Cardiology

Question 1

Warfarin INR ranges

Answer 1

Venous thromboembolism- INR 2.5, if recurrent 3.5
A fib INR 2.5
Mechanical heart valves differ by site

Question 2

Warfarin s/e

Answer 2

Haemorrhage
Teratogenic
Skin necrosis 
Purple toes 
Bleeding- stop 5 days prior to surgery

Question 3

Statins s/e

Answer 3

Myopathy- myalgia, myositis, rhabdomyolysis

Liver impairment - baseline 3, and 12 months

Question 4

Who should get statins?

Answer 4

All people with established cardiovascular disease
NICE- anyone with a 10 year cardiovascular risk
Patients with dm2 - QRISK2 and decide
Dm1 over 10 years or over 40 or nephropathy

New evidence suggests don’t need to be taken at night.

Question 5

Bradycardia treatment;

Answer 5

Management depends on
If signs of hemodynamic compromise
Identifying potential risk of asystole

Haemodynamic compromise; shock - bp<90, pallor, sweating, cold extremities, confusion, syncope.

Atropine is first line, doesn’t work or if risk of asystole-pacing is ind.

Question 6

ABPM results

Answer 6

If >135/85
Treat if under 80 and target organ damage, CV disease, renal disease, diabetes or QRISK over 20.

If 150>95
Treat

Question 7

PPV vaccine

Answer 7

Most only need one dose, if asplenia, splenic dysfunction or CKD need booster every 5 years

Question 8

Pericarditis - features

Answer 8

Differential in any patient presenting with chest pain

Features;
Chest pain- can be pleuritic- relieved by sitting forwards
Non productive cough, dyspnoea flu like symptoms
Pericardial rub
Tachypnoea
Tachycardia

Question 9

Pericarditis- causes

Answer 9

Viral infection- coxsackie
TB
Uremia
Trauma
Post MI- Dresslets syndrome 
CTD
Hypothyroidism

Question 10

ECG changes in pericarditis

Answer 10

Widespread saddle shaped ST elevation

PR depression

Question 11

WPW

Answer 11

Caused by a congenital accessory conducting pathway between atria and ventricle leaving to AV reentry tachycardia.
AF can become VF

ECG features;
Short PR
Wide QRS with slurred upstroke
LAD* usuallyor RAD

Question 12

WPW associations

Answer 12

HOCM
Mitral valve prolapse
Epstein’s anomaly 
Thyrotoxicosis 
Secundeum ASD

Question 13

WPW treatment

Answer 13

Definitive treatment; radio frequency ablation of the accessory pathway
Medical; amidarone, flecainide, sotalol

Question 14

Infective endocarditis

Risk factors

Answer 14

Most important is prev hx of endocarditis
Previously normal valves (50% at presentation)
Rheumatic valve disease 30%
Prosthetic valves
Congenital heart defects
IV drug users

Question 15

Causes of infective endo

Answer 15

Staph aureus now- strep viridans in developing world

Non infective- Libman sacks- seen in SLE
Malignancy- marantic endocarditis

Question 16

MI complications

Answer 16

Cardiac arrest- usually from v fib, most common cause of death following MI
Cardiogenic shock-damage to myocardium, reduced ejection fraction
Chronic heart failure
Tachyarrhythmias- V fib most common, VT also
Bradyarrthymias- AV block more common after anterior infaraction
Pericarditis- first 24hrs following trans mural 10%. Dressler tends to happen 2-6 weeks following mI
Left ventricular aneurysm- weaken myocardium, persistent st ELEVATION AND lv failure. Need to be anticog, thrombus might form in a.
LV free wall rupture 3% 1-2 weeks after
VSD 1-2% patient in first week
Acute MR- papillary muscle damage

Question 17

Anaphylaxis in <6months

Answer 17

Adeneline 0.15ml 1in 1000
Hydrocortisone; 25mg
Chorphenamine- 250mcg per kg

Question 18

Anaphylaxis in 6month- 6year

Answer 18

Adrenaline 0.15ml 1in 1000
Hydro or 50mg
Chlorphenamine 2.5mg

Question 19

6-12 years

Answer 19

Adrenaline 0.3ml 1 in 1000
Hydrocortisone 100mg
Chlorpheamine 5mg

Question 20

Over 12

Answer 20

Adrenaline 0.5mls 1 in 1000
Hydrocortisone 200mg
Chlorphenamine 10mg

Adrenaline repeat every 5 mins

Question 21

Long QT

Answer 21

Inherited condition- delayed repolarization of the ventricles.
Can lead to VT and death
Corrected QT in adults M is 430 and F 450

Question 22

Causes of prolonged QT

Answer 22

Congenital- jervell- Lange- Nielsen syndrome- includes deafness
Romano-ward- no deafness

Drugs- cispadone, domperidone, anti arrhythmic, citalopram, escitalopram, venlafaxine, erythromycin, clarithromycin, TCA, amiodarone, sotalol, methadone, chloroquine, haloperidol, chlorpromazine

Electrolyte imbalances- hypocalcemia, hypokalaemia, hypomg, hypothermia

Question 23

ECG In hypothermia

Answer 23

Prolonged QT
Bradycardia
J Wave
First degree heart block 
A and V arrhythmias

Question 24

Complete heart block following an MI

Answer 24

Right coronary artery lesion

Question 25

Complete heart block

Answer 25

``` Features; Syncope Heart failure Bradycardia Wide pulse pressure Cannon waves ```

Question 26

Types of heart block

Answer 26

First degree- prolonged PR > 0.2 s Second degree- type 1 mobitz Type 11- p wave often not followed by a QRS complex Third degree, no association between p WAVES AND QRS

Question 27

Takayasu arteritis

Answer 27

Large vessel vasculitis Typically causes occlusion of the aorta- often an absent limb pulse More common in females and Asian

Question 28

Features of Takayasu arteritis

Answer 28

``` Systemic features of vasculitis- malaise, headache Unequal pressure in upper limbs Carotid bruit Intermittent claudication Aortic regurg in 20% ``` Associated w renal artery stenosis Mgmt Steroids

Question 29

Ejection systolic

Answer 29

``` AS PS HOCM ASD Fallon’s ```

Question 30

Pansystolic

Answer 30

MR TR- both are blowing in character VSD

Question 31

Late systolic

Answer 31

Mitral valve prolapse | Coarc of Aorta

Question 32

Early diastolic

Answer 32

AR | Graham steel murmur- PR

Question 33

Mid-late diastolic

Answer 33

MS | Austin- flint

Question 34

Continuous

Answer 34

PDA

Question 35

Clopidogrel

Answer 35

Stop a week before elective surgery | If used with PPI- makes it less effective - still new data

Question 36

A flutter ECG findings

Answer 36

Sawtooth appearance Mgmt - similar to a fib but meds are less effective More sensitive to cardioversion Radiofreq abalation of the tricuspid valve isthmus is curative for most patients

Question 37

ECG myocardial disease

Answer 37

MI; Hyperactive T waves often the first sign- only last for a few mins ST elevation T wave inversion- in fist 24hours- can last for days to months Pathological Q waves

Question 38

Statin interaction

Answer 38

Statin +erythromycin/clarithromycin

Question 39

Loop diuretics

Answer 39

Furosemide and bumetanide - inhibit the Na K Cl cotransporter in the thick ascending limb of the loop of Henley Indication; heart failure Resistant hypertension- particularly if renal impairment ``` Adverse effects- Ototoxicity Hypokalemia Dehydration Angioedema Nephrotoxicty Gout ```

Question 40

LEAD IN MI

Answer 40

I V5 V6- Circumflex- LATERAL II III AVF- inferior- RCA V1-V4- LAD Anterior

Question 41

Don’t prescribe beta blockers with

Answer 41

Verapamil- Bradycardia and asystole

Question 42

Management of Torsades de POINTS

Answer 42

IV mag sul

Question 43

Causes of long QT

Answer 43

``` Congenital - jervell Lange Nielsen, Romano ward syndorme Antiarrhythmics- amiodarone, sotalol TCA Anti psychotics Chloroquine Tergenadine Erythromycin Hypoca, hypokalemia, hypomag, Myocarditis Hypothermia SAH ```

Question 44

SVT management

Answer 44

Fatal manoeuvres- valsalva IVO adenosine- use verapamil in asthma some Elective cardio venison Prevention- beta blockers, radiofreq abalation

Question 45

Amidarone

Answer 45

MOA- Blocks potassium channels which inhibits repolarisition and hence prolongs action potential. NEED TFT left every 6 months ``` S/e Thyroid dysfunction Corneal deposits Liver fibrosis Pulmonary fibrosis Peripheral neuropathy Photo sensitivity Slate grey appearance Brady cardia ```

Question 46

Thrombolysis

Answer 46

Activate plasminogen to form plasmin- degrades fibrin ``` Contraindications Active internal bleeding Recent haemorrhage, trauma or surgery- including dental extraction Intracranial neoplasm Stroke <3 months Recent head injury Pregnancy severe hypertension ```

Question 47

Hep E

Answer 47

Associated with face all oral spread, commonly affecting shellfish and pork products Bloods show elevated bilirubin and transaminits

Question 48

Mody

Answer 48

``` Mature onset diabetes of the young DM2 in under 25 Inherited in AD fashion Family history is often present Usually very sensitive to SUR ``` Mody 3 60% of cases

Question 49

C Diff

Answer 49

Gram positive - encountered in hospital practice Causes pseudomembranous colitis - intentional damage due to exotoxins. Commonly caused by broad spectrum antibiotics- suppress normal flora 2nd and 3rd generation cephalosporins

Question 50

Features of c diff

Answer 50

Diarrhoea Abdo pain Raised white blood cell count Toxic mega colon may develop Detect in stool

Question 51

Tx for c DIFF

Answer 51

Oral methronidazole for 10-14 days Add in vancomycin if not responding All oral IV if life threatening

Question 52

Raised ALP

Answer 52

``` Liver- cholestasis, hepatitis, fatty liver, neoplasia Pagets Osteomalacia Bone mets Hyperparathyroidism Renal failure Pregnancy Growing children Healing fractures ```

Question 53

Raised alp and raised calcium

Answer 53

Bone mets | Hyperparathyroidism

Question 54

Roared ALP and low calcium

Answer 54

Osteomalacia | Renal failure

Question 55

Goodpastures

Answer 55

Associated with rapidly progressive glomerulnephritis +- pulmonary haemorrhage Caused by anti glomerular basement membrane ab against IV collagen More common in men and has biomodal age dis 20-30 60-70 Hal dr2 Plamaphoeriss Steroids Cyclophosphamide

Question 56

Dipyridamole MOA

Answer 56

Used as an anti-coag Inhibits phosphodiesterase

Question 57

NICE BP targets for DM2

Answer 57

If end organ damage <130/80 | Otherwise <140/80

Question 58

Evidence of anterior MI and AR

Answer 58

Proximal aortic dissection ?

Question 59

Macklemore triad for Boerhaave syndrome

Answer 59

Vomiting Thoracic pain Subcutaneous emphysema Middle aged men with background of alcohol abuse

Question 60

Treating aortic dissection

Answer 60

Type a- Surg | Type b - non surg

Question 61

Boerhaaves syndrome

Answer 61

Rupture of the oesophagus as a result of repeated episodes of vomiting Usually c/o sudden onset severe chest pain that may complicate severe vomiting

Question 62

Nicorandil

Answer 62

Potassium channel activator - vasodilator effect on coronary arteries S/E- headache, flushing, anal ulceration Used to treat angina

Question 63

ACEi S/E

Answer 63

Cough- 15% of patients and may occur up to 1 year after starting treatment Angioedema- up to 1 year after starting treatment Hyperkalemia First dose hypotension

Question 64

ACEI cautions and CI

Answer 64

Avoid if preg/ breastfeeding Renal disease Aortic stenosis High dose diuretics U& E before - rise in creatinine and K may be expected. Cr rise of no more than 30% . EGFR should be less than 20%

Question 65

HTN in diabetes treatment

Answer 65

First line - ACEi - renal protective effect

Question 66

Isosorbide mononitrare

Answer 66

Patients may develop tolerance to this med and you might need to change dosing regime

Question 67

Angina drug mgmt

Answer 67

All patients should get aspirin and statin - if not CI Sublingual GTN for attacks Beta blocker or CCB first line based on co morbidities If CCB by itself- verapamil or diltiazem

Question 68

Ejection systolic

Answer 68

``` AS PS HOCM ASD Fallots ```

Question 69

Pansystolic

Answer 69

MR TR- blowing | VSD

Question 70

Late systolic

Answer 70

M prolapse | Coarch

Question 71

Early diastolic

Answer 71

AR- blowing | Graham steel

Question 72

Mid late diastolic

Answer 72

MS | Austin flint- severe AR

Question 73

Continuous machine like

Answer 73

PDA

Question 74

HOCM

Answer 74

AD disorder of muscle tissue caused by defects in the genes encoding contractile proteins. 1/500

Question 75

HCOM features

Answer 75

``` Often asymptomatic Dypnoea Angina Syncope Sudden death Ejection systolic murmur- increases valsalva- decreases squatting ```

Question 76

Associations HOCM

Answer 76

WPW | Friedrechihs ataxia

Question 77

Echo findings

Answer 77

MR Systolic anterior motion of MV leaflet Asymmetric hypertrophy MR SAM ASH

Question 78

ECG HOCM

Answer 78

LVhypertropghy Progressive t wave inversion Deep q waves A fib

Question 79

A fib rate control

Answer 79

Beta blockers CCB Digoxin- not first line

Question 80

Rate control if

Answer 80

Older than 65 | Hx of ischemic heart disease

Question 81

Rhythm control if

Answer 81

Younger than 65 Symptomatic First presentation Congestive heart failure

Question 82

Epstein anomaly

Answer 82

Low insertion of the tricuspid valve - large atrium and small ventricle Associations - tricupsid incompetence WPW Li exposure in uterus Tricuspid valve leaflets are attached to the walls of the septum and tight ventricle

Question 83

BNP

Answer 83

Made in response to strain- left ventricular myocardium Effects- vasodilator Diuretic and natriuretic

Question 84

Clinical uses of BNP

Answer 84

Diagnosisi of patients with a true dyspnoea Prognosis of chronic heart failure Guiding treatment in chronic HF Screen for cardiac dysfunction