Cardiology Qs Flashcards
(265 cards)
1
Q
Patient with a QRISK score of 12% is being managed for primary CVD prevention. What will they firstly be considered for?
A
Atorvastatin 20mg at night
2
Q
Patient required primary prevention of CVD, but is contraindicated for Atorvastatin. What is second line?
A
Ezetimibe
3
Q
After developing CVD, secondary prevention is the next course of action. What is the 4A (+1A) mneumonic for the basic plan?
A
Antiplatelets
Atorvastatin
Atenolol (Beta Blocker- Bisoprolol)
ACE Inhibitor (Ramipril)
~After MI
+Aspirin
and Clopidogrel/ Trigrelor (for 12mnths before de-prescribing
4
Q
What type of inheritance is Familial Hypercholesterolaemia?
A
Autosomal Dominant
5
Q
What is tendon xanthomata?
A
Hard nodules in the tendon containing cholesterol often on back of hand and Achilles.
6
Q
Patient presents with Tendon Xanthomata. What could this indicate?
A
Familial Hypercholesterolaemia
7
Q
Patient presents with Tendon Xanthomata. What feature of the family history would confirm diagnosis?
A
Family History : Family member had premature CVD (e.g MI before age of 60yrs)
–> Would confirm Familial Hypercholesterolaemia
8
Q
What are the reasons for a patient to have primary prevention of CVD?
A
1.QRISK Score >10%
2.Chronic Kidney Disease (eGFR <60)
3.Type 1 Diabetes
9
Q
Patient has been diagnosed with Familial Hypercholesterolaemia. What is the course of action? What will they be prescribed?
A
Statins
Specialist referral for genetic testing (and for family)
10
Q
90% of patients have primary hypertension. For the 10% that have Secondary, what are the reasons? (Remember mnemonic)
A
ROPED
Renal Disease (most common)
Obesity
Pregnancy induced / Pre-eclampsia
Endocrine
Drugs (alcohol, NSAIDs, Oestrogen)
11
Q
What is the definition of Hypertension?
A
BP of 140/90 in clinical setting, with ambulatory being 135/85
12
Q
Patient with Renal Disease presents with Hypertension. What should be checked?
A
Renal Artery Stenosis using Duplex Ultrasound, MRI or CT angiogram
13
Q
Patient has just been diagnosed with Hypertension. What investigations are necessary now to rule out the underlying reasons?
A
1.Urine Albumin creatine ratio (Rule out Proteinuria)
2.Dipstick (Rule out Bacterial infection)
3.Blood tests- Hba1c (Rule out Type 2 Diabetes), Renal Function and Lipids
4.Fundoscopy (Rule out Diabetic Retinopathy)
5.ECG (Rule outFor Left ventricular Hypertrophy)
6.QRISK score (Check for MI risk)
14
Q
What are the general BP readings for stage 1, 2 and 3 Hypertension
A
Stage 1 : 140/20
Stage 2 : 160/100
Stage 3 : 180/120
15
Q
What is the pharmacological treatment for a patient diagnosed with Hypertension? (Remember mneumonic)
A
ABCD
ACE Inhibitor (Lisinopril) / ARB (Candesartan)
Beta Blocker (Bisoprolol) -rarely prescribed for Primary
Calcium Channel Blocker (Amlodipine)
Diuretic (Thiazide like diuretic) !!ONLY IF CALCIUM CHANNEL BLOCKER IS NOT TOLERATED
+Atorvastatin if QRISK is >10%
16
Q
Patient is admitted to hospital presenting with a blood pressure of 180/20 with Retinal Haemorrhages (or Papilloedema). What investigations must be done?
A
-Fundoscopy (check for diabetic retinopathy)
-Urine albumin creatine ratio (Check for Proteinuria)
-Dipstick for bacterial infection
-Blood forHbA1c, renal and lipid function
-ECG (for left ventricular hypertrophy)
-QRISK score
=Most likely diagnosis will be Hypertensive Emergency
17
Q
What treatments in hospital will be given to a patient presenting with a Hypertensive emergency and why?
(Name 3)
A
-IV Sodium Nitroprusside = for rapid reduction of BP
-Labetalol =to descrease sympathetic stimulation (vasodilation)
-Glyceryl Trinitrate (Nitrate causing vasodilation)
18
Q
What is the pathological cause of Stable Angina?
A
Atherosclerosis affecting the coronary arteries
19
Q
Describe a typical presentation of a patient with Stable Angina.
A
Tightening of chest only upon exertion which resolves when resting.
20
Q
Describe the heart sounds of a patient with stable angina.
A
S4 sound
21
Q
What medication will be prescribed to patients with stable angina for immediate symptomatic relief?
A
Sublingual Glyceryl Trinitrate
22
Q
What are the key side effects of Sublingual Glyceryl Trinitrate?
(Name 2)
A
Headaches and Dizziness
23
Q
What are the usual medicines prescribed to a patient with stable angina?
A
1.Sublingual Glyceryl Trinitrate
2.Bisoprolol (beta blocker)
3.Diltazem or Verapamil (calcium channel blockers)
24
Q
What medication would be added to a patient’s medication plan if their stable angina symptoms are not fully resolved?
A
Isorbide Mononitrate
25
What medical intervention is necessary for patients with severe uncontrolled stable angina?
Percutaneous Coronary Intervention or Bypass Graft
26
What is the definition of Acute Coronary Syndrome?
Name the 3 types.
When a thrombus forms (made of platelets) from an atherosclerotic plaque blocking a coronary artery.
1.Unstable Angina
2.STEMI
3.NSTEMI
27
Patient presents with central constricting chest pain ongoing at rest for more than 15minutes. The pain is associated with radiation pain to jaw/arms, nausea and vomitting, sweating, shortness of breath, palpitations. What is the most likely diagnosis?
Acute Coronary Syndrome
(e.g Unstable Angina)
28
A patient presents with central constricting chest pain that has been going on for 1hour at rest. What is the immediate investigations to be done?
ECG, Troponin blood tests, Chest Xray (look for pulmonary oedema and other causes of chest pain)
Note: Echocardiogram can only be completed with the patient is stable
29
When would you want to conduct an echocardiogram on a patient with acute coronary syndrome and why?
i)When the patient is stable
ii)To assess the functional damage from attack specifically the left ventricular function
30
What does a ST elevation on an ECG indicate?
ST Elevation Myocardial Infarction (STEMI)
31
What would a T wave inversion on an ECG indicate?
NSTEMI
32
What kinds of ECGs could be related to a NSTEMI?
(Name 3)
-Normal ECG
-ST depression
-T wave inversion
33
What kinds of ECGs could be related to unstable angina?
(Name 3)
-Normal ECG
-ST depression
-T wave depression
34
What is the initial management of a patient presenting with Acute Coronary Syndrome?
(Name 4: Remember Mneumonic)
PAIN:
1.Perform ECG
2.Aspirin 300mg
3.IV Morphine for pain (perhaps with Metoclopramide)
4.Nitrate (GTN)
35
A patient has had a confirmed STEMI. What medications will this patient be required to take before surgery?
Aspirin and Prasugrel (Anti-platelet)
36
A patient has had a confirmed NSTEMI. What would be general plan of action be for long term management to consider before discharge?
(Remember mneumonic)
BATMAN
Base the decision on the Angiography
Aspirin
Trigrelor 180mg (or Clopidrogrel) *If risk of high bleeding
Morphine
Antithrombin therapy with Fonadparinux *Don't prescribe if patient has risk of high bleeding
Nitrate (GTN
37
A patient has a blood thinning disorder and has had a confirmed NSTEMI. What medications from BATMAN mneumonic can they have and not have?
Can have: Trigrelor
Cannot have: Antithrombin therapy with Fondaparinux
38
A patient has had a confirmed STEMI. What procedural intervention may be required?
(Name 2 possibilities)
1.Percutaneous Coronary Intervention
=treats the blockages
2.Thrombolysis
=Inject Fibrinolytic agent such as Streptokinase or Alteplase
39
Name some of the possible complications from suffering from Acute Coronary Syndrome?
(Name 6)
-Death
-Rupture
-Oedema
-Arrhythmia
-Aneurysm
-Dressler's Syndrome
40
When does Dressler's Syndrome usually occur?
2-3 weeks after acute MI
40
When does Dressler's Syndrome usually occur?
2-3 weeks after acute MI
41
What is the cause of Dressler's Syndrome?
Local immune response occurring after an acute MI
42
Describe the presentation of Dressler's Syndrome.
(Name 2 features)
-Pleuritic chest pain (sudden intense stabbing and burning when breathing)
-Low grade fever
43
A patient comes in 3 weeks after suffering a Myocardial Infarction with a fever and complains pleuritic chest pain.
What is the likely diagnosis and what initial investigations must be done?
i)Dressler's Syndrome
ii)ECG and Blood tests
44
What ECG findings would be expected from a patient with Dressler's syndrome?
ST elevation and T wave inversion
45
What blood results would you expect for a patient with Dressler's syndrome?
Raised CRP (infection marker) and ESR (sedimentation rate)
46
What would you expect on auscultation when listening to a Dressler's syndrome patient?
Pericardial rub
47
How would you treat a patient with Dressler's Syndrome?
1.NSAIDs (Aspirin or Ibeprofen)
2.Steroid (Prednisolone)
48
Dressler's Syndrome can cause significant pericardial effusion. What would therefore need to be done in this case?
Pericardiocentesis
=removal of fluid from around the heart
49
Describe a Type 2 MI
Ischaemia secondary to increased demand (e.g secondary to anaemia, tachycardia or hypotension)
50
Describe a Type 1 MI.
Traditional MI due to acute coronary event
51
Describe a Type 3 MI
Sudden cardiac death or arrest suggestive of ischaemic event
52
Describe a Type 4 MI
MI associated with procedures such as PCI, coronary stenting or CABG
53
Describe the presentation of a patient with Pericarditis.
(Name 2)
1.Chest pain (Sharp, central, worse with inspiration i.e Pleuritic, worse lying down, better sitting forward)
2.low grade fever
54
A patient presents with a low grade fever as well as sharp, central pain which worsens with inspiration and is worse lying down, yet improved when sitting forward.
What is the most likely diagnosis?
Pericarditis
55
What is the definition of
56
A patient presents with a low grade fever as well as sharp, central pain which worsens with inspiration and is worse lying down, yet improved when sitting forward.
What is the most likely diagnosis?
Pericarditis
56
What is the definition of Chronic Pericarditis?
Pericarditis usually resolves in a month but can reoccur - thus Chronic
57
What initial investigation should be done for a patient presenting with pleuritic pain and a low grade fever?
(Name 4)
1.Auscultation
2.Bloods (look for inflammation markers)
3.ECG
4.Echocardiogram to diagnose pericardial effusion
58
What findings would be expected upon auscultation of a patient with Pericarditis?
Pericardial rub
59
What findings would be expected from bloods of a patient with Pericarditis?
Raised inflammatory markers (CRP) and ESR (sedimentation)
60
What would be expected from an ECG of a patient with Pericarditis?
Saddle shaped ST elevation and PR depression.
61
What is the pharmacological treatment necessary for a patient with Pericarditis?
1.Aspirin (NSAIDs or Ibeprofen)
2.Colchicine (for around 3mnths)
+Treat underlying cause
62
Name 2 possible underlying causes for pericarditis.
TB and Renal failure
63
What is the pharmacological treatment necessary for a patient with Pericarditis?
1.Aspirin (NSAIDs or Ibeprofen)
2.Colchicine (for around 3mnths)
+Treat underlying cause
63
Name 2 possible underlying causes for pericarditis.
TB and Renal failure
64
A patient with Rheumatoid Arthiritis has been diagnosed with Pericarditis. What should now be prescribed?
Steroids e.g Prednisolone
65
When should a patient with Pericarditis be additionally prescribed Prednisolone?
If they have Rheumatoid Arthiritis
66
Describe the causes of Pericarditis.
-Inflammation of pericardium – most commonly due to Viral Infection (e.g TB, HIV, Epstein-Barr Virus) or Idiopathic (no cause)
-Other causes:
-Renal impairment,
-Methotrexate medications,
-Cancer,
-Autoimmune / Inflammatory conditions (e.g Lupus, Rheumatoid Arthritis)
67
What type of medications can cause Pericarditis?
Methotrexate medications
68
Describe the pathophysiology of Acute Ventricular Failure.
Due to issues with the Left Ventricle, blood is not being efficiently moved to systemic circulation causing backlog of blood in the left atrium, pulmonary veins and lungs. Increase of blood volume here causes these affected area to leak fluid and therefore caused pulmonary oedema.
69
Where does Acute Ventricular Failure cause backlog of blood?
(Name 3)
Left atrium, Pulmonary Veins and Lungs.
70
Name 5 potential triggers of Acute Left Ventricular Failure.
-MI
-Arrythmias
-Sepsis
-Hypertensive emergency (severe increase in blood pressure)
-Latrogenic (aggresive IV fluids in a frail elderly patinet with impaired left ventricular function
71
A 85 year old patient with chronic kidney disease and aortic stenosis is prescribed 2 L of fluid over 4hrs and has a drop in O2 saturation as well as feeling breathless. What would be the first course of action to immediately quell symptoms and why?
IV Furosemide
- Aggressive IV fluids could have been causing Acute Left Ventricular Failure
72
A patient presents with acute shortness of breath which exacerbates when lying flat and improves when sitting upright. They also have a cough producing frothy white/pink sputum. The patient also has type 1 respiratory failure. Patient has a history of arrhythmias.
What is the likely diagnosis?
Acute Left Ventricular Failure
73
Define Type 1 respiratory failure.
Low oxygen without an increase in Carbon Dioxide.
74
Describe auscultation findings of a patient with acute left ventricular failure.
-3rd heart sound
-Bilateral basal crackles of lungs
Way to remember:
LVF = 3
Back flow to lungs = Bilateral basal crackles of lungs
75
In a patient with acute left ventricular failure, how would the following be affected?
-Respiratory rate
-Oxygen saturation
-Blood pressure
-Heart rate
-Respiratory rate: Raised
-Oxygen saturation : Reduced
-BP : Low (Hypotension) *ONLY IN SEVERE CASES (Cardiogenic shock)
-Heart rate : Fast (Tachycardia)
76
Describe a typical presentation of a patient with Acute Left Ventricular Failure.
-Acute Shortness of breath
-Looking and feeling unwell
-Cough with frothy white or pink sputum
77
What additional findings on clinical assessment would you expect from a patient with Acute left Ventricular Failure who also has right sided heart failure?
(Name 2)
Raised JVP
Peripheral oedema
78
What are the initial investigations required for a patient presenting with symptoms of Acute Left Ventricular Failure?
-Clinical assessment
-ECG
-Bloods (BNP and Troponin)
-Arterial blood gas
-Chest Xray
-Echocardiogram
79
B-type Natriuretic Peptide is an indicator for which causes?
Name 6)
-Heart Failure
-Tachycardia
-Pulmonary embolism
-Renal impairment
-COPD
80
What is a key measure of left ventricular function and what is considered a 'normal' value?
Ejection fraction and above 50% is considered normal.
81
Describe the Chest Xray findings you would expect from a patient with Acute Left Ventricular Heart Failure.
1.Cardomegaly = Cardothoracic ratio of more than 0.5
2.Upper lobe diversion (increased diameter of upper lobe vessels)
Leaking fluid can also show:
1.Bilateral pleural effusions
2. Fluid in interlobar fissures
3.Kerley lines (fluid in the septal lines)
82
Describe the meaning of Cardomegaly.
Cardothoracic ratio of more than 0.5
83
Describe the meaning of Upper Lobe Diversion.
=Visible on Xray as increased prominence and diameter of the upper lobe vessels
A patient with conditions such as Acute Left Ventricular Failure when standing erect, the lower lobe veins contain more blood, and the upper lobe veins remain relatively small. In acute LVF, there is such a back-pressure that the upper lobe veins also fill with blood and become engorged. This is referred to as upper lobe diversion.
84
Describe 3 fluid leaking from oedematous lung tissue findings on Xray.
-Bilateral pleural effusions
-Fluid in interlobar fissures (between the lung lobes)
-Fluid in the septal lines (Kerley lines)
85
Describe the basic steps for management for a patient with Acute Left Ventricular Failure.
(Remember mneumonic)
SODIUM
S – Sit up
O – Oxygen
D – Diuretics (IV Furosemide)
I – Intravenous fluids should be stopped
U – Underlying causes need to be identified and treated (e.g., myocardial infarction)
M – Monitor fluid balance
86
What are Positive Inotropes and what are they used for?
i) Increase the contractility of the heart
ii)Used in patients with low cardiac output such as acute heart failure, recent MI or following heart surgery
87
How do positive inotropes affect Cardiac Output and Mean Arterial Pressure?
CO and MAP increases.
88
What are Vasopressors usually used for?
Anaesthetics - as a bolus dose or in the ICU as an infusion to improve BP
89
Examples of vassopressors?
Vasopressin, Epinephrine, Angiotensin II, Norepinephrine, Phenylephrine
90
What are examples of Positive Inotropes?
Digoxin, Epinephrine, Norepinephrine, Dopamine, Levosimendan
91
What are examples of Positive Inotropes?
Digoxin, Epinephrine, Norepinephrine, Dopamine, Levosimendan
92
Name the general causes of Chronic Heart Failure.
(Name 5)
1. Ischaemic heart disease
2. Valvular heart disease (commonly aortic stenosis)
3. Hypertension
4. Arrhythmias (commonly atrial fibrillation)
5. Cardiomyopathy
93
Describe the general presentation of a patient with Chronic Heart Failure.
(Name 6)
1.Breathlessness, worsened by exertion
2.Cough, which may produce frothy white/pink sputum
3.Orthopnoea, which is breathlessness when lying flat, relieved by sitting or standing (ask how many pillows they use)
4.Paroxysmal nocturnal dyspnoea
5.Peripheral oedema
6.Fatigue
94
What findings would you expect from an auscultation of a patient with Chronic Heart Failure?
-3rd Heart Sound
-Murmur
-Bilateral basal crackles on auscultation of the lungs (indicates pulmonary oedema)
-
95
How does Chronic Heart Failure affect heart rate, respiratory rate and JVP?
1.Tachycardia (raised HR)
2.Tachypnoea (raised resp rate)
3. Raised JVP
96
What are the general steps in establishing a diagnosis of Heart Failure?
1.Clinical Assessment
2.NT-proBNP blood test
3.ECG
4.Echocardiogram
5.Bloods for anaemia, renal function, thyroid function, liver function, lipids and diabetes
6.Chest Xray (to exclude lung pathology)
97
What does class 1 of Heart Failure mean?
No limitation on activity
98
What does class 2 of Heart Failure mean?
Comfortable at rest but symptomatic with ordinary activities
99
What does class 3 of Heart Failure mean?
Comfortable at rest but symptomatic with any activity
100
What does class 4 of Heart Failure mean?
Symptomatic at rest
101
A patient's NT-proBNP results have come back with a result between 400-2000ng/litre. What are the immediate next steps?
See Cardiology referral and have an Echocardiogram within 6 weeks.
102
A patient's NT-proBNP results have come back with a result above 2000ng/litre. What are the immediate next steps?
See Cardiology referral and have an Echocardiogram within 2 weeks.
103
What lifestyle choice is the main lifestyle choice to lead to Heart Failure?
Smoking
104
What are the first line medical treatments for Chronic Heart Failure?
(Remember the mneumonic)
BLAA*
Beta Blocker (e.g Bisoprolol) HIGH TITRATION
Loop Diuretics (Furosemide or Bumetanide)
ACE inhibitor (e.g Ramipril) HIGH TITRATION
*Aldosterone Antagonist (e.g Spironalctone or Eplernone)
-ONLY WHEN SYMPTOMS AREN'T CONTROLLED BY RAMIPRIL AND BISOPROLOL
105
A patient with a history of valvular heart disease has been diagnosed with Chronic Heart failure. What medication cannot be taken and what medication will they take instead?
Cannot take Ramipril (ACE Inhibitor )
Can take Candesartan (ARB)
-ARB instead
106
What needs to be regulary closely monitored when taking ACE Inhibitors?
U&E
107
What main electrolyte imbalance can be caused by ACE Inhibitors?
Potassium
108
Name a common underlying cause for Chronic Heart Failure.
Valvular Heart disease
109
What surgical intervention is commonly used for patients who previously has ventricular tachycardia or ventricular fibrillation?
Implantable Cardioverter defibrillators
110
A patient with severe heart failure has an ejection fraction of less that 35%. What surgical intervention will most likely be recommended?
Cardiac Resynchronisation Therapy
111
What is Cardiac Resynchronisation Therapy?
CRT involves biventricular (triple chamber) pacemakers, with leads in the right atrium, right ventricle and left ventricle. The objective is to synchronise the contractions in these chambers to optimise heart function.
112
What does Mitral Stenosis cause?
(Left or Right
Atria or Ventricle
Hypertrophy or Dilation)
Left Atrial Hypertrophy
113
What does Aortic stenosis cause?
(Left or Right
Atria or Ventricle
Hypertrophy or Dilation)
Left Ventricular Hypertrophy
114
What does Mitral regurgitation cause?
(Left or Right
Atria or Ventricle
Hypertrophy or Dilation)
Left atrial dilation
115
What does Aortic Regurgitation cause?
(Left or Right
Atria or Ventricle
Hypertrophy or Dilation)
Left ventricular dilation
116
What type of murmur does Aortic stenosis cause?
Ejection-systolic, high pitched murmur with crescendo-decrescendo character that radiates to the carotids
117
What type of murmur does Aortic stenosis cause?
Ejection-systolic, high pitched murmur with crescendo-decrescendo character that radiates to the carotids
118
Apart from auscultation what other clinical signs are there of Aortic Stenosis?
(Palpation, Pulse, BP etc)
Palpation : Thrills in aortic area
Pulse: Slow rising pulse
BP: Narrow pulse pressure (small difference between systolic and diastolic)
Exertional syncope (fainting when exercising)
119
What are the causes of Aortic Stenosis?
(Name 3)
-Bicuspid aortic valve
-Rheumatic heart disease
-Idiopathic age related calcification (most common cause)
120
What type of murmur does Aortic regurgitation cause?
i)Early diastolic, soft murmur
OR
ii)Austin-Flint murmur
=Rumbling murmur at Apex during Diastolic.
121
Apart from auscultation what other clinical signs are there of Aortic regurgitation?
Thrilling Wide Pulse Collapses
Palpation: Thrill in aortic area
Pulse: Collapsing pulse
BP: Wide pulse pressure
+Heart Failure and Pulmonary oedema
122
What type of murmur does Mitral stenosis cause?
Mid-diastolic, low pitched 'rumbling' murmur
(Loud S1 and snap sound after S2)
Remember:
My Sister Might Dance, Merrily Right Past Sunsets (3)
Mitral Stenosis Mid-Diastolic, Mitral Regurgitation Pan-systolic (S3 sound)
123
Apart from auscultation what other clinical signs are there of Mitral Stenosis?
-Tapping apex beat (prominent during S1)
-Malar flush
-Atrial fibrillation
MS TA, MF, AF
Mitral Stenosis Taps All Mother F**kers and Ass Flashers
124
Name 2 causes of Mitral stenosis.
-Rheumatic heart disease
-Infective endocarditis
125
What type of murmur does Mitral regurgitation cause?
Pan-systolic, high pitched 'whistling' murmur that radiates to the left axilla and potential S3
126
Apart from auscultation what other clinical signs are there of Mitral Regurgitation?
-Thrill
-Signs of heart failure and pulmonary oedema
-Atrial fibrillation
127
Name the causes of mitral regurgitation.
(Name 5)
1. Idiopathic weakening of the valve with age
2. Ischaemic heart disease
3. Infective endocarditis
4. Rheumatic heart disease
5. Connective tissue disorders, such as Ehlers-Danlos syndrome or Marfan syndrome
128
What type of murmur does Tricuspid Regurgitation cause?
Pan-Systolic Murmur with Split Second heart sound
Remember:
Might Sister Might Dance, Merrily Right To Rochester Past Sunset, And Sing Every Song
Mitral Stenosis Mid Diastolic, Mitral Regurgitation & Tricuspid Regurgitation Pan Systolic, Aortic Stenosis Ejection Systolic.
129
Apart from auscultation what other clinical signs are there of Tricuspid regurgitation?
(remember mneumonic)
TRAPP
-Thrill
-Raised JVP with Giant C-V waves
-Ascites
-Pulsatile Liver
-Peripheral Oedema
130
What are the causes of Tricuspid Regurgitation?
## Footnote
Remember mneumonic
Martians Let People Continue to Roam Everywhere on Earth
1.Marfan syndrome (and other connective tissue disorders)
2.Left sided heart failure
3.Pulmonary Hypertension
4.Carcinoid Syndrome
5.Rheumatic Heart Disease
5. Endocarditis (Infective)
6.Ebstein's Anomaly
131
What type of murmur does Pulmonary Stenosis cause?
-Ejection Systolic murmur loudest in the Pulmonary area with deep inspiration
-Widely Split second heart sound
Remember:
My Sister Might Dance, Merrily Right To Rochester Past Sunset, And Sing Pretty Songs Every Summer
Mitral Stenosis Mid-Diastolic, Mitral Regurgitation Tricuspid Regurgitation Pan-Systolic, Aortic Stenosis Pulmonary Stenosis Ejection Systolic
132
Apart from auscultation what other clinical signs are there of Pulmonary Stenosis?
-Thrill on pulmonary area
-Raised JVP
-Peripheral oedema
-Ascites
133
What is the usual cause of Pulmonary Stenosis and what is it usually associated with?
i)Congenital
ii)Noonan Syndrome and Tetralogy of Fallot
134
What are the 4 deformities of Tetralogy of Fallot?
1.Ventricular Septal Defect
2.Overriding Aorta
3.Pulmonary Valve Stenosis
4.Right Ventricular Hypertrophy
135
What are common risk factors for Infective Endocarditis?
-IV drug use
-Structural heart pathology
-Chronic kidney disease (particularly on dialysis)
-Immunocompromised (e.g., cancer, HIV or immunosuppressive medications)
-History of infective endocarditis
136
What structural pathologies can increase the risk of endocarditis?
-Valvular heart disease
-Congenital heart disease
-Hypertrophic cardiomyopathy
-Prosthetic heart valves
-Implantable cardiac devices (e.g., pacemakers)
137
What is the most common cause of Infective Endocarditis?
Staphylococcus aureus.
138
What other 2 causes are there of Infective Endocarditis (apart from the most common one)?
-Streptococcus
-Enterococcus (e.g., Enterococcus faecalis)
139
What are the (non-specific) of Infective Endocarditis?
-Fever
-Fatigue
-Night sweats
-Muscle aches
-Anorexia (loss of appetite)
140
What are the key examination findings of a patient with Infective Endocarditis?
(Name 8)
1. New or “changing” heart murmur
2. Splinter haemorrhages (thin red-brown lines along the fingernails)
3. Petechiae (small non-blanching red/brown spots) on the trunk, limbs, oral mucosa or conjunctiva
4. Janeway lesions (painless red flat macules on the palms of the hands and soles of the feet)
5. Osler’s nodes (tender red/purple nodules on the pads of the fingers and toes)
6. Roth spots (haemorrhages on the retina seen during fundoscopy)
7.Splenomegaly (in longstanding disease)
8.Finger clubbing (in longstanding disease)
141
What are Splinter Haemorrhages?
Thin red/brown lines along the fingernails
142
What are Petechiae?
Small non-blanching red/brown spots on the trunk, limbs, oral mucosa or conjuctiva
143
What are Janeway lesions?
Painless red flat macules on the palms of the hands and soles of the feet.
144
What are Osler's nodes?
Tender red/purple nodules on the pads of the fingers and toes.
145
What are Roth spots?
Haemorrhages on the retina seen during fundoscopy
146
What are the 2 key investigations central for diagnosing Infective Endocarditis?
1.Blood Cultures - 3 culture samples, 6hrs apart (can be shorter if antibiotics are required URGENTLY)
2.Echocardiography - Transoesophageal Echocardiography (TOE)
147
A patient with a prosthetic heart valve has suspected Infective Endocarditis. What is investigation procedure?
1.Blood cutlures (like with other patients)
2.Specialised Imaging
=i)F-FDG PET /CT
ii)SPECT -CT
148
What are the major criteria for Infective Endocarditis?
(Name 2)
-Persistantly positive blood cultures
-Specific imaging findings (e.g Vegetation see on the echocardiogram)
149
What is in the meaning of a Vegetation on an Echocardiogram?
Abnormal mass or collection on the heart valves.
150
What are the minor criteria or Infective Endocarditis?
(Name 5)
1.Predisposition: IV drug use or Heart Valve pathology
2.Fever above 38 degrees
3.Vascular Phenomena (Splenic infarction, Intracranial haemorrhage and Janeway lesions)
4. Immunological phenomena (e.g., Osler’s nodes, Roth spots and glomerulonephritis)
5.Microbiological phenomena (e.g., positive cultures not qualifying as a major criterion)
151
Give 3 examples of Vasular Phenomena.
1.Splenic infarction,
2. Intracranial haemorrhage 3. Janeway lesions
152
Give 3 examples of Immunological phenomena.
1.Osler nodes
2.Roth spots
3.Glomerulonephritis
153
Give an example of Microbiological phenomena.
Positive cultures not qualifying as major criteria
154
How many major and minor criteria are requIred for a diagnosis of Infective Endocarditis?
I) 1 MAJOR AND 3 MINOR
II) 5 MINOR
155
Describe the general management for Infective Endocarditis.
-Admission to hospital and referral to specialist
-IV antibiotics (e.g Amoxicillin and optional gentamicin)
156
How long do patients with Infective Endocarditis have to stay on IV antibiotics?
Normal heart- 4 weeks
Prosthetic heart - 6 weeks
157
Which patients with Infective Endocarditis will require surgery?
-Heart failure relating to valve pathology
-Large vegetations or abscesses
-Infections not responding to antibiotics
158
Infective Endocarditis has a high mortality. What are the key complications?
(Name 4)
1.Heart valve damage, causing regurgitation
2.Heart failure
3.Infective and non-infective emboli (causing abscesses, strokes and splenic infarction)
4.Glomerulonephritis, causing renal impairment
159
What is the pathophysiology of Hypertrophic Obstructive Caridopathy?
Autosomal Dominant
160
Patients with Hypertrohpic Obstructive Cardiomyopthy have an increased risk of...?
(Name 4)
1.Heart Failure
2.MI
3.Arrhythmias
4.Sudden Cardiac Death
161
What two areas of a clinical history are important to differentiate Hypertrophic Obstructive Cardiomyopathy?
Family History and Sudden Death
162
What are the main examination findings you would expect of a patient with Hypertrophic Obstructive Cardiomyopathy?
(Auscultation and Palpation)
1.Ejection systolic murmur at the lower left sternal border (louder with the valsalva manoeuvre)
2.Fourth heart sound
3.Thrill at the lower left sternal border
163
Apart from the main clinical examination findings, what additional examination findings confirm a diagnosis of Hypertrophic Obstructive Cardiomyopathy?
(Name 3)
1. Atrial fibrillation (irregularly irregular pulse)
2.Mitral regurgitation (high-pitched, pan-systolic
murmur)
3.Heart failure
164
What is the main investigation to establish Hypertrophic Obstructive Cardiomyopathy diagnosis?
Echocardiogram or Cardiac MRI.
165
What could you expect of an ECG of patient with Hypertrophic Obstructive Cardiomyopathy?
Left Ventricular Hypertrophy
166
What could you expect of a Chest Xray of a patient with Hypertrophic Obstructive Cardiomyopathy?
Normal
-Only show Pulmonary Oedema if Heart Failure is present
167
What are the management options for a patient with Hypertrophic Obstructive Cardiomyopathy?
(Start in order offirst line)
1. Beta Blockers
2.Surgical Myectomty (removal of part of heart)
3.Alcohol septal ablation (cathetar-based, minally invasive)
4.Implantable Cardioverter Defibrillator (only if at risk of sudden death)
5.Heart transplant
168
A patient is diagnosed with Hypertrophic Obstructive Cardiomyopathy. What medications must they stop taking?
ACE inhibitors and Nitrates
169
Name 5 possible prognosis outcomes of a patient with Hypertrophic Obstructive Cardiomyopathy.
1.Minimal symptoms and normal lifespan
2.Arrythmias (atrial fibrillation)
3.Mitral Regurgitation
4.Heart Failure
5.Sudden Cardiac Death
170
What are the common causes of Atrial Fibrillation?
(Remember mnemonic)
SMITH
Sepsis
Mitral valve pathology
Ischaemic heart disease
Thyrotoxicosis
Hypertension
171
What are the 2 main lifestyle causes of Atrial fibrillation?
Alcohol and Caffeine
172
What findings would you expect from an ECG of a patient with Atrial fibrillation?
-Absent P waves
-Narrow QRS
-Irregularly irregular ventricular rhythm
173
What is Paroxysmal Atrial Fibrillation?
Episodes of atrial fibrillation that reoccur and spontaneously resolve back to sinus rhythm. These episodes can last between 30 seconds and 48 hours.
174
What 2 investigations are key to confirming a suspected diagnosis of Paroxysmal Atrial Fibrillation?
-Holter Monitor (24hr ambulatory ECG)
-Cardiac event recorder for 1-2 weeks
175
What is the general combination of medications for treat Atrial Fibrillation?
Beta Blocker and Direct Oral Anticoagulant
e.g Bisoprolol and Dabigatran
176
An Asthmatic patient has been admitted to hospital following a stroke and has now been diagnosed with Atrial Fibrillation. What medications can they not take and what can they take instead for long term management?
Cannot : Beta blocker (contraindicated due to asthma)
Can:
-Calcium Channel Blocker (Diliazem or Verapamil)
-DOAC (Direct oral anticoagulant)
177
An 85 year old woman has been admitted to hospital following a stroke and has been diagnosed with Atrial Fibrillation. What medication must she also have and why?
Digoxin
=Only for sedentary people
(required risk of toxicity)
178
What treatment is generally prescribed to patients with Management of Paroxysmal Atrial Fibrillation?
Flecainide
179
What are the 2 surgical/procedural interventions if drug treatment for Atrial fibrillation doesn't work?
1.Left atrial ablation
2.Atrioventricular node ablation and a permanent pacemaker
180
Name 4 examples of Direct Oral Anticoagulants.
Dabigatran, Apixaban, and Edoxaban and Direct Factor Xa Inhibitor
181
A patient with Liver Failure has recently been diagnosed with Atrial Fibrillation. What medications can they not take and what can they take instead?
Cannot: DOACs (due to Hepatic impairment)
Can: Warafin
182
What agent is required to reverse the blood thinning effects of Apixaban and Rivaroxaban?
Andexanet Alfa
183
What agent is required to reverse the blood thinning effects of Monoclonal antibodies and Dabigatran?
Idarucizumab
184
Name 3 common indications of DOACs.
1.Stroke prevention
2.Deep Vein Thrombosis
3.Prophylaxis of Venous thromboembolism after hip of knee replacement
185
A patient with Atrial Fibrillation has a high stroke risk and cannot take anticoagulants. What is appropriate management?
Left Atrial Appendage Occlusion
186
A patient has an ECG with that is described as 'narrow complex tachycardia' with a narrow QRS complex. What is the general management?
1.Vagal Manoeuvres
2.Adenosine
3.Verapamil or a Beta Blocker
4.Synchronised DC cardioversion
187
What are the ECG changes in a patient with Wolff-Parkinson-White Syndrome?
-Short PR interval
-Wide QRS
-Delta wave (slurred upstroke in QRS complex)
188
What medications can a patient with Wolff-Parkinson-White syndrome take and not take?
Cannot: Adenosine, Verapamil or Beta blockers
Can: Procainamide
189
What is the usual medical management for Wolff-Parkinson-White syndrome ?
Procainamide
190
What arrhythmias can Radiofrequency Ablation permanently resolve?
-Atrial fibrillation
-Atrial Flutter
-Supraventricular tachycardias
-Wolff-Parkinson-White syndrome
191
What 2 rhythms in a pulseless patient is shockable?
1.Ventricular Tachycardia
2.Ventricular Fibrillation
192
What 2 rhythms in a pulseless patient are non-shockable?
1Pulseless electrical activity
2.Astyole
193
What type of Vasculitis presents with a purpuric rash affecting the lower limbs or buttocks in children?
Henoch-Schinlein Purpura
-Due to Immunoglobulin A
194
What are the four classic features of Henoch-Schonlein Purpura?
1.Purpura
2.Joint pain
3.Abdominal pain
4.Renal involvement
195
What are the triggers of Henoch-Schonlein Purpura?
1.Upper Airway infection e.g Tonsillitis
2.Gastroenteritis
196
What can 50% of Henoch-Schonlein patients also suffer from as a result?
IgA Nephritis
197
What is the general management for Henoch-Schonlein?
Simple analgesia, rest and hydration.
198
What type vasculitis usually presents with severe asthma in late teenage years or adulthood?
Eosinophilic Granulomatosis with Polyangiitis
aka Churg-Strauss
199
What is another name for Eosinophilic Granulomatosis with Polyangiitis ?
Churg-Strauss Syndrome
200
What is another name for Chur-Strauss Syndrome?
Eosinophilic Granulomatosis with Polyangiitis
201
What is a characteristic finding of a patient with Eosinophilic Granulomatosis with Polyangiitis?
Elevated eosinophil levels
202
What is the main feature of Microscopic polyangiitis?
Renal failure
203
Apart from the main feature of Microscopic Polyanigiitis, what are the other features?
Shortness of breath and Haemoptysis.
204
What organs does Granulomatosis with Polyangiitis affect?
Respiratory tract and kidneys
205
A patient comes in with Epistaxis and a cough. What type of vasculitis is this most likely to be and what is it usually misdiagnosed for?
i)Granulomatosis with Polyangiitis
ii)Misdiagnosed as pneumonia
206
What can Granulomatosis with Polyangiitis cause? Note that it will be rapidly progressing.
Glomerulonephritis
(kidneys)
207
What are the main symptoms of Granulomatosis with Polyangiitis ?
(Name 7)
1.Epistaxis (nose bleeds)
2.Crusty nasal secretions
3.Hearing loss
3.Sinusitis
4.Saddle shaped nose (perforated nasal septum)P
5.Cough
6.Wheeze
7.Haemoptysis
208
What is Polyarteritis Nodosa related to?
Hepatitis B
(sometimes Hep C and HIV)
209
What parts of the body does Polyarteritis Nodosa affect?
Skin, GI tract, Kidneys and Heart
210
What 2 serious issues can Polyarteritis Nodosa cause?
Renal impairment and MI
211
What rash is Polyarteritis Nodosa associated with?
Livedo Reticularis
=Mottled purplis, lace like rash
212
A child aged 3 years old presents with a persistent high fever, Erythematous rash and Strawberry tongue. What is the most likely diagnosis?
Kawasaki Disease
=Medium vessel vasculitis
213
List the main clinical features of Kawasaki Disease.
(Name 7)
-Presents in children under 5 years old
-Persistent high fever for more than 5days
-Erythematous rash
-Bilateral Conjuctivitis
-Erythema
-Desquamation (skin peeling) of palms and soles
-Strawberry tongue (red tongue with prominent papillae)
214
What is a key complication of Kawasaki disease?
Coronary Artery Aneurysm
215
What is the general treatment for Kawasaki disease?
Aspirin and IV immunoglobulins
216
What is the main investigation to confirm a diagnosis to Takayasu's arteritis?
CT or MRI angiography
(additionally do a Doppler)
217
What vessel does Takayasu's arteritis usually affect?
-Large vessels mainly Aorta
218
What are the general symptoms of Takayasu's arteritis?
Non-specific systemic symptoms
-Fever
-malaise
-Muscle aches
-Arm claudication
-Syncope
219
What does a p-ANCA blood test diagnose?
2 types of Vasculitis:
=Microscopic Polyangiitis and Churg-Strauss Syndrome
220
What does a c-ANCA blood test diagnose?
Granulomatosis with Polyangiitis
221
What is another name for a P-ANCA test?
Anti-MPO antibodies
222
What is another name for a C-ANCA test?
Anti-PR3 antibodies
223
What does an ANCA test stand for?
Anti-Neutrophil Cytoplasmic Antibodies
224
A patient has suspected Vasculitis. What referral is necessary here?
Rheumatology
225
What is the general combination of medications for managing Vasculitis?
Steroids and Immunosupressants
226
What is the pathophysiology of Rheumatic Fever?
Multi-system disorder that is an Autoimmune condition triggered by Streptococcus bacteria as the antibodies created against the bacteria also target the tissues in the body.
227
What bacteria is Rheumatic fever caused by?
Group A beta-haemolytic streptococcal
=Streptococcus Pyogenes
(that cause Tonsillitis)
228
How long after an initial infection would Rheumatic fever develop?
2-4 weeks
229
What is the typical presentation of a patient with Rheumatic Fever?
-2-4 weeks after Tonsilitis
-Fever
-Joint pain
-Rash
-Shortness of breath
-Chorea (irregular, uncontrolled rapid movements of limbs)
-Nodules
230
What are the 2 key skin findings from a patient with Rheumatic fever?
-Subcutaneous nodules (Firm painless nodules)
-Erythema marginatum rash (pink rings over torso and proximal limbs)
231
What investigations are necessary for a patient with suspected Rheumatic Fever?
-Throat swab for bacterial culture
-ASO antibody titres
-Echocardiogram, ECG and chest xray can assess the heart involvement
232
What antibodies would be present during Rheumatic fever?
Anti-streptococcal antibodies (ASO)
233
What treatment is necessary for a patient with Rheumatic Fever?
Treat Tonsillitis:
-Phenoxymethylpenicillin (penicillin V) for 10 days
Joint pain:
NSAIDs
Carditis:
Aspirin and Steroids
Prophylaxis (prevent further infections):
-Oral or Intramuscular Penicillin
234
What are the possible complications of Rheumatic Fever?
-Recurrence of rheumatic fever
-Valvular heart disease, most notably mitral stenosis
-Chronic heart failure
235
How does Rheumatic fever affect the joints?
=Migratory Arthiritis affecting large joints with hot, swollen, painful joints
Migratory means different joints affected at different times
236
How does Rheumatic Fever affect the Heart?
(Include heart rate, auscultation findings)
Inflammation of the heart = Carditis
Tachycardia or bradycardia
Murmurs from valvular heart disease, typically mitral valve disease
Pericardial rub on auscultation
Heart failure
237
What is the main finding you would expect from an ECG of patient with Rheumatic Fever?
Prolonged PR interval
238
What is the immediate treatment for a patient with Rheumatic Fever?
-Admit to hospital + Bed rest
-Intramuscular benzylpenicillin
-Oral Aspirin
-After commence on 10 day course of penicillin
239
A patient is in hospital following a Coronary Artery Bypass Grafting (CABG) surgery and is not presenting with Cardiogenic Shock. What are the 4 initial steps and what drug is contraindicated?
Cannot: B-Blockers
Can:
1.Inotropic Support
2.Repeat Coronary Angiography
3.Urgent Echo
4.Transfer to Cardiothoracic surgerical centre
240
Define Cardiomegaly.
Heart is larger than half of the width of the chest on CXR.
241
What is the most likely cause of bloody pericardial effusion?
Malignancy
242
A patient has Pericarditis and requires Pericardiocentesis. Where should the needle be inserted?
Subcostally in the midline aiming towards the left shoulder between the 5th and 6th ribs on the left side.
243
How would a left bundle branch block show on an ECG?
Prolongation of all QRS complexes
244
What is usually seen with Aortic Stenosis?
Left/Right
Atrial/Ventricular
Hypertrophy/Hypotrophy
Left Ventricular Hypertrophy
245
What immediate treatment would be given to a patient to immediately cease Tachycardia?
IV Bolus Adenosine
246
What manoeuvres will activate the Vagus Nerve to slow down the conduction of the AV Node required for arrhythmias.
-Valsalva (sticking fingers down throat against glottis)
-Diving Reflex (face in ice cold water)
-Pressing hard on eyeballs
-Carotid Sinus Massage
247
248
What is given instead to a patient who is allergic to Furosemide?
Ethacrynic acid
(is a loop diuretic which can be used in patients allergic to sulfa drugs (e.g. furosemide and bumetanide))
249
What is Rhabdomyolysis?
Destruction of muscle cells (causing significant rise in Creatinine Kinase)
presenting as:
-intense muscle aching or swelling.
-muscle weakness or stiffness.
-feeling generally exhausted.
-dark red or brown urine, or very little or no urine.
-fever.
-nausea and vomiting.
250
What drug interaction can induce Rhabdomyolysis?
Statins (and Amiodarone)
251
What is Amiodarone used for?
Atrial Fibrillation
252
What drug is given as an alternative to Warafin and required less monitoring?
Dabigatran
253
What results of a histology analysis would you expect from a patient with Rheumatic Disease?
Granulomatous nodules consisting of giant cells around areas of fibrinoid necrosis in the heart of the patient.
254
Rheumatic disease can be caused by what organism?
Streptococcus pyogenes
=causes pharyngeal infections that eventually lead to Rheumatic Heart Disease
255
Histiologically, describe the start and end of development of Atherosclerosis.
Start:
=Thickening of the tunica intima
End:
=Smooth muscle cells from the tunica media start to proliferative and migrate into the tunica intima.
256
A patient is being prescribed an ACEinhibitor (Ramipril). What should you advise them against as it will interfere with the absorption of the drug?
Don't take ANTACIDS
257
A patient presents at the ER with a Hypertensive Emergency. What should be given?
Hydralazine
=it increases cAMP which increases smooth muscle relaxation
258
What is Kawasaki Disease?
A serious condition that affects young children damaging blood vessels throughout the body with the worrying complication of Coronary Artery Aneurysm
259
What is a classical presentation of Kawasaki Disease?
Child under 5:
1.Fever persisting for more than 5 days
2. Rash (widespread erythematous maculopapular rash)
3.Strawberry tongue
4.Lymphadenopathy 5.Conjunctivitis
260
What is presentation of Deep Vein Thrombosis?
-Unilateral warmth and swelling in calf or thigh
-Pain on palpation of deep veins
-Distention of superficial veins
261
How do you calculate the probability of a patient have Deep Vein Thrombosis?
Well score. A score >2 is likely to be DVT
1.Active cancer = 1
2.Treatment or palliation within 6 months = 1
3.Bedridden recently >3 days or major surgery within 12 weeks = 1
4.Calf swelling >3 cm compared to the other leg (Measured 10 cm below tibial tuberosity) = 1
5.Collateral (non-varicose) superficial veins present = 1
6.Entire leg swollen = 1
7.Localised tenderness along the deep venous system = 1
8.Pitting edema, confined to symptomatic leg = 1
9.Paralysis, paresis, or recent plaster immobilization of the lower extremity = 1
10.Previously documented DVT = 1
11.An alternative diagnosis is at least as likely as DVT = -2
262
If someone's well score is >2, what does that mean and what should be done next?
Deep Vein Thrombosis is likely
=Ultrasound doppler of the proximal leg veins within 4 hours
(do D-dimer if this can't be done within 4hrs)
