Cardiology

Question 1

What ECG changes are seen in Brugada syndrome? (2)

Answer 1

1) Convex ST elevation >2mm in V1-V3, followed by a negative T wave

2) Partial RBBB

Question 2

What medications will worsen the ECG changes seen in Brugada syndrome? (2)

Answer 2

1) Flecainide

2) Ajmaline

Question 3

What percentage of patients with infective endocarditis have previously normal heart valves?

Answer 3

50%

Question 4

What is the most commonly affected valve in infective endocarditis?

Answer 4

Mitral valve

Question 5

What is the most commonly affected valve in infective endocarditis, in IVDU populations?

Answer 5

Tricuspid valve

Question 6

What is the most common cause of infective endocarditis in the developed world?

Answer 6

Staph. aureus

Question 7

What is the most common cause of infective endocarditis in the developing world?

Answer 7

Strep. viridans

Question 8

In what cohort of patients is Strep. viridian most commonly isolated? (3)

Answer 8

1) Patients in the developing world

2) Patients with poor oral hygiene

3) Patients having recently undergone dental surgery

Question 9

What bacteria in infective endocarditis is commonly associated with indwelling lines, or post-valvular surgery?

Answer 9

Coagulase-negative Staphylococci, including Staph. epidermis

Question 10

What bacteria in infective endocarditis is commonly associated with colorectal malignancy?

Answer 10

Strep. bovis

Question 11

What are some non-infective causes of endocarditis? (2)

Answer 11

1) SLE (Libra-Sacks Endocarditis)

2) Malignancy (Marantic endocarditis)

Question 12

What are the indications for surgery in patients with infective endocarditis? (5)

Answer 12

1) Severe valvular incompetence
2) Aortic abscess
3) Treatment-resistant infections
4) Cardiac failure
5) Recurrent emboli post-ABx treatment

Question 13

What changes on an ECG would be consistent with an aortic root abscess?

Answer 13

PR prolongation

Question 14

What scoring system is used to diagnose infective endocarditis?

Answer 14

Modified Duke’s criteria

Question 15

When can a positive diagnosis of infective endocarditis be made?

Answer 15

Modified Duke’s:

• Pathological criteria positive, OR
• 2 major criteria, OR
• 1 major and 3 minor criteria, OR
• 5 minor criteria

Question 16

What cardiac complication is associated with Long QT Syndrome?

Answer 16

1) VT
2) Torsades de pointes

Question 17

What drugs are implicated in the development of Long QT Syndrome? (10)

Think acronym

Answer 17

ASTHMATiC

Amiodarone
Sotalol/SSRIs
Haloperidol
Methadone/Metoclopramide/Macrolides
Antiarrhythmics class 1a
TCAs
Chloroquine

Question 18

What genetic defects are seen that lead to Long QT Syndrome?

Answer 18

Defect in alpha-subunit of slow-delayed rectifier potassium channel

Question 19

What genetic conditions are associated with Long QT Syndrome?

Answer 19

1) Jervelle-Lange-Mielsen (deaf)

2) Romero-Ward (non-deaf)

Question 20

What electrolyte abnormalities are associated with Long QT Syndrome?

Answer 20

1) Hypocalcaemia
2) Hypokalaemia
3) Hypomagnesaemia

Question 21

What types of Long QT Syndrome can manifest?

Answer 21

LQT 1 - Exertional syncope

LQT 2 - Emotional syncope

LQT 3 - Rest/nocturnal events

Question 22

What drug should be avoided in the treatment of Long QT Syndrome?

Answer 22

Sotalol (may worsen QT duration)

Question 23

What is the INR target for a patient with a mechanical aortic valve?

Answer 23

3.0

Question 24

What is the INR target for a patient with a mechanical mitral valve?

Answer 24

3.5

Question 25

What is the underlying cause of ventricular tachycardia?

Answer 25

1 or more ventricular ectopic foci

Question 26

What are the two types of ventricular tachycardia?

Answer 26

1) Monomorphic (1 ectopic focus) 2) Polymorphic (>1 ectopic foci)

Question 27

Torsades de Pointes is a subtype of what cardiac condition?

Answer 27

Ventricular tachycardia

Question 28

What is the most common underlying cause for monomorphic ventricular tachycardia?

Answer 28

Myocardial infarction

Question 29

What is the first-line treatment for a patient with monomorphic ventricular tachycardia, with no signs of severe symptoms?

Answer 29

Amiodarone 300mg IV over 10-60 minutes

Question 30

What is the treatment for polymorphic ventricular tachycardia, with no signs of severe symptoms?

Answer 30

Magnesium 2g IV over 10 minutes

Question 31

If drug therapy fails to resolve ventricular tachycardia, what are the next best management steps?

Answer 31

1) Electrophysiological studies (EPS) 2) ICD insertion (almost certain in those with LVSD)

Question 32

What does NICE recommend for initial management of Angina Pectoris?

Answer 32

1) Aspirin/Statin as secondary prevention (provided not contraindicated) 2) Either a beta-blocker (e.g. Atenolol), or rate-limiting CCB in monotherapy (e.g. Verapamil/Diltiazem)

Question 33

If prescribing both a beta-blocker and CCB for Angina Pectoris, what type of CCB should be used?

Answer 33

A longer-acting dihydropyridine CCB (Amlodipine, M/R Nifedipine)

Question 34

What drug should not be co-prescribed in patients taking a beta-blocker?

Answer 34

Verapamil (increased risk of complete heart block)

Question 35

If dual-therapy with beta-blockers and CCB are ineffective for treating Angina Pectoris, what drugs can be considered? (4)

Answer 35

1) Modified release Nitrates, OR 2) Ivabradine, OR 3) Nicorandil, OR 4) Ranolazine

Question 36

Why do patients experience tolerance when taking nitrates?

Answer 36

Depletion of intracellular sulfhydryl groups, which are needed to convert nitrates into NO, which then induces vasodilation

Question 37

In what conditions would you expect to see pulsus paradoxus? (2)

Answer 37

1) Severe asthma 2) Cardiac tamponade

Question 38

What is the clinical characteristics of pulsus paradoxus?

Answer 38

>10mmHg fall in BP during inspiration, leading to a faint/absent pulse on inspiration

Question 39

In what condition would you expect to find a slow-rising pulse?

Answer 39

Aortic stenosis

Question 40

In what condition would you expect to find a collapsing pulse? (6)

Answer 40

1) Patent ductus arteriosis 2) Anaemia 3) Thyrotoxicosis 4) Pyrexia 5) Exercise 6) Pregnancy

Question 41

What is the characteristic finding of pulsus alternans?

Answer 41

A regular alternation in the force of the arterial pulse

Question 42

In what conditions would you expect to find pulsus alternates?

Answer 42

Severe LVF

Question 43

What is the characteristic finding of Bisferiens pulse?

Answer 43

2 distinct systolic peaks of a pulse

Question 44

In what condition would you expect to find Bisferiens pulse?

Answer 44

Mixed aortic valve disease