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MRCP Part 1 > General Medicine: Cardio > Flashcards

General Medicine: Cardio Flashcards

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1
Q

Patient with BP of 145/96, what investigation findings would confirm a diagnosis of HTN?

A

ABPM reading of >=135/85

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2
Q

How do you manage a patient with BP >180/110

A

Start drugs immediately
Same day referral if
- retinal haemorrhage
- Life-threatening symptoms
- Suspected phaeochromocytoma

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3
Q

For HTN who gets the following first line
ACEi/ARB
CCB

A

A: <55yrs, T2DM
C: >55yrs, Black

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4
Q

What do you give after first line treatments for HTN?

A

A+C/D
A+C+D

If black, give ARB over ACEi

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5
Q

After triple therapy, how d you determine what drug to add for HTN?

A

LD spironolactone <= K+ @4.5 < a/B blocker

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6
Q

What are the blood pressure targets (clinic + ABPM) for
<80yrs
>80yrs

A

<80yrs
Clinic <140/90mmHg
ABPM <135/85mmHg
>80yrs
Clinic <150/90mmHg
ABPM < 145/85mmHg

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7
Q

What antihypertensive drug causes
Gout
Cough
High blood glucose
Headaches
Hypotension
Cold peripheries
Postural hypotension

A

Gout, glucose: thiazide
Cough: ACEi
Headache: CCBs
Hypotension: nd-CCBs
Cold peripheries: B-blockers, bronchospasm
Postural hypertension: doxazosin

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8
Q

How is stable angina different from acute coronary syndrome?

A

Chest tightness only present on exertion

Settles within 5 mins of rest

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9
Q

What investigation findings would you see for stable angina

A

cardiac markers and ECG normal

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10
Q

What entails symptom control in stable angina?

A

Mono: Nd-CCB OR B-blocker
Combo: d-CCB + B-blocker
+ GTN to relieve attacks

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11
Q

What drugs can you give for angina if CCBs or BBs not tolerated?

A

Nitrates
Ivabradine
Ranolazine
Nicorandil

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12
Q

How do you reduce chances of cardioembolism in stable angina

A

Aspirin + Statin

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13
Q

What are the risk factors for ACS?

A

2 non-modifiable

Age, Male

3-4 modifiable

Diabetes

Lifestyle (obesity, smoking, alcohol)

Hypertension

Hyperlipidaemia

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14
Q

How does unstable angina differ from other ACS types

A

No cardiac markers, no ECG changes

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15
Q

What ECG changes are seen in an NSTEMI?

A

ST-depression

T wave inversion

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16
Q

Whaat criteria must ST elevation meet for it to be a STEMI?

A

>1mm in 2 limbs

>2mm in a chest

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17
Q

Outline STEMI management

A

Aspirin 300mg

<120 mins: PCI

Give prasurgel (clopidogrel if already anticoagulated)

Stent or revascularise (if mutlivessel disease)

>120 mins: Fibrinolysis

Give ticagrelor + aspirin (aspirin +/- clopidogrel if high bleed risk)

Assess PCI need

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18
Q

Outline initial NSTEMI management for

<=3% mortality

>3% mortality

A

Aspirin 300mg

Fondapirinux (UFH if creat >265)

GRACE <=3% mortality

Ticagrelor + aspirin (aspirin +/-clopidogrel if high bleed risk)

GRACE >3% risk

Angiography: immediate if unstable, <72hrs otherwise

Prasurgel/tigagrelor, + aspirin (UFH during PCI)

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19
Q

What entails secondary prevention in ACS?

A

Risk factor modification

Aspirin 75mg + clopidogrel >= 12 months

Anticoagulate with LMWH until discharge

B-blokcade

80mg atorvostatin

+ ACEIs if LV dysfunction, HT, or DM

+ if echo <40% function: eplernone

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20
Q

What features carry a particularly poor prognosis for an ACS patient?

A

Frank pulmonary oedema (38%)

Features of cardiogenic shock (81%)

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21
Q

Chest pain relieved on sitting forwards and a pericardial rub indiate which condition?

A

Acute pericarditis

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22
Q

What are the ECG changes seen in acute pericarditis?

A

Widespread ST elevation, ‘saddle shaped’

PR depression is quite specific

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23
Q

What are the causes of pericarditis

A

Infections: Viral, TB

Tissue damage: trauma, MI (dressler’s)

Cancer

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24
Q

For pericarditis, what is the

Definitive investigation

Treatment

A

TT echo

NSAIDs + colchicine

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25
How do you treat a tachycardia in a haemodynamically compromised patient?
up to 3 synchronised shocks +/- amiodarone
26
What control is typically offered first in AF?
Rate control 1. B-blocker (not sotalol) OR nd-CCB (if not in heart failiure) OR digoxin (if sedentary, others CI) 2. Combo of 2 above
27
Who gets rhythm control... Generally Before rate control
Generally if... Symptoms persist despite rate-control strategy Before rate if - Reversible cause - new onset - Ablation would help - Clinical judgement
28
How do you manage acutely presenting AF that is \<48hrs \>48hrs Unstable
\<48hrs: Electrical\* OR Flecainide/amiodarone cardioversion \>48hrs: Electrical cardioversion\* +/- 4 weeks amiodarone/sotalol before, continuing for up to 12 months Unstable: Shock \*Anticoagulate for 4 weeks after electrical cardioversion\*
29
What do you offer if rhythm control of AF is not successful/wanted?
Left atrial ablation 4 weeks anticoagulation before + 3 months antiarrhythmic treatment after to prevent again
30
What drugs are used in maintaining rhythm control in AF?
B-blockers Dronendarone: 2nd line if cardioverted Amiodarone: If co-existing HF
31
How do you anticoagulate in acute AF?
Heparin if new acute AF DOACs if confirmed, high recurrence risk
32
How is AF anticoagulated post stroke
Aspirin for 2 weeks Then warfarin/DOAC
33
How can you distinguish between Fast AF and SVT
SVT regular and has p-waves
34
How do you treat SVTs
Valsalva manourvre Carotid massage Adenosine: Rapid 6mg bolus --\> 12mg more --\> 18mg more (verapamil if adenosine contraindicated) Cardioversion
35
How is atrial flutter distinguished from other tachycardias? How do you treat it?
P:QRS complexes 2:1 HR tends to hit 50s (eg 150, 200, 250) Electrical cardioversion If fails: Ablate tricuspid valve isthmus
36
Is this VF or VT?
VT VT: Very Tidy VF: Very Funny (see pic)
37
How do you treat ventricular tachycardia?
Unstable: Shock Stable Amiodarone/lidocaine/procainamide Get electrophysiology + ICD if fails
38
What drug is avoided in VT?
Verapamil Dampens normal SA node so promotes aberrant circuit .'. risk of Vfib
39
Slurred QRS, predominant R wave in V1 and Inverted T waves (inferior leads) are features in which condition?
Wolff-Parkinson-White syndrome
40
For Wolff-Parkinson-White what drugs do you... Give Avoid
Give: Amiodarone, flecainide + refer for ablation Avoid: Digoxin, verapamil and bisoprolol
41
How do you distinguish between the AV blocks
1st: Consistent PR \>0.2 2 type I: Progressive PR lengthening, dropped beat 2 type II: No progression, 2-3 Ps : QRS 3rd: No association between Ps and QRS
42
How is sinus bradycardia/complete heart block treated?
Acute: ABCDE Atropine 0.5mg IV every 2-3 mins Correct precipitants Chronic 24hr taping + pacemaker
43
What drugs can precipitate bradycardia
B-blockers nd-CCBs Digoxin Ivabradine a-agonists
44
What does this show?
Left bundle branch block WiLLaM V1: 'W'/rS V6: 'M'/R
45
What does this show?
Right bundle branch block MoRRoW V1: M (RsR) V6: W (qRS)
46
What is more worrying LBBB, RBBB
LBBB IS ALWAYS PATHOLOGICAL RBBB can be normal variant but acute resp/cardiac stuff can have it
47
How does a chronic heart failure patient present?
Breathlessness: Exertion, lying flat Coughing: Worse at night, wheezy Signs: Raised JVP, oedema
48
For suspected heart failure what is the first line investigation and how does this guide further investigation?
NT-proBNP 400-2000pgml (47-236pmol/L): Raised \>2000pgml (236pmol/L): High Raised: 6 week echo High: Urgent
49
What is the management of chronic heart failure?
1. B-blocker + ACE inihibitor 2. + Aldosterone antagonist (spironolactone, eplernone), MONITOR POTASSIUM
50
Failing initial management of chronic heart failure, when would you use Ivabradine Sacubitril-valsartan Digoxin Hydralazine
I: LVEF \<35% + sinus \>75/min S: LVEF \<35% + symptoms on other therapy D: Coexistent AF H: Afro-Carribbean
51
Acute shortness of breath with pink sputum, bibasal creps and 3rd heart sound indicative of what?
Acute heart failure
52
What does a firm, smooth, tender liver that can be pulsatile indicate?
Right heart failure
53
What investigations should you perform in acute heart failure?
BNP to rule it out CXR cardiothoracic ratio \>0.5 Echo to assess ejection fraction
54
What is the management of acute heart failure?
POUR SOD POUR away fluids Sit up Oxygen Diuretics (40mg IV furosemide)
55
Match the features to its cardiomyopathy Mitral regurgitation, anterior valve motion Alcohol, B1, reduced output Scarring procedures QRS notching in a fatty heart 39 weeks --\> 5 months post partum Stress
HOCM Dilated Restrictive ARVD Peripartum Takutsubo
56
When do you treat aortic stenosis? How do you treat it?
Symptomatic OR \>=40mmHg gradient Valve replacement if well Balloon valvuloplasty if unsuitable or children without calcification
57
What is the cause and treatment of rheumatic fever?
S.pyogenes Pen V 10 days
58
What electrolyte imbalance causes Small T-waves, U waves PR prolonged ST depression
Hypokalaemia (or magnasaemia)
59
What electrolyte imbalance gives the following ECG changes Prolonged QT
Hypocalcaemia Twitching, depression, cataracts are all features
60
What electrolyte disturbance shows the following Broad QRS Tall Tented T waves
Hyperkalaemia
61
What is the treatment for Hypocalcaemia?
IV Ca gluconate 10% 10ml 10 mins
62
What is the treatment for hyperkalaemia?
**Stabilise:** IV Ca gluconate **Shift:** insulin/dextrose + salbutamol **Send:** Ca resonium/ haemodialysis/diuretics
63
What is the treatment for hypomagnasaemia?
\<0.4mmol/L: IV MgSO4 over 24hrs \>0.4mmol/L: 10-20ml oral salts
64
Muffled heart sounds, raised JVP and hypotension indicates what cardiac condition?
Cardiac tamponade
65
How can you differentiate between constrictive pericarditis and cardiac tamponade? JVP Pulsus parodoxus Kussmaul's sign Characteristic features
Tamponade // Constrictive pericarditis X (tampaX) // X + Y Present // Absent Rare // Present Electrical alternans // Pericardial calcification on CXR
66
How do you treat cardiac tamponade
Pericardiocentesis
67
Which members of the following drug groups cause QT prolongation? Antibiotics Antidepressants Anti-psychotics Anti-emetics Opioid replacement Anti-arrhythmics
Erythromycin TCAs, SSRIs (citalopram) Haloperidol Odansetron Methadone Amiodarone, quinidine, sotalol
68
What condition presents with severe dyspnoea, often triggered by exertion?
HOCM Autosomal dominant
69
Outline PE anticoagulation where Provoked Unprovoked or cancer Unstable
3 Months DOAC (Heparin then VKA if renal impairment) +/3 further 3 months if bleeding risk allows 6 months DOAC Thrombolysis
70
How is adenosine administered?
16G cannula in right ACF vein or centrally
71
How do you treat aortic dissection if its Proximal/ascending aorta Distal/Descending
Proximal is type A: ASS Aortic root replacement Systolic BP 100-120 Surgery Type B: BooBs Bed rest + Beta blockers
72
As distended neck veins and hypotension are common, how do you distinguish between haemothorax and tamponade?
Haemothorax has reduced breath sounds on affected side Due to blood build up
73
How do you treat Mobitz II block?
Pacemaker
74
Which cardiac drug reduces hypo awareness?
B-blockers Reduces the physical symptoms (eg shaking)
75
Which cardiac marker is helpful to look for reinfarction 4-10 days from initial insult?
CK-MB Only elevated 3-4 days post event whereas troponin is 10 days, so CK-MB will spike again
76
What pulse changes are seen in aortic dissection?
Absent carotid, brachial or femoral pulses Arm pressure difference \>=20mmHg
77
What vaccinations are offered in heart failure
Yearly flu Single pneumococcal
78
How can AR and MS be differentiated by timing and conditions?
AR: Early diastolic, rheumatic fever MS: mid-late diastolic, **rheumatic fever**
79
How do thiazide and loop diuretics differ in terms of electrolyte imbalances?
Thiazides cause hypercalcaemia Loop cause hypocalcaemia
80
J-waves are seen in what acute condition?
Hypothermia
81
How do ACEis affect potassium levels?
Increase K+ as they reduce Na+
82
When does tachycardia require DC cardioversion?
Shock MI Heart failure
83
What do if haem instability and on warfarin?
Stop Warfarin Give vit K PCC/ FFP if not available
84
How do you manage a warfarin INR \>8.0 if... Minor bleeding No bleeding
Both get Stop warfarin Give Vit K\*, repeat if still high after 24 hrs Restart warfarin when \<5.0 **Minor bleed dose: 1-3mg** **No bleed dose: 1-5mg, give IV prep orally**
85
How does management of warfarin INR of 5.0-8.0 differ where Minor No bleed
Minor Stop warfarin, 1-3mg vit K, restart at 5.0 No bleed Withhold 1-2 doses Reduce subsequent maintenance
86
DVT causing stroke in patient with systolic murmur?
Atrial septal defect Allows embolism to bypass lungs to get to brain instead
87
What causes an S2 that is Loud Reverse split Widely split Fixed split Soft
Hypertension LBBB/Severe aortic stenosis RBBB Atrial septal defect Aortic stenosis
88
How do tricuspid regurg and mitral stenosis differ?
TR is systolic, MS is diastolic TR louder on inspiration, MS quieter
89
Persitent ST elevation following MI indicates what complication?
LV thromboembolism Blood stagnation in LV causes thombus formation
90
What anticoagulation is used for heart valves?
Warfarin Bioprosthetic: 3 months then aspirin if needed Mechanical: Warfarin with INR of 3.0 (aortic), 3.5 (mitral)
91
Sudden pan-systolic murmur following MI indicates what?
Acute mitral valve regurgitation Secondary to flash pulmonary oedema
92
How to separate pulomary stenosis and aortic stenosis?
Pulmonary louder on inspiration Aortic louder on expiratory
93
What post-MI complication can present similarly to cardiac tamponade?
Left ventricular free wall rupture
94
How can the R-R interval help determine what degree of heart block is present?
If the RR is not constant then its likely Mobitz II Since there is a dropped beat in there somewhere

MRCP Part 1 (32 decks)

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