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MRCP Part 1 > Cardiology 2 > Flashcards

Cardiology 2 Flashcards

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1
Q

Pre-existing HTN in pregnancy?

A
  1. A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation
  2. No proteinuria, no oedema
  3. Occurs in 3-5% of pregnancies and is more common in older women
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2
Q

Pregnancy-induced HTN mushkies (aka Gestational HTN?

A
  1. Hypertension (as defined above) occurring in the second half of pregnancy (i.e. after 20 weeks)
  2. No proteinuria, no oedema
  3. Occurs in around 5-7% of pregnancies
  4. Resolves following birth (typically after one month). Women with PIH are at increased risk of future pre-eclampsia or hypertension later in life
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3
Q

Pre-eclampsia mushkies?

A
  1. Pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours)
  2. Oedema may occur but is now less commonly used as a criteria
  3. Occurs in around 5% of pregnancies
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4
Q

Classification of AF?

A
  1. First detected episode (irrespective of whether it is symptomatic or self terminating)
  2. Recurrent episodes = when a patient has 2 or more episodes
    a. Paroxysmal AF = terminates spontaneously, episodes last <7 days, typically <24 hours
    b. Persistent AF = not self terminating, usually last >7 days
  3. Permanent AF = continuous AF which can not be cardioverted –> rate control and anticoagulation
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5
Q

Wellen’s syndrome?

A
  1. ECG manifestation of critical proximal LAD coronary artery stenosis in pts with unstable angina
  2. Characterised by symmetrical, often deep (>2mm) T wave inversions in the anterior precordial leads
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6
Q

Reversal of rivaroxaban or apixaban?

A

Andexanet alfa

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7
Q

What is pulsus alternans?

A
  1. Seen in LVF
  2. When the upstroke of the pulse alternates between strong and weak, indicated systolic dysfunction and is seen in pts with HF
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8
Q

Pulsus paradoxus?

A
  1. Greater than the normal (10 mmHg) fall in systolic blood pressure during inspiration → faint or absent pulse in inspiration
  2. Severe asthma, cardiac tamponade
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9
Q

Slow-rising pulse causes?

A
  1. AS

Slow upstroke

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10
Q

Collapsing pulse causes?

A
  1. AR
  2. PDA
  3. Hyperkinetic states = Anaemia, Thyrotoxicosis, Fever, Pregnancy

Forceful rapid upstroke AND descent

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11
Q

Bisferiens pulse causes?

A
  1. Mixed aortic valve disease

2. ‘Double pulse’ due to 2 sharp upstrokes due to systole

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12
Q

Jerky pulse cause?

A
  1. HOCM

2. Rapid forceful upstroke

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13
Q

What percentage of VSDs close spontaneously?

A

50%

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14
Q

Causes of VSDs?

A
  1. Congenital = Downs, Edwards, Pataus, Cri-du-Chat
  2. Congenital infections
  3. Acquired = post-MI
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15
Q

When may VSDs be detected in utero?

A

During the routine 20 week scan

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16
Q

Post-natal presentations of VSDs?

A
  1. Failure to thrive
  2. Features of HF = hepatomegaly, tachypnoea, tachycardia, pallor
  3. Pan-systolic murmur which is louder in smaller defects
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17
Q

Management of VSDs?

A
  1. Small VSDs which are asymptomatic often close spontaneously are simply require monitoring
  2. Moderate to large VSDs usually result in a degree of heart failure in the first few months
    a. nutritional support
    b. medication for heart failure e.g. diuretics
    c. surgical closure of the defect
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18
Q

Complications of VSDs?

A
  1. AR (poorly supported right coronary cusp resulting in cusp prolapse)
  2. IE
  3. Eisenmenger’s
  4. RHF
  5. Pulm HTN
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19
Q

Why is pregnancy c/i in pulmonary hypertension?

A

Carries a 30-50% risk of mortality

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20
Q

Poor prognostic factors for HOCM?

A
  1. Syncope
  2. Family history of sudden death
  3. Young age at presentation
  4. Non-sustained ventricular tachycardia on 24 or 48-hour Holter monitoring
  5. Abnormal blood pressure changes on exercise
  6. Increased septal wall thickness
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21
Q

Is risk of falls alone a sufficient reason to withhold anticoagulation?

A
  1. No
  2. A patient with a 5% annual stroke risk (CHADS 2-3) would need to fall approximately 295 times per year for the benefits of anticoagulation to be out-weighed by the risk of fall-related intracranial haemorrhage
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22
Q

AF + valvular heart disease is an absolute indication for?

A

Anticoagulation

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23
Q

What is eclampsia?

A

Development of seizures in association with pre-eclampia

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24
Q

Pre-eclampsia?

A
  1. Condition seen after 20 weeks gestation
  2. Pregnancy-induced hypertension
  3. Proteinuria
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25
What is used to prevent seizures in pts with severe pre-eclampsia and treat seizures once they develop?
Magnesium sulphate
26
Mag sulphate dose for eclampsia?
1. IV bolus of 4g over 5-10 minutes | 2. Followed by infusion of 1g/hour
27
What should be monitored whilst pt on mag sulph for severe pre-eclampsia/eclampsia?
1. Urine output 2. Reflexes 3. Respiratory rate 4. Oxygen saturation
28
Complication of mag sulph for eclampsia?
Respiratory depression
29
Mx of respiratory depression secondary to magnesium su;phate?
Calcium gluconate
30
How long should mag sulph continue after delivery in severe pre-eclampsia?
For 24 hours after last seizure or delivery (around 40% seizures occur post-partum)
31
Severe pre-eclampsia/eclampsia fluid management?
Fluid restriction
32
Statin MOA?
Inhibits action of HMG-CoA reductase, the rate-limiting enzyme in hepatic cholesterol synthesis
33
Statin adverse effects?
1. Myopathy 2. Liver impairment 3. Increased risk of intracerebral haemorrhage in pts who have had a stroke
34
Statin C/i?
1. Macrolides | 2. Pregnancy
35
Statin LFT monitoring?
1. Baseline, 3m, 12 months 2. Treatment should be discontinued if serum transaminase concentrations rise to and persist at 3x the upper limit of the reference range
36
Statin indications?
1. Established CVD (stroke, TIA, IHD, PAD) 2. 10 year cardiovascular risk >10% 3. T1DM diagnosed >10 years ago OR aged >4- OR have established nephropathy 4. CKD eGFR <60ml/min
37
Why are statins taken at night?
When majority of cholesterol synthesis takes place
38
Atorvastatin primary prevention?
20mg
39
Atorvastatin secondary prevention?
80mh
40
When do you increase atorvastatin 20mg?
If non-HDL has not reduced for >=40%, consider uptitrating to 80mg
41
What is WPW syndrome?
Congenital accessory conducting pathway between the atria and ventricles leading to AVRT - as the accessory pathway does not slow conduction, AF can degenerate rapidly to VF
42
WPW ECG features?
1. Short PR interval 2. Wide QRS complexes with slurred upstroke - delta wave 3. LAD if right sided accessory pathway 4. RAD if left sided accessory patway
43
Type A WPW?
1. Left sided pathway | 2. Dominant R wave in V1
44
Type B WPW?
1. Right sided pathway | 2. No dominant R wave in V1
45
WPW associations?
HEMAT 1. HOCM 2. Ebstein's anomaly 3. Mitral valve prolapse 4. Secundum ASD 5. Thyrotoxicosis
46
WPW management?
1. Definitive = RFA of accessory pathway | 2. Medical = sotalol, amiodarone, fleicanide
47
Type C WPW?
Delta waves are upright in leads V1-V4 but negative in V5-V6
48
When should sotalol be avoided in WPW?
If coexistent AF - prolonging the refractory period at the AV node may increase the rate of transmission through the accessory pathway, increasing the ventricular rate and potentially deteriorating into ventricular fibrillation
49
How is PCWP measured?
Using a balloon-tipped Swan-Ganz catheter which is inserted into the pulmonary artery
50
What is PCWP indicative of?
LA pressure, normally 6-12mmHg
51
Main use of PCWP?
Whether pulmonary oedema is caused by either HF or ARDS
52
Atropine MOA?
Muscarinic AChR antagonist
53
Atropine use?
1. Organophosphate poisoning | 2. Bradycardia
54
Physiological effects of atropine?
1. Tachycardia | 2. Mydriasis
55
Biggest RF for post-PCI stent thrombosis?
Withdrawal of antiplatelets
56
PCI stent MOA?
1. Following stent insertion, migration and proliferation of smooth muscle cells and fibroblasts occur to the treated segment 2. The stent struts eventually become covered by endothelium 3. Until this happens there is an increased risk of platelet aggregation leading to thrombosis
57
2 main complications of PCI stent?
1. Stent Thrombosis = due to platelet aggregation, occurs in 1-2% of patients, most commonly in first month, usually presents with acute MI 2. Stent Restenosis = due to excessive tissue proliferation around the stent, occurs in 5-20% of patients, most common in the first 3-6 months, usually presents with recurrence of angina symptoms
58
RFs for stent restenosis?
1. DM 2. Renal impairment 2. Stents in venous bypass grafts
59
Types of stents?
1. Bare metal stents (BMS) | 2. Drug-eluting stents (DES)
60
What is a drug-eluting stent?
1. Coated with paclitaxel or rapamycin which inhibit local tissue growth 2. Whilst this reduces restenosis rates, the stent thrombosis rates are increased as the process of stent endothelialisation is slowed
61
Antiplatelet therapy following stent insertion?
1. Aspirin indefinitely | 2. Clopidogrel length depends on type of stent, reason for insertion, and consultant preference
62
Complete heart block following an MI lesion?
Right coronary artery
63
Severe mitral stenosis management?
Percutaneous mitral commissurotomy
64
Causes of mitral stenosis?
1. Rheumatic fever 2. Mucopolysaccharidoses 3. Carcinoid syndrome 4. Endocardial fibroelastosis
65
Mitral stenosis CXR?
LA enlargement
66
Mitral stenosis Echo?
1. Cross sectional ares <1sq cm | 2. (Usually cross-sectional area 4-6cm)
67
Amiodarone effect on QT interval?
Lengthens QT interval
68
Most common cause of secondary hypertension?
Primary hyperaldosteronism incl. Conn's
69
Classification of secondary hypertension?
1. Renal 2. Endocrine 3. Drugs 4. Other
70
Renal causes of hypertension?
1. GN 2. PN 3. ADPKD 4. RAS
71
Endocrine causes of hypertension?
1. Primary hyperaldosteronism (most common) 2. Cushing's syndrome 3. Liddle's syndrome 4. CAH (11-beta hydroxylase activity) 5. Acromegaly
72
Drug causes of hypertension?
1. Steroids 2. MOAi 3. COCP 4. NSAIDs 5. Leflunomide
73
'Other' causes of hypertension?
1. Pregnancy | 2. Coarctation of the aorta
74
Cardiac tamponade presentation?
Beck's triad 1. Falling BP 2. Rising JVP 3. Muffled heart sounds
75
Mx of cardiac tamponade?
Urgent pericardiocentesis
76
How long should DAPT be present post insertion of DES?
12 months, very important
77
Within how many hours should PCI be offered to NSTEMI pts?
Within 72 hours
78
Tirofiban MOA?
GpIIb/IIIa inhibitor
79
GpIIb/IIIa inhibitor examples?
1. Abciximab 2. Eptifibatide 3. Tirofiban
80
Aortic dissection pathophysiology?
Tear in the tunica intima of the wall of the aorta
81
Aortic dissection RFs?
1. HTN 2. Trauma 3. Bicuspid aortic valve 4. Collagen = MS, EDS 5. Congenital = Turners, Noonans 6. Pregnancy 7. Syphilis
82
Cause of short PR interval?
WPW
83
Causes of a prolonged PR interval?
1. Idiopathic 2. IHD 3. Infection = rheumatic fever, aortic root abscess due to endocarditis, lyme disease 4. Inflammatory = sarcoidosis 5. Drugs = digoxin 6. Electrolytes = hypokalaemia 7. Neuro = myotonic dystrophy 8. Athletes
84
Causes of LBBB?
1. IHD 2. HTN 3. AS 4. CM 5. Rare = Idiopathic fibrosis, digoxin toxicity, hyperkalaemia
85
Diagnosing MI in pts with existing LBBB?
Sgarbossa criteria
86
Aortic dissection on CXR?
Separation of the intimal calcification from the outer aortic soft tissue by border by 10mm
87
Ix for Aortic dissection?
CT chest with contrast
88
Pts on warfarin undergoing emergency surgery?
Give four-factor prothrombin complex concentrate 25-50 units/kg
89
Pts on warfarin undergoing surgery in 6-8 hours?
5mg Vitamin K IV
90
Bicuspid aortic valve associations?
1. Turner's syndrome 2. Left dominant coronary circulation (the posterior descending artery arises from the circumflex instead of the right coronary artery) 3. Coarctation of the aorta
91
Complications of bicuspid aortic valve?
1. Stenosis/regurgitation | 2. Higher risk for aortic dissection and aneurysm formation of the ascending aorta
92
Suspected DVT in pregnancy Ix?
Compression duplex ultrasound
93
Suspected PE in pregnancy Ix?
1. ECG and CXR 2. Compression duplex ultrasound 3. V/Q or CTPA should be taken at a local level after discussion with the pt and radiologist
94
CTPA pregnancy risk?
Increases lifetime risk of maternal breast cancer by 13.6%
95
V/Q scanning pregnancy risk?
Increased risk of childhood cancer compared with CTPA
96
D-dimer used for PE in pregnancy?
No
97
Bisferiens pulse?
Mixed aortic valve disease
98
Statins and pregnancy?
Should be avoided in pregnancy and also 3 months before attempting pregnancy
99
Most common gene mutation for Brugada syndrome?
Mutations in the SCN5A gene (encode myocardial sodium ion channel protein)
100
CPVT (catecholaminergic polymorphic ventricular tachycardia) mutation?
CASQ2
101
Romano-Ward syndrome genes?
1. KCNQ1 | 2. KCNH2
102
ARVC gene?
RYR2
103
What is Brugada syndrome?
A form of inherited cardiovascular disease which may present with sudden cardiac death
104
Brugada inheritance?
1. AD 2. 1:5000-10,000 3. Asians
105
Brugada syndrome ECG changes?
1. Convex ST segment elevation >2mm in >1 of V1-V3 followed by a negative T wave 2. Partial RBBB 3. ECG changes may be more apparent following the administration of fleicanide or ajmaline (the investigation of choice in suspected cases of Brugada)
106
Brugada syndrome management?
ICD
107
PFO present in what percentage of population?
20
108
Wilson's disease associated with what cardiomyopathy?
Restrictive cardiomyopathy
109
MAT?
Multifocal atrial tachycardia
110
What is Multifocal atrial tachycardia?
Irregular cardiac rhythm caused by at least 3 different sites in the atria, which may be demonstrated by morphologically distinctive p waves
111
MAT is more common in what pts?
Elderly pts with chronic lung disease e.g. COPD
112
Mx of MAT?
1. Correction of hypoxia and electrolyte disturbances 2. Rate-limiting CCBs are often first line 3. Cardioversion and digoxin are not useful in the management of MAT
113
Ix of aortic dissection?
1. CXR = widened mediastinum 2. CT Angio of chest = false lumen 3. TOE = usntable pts too risky to take to CT
114
Mx of aortic dissection?
1. Type A = surgical management, but blood pressure should be controlled to a target systolic 100-120 whilst awaiting intervention 2. Type B = conservative management, bed rest, reduce blood pressure with IV labetalol to prevent progression
115
Complications of aortic dissection?
1. Backward tear = aortic incompetence/regurgitation, MI (inferior pattern due to right coronary involvement) 2. Forward Tear = unequal arm pulses and BP, stroke, renal failure
116
Management of xanthelasma?
1. Surgical excision 2. Topical trichloroacetic acid 3. Laser therapy 4. Electrodissection
117
Causes of ST elevation?
1. MI 2. Myocarditis/pericarditis 3. Normal variant 'high take-off' 4. LV aneurysm 5. Prinzmetal's angina 6. Takotsubo's cardiomyopathy 7. Rare = SAH
118
AR causes?
1. Valve = Rheumatic, IE, CTD (e.g. RA/SLE), bicuspid | 2. Aortic root = Dissection, Ank Spond, HTN, Syphilis, MS + EDS
119
LAD causes?
1. Left anterior hemiblock 2. LBBB 3. Inferior MI 4. WPW right sided 5. Hyperkalaemia 6. Congenital = ostium primum ASD, tricuspid atresia 7. Minor LAD in obese people
120
Tachycardia with rate of 150/min?
Atrial flutter
121
What is atrial flutter?
A form of SVT characterised by a succession of rapid atrial depolarisation waves
122
Atrial flutter ECG?
1. Sawtooth 2. As underlying atrial rate is around 300/min the ventricular rate is dependent upon the degree of AV block 3. Flutter waves may be visible following carotid sinus massage or adenosine
123
Atrial flutter management?
1. Similar to AF though medication may be less effective 2. More sensitive to cardioversion, so less energy may be used 3. RFA of tricuspid valve isthmus is curative for most patients
124
What system used to stratify risk post-MI?
Killip class
125
Killip classes?
Class = Features = 30 day mortality 1. I = no clinical signs of HF --> 6% 2. II = lung crackles, S3 = 17% 3. III = Frank pulmonary oedema = 38% 4. IV = Cardiogenic shock = 81%
126
Is WPW an indication for ICD?
No
127
ICD indications?
1. LQTS 2. HOCM 3. Prev. cardiac arrest due to VT/VF 4. Previous myocardial infarction with non-sustained VT on 24 hr monitoring, inducible VT on electrophysiology testing and ejection fraction < 35% 5. Brugada syndrome
128
Pre-eclampsia complications?
1. Fetal = prematurity, IUGR 2. Eclampsia 3. Haemorrhage = placental abruption, intra-abdominal, intra-cerebral 4. Cardiac Failure 5. Multi-organ failure
129
Features of severe pre-eclampsia?
1. HTN >170/110 2. Proteinuria ++/+++ 3. Headache 4. Visual disturbance 5. Papilloedema 6. RUQ/epigastric pain 7. Hyperreflexia 8. Ply count <100, abnormal liver enzymes or HELLP
130
Prinzmetal angina treatment?
Dihydropyridine receptor calcium channel blocker e.g. Felodipine
131
Infective endocarditis diagnosis?
Modified Duke Criteria 1. Pathological criteria positive OR 2. 2 major criteria OR 3. 1 major and 3 minor criteria OR 4. 5 minor criteria
132
IE Pathological criteria?
Positive histology or microbiology of pathological material obtained at autopsy or cardiac surgery (valve tissue, vegetations, embolic fragments or intracardiac abscess content)
133
IE major criteria?
1. Positive Blood Cultures | 2. Evidence of endocardial involvement = positive echo or new valvular regurgitation
134
IE minor criteria?
1. Predisposing heart condition or IVDU 2. Microbiological evidence that doesnt meet major criteria 3. Fever > 38 4. Vascular phenomena 5. Immunological phenomena
135
Most common cause of VT clinically?
Hypokalaemia, followed by hypomagnesaemia
136
Causes of ST depression?
1. Secondary to abnormal QRS (LVH, LBBB, RBBB) 2. Ischaemia 3. Digoxin 4. Hypokalaemia 5. Syndrome X

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