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Y4S2 Medicine > Cardiology > Flashcards

Cardiology Flashcards

1
Q

Which valvular disorder is most strongly associated with atrial fibrillation?

A

Mitral stenosis

2/3 of patients develop AF

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2
Q

What are the two treatment approaches to AF?

A

Rate and rhythm control

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3
Q

When and why is rhythm control used to treat AF?

A

Young patients

Restoration of sinus rhythm prevents atrial remodelling

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4
Q

What are the 1st, 2nd and 3rd line rate control drugs for AF?

A
  1. Beta blockers, non-dihydropyridine calcium channel blockers
  2. Digoxin
  3. Amiodarone
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5
Q

When is percutaneous coronary intervention (PCI) vs fibrinolytic therapy used for STEMI?

A

PCI within 90 minutes of symptom onset

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6
Q

How are unstable angina and NSTEMI differentiated?

A

No troponin elevation in unstable angina

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8
Q

What causes unstable angina?

A

Rupture of an unstable plaque → thrombus → partial occlusion of a coronary vessel

The interaction between thrombus formation and endogenous thrombolysis prevents complete vessel occlusion

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9
Q

How does blood vessel occlusion differ in a NSTEMI vs a STEMI?

A

NSTEMI - complete occlusion of small branches

STEMI - complete occlusion of a main coronary artery

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10
Q

What are 3 late complications of an MI?

A
  1. Rupture (LV wall, ventricular septal, papillary muscle)
  2. Atrial and ventricular aneurysms
  3. Arterial thromboembolism (due to venous stasis → stroke risk)
  4. Reinfarction
  5. Pericarditis
  6. Congestive heart failure
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11
Q

What are the complications of atrial/ventricular aneurysms following MI?

A

Arrhythmias (VF)

Rupture → tamponade

Thrombus formation

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12
Q

MI affecting which artery is most associated with mitral regurgitation?

A

Posterior descending artery → rupture of posteromedial papillary muscle

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13
Q

What is Dressler syndrome?

A

Pericarditis 2-10 weeks following MI without an infective cause

Autoimmune aetiology

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15
Q

Name two GPIIb/IIIa receptor inhibitors

A

Eptifibatide

Tirofiban

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16
Q

When is aspirin given in patients with symptoms of ACS?

A

All patients with possible ACS and without contraindications

300mg orally, as soon as possible after presentations

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17
Q

How long following STEMI is reperfusion therapy (PCI or fibrinolytic therapy) no longer indicated?

A

12 hours

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18
Q

Which medications are given to all patients with confirmed ACS?

A

Aspirin 300mg orally

P2Y12 inhibitor (ticagrelor, prasugrel, clopidogrel)

Double anti-platelet therapy

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25
Q

Which ECG leads show an inferior view of the heart?

A

II, III, aVF (right coronary/marginal artery)

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26
Q

Which ECG leads show the lateral side of the heart?

A

I, aVL, V5, V6 (left circumflex artery)

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27
Q

Which ECG leads show an anteroseptal view of the heart?

A

V1, V2 (LAD)

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28
Q

What is a normal ejection fraction?

A

>55%

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29
Q

Which drug prevents remodelling of the heart following an AMI?

A

ACEi

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30
Q

When is a bubble study used?

A

Patent foramen ovale

Atrial septal defect

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31
Q

Which congenital heart disease has a pansystolic murmur?

A

VSD

Pansystolic murmur over the left lower sternal border

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32
Q

What is the HAS-BLED score?

A

Way of assessing 1 year risk of major bleeding in patients taking anticoagulants for atrial fibrillation

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33
Q

What is the CHA2DS2-VASc score?

A

Predictor of stroke risk in patients with atrial fibrillation

Used to determine whether anticoagulant/antiplatelet therapy is required

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34
Q

What are the 5 types of MI?

A
  1. Primary coronary event e.g. plaque erosion, rupture, fissuring or dissection
  2. Supply-demand mismatch
  3. Sudden unexpected cardiac death
  4. Associated with PCI or stent thrombosis
  5. Associated with cardiac surgery
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35
Q

Which beta blockers can be used for heart failure?

A

Bisoprolol

Carvedilol

Metoprolol XR

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36
Q

What are the potential side effects of amiodarone?

A

Amiodarone is a BITCH

B - bradycardia/blue man

I - interstitial lung disease

T - thyroid (hyper and hypo)

C - corneal microdeposits (visual haloes and photophobia)/cutaneous

H - hepatic/hypotension

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37
Q

What are the potential side effects of amiodarone?

A

Amiodarone is a BITCH

B - bradycardia/blue man

I - interstitial lung disease

T - thyroid (hyper and hypo)

C - corneal microdeposits (visual haloes and photophobia)/cutaneous

H - hepatic/hypotension

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38
Q

Which condition is Watson’s water hammer pulse/collapsing pulse associated with?

A

Aortic regurgitation

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39
Q

Which condition is pulsus alternans associated with?

A

Advanced LV failure, aortic valve disease

Regular pulse with alternating strong and weak beats

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40
Q

What anticoagulation is given to patients with atherosclerosis?

A

Aspirin

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41
Q

What anticoagulation is given to patients with acute coronary syndromes?

A

Aspirin PLUS clopidogrel/prasugrel/ticagrelor

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42
Q

What is the mechanism of hydralazine?

A

Arteriolar vasodilation

Antihypertensive

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43
Q

What are the two most significant side effects of hydralazine?

A

Tachycardia

Fluid retention

Give with a beta blocker and a diuretic

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44
Q

What is the most common electrolyte abnormality with ACEi used? Why does this occur?

A

Hyperkalaemia

ACEi → reduced angiotensin II → reduced aldosterone → reduced urinary potassium excretion

45
Q

Why do ACEis reduce proteinura?

A

Angiotensin II usually increases GFR

+ afferent arteriole constriction

++ efferent constriction

ACEis reduce glomerular pressure

46
Q

Why do patients with bilateral renal artery stenosis have a reduction in GFR with ACEi use?

A

When renal perfusion is significantly impaired, angiotensin II induces efferent constriction, helping maintain GFR

ACEis block this effect

Because angiotensin II is not used to maintain renal perfusion in healthy patients, they do not have impaired renal function with ACEis

47
Q

What constitutes a long QT on ECG?

A

QTc > 440ms

11 small squares or T wave after half the R-R distance

48
Q

Which drugs are most strongly associated with long QT syndrome?

A

Amiodarine

TCAs

Haloperidol

Antibiotics e.g. macrolides, fluoroquinolones

Ondansetron

49
Q

How is blood pressure calculated?

A

Cardiac output x systemic vascular resistance

50
Q

What is a measurement of pulmonary capillary wedge pressure used for?

A

Estimate left atrial pressure

Evaluating the severity of LV failure and quantifying the degree of mitral valve stenosis

Normally 8-10 mmHg

51
Q

What is an anacrotic pulse (pulsus tardus) and when is it felt?

A

Low amplitude with slow rise and fall

Prolonged pulse duration

Seen in aortic stenosis

52
Q

What is bumetanide?

A

Loop diuretic

53
Q

What is the mechanism of rivaroxaban/apixaban? What does factor X do?

A

Factor Xa inhibitor

Factor X cleaves prothrombin, forming thrombin

Thrombin stimulates the conversion of fibrinogen to fibrin

54
Q

Why is bridging therapy often used with warfarin?

A

Warfarin inhibits both factor II, VII, IX and X

AND anticoagulants protein C and S

Protein C and S are inhibited immediately but inhibition of clotting factors requires a couple of days

Patients initially have a hypercoagulable state

Why warfarin is not used for acute PE/DVT therapy

55
Q

From which value is an INR derived?

A

Prothrombin time

(measure of the extrinsic and common pathways)

56
Q

Which coagulation pathway does warfarin predominantly act on?

A

Extrinsic

(prothrombin time/INR measures the extrinsic + common pathways)

Warfarin has a greatest inhibitory effect on factor VII

57
Q

What are the 4 Hs and 4 Ts of pulseless electrical activity (PEA)?

A

Hypoxia

Hypovolemia

Hypothermia

Hypo/hyperkalaemia

Thrombosis - coronary or pulmonary

Tamponade - cardiac

Toxins

Tension pneumothorax

58
Q

What does the breadth of the QRS complex tell you about pulseless electical activity?

A

Broad: metabolic/ischaemia/LV failure

Narrow: mechanic (poor RV inflow or outflow obstruction)

59
Q

What is the most common cause of sudden cardiac death in young people, especially elite athletes?

A

Hypertrophic cardiomyopathy (HOCM)

60
Q

Systolic anterior motion of the mitral valve is characteristic of which disease?

A

HOCM

Obstruction → high flow rate during systole → mitral valve is sucked into the ventricle by negative pressure

61
Q

Pain that is worse when lying flat and better when sitting up is characteristic of what?

A

Pericarditis

62
Q

What murmur is heard in mitral stenosis?

A

Decreascendo diastolic murmur with an opening snap

63
Q

How are murmurs graded?

A
64
Q

What is afterload?

A

The force or load against which the heart has to contract to eject blood (aortic pressure and systemic vascular resistance)

65
Q

What is preload?

A

Stretcing of the myocytes prior to contraction

66
Q

How do ACE inhibitors help hypertension and heart failure?

A
  1. Vasodilation
  2. Decreased sympathetic activity
  3. Diuresis
  4. Inhibits remodelling
67
Q

What are the actions of angiotensin II?

A

Vasoconstriction

Increased ADH

Thirst → fluid retention

Stimulates aldosterone

68
Q

How is blood pressure calculated?

A

CO x SVR

69
Q

What is Beck’s triad of cardiac tamponade?

A
  1. Hypotension
  2. Distended neck veins
  3. Muffled heart sounds
70
Q

What complications can occur in the first 24 hours following an AMI?

A

Suddent cardiac death (VF/VT)

Arrhythmias

Acute left heart failure

Cardiogenic shock

71
Q

What is the most common complication 1-3 days post AMI?

A

Early infarct-associated pericarditis

72
Q

What complications occur 3-14 days post AMI?

A

Papillary muscle rupture

Ventricular septal rupture

Left ventricular free wall rupture

73
Q

What complications occur 2 weeks to months post AMI?

A

Atrial and ventricular aneurysms

Dressler syndrome (autoimmune pericarditis)

Arrhythmias

Congestive heart failure

Reinfarction

74
Q

For how long is dual antiplatelet therapy continued following an ACS?

A

12 months, then reassess risk of bleeding and risk of discontinuation

75
Q

Following AMI, which patients should be given beta blockers?

A

Reduced LV systolic function (ejection fraction < 40%)

76
Q

Following an ACS, which patients should be given an ACEi/ARB?

A

Heart failure

LV systolic dysfunction

Diabetes

Anterior MI

Co-existent hypertension

77
Q

What are indications for revascularisation in patients with stable coronary artery disease?

A

Activity-limiting symptoms despite optimal medical therapy

Active patients who prefer PCI for improved quality of life compared to medical therapy

78
Q

Which patients are at a very high risk of further thrombotic events following an ACS?

A

Haemodynamic instability

Heart failure

Cardiogenic shock

Mechanical complications of MI

Recurrent or ongoing ischaemia

79
Q

Which patients are at a high risk of further thrombotic events following an ACS?

A

Rise and/or fall in troponin level consistent with MI

Dynamic ST-segment and/or T wave changes with or without symptoms

GRACE score > 140

80
Q

Which patients are at an intermediate risk of further thrombotic events following an ACS?

A

Diabetes mellitus

Renal insufficiency (GFR < 60)

LVEF < 40%

Prior revascularisation

GRACE score 109-140

81
Q

What PaO2 is an indication for oxygen therapy in ACS?

A

< 93%

82
Q

Which P2Y12 inhibitors are preferred in dual antiplatelet therapy?

A

Ticagrelor and prasugrel

83
Q

What are the indications for long-term ACEi use following an ACS?

A

Heart failure

LV systolic dysfunction

Diabetes

Anterior MI

Co-existent hypertension

84
Q

What are the indications for long-term anticoagulation following an ACS?

A

Mechanical heart valves

LV thrombus

Chronic AF

CHA2DS2VASC score 2 or more

85
Q

What are the indications for long-term beta blockers in patients with an ACS?

A

LVEF < 40%

86
Q

For how long is dual antiplatelet therapy continued following an ACS?

A

12 months

87
Q

Within what timeframe should invasive therapies (PCI/CABG) be commenced in patients with NSTEMI/UA?

A

Very high risk - 2 hours

High risk - 24 hours

Intermediate risk - 72 hours

88
Q

What anticoagulation is given to patients with non-valvular AF based on their CHA2DS2-VASc score?

A

0 = no anticoagulation

1 = no anticoagulation OR treatment with oral anticoagulants

2+ = oral anticoagulation with either warfarin or NOACs

89
Q

What anticoagulation is given to patients with valvular AF based on their CHA2DS2-VASc score?

A

Warfarin regardless of score

Valvular AF = patients with mitral stenosis, artificial heart valves and/or repaired mitral valves

90
Q

What ECG changes are seen in hyperkalaemia?

A

Tall, peaked T waves
Lengthening of the QRS interval
P wave flattening
Lengthening of PR interval
Shortening of the QT interval

91
Q

What causes a notched P wave?

A

Left atrial enlargement

“P mitrale” - enlargement is commonly due to mitral disease

P pulmonale - RA enlargement due to pulmonic disease

92
Q

Inverted T waves are normal in which leads?

A

aVR and V1

93
Q

What are hyperacute T waves?

A

Broad, asymmetrically peaked T waves

Seen in the early stages of a STEMI, often preceding ST elevation

94
Q

What are the causes of biphasic T waves?

A

Myocardial ischaemia - up then down (pictured)

Hypokalaemia - down then up

95
Q

What is Wellens syndrome?

A

A pattern of inverted or biphasic T waves in V2-3 that is highly specific for critical stenosis of the LAD

96
Q

What do the a and v JVP waves reflect?

A

a wave = atrial contraction

v wave = atrial filling (ventricular contraction)

Y4S2 Medicine (18 decks)

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