Cardiology Flashcards

Question

Adverse effects of Adenosine

Answer 1

chest pain bronchospasm transient flushing can enhance conduction down accessory pathways, resulting in increased ventricular rate (e.g. WPW syndrome)

Answer 2

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

Answer 3

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

Answer 4

closure of tricuspid valve | not normally visible

Answer 5

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

Answer 6

fall in atrial pressure during ventricular systole

Answer 7

opening of tricuspid valve

Answer 8

the most common defects involve a mutation in the gene encoding β-myosin heavy chain protein or myosin-binding protein C results in predominantly diastolic dysfunction left ventricle hypertrophy → decreased compliance → decreased cardiac output characterized by myofibrillar hypertrophy with chaotic and disorganized fashion myocytes ('disarray') and fibrosis on biopsy

Answer 9

often asymptomatic exertional dyspnoea angina syncope typically following exercise due to subaortic hypertrophy of the ventricular septum, resulting in functional aortic stenosis sudden death (most commonly due to ventricular arrhythmias), arrhythmias, heart failure jerky pulse, large 'a' waves, double apex beat ejection systolic murmur increases with Valsalva manoeuvre and decreases on squatting hypertrophic cardiomyopathy may impair mitral valve closure, thus causing regurgitation

Answer 10

Freidreich's ataxia | Wolf-Parkinson's White

Answer 11

mnemonic - MR SAM ASH mitral regurgitation (MR) systolic anterior motion (SAM) of the anterior mitral valve leaflet asymmetric hypertrophy (ASH)

Answer 12

``` mid-late diastolic murmur (best heard in expiration) loud S1, opening snap low volume pulse malar flush atrial fibrillation ```

Answer 13

lengthening of murmur | opening snap becomes closer to S2

Answer 14

left atrial enlargement may be seen

Answer 15

caused by diastolic filling of the ventricle considered normal if < 30 years old (may persist in women up to 50 years old) heard in left ventricular failure (e.g. dilated cardiomyopathy), constrictive pericarditis (called a pericardial knock) and mitral regurgitation

Answer 16

may be heard in aortic stenosis, HOCM, hypertension caused by atrial contraction against a stiff ventricle therefore coincides with the P wave on ECG in HOCM a double apical impulse may be felt as a result of a palpable S4

Answer 17

V1-V4 | Left anterior descending

Answer 18

II, III, aVF, | Right coronary artery

Answer 19

V4-6, I, aVL, | Left anterior descending or left circumflex

Answer 20

I, aVL, V5-6 | Left circumflex

Answer 21

Tall R Waves in V1-2 | Left circumflex and right coronary

Answer 22

left anterior hemiblock left bundle branch block inferior myocardial infarction Wolff-Parkinson-White syndrome* - right-sided accessory pathway hyperkalaemia congenital: ostium primum ASD, tricuspid atresia minor LAD in obese people

Answer 23

``` right ventricular hypertrophy left posterior hemiblock lateral myocardial infarction chronic lung disease → cor pulmonale pulmonary embolism ostium secundum ASD Wolff-Parkinson-White syndrome* - left-sided accessory pathway normal in infant < 1 years old minor RAD in tall people ```

Answer 24

produced mainly by left ventricle in response to strain

Answer 25

vasodilator diuretic and natriuretic suppresses both sympathetic tone and the renin-angiotensin-aldosterone system

Answer 26

ACE-i ARBs diuretics

Answer 27

- previously normal mitral valve - rheumativ heart disease - congenital defects - IVDU - recent piercings

Answer 28

- used to be staph epidermidis - up to 2 months post valve replacement- strep viridans - 2+ post valve replacement/ generally most common - staph aureus - SLE

Answer 29

``` prior antibiotic therapy Coxiella burnetii Bartonella Brucella HACEK: Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella) ```

Answer 30

- TB | - any cause of pericarditis

Answer 31

dyspnoea right heart failrue - raised JVP, ascites, oedema, hepatomegaly. JVP - prominent X & Y descent pericardial knock - loud S3 Kussmaul positive (paradoxical rise in JVP on inspiration

Answer 32

calcified pericardium

Answer 33

JVP - absent Y descent pulsus paradoxus Kussmaul - rare

Answer 34

class III antiarrhythmic agent used in the treatment of atrial, nodal and ventricular tachycardias. The main mechanism of action is by blocking potassium channels which inhibits repolarisation and hence prolongs the action potential. Amiodarone also has other actions such as blocking sodium channels (a class I effect)

Answer 35

TFT, LFT, U&E, CXR prior to treatment | TFT, LFT every 6 months

Answer 36

``` thyroid dysfunction: both hypothyroidism and hyper-thyroidism corneal deposits pulmonary fibrosis/pneumonitis liver fibrosis/hepatitis peripheral neuropathy, myopathy photosensitivity 'slate-grey' appearance thrombophlebitis and injection site reactions bradycardia lengths QT interval ```

Answer 37

``` idiopathic ischaemic heart disease digoxin toxicity hypokalaemia* rheumatic fever aortic root pathology e.g. abscess secondary to endocarditis Lyme disease sarcoidosis myotonic dystrophy ```

Answer 38

a 60-year-old man with a history of lung cancer presents with dyspnoea. On examination he is tachycardic, hypotensive, has a raised JVP with an absent Y descent and has pulsus paradoxus

Answer 39

a 60-year-old man with a history of tuberculosis presents with dyspnoea and fatigue. On examination the JVP is elevated, there is a loud S3 and Kussmaul's sign is positive. Hepatomegaly is also noted

Answer 40

TB | any other cause of pericarditis

Answer 41

``` dyspnoea right heart failure: elevated JVP, ascites, oedema, hepatomegaly JVP shows prominent x and y descent pericardial knock - loud S3 Kussmaul's sign is positive ```

Answer 42

inhibiting sodium reabsorption at the beginning of the distal convoluted tubule (DCT) by blocking the thiazide-sensitive Na+-Cl− symporter. Potassium is lost as a result of more sodium reaching the collecting ducts.

Answer 43

``` dehydration postural hypotension hyponatraemia, hypokalaemia, hypercalcaemia* gout impaired glucose tolerance impotence ```

Answer 44

thrombocytopaenia agranulocytosis photosensitivity rash pancreatitis

Answer 45

Takayasu's arteritis is a large vessel vasculitis. It typically causes occlusion of the aorta and questions commonly refer to an absent limb pulse. It is more common in females and Asian people Associated with renal artery stenosis Managed with steroids

Answer 46

systemic features of a vasculitis e.g. malaise, headache unequal blood pressure in the upper limbs carotid bruit intermittent claudication aortic regurgitation (around 20%)

Answer 47

``` idiopathic ischaemic heart disease digoxin toxicity hypokalaemia* rheumatic fever aortic root pathology e.g. abscess secondary to endocarditis Lyme disease sarcoidosis myotonic dystrophy ```

Answer 48

a patient develops acute heart failure 10 days following a myocardial infarction. On examination he has a raised JVP, pulsus paradoxus and diminished heart sounds

Answer 49

a patient develops acute heart failure 5 days after a myocardial infarction. A new pan-systolic murmur is noted on examination

Answer 50

``` ischaemic heart disease hypertension aortic stenosis cardiomyopathy rare: idiopathic fibrosis, digoxin toxicity, hyperkalaemia ```

Answer 51

idiopathic: the most common cause myocarditis: e.g. Coxsackie B, HIV, diphtheria, Chagas disease ischaemic heart disease peripartum hypertension iatrogenic: e.g. doxorubicin substance abuse: e.g. alcohol, cocaine inherited: Duchenne's infiltrative e.g. haemochromatosis, sarcoidosis + these causes may also lead to restrictive cardiomyopathy nutritional e.g. wet beriberi (thiamine deficiency)

Answer 52

``` dilated heart leading to predominately systolic dysfunction all 4 chambers are dilated, but the left ventricle more so than right ventricle eccentric hypertrophy (sarcomeres added in series) is seen ```

Answer 53

classic findings of heart failure systolic murmur: stretching of the valves may result in mitral and tricuspid regurgitation S3 'balloon' appearance of the heart on the chest x-ray

Answer 54

``` Female sex Lower body mass Age Renal dysfunction Prior myocardial infarction Prior mitral stenosis or valve prolapse Collagen disorders e.g. Marfan's Syndrome and Ehlers-Danlos syndrome ```

Answer 55

``` Following coronary artery disease or post-MI Mitral valve prolapse Infective endocarditis Rheumatic fever. Congenital ```

Answer 56

Symptoms tend to be due to failure of the left ventricle, arrhythmias or pulmonary hypertension.

Answer 57

The murmur heard on auscultation of the chest is typically a pansystolic murmur described as “blowing”. It is heard best at the apex and radiating into the axilla. S1 may be quiet as a result of incomplete closure of the valve. Severe MR may cause a widely split S2

Answer 58

ECG may show a broad P wave, indicative of atrial enlargement Cardiomegaly may be seen on chest x-ray, with an enlarged left atrium and ventricle Echocardiography is crucial to diagnosis and to assess severity

Answer 59

Medical management in acute cases involves nitrates, diuretics, positive inotropes and an intra-aortic balloon pump to increase cardiac output If patients are in heart failure, ACE inhibitors may be considered along with beta-blockers and spironolactone In acute, severe regurgitation, surgery is indicated The evidence for repair over replacement is strong in degenerative regurgitation, and is demonstrated through lower mortality and higher survival rates When this is not possible, valve replacement with either an artificial valve or a pig valve is considered

Answer 60

thrombus aspiration, but not mechanical thrombus extraction, should be considered complete revascularisation should be considered for patients with multivessel coronary artery disease without cardiogenic shock

Answer 61

patients undergoing PCI with radial access: unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor (GPI) - this is the action of using a GPI during the procedure when it was not intended from the outset, e.g. because of worsening or persistent thrombus patients undergoing PCI with femoral access: bivalirudin with bailout GPI

Answer 62

this is termed 'dual antiplatelet therapy', i.e. aspirin + another drug if the patient is not taking an oral anticoagulant: prasugrel if taking an oral anticoagulant: clopidogrel

Answer 63

Fibrinolysis used to be the only form of coronary reperfusion therapy available. However, it is used much less commonly now given the widespread availability of PCI. Patients undergoing fibrinolysis should also be given an antithrombin drug. An ECG should be repeated after 60-90 minutes to see if the ECG changes have resolved. If patients have persistent myocardial ischaemia following fibrinolysis then PCI should be considered.

Answer 64

antithrombin treatment fondaparinux should be offered to patients who are not at a high risk of bleeding and who are not having angiography immediately if immediate angiography is planned or a patients creatinine is > 265 µmol/L then unfractionated heparin should be given

Answer 65

``` Global Registry of Acute Coronary Events age heart rate, blood pressure cardiac (Killip class) and renal function (serum creatinine) cardiac arrest on presentation ECG findings troponin levels ```

Answer 66

immediate: patient who are clinically unstable (e.g. hypotensive) within 72 hours: patients with a GRACE score > 3% i.e. those at intermediate, high or highest risk coronary angiography should also be considered for patients if ischaemia is subsequently experienced after admission

Answer 67

unfractionated heparin should be given regardless of whether the patient has had fondaparinux or not further antiplatelet ('dual antiplatelet therapy', i.e. aspirin + another drug) prior to PCI if the patient is not taking an oral anticoagulant: prasugrel or ticagrelor if taking an oral anticoagulant: clopidogrel

Answer 68

``` further antiplatelet ('dual antiplatelet therapy', i.e. aspirin + another drug) if the patient is not at a high risk of bleeding: ticagrelor if the patient is at a high risk of bleeding: clopidogrel ```

Answer 69

cor pulmonale

Answer 70

often most pronounced in lead II | a sign of left atrial enlargement, classically due to mitral stenosis

Answer 71

Large A waves

Answer 72

normal variant - more common with increasing age right ventricular hypertrophy chronically increased right ventricular pressure - e.g. cor pulmonale pulmonary embolism myocardial infarction atrial septal defect (ostium secundum) cardiomyopathy or myocarditis

Answer 73

Thrombolytic drugs activate plasminogen to form plasmin. This in turn degrades fibrin and help breaks up thrombi. They in primarily used in patients who present with a ST elevation myocardial infarction. Other indications include acute ischaemic stroke and pulmonary embolism, although strict inclusion criteria apply. Examples alteplase tenecteplase streptokinase

Answer 74

``` active internal bleeding recent haemorrhage, trauma or surgery (including dental extraction) coagulation and bleeding disorders intracranial neoplasm stroke < 3 months aortic dissection recent head injury severe hypertension ```

Answer 75

``` left subclavicular thrill continuous 'machinery' murmur large volume, bounding, collapsing pulse wide pulse pressure heaving apex beat ```

Answer 76

indomethacin or ibuprofen given to the neonate inhibits prostaglandin synthesis closes the connection in the majority of cases if associated with another congenital heart defect amenable to surgery then prostaglandin E1 is useful to keep the duct open until after surgical repa

Answer 77

a form of congenital heart defect generally classed as 'acyanotic'. However, uncorrected can eventually result in late cyanosis in the lower extremities, termed differential cyanosis connection between the pulmonary trunk and descending aorta usually, the ductus arteriosus closes with the first breaths due to increased pulmonary flow which enhances prostaglandins clearance more common in premature babies, born at high altitude or maternal rubella infection in the first trimester

Answer 78

early diastolic murmur: intensity of the murmur is increased by the handgrip manoeuvre collapsing pulse wide pulse pressure Quincke's sign (nailbed pulsation) De Musset's sign (head bobbing) mid-diastolic Austin-Flint murmur in severe AR - due to partial closure of the anterior mitral valve cusps caused by the regurgitation streams

Answer 79

rheumatic fever infective endocarditis connective tissue diseases e.g. RA/SLE bicuspid aortic valve

Answer 80

``` aortic dissection spondylarthropathies (e.g. ankylosing spondylitis) hypertension syphilis Marfan's, Ehler-Danlos syndrome ```

Answer 81

Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg

Answer 82

Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg

Answer 83

Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 110 mmHg

Answer 84

patients < 55-years-old or a background of type 2 diabetes mellitus: ACE inhibitor or a Angiotensin receptor blocker (ACE-i or ARB): (A) angiotensin receptor blockers should be used where ACE inhibitors are not tolerated (e.g. due to a cough) patients >= 55-years-old or of black African or African–Caribbean origin: Calcium channel blocker (C) ACE inhibitors have reduced efficacy in patients of black African or African–Caribbean origin are therefore not used first-line

Answer 85

if already taking an ACE-i or ARB add a Calcium channel blocker or a thiazide-like Diuretic if already taking a Calcium channel blocker add an ACE-i or ARB or a thiazide-like Diuretic for patients of black African or African–Caribbean origin taking a calcium channel blocker for hypertension, if they require a second agent consider an angiotensin receptor blocker in preference to an ACE inhibitor (A + C) or (A + D) or (C + A) or (C + D)

Answer 86

add a third drug to make, i.e.: if already taking an (A + C) then add a D if already (A + D) then add a C (A + C + D)

Answer 87

NICE define step 4 as resistant hypertension and suggest either adding a 4th drug (as below) or seeking specialist advice first, check for: confirm elevated clinic BP with ABPM or HBPM assess for postural hypotension. discuss adherence if potassium < 4.5 mmol/l add low-dose spironolactone if potassium > 4.5 mmol/l add an alpha- or beta-blocker

Answer 88

e.g. Aliskiren (branded as Rasilez) by inhibiting renin blocks the conversion of angiotensinogen to angiotensin I 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

Answer 89

a patient is noted to have a new early-to-mid systolic murmur 10 days after being admitted for a myocardial infarction

Answer 90

a patient develops acute heart failure 5 days after a myocardial infarction. A new pan-systolic murmur is noted on examination

Answer 91

Bivalirudin is a reversible direct thrombin inhibitor used as an anticoagulant in the management of acute coronary syndrome.

Answer 92

hypotension tachycardia headaches flushing

Answer 93

nitrates cause the release of nitric oxide in smooth muscle, activating guanylate cyclase which then converts GTP to cGMP, which in turn leads to a fall in intracellular calcium levels in angina they both dilate the coronary arteries and also reduce venous return which in turn reduces left ventricular work, reducing myocardial oxygen demand

Answer 94

many patients who take nitrates develop tolerance and experience reduced efficacy the BNF advises that patients who develop tolerance should take the second dose of isosorbide mononitrate after 8 hours, rather than after 12 hours. This allows blood-nitrate levels to fall for 4 hours and maintains effectiveness this effect is not seen in patients who take modified release isosorbide mononitrate

Answer 95

inhibit the conversion angiotensin I to angiotensin II | ACE inhibitors are activated by phase 1 metabolism in the liver

Answer 96

cough occurs in around 15% of patients and may occur up to a year after starting treatment thought to be due to increased bradykinin levels angioedema: may occur up to a year after starting treatment hyperkalaemia first-dose hypotension: more common in patients taking diuretics

Answer 97

pregnancy and breastfeeding - avoid renovascular disease - may result in renal impairment aortic stenosis - may result in hypotension hereditary of idiopathic angioedema specialist advice should be sought before starting ACE inhibitors in patients with a potassium >= 5.0 mmol/L

Answer 98

patients receiving high-dose diuretic therapy (more than 80 mg of furosemide a day) significantly increases the risk of hypotension

Answer 99

urea and electrolytes should be checked before treatment is initiated and after increasing the dose a rise in the creatinine and potassium may be expected after starting ACE inhibitors acceptable changes are an increase in serum creatinine, up to 30% from baseline and an increase in potassium up to 5.5 mmol/l. significant renal impairment may occur in patients who have undiagnosed bilateral renal artery stenosis

Answer 100

Arrhythmogenic right ventricular cardiomyopathy (ARVC, also known as arrhythmogenic right ventricular dysplasia or ARVD) is a form of inherited cardiovascular disease which may present with syncope or sudden cardiac death. It is generally regarded as the second most common cause of sudden cardiac death in the young after hypertrophic cardiomyopathy.

Answer 101

inherited in an autosomal dominant pattern with variable expression the right ventricular myocardium is replaced by fatty and fibrofatty tissue around 50% of patients have a mutation of one of the several genes which encode components of desmosome

Answer 102

palpitations syncope sudden cardiac death

Answer 103

ECG abnormalities in V1-3, typically T wave inversion. An epsilon wave is found in about 50% of those with ARV - this is best described as a terminal notch in the QRS complex echo changes are often subtle in the early stages but may show an enlarged, hypokinetic right ventricle with a thin free wall magnetic resonance imaging is useful to show fibrofatty tissue

Answer 104

drugs: sotalol is the most widely used antiarrhythmic catheter ablation to prevent ventricular tachycardia implantable cardioverter-defibrillator

Answer 105

an autosomal recessive variant of ARVC | a triad of ARVC, palmoplantar keratosis, and woolly hair

Answer 106

(also known as thromboangiitis obliterans) is a small and medium vessel vasculitis that is strongly associated with smoking.

Answer 107

``` extremity ischaemia intermittent claudication ischaemic ulcers superficial thrombophlebitis Raynaud's phenomenon ```

Answer 108

uncontrolled heart failure asthma sick sinus syndrome concurrent verapamil use: may precipitate severe bradycardia

Answer 109

``` bronchospasm cold peripheries fatigue sleep disturbances, including nightmares erectile dysfunction ```

Answer 110

Adenosine is most commonly used to terminate supraventricular tachycardias. The effects of adenosine are enhanced by dipyridamole (antiplatelet agent) and blocked by theophyllines. It should be avoided in asthmatics due to possible bronchospasm.

Answer 111

causes transient heart block in the AV node agonist of the A1 receptor in the atrioventricular node, which inhibits adenylyl cyclase thus reducing cAMP and causing hyperpolarization by increasing outward potassium flux adenosine has a very short half-life of about 8-10 seconds

Answer 112

Chest pain bronchospasm transient flushing can enhance conduction down accessory pathways, resulting in increased ventricular rate (e.g. WPW syndrome)

Answer 113

vasodilatory drug used to treat angina. It is a potassium-channel activator with vasodilation is through activation of guanylyl cyclase which results in increase cGMP.

Answer 114

flushing headache kin, mucosal and eye ulceration gastrointestinal ulcers including anal ulceration Cntra indicated in LVF

Answer 115

``` bradycardia 'J' wave - small hump at the end of the QRS complex first degree heart block long QT interval atrial and ventricular arrhythmias ```

Answer 116

Aspirin (lifelong) & ticagrelor (12 months)

Answer 117

If aspirin contraindicated, clopidogrel (lifelong

Answer 118

Aspirin (lifelong) & prasurgrel or ticagrelor (12 months)

Answer 119

If aspirin contraindicated, clopidogrel (lifelong)

Answer 120

Clopidogrel (lifelong)

Answer 121

Aspirin (lifelong) & dipyridamole (lifelong)

Answer 122

Clopidogrel (lifelong)

Answer 123

Aspirin (lifelong) & dipyridamole (lifelong)

Answer 124

Clopidogrel (lifelong)

Answer 125

Asprin (lifelong)

Answer 126

Staphylococcus aureus infection (see below) prosthetic valve (especially 'early', acquired during surgery) culture negative endocarditis low complement levels

Answer 127

can drive unless treatment causes unacceptable side effects, no need to notify DVLA if Group 2 Entitlement the disqualifies from driving if resting BP consistently 180 mmHg systolic or more and/or 100 mm Hg diastolic or more

Answer 128

1 week off driving

Answer 129

4 weeks off driving

Answer 130

4 weeks off driving | 1 week if successfully treated by angioplasty

Answer 131

driving must cease if symptoms occur at rest/at the wheel

Answer 132

1 week off driving

Answer 133

if implanted for sustained ventricular arrhythmia: cease driving for 6 months if implanted prophylactically then cease driving for 1 month. Having an ICD results in a permanent bar for Group 2 drivers

Answer 134

2 days off driving

Answer 135

notify DVLA. Licensing will be permitted subject to annual review. an aortic diameter of 6.5 cm or more disqualifies patients from driving

Answer 136

do not drive for 6 weeks, no need to notify DVLA

Answer 137

Acute pancreatitis

Answer 138

Assesses the risk of a patient developing a pressure sore

Answer 139

FAST CAGE Audit

Answer 140

Used to determine the need to anticoagulate a patient in atrial fibrillation

Answer 141

Prognostic score for risk stratifying patients who've had a suspected TIA

Answer 142

Brugada syndrome is a form of inherited cardiovascular disease with may present with sudden cardiac death. It is inherited in an autosomal dominant fashion and has an estimated prevalence of 1:5,000-10,000. Brugada syndrome is more common in Asians.

Answer 143

a large number of variants exist around 20-40% of cases are caused by a mutation in the SCN5A gene which encodes the myocardial sodium ion channel protein

Answer 144

convex ST segment elevation > 2mm in > 1 of V1-V3 followed by a negative T wave partial right bundle branch block the ECG changes may be more apparent following the administration of flecainide or ajmaline - this is the investigation of choice in suspected cases of Brugada syndrome

Answer 145

implantable cardioverter-defibrillator

Answer 146

B-type natriuretic peptide (BNP) is a hormone produced mainly by the left ventricular myocardium in response to strain. Whilst heart failure is the most obvious cause of raised BNP levels any cause of left ventricular dysfunction such as myocardial ischaemia or valvular disease may raise levels. Raised levels may also be seen due to reduced excretion in patients with chronic kidney disease. Factors which reduce BNP levels include treatment with ACE inhibitors, angiotensin-2 receptor blockers and diuretics.

Answer 147

vasodilator diuretic and natriuretic suppresses both sympathetic tone and the renin-angiotensin-aldosterone system

Answer 148

Streptococcus pyogenes infection → activation of the innate immune system leading to antigen presentation to T cells B and T cells produce IgG and IgM antibodies and CD4+ T cells are activated there is then a cross-reactive immune response (a form of type II hypersensitivity) thought to be mediated by molecular mimicry the cell wall of Streptococcus 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 this response leads to the clinical features of rheumatic fever Aschoff bodies describes the granulomatous nodules found in rheumatic heart fever

Answer 149

treptococcus pyogenes infection → activation of the innate immune system leading to antigen presentation to T cells B and T cells produce IgG and IgM antibodies and CD4+ T cells are activated there is then a cross-reactive immune response (a form of type II hypersensitivity) thought to be mediated by molecular mimicry the cell wall of Streptococcus 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 this response leads to the clinical features of rheumatic fever Aschoff bodies describes the granulomatous nodules found in rheumatic heart fever

Answer 150

``` ventricular septal defects (VSD) - most common, accounts for 30% atrial septal defect (ASD) patent ductus arteriosus (PDA) coarctation of the aorta aortic valve stenosis ```

Answer 151

tetralogy of Fallot transposition of the great arteries (TGA) tricuspid atresia

Answer 152

Hypotension Raised JVP Muffled heart sounds

Answer 153

dyspnoea tachycardia an absent Y descent on the JVP - this is due to the limited right ventricular filling pulsus paradoxus - an abnormally large drop in BP during inspiration Kussmaul's sign - much debate about this ECG: electrical alternans

Answer 154

``` left subclavicular thrill continuous 'machinery' murmur large volume, bounding, collapsing pulse wide pulse pressure heaving apex beat collapsing pulse ```

Answer 155

indomethacin or ibuprofen given to the neonate inhibits prostaglandin synthesis closes the connection in the majority of cases if associated with another congenital heart defect amenable to surgery then prostaglandin E1 is useful to keep the duct open until after surgical repair

Answer 156

'bones, stones, groans and psychic moans' corneal calcification shortened QT interval on ECG hypertension

Answer 157

Holosystolic murmur, high-pitched and 'blowing' in character

Answer 158

inverted T waves

Answer 159

a non-pulsatile raised JVP

Answer 160

cannon A wave pulse

Answer 161

increases cGMP leading to smooth muscle relaxation | Contra-indicated in SLE, IHD, CVD

Answer 162

``` tachycardia palpitations flushing fluid retention headache drug-induced lupus ```

Answer 163

Collapsing pulse

Answer 164

slow rising pulse

Answer 165

Aspirin (lifelong) & prasugral or ticagrelor (12 months), no other antiplatelets

Answer 166

peripheral arterial disease (no drug allergies) ischaemic stroke (no drug allergies) TIA (no drug allergies)

Answer 167

``` TIA (cannot take clopidogrel) ischaemic stroke (cannot take clopidogrel) ```

Answer 168

Flucloxacillin + rifampicin + low-dose gentamicin

Answer 169

Flucloxacillin

Answer 170

chest pain bronchospasm transient flushing can enhance conduction down accessory pathways, resulting in increased ventricular rate (e.g. WPW syndrome)

Answer 171

Freidreich's ataxia

Answer 172

Buerger's disease (also known as thromboangiitis obliterans) is a small and medium vessel vasculitis that is strongly associated with smoking. ``` Features extremity ischaemia intermittent claudication ischaemic ulcers superficial thrombophlebitis Raynaud's phenomenon ```

Answer 173

Vancomycin + rifampicin + low-dose gentamicin

Answer 174

Continuous 'machinery' murmur

Answer 175

Mitral stenosis

Answer 176

mitral regurgitation

Answer 177

cardiac tamponade

Answer 178

PCI within 72hrs

Answer 179

Ivabradine is a class of anti-anginal drug which works by reducing the heart rate. It acts on the If ('funny') ion current which is highly expressed in the sinoatrial node, reducing cardiac pacemaker activity

Answer 180

visual effects, particular luminous phenomena, are common headache bradycardia, heart block

Answer 181

Usually due to a mutation in the gene encoding beta-myosin heavy chain protein

Answer 182

Hyperkalaemia | Hypotension

Answer 183

ST depression a long QT interval a prolonged PR interval U waves

Answer 184

Elevated ST | inverted T wave

Answer 185

Increases cGMP leading to smooth muscle relaxation

Answer 186

a 50-year-old man with Marfan syndrome presents with palpitations and dyspnoea. On examination he has a collapsing pulse, the blood pressure is 160/60 mmHg and a high-pitched diastolic murmur is heard

Answer 187

a 70-year-old woman is found to have a pan-systolic murmur after presenting with dyspnoea. A soft S1 and split S2 is also noted

Answer 188

severe asthma, cardiac tamponade

Answer 189

antagonist of the P2Y12 adenosine diphosphate (ADP) receptor, inhibiting the activation of platelets

Answer 190

Everyone who has a MI - NSTEMI or STEMI

Answer 191

Concurrent verapamil - can cause complete heart block | Use nicorandil instead

Answer 192

Dipyridamole increases the levels adenosine and inhibits the phosphodiesterase enzymes that normally break down cAMP. Exogenous use of adenosine (e.g. treatment of supraventricular tachycardia) is contraindicated in patients on dipyridamole for this reason.

Answer 193

relaxes coronary vascular smooth muscle by stimulating guanylyl cyclase and increasing cyclic GMP (cGMP) levels (as shown first in our laboratory) as well as by a second mechanism resulting in activation of K+ channels and hyperpolarization

Answer 194

tricuspid regurgitation → pansystolic murmur, worse on inspiration associated with benzos and lithium in pregnancy

Answer 195

severe valvular incompetence aortic abscess (often indicated by a lengthening PR interval) infections resistant to antibiotics/fungal infections cardiac failure refractory to standard medical treatment recurrent emboli after antibiotic therapy

Answer 196

Aminophylline | Dipyramidole enhances the impact of adenosine

Answer 197

``` secondary to abnormal QRS (LVH, LBBB, RBBB) ischaemia digoxin hypokalaemia syndrome X ```

Answer 198

Microvascular angina Relieved by rest or nitroglycerin Normal coronary arteriograms the cause of ischemia seems to be reflex intramyocardial coronary constriction and reduced coronary flow reserve. Other patients have microvascular dysfunction within the myocardium: The abnormal vessels do not dilate in response to exercise or other cardiovascular stressors; sensitivity to cardiac pain may also be increased.

Answer 199

much more common than a positive response, can be treated with prostacyclin analogues, endothelin receptor antagonists or phosphodiesterase inhibitors. Patients often require combination therapy. Bosentan is the correct answer and is an endothelin receptor antagonist. Treprostinil and iloprost are prostacyclin analogue

Answer 200

cyanotic: TGA most common at birth, Fallot's most common overall acyanotic: VSD most common cause

Answer 201

cholesterol emboli may break off causing renal disease the majority of cases are secondary to vascular surgery or angiography. Other causes include severe atherosclerosis, particularly in large arteries such as the aorta

Answer 202

eosinophilia purpura renal failure livedo reticularis

Answer 203

esting mean pulmonary artery pressure of >= 25 mmHg. Endothelin thought to play a key role in pathogenesis of PAH. It is more common in females and typically presents between the ages of 30-50 years. Pulmonary hypertension may of course develop secondary to chronic lung diseases such as COPD. 10% Autosomal dominant inheritance

Answer 204

progressive exertional dyspnoea is the classical presentation other possible features include exertional syncope, exertional chest pain and peripheral oedema cyanosis right ventricular heave, loud P2, raised JVP with prominent 'a' waves, tricuspid regurgitation

Answer 205

prostacyclin analogues: treprostinil, iloprost endothelin receptor antagonists: bosentan, ambrisentan phosphodiesterase inhibitors: sildenafil

Answer 206

oral calcium channel blockers

Answer 207

cardiac catheterisation to measure right heart pressures

Answer 208

short PR interval wide QRS complexes with a slurred upstroke - 'delta wave' left axis deviation if right-sided accessory pathway* right axis deviation if left-sided accessory pathway*

Answer 209

``` type A (left-sided pathway): dominant R wave in V1 type B (right-sided pathway): no dominant R wave in V ```

Answer 210

definitive treatment: radiofrequency ablation of the accessory pathway medical therapy: sotalol***, amiodarone, flecainide **sotalol should be avoided if there is coexistent atrial fibrillation as prolonging the refractory period at the AV node may increase the rate of transmission

Answer 211

``` HOCM mitral valve prolapse Ebstein's anomaly thyrotoxicosis secundum ASD ```

Answer 212

blocking potassium channels which inhibits repolarisation and hence prolongs the action potential. Amiodarone also has other actions such as blocking sodium channels (a class I effect)

Answer 213

to detect underlying hypokalaemia- dramatically increases the risk of arrhythmias

Answer 214

hypertension: the most important risk factor trauma bicuspid aortic valve collagens: Marfan's syndrome, Ehlers-Danlos syndrome Turner's and Noonan's syndrome pregnancy syphilis

Answer 215

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

Answer 216

type A - ascending aorta, 2/3 of cases | type B - descending aorta, distal to left subclavian origin, 1/3 of cases

Answer 217

chest pain: typically severe, radiates through to the back and 'tearing' in nature pulse deficit weak or absent carotid, brachial, or femoral pulse variation (>20 mmHg) in systolic blood pressure between the arms aortic regurgitation hypertension other features may result from the involvement of specific arteries. For example coronary arteries → angina, spinal arteries → paraplegia, distal aorta → limb ischaemia the majority of patients have no or non-specific ECG changes. In a minority of patients, ST-segment elevation may be seen in the inferior leads

Answer 218

check INR 72 hours before procedure, proceed if INR < 4.0

Answer 219

``` bradycardia 'J' wave - small hump at the end of the QRS complex first degree heart block long QT interval atrial and ventricular arrhythmias ```

Answer 220

sinus bradycardia junctional rhythm first degree heart block Wenckebach phenomenon

Answer 221

Staphylococcus aureus infection prosthetic valve (especially 'early', acquired during surgery) culture negative endocarditis low complement levels

Answer 222

Colonoscopy. | Streptococcus gallolyticus is the subtype of Streptococcus bovis most linked with colorectal cancer

Answer 223

``` amiodarone, sotalol, class 1a antiarrhythmic drugs tricyclic antidepressants, selective serotonin reuptake inhibitors (especially citalopram) methadone chloroquine terfenadine** erythromycin haloperidol ondanestron ```

Answer 224

amiodarone: ideally administered through a central line lidocaine: use with caution in severe left ventricular impairment procainamide Verapamil should NOT be used in VT.

Answer 225

shortening of the QT interval. Other findings include prolonged PR, widened QRS and ST elevation Hypercalcaemia causes certain calcium ion channels to be opened for shorter amounts of time which in turn reduce phase 2 (the plateau phase) of the cardiomyocyte. This shortens the QT interval.

Answer 226

younger patients < 65 years: bicuspid aortic valve | older patients > 65 years: calcification

Answer 227

chest pain dyspnoea syncope murmur an ejection systolic murmur (ESM) is classically seen in aortic stenosis classically radiates to the carotids this is decreased following the Valsalva manoeuvre

Answer 228

``` narrow pulse pressure slow rising pulse delayed ESM soft/absent S2 S4 thrill duration of murmur left ventricular hypertrophy or failure ```

Answer 229

degenerative calcification (most common cause in older patients > 65 years) bicuspid aortic valve (most common cause in younger patients < 65 years) William's syndrome (supravalvular aortic stenosis) post-rheumatic disease subvalvular: HOCM

Answer 230

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

Answer 231

venous thromboembolism: target INR = 2.5, if recurrent 3.5 atrial fibrillation, target INR = 2.5 mechanical heart valves, target INR depends on the valve type and location. Mitral valves generally require a higher INR than aortic valves.

Answer 232

liver disease P450 enzyme inhibitors, e.g.: amiodarone, ciprofloxacin cranberry juice drugs which displace warfarin from plasma albumin, e.g. NSAIDs inhibit platelet function: NSAIDs

Answer 233

haemorrhage teratogenic, although can be used in breastfeeding mothers skin necrosis: when warfarin is first started biosynthesis of protein C is reduced. This results in a temporary procoagulant state after initially starting warfarin, normally avoided by concurrent heparin administration. Thrombosis may occur in venules leading to skin necrosis purple toes

Cardiology Flashcards

(258 cards)