Cardiology Flashcards
(154 cards)
1
Q
Initial management of all patients with ACS?
A
Aspirin 300mg, oxygen if sats less than 94%, morphine, nitrates
2
Q
When to do PCI?
A
If presentation is within 12 hours of onset of symptoms and PCI can be delivered within 120 minutes of the time when thrombolysis could have been given
3
Q
When to do thrombolysis?
A
should be offered within 12 hours of onset of symptoms if primary PCI cannot be delivered within 120 minutes of the time when thrombolysis could have been given
4
Q
Common dual antiplatelet therapy given for patients with STEMI?
A
If patient not taking an oral anticoagulant then prasugrel and aspirin. If patient is taking oral anticoagulant then clopidogrel and aspirin.
5
Q
Which patients with NSTEMI/ unstable angina should have coronary angiography?
A
immediate - patients who are clinically unstable,
within 72 hours - patients with a GRACE score of >3%
6
Q
Patient presents with raised JVP, pulsus paradoxus and diminished heart sounds a week after they had an MI?
A
Left ventricular free wall rupture - patients present with acute heart failure secondary to cardiac tamponade
7
Q
A fews day after MI, patient experiences acute heart failure associated with a pan-systolic mumur?
A
Ventricular septal defect due to rupture of interventricular septum
8
Q
What is Dressler’s syndrome?
A
A post MI syndrome that tends to occur around 2-6 weeks after. It is a secondary form of pericarditis and is characterised by a combo of fever, pleuritic pain, pericardial effusion and a raised ESR
9
Q
What is Killip class used to stratify?
A
30 day mortality post MI - uses features such as lung crackles, pul oedema and cardiogenic shock
10
Q
What is Levine’s sign?
A
patient describing pain from ischemic heart disease with a clenched fist in middle of chest
11
Q
What is Prinzmetal’s or variant angina?
A
Transient ST elevation due to coronary vasospasm - might present as heart attack but actually its just spasming
12
Q
Side effect for glyceryl trinitrate to warn about?
A
Dizziness
13
Q
What is the LDL target post MI for secondary prevention
A
<2
14
Q
What is the target BP for secondary prevention of MI?
A
<130/80
15
Q
Patients with reduced ejection fraction that are taking ACE or ARB plus beta blocker and continue to have symptoms of heart failure should be offered what?
A
A mineralcorticoid receptor antagonist eg eplerenone or spironalactone
16
Q
Antiplatelet medications following stroke?
A
Aspirin 300mg for two weeks then clopidogrel 75mg daily long-term
17
Q
ECG changes in pericarditis?
A
global changes rather than changes in specific leads, saddle-shaped ST elevation, PR depression
18
Q
Third-line treatment for heart failure that might be particularly indicated in afro-caribbean patients who are not responding to ACE-inhibitor, beta-blocker and aldosterone antagonist therapy?
A
Hydralazine in combination with nitrate
19
Q
First-line investgation for stable chest pain of suspected coronary artery disease?
A
Contrast-enhanced CT coronary angiogram
20
Q
If starting erythromycin/ clarithromycin which CVD drug should be stopped?
A
Statins - as clarithyromycin increases systemic exposure to simvastatin leading to an increased risk of myopathy
21
Q
What drug is contra-indicated in ventricular tachycardia?
A
Verapamil - bc VTach causes cardiac output to reduce and so calcium channel blocker can reduce contractility further and result in death
22
Q
What should you consider in a young adult with hypertension and a systolic murmur?
A
coarctation of the aorta
23
Q
If angina is not controlled with a beta blocker, what should be added?
A
a long-acting calcium channel blocker (ie nifedipine)
24
Q
Nifedipine or verapamil for angina?
A
When used as a monotherapy a rate limiting calcium channel blocker ie verapamil, when in combination - longer acting ie nifedipine
25
ECG features in Wolff-Parkinson White?
Short PR interval, wide QRS with slurred upstroke (delta wave), axis deviation on opposite side to the accessory pathway
26
If patient starts an ACE inhibitor and then has an acute signif drop in renal function after starting it then what should be considered?
That they might have an undiagnosed bilateral renal artery stenosis
27
What antibiotics can cause torsades de pointes?
Macrolides eg erythromycin
28
Reversal agent of dabigatran?
idarucizumab
29
Reversal agent for rivaroxaban or apixaban?
Andexanet alfa (it is a recombinant form of factor Xa)
30
Reversal agent in patients bleeding on heparain, enoxaprin or dalteparin?
Protamine sulphate
31
Breathing problems with a clear chest?
Think pulmonary embolism
32
Inheritance patten of HOCM?
Autosomal dominant - 50% chance of inheriting
33
If a patient has had ablation for atrial fibrillation do they still need to continue anti-coagulation?
Yes, anti coag should be based on a patient's stroke risk profile (CHA2DS2VASc)
34
What artery is occluded to cause a new LBBB due to ischaemia?
The left anterior descending or sometimes the large main stem artery
35
Key differences between thrombotic and embolic acute ischemic limb?
Embolic, sudden and severe. Normally has a history of AF or a recent MI. Thrombotic, more gradual, history of PAD symptoms and sometimes previous vascular surgery
36
What are the Rutherford classifications for ALI?
I limb viable
IIa limb marginally threatened
IIb limb immediately threatened
III limb irreversibly damaged
37
Critical limb ischaemia vs acute limb ischaemia?
critical is chronic and symptoms last for longer than 2 weeks, will often have ulcers and gangrene
38
First line investigation of acute limb ischemia?
Duplex ultrasound/ Doppler
39
What can happen in reperfusion injury?
massive oedema resulting in compartment syndrome and hypovolaemic shock. Hyperkalaemia due to release of K+ ions which can cause arrythmias, acidosis from release of H+ ions, AKI from release of myoglobin
40
AAA of 6cm?
Any AAA greater than 5.5cm should be seen by vascular specialist within 2 weeks
41
AAA of 5cm?
surveillance and conservative management - every 3 months for aneurysms of 4.5 - 5.4 cm
42
When will a patient need surgical repair of AAA?
If aneurysm is greater than 5.5cm in diameter or greater than 4cm and rapidly growing greater than 1cm a year
43
Conservative management plan for AAA?
stop smoking, antiplatelet therapy of aspirin 75mg OD, statins and anti-hypertensives if BP is greater than 140mmHg
44
Stanford classification of aortic dissection?
Type A - ascending aorta 2/3 of cases
Type B - descending aorta distal to left subclavian origins
45
How does the pain location vary depending on aortic dissection origin?
Ascending aortic dissections = anterior chest pain
Descending aortic dissections = intrascapular back pain
46
Gold standard for diagnosing aortic dissection?
Computed Tomography Angiography (CTA). Transoesophagel echo can be used in haemodynamically unstable patients
47
What medication is first line for BP in control in immediate stabilisation of aortic dissection patient?
beta blockers
48
Difference between how type A and B aortic dissections are managed?
Type A dissections - urgent surgical repair, type B initial medical management with close monitoring
49
Clinical exam findings of aortic regurgitation
early diastolic murmur, collapsing pulse, wide pulse pressure, Quinke's sign (nailbed pulsation),
De Musset's sign (head bobbing)
50
The classic symptoms of aortic stenosis:
exertional dyspnoea, exertional angina, exertional syncope or presyncope. Might also have heart failure
51
Exam findings in aortic stenosis?
Loud mid-to late peaking systolic ejection murmur. Radiates to carotids and becomes more prominent sitting forward. Murmur becomes softer the more severe the stenosis. (Severe AS might have pulsus parvus et tardus, absent S2, narrow pulse pressure, thrill, S4)
52
52
Best way to diagnose aortic stenosis?
transthoracic echo - can calculate trans-valvular velocity, mean pressure gradient and LV function
53
Palliative measure for AS patients that aren't suitable for cardiac surgery?
percutaneous balloon valvotomy
54
Primary vs secondary atrial fibrillation?
primary in individuals under 60 without evidence of cardiopulmonary disease. Secondary - associated with conditions like hypertension, coronary artery disease, chronic lung disease etc
55
management of patients presenting acutely with AF and signs of haemodynamic instability?
They should be electrically cardioverted as per peri-arrest tachycardia guidelines
56
Rate or rhythm control for acute presentation of AF?
If the AF has been occurring for less than 48 hours then rate or rhythm control. If longer than 48 hours rate control only until they've been on anti coag for minimum of three weeks
57
Rhythm control in AF?
beta blocker first-line, dronedarone is second-line in patients following cardioversion, amiodarone if coexisting hear failure
58
Agents for rate control in AF?
beta blockers (not in asthma), calcium channel blockers, digoxin if other options ruled out and they dont do any physical exercise. If monotherapy doesnt work, then combination therapy
59
If patient has had catheter ablation and they have a CHA2DS2-VASc score of 0 then how long is anticoagulation needed for?
2 months. If the score is greater than 1 then longterm anticoag is needed
60
If a patient is on warfarin for atrial fibrillation, what are you recommended to do?
switch to a DOAC during a routine appointment
61
Difference between AVNRT vs AVRT?
AVNRT- re-entrant involving the AV node
AVRT- re-rentrant but involves an accessory pathway between atria and ventricles
62
First-line in stable patients for terminating acute episode of regular narrow complex SVT?
vagal manouvres - valsalva, cold stimulus to face, carotid sinus massage
63
Pharmalogical treatment of regular narrow complex tachycardia?
Adenosine - rapid IV 6mg, if unsuccessful give 12, if unsuccessful again give further 18.
If adenosine contra-indicated or fails give verapmail
64
Management V tach with Broad complex QRS (<0.12)?
Amiodarone 300mg IV over 10-60 mins
65
medical treatment of polymorphic VT?
If QT is prolonged treat underling cause such as electrolyte imbalance. If Torsades de Pointes suspected give magnesium sulfate
66
What ankle-brachial pressure index suggests peripheral arterial disease?
Less than 0.9
67
Difference in locations between venous and arterial ulcers?
venous tend to present between knee and ankle particularly on the medial side. Arterial ulcers normally more distally - toes or lateral malleolus
68
What are the New York Heart association classes of heart failure?
NYHA class 1 - no symptoms
NYHA class II - mild symptoms, slight limitation of physical activity
Class III - moderate symptoms, marked limitation of physical activity
Class IV - severe symptoms, present even at rest
69
First-line for investigating HF?
N-terminal pro-B-type natriuretic peptide (NT-proBNP) blood test
If levels high - specialist assessment within 2 weeks,
If levels rasied - specialist assessement within 6 weeks
70
First -line medications for heart failure?
An ACE and a beta blocker, start and settle on one before starting next.
If ACE side effects then an ARB
If neither ACE or ARB, then consider hydralazine in combination with a nitrate
71
If patient experiencing symptoms of HF still whilst on ACE and beta blocker, what next?
Offer a mineralcorticoid receptor antagonist eg spironolactone and eplerenone
72
What ethnicity are more likely to benefit from hydralazine in combo with a nitrate for severe heart failure?
african or Caribbean origina
73
What class of drug is bumetanide?
Loop diuretic
74
If suspected of having a DVT and the two level Well's score is 2 then what should be done?
a proximal leg vein ultrasound within 4 hours. Ig this is neg, D dimer should be arranged
75
If a clinic reading shows a blood pressure higher than 140/90 what should be done?
ambulatory or at home blood pressure monitoring
76
If ABPM shows a BP greater than 135/85 but less than 150/90 what should be done?
It should be treated if they are less than 80 and have any of target organ damage, CVD, renal disease, diabetes, 10 year CVD risk >10%
77
If ABPM readings are higher than 150/95 what should be done?
Should be pharmacologically treated in all patients regardless of age
78
What constitutes stage 1 hypertension?
Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg
79
What constitutes stage 2 hypertension?
Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg
80
How many measurements should be taken during Ambulatory blood pressure monitoring (ABPM)?
The average of at least 14 measurements should be used. At least 2 measurements per hour during the persons usual waking hours
81
If a patient is already taking an ACE inhibitor, calcium channel blocker and thiazide diuretic and still has high blood pressure what drugs could you add?
If potassium is less than 4.5 mmol/L add low-dose spiro
If potassium is greater than 4.5 mmol/L add an alpha or beta blocker
82
What are the indications for starting calcium channel blocker over ACE or ARB?
No diabetes, if theyre 55 or over, or if black
83
If patients have diabetes what hypertension drugs should they be started on?
ACE or ARB
84
Blood pressure targets for those over 80?
clinic 150/90. ABPM 145/85
85
Blood pressure targets for those under 80
clinic 140/90. ABPM 135/85
86
Difference between Janeway lesions and Osler nodes?
Janeway lesions are non-tender macules on palms and soles. Osler nodes are tender nodules on fingers and toes
87
Imaging for IE?
TTE usually first-line but TOE preferred if available as it has higher sensitivity
88
If group D streptococci is found to be causing IE, what should be done next?
A colonscopy, as normally only found it bowel want to find any bowel lesions that may have facilitated its transfer
89
Why might you do early surgical intervention in IE, ie prior to finishing antibiotic therapy?
If there is IE associated regurgitation, new heart failure, intracardiac abscess or persistent infection
90
What is normal QT interval and what electrolyte imbalances can cause it to be prolonged?
Normal QT is less than 430ms in males and less than 450ms in females. Hypokalaemia, hypocalcaemia and hypomagnesaemia can cause it
91
What is the most common cause of endocarditis if less than 2 months post valve surgery?
Staphylococcus epidermis
92
Type of murmur in pulmonary stenosis?
Ejection systolic
93
A patient with new AF and an acute ischemic stroke, when should anticoagulation be started??
Two weeks after event
94
What hypertensive drug should be stopped in the case of gout?
Thiazide like diuretics - they reduce uric acid excretion from kidneys so can cause hyperuircaemia
95
If a patient has mechanical valve replacement, what anticoagulant will they need?
Lifelong warfarin. (Aspirin would be used in tissue replacement as they have lower thrombotic risk)
95
Statin doses for cardiovascular disease?
Atorvastatin 20mg for primary prevention, 80mg for secondary prevention
96
Antiplatelet choices for NSTEMI that is going to be managed conservatively?
Aspirin plus either ticagrelor if not high bleeding risk, or clopidogrel if high bleeding risk
97
What kind of drugs is indapamide?
Thiazide like diuretic
98
If pulmonary embolus is suspected for reason for cardiac arrest and thrombolytic drugs are given, how long should CPR be continued for?
An extended period of 60-90 mins to give the drug a chance to work
99
Clinical symptoms of papillary muscle rupture?
hypotension, pulmonary oedema, widespread systolic murmur
100
The most common causative agent of IE owing to poor dental hygiene or following a dental procedure?
Streptococcus viridans - the most notable of these being streptococcus mitis and streptococcus sanguinis
101
First-line for symptomatic bradycardia
Atropine 500mcg (IV), up to a maximum to 3mg
102
What is the most common cause of acute mesenteric ischaemia?
arterial embolism, typically from a cardiac source, usually secondary to a fib or MI
103
Risk factors for arterial thrombosis causing acute mesenteric ischaemia?
Similar to peripheral arterial disease - over 60, hypertension, hyperlipidaemia, diabetes meilitus and smoking
104
What might you see on blood tests if someone has acute mesenteric ischaemia?
Leukocytosis (raised white cells), raised lactate, maybe metabolic acidosis
105
Presenting features of acute mesenteric ischaemia??
Sudden onset, abdominal pain that is out of proportion. Might be accompanied by N&V, and diarrhoea. Might get signs of peritonitis
106
Imaging of choice for acute mesenteric ischaemia?
CT Angio. (IF CTA isn't available, consider mesenteric duplex ultrasound or MRA)
107
The classic triad of symptoms in chronic mesenteric ischaemia?
Postprandial abdominal pain (cramping that occurs within 30 mins - 2 hours of eating), weight loss and food aversion (sitophobia)
108
What might a posterior STEMI look like on an ECG?
Reciprocal changes - ST depression, tall broad R waves, upright T waves in leads V1-3 which then will need to be confirmed by posterior leads v7-v9 ST elevation
109
What drug treatment should be given NSTEMI patients who are not at high risk of bleeding and are not having angiography immediately?
Fondaparinux
110
Primary cause of mitral stenosis?
History of rheumatic fever - accounts for 90% of cases
111
Murmur that you hear in mitral stenosis?
Mid-late diastolic murmur with loud S1
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Symptoms you might see in mitral stenosis?
dyspnoea, haemoptysis, malar flush
113
What medications might you give someone with mitral stenosis?
diuretics to alleviate pulmonary congestion, and rate control and anti coagulation for co-existing atrial fibrillation
114
What's the most common cause of myocarditis?
Viral infections - including paraovirus B19, Human herpes virus 6
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What might you see on ECG for myocarditis?
Sinus tachy, with or without ST segment and T wave changes. The findings are normally diffuse and the ST segments tend to be concave
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When might steroids be given for myocarditis?
In patients with suspected giant cell myocarditis
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Clinical signs of acute pericarditis?
sudden onset retrosternal chest pain that is improved by sitting up and leaning forward (radiation to trapezius ridge specific for pericarditis), pericardial friction rub (can be differentiated from pleural rub by asking patient to hold breath)
118
ECG changes for pericarditis?
Widespread concave ST elevations, with PR segment depression (PR segment depression specific for acute pericarditis)
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What might you see on echo for pericarditis and when might pericardiocentesis be done?
Mild pericardial effusion (happens in 60% of patients), pericardiocentesis only done if suspcion of bacterial or neoplastic aetiology
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Which pericarditis patients should be managed as inpatients?
patients with high risk features such as fever greater than 38 degrees and elevated trops
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Firstline medical management for patients with acute idiopathic or viral pericarditis?
A combination of NSAIDs and colchicine
122
Beck's triad?
Hypotension, raised JVP, muffled heart sounds - indicates cardiac tamponade
123
other features besides Beck's triad suggestive of cardiac tamponade?
dyspnoea, tachycardia, pulsus paradoxus - large drop in BP during inspiration, Kussmaul's sign
124
What angina medication requires asymmetrical dosing regime due to potential of building up tolerance?
Isosorbide mononitrate
125
What kind of medication is doxazosin?
alpha blocker - can add as a fourthline if patient has resistant hypertension and potassium levels mean thye arent suitable for spiro
126
What might you feel on palpating the chest of someone with chronic tricuspid regurgitation?
a left parasternal heave - in chronic TR volume overload leads to right ventricular hypertrophy which produces a left parasternal heave
127
Infarction of which vessel is associated with a complete heart block?
The right coronary artery as it supplies the AV node in the majoiryt of people
128
In ALS what should be given to patients who are in VF/ pulseless VT after 3 shocks have been administered?
Amiodarone 300mg and adrenaline.
Amiodarone after 3rd and 5th shocks. Adrenaline after 3rd shock and then every 3-5mins in shockable algorithm and straight away in non-shockable algorithm
129
What can be given to reverse warfarin?
Prothrombin complex
129
Patient in V tach displaying signs of shock?
Synchronised cardioversion
130
What will you see on ECG in Wellen's syndrome?
biphasic or deeply inverted T waves in V2-V3 (normally with a history of chest pain now resolved)
131
Occlusion of what artery causes Wellen syndrome?
Left anterior descending artery (LAD)
132
What should an inferior myocardial infarction and an AR mumur raise concerns of?
an ascending aorta dissection
133
If adenosine is contraindicated because of asthma then what is the next appropriate treatment for narrow complex tachycardia?
Verapamil
134
What heart failure drug can cause ototoxicity?
Bumetanide
135
What is most common causative agent of IE in iV drug users?
Staphylococcus aureus
136
Mechanism of action of class I anti arrythmatics and examples?
Sodium channel blocker, lidocaine, flecainide, phenytoin
137
Mechanism of action of class II antiarrhytmics? and examples
beta blockers which reduce sympathetic activity - propanolol, bisoprolol
138
mechanism of action of class III antiarrythmics and examples?
mixed category which prolong action potential by blocking potassium channels - examples amiodarone, sotalol
139
mechanism of action of class IV antiartyhmatics and examples?
non-dihydropyridine CCBs eg verapamil and diltiazem (the dihydropyridines are the antihypertensives and dont give the same anti arrythmic effects eg amlodipine)
140
How does digoxin work?
It inhibits the Na/K ATPase pump on cardiomyocyte and leads to more forceful contraction
141
MOA of atropine?
It is a muscarinic antagonist, inhibits vagal activity increasing heart rate
142
How does adenosine work and who is it contraindicated in?
Acts on SA and AV node, contraindicated in asthmatics as it causes bronchospasm
143
Narrow QRS, tachycardia, regular, stable. What should be done?
First vagal manoeuvres, then adenosine 6mg rapid IV, if no effect further 12, then further 12 again
144
Narrow QRS, tachycardia, irregular, stable. What should be done?
probably AF - control with beta blocker or diltiazem (if in heart failure consider digoxin or amiodarone)
145
What constitutes a narrow QRS?
<0.12
146
How does acute heart rate control in AF differ if the LVEF is less than 40% or if theres signs of congestive HF?
if LVEF less than 40 then use the smallest dose of beta blocker to achieve rate control, if not can use beta blocker, diltiazem or verapamil
147
What will you see on ecg of someone with pre-excitation?
slurring of QRS and shorter PR interval. represents accessory pathway
148
Will broad complex AVRT be antidromic or orthodromic?
antidromic - means its activated down the accessory pathway and back around rather than down the his-purkinje system
148
What grade is a murmur if it can be heard without stethoscope touching the chest?
grade 6
149
What grade is a murmur if it is described as "loud with a palpable thrill"?
grade 4
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