Cardiology Flashcards
(131 cards)
1
Q
How do we treat SVT if vasovagal maneuvers haven’t worked?
A
IV adenosine, and if this doesn’t work electric cardioversion
2
Q
When is amiodarone given in ALS?
A
amiodarone 300 mg should be given to patients who are in VF/pulseless VT after 3 shocks have been administered.
a further dose of amiodarone 150 mg should be given to patients who are in VF/pulseless VT after 5 shocks have been administered
3
Q
Where do you see U waves on ECG?
A
Hypokalaemia
4
Q
What electrolyte abnormalities does bendroflumethiazide cause?
A
Bendroflumethiazide causes both hyponatraemia and hypokalaemia.
5
Q
For which arrhythmia do we give amiodarone?
A
Ventricular tachycardia
6
Q
What is bumetanide?
A
Loop diuretic
7
Q
What is the most common organism that causes IE?
A
Gram +ve cocci
8
Q
How do we treat stable fast AF?
A
Starting bisoprolol would be correct if the patient were haemodynamically stable. If the patient’s blood pressure was higher, they could receive a beta blocker to slow down the heart and allow the ventricles to fill. However in this case if the heart is slowed momentarily it will drop blood pressure and the patient may arrest, due to inadequate coronary artery perfusion.
Starting digoxin is incorrect. Digoxin is the second line of management for atrial fibrillation if the patient is haemodynamically stable. In this case, the patient is not haemodynamically stable, so pharmacologic therapies are not considered until cardioversion has been attempted and blood pressure returns to normal.
9
Q
How do we treat unstable AF?
A
Electric cardioversion
9
Q
Which abx can lead to torsades de pointes?
A
Macrolides like Clari
10
Q
What is furosemide?
A
Loop diuretic - can cause hypokalaemia
11
Q
Which post MI medication can cause angioedema?
A
Ramipril - characterised by marked tongue and facial swelling
12
Q
Which type of BBB is never normal?
A
LBBB
13
Q
Which medication is teratogenic: LMWH or warfarin?
A
Warfarin
14
Q
What do we use DAS-28 scale for?
A
Measure of disease activity in rheumatoid arthritis
15
Q
A 45-year-old man presents to his general practitioner concerned about his sex life. He is unable to get and maintain an erection and feel it is affecting him mentally. Which HF med may cause this?
A
Beta blockers
16
Q
When do we use pericardiocentesis?
A
Cardiac tamponadeW
17
Q
When do we use the Bishop score?
A
Used to help assess the whether induction of labour will be required
18
Q
What is the APGAR score used for?
A
Assesses the health of a newborn immediately after birth
19
Q
What is the Child-Pugh classification used for?
A
A scoring system used to assess the severity of liver cirrhosis
20
Q
How do we treat torsades de pointes?
A
Magnesium sulphate
21
Q
How do we treat htn in diabetics?
A
ACE inhibitors/A2RBs are first-line regardless of age
22
Q
What is Beck’s triad?
A
Beck’s triad of falling BP, rising JVP and muffled heart sound is characteristic of cardiac tamponade
23
Q
What is indapamide?
A
Loop diuretic
24
How does mitral stenosis present?
shortness of breath, fatigue, and a malar flush on his cheeks. Cardiovascular examination reveals a regular, low-volume pulse and a mid-diastolic murmur loudest with the patient leaning to his left-hand side.
25
What is the murmur seen in mitral stenosis?
Mid-diastolic murmur loudest with the patient leaning to the LHS
26
What ECG change might you see in mitral stenosis?
P mitrale
27
What is first line tx for a pt with heart failure with reduced LVEF
A beta blocker and an ACE inhibitor as first-line treatment
28
What is the GRACE score?
The doctor is calculating the 6-month mortality of NSTEMI using a GRACE score - this includes age, ECG, troponin, renal function. Other factors that are considered include blood pressure, heart rate, and if the patient had a cardiac arrest on presentation. Renal function is important for consideration as the kidney is a common target organ that is injured in an acute myocardial infarction (AMI).
29
Being treated for HF. For the past few months she has noticed bilateral tinnitus and hearing loss. Which med might be responsible?
Furosemide - loop diuretics can cause ototoxicity
30
When is an S3 sound normal?
If <30 y.o.
An S3 heart sound is typically associated with conditions that lead to rapid ventricular filling
31
Give a common SE of adenosine
Patients should be warned that adenosine administration can cause a transient feeling of warmth/flushing
32
When may we stop ACEi in renal deterioration?
The BNF recommends the angiotensin-converting enzyme inhibitors should only be stopped if the creatinine increases by 30% or eGFR falls by 25% or greater.
33
What is the murmur seen in aortic regurg?
early diastolic murmur, high-pitched and 'blowing' in character
34
Which medications should a pt be taking four weeks post-MI?
TABAS (Ticagrelor, Aspirin, Betablocker, ACEI, Statin)
35
What is the first line treatment for regular broad complex tachycardias without adverse features?
IV amiodarone is the first-line treatment for regular broad complex tachycardias without adverse features
36
What is Buerger's disease?
Buerger's disease, or thromboangiitis obliterans, is a condition characterised by progressive inflammation and thrombosis of the small and medium arteries in the hands and feet. It can present as acute ischaemia or chronic progressive ischaemic changes to the skin/tissues. Ultimately it may result in gangrene of the affected area, often needing amputation. It is strongly associated with an extensive smoking history. The exact pathophysiology is not fully understood. Often follows from Raynaud's
37
Is the most appropriate first-line anti-anginal for stable angina in a patient with known heart failure, if there are no contraindications
Beta blockers
38
When do we use transcutaneous pacing?
If atropine alone fails to control a patient's bradyarrhythmia, alternative options include isoprenaline infusions or transcutaneous pacing.
39
What foodstuff is contraindicated with simvastatin?
Grapefruit juice
40
What is diltiazem?
Rate-limiting calcium channel blocker
41
What is verapamil?
Rate-limiting calcium channel blocker
42
How does pericarditis present?
anterior chest pain that is worse on deep inspiration and lying down
43
How do we manage acute onset of AF?
Acute onset of atrial fibrillation: if ≥ 48 hours - rate control initially, then if considered for long-term rhythm control, delay cardioversion until they have been maintained on therapeutic anticoagulation for a minimum of 3 weeks
44
How may we manage orthostatic hypotension?
Fludrocortisone or midodrine
45
Following ACS, what medical mx is started?
DABS:
Dual anti-platelet
ACEi
Beta-blocker
Statin
46
What do we start if there is co-existent AF with chronic HF?
Digoxin
47
How do we treat WPW?
accessory pathway ablation
48
How does WPW present on ECG?
a shortened PR interval and wide QRS complexes associated with a slurred upstroke seen in lead II
49
What do statins do?
Statins inhibit HMG-CoA reductase, the rate-limiting enzyme in hepatic cholesterol synthesis
50
Which kind of MI infarct can cause arrhythmias?
So the RCA is the artery typically implicated in an Inferior STEMI - which presents with STE in II, III, AVF.
The RCA also supplies the AV node, so if infarcted, this can lead to arrhythmia.
As such, Inferior STEMIs can be associated with arrhythmia
51
Where may you see notching of the inferior border of the ribs
Notching of the inferior border of the ribs is present in around 70% of adults with coarctation of the aorta
52
What is the pattern of inheritance in HOCM?
Autosomal dominant
53
What are janeway lesions?
Janeway lesions are painless, erythematous haemorhagic lesions seen on the palms and soles.
54
What are Roth spots?
Roth spots are retinal haemorrhages.
55
What is erythema multiforme?
Erythema multiforme is again caused by immune complex deposition classically appearing as a target or 'bulls eye'.
56
How would you manage first degree heart block in an athlete?
First-degree heart block is a normal variant in an athlete. It does not require intervention
57
How is the BP altered in coarctation of the aorta?
The most common type of coarctation of the aorta seen in adults is the postductal variety, i.e. the aortic narrowing is distal to the ductus arteriosus. This means that the upper limb blood pressure is greater than that in the lower limbs as the narrowing occurs after the left subclavian artery branches from the aorta.
58
How long do we treat PE for?
Length of anticoagulation
* all patients should have anticoagulation for at least 3 months
* if the VTE was provoked = 3 months
* if the VTE was unprovoked = 6 months
* If patient has cancer = 6 months
59
When are nitrates contraindicated
When systolic <90 - vasodilator
59
What is the most common cause of death in patients following a myocardial infarction?
Ventricular fibrillation
60
What are the indications for aortic valve replacement?
Syncope, angina and dyspnoea
61
How do we manage INR > 8.0 with minor bleeding?
Stop warfarin and IV vit k 1-3mg
62
How do we manage major bleeding with warfarin use?
Stop warfarin
Give intravenous vitamin K 5mg
Prothrombin complex concentrate - if not available then FFP*
63
How do we manage INR >8.0 with no bleeding?
Stop warfarin
Give vitamin K 1-5mg by mouth, using the intravenous preparation orally
64
How do we manage INR >5.0 with minor bleeding?
Stop warfarin
Give intravenous vitamin K 1-3mg
Restart when INR < 5.0
65
A patient with AF + an acute stroke (not haemorrhagic) should have anticoagulation therapy started two weeks after the event
Why wait 2/52?
This is due to the risk of haemorrhagic transformation in the area of ischaemia.
66
Who does Buerger's disease affect?
It most commonly affects young males who smoke
67
Complete heart block following a MI. Most likely coronary to be affected?
RCA
68
What is adenosine used for?
This drug is used to terminate supraventricular tachycardias after vagal manoeuvers have failed. It can cause a brief sensation of flushing and intense chest pain, but the side-effects should resolve fastly. This medication should not be administered to asthmatics as it can cause bronchospasm.
69
How do we treat HF?
1st line: ACEi/BB(Bisoprolol, Carvedilol)
2nd line Aldosterone antagonist(Spironolactone, Eplerenone)
70
How do we treat regular broad-complex tachycardia?
IV amiodarone is the first-line treatment for regular broad complex tachycardias without adverse features
Direct Current Cardioversion if signs of shock
Amiodarone has more letters than adenosine so it's amiodarone for broad complex and adenosine for narrow complex
71
What is azithromycin?
Macrolide - can cause QT prolongation
72
Where would you see a wide pulse pressure?
Aortic regurg
73
What should he receive as prophylaxis against infective endocarditis before his procedure?
None
74
Which electrolyte imbalance would you expect with bendroflumethiazide?
Hyponatremia is an adverse effect that is associated with thiazide diuretics.
75
How do we manage aortic stenosis?
Transcatheter aortic valve replacement
Balloon valvuloplasty is incorrect. This is an option for the management of aortic stenosis. However, it is less commonly offered as its efficacy lasts for approximately 6-12 months. Therefore, the procedure is often reserved for people who cannot undergo any surgical intervention.
76
What is fondaparinux?
Fondaparinux is an antithrombin medication. It works by activating antithrombin 3 which causes the inactivation of factor Xa. In patients undergoing fibrinolysis. Its role in STEMI is to prevent the clot from getting bigger. It should be given before fibrinolysis.
77
What is the difference between nifedipine and verapamil?
Verapamil is incorrect. Although this is also a CCB, this differs from nifedipine as it is rate-limiting. Rate-limiting CCBs are typically used in patients with co-existing angina where beta-blockers are contraindicated or not tolerated
78
A 62-year-old male with a recent myocardial infarction goes into ventricular fibrillation on the coronary care unit. This is recorded on his heart monitor.
An emergency call is put out and a defibrillator is immediately brought over.
What is the most appropriate course of action?
Witnessed cardiac arrest while on a monitor - up to three successive shocks before CPR
79
How do we manage symptomatic heart failure patients who are on optimal medical therapy?
Cardiac resynchronisation therapy (biventricular pacemaker) is indicated in patients with left ventricular dysfunction, ejection fracture <35% and QRS duration >120ms. An Implantable cardiac defibrillator (ICD) is indicated in patients with previous sustained ventricular tachycardia, ejection fraction <35% and symptoms no worse than class III of of the New York Heart Association functional classification.
80
How do we manage poorly-controlled angina with a pt taking bisoprolol?
If angina is not controlled with a beta-blocker, a longer-acting dihydropyridine calcium channel blocker e.g. nifedipine should be added
Verapamil is a non-dihydropyridine calcium channel blocker. This must never be given with beta-blockers due to the risk of heart block and bradycardia.
81
Infective endocarditis in intravenous drug users most commonly affects the ...
Infective endocarditis in intravenous drug users most commonly affects the tricuspid valve
82
How do we manage heart failure?
1=Acei + BB.
2=Aldosterone antagonist.
3=dig for sx. entresto for sx on ACE/ARB. cardiac resync for wide QRS
83
Why does ramipril reduce the BNP?
BNP increases due to heart stress. Main function of BNP is to reduce BP and blood volume to help the heart. Ramipril reduces preload and afterload and thus less BNP required
84
How does aortic regurgitation present?
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
85
What is the murmur found in aortic regurgitation?
early diastolic murmur: intensity of the murmur is increased by the handgrip manoeuvre
mid-diastolic Austin-Flint murmur in severe AR - due to partial closure of the anterior mitral valve cusps caused by the regurgitation streams
86
What is Quincke's sign?
Nailbed pulsation seen in AR
87
What is De Musset's sign?
Head bobbing - seen in AR
88
Which diuretic is used in post-MI HF?
Spiro
89
Why do beta blockers cause insomina?
The exact mechanism is not fully understood but it's believed that beta-blockers can interfere with the production of melatonin, a hormone that helps regulate sleep.
90
Which ECG finding is associated with hypokalaemia?
Long QT syndrome
In hypokalaemia, U have no pot (K+) and no T, but a long PR and a long QT
91
What is Electrical alternans?
Electrical alternans is an electrocardiogram (ECG) finding that describes beat-to-beat variations in the amplitude, direction, or duration of the QRS complex or other components of the ECG waveform.
92
Where do you see electrical alternans?
pathognomic for cardiac tamponade. It is also sometimes seen in very large pericardial effusions
93
Poorly controlled hypertension, already taking an ACE inhibitor, calcium channel blocker and a standard-dose thiazide diuretic. Mx?
NICE advises adding an alpha-blocker such as doxazosin or beta-blocker at this stage if potassium is >4.5 mmol/l.
Spironolactone would be the appropriate next step if his potassium had been less than 4.5 mmol/l.
94
When do we use prosthetic heart valves vs mechanical heart valves?
Prosthetic heart valves - mechanical valves last longer and tend to be given to younger patients
65 cut off
95
Which individuals with T1DM need statin therapy?
Individuals with type 1 diabetes who do not have established cardiovascular disease (CVD) risk factors should be offered atorvastatin 20 mg for primary prevention of CVD if they are:
Older than 40 years of age
Have had diabetes for more than 10 years
Have established nephropathy
Have other CVD risk factors (such as obesity and hypertension)
96
How does aortic dissection present on CT?
A false lumen is a key finding suggestive of aortic dissection on CT angiography
97
Which structural heart abnormality is associated with polycystic kidney disease?
Mitral valve prolapse
98
What increases BNP levels?
Heart failure meds will reduce your BNP , fat cells seem to be able to metabolise BNP so will also reduce it. Other then that anything that causes ischemia or induces a stressful environment will increase it.
99
A 65-year-old man presents to the emergency department with central crushing chest pain 2 hours ago. His ECG on admission showed ST elevation in leads II, III and aVF. Suddenly, the patient develops worsening breathlessness. Upon cardiac auscultation, a new pan-systolic murmur is heard.
What complication is the most likely cause of this patient's breathlessness?
Flash pulmonary oedema can occur after acute mitral valve regurgitation due to myocardial infarction.
100
What is Dressler's syndrome?
This is pericarditis post-MI which can cause saddle-shaped ST elevation, but this is global across all ECG leads. Furthermore, pericarditis-related complications of MI usually happen in the sub-acute phase (i.e. around 48 hours following a transmural MI)
101
How does aortic stenosis present?
The mnemonic 'SAD' (syncope, angina, dyspnoea on exertion)
The typical murmur of aortic stenosis is a crescendo-decrescendo, high-pitched ejection systolic murmur, heard loudest in the second right intercostal space, which radiates to the carotids. If severe stenosis is present other examination findings may include:
Narrow aortic valve = narrow pulse pressure
slow rising pulse
a thrill palpable over the cardiac apex
a fourth heart sound (S4) indicative of left ventricular hypertrophy
a soft/absent S2
102
Which antiplatelets do we give in NSTEMI?
NSTEMI (managed conservatively) antiplatelet choice
aspirin, plus either:
ticagrelor, if not high bleeding risk
clopidogrel, if high bleeding risk
103
Which heart rhythm is aortic stenosis associated with?
atrial fibrillation
secondary to ↑ left atrial pressure → left atrial enlargement
104
How do we monitor statin prescription?
LFTs at baseline, 3/12 and 12/12
105
How do we treat acute fast AF pharmacologically?
If pharmacological cardioversion has been agreed on clinical and resource grounds for new-onset atrial fibrillation, offer:
flecainide or amiodarone if there is no evidence of structural or ischaemic heart disease or
amiodarone if there is evidence of structural heart disease.'
106
How does PE show on ABG?
Pulmonary embolism causes hyperventilation, causing a drop in arterial carbonic dioxide partial pressure and thus alkalosis.
107
How does HOCM present on echo?
characteristic signs of HOCM on his echocardiogram; mitral regurgitation, systolic anterior motion of the anterior mitral valve leaflet, asymmetric hypertrophy.
108
How do we treat HOCM?
Management
Amiodarone
Beta-blockers or verapamil for symptoms
Cardioverter defibrillator
Dual chamber pacemaker
Endocarditis prophylaxis*
109
Which drugs must we avoid in HOCM?
Nitrates
ACE-inhibitors
inotropes
110
What tests is it important to ensure the patient has had prior to starting oral amiodarone?
TFT, LFT, U&E, CXR (risk of pulmonary fibrosis/pneumonitis)
111
Pregnancy
Her regular medications include lamotrigine, labetalol, atorvastatin, low molecular weight heparin, and clozapine. She has recently begun a course of nitrofurantoin for a urinary tract infection.
What medication is contraindicated in this woman?
Atorvastatin - all statins are contraindicated in pregnancy
112
Give the common SEs of nicorandil
Nicorandil is a 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.
Adverse effects
headache
flushing
skin, mucosal and eye ulceration
gastrointestinal ulcers including anal ulceration
113
How does aortic regurgitation present OE?
On examination, abrupt distension and collapse of the carotid arteries are noted along with visualization of capillary pulsations with light compression applied to the fingernail bed.
114
How do we interpret the GRACE score?
GRACE score >3% would be classed as intermediate to high risk = angiography in <72hrs. Immediate angiography would be even more urgent if the patient is clinically unstable.
115
How does posterio-lateral MI appear on ECG?
ST elevation in leads I, aVL and V6, which is consistent with a lateral MI. ST depression in V1-V3 (significant in V3) and large, broad R waves in several leads are consistent with a posterior myocardial infarction
116
How does left ventricular aneurysm present?
Fatigue, breathlessness
Persistent ST elevation following recent MI, no chest pain - left ventricular aneurysm
117
How does LCx occlusion show on ECG?
1,AVL,V5,V6
118
How does RCx or LCx occlusion show in ECG?
V7,V8,V9 with reciprocal ST depressions are frequently evident in V1-V3
119
When do we treat stage-1 htn?
Stage 1 hypertension is defined by an ABPM reading of >= 135/85 mmHg, with stage 2 hypertension having a cut-off of >= 150/95 mmHg.
This patient therefore has stage 1 hypertension. As they are < 80 years they should be considered for treatment but as their 10-year cardiovascular risk if < 10% no action is needed.
120
What is the DVLA guidance on driving after ACS?
If successfully treated by coronary angioplasty, driving may recommence after 1 week provided:
No other urgent revascularisation is planned. (Urgent refers to within 4 weeks from acute event)
Left ventricular ejection fraction is at least 40% prior to hospital discharge.
There is no other disqualifying condition.
If not successfully treated by coronary angioplasty, driving may recommence after 4 weeks provided:
There is no other disqualifying condition.
121
What is the PESI score?
The Pulmonary Embolism Severity Index (PESI) score is recommended by BTS guidelines to be used to help identify patients with a pulmonary embolism that can be managed as outpatients
122
What is the ABCD2 tool?
The ABCD2 is used to triage patients presenting with an acute Transient Ischaemic Attack (TIA).
123
What causes torsades de pointes?
All common HYPOs will cause Torsades de pointes : K, Ca, Mg, Temp
124
Why is verapamil contraindicated in VT?
Verapamil is contraindicated in VT as intravenous administration of a calcium channel blocker can precipitate cardiac arrest.
125
How does renal artery stenosis present?
A 68-year-old with a history of ischaemic heart disease is seen in the hypertension clinic. Despite four antihypertensives his blood pressure is 172/94 mmHg. An abdominal ultrasound shows asymmetrical kidneys
126
A 76-year-old lady is brought in by ambulance to the emergency department. She presents with a right-sided limb weakness, a facial droop and slurred speech. A CT head was arranged which ruled out a haemorrhage, but did report a left-sided infarct. Her admission ECG shows that she has new atrial fibrillation (AF). She is treated with aspirin 300mg for the acute stroke and doing well on the ward.
Two weeks later she is reviewed. What medication should the patient be started on to reduce the risk of further stroke?
If a patient with AF has a stroke or TIA, the anticoagulant of choice should be warfarin or a direct thrombin or factor Xa inhibitor
127
How do we manage stable torsades de pointes?
Administer IV magnesium sulphate
128
How do we manage unstable torsades de pointes?
Administer 1 synchronised DC shock
129
A patient dies from MI. He has had previous asbestos exposure. What would we put on the crem form?
If a person with previous asbestos exposure dies, regardless of the cause of their death, the coroner should be notified
