MI?
6 months
63
In what patients should PDE5 inhibitors be avoided?
Those on nitrates/nicorandil
64
MOA of Ticagrelor/Prasugrel?
ADP receptor inhibitors (P2Y12 receptor antagonist that prevents ADP-mediated P2Y12 dependent platelet activation and aggregation)
65
When should ticagrelor be stopped post-MI?
12 months
66
When should ticagrelor be stopped post-PCI?
12 months
67
When should aldosterone antagonists be used post-MI?
Symptoms and/or signs of HF and LV systolic dysfunction, e.g. Epleronone should be initiated within 3-14 days of the MI, preferably after ACEi therapy
68
Intervention of choice for severe mitral stenosis?
Percutaneous mitral commissurotomy
69
Mx for severe mitral stenosis who cant tolerate PMC?
TMVR = transcatheter mitral valve repair
70
Causes of mitral stenosis?
1. Rheumatic fever, rheumatic fever, rheumatic fever
2. Mucopolysaccharidoses
3. Carcinoid syndrome
4. Endocardial fibroelastosis
71
Features of mitral stenosis?
1. Mid-late diastolic murmur heard best on expiration
2. Loud S1, opening snap
3. Low volume pulse
4. Malar flush
5. AF
72
Mitral stenosis on CXR?
LA enlargement
73
Mitral stenosis on Echo?
Normal cross sectional area of mitral valve is 4-6 sq cm, tight mitral stenosis implies a cross sectional area of <1 square centimetre
74
PAH definition?
Resting mean pulmonary artery pressure of >= 25mmHg
75
What plays a key role in the pathogenesis of PAH?
Endothelin
76
PAH usually affects?
30-50 y/o females
77
What percentage of PAH is inherited in an AD fashion?
10%
78
What increases the risk of PAH?
1. HIV
2. Cocaine
3. Anorexigens e.g. fenfluramine
79
Features of PAH?
1. Progressive exertional dyspnoea
2. Exertional syncope, exertional chest pain
3. Peripheral oedema
4. Cyanosis
5. RV heave, loud P2, raised JVP with prominent 'a' waves, tricuspid regurgitation
80
Management of PAH?
Acute vasodilator testing = to decide which patients show a significant fall in pulmonary arterial pressure following the administration of vasodilators such as intravenous epoprostenol or inhaled nitric oxide
1. Positive response (minority) = oral CCB
2. Negative response (majority) = Prostacyclin analogues, endothelin receptor antagonists, PDE5 inhibitors
81
Examples of prostacyclin analogues?
Treprostinil, Iloprost
82
Examples of endothelin receptor antagonists?
Bosentan, ambrisentan
83
Pt with PAH with progressive symptoms?
Should be considered for a heart-lung transplant
84
Normal corrected QT interval?
1. <430ms in males
| 2. <450ms in females
85
What is LQTS?
Inherited condition associated with delayed repolarisation of the ventricles
86
Cause of LQTS 1 and 2?
Defects in the alpha subunit of the slow delayed rectifier potassium channel
87
Congenital cause of prolonged QT interval?
1. LQTS 1,2,3
2. Jervell-Lange Nielsen Syndrome
3. Romano-Ward syndrome
88
Jervell Lange Nielsen Syndrome?
Includes deafness and is due to an abnormal potassium channel
89
Acquired causes of LQT?
1. E- = hypokalaemia, hypocalcaemia, hypomagnesaemia
2. Drugs
3. Cardiac = Acute MI Myocarditis
4. CNS = SAH and ischaemic stroke
5. Hypothermia
6. Malnutrition
90
Drugs that cause LQT?
1. Anti-arrhythmics = Amiodarone, Sotalol, Class 1a
2. Anti-depressants = TCAs, SSRIs (esp. citalopram)
4. Antibiotics = erythromycin
5. Antiemetics = ondansetron, metoclopramide, domperidone
6. Antipsychotics = haloperidol
7. Antipain = tramadol
91
LQT1 buzzwords?
Exertional syncope often swimming
92
LQT2 buzzwords?
Syncope following emotional stress, exercise, or auditory stimuli
93
LQT3 buzzwords?
Events occur at night or at rest
94
Management of LQT?
1. Avoid drugs which prolong the QT interval
2. Avoid strenuous exercise
3. Beta blockers
4. ICD in high risk cases
95
Usual mechanism by which drugs prolong the QT interval?
Blockage of potassium channels
96
How does LQTS typically present?
In young people, with cardiac syncope, tachyarrhythmias, palpitations, cardiac arrest
97
What is Takayasu's arteritis?
Large vessel vasculitis, typically causes occlusion of the aorta
98
Takayasu's arteritis common in?
Asian females
99
Features of Takayasu's arteritis?
1. Systemic vasculitis = malaise, headache
2. Unequal BP in upper limbs
3. Carotid bruit
4. Intermittent claudication
5. Aortic regurgitation (20%)
100
Association of takayasu's arteritis?
Renal artery stenosis
101
Management of takayasu's arteritis?
Steroids
102
Mx of haemodynamically stable pt with broad complex tachycardia?
IV Amiodarone
103
When is adrenaline given during VF/VT arrest?
Adrenaline 1mg is given once chest compressions have restarted after the third shock and then every 3-5 minutes during alternate cycles of CPR
104
Mx if cardiac arrest is witnessed in a monitored patient?
Up to three quick successive (stacked) shocks
105
Mx of asystole/PEA?
Adrenaline 1mg should be given ASAP, should be treated with 2 minutes of CPR prior to assessment of rhythm
106
O2 target following successful resuscitation?
94-98%
107
4Hs of reversible causes of cardiac arrest?
1. Hypoxia
2. Hypovolaemia
3. Hypothermia
4. Hypo/hyperkalaemia, hypoglycaemia, hypocalcaemia, acidaemia and other metabolic disorders
108
4Ts of reversible causes of cardiac arrest?
1. Tension pneumothorax
2. Thrombus (coronary or pulmonary)
3. Tamponade (cardiac)
4. Toxins
109
Management of uraemic pericarditis?
Urgent haemodialysis
110
What extra heart sound is heard with AR?
S3
111
What extra heart sound is heard with AS?
S4
112
What extra heart sound is heard with MR?
S3
113
What extra heart sound is associated with TR?
S3
114
Features of aortic stenosis?
1. Chest pain
2. Dyspnoea
3. Syncope
4. Murmur = ESM radiating to the carotids, decreased following the valsalva manoeuvre
115
Features of severe aortic stenosis?
1. Narrow pulse pressure
2. Slow rising pulse
3. Delayed ESM
4. Soft/absent S2
5. S4
6. Thrill
7. LVH/failure
116
Causes of AS?
1. Supravalvular = William's syndrome
2. Valvular = degenerative calcification (>65y/o most common), biscuspid valve (<65/yo most common), rheumatic
3. Subvalvular = HOCM
117
Management of AS?
1. Asymptomatic = observe
| 2. Symptomatic = valve replacement
118
When are asymptomatic patients with AS operated on?
Valvular gradient >40mmHg and with features such as LV systolic dysfunction
119
Who is balloon valvuloplasty limited to?
Pts with critical AS who are not fit for valve replacement
120
What is Hedinger syndrome?
Carcinoid valvular heart disease, leads to fibrosis and subsequent pulmonary stenosis
121
What is Eisenmenger's syndrome?
Reversal of a left to right shunt in a congenital heart defect due to pulmonary hypertension
122
What is Eisenmenger's syndrome associated with?
1. VSD
2. ASD
3. PDA
123
Features of Eisenmenger's syndrome?
1. Original murmur may disappear
2. Cyanosis
3. Clubbing
4. RV failure
5. Haemoptysis, embolism
124
Mx of Eisenmenger's syndrome?
Heart-lung transplant
125
MOA of dipyridamole?
An antiplatelet agent, a non-specific phosphodiesterase inhibitor and decreases cellular uptake of adenosine
1. Elevates platelet cAMP levels which in turn reduce intracellular calcium levels, reduced cellular uptake of adenosine, inhibition of thromboxane synthase
126
What platelet receptor is targeted by clopidogrel?
P2Y12 receptor for ADP
127
What is dipyridamole used for?
An antiplatelet mainly used in combination with aspirin after an ischaemic stroke or TIA
128
Treatment for Prinzmetal angina?
Dihydropyridine calcium channel blocker e.g. felodipine
129
Management of stable angina?
1. Lifestyle changes
2. Medication
3. PCI
4. Surgery
130
Medications for stable angina?
1. All pts should receive aspirin and a statin in the absence of any contraindication
2. Sublingual GTN to abort angina attacks
3. NICE recommend either a BB or CCB as first line
131
If a CCB is given for stable angina, what type should be used?
1. A rate-limiting one such as verapamil or diltiazem should be used if monotherapy
2. If used in combination with BB, then a long-acting dihydropyridine CCB e.g. nifedipine should be used
132
What should not be prescribed with verapamil and why?
Beta blockers, due to risk of complete heart block
133
Poor response to initial medical mx of angina?
Increase dose to maximum tolerated dose
134
If a patient is on monotherapy for stable angina and cannot tolerate addition of a CCB or BB?
Consider: LINRWhat
1. Long acting nitrate
2. Ivabridine
3. Nicorandil
4. Ranolazine
135
When should a third drug be added to BB and CCB for management of stable angina?
Whilst a pt is awaiting assessment for PCI or CABG
136
How can you minimise development of nitrate tolerance?
Pts who take standard release ISMN should use an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimise the development of nitrate tolerance
137
What type of ISMN dont you see nitrate tolerance in?
OD modified-release ISMN
138
Is temporary pacing indicated for complete heart block following an inferior MI?
No
139
Is temporary pacing indicated for complete heart block following an anterior MI?
Yes
140
When is transcutaneous pacing indicated?
1. For pts who remain haemodynamically stable and bradycardic following treatment with atropine
2. Post-anterior MI: Type 2 or complete heart block
3. Trifascicular block prior to surgery
141
MOA of atropine?
Anti-muscarinic drug which can increase heart rate by inhibition of vagal tone modulating the SAN
142
Indications for temporary pacemaker?
1. Symptomatic/haemodynamically unstable bradycardia, not responding to atropine
2. Post-Anterior MI = type 2 or complete heart block
3. Trifascicular block prior to surgery
143
What is Carvallo's sign?
When the pansystolic murmur in tricuspid regurgitation becomes louder during inspiration
144
MOA of warfarin?
Inhibits Vitamin K epioxide reductase, stopping Vitamin K being converted to its active hydroquinone form, which in turn acts as a cofactor in the carboxylation of clotting factors 2, 7, 9,10 and Protein C
145
Can warfarin be used during breastfeeding?
Yes
146
Recurrent VTE INR target?
3.5
147
AF INR target?
2.5
148
How is INR calculated?
PT/Normal PT
149
Factors that may potentiate warfarin?
1. Liver disease
2. P450 inhibitors e.g. amiodarone, ciprofloxacin
3. Cranberry juice
4. Drugs which displace warfarin from plasma albumin e.g. NSAIDs
5. Inhibit platelet function e.g. NSAIDs
150
S/e of warfarin?
1. Haemorrhage
2. Teratogenic
3. Skin necrosis
4. Purple toes
151
MOA of skin necrosis with warfarin?
When warfarin is first started, biosynthesis of protein C is reduced, resulting in a temporary procoagulant state after initially starting warfarin, normally avoided by concurrent heparin administration, thrombosis may occur in venules leading to skin necrosis
152
Dentistry in warfarinised patients?
Check INR 72 hours before procedure, proceed if INR < 4.0
153
What medication is c/i in ventricular tachycardia?
Verapamil
154
What medication is c/i in irregular broad complex tachycardia?
Adenosine
155
Anteroseptal MI ECG and artery?
1. V1-V4
| 2. LAD
156
Inferior MI ECG and artery?
1. II, III, aVF, RCA
157
Anterolateral MI ECG and artery?
1. V4-V6, I, aVL
| 2. LAD or Left circumflex
158
Lateral MI MI ECG and artery?
1. I, aVL, V5-6
| 2. Left circumflex
159
Posterior MI ECG and artery?
1. Tall R waves V1-V2
| 2. Usually left circumflex, also right coronary
160
What is VT?
A broad complex tachycardia originating from a ventricular ectopic focus
161
2 main types of VT?
1. Monomorphic VT = most commonly caused by MI
| 2. Polymorphic VT = A subtype of polymorphic VT is torsades de pointes
162
What is S3 (gallop rhythm) a sign of?
1. Caused by diastolic filling of the ventricle
2. Considered normal if <30 years old and may persist in women up to 50 years old
3. Heard in LV failure (e.g. dilated cardiomyopathy, constrictive pericarditis, mitral regurgitation)
163
Soft S1?
Mitral regurgitation
164
Loud S1?
Mitral stenosis
165
Soft S2?
Aortic Stenosis
166
Causes of splitting S2?
Normal during inspiration
167
What is S4 a sign of?
1. Caused by atrial contraction against a stiff ventricle, therefore coincides with the p wave on ECG
2. May be heard in AS, HOCM, HTN
168
Why may you feel a double apical impulse in HOCM?
Due to palpable S4
169
What should be avoided in pts with HOCM?
ACE inhibitors, Nitrates, Inotropes
170
What should be avoided in pts with WPW?
Verapamil as it may precipitate VT or VF
171
Deteriorating renal function with purpuric rash on feet a few days after coronary angiogram?
Cholesterol embolisation
172
Features of cholesterol embolisation?
1. Eosinophilia
2. Purpura
3. Renal failure
4. Livedo reticularis
173
How does cholesterol embolisation occur?
1. Majority secondary to vascular surgery or angiography
2. Cholesterol emboli may break off causing renal disease
3. Other causes include severe atherosclerosis, particularly in large arteries such as the aorta
174
What is Ebstein's anomaly?
1. Congenital heart defect characterised by low insertion of the tricuspid valve resulting in a large atrium and small ventricle, a.k.a. 'atrialisation' of the right ventricle
2. Septal and posterior leaflets of the tricuspid valve are displaced towards the apex of the right ventricle
175
Cause of Ebstein's anomaly?
Lithium exposure in utero
176
Associations of Ebstein's anomaly?
1. PFO or ASD is seen in at least 80% of patients, resulting in a shunt between the right and left atria
2. WPW syndrome
177
Clinical features of Ebstein's anomaly?
1. Cyanosis
2. Prominent 'a' wave in the distended JVP
3. Hepatomegaly
4. Tricuspid regurgitation (pansystolic murmur, worse on inspiration)
5. RBBB --> widely split S1 and S2
178
Factors favouring rate control of AF?
1. Older than 65 years old
| 2. History of IHD
179
Factors favouring rhythm control of AF?
1. Younger than 65 years old
2. Symptomatic
3. First presentation
4. Lone AF or AF secondary to a corrected precipitant e.g. alcohol
5. Congestive heart failure
180
Rate control medications for AF?
1. Beta blockers
2. Calcium channel blockers
3. Digoxin (not considered first line as they are less effective at controlling heart rate during exercise, however they are the preferred choice if the patient has coexistent HF)
181
Rhythm control medications for AF?
1. Sotalol
2. Amiodarone
3. Fleicanide
182
When is catheter ablation indicated for AF?
For those with AF who have not responded or wish to avoid anti-arrhythmic medication
183
How can tissue be ablated in AF?
1. Radiofrequency (heat generated from medium frequency alternating current)
2. Cryotherapy
184
Where is typically ablated for AF?
Between the pulmonary veins and the left atrum
185
Anticoagulation before ablation for AF?
1. Should be used 4 weeks before and during the procedure
2. Catheter ablation controls rhythm but does not reduce stroke risk, even if patients remain in sinus rhythm, therefor still anticoagulate as per CHA2DS2VASC
a. 0 = 2 months anticoagulation
b. >1 = longterm anticoagulation
186
Complications of ablation for AF?
1. Cardiac tamponade
2. Pulmonary valve stenosis
3. Cardiac tamponade
187
Success rate of ablation for AF?
1. 50% experience an early recurrence (within 3 months) of AF that often resolves spontaneously
2. Longer term, after 3 years, around 55% of pts who have had a single procedure remain in sinus rhythm, of patients who have undergone multiple procedures around 80% are in sinus rhythm
188
Doxazosin MOA and use?
Alpha blocker used in refractory hypertension
189
Why are nitrates c/i on HOCM?
Vasodilators increase the outflow tract gradient and cause a reflex tachycardia that further worsens ventricular diastolic function
190
Why are inotropic drugs c/i in HOCM?
Worsen outflow tract obstruction, do not relieve the high end-diastolic pressure, and may induce arrhythmias
191
First line drug treatment for HF?
Both an ACEi AND a BB
1. Generally, one drug should be started at a time, NICE advise clinical judgement when determining which one to start first
2. BB licensed to treat HF in UK incl. bisoprolol, carvedilol, nebivolol
192
Do ACEi and BB have an effect on mortality in pts with HFpEF?
No
193
Second line drug treatment for HF?
Aldosterone antagonist
1. E.g. spironolactone and epleronone
2. It should be noted that both ACEi and aldosterone antagonists cause hyperkalaemia, so K should be monitored
194
Third line drug treatment for HF?
Should be initiated by a specialist
1. Ivabridine = sinus rhythm >75 and LVEF <35%
2. Sacubitril-Valsartan = LVEF <35%, for pts still symptomatic on ACEi/ARBs, should be initiated following ACEi or ARB wash out period
3. Digoxin = not been shown to reduce mortality, may improve symptoms due to its inotropic properties
4. Hydralazine + Nitrate = particularly indicated in Afro-Caribbean pts
5. CRT = widened QRS (LBBB) on ECH
195
'Other' treatments for HF?
1. Annual influenza vaccine
| 2. One-off pneumococcal vaccine
196
What pts require pneumococcal booster vaccine every 5 years?
1. Asplenia
2. Splenic dysfunction
3. CKD
197
Infective endocarditis indications for surgery?
1. Severe valvular incompetence
2. Aortic root abscess (often indicated by lengthening of PR interval)
3. Infections resistant to abx/fungal infections
4. HF refractory to standard medical treatment
5. Recurrent emboli after antibiotic therapy
198
Poor prognostic factors for IE?
1. S. aureus infection
2. Prosthetic valve
3. Culture negative IE
4. Low complement levels
199
Mortality according to organism for IE?
1. Staph = 30%
2. Bowel organism = 15%
3. Strep = 5%
200
Initial blind therapy for IE?
1. Native valve = amoxicillin, consider adding low-dose gentamicin
2. If pen allergic/MRSA/severe sepsis = vancomycin + low dose gentamicin
3. If prosthetic valve = vancomycin + rifampicin + low dose gentamicin
201
Native valve endocarditis caused by staph abx?
1. Flucloxacillin
| 2. Pen allergic/MRSA = Vancomycin + rifampicin
202
Prosthetic valve endocarditis caused by staph abx?
1. Flucloxacillin + rifampicin + low dose gentamicin
| 2. If pen allergic/MRSA = vancomycin + rifampicin + low dose gentamicin
203
Endocarditis caused by fully sensitive streptococci e.g. viridans abx?
1. Benzylpenicillin
| 2. Pen allergic/MRSA = Vancomycin + low dose gentamicin
204
Endocarditis caused by less sensitive streptococci?
1. Benzylpenicillin + low dose gentamicin
| 2. If pen allergic = vancomycin + low dose gentamicin
205
ARBs or ACEi preferred in african-caribbean pts?
ARBs
206
QRISK threshold for treated stage 1 hypertension in pts <80 y/o?
10%
207
Most common valvular abnormality in IE?
Tricuspid regurgitation
208
Why are right sided murmurs louder during inspiration?
Increased venous blood return to the right side of the heartt
209
When can CKD cause raised serum natriuretic petides?
eGFR < 60
210
What is BNP?
Hormone produced mainly by the LV myocardium in resopnse to strain
211
Effects of BNP?
1. Vasodilator
2. Diuretic and natriuretic
3. Suppresses both sympathetic tone and the renin-angiotensin aldosterone system
212
4 clinical uses of BNP?
1. Diagnosing pts with acute dyspnoea = good for ruling out
2. Prognosis in pts with chronic HF
3. Guiding treatment in pts with chronic HF = effective treatment lowers BNP levels
4. Screening for cardiac dysfunction = not currently recommended
213
Bioprosthetic heart valve antithrombotic therapy?
Aspirin
214
Mechanical heart valve antithrombotic therapy?
Warfarin + Aspirin (aspirin is only normally given in addition if there is an additional indication e.g. ischaemic heart disease)
215
Most common valves which need replacing?
Aortic and vitral
216
Options for valve replacement?
Biological (bioprosthetic) or mechanical
217
Bioprosthetic valve mushkies?
1. Usually bovine or porcine in origin
2. Major disadvantage is structural deterioration and calcification over time (most older pts, >65 for aortic and >70 for mitral) receive a bioprosthetic valve
3. Long term anticoagulation not usually needed, warfarin may be given for the first 3 months depending on patient factors, long term aspirin is given
218
Mechanical valve muskies?
1. Most common is bileaflet, ball and cage is now rare
2. Mechanical valves have a low failure rate
3. Major disadvantage is increased risk of thrombosis
3. Aortic target INR = 3, mitral target INR = 3.5
219
Risk of bisphosphonate infusion?
Can lead to hypocalcaemia
220
QT interval of greater than ? is associated with ventricular arrhythmia, syncope and SCD?
>0.44 seconds
221
Chvostek's sign?
Tapping over the facial nerve at the angle of the jaw, +ve = ipsilateral twitching of the muscles around the nose and lips
222
2 scenarios where cardioversion may be used in AF?
1. Electrical cardioversion as an emergency if haemodynamically unstable
2. Electrical or pharmacological cardioversion as an elective procedure where a rhythm control strategy is preferred
223
What is electrical cardioversion synchronised to?
To the R wave to prevent delivery of a shock during the vulnerable period of cardiac repolarisation when ventricular fibrillation can be induced
224
AF onset <48 hours management?
1. Pt should be heparinised
2. Electrical DC cardioversion OR pharmacological cardioversion (amiodarone if structural heart disease, fleicanide or amiodarone in those without structural heart disease)
3. Pts with RFs for ischaemic stroke should be put on lifelong oral anticoagulation
4. Following electrical cardioversion if AF is confirmed as being less than 48 hours duration then further anticoagulation is unnecessary
225
AF onset >48 hours management?
1. Anticoagulation should be given for at least 3 weeks prior to cardioversion
2. Alternative is to perform a TOE to exclude a LAA thrombus, if excluded then can be heparinised and cardioverted immediately
3. If high risk of cardioversion failure (e.g. previous failure or AF recurrence) then it is recommended to have at least 4 weeks of amiodarone or sotalol prior to electrical cardioversion
4. Following electrical cardioversion, pts should be anticoagulated for at least 4 weeks
226
Pathophysiology of HOCM?
1. Most common defects involve mutation in gene encoding BMHC or MBPC
2. Results in predominantly diastolic dysfunction (LV hypertrophy --> decreased compliance --> decreased cardiac output)
227
HOCM on biopsy?
Myofibrillar hypertrophy with chaotic and disoarganised fashion myocytes ('disarray') and fibrosis
228
Why may HOCM cause mitral regurgitation?
May impair mitral valve closure
229
Associations of HOCM?
1. WPW
| 2. Friedrich's Ataxia
230
Echo findings of HOCM?
MR SAM ASH
1. Mitral regurgitation
2. SAM of mitral valve
3. Asymmetric hypertrophy
231
ECG of HOCM?
1. LVH
2. Non-specific ST segment and T wave abnormalities, progressive T wave inversion may be seen
3. Deep Q waves
4. AF may occasionally be seen
232
Type 1 respiratory failure in a tachycardic, tachypnoeic female with an absence of chest signs?
PE
233
First line treatment for VTE?
DOAC e.g. apixaban or rivaroxaban
234
VTE in active cancer management?
DOAC e.g. apixaban or rivaroxaban
235
Is routine cancer screening recommended following a VTE diagnosis?
No
236
How to decide what PE pts can be managed as outpatients?
1. PESI score, though no formal risk stratification tool is recommended by NICE
2. Key requirements would be haemodynamic stability, lack of comorbidities and support at home
237
Treatment for PE if neither apixaban or rivaroxaban are suitable?
1. LMWH followed by dabigatran or edoxaban OR
| 2. LMWH followed by VKA e.g. Warfarin
238
PE treatment if eGFR < 15?
LMWH, UFH, or LMWH followed by VKA
239
PE treatment in pt with antiphospholipid syndrome?
LMWH followed by VKA
240
How long should pts with PE be anticoagulated for?
1. At least 3 months
| 2. Continuing anticoagulation after this period is partly determined by whether VTE was provoked or unprovoked
241
Provoked VTE treatment length?
3 months
242
Active cancer VTE treatment length?
3-6 months
243
Unprovoked VTE treatment?
6 months
244
Mx of PE with haemodynamic instability?
Thrombolysis
245
Mx of repeated PEs despite adequate anticoagulation?
IVC filter
246
Treatment of torsades de pointes?
IV magnesium sulfate
247
What is torsades de pointes?
A form of polymorphic VT associated with Long QT interval
248
What anti-HTN increases risk of gout?
Thiazide-like diuretics
249
Common side effect of ticagrelor?
Dypsnoea (in 15%) --> start on clopidogrel instead
250
MOA of ticagrelor causing dyspnoea?
Ticagrelor inhibits adenosine clearance (by inhibiting enzyme adenosine deaminase) thereby increasing its concentration in the circulation
251
Medically treated ACS antiplatelet management?
1. 1st line = aspirin (lifelong) and ticagrelor (12 months)
| 2. 2nd line = if aspirin c/i, clopidogrel (lifelong)
252
PCI antiplatelet management?
1. 1st line = aspirin (lifelong) and ticagrelor/prasugrel (12 months)
2. 2nd line = if aspirin c/i, clopidogrel (lifelong)
253
TIA antiplatelet management?
1. 1st line = lifelong clopidogrel
| 2. 2nd line = lifelong aspirin and dipyridamole
254
Ischaemic stroke antiplatelet management?
1. 1st line = lifelong clopidogrel
| 2. 2nd line = lifelong aspirin and dipyridamole
255
Peripheral arterial disease antiplatelet management?
1. 1st line = lifelong clopidogrel
| 2. 2nd line = lifelong aspirin
256
Cardiac imaging techniques?
1. Echo
2. CT
3. MRI
4. Nuclear
257
Cardiac CT mushkies?
Useful for assessing suspected IHD using 2 main methods, and if combined has a very high negative predictive value for IHD:
1. Calcium score
2. Contrast enhanced CT = allowed visualisation of coronary artery lumen
258
Cardiac MRI mushkies?
Gold standard for structural images of the heart
1. Assessing congenital heart disease, determining right and left ventricular mass, and differentiating forms of cardiomyopathy
2. Myocardial perfusion can also be assessed following the administration of gadolinium
259
Cardiac nuclear imaging mushkies?
Use radiotracers which are extracted by normal myocardium e.g. thallium, Technetium (99mTc, used in MIBI or SPECT scans), Fluorodeoxyglucose (used in PET scans)
1. SPECT is used to assess myocardial perfusion and viability, by comparing rest images with stress images any areas of ischaemia can be classified as reversible or fixed (e.g. following MI)
2. MUGA
260
What is MUGA?
1. Multi Gated Acquisition Scan
2. Technetium-99m is injected IV, pt is placed under a gamma camera
3. Can accurately measure LVEF, typically used before and after cardiotoxic drugs are used
261
MOA of furosemide and bumetanide?
1. Inhibits the Na-K-Cl cotransporter in the thick ascending limb of the loop of Henle, reducing the absorption of NaCl
2. There are 2 variants of the NKCC, loop diuretics act on NKCC2, which is more prevalent in kidneys
262
Indications for loop diuretics?
1. HF = acute IV, chronic oral
| 2. Resistant HTN, particularly in pts with renal impairment
263
6 S/e of loop diuretics?
1. Hypotension
2. Hyponatraemia, hypokalaemia, hypomagnesaemia, hypocalcaemia, hypochloraemic alkalosis
3. Ototoxicity
4. Renal impairment
5. Hyperglycaemia
6. Gout
264
Complication of coronary angiogram secondary to irritation of the myocardium?
Ventricular arrhythmia, offending catheter must be pulled back immediately to restore normal sinus rhythm
265
Typical Angina?
All 3 of:
1. Constricting discomfort in the front of the chest or in the neck/shoulders/jaws/arms
2. Precipitated by physical exertion
3. Relieved by rest or GTN in about 5 minutes
266
Atypical Angina?
2 of:
1. Constricting discomfort in the front of the chest or in the neck/shoulders/jaws/arms
2. Precipitated by physical exertion
3. Relieved by rest or GTN in about 5 minutes
267
Non-anginal chest pain?
1 or none of:
1. Constricting discomfort in the front of the chest or in the neck/shoulders/jaws/arms
2. Precipitated by physical exertion
3. Relieved by rest or GTN in about 5 minutes
268
Ix of pts in whom stable angina cannot be excluded by clinical assessment alone (e.g. symptoms with typical//atypical angina OR ECG changes)?
1. 1st line = CTCA
2. 2nd line = Non-invasive functional imaging
3. 3rd line = Invasive CA
269
Examples of non-invasive functional cardiac imaging?
1. Myocardial perfusion scintigraphy with SPECT
2. Stress echo
3. First pass contrast-enhanced MR perfusion
4. MR imaging for stress-induced WMA
270
Where do HACEK organisms live?
On dental gums and are more common in IVDU
271
What would cause pseudomonas IE?
When infected water enters the blood stream
272
Ejection systolic murmur which increases with valsalve manoeuvre and decreases on squatting?
HOCM
273
Management of PDA?
1. Indomethacin/Ibuprofen given to the neonate, inhibits prostaglandin synthesis, closes the connection in the majority of cases
2. If associated with another congenital heart defect amenable to surgery, then Prostaglandin E1 is used to keep duct open until after surgical repair
274
PDA cyanotic or acyanotic?
1. Acyanotic
| 2. Uncorrected, can eventually result in late cyanosis in the lower extremities, termed differential cyanosis
275
PDA is between which 2 vessels?
Descending aorta and the pulmonary trunk
276
Factors increasing PDA risk?
1. Premature babies
2. Born at high altitude
3. Maternal rubella infection in 1st trimester
277
PDA on examination?
1. Left subclavicular thrill
2. Continuous machinery murmur
3. Large volume, bounding, collapsing pulse
4. Wide pulse pressure
5. Heaving apex beat
278
What should amiodarone ideally be administered through?
A central line
279
When is a non-pulsatile JVP seen?
SVC obstrution
280
Kussmaul's sign?
Paradoxical rise in JVP during inspiration, seen in constrictive pericarditis
281
Parts of the JVP waveform?
ACX is VY
| A cat's xylophone is very yellow
282
A wave of JVP?
Atrial contraction
1. Large if atrial pressure e.g. tricuspid stenosis, pulmonary stenosis, pulmonary HTN
2. Absent if in AF
283
Canon 'a' waves of JVP?
1. Caused by atrial contractions against a closed tricuspid valve
2. Seen in complete heart block, VT/ectopics, nodal rhythm, single chamber ventricular pacing
284
C wave of JVP?
Closure of tricuspid valve, not normally visible
285
V wave of JVP?
1. Due to passive filling of blood into the atrium against a closed tricuspid valve
2. Giant A waves in tricuspid regurgitation
286
X descent of JVP?
Fall in atrial pressure during ventricular systole
287
Y descent of JVP?
Opening of tricuspid valve
288
First line drug for pregnancy induced hypertension?
Labetalol
289
Pre-eclampsia definition?
Condition seen after 20 weeks gestation characterised by pregnancy-induced hypertension in association with proteinuria (>0.3g/24 hours), oedema used to be the third element of the classic triad but is now often not included in the definition as it is not specific
290
Pre-eclampsia pre-disposes to what conditions?
1. Fetal = prematurity, IUGR
2. Eclampsia
3. Haemorrhage = placental abruption, intra-abdominal, intra-cerebral
4. Cardiac failure
5. Multi-organ failure
291
High risk factors for pre-eclampsia and so should take aspirin?
1. HTN in prev. pregnancy
2. CKD
3. AI e.g. SLE/APLS
4. T1DM/T2DM
5. HTN
292
Moderate risk factors for pre-eclampsia?
1. 1st pregnancy
2. >40 y/o
3. Pregnancy interval >10 years
4. BMI >35
5. FHx of pre-eclampsia
6. Multiple pregnancy
293
Features of severe pre-eclampsia?
1. HTN > 170/110
2. Proteinuria
3. Headache
4. Visual disturbance
5. Papilloedema
6. RUQ/epigastric pain
7. Hyperreflexia
8. Plt count <100, abnormal liver enzymes or HELLP
294
Management of pre-eclampsia?
1. Moderate/high risk should take aspirin 75mg from 12 weeks gestation until birth
2. Treat BP >160/110 with oral labetalol
3. Nifedipine and hydralazine may be used if asthmatic
4. Delivery of the baby is the most important and definitive management step
295
Gold standard treatment for STEMI?
Primary PCI
296
PESI scores and subsequent risks?
1. <65 points = very low (OP)
2. 65-85 points = low risk (OP)
3. >85 = IP management
297
Mechanisms of BNP?
1. Vasodilator
2. Diuretic and Natriuretic
3. Suppresses both sympathetic tone and the RAAS
298
Factors which reduce BNP levels?
ACEi, AR2Bs and diuretics
299
2 commonest causes of CKD in developed countries?
HTN and diabetes
300
Hypertensive indications for admission?
1. Severe HTN (>220/120mmHg)
2. Grade 3-4 retinopathy
3. Hypertensive emergencies e.g. encephalopathy, aortic dissections etc.
4. Impending complications e.g. LVF and TIAs
301
Lifestyle salt advice?
1. Aim <6g a day, ideally 3g/day
2. Average adult in the UK consumes 8-12g/day of salt
3. Reducing salt intake by 6g/day can lower SBP by 10mmHg
302
CHA2DS2-VASc score?
1. Congestive heart failure = 1 point
2. HTN = 1 point
3. Age >75 = 2 points, Age 65-74 years = 1 point
4. Diabetes
5. S2 = prior stroke or TIA
6. Vascular disease incl. IHD and peripheral arterial disease
7. Sex (female) = 1 point
303
CHADSVASC score interpretation?
1. 0 = no treatmen
2. 1 = Males = consider anticoagulation, Females = no treatment
3. 2 or more = offer anticoagulation
304
HAS BLED score (all worth 1)?
1. Hypertension, uncontrolled, systolic BP >160
2. Abnormal renal function (dialysis or creatinine >200)
3. Abnormal liver function (cirrhosis, bilirubin > 2 times normal, ALT/AST/ALP >3 times normal)
4. Stroke
5. Bleeding history/tendency
6. Labile INRs (unstable/high INRs, time in therapeutic range <60%)
7. Elderly <65 years
8. Drugs predisposing to bleeding (antiplatelets, NSAIDs
9. Alcohol Use (>8 drinks/week)
305
HAS BLED score interpretation?
1. >= 3 indicates a 'high risk' of bleeding
306
What can happen if cardioversion shock is delivered later in the cycle during ventricular repolarisation (T wave)?
Can trigger the R on T phenomenon, which invariably leads to ventricular fibrillation
307
What is the R on T phenomenon?
Superimposition of an ectopic beat on the T wave of a preceding beat, likely to initiates sustained ventricular tachyarrhythmias
308
All patients with STEMI should be given?
1. Aspirin
2. P2Y12 antagonist e.g. ticagrelor/clopidogrel, or prasugreal if they are going to have PCI
3. UFH given for patients who will have PCI
309
Choice of tPA for thrombolysis?
Tenecteplase (shown to be superior to alteplase)
310
What should be done 90 minutes following thrombolysis?
ECG to assess whether there has been a greater than 50% resolution in the ST elevation
1. If there has not been adequate resolution, then rescue PCI is superior to repeat thrombolysis
2. For pts successfully treated with thrombolysis, PCI has been shown to be beneficial, optimal timing of this is still under investigation
311
Glycaemic control in MI patients?
Using a dose-adjusted insulin infusion with regular monitoring of blood glucose levels to <11mmol/l
312
What should a single episode of paroxysmal AF, even if provoked, prompt?
Consideration of anticoagulation
313
Causes of tricuspic regurgitation?
1. RV infarction
2. Pulmonary HTN e.g. COPD
3. Rheumatic heart disease
4. IE, esp. IVDU
5. Ebstein's anomaly
6. Carcinoid syndrome
314
ARVC pathophysiology?
1. AD inheritance pattern with variable expression
2. RV myocardium is replaced by fatty and fibrofatty tissue
3. 50% of pts have a mutation of genes encoding desmosomes
315
What is ARVC?
Form of inherited cardiovascular disease which may present with syncope or SCD
316
Most common causes of SCD in the young?
1. HOCM
| 2. ARVC
317
Presentation of ARVC?
1. Palpitations
2. Syncope
3. SCD
318
Investigation of ARVC?
1. ECG = TWI in V1-V3, epsilon wave found in about 50% (terminal notch in the QRS complex)
2. Echo - enlarged, hypokinetic right ventricle with a thin free wall
3. MRI = useful for showing fibrofatty tissu
319
Management of ARVC?
1. Drugs = sotalol
2. Catheter ablation to prevent VT
3. ICD
320
What is Naxos disease?
Autosomal recessive variant of ARVC
321
Triad of Naxos disease?
1. ARVC
2. Palmoplantar keratosis
3. Woolly hair
322
Peri-arrest tachycardia - what are 'adverse signs' which would mean pt is unstable?
1. Shock (SBP<90mmHg), pallor, sweating, cold clammy extremities, confusion or impaired consciousness
2. Syncope
3. MI
4. HF
If any of these are present, then synchronised DC shocks should be given
323
Management of regular narrow complex tachycardia?
1. Vagal manoeuvres followed by IV adenosine
| 2. If unsuccessful, consider diagnosis of atrial flutter and control rate with e.g. beta blockers
324
Management of irregular narrow complex tachycardia?
1. Probable AF
2. If onset <48 hours consider electrical or chemical cardioversion
3. Rate control e.g. beta blocker or digoxin and anticoagulation
325
Management of regular broad complex tachycardia?
1. Assume VT (unless previously confirmed SVT with bundle branch block)
2. Loading dose of amiodarone followed by 24 hour infusion
326
Management of irregular broad complex tachycardia?
1. AF with BBB = treat as for narrow complex tachycardia
| 2. Torsades de pointes = IV magnesium sulphate
327
What should be added to CCB for black pts with HTN?
ARB
328
3 causes of S3?
1. LVF e.g. DCM
2. Constrictive pericarditis (also called pericardial knock)
3. Mitral regurgitation
329
Side effects of sulfonylurea?
1. Common = hypoglycaemia, weight gain
| 2. Rare = Hyponatraemia (SIADH), bone marrow suppression, hepatotoxicity, peripheral neuropathy
330
Sulfonylurea MOA?
Bind to ATP-dependent K+ channel on the cell membrane of pancreatic beta cells, and increase pancreatic insulin secretion, only effective if functional B cells are present
331
When should sulfonylureas be avoided?
Breastfeeding and pregnancy
332
Anti-CCP?
Rheumatoid Arthritis
333
What is Rheumatoid Factor?
A circulating antibody (usually IgM) which reacts with the Fc portion of the patient's own IgG
334
How can Rheumatoid factor be detected?
1. Rose-Waaler Test = sheep red cell agglutination
| 2. Latex agglutination test = less specific
335
What % of pts with RA are RF +ve?
70-80%
336
What are high RF titre levels associated with in RA?
Are associated with severe progressive disease but NOT a marker of disease activity
337
Conditions associated with positive positive RF?
1. Felty's = 100%
2. Sjogren's = 50%
3. IE = 50%
4. SLE = 20-30%
5. SS = 30%
6. General population = 5%
7. Rarely = TB, HBV, EBV, leprosy
338
What % of general population are RF positive?
5%
339
When may anti-CCP be detected?
Up to 10 years before the development of rheumatoid arthritis
340
Sensitivity and specificity of anti-CCP for RA?
1. Sensitivity = 70%
| 2. Specificity = 90-95%
341
Vincristine acts during what stage of mitosis?
Metaphase
342
Vincristine is part of what class of agents and MOA?
1. Vinca alkaloids, microtubule targeting agents affecting the M phase of mitosis
2. Bind to tubulin and stop the polymerisation and assembly of microtubules, in turn disrupting spindle formation, arresting mitosis at metaphase
343
Taxane MOA?
Enhances polymerisation of tubulin where the microtubule disassemble
344
Pathophysiology of aortic dissection?
Tear in the tunica intima of the wall of the aorta
345
Associations of aortic dissection?
1. HTN
2. Trauma
3. Bicuspid aortic valve
4. Collagen = Marfans, EDS
5. Turner's and Noonan's
6. Pregnancy
7. Syphilis
346
Sx of aortic dissection involving coronary arteries?
Angina
347
Sx of aortic dissection involving spinal arteries?
Paraplegia
348
Sx of aortic dissection involving distal aorta?
Limb ischaemia
349
Classification of aortic dissection?
Stanford and DeBakey classification
350
Stanford classification of aortic dissection?
1. Type A = ascending aorta, 2/3 of cases
| 2. Type B = descending aorta, distal to left subclavian origin, 1/3 of cases
351
DeBakey classification of aortic dissection?
1. Type I = Originates in ascending aorta, propagates to at least the aortic arch and possibly beyond it distally
2. Type II = Originates in and is confined to the ascending aorta
3. Type III = originates in descending aorta, rarely extends proximally but will extend distally
352
Hypothermia ECG changes?
1. Bradycardia
2. J wave = small hump at the end of the QRS complex
3. 1st Degree HB
4. Long QT interval
5. Atrial and ventricular arrhythmias
353
What is a valsalva manoeuvre?
A forced expiration against a closed glottis, leading to increased intrathoracic pressure which in turn has a number of effects on the cardiovascular system
354
Uses of valsalva manoeuvre?
1. To terminate an episode of SVT
| 2. To normalise middle ear pressures
355
Stages of the valsalva manoeuvre?
1. Increased intrathoracic pressure
2. Resultant increase in venous and right atrial pressure reduces venous return
3. Reduced preload lead to a fall in cardiac output (Frank-Starling mechanism)
4. When the pressure is released there is a further slight fall in cardiac output due to increased aortic volume
5. Return of normal cardiac output
356
Most common cyanotic congenital heart disease?
1. TGA most common at birth
2. TOF most common overall
3. Tricuspid atresia
4. Pulmonary valve stenosis
357
Most common acyanotic congenital heart diseases?
1. VSD most common (30%)
2. ASD
3. PDA
4. Coarctation of the aorta
5. Aortic valve stenosis
358
When does ToF typically present?
1-2 months after birth following the identification of a murmur or cyanosis
359
What are Aschoff bodies?
Granulomatous nodules found in rheumatic heart fever
360
What valve is most commonly affected by rheumatatic heart disease?
Mitral
361
How do you assess exposure to group A streptococcus bacteria?
ASO titre
362
Histology of rheumatic fever?
1. Aschoff bodies (granuloma with giant cells)
| 2. Anitschkow cells (enlarged macrophages with ovoid, wavy, rod-like nucleus)
363
Councilman bodies?
Hepatitis C, Yellow Fever
364
Mallory Bodies?
Alcoholism (hepatocytes)
365
Call-Exner bodies?
Granulosa cell tumour
366
Schiller-Duval bodies?
Yolk Sac tumour
367
What is rheumatic fever?
Autoimmune reaction to recent (2-6 weeks ago) S. pyogenes infection
368
Pathogenesis of rheumatic fever?
1. S. pyogenes infection --> activation of innate immune system leading to antigen presentation to T cells
2. B and T cells produce IgM and IgG antibodies and CD4+ T cells are activated
3. There is then a cross-reactive immune response (a form of Type II hypersensitivity) thought to be mediated by molecular mimicry
4. Cell wall of S. pyogenes includes M protein, a virulence factor that is highly antigenic. It is thought that the antibodies against M protein cross-react with myosin and the smooth muscle of arteries
5. Their response leads to clinical features of rheumatic fever
369
Management of rheumatic fever?
1. Abx = Oral penicillin V
2. Anti-inflammatories = NSAIDs are first line
3. Treatment of any complications that develop e.g. heart failure
370
Diagnosis of rheumatic fever?
Evidence of recent streptococcal throat infection accompanied by:
1. 2 major criteria
2. 1 major with 2 minor criteria
371
Evidence of recent streptococcal throat infection for dx of rheumatic fever?
1. Raised or rising streptococcal antibodies
2. Positive throat swab
2. Positive rapid Group A streptococcal antigen test
372
Major criteria for rheumatic fever?
CASES
1. Carditis (must be evidence of endocarditis in addition to pericarditis/myocarditis)
2. Polyarthritis
3. Sydenham's chorea (late feature)
4. Erythema marginatum
5. Subcutaneous nodules
373
Minor criteria for rheumatic fever?
1. Raised ESR or CRP
2. Pyrexia
3. Arthralgia (not if arthritis a major criteria)
4. Prolonged PR interval
374
How long after stroke should you start anticoagulation?
2 weeks to reduce the risk of haemorrhagic transformation
375
How long after TIA should you start anticoagulation?
In the absence of cerebral infarction or haemorrhage, anticoagulation should begin as soon as possible
376
Why are loading doses of amiodarone needed?
Has a very long half life of 20-100 days
377
What is amiodarone?
Class III anti-arrhythmic agent used in the treatment if atrial, nodal and ventricular tachycardias
378
Main MOA of amiodarone?
1. Blocks potassium channels, inhibiting repolarisation and thus prolonging the action potential
2. Also has other actions e.g. blocking Na channels (Class I effect)
379
What limits use of amiodarone?
1. Very long 1/2 life = 20-100 days, so loading doses frequently used
2. Should ideally be given into central veins (causes thrombophlebitis)
3. Has proarrhythmic effects due to lengthening of QT interval
4. p450 Inhibitor
5. Numerous long-term adverse effects
380
Monitoring of pts taking amiodarone?
1. TFT, LFT, U&E, CXR prior to treatment
| 2. TFT, LFT every 6 months
381
Adverse effects of amiodarone use?
1. Eye = corneal deposits, photosensitivity
2. Thyroid = hypo and hyperthyroidism
3. Lung = pulmonary fibrosis/pneumonitis
4. Liver = fibrosis/hepatitis
5. Heart = Bradycardia, prolongs QT interval
6. Veins = Thrombophlebitis and injection site reactions
7. Skin = slate grey appearance
8. Nerve = peripheral neuropathy, myopathy
382
MOA of ACEi?
1. Inhibit conversion of angiotensin I to angiotensin II
| 2. ACE inhibitors are activated by Phase 1 metabolism in the liver
383
S/e of ACEi?
1. Cough = occur in 15% of pts and may occur up to a year after starting treatment, thought to be due to increased bradykinin levels
2. Angioedema = may occur up to a year after starting treatment
3. Hyperkalaemia
4. First-dose hypotension = more common in pts taking diuretics
384
Cautions of ACEi?
1. Pregnancy and breastfeeeding = avoid
2. Renovascular disease = may result in renal impairment
3. AS = may result in hypotension
4. Hereditary/idiopathic angioedema
5. Specialist advice should be sought before starting ACEi in pts with a potassium >=5
385
Interactions of ACEi?
Significantly increases the risk of hypotension in pts receiving high dose diuretic therapy (>80mg Furosemide per day)
386
Monitoring of ACEi?
1. U&E should be checked before treatment is initiated and after increasing dose
2. A rise in creatinine and potassium may be expected after starting ACEi
387
Significant renal impairment in pt started on ACEi?
Undiagnosed bilateral renal artery stenosis?
388
Acceptable e- changes with ACEi?
1. Increase in creatinine up to 30% from baseline
| 2. Increase in potassium up to 5.5mmol/mol
389
Most common causes of viral myocarditis?
Parvovirus B19 and HHV6
390
Most common cardiomyopathy?
DCM, 90% of cases
391
Causes of DCM?
1. Idiopathic = most common
2. Myocarditis = Coxsackie B, HIV, Diphtheria, Chagas disease
3. IHD, HTN
4. Peripartum
5. Iatrogenic = doxorubicin
6. Drugs = alcohol, cocaine
7. Infiltrative = haemochromatosis, sarcoidosis
392
Inherited cause of DCM?
1. Either familial or syndromic e.g. DMD
2. 1/3rd pts with DCM have genetic predisposition, many heterogeneous defects identified
3. Most defects inherited in AD fashion
393
Pathophysiology of DCM?
1. Dilated heart leading to predominantly systolic dysfunction
2. All 4 chambers are dilated but the LV more so than the RV
3. Eccentric hypertrophy (sarcomeres added in series) is seen
394
DCM findings?
1. HF
2. Systolic murmur = stretching of valves may result in mitral and tricuspid regurgitation
3. S3
4. Balloon appearance of the heart on the CXR
395
ARB MOA?
Angiotensin II receptor blockers block the effects of angiotensin II at the AT1 receptor
396
ARB examples?
Candesartan, losartan, irbesartan
397
S/e of ARBS?
1. Should be used with caution in pts with renovascular disease
2. S/e = hypotension and hyperkalaemia
398
Evidence base of ARBs?
1. Shown to reduce progression of renal disease in pts with diabetic nephropathy
2. Evidence base that losartan reduces CVA and IHD mortality in hypertensive patients
399
Thiazide diuretic MOA?
1. Inhibits Na reabsorption by blocking the NaCl symporter at the proximal part of the DCT
2, Potassium is lost as a result of more sodium reaching the collecting ducts
400
Common S/e of thiazides?
1. Dehydration
2. Postural hypotension
3. Hyponatraemia, hypokalaemia, hypercalcaemia
4. Gout
5. Impaired glucose tolerance
6. Impotence
401
Rare s/e of thiazides?
1. Thrombocytopenia
2. Agranulocytosis
3. Photosensitivity rash
4. Pancreatitis
402
Why may thiazides be helpful in treating renal stones?
Causes hypercalciuria
403
Causes of myocarditis?
1. Viral = coxsackie B, HIV
2. Bacteria = diphtheria, clostridia
3. Spirochaetes = Lyme
4. Protozoa = Chagas disease, toxoplasmosis
5. AI
6. Drugs = doxorubicin
404
Ix of Myocarditis?
1. Bloods = raised inflammatory markers in 99%, raised cardiac enzymes, raised BNP
2. ECG = tachycardia, arrhythmias, ST/T wave changes incl. ST segment elevation and TWI
405
Mx of myocarditis?
1. Tx of underlying cause e.g. Abx if bacterial
| 2. Supportive = of HF or arrhythmias
406
Complications of myocarditis?
1. HF
2. Arrhythmia, possibly leading to sudden death
3. DCM = usually a late complication
407
What is CPVT?
1. Chatecholaminergic polymorphic VT
2. Inherited cardiac disease associated with SCD
3. AD inheritance, 1:10,000
408
Ambrisentan and Bosentan MOA?
Endothelin-1 receptor antagonist
409
Endothelin and PAH pathophysiology?
1. In PAH the expression of endothelin 1 is increased resulting in vasoconstriction
2. Endothelin primarily acts upon 2 receptors ETA and ETB
3. ETA is found in vascular smooth muscle and facilitates vasoconstriction
4. ETB is found on the endothelium and mediates vasodilation (ambrisentan is selective for ETA receptors)
410
S/e of ambrisentan?
1. Peripheral oedema
2. Sinusitis
3. Flushing
4. Nasal congestion
411
PE triad?
Pleuritic chest pain, dyspnoea and haemoptysis
412
Most common clinical signs of PE?
1. Tachypnoea = 96%
2. Crackles = 58%
3. Tachycardia = 44%
4. Fever = 43%
413
What criteria could be used to rule out PE?
1. PERC = Pulmonary embolism rule out criteria
2. ALL the criteria must be absent to have a negative PERC result
3. Negative PERC reduces probability of PE to <2%
414
What score for suspected PE?
2-level PE Wells score
1. PE likely >4 points
2. PE unlikely <= 4 points
415
'Likely' PE management?
1. CTPA (if delay, treatment should be started)
2. DOAC e.g. apixaban/rivaroxaban
3. If CTPA -ve then consider proximal leg vein US scan if DVT is suspected
416
'Unlikely' PE management?
1. D-dimer --> if positive then CTPA
| 2. If negative then stop anticoagulation and consider alternative diagnosis
417
CTPA diagnosis in pt with renal impairment?
V/Q scan
418
PE ECG?
1. S1Q3T3 = large S wave in Lead I, large Q wave in Lead III, Inverted T wave in Lead III (20% pts)
2. RBBB and RAD
3. Sinus tachycardia
419
PE CXR?
Either normal or wedge-shaped opacification
420
SVT acute management?
1. Vagal manoeuvres e.g. Valsalva, carotid sinus massage
2. IV adenosine 6mg --> 12mg --> 12mg (c/i in asthmatics, verapamil is favourable option)
3. Electrical cardioversion
421
SVT chronic management (prevention)?
1. BB
| 2. RFA
422
Why should rate-limiting CCBs be avoided in pts with AF and HFrEF?
Due to their negative inotropic effects
423
Mx of Dressler's syndrome?
NSAIDs or a prolonged course of colchicine or steroids
424
When does Dressler's syndrome occur?
2-6 weeks following an MI (autoimmune reaction against antigenic proteins formed as the myocardium recovers)
425
Features of Dressler's syndrome?
1. Fever
2. Pleuritic Pain
3. Pericardial effusion
4. Raised ESR
426
Persistent ST elevation and LV failure after MI?
LV aneurysm
427
How does LV free wall rupture present?
1. Occurs in 3% MIs and occurs around 1-2 weeks afterwards
| 2. Present with acute failure secondary to cardiac tamponade (raised JVP, pulsus paradoxus, diminished heart sounds)
428
Mx of LV free wall rupture?
Urgent pericardiocentesis and thoracotomy
429
What causes acute MR post-MI?
More common with infero-posterior infarction and may be due to ischaemia or rupture of the papillary muscle
430
What should be avoided in RV MI?
Nitrates, due to causing reduced preload
431
Acute RV dysfunction triad?
1. Clear lung fields
2. JVP distension
3. Hypotension
432
RV MI occurs in what percentage of inferior MI?
30-50%
433
Hypertension in diabetics 1st lin?
ACEi
434
HTN aims for T1DM?
Intervention levels for recommending blood pressure management should be 135/85 mmHg unless the adult with type 1 diabetes has albuminuria or 2 or more features of metabolic syndrome, in which case it should be 130/80 mmHg
435
ICD and HGV licence?
Loss of license
436
Angipoplasty DVLA?
1 week off
437
CABG DVLA?
4 weeks off
438
ACS DVLA?
4 weeks off, 1 week off if succesfully treated by angioplasty
439
Heart transplant DVLA?
6 weeks off
440
ICD DVLA?
1. If implanted for sustained ventricular arrhythmia: cease driving for 6 months
if implanted prophylactically then cease driving for 1 month. 2. Having an ICD results in a permanent bar for Group 2 drivers
441
Pacemaker DVLA?
1 week off
442
Aortic aneurysm DVLA?
1. >6.5cm disqualified
| 2. >6cm = notify DVLA, annueal review
443
SVT prophylaxis in pregnancy?
Metoprolol
444
Following electrical cardioversion for AF, how long should pts be anticoagulated for?
At least 4 weeks
445
Most accurate way to assess LVEF?
MUGA Scan
446
Williams syndrome cardiac association?
Supravalvular aortic stenosis
447
Features of complete heart block?
1. Syncope
2. HF
3. Regular bradycardia (30-50bpm)
4. Wide pulse pressure
5. JVP = cannon waves in neck
6. Variable Intensity of S1
448
1st degree HB?
PR interval > 0.2s
449
2nd degree HB?
1. Type I (Mobitz I, Wenckebach) = progressive prolongation of the PR interval until a dropped beat occurs
2. Type II (Mobitz II) = PR interval is constant but the p wave is often not followed by a QRS comples
450
3rd degree HB?
No association between p waves and QRS complexes
451
What is the J point on ECG?
The point at which the S wave ascends to meet the isoelectric line
452
Indications for ETT?
1. Assessing pts with suspected angina
2. Risk stratifying pts following MI
3. Assessing ET
4. Risk stratifying pts with HOCM
453
ETT S&S for IHD?
1. Sensitivity = 80%
| 2. Specificity = 70%
454
Max HR for ETT?
1. 220 - patient's age
2. The target heart rate is at least 85% of maximum predicted to allow reasonable interpretation of test as low risk or negative
455
C/I for ETT?
1. MI < 7 days ago
2. Unstable angina
3. Uncontrolled hyper/hypotension (SBP > 180mmHg or SBP <90mmHg)
4. AS
5. LBBB (would make ECG difficult to interpret)
456
When to stop ETT?
1. exhaustion / patient request
'severe', 'limiting' chest pain
2. > 3mm ST depression
3. > 2mm ST elevation
4. Stop if rapid ST elevation and pain
5. Systolic blood pressure > 230 mmHg
6. Systolic blood pressure falling > 20 mmHg
7. Attainment of maximum predicted heart rate
8. Heart rate falling > 20% of starting rate
9. Arrhythmia develops
457
4 ADP receptor inhibitors?
1. Clopidogrel
2. Prasugrel
3. Ticagrelor
4. Ticlodipine
458
Why are prasugrel and ticagrelor now being used more commonly?
Due to its interindividual variability in antipaltelet effects
459
What is NICE DAPT atm?
Aspirin 75mg OD and Ticagrelor 90mg BD
460
Clopigrel interaction?
1. With PPIs, particularly omeprazole and esomeprazole, leading to reduced antiplatelet effects
461
C/I for prasugral use?
1. Prior stroke or TIA
2. High risk of bleeding
3. Prasugrel hypersensitivity
462
C/I for ticagrelor use?
1. High risk of bleeding
2. Prior intracranial haemorrhage
3. Severe hepatic dysfunction
463
Caution for ticagrelor use?
In Asthma and COPD, as ticagrelor-treated patients experience higher rates of dyspnoea
464
Classes of drugs used to treat negative response to acute vasodilator testing PAH?
1. Prostacyclin analogues = treprostinil, iloprost
2. Endothelin receptor antagonist = bosentan, ambrisentan
3. PDE inhibitors = sildenafil
465
Features of tricuspid regurgitation?
1. Pan-systolic murmur
2. Prominent/giant V waves in JVP
3. Pulsatile hepatomegaly
4. Left parasternal heave
466
Causes of tricuspid regurgitation?
1. RV infarction
2. Pulm HTN e.g. COPD
3. Rheumatic heart disease
4. IE
5. Ebstein's Anomaly
6. Carcinoid syndrome
467
Post-stroke AF management?
1. Warfarin/DOAC should be started after 2 weeks (in the absence of haemorrhage)
2. If imaging shows a very large cerebral infarction then the initiation of anticoagulation should be delayed
468
Most common cause of restrictive cardiomyopathy in the UK?
Amyloidosis secondary to myeloma
469
Causes of restrictive cardiomyopathy?
PLEASSH
1. Post-radiation fibrosis
2. Loffler's syndrome
3. Endocardial fibroelastosis
4. AMYLOIDOSIS
5. Sarcoidosis
6. Scleroderma
7. Haemochromatosis
470
What is Loffler's syndrome?
Endomyocardial fibrosis with a prominent eosinophilic infiltrate
471
What is endocardial fibroelastosis?
Thick fibroelastic tissue forms in the endocardium, most commonly seen in young chidlren
472
Pathophysiology of restrictive cardiomyopathy?
1. Primarily characterised by decreased compliance of the ventricular endomyocardium
2. Causes predominantly diastolic dysfunction
473
Features of restrictive cardiomyopathy?
1. Similar to constrictive pericarditis
| 2. Low voltage ECG
474
Ix for restrictive cardiomyopathy?
1. Echo
| 2. Cardiac MRI
475
Features suggesting restrictive cardiomyopathy rather than constrictive pericarditis?
1. Prominent apical pulse
2. Absence of pericardial calcification on CXR
3. Heart may be enlarged
4. ECG abnormalities = BBB, Q waves
476
What is Eisenmenger's syndrome?
Reversal of a left-to-right shunt in a congenital heart defect due to pulmonary hypertension
477
Pathophysiology of eisenmenger's syndrome?
When uncorrected left to right shunt leads to remodelling of the pulmonary vasculature, eventually causing obstruction to the pulmonary blood and pulmonary hypertension
478
3 associations of eisenmenger's syndrome?
1. ASD
2. VSD
3. PDA
479
Features of eisenmenger's syndrome?
1. Original murmur may disappear
2. Cyanosis
3. Clubbing
4. RV Failure
5. Haemoptysis, embolism
480
Mx of eisenmenger's syndrome?
Heart-lung transplantation is required
481
Soft S2?
AS
482
Loud S2?
HTN
483
Fixed split S2?
ASD
484
Reversed split S2?
LBBB
485
Hypercalcaemia ECG abnormality?
Short QT interval
486
Severe hypercalcaemia ECG findings?
Osborne (J) waves
487
Features of hypercalcaemia?
1. 'Bones, stones, groans and psychic moans'
2. Corneal calcification
3. Shortened QT interval on ECG
4. Hypertension
488
Cannon A waves?
Complete heart block and atrial flutter
489
Absent A waves?
AF
490
Slow Y descent?
Tricuspid stenosis or cardiac tamponase
491
Exaggerated X descent?
Constrictive pericarditis
492
Abciximab MOA?
Glycoprotein IIb/IIIa inhibitor
493
Dabigatran MOA?
Direct thrombin inhibitor
494
Dabigatran indications?
1. Prophylaxis of VTE in pts following hip or knee replacement surgery
2 Prevention of stroke in pts with non-valvular AF who have further risk factors (CBA)
495
Dabigatran s/e?
1. Haemorrhage
| 2. Dose should be reduced in CKD and not prescribed if creatinine clearance is <30ml/min
496
Rapid reversal of dabigatran?
Idarucizumab
497
RE-ALIGN study?
Significantly higher bleeding and thrombotic events in patients with recent mechanical heart valve replacement using dabigatran compared with warfarin
498
Pregnancy effect on BP?
Falls in first half of pregnancy (continues to fall until 20-24 weeks) before rising to pre-pregnancy levels before term
499
Pregnancy HTN definition?
1. Systolic > 140 mmHg or diastolic > 90 mmHg
| 2. Increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic
500
Pregnancy HTN classification?
1. Pre-existing hypertension
2. Pregnancy-induced hypertension
3. Pre-eclampsia
