Cardiology

Question 1

Systolic Heart Failure

Heart Failure Reduced Ejection Fraction

Answer 1

• LVEF

Question 2

Diastolic Heart Failure

(Heart Failure Preserved Ejection Fraction

Answer 2

LVEF >40%

Exclude IHD and Valvular Disease

Question 3

NYHA Classification

Answer 3

I - No symptoms, even during exercise
II - Reduced physical capacity during medium exercise
III - Severely reduced physical capacity
during slight exercise, but asymptomatic at rest
IV - Symptomatic at rest

Question 4

Ix of HF

Answer 4

Bloods

- FBE, UEC, LFTs, BNP, TFT, Fe Studies

Question 5

Cardiac adaptations to HF

Answer 5

• Cardiomegaly (same %, of a bigger volume)
• 2ndary LVH
• Valvular disfunction due to dilation

Question 6

Management of Sys HF

Answer 6

Mx
# Non-Pharmacologica Therapy - Na, Diet, Smoking, Exerc
# Initial Pharmacological Therapy
1. Low pressure/No oedema
- Inotropes +/- fluids
2. Low pressure/ Oedema
- Inotropes
3. High Pressure/No Oedema
- ACE/ARB
4. High Pressure/Oedema
- ACE/ARB + diuretics

Question 7

CHADS2VASc

Answer 7

C - Congestive heart failure - 1
 H - Hypertension - 1
 A2 - Age ≥75 years - 2
 D - Diabetes Mellitus - 1
 S2 - Prior Stroke or TIA - 2
 V - Vascular disease PVD, AMI, aortic plaque - 1
 A - Age 65–74 years - 1
 Sc - Sex category (Female) - 1

Question 8

Pharmacological management of HF

Answer 8

1. Diuretics
2. ACEi/ARB
3. Beta Blocker - Best NNT
4. Ivabradine
5. Hydralazine/nitrates

Question 9

Diuretics - Heart Failure

Answer 9

Frusemide
- increased survival in APO
# Thiazide
- Good symptom relief (no good long/short term data)
# Aldactone
- Increased survival - good long term data
- RALES Trial 30% better survival

Question 10

ACEi/ARB - Heart Failure

Answer 10

# ACE
- Survival benefit (~7%)
- Dose that can be tolerated (K/BP) 
# ARB
- Similar improvement to ACE
- Used if intolerance to ACE

No benefit in Diastolic function

Question 11

Beta Blockers - Heart Failure

Answer 11

Survival Benefit - highest dose tolerated
# Cardio selective - no head to head studies (~34%)
- Carvidolol
- Bisoprolol
- Metoprolol XL

Question 12

Ivabradine - Heart Failure

Answer 12

# SHIFT Study 
- 18% Decrease in major outcome - admission/CV death
# Mechanism
- Decrease HR - (funny channels)
- Neutral inotrope capacity
- Doesn't decrease BP
# Criteria
- NYHA II, III
- EF77
- Sinus

Question 13

Hydralazine/Nitrates - Heart Failure

Answer 13

• Consider if high BP/poor renal function

Question 14

HF Drugs to Avoid

Answer 14

• NSAIDs
• Anti-arrhythmic
• Ca Channel blockers

Question 15

ICD in HF

Answer 15

• LVEF

Question 16

Neprilysin & Valsartan - Heart Failure

Answer 16

Paradigm HF Trial

• 20% Decrease in death
• additional therapy
• Superior to ACE

Question 17

AF

Answer 17

2 Components
# Substrate abnormalities
- LA stretch
- Increased LA pressure
- LA fibrosis
- Autonomic Abnormalities
# Electrical triggers

Question 18

Indications for ICD

Answer 18

Class I

- Symptomatic Sinus bradycardia (

Question 19

Vibrates

Answer 19

• Increase lipoprotein lipase activity - decrease LDL, increase HDL and importantly decrease Trig

Question 20

HCM

Answer 20

Key Finding in HCM

• Hypertrophy and diastolic dysfunction
• Dynamic pressure gradient
• 1st Degree relative screening – 5yrs screening

Question 21

ICD in HCM

Answer 21

• Unexplained Syncope
• Abnormal BP response to exercise
• > 30mm ventricular wall thickness
• Non-Sustained VT
• Cardiac MRI >15% gallium uptake - Fibrosis
• CAD

Question 22

Prolonged QT (congenital)

Answer 22

• Betablocker (not sotalol)

- ICD - Indications

Question 23

Acute Management of Chest Pain

Answer 23

• Aspirin

- O2 if

Question 24

Avoid Study

Answer 24

• O2 if Stats

Question 25

STEMI

Answer 25

1. Dx - Solely by ECG 2. Mx # PCI # Thrombolytic 3.

Question 26

Long QT Syndrome

Answer 26

Delayed/abnormal polarisation/repolarisation Dx - on routine ECG or following family screening - Need to look at corrected (rate dependant) Management - avoid drugs which prolong the QT interval and other precipitants if appropriate (e.g. Strenuous exercise) beta-blockers*** - implantable cardioverter defibrillators in high risk cases *the usual mechanism by which drugs prolong the QT interval is blockage of potassium channels. **a non-sedating antihistamine and classic cause of prolonged QT in a patient, especially if also taking P450 enzyme inhibitor, e.g. Patient with a cold takes terfenadine and erythromycin at the same time

Question 27

Types of long QT Sydromes - Genetic

Answer 27

- Long QT1 - usually associated with exertional syncope, often swimming - Long QT2 - often associated with syncope occurring following emotional stress, exercise or auditory stimuli - Long QT3 - events often occur at night or at rest sudden cardiac death

Question 28

Enzymes and AMI

Answer 28

``` 1st - Myoglobin - 1-2 hours 2nd - CK-MB - 2-6 hours 3rd - CK - 4-8 hours 4th - Trop T 5th - AST 6th - LDH ``` CK-MB is useful to look for reinfarction as it returns to normal after 2-3 days (troponin T remains elevated for up to 10 days)

Question 29

Hypertrophic obstructive cardiomyopathy (HOCM)

Answer 29

- HOCM is the most common cause of death in young people - is an autosomal dominant disorder of muscle tissue caused by defects in the genes encoding contractile proteins. - The most common defects involve a mutation in the gene encoding β-myosin heavy chain protein or myosin binding protein C. - The estimated prevalence is 1 in 500

Question 30

Infective Endocarditis

Answer 30

- Streptococcus viridans (most common cause - 40-50%). - Staphylococcus epidermidis (especially prosthetic valves) - Staphylococcus aureus (especially acute presentation, IVDUs) - Streptococcus bovis is associated with colorectal cancer - non-infective: systemic lupus erythematosus (Libman-Sacks), malignancy: marantic endocarditis

Question 31

Agents with proven efficacy in the pharmacological cardioversion of atrial fibrillation

Answer 31

- amiodarone - flecainide (if no structural heart disease) - others (less commonly used in UK): quinidine, dofetilide, ibutilide, propafenone

Question 32

Congenital heart disease

Answer 32

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

Question 33

Aortic dissection

Answer 33

- type A - ascending aorta - control BP(IV labetalol/betablocker) + surgery - type B - descending aorta - control BP(IV labetalol/beta blocker)

Question 34

Management of AF

Answer 34

1. Rate Control - 1st beta blockers preferable to digoxin - 2nd Ca Channel Blockers - 3rd Digoxin not used 1st line unless cardiac failure 2. Rhythm Control - if >48hrs - Toe DCR/ameoderone - if <48hrs - DCR/ameroderone

Question 35

Acute Pericarditis causes

Answer 35

viral infections (Coxsackie) tuberculosis uraemia (causes 'fibrinous' pericarditis) trauma post-myocardial infarction, Dressler's syndrome connective tissue disease hypothyroidism

Question 36

Acute Pericarditis Dx

Answer 36

- Chest pain relieved by sitting forward - Chest pain relieved by exhaling ECG changes - widespread 'saddle-shaped' ST elevation - PR depression: most specific ECG marker for pericarditis

Question 37

Myocardial infarction: secondary prevention

Answer 37

All patients should be offered the following drugs: - dual antiplatelet therapy (aspirin plus a second antiplatelet agent) - event without stent - ACE inhibitor - beta-blocker - statin

Question 38

AMI regions

Answer 38

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