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3b/4 > cardiology > Flashcards

cardiology Flashcards

1
Q

how does GTN spray relieve symptoms of angina?

A

Vasodilates

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2
Q

How should patients be advised to use their GTN spray?

A

Take spray, rest, wait 5 mins, take again if still have sx, then if not relieved sx after a second 5 mins, call 999

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3
Q

which vein commonly used in CABG?

A

Great saphenous vein (leg)
also used for venous cutdown.
anterior to med malleolus

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4
Q

what makes up a thrombus in a fast flowing artery (ACS)?

A

Platelets

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5
Q

What does the LCA become?

A

Circumflex artery

LADA

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6
Q

What does RCA supply?

A

RA
RV
Inferior LV
Posterior septal area

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7
Q

what does circumflex artery supply?

A

LA

post LV

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8
Q

what does LADA supply?

A

Ant LV

Ant septum

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9
Q

ACS - 3 conditions?

A

Unstable angina
STEMI
NSTEMI

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10
Q

How are the 3 ACS differentiated?

A

ECG -
if ST elevation/new LBBB - STEMI
if no ST elevation - trop levels, other ecg changes

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11
Q

How does ACS present?

A

cardiac sounding chest pain
non-pleuritic
non-positional
non-tender

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12
Q

How is NSTEMI identified?

A

Raised troponin levels

ST depression, T wave inversion, pathological Q waves

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13
Q

If troponins normal, and ECG normal - dx?

A

unstable angina

MSK chest pain

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14
Q

cardiac chest pain?

A 
central
constricting/crushing
ass with n/v, sweating, clamminess
SOB
feeling impending doom
palpitations,
radiates to jaw/left arm - numbness
continues at rest >20mins
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15
Q

which patients may experience a silent MI?

A

DM

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16
Q

where is ST elevation seen in STEMI?

A

in leads corresponding with particular area of heart

new LBBB

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17
Q

What indicates a late presentation of ACS?

A

path Q waves

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18
Q

anteriolateral area of heart (front/L side of heart) - which artery?

A

LCA

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19
Q

which leads affected in anteriolateral area infarct?

A

1
AVL
V3-6

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20
Q

which artery affected in anterior (front) area of heart

A

LADA

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21
Q

which leads affected in anterior area infarct?

A

V1-4

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22
Q

Which artery supplies the lateral aspect of heart? (Left side)

A

circumflex artery

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23
Q

which leads affected in lateral aspect infarct?

A

1
AVL
V5-6

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24
Q

Inferior aspect of heart - which artery?

A

RCA

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25
Q

which leads affected in inferior aspect infarct?

A

2
3
AVF

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26
Q

What are troponins?

A

proteins found in cardiac muscle

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27
Q

when would you measure troponins?

A

baseline
6 hours
12 hours
after onset of sx

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28
Q

What does raised troponins indicate and why?

A

myocardial ischemia - the troponins are released from the ischemic muscle in the heart

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29
Q

Other causes of raised trops (non-spec):

A 
chronic RF
sepsis - cap
myocarditis
aortic dissection 
PE
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30
Q

Other cardiac ix for ACS:

A 
Ex
BMI
ECG
FBC - anaemia
U/E - ACEi
LFT - statin
Lipid profile
TFT
HbA1c
\+
CXR - other causes (pneumonia), also oedema - HF
ECHO - functional damage
CT coronary angiogram
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31
Q

Acute STEMI treatment:

A

<2 hours presentation - primary PCI (‘cath’) / CABG

Thrombolysis if not

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32
Q

which arteries is catheter fed into in PCI?

A

Brachial or femoral

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33
Q

Thrombolysis - what kind of medication?

A

fibrinolytic agent - breaks down fibrin

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34
Q

risk of what in thrombolysis?

A

bleeding

can’t use if had a recent stroke

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35
Q

examples of thrombolytic agents? (TPA)

A

streptokinase
alteplase
tenecteplase

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36
Q

Acute NSTEMI tx:

A

BBs
Aspirin 300mg stat
Ticagrelor 180mg stat (alt clopidogrel 300mg)
Morphine titrated for pain (ony if SEVERE)
Anticoagulant - LMWH (eg enoxaparin BD for 8/7)
Nitrates - GTN to relieve CA spasm

O2 only if drop sats

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37
Q

what is the GRACE score used for?

A

to decide if PCI in NSTEMI

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38
Q

what does Grace score measure?

A

6 month risk of death/repeat MI following NSTEMI

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39
Q

how is grace score graded?

A

low risk <5%
med risk 5-10
high risk >10%

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40
Q

Who gets early PCI <4 days based on grace score?

A

medium and high risk patient

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41
Q

Cx of MI:

A 
Death
Rupture of septum or papillary muscles
Edema - HF onset
Arrhythmia/aneurysm 
Dressler's syndrome
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42
Q

What is Dressler’s Syndrome?

A

post MI syndrome
2-3 weeks post MI
due to localised immune response
pericarditis

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43
Q

Dressler’s syndrome presentation:

A

pleuritic chest pain
low grade fever
pericardial rub on auscultation

can cause pericardial effusion/tamponade

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44
Q

How is Dressler’s syndrome diagnosed?

A

ECG - GLOBAL ST elevation, T wave inversion (SADDLE ST) (also referred to as concave st)
ECHO - pericardial effision
raised inflamm markers - ESR, CRP

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45
Q

Mx: Dressler’s syndrome:

A

NDAIDs (aspirin/ibuprofen)
steroids if severe (pred)
pericardiocentesis if tamponade

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46
Q

Secondary prevention of MI:

A

6As
Aspirin 75mg OD
Another AP - clopidogrel 3/12, ticagrelor 12/12 (P2Y12)
Atorvastatin 80mg OD
ACEi
Atenolol/BB
Aldosterone antagonist - if clinical evidence of HF (eplerenone)

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47
Q

Secondary prevention lifestyle advice:

A 
stop smoking
reduce alcohol
healthy med diet
cardiac rehab - specific exercises for MI 
optimise other meds - DM, HTN
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48
Q

Types of MI: 1-4

A

1 - traditional due to ACS
2 - ischemia secondary due to decreased supply of 02 to heart (anaemia, tachy, Hypotension)
3 - sudden cardiac death/arrest suggestive of ischemic event
4 - MI ass with PCI/stunt/CABG

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49
Q

LV failure definition: (pathophys)

A

LV unable to adequately move blood through the left side of the heart and out into the body
causes a backlog of blood behind LV - LA/PVs, lungs
Vessels become engorged - increased vol and P - leak fluid - oedema
Leads to SOB, 02 desats

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50
Q

Triggers for LVF:

A

Iatrogenic - IV fluids in elderly patients with already impaired LV function
Sepsis
MI
Arrhythmias

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51
Q

Presentation acute LVF:

A

Acute SOB - worse by lying flat, better sitting up
T1RF - low sats, w/o hypercapnia
look/feel unwell
cough up frothy pink/white sputum

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52
Q

Examination LVF:

A 
Increased RR
Decreased sats
tachycardia 
3rd heart sound
apex beat moves down/laterally
bilat basal crackles - wet crackling 
if severe - hypotension - cardiogenic shock
abdo pain, weight gain
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53
Q

signs of RHF:

A 
Raised JVP (jugular venous distension) - backlog on RH
peripheral oedema (ankles, legs, sacral)
hepatosplenomegaly 
congestive hepatopathy 
dyspnoea OE
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54
Q

Ix of acute LVF:

A 
hx/ex
ECG - ischemia - ACS/arrhythmias (AF)
ABG - RF? 
CXR
bloods - inf, renal function, BNP, trops
ECHO - function
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55
Q

what is BNP?

A

Hormone released from the ventricles when cardiac muscle is stretched beyond normal range

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56
Q

High BNP?

A

heart overloaded beyond its ability to pump effectively

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57
Q

Normal action of BNP?

A

to relax the smooth muscle in BVs
reduces systemic vascular resistance
acts on kidneys as diuretic

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58
Q

BNP - sens/spec??

A

Sensitive, not specific

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59
Q

other causes of high BNP?

A 
tachycardia
sepsis 
PE
renal impairment
COPD
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60
Q

how will echo inform LVF dx?

A

Echo assesses function of ventricles, anatomical abnormalities
measures ejection fraction (>50% normal)
pulmonary artery pressure
diastolic function

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61
Q

what is an ejection fraction?

A

the percentage of blood in the LV squeezed out with each ventricular contraction

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62
Q

CXR acute LVF:

A 
Cardiomegaly (>0.5 ratio)
Upper lobe venous diversion 
bilat pleural effusions
fluid in interlobar fissures
fluid in septal lines - Kerley B lines
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63
Q

Mx Acute LVF:

A 
Poor sod
Pour away IV fluids
Sit patient up 
Oxygen if sats <95%
Diuretics - furosemide 40mg stat
also LMNOP
Lasix / furosemide
Morphine (venodilators)
Nitrates (venodilator)
O2
Position
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64
Q

2 loop diuretic examples:

A

furosemide

bumetinide

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65
Q

other management options if severe pulmonary oedema/cardiogenic shock: (HF)

A

IV opiates - morphine vasodilates
CPAP
Inotropes - NAd
ICU/HDU

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66
Q

causes of chronic heart failure:

A

impaired LV contraction - systolic
impaired LV relaxation - diastolic
both lead to chronic backlog of blood trying to flow through the L side of heart (increase pressure LA, PVs, lungs)

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67
Q

presentation chronic HF:

A 
breathlessness worse on exertion 
cough - frothy pink white sputum 
orthopnoea 
paroxysmal nocturnal dyspnoea 
peripheral oedema
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68
Q

orthopnoea?

A

worsening SOB on lying flat - how many pillows?

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69
Q

PND?

A

patients experience sudden waking in night with acute SOB, cough, wheeze, suffocating sensation
Open window- fresh air. sx improve over mins

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70
Q

Diagnosis chronic HF?

A

hx/ex - bibasal crackles, periph oedema
NTproBNP
ECHO
ECG

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71
Q

causes of chr HF?

A

Ischemic HD
Valvular HD - AS
HTN
arrhythmias - af

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72
Q

Mx Chr HF?

A
  1. BNP
  2. Refer to cardiology (urgently if BNP>2000ng/L)
  3. Medical mx
  4. surgical mx (AS/MR)
  5. HF specialist nurse
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73
Q

additional chr HF mx:

A 
yearly flu jab
stop smoking advice
fluid restrict, salt load down (<2L, <2g)
optimise tx of comorbidities
exercise as tolerated
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74
Q

medical chr HF mx:

A 
ABAL
ACEi (ramipril up to 10mg OD) 
BB (bisoprolol up to 10mg)
Aldosterone antag (spironolactone, eplerenone) 
Loop diuretics (furosemide, bumetinide)
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75
Q

If can’t tolerate ACEi in chr HF mx:

A

use ARB (candesartan up to 32mg OD)

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76
Q

which type of HF patients should ACEis be avoided in?

A

valvular HD until specialist has seen them

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77
Q

what needs measuring when pts on ACEis, loop diuretics, aldosterone antagonists?

A

U/Es

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78
Q

what is cor pulmonale?

A

RHF caused by respiratory disease
increased pressure and resistance in PAs - PHTN -> RV insufficiency -> back pressure blood RA, vena cava, systemic circulation

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79
Q

respiratory causes of cor pulmonale?

A 
copd
PE
interstitial lung disease
CF
primary pulm HTN
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80
Q

presentation of cor pulmonale?

A 
early - asymptomatic 
SOB 
peripheral oedema 
syncope
chest pain
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81
Q

signs of cor pulmonale?

A 
hypoxia
cyanosis
raised JVP
peripheral oedema 
3rd HS
murmur - tricuspid regurgitation - pansystolic murmur
hepatomegaly (pulsatile if TR)
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82
Q

Mx cor pulmonale:

A

underlying cause

LTOT

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83
Q

Hypertension NICE 2019: dx:

A

140/90 clinic

135/85 home readings

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84
Q

causes of HTN:

A

essential 95% - primary

secondary causes 5%

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85
Q

secondary causes HTN: ROPE

A

Renal disease (Renal artery stenosis)
Obesity
Pregnancy (preeclampsia)
Endocrine (hyperaldosteronism - Conn’s syndrome)

conns is commonest cause of secondary htn

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86
Q

Ix: Conn’s syndrome:

A

renin:aldosterone ratio blood test

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87
Q

HTN cx:

A 
IHD
Cerebrovascular accident
retinopathy
nephropathy 
HF
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88
Q

stages of HTN:

A

1 - >140/90
2- >160/100
3 - >180/120

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89
Q

end organ damage: investigations for those newly dx with HTN:

A 
urine albumin:creatinine ratio (proteinuria)
dipstick - microscopic haematuria 
Bloods - HbA1c, renal, lipid levels 
fundus ex
ECG
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90
Q

HTN medications:

A

ACEis (ramipril)
BBs (bisoprolol)
CCBs (amlodipine)
Diuretics (indapamide) - thiazide-like

ARBs (candesartan) - if African/ACEi CI

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91
Q

lifestyle advice for HTN:

A 
healthy diet
stop smoking
reducing alcohol, caffeine
reduce salt
regular exercise
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92
Q

who gets offered medical mx of HTN (stage related)

A
  • stage 2 or higher

- stage 1 if under 80 with QRisk >10%, DM, CKD, CVD, end organ damage

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93
Q

if age <55 and white, what HTN first line drugs:

also T2DM pts

A

ACEi

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94
Q

if age >55 or black, what HTN first line drug:

A

CCB

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95
Q

step 2 of HTN mx:

A

ACE+CCB, if black ARB+CCB

or A+D or C+D

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96
Q

step 3 of HTN mx:

A

A+C+D

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97
Q

step 4 HTN mx:

A

If serum K<4.5mmol/L - K sparing diuretic - spironolactone
if serum K>4.5mmol/L - alpha blocker (doxazosin)
or BB (atenolol)
refer

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98
Q

how does spironolactone work:

A

K sparing diuretic

Aldosterone antagonist - blocks aldosterone in kidneys->Na excretion, K reabsorption

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99
Q

HTN treatment targets:

A

<140/90

if >80yo <150/90

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100
Q

what is the first heart sound:

A

closing of AV valves at the start of the systolic contraction of ventricles

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101
Q

what is the second heart sound:

A

closing of the semilunar valves at the end of systolic contraction

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102
Q

when is the third hs heard?

A

0.1 seconds after the second heart sound

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103
Q

what causes the third hs?

A

rapid ventricular filling leading to the chordae tendineaa to pull to their full length and twang like a guitar string

can be normal in 15-40yos (healthy) as the ventricles easily allow rapid filling

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104
Q

what is cause of third hs in pathology?

A

elderly - HF - ventricles and chordae stiff and weak and reach their limit much faster
(“galloping s3”)

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105
Q

when is 4th hs heard?

A

right before s1

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106
Q

is hs4 ever normal?

A

no

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107
Q

what does s4 indicate?

A

stiff or hypertrophic ventricle and caused by turbulent flow from atria contracting against a non-compliant ventricle

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108
Q

which part of stethoscope used to listen to low pitched sounds?

A

bell

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109
Q

which part of stethoscope used to listen to high pitched sounds?

A

diaphragm

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110
Q

where do you listen for pulmonary valve?

A

2nd ICS left sternal border

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111
Q

where do you listen for aortic valve?

A

2nd ICS right sternal border

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112
Q

where do you listen for tricuspid valve?

A

5th ICS left sternal border

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113
Q

where do you listen for mitral valve?

A

5th ICS midclavicular line (apex area)

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114
Q

where is Erb’s point?

A

3rd ICS Left sternal border - best place to listen to S1 and S2

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115
Q

how do you manouvre patient to listen for mitral stenosis?

A

left side

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116
Q

how do you manouvre patient to listen to aortic regurgitation?

A

sat up, leaning forwards, holding exhalation

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117
Q

assessing a murmur: SCRIPT

A

Site - where heard loudest
Character - soft, blowing, cresc, decresc
Radiation - heard over carotids (AS) or left axilla (MR)
Intensity - grade
Pitch - indicates velocity
Timing - systolic, diastolic

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118
Q

murmur grade:

A

1 difficult to hear s1,2> murmur
2 quiet s1,2=murmur
3 easy to hear s1,2
6 - can hear off chest

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119
Q

what does mitral stenosis cause in the muscle?

A

LA hypertrophy

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120
Q

what does aortic stenosis cause in the muscle?

A

LV hypertrophy

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121
Q

what does mitral regurgitation cause in the muscle?

A

LA dilation

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122
Q

what does aortic regurgitation cause in the muscle?

A

LV dilatation

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123
Q

what causes mitral stenosis?

A

Rh disease

Infective endocarditis`

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124
Q

mid-diastolic low pitched murmur? (rumbling)

with opening snap

A

mitral stenosis

lub drrrrrrrrr

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125
Q

which valvular condition is associated with malar flush and AF? also tapping apex beat?

A

mitral stenosis

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126
Q

what can mitral regurgitation cause long term?

A

congestive cardiac failure

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127
Q

pan-systolic high pitched whistling/blowing murmur?

(holo-systolic). louder on expiration

A

mitral regurgitation

brrrrrrrrr throughout systole

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128
Q

causes of mitral regurgitation?

A 
idiopathic weakening of valve with age
ischemic heart disease
infective endocarditis 
rheumatic heart disease
CT disorders: Ehlers Danlos/Marfan
(Infection or infarction)
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129
Q

commonest valve disease?

A

Aortic stenosis

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130
Q

ejection-systolic high pitched, crescendo-decrescendo murmur? (louder on expiration)

A

Aortic stenosis

brrrr dub

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131
Q

which murmur radiates to carotids, has slow rising pulse and narrow pulse pressure, also has reporting of exertional sycope ?

A

Aortic stenosis

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132
Q

causes of Aortic stenosis?

A

atherosclerosis
idiopathic age related calcification
rheumatic heart disease
if <65 - bicuspid valve

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133
Q

early diastolic, soft murmur?

rumbling

A

aortic regurgitation

lub tarrrr

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134
Q

which murmur is associated with Corrigan’s pulse?

A

Aortic regurgitation

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135
Q

What is Corrigan’s pulse?

A

collapsing pulse
rapidly appearing and disappearing pulse at carotids
also brachial, femoral weak pulses

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136
Q

what does aortic regurgitation often lead to?

A

heart failure due to backlog of pressure in LV

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137
Q

What is an Austin-Flint murmur?

A

caused by Aortic regurgitation,
heard at apex, early diastolic rumbling - blood flowing through the aortic valve and over the mitral valve, causing it to vibrate

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138
Q

causes of aortic regurgitation?

A

idiopathic age related weakness
CT disorders - Ehlers Danlos/Marfan
infection or infarction
aortic dissection

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139
Q

what does midline sternotomy scar indicate?

A

mitral or aortic valve replacement or CABG

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140
Q

lateral right sided thoracotomy scar from?

A

mitral valve replacement

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141
Q

where do porcine bioprosthetic heart valves come from?

A

pigs

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142
Q

how long do bioprosthetic heart valves last?

A

10 years

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143
Q

how long do mechanical heart valves last and what do patients need to take?

A

> 20 years, lifelong anticoagulation - warfarin

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144
Q

what is the INR range for warfarin patients due to mechanical heart valves?

A

2.5-3.5

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145
Q

name 3 types of mechanical heart valve:

A

starr-Edwards
tilting disc
st jude

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146
Q

what is a problem with starr edward valves?

A

high thrombus formation risk

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147
Q

mechanical heart valves (3) major complications:

A

thrombus formation
infective endocarditis
haemolysis->anaemia

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148
Q

click replaces S1 for?

A

metallic mitral valve

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149
Q

click replaces S2 for?

A

metallic aortic valve

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150
Q

what does TAVI stand for?

A

Transcatheter Aortic Valve Implantation

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151
Q

who may have a TAVI?

A

high risk severe aortic stenosis patients, who can’t have open heart surgery

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152
Q

what type of valve is implanted in a TAVI?

A

bioprosthetic

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153
Q

which 3 organisms are most likely responsible for infective endocarditis?

A

staphylococcus (IVDU)
Streptococcus
Enterococcus

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154
Q

describe the pathophysiology of AF?

A

disorganised electrical activity overrides the normal activity from the SAN
contraction of atria is rapid, irregular and uncoordinated
-> irregular conduction of ventricles leading to irregularly irregular contractions, tachy, HF, stroke

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155
Q

ecg findings AF:

A

absence of p-waves
narrow QRS tachy
irregularly irregular ventricular rhythm

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156
Q

why is there a risk of stroke in AF?

A

tendency for blood to collect in LA and clot -> emboli which travel through LV, aorta, carotids, to brain, block cerebral arteries causing ischemic stroke

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157
Q

symptoms of AF:

A

asymptomatic
palpitations
SOB
Syncope

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158
Q

ddx for irregularly irregular pulse? (2)

A

AF

Ventricular ectopics

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159
Q

what is valvular AF?

A

AF in those who have a mod/severe mitral stenosis/mechanical heart valve
assumed that valvular pathology lead to AF

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160
Q

AF without valve pathology or with other valve pathology such as mitral regurgitation or aortic stenosis is classed as?

A

non-valvular AF

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161
Q

commonest causes of AF? Mrs Smith

A 
Sepsis
Mitral valve pathology
IHD
Thyrotoxicosis
HTN
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162
Q

2 principles to treating AF:

A

rate control OR rhythm control

anticoagulation

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163
Q

why does rhythm control help AF patients?

A

allows ventricles more time to fill during diastole, maintaining a cardiac output

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164
Q

4 instances where rate control is NOT first line in AF tx?

A

There is reversible cause for their AF
Their AF is of new onset (within the last 48 hours)
Their AF is causing heart failure
They remain symptomatic despite being effectively rate controlled
younger than 65

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165
Q

rate control drugs (AF) 3:

A
  1. BBs (atenolol 50-100mg OD)
  2. CCBs (diltiazem - not in HF)
  3. Digoxin
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166
Q

what is offered to those AF patients unsuited to rate control drugs?

A

rhythm control drugs

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167
Q

2 ways of achieving rhythm control?

A

cardioversion

long term medical rhythm control

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168
Q

who is suitable for immediate cardioversion?

A

AF has been present for less than 48 hours or they are severely haemodynamically unstable.

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169
Q

what should happen to patient in delayed cardioversion (meds given as prep):

A

anticoagulated 3 weeks prior

rate control while waiting

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170
Q

2 options for cardioversion? (+egs)

AF

A 
electrical cardioversion (GA+defib)
chemical cardioversion (pharmacological)
- flecanide
-amiodarone (if structural heart disease)
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171
Q

long term medical rhythm control drugs (3):

A

BBs first line
dronedarone (maintaining cardioversion)
amiodarone (HF)

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172
Q

define paroxysmal AF:

A

where the AF comes and goes, usually episodes NOT lasting >48hrs

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173
Q

management of paroxysmal AF:

A

anticoagulated (based on chadsvasc)

pill in pocket approach

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174
Q

what is a pill in the pocket approach to paroxysmal AF management?

A

use of flecanide when patients experience AF sx, with no underlying structural heart disease

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175
Q

when should flecanide be avovided

A

atrial flutter -> extreme tachy

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176
Q

where does blood often stagnate in AF?

A

atrial appendage

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177
Q

risk of stroke in AF if no anticoagulation?

A

5%

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178
Q

risk of stroke with anticoagulation meds in AF?

A

1-2%

2/3 lower than if not anticoagulated

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179
Q

risk of anticoagulation meds ? (risk per year)

A

risk of serious bleed ( haemorrhage )

3% year

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180
Q

how is a patients bleeding risk on anticoagulation drugs measured?

A

HASBLED score

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181
Q

what type of drug is warfarin?

how does it act?

A

vitamin K antagonist
vitK is essential for clotting factors
prolongs prothrombin time

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182
Q

what is INR a measure of?

A

how anticoagulated someone is by warfarin
compares prothrombin time of warfarin patient with that of a healthy adult
1 is normal/ 2 indicates it takes double the time for blood to clot

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183
Q

target INR range for warfarin patients?

A

2-3

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184
Q

which system in the liver affects warfarin?

A

cytochrome p450 system

affected by antibiotics

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185
Q

dietary advice to warfarin patients?

A 
leafy greens (high vit K)
cranberry juice, alcohol (affect cp450)
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186
Q

what is the half life of warfarin and what can be used as an antidote?

A

1-3 days

vit K

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187
Q

what does DOAC stand for?

A

Direct Oral Anticoagulant

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188
Q

what is the half life of DOAC and what is the risk with doacs?

A 
7-15 hours
no antidote (but lower risk of bleeding overall)
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189
Q

name 4 advantages of DOACs over warfarin?

A

No monitoring is required
No major interaction problems
Equal or slightly better than warfarin at preventing strokes in AF
Equal or slightly less risk of bleeding than warfarin

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190
Q

what does chads2vasc measure?

A

whether an AF patient should be started on anticoagulation

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191
Q

what is no longer recommended for lowering stroke risk in AF?

A

aspirin

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192
Q

what chadsvasc score should consider/give anticoagulation?

A

1 - consider

2+ give

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193
Q

what does chads2vasc mnemonic stand for?

A 
CCF
HTN
Age >75 (scores 2)
DM
Stroke/TIA prev (scores 2)
Vascular disease
Age (65-75)
Sex (female)
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194
Q

what does hasabled assess?

A

risk of someone having a bleed/stroke while on anticoagulation medication

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195
Q

what does HASBLED mnemonic?

A 
HTN
Abnormal renal/liver function 
Stroke
Bleeding
Labile INRs 
Elderly
Drugs/alcohol
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196
Q

name the 4 cardiac arrest rhythms?

A

ventricular tachycardia
ventricular fibrilation
pulseless electrical activity
asystole

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197
Q

which 2 cardiac arrest rhythms are shockable?

A

ventricular tachy

v fib

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198
Q

if unstable tachycardia, how do you manage?

A

up to 3 synchronised shocks
amiodarone infusion every 3 shocks
adrenaline 3-5mins 1mg

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199
Q

in a stable patient, what are the 3 possible arrhythmias causing narrow complex (<0.12s) tachycardia?

A

AF
Atrial flutter
Supraventricular tachycardia

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200
Q

how do you treat atrial flutter?

A

BB rate control
tx underlying
radiofrequency ablation of re-entry rhythm
anticoag

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201
Q

how do you treat SVT?

A

vagal manouvres and adenosine
(Valsava, carotid sinus massage)
cardioversion if BP <90

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202
Q

in a stable patient, what are the 3 possible arrhythmias causing broad complex tachycardia?

A

ventricular tachycardia
SVT with BBB
AF variation

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203
Q

how do you treat ventricular tachy>

A

amiodarone infusion 300mg

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204
Q

what causes atrial flutter?

pathophys

A

re-entry rhythm in either atria
aka re-entry loop
stimulates atrial contraction at 300bpm
signal makes its way to ventricles every second lap -> 150bpm ventricular contraction

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205
Q

sawtooth appearance on ecg with p wave after p wave?

A

atrial flutter

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206
Q

conditions associated with atrial flutter (4):

A

HTN
ischemia
cadiomyopathy
thyrotoxicosis

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207
Q

what causes SVT (pathphys)?

A

re-entry rhythm from ventricles to atria
self-perpetuating electrical loop
results in NARROW QRS

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208
Q

3 main types of SVT:

A

AV nodal re-entrant tachycardia
AV re-entrant tachycardia
Atrial tachycardia

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209
Q

how does adenosine work?

A

slowing cardiac conduction primarily through the AV node, interrupting the AVN/accessory pathway during SVT and resets to sinus rhythm
half life 8-10 seconds

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210
Q

which conditions should adenosine be avoided in?

A 
asthma 
copd
HF
heart block 
severe hypotension
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211
Q

what causes Wolff-Parkinson White syndrome?

A

extra electrical pathway connecting the atria and ventricles, normally there is only one pathway - the AVN.
the extra pathway is called the bundle of kent

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212
Q

what is the bundle of kent?

A

extra electrical pathway connecting the atria and ventricles in WPW syndrome

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213
Q

definitive treatment for Wolff-Parkinson White syndrome ?

A

radiofrequency ablation of the accessory pathway

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214
Q

ecg changes in WPW syndrome?

A

short PR intervals
wide QRS
Delta wave
axis deviation depending on which accessory pathway (L/R)

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215
Q

what is torsades de pointes and what does it mean?

A

polymorphic ventricular tachycardia

means twisting of the tips

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216
Q

torsades de pointes ecg changes:

A

normal ventricular tachy
QRS twisted around the baseline
height of QRS get progressively smaller then larger then smaller…
prolonged QT interval

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217
Q

where are afterdepolarisations found?

A

torsades de pointes

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218
Q

what is the prognosis for torsades de pointes?

A

either spontaneously revert back to sinus or progress to VT (and maybe cardiac arrest)

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219
Q

causes of prolonged QT: from start of Q to end of T!

A

Long QT syndrome (inherited)
iatrogenic (APs, ADs, flecanide, sotalol, macrolides)
electrolyte disturbance (hypokalaemia, hypomagnesia, hypocalcaemia)

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220
Q

acute mx of torsades de pointes?

A

correct the cause - meds or electrolytes (macrolides - clari)
magnesium infusion
defib if VT

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221
Q

long term mx of torsades de pointes?

A

BBs

pacemaker

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222
Q

ECG changes for ventricular ectopics?

A

individual, random, abnormal broad QRS complexes on otherwise normal ECG

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223
Q

what is bigeminy?

A

ventricular ectopics are happening so commonly that they occur after every sinus beat

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224
Q

mx of bigeminy?

A

check bloods for anaemia, electrolyte disturbance, thyroid abnormalities

225
Q

what is heart block generally referring to ?

A

AV node block

226
Q

what is first degree heart block?

A

delayed AV conduction through AVN
every atrial impulse leads to a ventricular contraction
every p -> QRS
PRI>0.2s

227
Q

what is second degree heart block?

A

some atrial impulses do not reach the ventricles
not all p -> QRS
several patterns of 2nd degree HB

228
Q

what is Wenckebach’s phenomenon (Mobitz Type 1) HB? (description)

A

atrial impulses become gradually weaker until they don’t pass through the AVN
after failing to stimulate a ventricular contraction, the atrial impulse returns to being strong and cycle repeats

229
Q

ECG changes Wenckebach’s phenomenon (Mobitz Type 1)?

A

increasing PRI until absent QRS, cycle

230
Q

what is Mobitz type 2 HB? (description)

A

intermittent failure of AV conduction
results in absent QRS complexes, set ratio of p:QRS (eg 3:1 block)
PRI normal

231
Q

what happens to PRI in Mobitz type 2 HB? what is there a risk of in this condition?

A

normal pri

risk of asystole

232
Q

what causes 2:1 block?

A

either mobitz 1 or 2, hard to tell which

2 p waves to each QRS

233
Q

3rd degree HB (description and ECG changes)

A

complete HB
no observable relationship between p and QRS
significant risk of asystole

234
Q

treatment for stable bradycardia / AV blocks?

A

observe

235
Q

tx for unstable bradycardia / AV blocks (risk of asystole in Mobitz type 2/ 3rd degree)?

A
  1. atropine 500mcg stat IV up to 6 doses
  2. other inotropes (NAd)
  3. transcutaneous cardiac pacing (using defib)
236
Q

tx for high risk of asystole (M2/3rd):

A

temporary transvenous cardiac pacing

permanent implantable pacemaker when available

237
Q

how does atropine work?

A

antimuscarinic - inhibits parasympathetic NS

238
Q

sfx atropine:

A

dilated pupils,
urinary retention,
dry eyes,
constipation

239
Q

how do pacemakers work?

A

deliver controlled electrical impulses to specific areas of the heart to restore normal rhythm and improve heart function
consist of pulse generator, pacing leads

240
Q

where are pacemakers commonly implanted?

A

Left anterior chest wall/axilla

241
Q

how long do pacemaker batteries last?

A

5 years

242
Q

what can pacemakers be a contraindication for having:

A

MRI
TENS machines,
diathermy in surgery

243
Q

indications for pacemaker (5):

A

Symptomatic bradycardias
Mobitz Type 2 AV block
Third degree heart block
Severe heart failure (biventricular pacemakers)
Hypertrophic obstructive cardiomyopathy (ICDs)

244
Q

where are single chamber pacemakers implanted (2 options):

A

RA

RV

245
Q

where are dual chamber pacemakers implanted?

A

RA+RV

246
Q

where are biventricular pacemakers inserted?

A

triple chamber/cardiac resynchronisation pacemakers

RA, RV, LV

247
Q

what continually monitor the heart and apply a defibrillator shock to cardiovert the patient back in to sinus rhythm if they identify a shockable arrhythmia.?

A

implantable cardioverter defibrilator

248
Q

ECG changes in single chamber pacemaker?

A

line before each p/QRS in all leads

249
Q

ECG changes in dual chamber pacemaker?

A

line before each p and QRS in all leads

250
Q

which coronary artery disease is described as ‘supply ischemia’

A

STEMI

251
Q

which coronary artery diseases are described as ‘demand ischemia’?

A

stable angina
unstable angina
NSTEMI

252
Q

diamond classification for chest pain from HPI (3):

A
  1. left sided
  2. worse OE/relieved with rest
  3. relieved by nitroglycerin
253
Q

if 3/3 diamond classification for chest pain from HPI: dx:

A

typical angina

254
Q

if 2/3 diamond class HPI chest pain dx:

A

atypical angina

255
Q

0/1 out of 3 of diamond classification for chest pain:

A

non-anginal chest pain

256
Q

if assessing someone on ward who already had NSTEMI and ?another one, why can’t you use troponins and what can you use instead?

A

Can’t use troponins as they peak first during first MI, then stay elevated, so won’t be sensitive to second MI
Instead can check CPK-MB (creatine kinase myocardial band)

257
Q

patient presents with cardiac sounding chest pain, normal ECG normal troponins, what is next in management pathway?

A

? unstable angina -> need PCI ‘cath’ anyway

is this cardiac coronary artery ischemia at all? - rule this out with cardiac stress test.

258
Q

if stress test positive, what is the management?

A

f/u with cardiologist, will need PCI elective

259
Q

how do you carry out stress test?

A

exercise or pharmacological
(exercise if they can exercise)
pharm - adenosine, dobutamine

260
Q

how do you evaluate in cardiac stress test?

A

ECG (when baseline ECG normal)
ECHO (when baseline not normal)
MRI (when prev CABG/HF)

261
Q

what are ECHO and MRI looking for during stress test?

A

dead tissue (doesn’t move) - scar tissue
at risk tissue (at rest and under stress - STUNNING)
AREA OF REVERSIBILITY
healthy tissue

262
Q

what does angiography determine?

A

PCI (stent/balloon) - angioplasty

or CABG - if 3+ vessels involved

263
Q

general medical management of ACS: (MONA BASH C)

*all

A 
Morphine (worse prog if needed. SEVERE ONLY)
O2 (during initial ex, nasal canula) 
Nitrates (if angina persists)
Aspirin* 
BB*
ACEi*
Statin*
Heparin (therapeutic dose)
Clopidogrel (if post stent or high risk STEMI)
264
Q

when in a rural setting, and cardiologist who can do PCI is far away, what do you give before transfer?

A

TPA if >60 mins away

BUT! The time from MI onset to PCI <2hours

265
Q

if person is having a right sided STEMI (2,3,avf) - what tx don’t they get and why?

A

nitrates - right ventricle is pre-load dependent

266
Q

investigations to diagnose heart failure: (3)

A

BNP
ECHO
Angiogram - ischemic or non-ischemic?

267
Q

What is heart failure with preserved ejection fraction?

A

2 types of HF - systolic, diastolic
Diastolic the ventricle is thick, has trouble relaxing, ejection fraction normal or increased, but can’t relax to fill so well

268
Q

classification of heart failure? how many classes?

A

New York Heart Association Classification
4
1 - asx
4 SOB rest

269
Q

Heart failure step wise mx based on NYHACHF:

A
  1. BB and ACEi (or ARB)
  2. Loop diuretic (furosemide)
  3. Isosorbide dinitrate / spironalactone (to adddress pre load and afterload) / digoxin
  4. Inotropes
270
Q

if HF, and have an ejection fraction <35% and not class 4, what is mx->

A

implantable cardiac defibrilator

271
Q

if ejection fraction <30%, LBBB, mx:>

A

CRT with biventricular pacemaker

272
Q

if ischemic cause of heart failure, in addition to other tx, what do they need:

A

aspirin, statin

273
Q

how to investigate a murmur and which murmurs to ix?

A

ECHO
systolic g3+
any diastolic

274
Q

how will Mitral stenosis present?

A

younger patients
CHF sx - dyspnoea OE, PND, crackles
A Fib

275
Q

what treatment for Mitral stenosis?

A

balloon valvuloplasty

276
Q

how will aortic regurgitation present?

A

acute - cardiogenic shock, flash pulmonary oedema

chronic - CHF, chest pain

277
Q

tearing chest pain - classical dx?

A

aortic dissection

278
Q

treatment for aortic regurgitation?

A 
acute - urgent
chronic - urgent/elective 
REPLACEMENT 
before onset of angina/HF
remember to consider cabg
279
Q

how will aortic stenosis present?

A

old man with atherosclerosis
chest pain, HF sx, syncope
bicuspid Aortic valve accelerates the pathology

280
Q

treatment for Aortic stenosis:

A

NOT valvuloplasty -> REPLACEMENT

remember to consider CABG

281
Q

mitral regurgitation presentation?

A

acute - cardiogenic shock, flash pulmonary oedema

chronic - CHF, AF

282
Q

treatment for mitral regurgitation?

A

emergent valve replacement if acute

elective if chronic but before AF, HF sets in

283
Q

why do you have to consider cabg in aortic valve replacements?

A

ostea of coronary vessels are in aortic valve

if lose an ostea - lose coronary flow

284
Q

hypertrophic cardiomyopathy - what causes it?

A

unilateral septum hypertrophy

covers aortic opening -> LV outlet obstruction

285
Q

who gets HCM?

A 
patients with sarcomere mutations 
young
athletic 
sudden death - due to ventricular arrhythmia 
SOB/syncope OE
FHx sudden cardiac death
286
Q

systolic murmur, but more blood->less murmur (better when they squat or leg-lift):
(like Aortic stenosis)

A

HCM

287
Q

treatment for HOCM:

A 
avoid dehydration 
Beta blockade 
transplant
alcohol ablation
myomectomy 
AICD
288
Q

what is mitral valve prolapse:

A

leaflets of the mitral valve don’t touch well, too big

so during systole they blow through

289
Q

systolic murmur but more blood->less murmur (better when squat or leg lift):
(like mitral regurg)

A

mitral valve prolapse

290
Q

pathophysiology of mitral valve prolapse:

A

congenital

291
Q

what type of person gets mitral valve prolapse:

A

young women

292
Q

treatment of mitral valve prolapse:

A

avoid dehydration
BB
doesn’t need to be replaced

293
Q

dilated cardiomyopathy: pathophys

A

chambers become dilated
minimal actin and myosin overlap
so no contractility

294
Q

what generates contractility force in heart muscle?

A

actin and myosin overlap

295
Q

causes of dilated cardiomyopathy:

A 
virus - coxsackie, chagas
wet beriberi 
alcohol
ischemia
chemo
296
Q

how will patient with dilated cardiomyopathy present?

A

systolic CHF, 3rd HS
orthopnoea, PND, dyspnoea OE, crackles, peripheral oedema
reduced LVEF<55%, dilated LV
TR, MR

297
Q

tx of dilated cardiomyopathy:

A

CHF sx: BB, ACEi, diuretics (furosemide)
definitive: transplant
stop alcohol/chemo

298
Q

what should happen to relatives of HCM?

A

first degree relatives screened by echo

299
Q

concentric hypertrophic cardiomyopathy: causes:

A

longstanding HTN

300
Q

concentric hypertrophic cardiomyopathy: CP:

A

diastolic CHF

301
Q

how to treat concentric hypertrophic cardiomyopathy/diastolic CHF:

A

avoid dehydration
BB/ccb
transplant
HTN control *** (1.)

302
Q

restrictive cardiomyopathy: pathology:

A

no room for ventricle to relax due to interference in the wall of the ventricle, interfering with the myocyte normal function

303
Q

causes of restrictive cardiomyopathy (3):

A

amyloid
sarcoid
haemachromatosis

cancers
idiopathic fibrosis

304
Q

how will patient with restrictive cardiomyopathy present?

A

diastolic CHF

305
Q

if restrictive cardiomyopathy + peripheral neuropathy -> dx

A

amyloidosis

306
Q

if restrictive cardiomyopathy + pulmonary disease->

A

sarcoidosis

307
Q

if restrictive cardiomyopathy + cirrhosis, bronze diabetes->

A

haemachromatosis

308
Q

If suspect amyloidosis, which ix?

A

abdo wall fat pad biopsy

gingiva biopsy

309
Q

is suspect sarcoidosis, which ix?

A

cardiac MRI then do endomyocardial biopsy

310
Q

is suspect haemachromatosis, which ix?

A 
screen ferratin (up)
then get genetic test
311
Q

tx restrictive cardiomyopathy:

A 
diastolic chf so:
rate control - BB, CCB
gentle diuresis 
transplant definitive
tx underlying disease
312
Q

what will echo of HOCM show?

A

asymmetric hypertrophy of septum

313
Q

in suspected chronic heart failure first line ix?

A

BNP

then echo

314
Q

45-year-old man is admitted to the intensive care unit following a laparotomy. He has a central line, pulmonary artery catheter and arterial lines inserted. The following results are obtained:
low pulm artery occlusion pressure
low cardiac output
high systemic vascular resistance

cause?

A

hypovolaemia

causes low cardiac output due to low preload

315
Q

75-year-old man is admitted to the intensive care unit following a laparotomy. He has a central line, pulmonary artery catheter and arterial lines inserted. The following results are obtained:
high pulm artery occlusion pressure
low cardiac output
high systemic vascular resistance

cause:

A

cardiogenic shock

in this, pulm pressures usually high
tx using venodilators as in pulm oedema

316
Q

22-year-old lady is admitted to the intensive care unit following a laparotomy. She has a central line, pulmonary artery catheter and arterial lines inserted. The following results are obtained:
low pulm artery pressure
high cardiac output
low systemic vasc resistance

cause?

A

septic shock

decresed SVR is often major feature of sepsis
hyperdynamic circulation often present
tx using vasoconstrictors

317
Q

palpitations ix?

A

after bloods and ecg

next important is holter monitor

318
Q

60-M -> ED shocked with sudden onset, severe chest pain at rest. radiates to his back and down his arms. PMH HTN, angina and DVT 4 years ago. His regular medications include ramipril, GTN and simvastatin. He has never smoked, doesn’t drink alcohol and has not had any recent travel. CXR: widened mediastinum and ECG: sinus tachycardia. Found some relief from the pain 20 minutes after using his GTN spray. dx?

A

aortic dissection

319
Q

which classification for aortic dissection?

A

stanford

or debakey

320
Q

Massive PE + hypotension - tx?

A

thrombolyse

321
Q

what happens to DM meds when someone comes in having been thrombolysed post anterior MI to CCU?

A

stop metformin and gliclazide

start IV insulin infusion

322
Q

what is kussmauls sign associated with ?

A

raised JVP on inspiration
associated with constrictive pericarditis
used to differentiate constrictive pericarditis from tamponade

323
Q

calcification of pericardium?

A

constrictive pericarditis

324
Q

if ?PE but can’t get a scan - mx?

A

start on treatment dose anticoagulant and wait for scan

325
Q

PE: ECG changes (commonest)?

A

sinus tachycardia

T inversion v1-3 +/- inferior leads (RV strain)
s1Q3T3
right axis deviation

326
Q

hypercalcaemia ecg?

A

short qt interval

J waves if severe

327
Q

right ventricular strain ecg features:

A

ST depression and T wave inversion
v1-3 (+4)
2,3,avf

328
Q

what does RBBB look like on ecg?

A

first part of QRS normal
secondary R wave in v1-3 (looks like M)
slurred ‘S’ in the lateral leads (looks like W)
ST depression, T wave inversion in R precordials
broad QRS >120ms

329
Q

what does LBBB look like on ecg?

A

QRS broad >120ms
tall R waves in lateral leads (1,v5,v6) (looks like M)
deep S waves in R precordials (v1-3) - (looks like W)
LAD
dominant S wave in v1

330
Q

Right axis deviation on ecg?

A

QRS is positive in 2,3,avf

QRS is negative in lead 1

331
Q

left axis deviation on ecg?

A

QRS is positive in lead 1

QRS is negative in 2, 3, avf

332
Q

which drugs can lead to hypocalcaemia?

A

furosemide
loop diuretics sfx

also can cause ototoxicity

333
Q

85 yom, 142/84 BP. Q-Risk of 8% on no meds: tx?

A

lifestyle advice as risk not >10%, he’s over 80, no comorbidities

334
Q

which anti-infective agent will cause the INR to increase?

A

fluconazole

335
Q

INR 5.0-8.0 (no bleeding) - mx?

A

withhold 1 or 2 doses of warfarin, reduce subsequent maintenance dose

336
Q

which complications do Type A aortic dissection patients sometimes present with?

A

hemiplegia

neuro complaints

337
Q

71yof 147/92 BP confirmed on 2 readings - next step?

A

Ambulatory BPM

338
Q

first line mx acute pericarditis?

A

NSAIDS AND colchicine

339
Q 
obvious MI hx with tall R waves in v1-3 - where is MI?
ST depression in leads V1-V3
Tall R waves in leads V1-V3
Inverted T-wave in lead aVR
All other T-waves are normally oriented
A

posterior MI

340
Q

NSTEMI first line tx?

A

aspirin 300 to prevent progression to stemi

341
Q

which drug sometimes used as anti htn will worsen glucose control in t2dm?

A

indapamide

342
Q

A 75-year-old lady presented to the emergency department after suffering a fall 2 hours ago. Before the fall, she was nauseous and experienced sweating, pallor and discomfort in the stomach. She believed that she briefly lost her consciousness but then recovered quickly. She did not have any confusion or weakness after the fall. There were no tongue bites. Neurological examination was normal. Her hearing has always been bad since she was young.

What is the diagnosis?

A

neurally mediated syncope

343
Q

how should adenosine be given?

A

large bore cannula (16G) or centrally

344
Q

adenosine sfx:

A

chest pain
bronchospasm
transient flushing
can enhance conduction down accessory pathways, resulting in increased ventricular rate (e.g. WPW syndrome)

345
Q

what type of organism (gram and shape) are the bugs that cause bacterial endocarditis?

A

gram positive cocci

346
Q

which htn drugs cause cold peripheries?

A

BBs

can also cause reduced awareness of hypos

347
Q

pulsus paradoxus - describe?

A

In cardiac tamponade, there will be an abnormally large drop in BP during inspiration, known as pulsus paradoxus

348
Q

fondaparinux is sometimes used in nstemi tx - what is it’s moda?

A

activates antithrombin III

LMWH also does this

349
Q

Abciximab, eptifibatide, tirofiban - moda?

A

Glycoprotein IIb/IIIa receptor antagonists

350
Q

how to calculate the cardiac axis?

A

find most isoelectric line (pos=neg) out of first 6 (1,2,3,avl,avr,avf). direction of conduction is 90 degrees from that lead on the axis man

351
Q

what condition is associated with an inverted P wave in lead I, right axis deviation, and loss of R wave progression??

A

dextrocardia

heart apex on the right, flipped heart

352
Q

which drugs actually improve prognosis of heart failure?

A

ACEIs, BB, spironalactone

not furosemide

353
Q

hypokalaemia ecg?

A

t wave flattening and u waves present

354
Q

The most common valvular abnormality in infective endocarditis is ???

A

tricuspid regurgitation

355
Q

tricuspid regurg murmur?

A

pan-systolic louder during inspiration (aka holo-systolic)

356
Q

what is Beck’s triad of cardiac tamponade? (do ECHO)

A

hypotension
soft heart sounds
raised JVP

357
Q

cardiac tamponade ECG?

A

electrical aleternans

358
Q

the CT shows a large saddle embolus where the pulmonary trunk splits - dx?

A

PE

359
Q

what else other than HF can raise a BNP?

A

CKD/renal failure

360
Q

Orthostatic hypotension (A fall in SBP of >20mmHg on 3 mins standing) accompanied by an exaggerated increase in HR is indicative of which 2 conditions?

A

anaemia

hypovolaemia

361
Q

Orthostatic hypotension (A fall in SBP of >20mmHg on 3 mins standing) accompanied by no change in HR is indicative of which condition?

A

DM

362
Q

well’s score >4 which ix first line?

A

CTPA

if 4 or below do d-dimer to r/o

363
Q

PE + hypotension tx?

A

alteplase (thrombolysis)

364
Q

when to stop warfarin before surgery?

A

5 days before

surgery can go ahead after <1.5

365
Q

where do loop diuretics act?

A

ascending loop of henle

366
Q

how long do trop and CKMB stay elevated for post-MI?

A

trop 10 days

CK-MB 3-4 days

367
Q

which drug is CI in ventricular tachycardia?

A

verapamil

can cause haemodynamic collapse

368
Q

which drug is used in pulseless arrest / asystole?

A

adrenaline stat then 3-5minutely

not atropine anymore

369
Q

which factors should determine if an intravenous glycoprotein Iib/IIIa receptor antagonist is to be given in nstemi?

A

GRACE score and whether the pt is having PCI

- give alongside

370
Q

PCI criteria stemi?

A

presents in <12hrs and PCI can be delivered in <120 mins

371
Q

PE + renal failure -> ix?

A

VQ scan

372
Q

what cause of chest pain is commoner in Marfan’s syndrome?

A

pneumothorax

373
Q

42-year-old overweight man presents with a two day history of anterior chest pain that is worse on deep inspiration and lying down
relieved by sitting forwards: dx

A

pericarditis

374
Q

aortic dissection management:

A

type A - ascending aorta - control BP(IV labetalol) + surgery
type B - descending aorta - control BP(IV labetalol)

375
Q

electrolyte causes of torsades de pointes?

A

hypokalaemia
hypomagnesia
hypocalcaemia

376
Q

what examination sign is classic for HCM?

A

s4 sound

377
Q

What is the most common cause of death in patients following a myocardial infarction?

A

ventricular fibrilation

378
Q

if d-dimer negative and wells score of 4: mx?

A

consider alternative dx and reassure patient PE ruled out

379
Q

If patients have persistent myocardial ischaemia following fibrinolysis what is next mx step?

A

consider PCI

380
Q

when is fondaparinux used in nstemi mx?

A

those who are NOT having angiography immediately

381
Q

child with inhaled foreign body - where is the blockage likely to occur and which lobe?

A

right side - right inferior bronchus

382
Q

STEMI and patient suitable for PCI -> which drugs do they get?

A

aspirin and prasugrel

383
Q

Witnessed cardiac arrest while on a monitor - tx?

A

3xshocks then CPR

if not witnessed on monitor -> do 1 shock then 2 mins CRP

384
Q

hypothermia ecg changes:

A 
bradycardia
'J' wave - small hump at the end of the QRS complex
first degree heart block
long QT interval
atrial and ventricular arrhythmias
also torsades de pointes
385
Q

which rule out criteria used in 18yo with <15% chance PE?

A

PERC

386
Q

what is a late neuro manifestation (and complication) of rheumatic fever?

A

sydenham’s chorea

loss of control of facial and arm muscles

387
Q

organism responsible for rheumatic fever?

A

strep pyogenes

388
Q

which drugs can precipitate gout attacks?

A

thiazide diuretics - bendroflumethiazide

reduces uric acid secretion from kidneys

389
Q

which patients, regardless of age, should be started on statin for primary prevention :

A 
T1DMs if: 1 of:
over 40
had DM for >10yrs
nephropathy
other RFs - HTN, obesity
qrisk >10%
390
Q

how do statins work? (MODA)

A

inhibit the action of HMG-CoA reductase, the rate-limiting enzyme in hepatic cholesterol synthesis.

391
Q

statin CI:

A

macrorlides

pregnancy

392
Q

doses of atorvastatin for different preventions:

A

20mg for primary

80 for secondary

393
Q

patient is two days following a large abdominal procedure. increased SOB. sinus tachy. reduced AE at both bases. ddimer normal - dx?

A

basal atelectasis

394
Q

The history of ischaemic heart disease combined with the presence of fusion and capture beats strongly suggests a diagnosis?

A

Ventricular tachycardia

395
Q

Deep ‘arrowhead’ T wave inversion in the anterior leads is a sign of ?

A

wellens syndrome

cardiac ischaemia in the setting of unstable angina and is a high-risk trace

396
Q

hyperkalaemia ecg?

A

peaked T waves

397
Q

which drug should never be taken with verapamil and why?

A

BBs

can cause heart block and fatal arrest

398
Q

which cardiomyopathy is WPW associated with?

A

HOCM

Friedrich’s ataxia as well

399
Q

type of inheritance of HOCM?

A

autosomal dominant

400
Q

ECHO findings HOCM? MR SAM ASH

A

Mitral regurg
Systolic anterior motion
Asymmetrical hypertrophy

401
Q

suspected ruptured abdominal aorta aneurysm - which blood procducts?

A

crossmatch 6 units of blood

402
Q

Major bleeding on warfarin. INR 8.5. mx?

A

stop warfarin + vit K 5mg IV + prothrombin complex concentrate (only give PCC if MAJOR bleed)
restart warfarin when INR<5

403
Q

STEMI presents 6hrs after onset, would take >120mins to transfer to PCI centre - mx?

A

thrombolysis and repeat ECG 90 mins
(cannot wait for more than 120 mins to PCI if thrombolysis could be given)
also give unfractioned heparin

404
Q

bendrofluemthiazide MODA?

A

inhibits Na reabsorption by blocking the Na+-Cl− symporter at the proximal part of the distal convoluted tubule

405
Q

54M obese. ED. sudden onset severe frontal headache and neck pain unbearable. PMH: HTN, aortic regurgitation (bicuspid valve), hyperlipidaemia. 94% air, RR 16/min, hr 117/min, BP 101/68mmHg left arm and 122/82mmHg right arm, temperature 36.8ºC. ECG sinus tachycardia. dx?

A

aortic dissection

if presents like R-sided stemi and AR murmur -> ascending

406
Q

which comes first in nstemi mx - grace score or DAPT?

A

grace score

407
Q

NSTEMI first 2 drugs given if not major bleeding risk:

A

aspirin and fondaparinux if PCI NOT planned for immediately

408
Q

60M is admitted with severe central chest pain to the resus department. The admission ECG shows ST elevation in leads V1-V4 with reciprocal changes in the inferior leads. What % occlusion of which artery likely?

A

100% occlusion LADA

409
Q

45-F ED chest pain worse on deep inspiration and SOB. denies coryzal symptoms or cough. rr25/min, 96% air, HR 114/min, BP 114/81mmHg, 36.8°C. She is concerned that this may be due to her total mastectomy one week ago for breast cancer despite the wound site appearing to be healing well.
What is the next, most appropriate management step?

A

CTPA

Wells > 4

410
Q

ECG shows both right bundle branch block and left axis deviation indicating???

A

bifascicular block

411
Q

features of bifascicular block as above + 1st-degree heart block is called?

A

trifascicular block

412
Q

MI+ bradycardia -> where?

A

inferior MI

413
Q

STEMI > 12h since onset - ongoing ECG ischemia - mx?

A

PCI

414
Q

what is a poor prognostic indicator in ACS??

A

cardiogenic shock - crackles on auscultation
age>65
initially raised creatinine

415
Q

Young man with AF, no TIA or risk factors, mx?

A

no treatment now preferred over aspirin

416
Q

44M central, severe chest pain started around one hour ago. No radiation of the pain or associated shortness-of-breath. He has had some similar fleeting pains over the past two weeks but these settled spontaneously after a few seconds. hr 84 / min, blood pressure 134 / 82 mmHg and respiratory rate 18 / min. dx?

A

MI

417
Q

25M intermittent central chest pains 4/52. PMH: pilonidal abscess operation 9 months ago. The pain is described as ‘heavy’ and often associated with tingling in his lips and fingers. The episodes usually happen at rest and last several minutes. dx?

A

anxiety

418
Q

31F 4/52 retrosternal ‘burning’ pain. The pain is often worse following eating. PMH depression and she uses Microgynon. Clinical examination is unremarkable. dx?

A

gord

419
Q

In the context of a tachyarrhythmia, a systolic BP < 90 mmHg →

A

DC cardioversion

420
Q

77F to ED with 3/7 hx lethargy and shortness-of-breath. She is confused and unable to give much useful history. On examination she is noted to be pale, hr 160/min bp 80/56 mmHg. sats 96% air. anaemic. ECG shows irregularly irregular narrow complex tachycardia. mx?

A

dc cardioversion

due to unstable BP

421
Q

polycystic kidney disease: which murmur?

A

mitral valve prolapse (and MR)

422
Q

2M ->GP parents are concerned that he is struggling to gain weight and is excessively short of breath on exertion. PMH congenital pulmonary stenosis which was managed conservatively however the parents are now questioning whether surgical intervention may be required.
What murmur is likely to be heard on examination?

A

ejection systolic louder on inspiration

423
Q

late systolic murmur inidcates:

A

mitral valve prolapse and coarctation of the aorta

associated with bicuspid aortic valve

424
Q

mid-systolic click :

A

prolapse of the mitral valve

425
Q

tetralogy of fallot murmur:

A

ejection systolic

426
Q

ventricular septal defect murmur:

A

pansystolic

427
Q

nicorandil is useful in mx of?

A

angina - K channel activator - dilates coronary vessels

sfx - ulcer anywhere on GI tract

428
Q

A patient develops acute heart failure 5 days after a myocardial infarction. A new pan-systolic murmur is noted on examination - dx?

A

VSD

429
Q 
67-M ->ED sudden onset chest pain. central chest, and started an hour ago. maximal at onset, and is not exacerbated with deep breaths. most intense pain he's ever experienced. nil previous.
PMH HTN (ramipril and bendroflumethiazide). He has a 15-pack-year.
Drowsy. He has left-sided ptosis and miosis of his left pupil. dx?
A

aortic dissection

can present with neuro sx

430
Q

‘Provoked’ pulmonary embolisms are typically treated for?

A

3 months

unprovoked is 6 months

431
Q

41-M ->GP due to erectile dysfunction and dizziness. He has a complex PMH and is on multiple medications. On examination his heart rate does not slow on deep breathing and his lying/standing blood pressure drops significantly. dx?

A

autonomic dysfunction effects of T2DM

432
Q

Investigating suspected PE: if the CTPA is negative then consider??

A

proximal leg vein USS if DVT suspected

433
Q

23-F -> ED with palpitations. No chest pain. No signs of shock, heart failure or syncope. ECG: regular narrow complex tachycardia, rate of 168 bpm. There are no obvious P waves visible. Vagal manoeuvres fail to terminate the arrhythmia.
What should be the next step in management?

A

SVT dx

Adenosine is next 6mg->12mg->12mg

434
Q

67M COPD and paroxysmal atrial fibrillation who you are currenly looking after. Around 30 minutes ago he developed retrosternal chest pain which has not settled with Gaviscon. HR 90/min, sats 95% air, bp 134/82 mmHg, The ECG: STE in AVR and STD v2-6: mx:

A

acs mx - trasnfer to CCU

435
Q

If a patient with AF has a stroke or TIA, the anticoagulant of choice should be?

A

warfarin or DOAC

436
Q

68-M -> ED with sudden onset pleuritic chest pain. CTPA shows PE. Nil previous, and is normally fit and well, and not on any medications. He is normotensive but tachycardic. What is the most appropriate initial management for this man?

A

DOAC

437
Q

what is Ivabradine and what are its commonest sfx?

A

angina tx if HR>70

visual disturbances including phosphenes and green luminescence, brady, HB

438
Q

alteplase (thrombolysis) MODA:

A

activates plasminogen -> plasmin

439
Q

which ACS drug to be cautious with if pt normotensive/hypotensive?

A

nitrates - can cause collapse

440
Q

which bloods indicate stop statin?

A

serum transaminase concentrations rise to and persist at 3 times the upper limit of the reference range.

441
Q

Complete heart block following an inferior MI: mx?

A

reassure and observe

this is not an indication for pacing, unlike with anterior MI

442
Q

what will make aortic stenosis murmur quieter?

A

LV dysfunction - reduced flow over the aortic valve - quieter murmur

443
Q

50M cardiac ward following a stroke. 4/12 hx weight loss and fever. diastolic murmur. ECHO:
‘A pedunculated heterogeneous mass attached to the interatrial septum of the left atrium. Mitral valve obstruction also noted’. dx?

A

atrial myxoma

444
Q

New onset AF presented within <48h - mx?

A

anticoagulate and dc cardioversion

must be sx for <48h!!!

445
Q

Aortic stenosis management:

A

AVR if symptomatic otherwise cut-off gradient is 40mmHg

446
Q

Downsloping ST depression (‘reverse tick’ sign) indicates ?

A

digoxin toxicity

447
Q

A 50-year-old man complains of central, pleuritic chest pain 24 hours after being admitted with an anterior myocardial infarction. The pain is eased when he sits upright.dx?

A

pericarditis

448
Q

After being admitted to the coronary care unit a middle aged man develops a regular, broad complex tachycardia. His blood pressure drops to 88/50 mmHg. He was admitted 6 hours previously following an anterolateral myocardial infarction.
dx?

A

ventricular tachycardia

449
Q

A 66-year-old woman suddenly develops dyspnoea 10 days after having an anterior myocardial infarction. Her blood pressure is 78/50 mmHg, JVP is elevated and the heart sounds are muffled. There are widespread crackles on her chest and the oxygen saturations are 84% on room air. dx?

A

left ventricular free wall rupture

sudden HF, raised JVP, pulsus paradoxus, recent MI

450
Q

which cardiac drugs can cause erectile dysfunction and insomnia?

A

BB

451
Q

Carotid sinus hypersensitivity may be cardioinhibitory or vasopressive - quantify?

A

vantricular pause >3seconds

SPB drop >50

452
Q

which valve for infective endocarditis in IVDU?

A

tricuspid

453
Q

what are pharmacological options for treatment of orthostatic hypotension?

A

fludrocortisone and midodrine

454
Q

angina and not controlled on BB, next in line is?

A

CCB

455
Q

If new BP >= 180/120 mmHg + no worrying signs then the first step is ?

A

ix for end-organ damage

if signs - admit for specialist assessment

456
Q

rate control AF but asthmatic - first line?

A

CCB - diltiazem

457
Q

second episode AF. During admission he was warfarinised and discharged with planned follow-up in the cardiology clinic. However, on review today he is found to be in sinus rhythm. What should happen regarding anticoagulation?

A

lifelong warfarin (as 2nd episode)

458
Q

Long Q-T syndrome mx?

A

stop drugs worsening
BB
ICD if high risk

459
Q

what is the first line investigation for stable chest pain of suspected coronary artery disease aetiology?

A

Contrast CT coronary angiogram
on-invasive functional imaging 2nd line
invasive coronary angiography 3rd line

460
Q

previously asx 30-F -> ED severe dyspnoea while jogging. twice in past month but this time it was more serious which prompted her to seek help. She is adopted and is aware that her biological mother suffered from rheumatic fever as a child and biological father had ‘some sort of heart problem’. All vital signs were within normal range. An ECG was done and showed left ventricular hypertrophy. diagnosis?

A

HOCM

461
Q

if had catheter ablation for AF - what changes regarding anticoag needed?

A

stay on anticoag per chadsvasc for life

462
Q

what ECG finding is NOT normal variant for young athlete?

A

LBBB

463
Q

A patient with AF + an acute stroke (not haemorrhagic) should have anticoagulation therapy started when in timeline?

A

after 2 weeks

464
Q

pericarditis ix?

A

echo - tte

465
Q

pt on anti-epileptic meds. goes on warfarin. gets skin changes but INR in normal range - what side effect is this?

A

skin necrosis

466
Q

In Raynaud’s phenomenon with extremity ischaemia think??

A

buerger’s disease
thromboangiitis obliterans
(young male smoker)

467
Q

De Musset’s sign (head bobbing) is a clinical sign of ?

A

aortic regurgitation

468
Q

One day following a thrombolysed inferior myocardial infarction a 72-year-old man develops signs of left ventricular failure. His blood pressure drops to 100/70mmHg. On examination he has a new early-to-mid systolic murmur. dx?

A

papillary muscle rupture
-> acute mitral regurgitation
could also be new VSD

469
Q

Four weeks after an anterior myocardial infarction a 69-year-old presents with pulmonary oedema. The ECG shows persistent ST elevation in the anterior leads. dx?

A

left ventricular aneurysm

no chest pain

470
Q

angina step wise mx:

A
  1. BB
  2. CCB
  3. long-acting nitrate, ivabradine, nicorandil or ranolazine
471
Q

how do ISMN takers minimise the development of nitrate tolerance?

A

assymetric dosing regime to maintain a daily nitrate-free time of 10-14 hours
no mortality benefit - sx only

472
Q

For adults with type 1 diabetes, if there is no albuminuria the target BP should be < ??

A

135/85

473
Q

adult with type 1 diabetes has albuminuria or 2 or more features of metabolic syndrome, in which case BP target should be?

A

130/80

474
Q

Bleeding on dabigatran? (eg haemorrhagic stroke) - which reversal agent??

A

idarucizumab

475
Q

drug monitoring for statin?

A

LFTs at baseline, 3months, 12 months

476
Q

when to take statins?

A

last thing in evening - works overnight

477
Q

Takotsubo cardiomyopathy is associated with which echo change?

A

apical ballooning of myocardium (resembling an octopus pot)

478
Q

middle-aged lorry driver presents with central chest pain and ST elevation on electrocardiogram. He is treated for myocardial infarction with (PCI) and a stent is deployed to his left circumflex artery to good effect. Now asymptomatic and has been started on secondary prevention medications. He is keen to get back to work. What guidance should he be given on discharge?

A

contact DVLA and not drive for 6/52

if not lorry driver, should wait 4/52 before driving but no need to tell dvla

479
Q

Acute heart failure not responding to treatment - next step?

A

CPAP

480
Q

warfarin and pregnancy?

A

NO - teratogenic

but can be used in breast-feeding mothers

481
Q

dental procedure on background of endocarditis - which abx prophylaxis?

A

none - not routinely recommended

482
Q

ventricular tachycardia: tx if adverse sign and examples of adverse signs?

A

synchronised cardioversion

shock (systolic BP of <90), syncope, myocardial ischemia and heart failure.

483
Q

if ventricular tachy without adverse sign (stable) - mx?

A

amiodarone IV

sfx causes thrombophlebitis

484
Q

which drugs cause orthostatic hypotension?

A

diuretics, vasodilators (including CCB), alcohol

485
Q

how to treat AF if there is coexistent heart failure, first onset AF or an obvious reversible cause?

A

rhythm control

486
Q

ace-i in pregnancy?

A

NO

foetal abnormalities and renal failure

487
Q

useful investigation in clinically unstable patients with a suspected aortic dissection??

A

TOE (transoesophageal echo)

normally ct angiography is ix of choice if clinically stable = false lumen (of CAP)

488
Q

CCB and heart failure:?

A

CI - negative inotropic effect; they reduce heart rate and cardiac output
(except for amlodipine)

489
Q

In cases of hypothermia causing cardiac arrest, defibrillation…………..?

A

do 3 shocks but then if unsuccessful continue chest compressions and only shock again once pt temp >30degrees

490
Q

ECG shows electrical alternans, which is considered pathognomic for?

A

tamponade

alteration of QRS amplitutes between beats

491
Q

choking - mild mx?

A

ask are they choking - if yes encourage cough

492
Q

severe choking - mx?

A

give up to 5 back-blows
if unsuccessful give up to 5 abdominal thrusts
if unsuccessful continue the above cycle

493
Q

A 24-year-old Asian female presents to her GP with lethargy and dizzy spells. On examination she is noted to have an absent left radial pulse. Blood tests are as follows:
ESR high - dx?

A

takayasu’s arteritis

associated with renal artery stenosis and different BP in each arm

494
Q

3 of these = typical chest pain
2= atypical
what are the three criteria?

A

pain is described as sharp (rather than constricting)
pain may be precipitated by physical exertion
pain is relieved by GTN spray within 5 minutes

495
Q

chest pain relieved by sitting forwards?

A

pericarditis

496
Q

A 52-year-old male presents with central chest pain and vomiting. He has drunk a bottle of vodka. On examination there is some mild crepitus in the epigastric region. dx?

A

boerhave syndrome

Spontaneous rupture of the oesophagus that occurs as a result of repeated episodes of vomiting.

497
Q

boerhave syndrome: mackler triad?

A

vomiting, thoracic pain, subcutaneous emphysema. It commonly presents in middle aged men with a background of alcohol abuse.

498
Q

statin + clari ->

A

an important and common interaction

massively raised CK

499
Q

commonest cause of mitral stenosis?

A

rheumatic fever

500
Q

55-F -> GP 3/12 hx breathlessness on exertion, fatigue and ankle swelling. She reports that she requires 2 pillows to sleep at night. PMH: feverish illness 4-months previously. Mid-diastolic murmur present and a loud S1 opening snap consistent with mitral stenosis. Annular erythematous rash on her chest. ECG: right ventricular hypertrophy and P-mitrale. dx?

A

rheumatic fever

erythema marginatum

501
Q

45-F->ED sudden onset weakness on the right side of her body. 30m ago. Her vision is unaffected but her speech is confused and slurred. Nil PMH. DH: COCP. 40 pack-years and drinks two bottles of wine/wk.
Clinically stable. 2/5 power down her right side. Peripheral cyanosis and clubbing with an ejection systolic murmur at the left upper sternal edge radiating through to the back and fixed splitting s2. There is also erythematous tender enlargement of the right calf.
what caused this?

A

atrial septal defect

embolism from peripheral veins may bypass pulmonary circulation

502
Q

62-M 2 episodes of syncope. hr 90 bp 110/86 mmHg, his lungs are clear and there is a systolic murmur which radiates to the carotid area. Which ix first?

A

ECHO

syncope a late sign in aortic stenosis

503
Q

ACE-I and worsening BP control but doesn’t tolerate CCB - which drug to add?

A

thiazide

504
Q

which AD drug associated with dose dependent QT prolongation?

A

citalopram

505
Q

used to reduce dyspnoea and anxiety in acute exacerbation of heart failure?

A

morphine

506
Q

what is CI in aortic stenosis (drug):

A

nitrates - cause hypotension

507
Q

58-F PE 1/52 ago. Warfarinised. She was covered with low molecular weight heparin until the INR was > 2 for 24 hours. For the past week she has been taking 4mg of warfarin and her INR four days ago was 2.2. Her INR has been checked today and is 1.3. mx?

A

up warfarin to 6mg/day and LMWH bridge

508
Q

A 12-F from Bulgaria presents to the surgery. She reports being unwell for the past 2 weeks. Initially she had a sore throat but she is now experiencing joint pains intermittently in her knees, hips and ankles. On examination there are some pink, ring shaped lesions on the trunk and occasional jerking movements of the face and hands. dx?

A

rheumatic fever

509
Q

severe hypertension and bilateral retinal hemorrhages and exudates - ? (or epistaxis)

A

malignant hypertension

510
Q

If patients treated with PCI for MI are experiencing pain or haemodynamic instability post PCI - mx?

A

CABG

511
Q

which anti-hypertensives cause hyperkalaemia?

A

ace-is

512
Q

coarctation mx:

A

immediate prostaglandins

until corrective surgery can occur

513
Q

ix endocarditis?

A

3 separate blood cultures taken

ECHO

514
Q

absence of a carotid pulse in the presence of sinus tachycardia indicates that this is?

A

non-shockable rhythm

515
Q

20-F. On feeling the woman’s radial pulse, the doctor can feel 2 separate systolic beats, as if there was a double pulse. dx and name of this phenomenon?

A

HOCM

bisferiens pulse

516
Q

slight discomfort with ordinary activity. No symptoms on resting - NYHA ??

A

II

517
Q

recurrent DVTs, warfarinised - target INR?

A

3.5 (3-4)

518
Q

sfx GTN?

A

hypotension
tachycardia
headache
flushing

519
Q

VF/pulseless VT should be treated with ?

A

1 shock as soon as identified then CPR
adrenaline after the 3rd shock
only ever 3 successive shocks when whole event witnessed on monitor eg post MI

520
Q

ECG HOCM:

A

left ventricular hypertrophy (deep S in v1, tallest R in V5,6)
progressive t-wave inversion
deep Q waves

521
Q

A sigmoid colon perforation of unknown cause, given his age;
Translucent looking skin and hypermobility of the small joints;
A presentation compatible with aortic dissection.
cause and ix of aortic dissection?

A

ehlers-danlos

TOE

522
Q

NSTEMI management: unstable patients should have immediate?

A

coronary angiography

523
Q

drug causes both hyponatraemia and hypokalaemia.?

A

bendroflumathiazide

also hypercalcaemia + hypocalciuria

524
Q

A 25-year-old female is found to have a left hemiparesis following a deep vein thrombosis. An ECG shows RBBB with right axis deviation. What is the most likely underlying diagnosis?

A

ostium secundum atrial septal defect

525
Q

drugs to avoid in HOCM?

A

ace-inhibitors

reduce afterload

526
Q

falsely low BNP?

A

on ramipril for BP

angiotensin-II receptor antagonists, beta-blockers and diuretics can all falsely lower BNP levels, as can obesity.

527
Q

commonest association for aortic dissection>

A

htn

528
Q

NICE HF guidelines - if already on Ace, BB, on step 2:

A

aldosterone antagonist
ARB
Hydralazine+ nitrate (especially if black)

529
Q

NICE HF guidelines step 3: cardiac resynchronisation therapy or?

A

digoxin

530
Q

A 52-year-old male attends the stroke unit with dizziness and vertigo while playing tennis. He is known to have hypertension and a previous myocardial infarct. He now complains of right arm pain. What is the most likely diagnosis?

A

subclavian steal syndrome

531
Q

thrombolyisis CI:

A 
active internal bleeding
recent haemorrhage, trauma or surgery (including dental extraction)
coagulation and bleeding disorders
intracranial neoplasm
stroke < 3 months
aortic dissection
recent head injury
severe hypertension
532
Q

breathing problems with a clear chest - think?

A

PE

533
Q

There are regular p waves at a rate of around 90 / min but they do not conduct. The ventricular escape rhythm has a rate of about 36 / min and has a right bundle branch block (RBBB) like morphology. The bizarre, wide, inverted T-waves can be seen in?

A

stokes-adams attacks

534
Q

Global’ T wave inversion (not fitting a coronary artery territory) - think?

A

non-cardiac cause

535
Q

effect of phenobarbitone on warfarin?

A

decreases INR

536
Q

first line investigation for stable chest pain of suspected coronary artery disease aetiology (angina):

A

contrast enhanced CT angiography

537
Q

59F -ED 3/7 hx of new-onset palpitations. She has no structural or ischaemic heart disease. HR 120bpm, and she shows no signs haemodynamic compromise. Her ECG shows an irregularly irregular rhythm with the absence of p waves. The consultant recommends elective cardioversion for this patient. Which mx plan is most appropriate?

A

bisoprolol and oral anticoagulation for 3 weeks then electrical cardioversion

patients must either be anticoagulated or have had symptoms for < 48 hours to reduce the risk of stroke

538
Q

After starting an ACE inhibitor, significant renal impairment may occur if the patient has undiagnosed?

A

bilateral renal artery stenosis

539
Q

cause of a loud S2 (due to a loud P2)??

A

pulmonary HTN

540
Q

A 43-year-old lady presents with severe chest pain. Investigations demonstrate a dissecting aneurysm of the ascending aorta which originates at the aortic valve. What is the optimal long term treatment?

A

aortic root replacement

541
Q

angiodema is sfx of which drug?

A

ace-i ramipril

542
Q

Tachycardia with a rate of 150/min ?

A

atrial flutter

543
Q

primary PCI via which artery?

A

radial

544
Q

Complete heart block following a MI? - where is lesion?

A

Right coronary artery

545
Q

A newborn child is assessed. They are found to be in the 25th centile for their weight along with a systolic murmur heard best over the back. When feeling the femoral pulses the doctor notices that there is a radio-femoral delay. Which condition causing these examination findings?

A

coarctation

Tuner’s syndrome

546
Q

A 43-year-old lady presents with central chest pain, worse on deep inspiration, and shortness of breath. After her history and examining her, you suspect a pulmonary embolus (PE). Her Wells’ score is 9. You plan to do a CTPA, but the radiologists request you order one further investigation prior to a CTPA. What investigation is this likely to be?

A

CXR - do before CTPA acc to nice

547
Q

Patients on warfarin undergoing emergency surgery -?

A

give four-factor prothrombin complex concentrate

548
Q

amiodarone sfx?

A

grey skin appearance

549
Q

ABG in a PE?

A

respiratory alkalosis

550
Q

which HTN med can increase creat by 30% from baseline but should be continued?

A

ramipril

551
Q

notching of the rib =

A

coarctation of aorta

552
Q

ix before starting amiodarone?

A

CXR - pneumonitis
UE - hypokalaemia
LFT
TFT

553
Q

Infective endocarditis causing congestive cardiac failure is an indication for?

A

emergency valve replacement

554
Q

what is ebstein’s anomoly?

A

tricuspid regurgitation → pansystolic murmur, worse on inspiration

555
Q

HOCM caused by?

A

mutation in the gene encoding β-myosin heavy chain protein or myosin binding protein C

556
Q

clubbing, fever, AF, mid-diastolic murmur seen in?

A

atrial myxoma (more commonly LA)

557
Q

furosemide/bumetanide MOA:

A

inhibits the Na-K Cl cotransporter in the thick ascending loop of henle

558
Q

what are the name of the nodules found in rheumatic heart fever?

A

Aschoff bodies are granulomatous nodules

559
Q

65M palpitations. ECG: VR 150/min with an underlying atrial rate of 300/min. Atrial flutter is suspected. What is the treatment of choice to permanently restore sinus rhythm?

A

radiofrequency ablation of tricuspid valve isthmus

3b/4 (19 decks)

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