Cardiology Flashcards

Question

Causes of long QT

Answer 1

1) Genetic 2) electrolytes - hypomagnesaemia - hypocalcaemia - hypokalaemia 3) Drugs - Anti arrhythmic e.g, amiodarone, SOTALOL - antibiotics e.g. erythromycin, clarithromycin, ciprofloxacin - psychotropic drugs e.g. SSRI, TCA, Neuroleptic

Answer 2

Young athletic Sleep Chronic degeneration of sinus or AV nodesu or atria Drugs e.g. Bb, morphing, amiodarone, CCB, lithium, propafenone Increased Vagal tone - vasovagal attack, N&V, carotid sinus hypersentivify Hypothyroid Hypothermia MI or ischaemia of the sinus node Raised ICP

Answer 3

Clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of the deep veins) 3 An alternative diagnosis is less likely than PE 3 Heart rate > 100 beats per minute 1.5 Immobilisation for more than 3 days or surgery in the previous 4 weeks 1.5 Previous DVT/PE 1.5 Haemoptysis 1 Malignancy (on treatment, treated in the last 6 months, or palliative) 1 >4 -- CTPA 4 or less -- D dimer

Answer 4

``` C Congestive heart failure 1 H Hypertension (or treated hypertension) 1 A2 Age >= 75 years 2 Age 65-74 years 1 D Diabetes 1 S2 Prior Stroke or TIA 2 V Vascular disease (including ischaemic heart disease and peripheral arterial disease) 1 S Sex (female) 1 ``` ``` Strategy based on score 0 No treatment 1 Males: Consider anticoagulation Females: No treatment (this is because their score of 1 is only reached due to their gender) 2 or more Offer anticoagulation ```

Answer 5

Venous thromboembolism: 2.5, if recurrent 3.5 AF: 2.5 Mechanical heart valves, target INR depends on the valve type and location. Mitral valves generally require a higher INR than aortic valves.

Answer 6

Uncontrolled HF Concurrent verapamil: May precipitate severe bradycardia Asthma Sick sinus syndrome Side effects - Bronchospasm - Trouble sleeping - ED - Fatigue - Cold peripheries

Answer 7

Pregnancy + breast feeding Bilateral RAS Aortic stenosis Side effects - Cough - Angiodema - Hyperkalaemia

Answer 8

``` Alveolar oedema kelley B lines (expansion of interstitial space by fluid) Cardiomegaly Dilated upper lobe vessels Effusions (pleural) ```

Answer 9

``` Examples Antibiotics: ciprofloxacin, erythromycin Isoniazid Cimetidine,omeprazole Amiodarone Allopurinol Imidazoles: ketoconazole, fluconazole SSRIs: fluoxetine, sertraline ritonavir Sodium valproate Acute alcohol intake quinupristin ``` Cause an increase in INR - often rapid

Answer 10

``` Antiepileptics: phenytoin, carbamazepine barbiturates: phenobarbitone rifampicin St John's Wort chronic alcohol intake griseofulvin smoking (affects CYP1A2, reason why smokers require more aminophylline) ``` Causes decrease in INR - often takes a while

Answer 11

Activates antithrombin III. Forms a complex that inhibits thrombin, factors Xa, IXa, Xia and XIIa Adverse effects - Bleeding - Thrombocytopenia - HIT - Osteoporosis and an increased risk of fractures - Hyperkalaemia - this is thought to be caused by inhibition of aldosterone secretion Administration IV Duration of action Short Monitoring APTT Advantage over LMWH? Useful in situations where there is a high risk of bleeding as anticoagulation can be terminated rapidly. Also useful in renal failure

Answer 12

Activates antithrombin III. - Forms a complex that inhibits factor Xa Adverse effects - Bleeding - Lower risk of HIT and osteoporosis with LMWH Administration Subcut Duration of action Long Monitoring Anti-Factor Xa (although routine monitoring is not required) Advantage over LMWH Now standard in the management of venous thromboembolism treatment and prophylaxis and acute coronary syndromes

Answer 13

Cardiac: IHD (MI, CAD), Mitral valve disease, Pericarditis, Cardiomyopathy, Rheumatic heart disease Pulmonary: PE/Bronchial carcinoma Systemic: Sepsis/Infection, Thyrotoxicosis, HTN, Alcohol, Caffeine O/E - Irregularly irregular pulse, difference in apical beat and radial pulse - Valvular disease/thyroid disease? - Tachy/palpitations/stroke Investigations ECG Bloods Echo Management 1) Haemodynamically unstable: DC cardioversion 2) Rate control if long standing/mitral stenosis: BISOPROLOL or CCB (Verapamil/Diltiazam) if asthma. 2nd line: Add digoxin 3) Rhythym control If paroxysmal or new onset - Pt choice unless unstable - DC cardiversion vs amiodarone/flecanice 4) Stroke risk prevention - Use CHA2DS2VASc - 1 (M) or 2 (F) needs anticoagulation with NOAC unless prosthetic valve AF Complications - Thromboembolism - HF/ Worsening of HF

Answer 14

SVT = Narrow complex (<0.12s), + HR >100 Differentials 1) Sinus tachycardia 2) Atrial: AF, Atrial Futter, Atrial tachycardia 3) AVNRT 3) AVRT

Answer 15

VT Torsades de Pointes SVT with BBB VT causes IM QVICK 1) Infarction (esp. ̄c ventricular aneurysm) 2) Myocarditis 3) QT interval↑ 4) Valve abnormality: mitral prolapse, AS 5) Iatrogenic: digoxin, antiarrhythmics, catheter 6) Cardiomyopathy (esp. dilated) 7) K↓, Mg↓, O2↓, acidosis

Answer 16

Lifestyle: Stop smoking; Diet; Activity; Aspirin 75mg OD Statin Sublingual GTN for episodes BB for symptoms CCB if bb not working Can try ivabradine + long acting nitrates, Nicorandil, Ranolazine If angina persists --> consider CABG or PCI Complications - Unstable angina - MI - Stroke - QOL

Answer 17

RCA - Inferior - leads II, III, avF - RA, RV, Inferior aspect of LV, Posterior Septal area Circumflex - Lateral - leads I, avL, v5-6 - LA, Posterior aspect of LV LAD - Anterior - leads v1-v4 - Anterior aspect of LV, Anterior aspect of septum LCA - Anteroleateral - leads I, avL, v3-v6

Answer 18

MONA - as for all ACS - Morphine 1-10mg IV, Metoclopramide 10mg IV - Oxygen (if needed) - GTN spray - Aspirin 300mg + Ticagrelor 180mg Reperfusion if within 12 h onset - PCI if within 120mins - Fibrinolysis if PCI not available in 120 mins (Activates plasminogen to form plasmin, which breaks down fibrin)

Answer 19

MONA as for all ACS - Morphine 1-10mg IV, Metoclopramide 10mg IV - Oxygen (if needed) - GTN spray - Aspirin 300mg + Ticagrelor 180mg BANE 1) BB e.g. metoprolol (unless CI - use CCB if so) 2) Anti-coagulate: Fondaparinux 2.5mg OD SC or LMWH e.g. Enoxaparin 1mg/kg BD (This should be UF heparin if going for angiography) 3) IV nitrates if pain continues e.g. GTN 50mg in 50ml 0.9% saline 4) ECG (whilst in pain) - determine risk Invasive (high-risk pt) - Rise in trop - Dynamic ST/T wave changes - Secondary criteria: DM, CKD, LVEF <40%, Early angina post MI, recopt PCI, prior CABG, Intermediate to high grace score ==> Infusion of GpIIb/IIIa antagonist (e.g. tirodiban) and refer for angioplasty as inpatient (within 72h) 1) Urgent (<120mins) if ongoing angina despite Rx + evolving ST changes, signs of cardiogenic shock or life threatening arrhythmia 2) Early (<24h) if grace score >140 and high risk pt 3) Within 72h if lower risk pt ``` Conservative strategy (low risk pt) - No recurrence of chest pain - No signs of HF - Normal ECG - Negative baseline + 6-9h Trop - No inducible ischaemia ==>May be discharged if a repeat trop is -ve. Treat medication and arrange further ivg e.g. stress test, angiogram Risk score - GRACE ```

Answer 20

Aspirin 75mg OD + Another anti-platelet for 12months Atorvostatin 80mg OD ACEi e.g. ramipril 10mg Atenolol (or other beta blocker) Aldosterone antagonist for those with clinical HF NB dual antiplatelet therapy varies following PCI depending on stent use

Answer 21

``` Death Rupture of septum of papillary muscle Eodema - HF Aneurysm + Arrhythmia Dressler's syndrome ``` ``` ACS poor prognosis Age Development (or history) of heart failure - crackles Peripheral vascular disease Reduced systolic blood pressure Killip class* Initial serum creatinine concentration Elevated initial cardiac markers Cardiac arrest on admission ST segment deviation ```

Answer 22

1st line for all = ACE-inhibitor and a beta-blocker*. (start one drug at a time 2nd line: Aldosterone antagonist, angiotensin II receptor blocker or a hydralazine in combination with a nitrate If symptoms persist: - CRT or DIGOXIN to be considered - An alternative supported by NICE in 2012 is ivabradine. The criteria for ivabradine include that the patient is already on suitable therapy (ACE-inhibitor, beta-blocker + aldosterone antagonist), has a heart rate > 75/min and a left ventricular fraction < 35% Diuretics should be given for fluid overload Offer annual influenza vaccine Offer one-off*** pneumococcal vaccine Other drugs sacubitril-valsartan is considered in heart failure with reduced ejection fraction who are symptomatic on ACE inhibitors or ARBs sacubitril-valsartan should be initiated following ACEi or ARB wash-out period ``` A number of drugs have been shown to improve mortality in patients with chronic heart failure: ACE inhibitors (SAVE, SOLVD, CONSENSUS) spironolactone (RALES) beta-blockers (CIBIS) hydralazine with nitrates (VHEFT-1) ``` No long-term reduction in mortality has been demonstrated for loop diuretics such as furosemide.

Answer 23

``` Contraindications: AGAINST Aortic dissection GI bleeding Allergic reaction previously Iatrogenic: recent surgery Neuro: cerebral neoplasm or CVA Hx Severe HTN (200/120) Trauma, inc. CPR ```

Answer 24

Inflammation of the pericardium lasting <6 weeks Causes - VIRUS e.g. coxsackie B, echovirus, HIV - Other: Uraemia, Trauma, Infection + Malignancy Presentation - Sharp retrosternal chest pain - - relieved by leaning forwards - - May be worse on inspiration and radiate to the neck May be pericardial friction rub (may be transient) Dx: ECG: Saddle shaped ST segment elevation CXR - may show enlargement of cardiac shadow Echo: useful if suspision of pericardial effusion (normal kn uncomplicated pericarditis) Ddx: DISSECTION Management - Treat underlying cause and NSAIDs (unless in few days after MI as risk of myocardial rupture) - If resistant - steroids Complications - Chronic pericarditis - Chronic pericarditis

Answer 25

ABPM/HBPM >= 135/85 mmHg (i.e. stage 1 hypertension) treat if < 80 years of age AND any of the following apply; target organ damage, established cardiovascular disease, renal disease, diabetes or a 10-year cardiovascular risk equivalent to 10% or greater - if >80 just lifestyle advice ABPM/HBPM >= 150/95 mmHg (i.e. stage 2 hypertension) offer drug treatment regardless of age

Answer 26

Statins inhibit the action of HMG-CoA reductase, the rate-limiting enzyme in hepatic cholesterol synthesis. Adverse effects 1) Myopathy: includes myalgia, myositis, rhabdomyolysis and asymptomatic raised creatine kinase. Risks factors for myopathy include advanced age, female sex, low body mass index and presence of multisystem disease such as diabetes mellitus. Myopathy is more common in lipophilic statins (simvastatin, atorvastatin) than relatively hydrophilic statins (rosuvastatin, pravastatin, fluvastatin) 2) Liver impairment: the 2014 NICE guidelines recommend checking LFTs at baseline, 3 months and 12 months. Treatment should be discontinued if serum transaminase concentrations rise to and persist at 3 TIMES BASELINE There is some evidence that statins may increase the risk of intracerebral haemorrhage in patients who've previously had a stroke. This effect is not seen in primary prevention. For this reason the Royal College of Physicians recommend avoiding statins in patients with a history of intracerebral haemorrhage

Answer 27

Cardiac tamponade is characterized by the accumulation of pericardial fluid under pressure. Classical features - Beck's triad: hypotension raised JVP muffled heart sounds ``` Other features: dyspnoea tachycardia an absent Y descent on the JVP - this is due to the limited right ventricular filling pulsus paradoxus - an abnormally large drop in BP during inspiration Kussmaul's sign - much debate about this ECG: ELECTRICAL ALTERNANS Management = Urgent pericardiocentesis ```

Answer 28

denosine is most commonly used to terminate supraventricular tachycardias. The effects of adenosine are enhanced by dipyridamole (antiplatelet agent) and blocked by theophyllines. It should be avoided in asthmatics due to possible bronchospasm. Mechanism of action causes transient heart block in the AV node agonist of the A1 receptor in the atrioventricular node, which inhibits adenylyl cyclase thus reducing cAMP and causing hyperpolarization by increasing outward potassium flux adenosine has a very short half-life of about 8-10 seconds Adenosine should ideally be infused via a large-calibre cannula due to it's short half-life, ``` Adverse effects chest pain bronchospasm transient flushing can enhance conduction down accessory pathways, resulting in increased ventricular rate (e.g. WPW syndrome) ```

Answer 29

Management options in acute heart failure include: oxygen loop diuretics opiates - reduce anxiety and reduce dyspnoea vasodilators inotropic agents CPAP ultrafiltration mechanical circulatory assistance: e.g. intra-aortic balloon counterpulsation or ventricular assist devices Consideration should be given to discontinuing beta-blockers in the short-term.

Answer 30

``` Interpretation of PAOP PAOP mmHg Scenario Normal 8-12 Low <5 Hypovolaemia Low with pulmonary oedema <5 ARDS High >18 Overload ```

Answer 31

If PCI and car driver - no need, can drive in 4 weeks If lorry driver - notify DVLA, stay off for 6 weeks then DVLA will assess

Answer 32

ASD Risk - Stroke as embolism may pass from venous system to left side of heart causing a stroke

Answer 33

1) hyperacute T waves are often the first sign of MI but often only persists for a few minutes 2) ST elevation may then develop 3) T waves typically become inverted within the first 24 hours. The inversion of the T waves can last for days to months 4) pathological Q waves develop after several hours to days. This change usually persists indefinitely

Answer 34

Start LMWH, Increase warfarin dose

Answer 35

Aortic stenosis Pulmonary stenosis, hypertrophic obstructive cardiomyopathy Atrial septal defect, tetralogy of Fallot

Answer 36

Education and lifestyle measures such as adequate Hydration and salt intake Discontinuation of vasoactive drugs e.g. nitrates, antihypertensives, neuroleptic agents or dopaminergic drugs If symptoms persist, consider compression garments, fludrocortisone, midodrine, counter-pressure manoeuvres, and head-up tilt sleeping Dx of orthostatic hypotension A symptomatic fall in systolic BP > 20 mmHg or diastolic BP > 10 mmHg or decrease in systolic BP < 90 mmHg is considered diagnostic Causes Hypovolaemia Autonomic dysfunction: diabetes, Parkinson's Drugs: diuretics, antihypertensives, L-dopa, phenothiazines, antidepressants, sedatives alcohol

Answer 37

Think proximal aortic dissection Other features may include pericardial effusion, carotid dissection and absent subclavian pulse.

Answer 38

4 weeks off driving

Answer 39

``` Features 'bones, stones, groans and psychic moans' corneal calcification shortened QT interval on ECG hypertension ```

Answer 40

aortic regurgitation patent ductus arteriosus hyperkinetic states (anaemia, thyrotoxic, fever, exercise/pregnancy)

Answer 41

Aspirin Antiplatelet - inhibits the production of thromboxane A2 Clopidogrel Antiplatelet - inhibits ADP binding to its platelet receptor Enoxaparin Activates antithrombin III, which in turn potentiates the inhibition of coagulation factors Xa Fondaparinux Activates antithrombin III, which in turn potentiates the inhibition of coagulation factors Xa Bivalirudin Reversible direct thrombin inhibitor Abciximab, eptifibatide, tirofiban Glycoprotein IIb/IIIa receptor antagonists

Answer 42

V/Q if renal impairment

Answer 43

Takayasu's arteritis is a large vessel vasculitis. It typically causes occlusion of the aorta and questions commonly refer to an absent limb pulse. It is more common in females and Asian people Features systemic features of a vasculitis e.g. malaise, headache unequal blood pressure in the upper limbs carotid bruit intermittent claudication aortic regurgitation (around 20%) Associations renal artery stenosis Management steroids

Answer 44

S3 Caused by diastolic filling of the ventricle Considered normal if < 30 years old (may persist in women up to 50 years old) Heard in left ventricular failure (e.g. dilated cardiomyopathy), constrictive pericarditis (called a pericardial knock) and mitral regurgitation S4 Caused by atrial contraction against a stiff ventricle therefore coincides with the P wave on ECG May be heard in aortic stenosis, HOCM, hypertension in HOCM a double apical impulse may be felt as a result of a palpable S4

Answer 45

Causes of radio-femoral delay A significant delay between the radial and femoral pulse suggests aortic coarctation distal to the left subclavian artery. - Aortic co-arctation ``` Causes of radio-radial delay If present, a delay between bilateral radial pulses suggests narrowing of the aorta proximal to the left subclavian artery - classically in the context of coarctation of the aorta. - Aortic coarctation - Subclavian stenosis - Takayasu arteritis ```

Answer 46

If surgery can wait for 6-8 hours - give 5 mg vitamin K IV | If surgery can't wait - 25-50 units/kg four-factor prothrombin complex

Answer 47

Causes any cause of pericarditis particularly TB ``` Features dyspnoea right heart failure: elevated JVP, ascites, oedema, hepatomegaly JVP shows prominent x and y descent pericardial knock - loud S3 Kussmaul's sign is positive ``` CXR pericardial calcification Signs - KUSSMAUL SIGN (differentiates from cardiac tamponade)

Answer 48

Broccoli, spinach, kale and sprouts are all high in vitamin K so should be avoided in excess by patients taking warfarin.

Answer 49

class III antiarrhythmic agent used in the treatment of atrial, nodal and ventricular tachycardias. The main mechanism of action is by blocking potassium channels which inhibits repolarisation and hence prolongs the action potential. Amiodarone also has other actions such as blocking sodium channels (a class I effect) Monitoring of patients taking amiodarone TFT, LFT, U&E, CXR prior to treatment TFT, LFT every 6 months Factors that limit use very long half-life (20-100 days). For this reason, loading doses are frequently used should ideally be given into central veins (causes thrombophlebitis) has proarrhythmic effects due to lengthening of the QT interval interacts with drugs commonly used concurrently (p450 inhibitor) e.g. Decreases metabolism of warfarin numerous long-term adverse effects (see below)

Answer 50

50% of upper limb emboli will lodge in the brachial artery 30% of upper limb emboli will lodge in the axillary artery Symptoms Sudden onset of symptoms; pain, pallor, paresis, pulselessness, paraesthesia Cause Sources are left atrium with cardiac arrhythmia (mainly AF), mural thrombus Cardiac arrhythmias may cause result in impaired consciousness in addition to the embolus

Answer 51

0.2-0.4% incidence Consist of an anomalous fibrous band that often originates from C7 and may arc towards, but rarely reaches the sternum Congenital cases may present around the third decade, some cases are reported to occur following trauma Bilateral in up to 70% Symptoms Compression of the subclavian artery may produce absent radial pulse on clinical examination and in particular may result in a positive Adsons test (lateral flexion of the neck away from symptomatic side and traction of the symptomatic arm- leads to obliteration of radial pulse) Treatment is most commonly undertaken when there is evidence of neurovascular compromise. A transaxillary approach is the traditional operative method for excision

Answer 52

1) Fixed pupils which do not respond to sharp changes in the intensity of incident light 2) No corneal reflex 3) Absent oculo-vestibular reflexes - no eye movements following the slow injection of at least 50ml of ice-cold water into each ear in turn (the caloric test) 4) No response to supraorbital pressure 5) No cough reflex to bronchial stimulation or gagging response to pharyngeal stimulation 6) No observed respiratory effort in response to disconnection of the ventilator for long enough (typically 5 minutes) to ensure elevation of the arterial partial pressure of carbon dioxide to at least 6.0 kPa (6.5 kPa in patients with chronic carbon dioxide retention). Adequate oxygenation is ensured by pre-oxygenation and diffusion oxygenation during the disconnection (so the brain stem respiratory centre is not challenged by the ultimate, anoxic, drive stimulus) The test should be undertaken by two appropriately experienced doctors on two separate occasions. Both should be experienced in performing brain stem death testing and have at least 5 years post graduate experience. One of them must be a consultant. Neither can be a member of the transplant team (if organ donation contemplated).

Cardiology Flashcards

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