Medicine - Cardiology Flashcards
(265 cards)
1
Q
Recall 2 observations about a person’s pulse that may be seen if they have aortic stenosis vs aortic regurgitation
A
Aortic stenosis: NARROW pulse pressure, slow rising pulse
Aortic regurgitation: WIDE pulse pressure, ‘waterhammer’ pulse (Corrigan’s pulse)
Pulse pressure = SBP-DBP (eg if BP = 120/80, PP = 40)
2
Q
Define hypertension
A
Clinical BP >140/90 mmHg
or
24h BP average >135/85 mmHg
3
Q
List 4 renal causes of secondary hypertension
A
Glomerulonephritis
Chronic pyelonephritis
Adult PKD
Renal artery stenosis
4
Q
List 6 endocrine causes of secondary hypertension
A
Primary hyperaldosteronism
Phaeochromocytoma
Cushing’s syndrome
Liddle’s syndrome
Congenital adrenal hyperplasia
Acromegaly
5
Q
List 5 other causes of secondary hypertension
A
Pregnancy
COCP
Coarctation of the aorta
NSAIDS
Glucocorticoids
6
Q
List 3 symptoms that may be experienced from sever hypertension e.g. 200/120 mmHg
A
Headaches
Visual disturbance
Seizures
7
Q
What investigations can be used to detect end-organ damage in hypertension?
A
Fundoscopy: hypertensive retinopathy
Urine dip: renal disease (cause/ consequence)
ECG: LV hypertrophy/ ischaemic heart disease
8
Q
What bloods should be performed following hypertension diagnosis?
A
U+Es: renal disease (cause/ consequence)
HbA1c: co-existing DM
Lipids: co-existing hyperlipidaemia
9
Q
List 3 common side effects of ACE inhibitors
A
Cough
Angioedema
Hyperkalaemia
10
Q
What monitoring requirement applies to ACE inhibitors?
A
Renal function must be checked 2-3w after initiation due to risk of worsening renal function in patients with renovascular disease
11
Q
3 side effects of calcium channel blockers
A
Flushing
Ankle swelling
Headache
12
Q
MOA of thiazide type diuretics
A
Inhibit sodium absorption at the beginning of the distal convoluted tubule
13
Q
3 side effects of thiazide type diuretics
A
Hyponatraemia
Hypokalaemia
Dehydration
14
Q
Name 1 side effect of angiotensin II receptor blockers
A
Hyperkalaemia
15
Q
How would you describe the heart sounds that are auscultated in aortic stenosis vs regurgitation?
A
Aortic stenosis = soft S2 +/- S4
Aortic regurgitation = soft S2 +/- S3
16
Q
What is the difference in cause between an S3 and S4 heart sound?
A
S3 heart sound is caused by blood filling against a non-compliant ventricle, whereas S4 is blood filling against a compliant ventricle
17
Q
How can you hear the difference between an S3 and S4 heart sound?
A
S3 is early diastolic
S4 is late diastolic
18
Q
What clinical examination findings can help differentiate aortic stenosis caused by valve sclerosis from aortic stenosis caused by HOCM?
A
In HOCM, the valsalva manoevre increases the volume of the murmur, whereas squatting decreases it
19
Q
What might a CXR reveal in aortic stenosis?
A
Left ventricular hypertrophy
Pulmonary oedema
Valve calcification
20
Q
What is the most useful investigation for assessing the severity of aortic stenosis?
A
Echo +/- doppler
21
Q
Recall some general principles of management of heart valve disease
A
QRISK3 score to stratify risk
Manage risk with a statin (eg atorvastatin) and an antiplatelet (aspirin/ clopidogrel)
Manage coexistent HTN/ angina etc
22
Q
Recall some indications for open replacement of the aortic valve (rather than cath lab procedure)
A
Symptomatic
Non-symptomatic with a low EF
Severe undergoing CABG
23
Q
What does CABG stand for?
A
Coronary artery bypass graft
24
Q
What are the 2 main types of artificial aortic valve?
A
Ball-in-cage
Bileaflet/ tilting disc
25
Recall some pros and cons of TAVI
Pros: no bypass required, no large scars
Cons: higher risk of stroke compared to open replacement
26
What is a balloon aortic valvuloplasty
Procedure which stretches the aortic valve to improve symptoms of aortic stenosis
27
When is the aortic stenosis murmur heard vs aortic regurgitation?
AS: Ejection systolic
AR: Early diastolic
28
What is an Austin Flint murmur?
'Rumbling diastolic murmur'
- Associated with severe aortic regurgitation
- Best auscultated in 5th ICS in MCL
- Caused by blood flowing back through the aortic valve and over the mitral valve
29
When in the heart cycle is an Austin flint murmur heard, and what causes it?
Mid-diastole
Caused by regurgitant jet that runs over the mitral valve leaflets
30
Which heart murmurs are best heard on expiration?
Left heart murmurs
31
Where is the aortic regurgitation murmur best auscultated?
Erb's point - Left 3rd ICS parasternal
32
Where is the main site of production of BNP?
Left ventricle (not actually brain, as name may suggest)
33
What is the advantage of measuring NT-proBNP over BNP?
NT-proBNP has a much longer half life as it is inactive - BNP, being an active hormone, has a much shorter half life
34
What can an echo and doppler be used to determine in cases of aortic regurgitation?
Severity
LV function
Cause
35
What is the mainstay of medical management for aortic regurgitation (other than managing cardiac risk with statins etc)?
Reduce afterload - can use:
ACE inhibitors (eg enalopril/ captopril)
Beta blockers (bisoprolol etc)
Diuretics (furosemide etc)
36
Which 2 antihypertensives are contra-indicated in aortic stenosis?
Beta blockers (don't want to depress LV function)
Nitrates (may precipitate life-thretening hypotension)
37
Which heart murmur is most associated with atrial fibrillation?
Mitral stenosis
38
Which of the left heart murmurs will NOT produce a displaced apex beat?
Mitral stenosis (causes atrial hypertrophy not ventricular)
39
By what mechanism can heart valve disease cause a parasternal heave, and which murmurs can cause this?
Right ventricular hypertrophy (RVH) is cause of PSH (RV is most anterior chamber of the heart so can cause heave)
MS and MR can cause RVH - as increased left atrial pressure --\> pulmonary HTN --\> RVH
40
Why might the apex beat be displaced in mitral regurgitation?
Left ventricle is pumping the stroke volume AND the regurgitant volume
41
Differentiate the timing of mitral stenosis and mitral regurgitation
Mitral stenosis is a MID DIAstolic murmur
Mitral regurgitation is a pan SYStolic murmur
42
Which of the heart murmurs might radiate to the axilla?
Mitral regurgitation
43
Recall some clinical signs of pulmonary hypertension
Malar flush
Raised JVP
Right ventricular (parasternal) heave
Loud S2
44
What might be seen on an ECG in mitral valve disease
```
Atrial fibrillation
P mitrale (bifid 'm-shaped' p waves in lead II as well as V1-V6)
```
45
What is the mainstay of medical management for mitral stenosis, other than heart disease risk modification eg statins?
RhF prophylaxis with benzylpenicillin
AF (rate control + DOAC)
Diuretics for symptomatic relief
46
What is the first line surgical treatment for mitral stenosis?
Balloon valvuloplasty
47
What is the mainstay of medical management for mitral regurgitation (other than managing cardiac risk with statins etc)?
Like AR, reduce afterload - can use:
ACE inhibitors (eg enalopril/ captopril)
Beta blockers (bisoprolol etc)
Diuretics (furosemide etc)
48
What are the classifications of heart failure based on ejection fraction?
LV EF >50% - preserved = HF-PEF
LV EF 41-49% - mildly reduced = HFmrEF
LV EF <40% - reduced = HFrEF
49
What are the 3 most common causes of chronic heart failure?
Coronary artery disease
DM
HTN
50
List 4 cardiac causes of heart failure
Valvular disease e.g. aortic stenosis
Cardiomyopathies
Constrictive pericarditis
Arrhythmias e.g. AF
51
What is heart failure?
Syndrome with typical Sx (SOB, ankle swelling, fatigue) + signs (elevated JVP, basal crepitations + peripheral oedema)
52
Give 4 symptoms of chronic heart failure
Breathlessness: exertional, rest, orthopnoea, PND
Fluid retention: ankle swelling, bloating, weight gain
Fatigue: decreased exercise tolerance/ increased recovery time
Lightheadedness/ hx of syncope
53
Give 3 signs of heart failure on examination
Tachycardia
S3/S4 gallop
Pulsus alternans
54
Give 3 findings on examination of a patient with left heart failure
Bibasal fine crackles/ rales
Laterally displaced apex beat (cardiomegaly)
Coolness + pallor of lower extremities
55
Give 5 findings on examination of a patient with right heart failure
Peripheral pitting oedema
Raised JVP
Hepatosplenomegaly
Weight gain due to fluid retention
Anorexia ('cardiac cachexia')
56
Describe briefly the NYHA classifications
1. no limitation on activity
2. comfortable at rest but dyspnoea on ordinary activity
3. marked limitation on ordinary activity
4. dyspnoea at rest
57
What is the first line investigation for heart failure?
NT-proBNP
High (>2000): refer urgently for assessment + TOE within 2w
Raised (>400): refer for assessment + TOE within 6w
58
What complimentary investigations should be performed in heart failure?
ECG
CXR
Bloods: FBC, U+Es, GFR, TFTs, LFTs, HbA1c + lipids
Urine dip (protein + blood)
Lung function tests: peak flow/ spirometry
59
Name 3 factors that can cause reduced BNP
Obesity (BMI >35)
Afro-carribbean
Drugs
60
List 5 drug classes that can reduce BNP
ACEi
B-blockers
ARBs
Aldosterone antagonists
Diuretics
61
List 11 factors that elevate BNP
Age >70
Sepsis
LV hypertrophy, myocardial ischaemia, tachycardia
RV overload
Hypoxia
Pulmonary HTN
Pulmonary embolism
CKD
COPD
DM
Cirrhosis
62
Recall the broad approach to medically managing heart failure
BASHeD up by the heart:
Beta blocker: bisoprolol, carvedilol, nebivolol
ACE inhibitor
Spironolactone (2nd line/ Eplerenone)
Hydralazine (+ nitrate): inidicated in afro-carribbean
Digoxin: improves Sx. Indicated if co-existent AF
63
What third line therapies can be initiated by a specialist in heart failure?
Ivabradine: sinus rhythm, >75 bpm, LVEF <35%
Sacubitril-valsartan: LVEF <35%, following ACEi/ ARB washout period
64
Which anti-diabetic drug is used in heart failure with reduced ejection fraction?
SGLT-2 inhibitors: Dapaglifozin, Empagliflozin
Reduce glucose reabsorption + increase urinary glucose excretion
65
Which extra immunisations should be offered in patients with heart failure?
Annual influenza
Pneumococcal
66
What must be monitored whilst patients are on spironolactone?
Potassium (as is a potassium-sparing diuretic)
67
Recall some drugs that are contra-indicated in heart failure
Thiozolidinediones (type 2 diabetes)
Verapamil (as is -ve inotrope)
NSAIDs (can cause fluid retention)
Glucocorticoids (can cause fluid retention)
Flecainide (-ve inotrope, arrhythmogenic)
68
What is high output heart failure?
Where a 'normal' heart is unable to pump enough blood to meet metabolic needs
69
List 6 causes of high output heart failure
Anaemia
AV malformation
Paget's disease
Pregnancy
Thyrotoxicosis
Thiamine deficiency (wet Beri-Beri)
70
What is acute heart failure?
Sudden onset / worsening of Sx of HF
No hx HF = de novo AHF
Hx HF = decompensated AHF
71
What causes de-novo heart failure
Increased cardiac filling pressures + myocardial dysfunction usually as a result of ischaemia
Causes reduced CO + hypoperfusion, this can cause pulmonary oedema
72
Give 4 common precipitants to decompensated AHF
Acute coronary syndrome
Hypertensive crisis
Acute arrhythmia
Valvular disease
73
List 3 symptoms of acute heart failure
Breathlessness
Reduced exercise tolerance
Fatigue
74
List 7 signs of acute heart failure
Cyanosis
Tachycardia
Oedema
Elevated JVP
Displaced apex beat
Chest signs: bibasal crackles + wheeze
S3 heart sound
75
Describe the diagnostic work up for acute heart failure
Bloods: anaemia, abnormal electrolytes, infection
CXR: pulmonary venous congestion, interstitial oedema, cardiomegaly
Echo
BNP: >100mg/l support dx + indicate myocardial damage
76
What is recommended for all patients with acute heart failure?
IV Loop diuretics e.g. Furosemide or Bumetanide
+/- O2 to keep sats 94-98%
77
What management needs to be considered in acute heart failure with hypotension/ cardiogenic shock?
Inotropic agents e.g. Dobutamine
Vasopressor agents e.g. Norepinephrine
Mechanical circulatory assistance e.g. intra-aortic balloon counter pulsation/ ventricular assist devices
78
How quickly should GTN spray relieve angina pain?
Within 5 mins
79
What is the first line investigation for angina in stable patients, and what score is this investigation used to calculate?
CT coronary angiography
Calcium score
80
What are some pharmacological options for preventing angina (NOT symptomatic relief)?
Aspirin (75mg, OD)
Atorvastatin (80mg, ON)
ACE inhibitor (esp. if co-existent DM)
Antihypertensives
81
What calcium score would be classified as low risk, and what score would be high risk?
Low risk \< 100
High risk \> 400
82
What care needs to be taken when prescribing CCBs and BBs together?
If you prescribe a non-dihydropyrimidine CCB (eg verapamil) with a BB it can cause complete heart block
83
What are some medical options for managing angina symptoms?
1st line: GTN (spray or sublingual) + b-blocker or CCB (if CCB used as monotherapy, use a rate limiting one like verapamil or dilitiazem)
2nd line: GTN + BB AND CCB
3rd line options:
- Long-acting nitrates eg Isosorbide mononitrate
- Ivabradine
84
What are the 3 types of AF?
Paroxysmal: episodes >30s <7 days (often <48h), self-terminating + recurrent
Persistent: episodes >7 days or <7d requiring cardioversion
Permanent: cardioversion fails to terminate/ has relapsed within 24h or longstanding >1y when cardioversion not indicated/ attempted
85
List the 7 cardiac/ valvular causes of atrial fibrillation
Congestive HF
Atrial/ Ventricular dilation/ hypertrophy
Pre-excitation syndromes
Sick sinus syndrome
Congenital HD
Inflammatory/ infiltrative disease- pericarditis, amyloidosis, myocarditis
RHD
86
What 3 conditions is atrial fibrillation most commonly associated with?
HTN
Coronary artery disease
MI
87
List 7 non-cardiac causes of AF
PEACHES
P- PE
E- Endo: Thyrotoxicosis, Phaeo
A- Alcohol
C- Caffeine
H- Hypothermia
E- Electrolyte abnormality
S- Sepsis/ acute infection
88
4 S/S of AF
Palpitations
Dyspnoea
Chest pain
Irregularly irregular pulse
89
ECG characteristics of AF
No p waves (irregular baseline)
Irregular QRS
Often 160-180bpm
Normal shape QRS (AVN conduction normal)
Normal T
90
What bloods should be taken in AF?
FBC: anaemia, infection
TFTs: Thyrotoxicosis
U+Es: electrolyte abnormalities
91
Why is cardioversion only suitable for patients with short duration of symptoms or those who have been anticoagulated?
Switching from AF to sinus rhythm could suddenly push a thrombus out of the atrium
92
How should new onset AF be managed if haemodynamically unstable?
Anticoagulate with LMWH: Enoxaparin
Synchronised DC Cardioversion
93
When is the shock delivered in synchronised DC cardioversion?
Synchronised to the R wave to prevent delivery during vulnerable period of cardiac repolarisation (would induce ventricular fibrillaiton)
94
If a CHA2DS2VASc score suggests no need for anticoagulation what must be done?
TTE to r/o valvular heart disease
In combination with AF is an absolute indication for anticoagulation
95
What anticoagulation approach should be taken in AF?
Immediate LMWH (Enoxaparin)
Transition to DOAC
96
When is rhythm control indicated (instead of rate control)?
Reversible cause
Co-existent HF caused by AF
New onset AF <48h
Atrial flutter if suitable for ablation strategy
97
What parameters make the CHA2DS2VASc score?
Congestive heart failure
HTN (inc. treated HTN)
Age >75 (2) or >65 (1)
DM
Stroke, TIA or Thromboembolism
Vascular disease: IHD, PAD
Sex (F)
98
What is indicated by the CHA2DS2VASc score?
0: No Tx
1: Consider anticoagulation in M. No Tx in F
>,2: Offer anticoagulation
99
What tool is used to assess bleeding risk? What are the parameters?
ORBIT
Hb <130 in M or <120 in F (2)
Age >74y
Bleeding Hx: GI/ Intracranial bleed or haemorrhagic stroke (2)
Renal impairmentL GFR <60
Tx with antiplatelet agents
100
How is ORBIT score interpreted?
0-2: Low risk
3: Medium risk
4-7: High risk
101
What drugs can be used first line for rate control in AF?
B-blocker: Metoprolol, Propanolol, Atenolol
Rate-limiting CCB: Diltiazem, Verapamil
102
What is the second line approach to rate control in AF?
Combination therapy with any 2 of:
B-Blocker
Diltiazem
Digoxin
103
Which anticoagulants are indicated in AF?
DOACs
Apixaban
Dabigatran
Edoxaban
Rivaroxaban
104
Which drugs can be used for pharmacological cardioversion?
Flecainide (if no structural heart disease)
Amiodarone
105
How does anti-clotting drug choice differ following a stroke, depending on whether or not they have AF?
If they have AF: anti-coagulant (DOAC or warfarin if DOAC is CI)
If they do NOT have AF: anti-platelet
106
Why are anti-platelets not used in AF?
Anti-platelets are specifically for artherogenic causes of clots eg atheroma
107
Within what window of AF beginning can it be treated differently to longer-standing AF? What is this different treatment? Why is it so difficult to treat within the initial window of time?
AF \<48h duration + HAEMODYNAMICALLY UNSTABLE can be cardioverted electrically
Difficult to establish onset of AF as patient may not have palpitations, or may be unsure as to when they started
108
For how long before and after cardioversion for arrhythmia should a patient be anti-coagulated?
3w before and 4w after OR lifelong (if CHA2DS2VASc high or if paroxysmal AF)
109
How can chadsvasc score be used to determine the need for longterm anticoagulation?
Score:
0 = no need for longterm anticoagulation
1 = anticoagulate if male, do not anticoagulate if female
2 or more: anticoagulate
110
What is the main contraindication to be aware of for all CCBs?
Peripheral oedema (increased capillary hydrostatic pressure that results from greater dilation of pre-capillary than post-capillary vessels)
111
What are the 1st, 2nd and 3rd line options for rate control in AF?
1st line: beta blocker or CCB (verapamil is better than dilitiazem)
2nd line: digoxin
3rd line: amiodarone
112
With what waveform on the ECG should DC cardioversion be synchronised?
R wave
If synchronised with T wave it can cause VT
113
Recall 2 options for chemical cardioversion, and any important indications/ contra-indications for each
Flecainide: if young + no structural heart disease
Amiodarone: in structural heart disease (eg HF)
114
Recall 2 surgical options for managing AF
1. Radiofrequency ablation of AV node
2. Maze procedure
115
Recall the components of the CHA2DS2VASc score
CHF
HTN
Age \>75
DM
Stroke
Vascular disease
Age 65-74
Sex Category (female)
116
In HTN, what BP is defined as 'severe'?
\>180/110
117
What is the first line treatment for HTN for diabetics?
ACE inhibitor
118
What is the first line treatment for HTN for black Africans?
CCB
119
What is the first line treatment for HTN for under vs over 55s who are not diabetic or Black African?
<55: ACE inhibitor or ARB
>55: CCB
120
Recall some side effects of ACE inhibitors
Angioedema (for around 4w), cough, hyperkalaemia
121
Recall the name of one thiazide-like diuretic
Indapamide
nb bendroflumethiazide is thiazide, not thiazide-like
122
What side effect of thiazide diuretics may be useful for non-cardiac disease?
Hypercalcaemia
Causes hypocalciuria which may reduce incidence of renal stones
123
Why do CCBs cause oedema?
Cause dilation of arterioles but not venules
124
What is the atorvastatin dose for primary vs secondary prevention?
Primary prevention: 20mg OD
Secondary prevention: 80mg OD
125
What is the most commonly affected heart valve in infective endocarditis when the patient is an IVDU?
Tricuspid
126
What is the most common pathogen to cause an acute presentation of infective endocarditis?
Strep epidermidis
127
How does strep viridans infective endocarditis most commonly present?
Subacute presentation, most commonly in the developing world
128
What is Libman-Sacks endocarditis?
Non-infective endocarditis caused by SLE
129
Differentiate the empirical antibiotics used in native vs prosthetic valves affected by infective endocarditis
Native valve: amoxicillin +/- gentamicin
Prosthetic valve: vancomycin + rifampicin + gentamicin
130
How far apart should blood cultures be taken to investigate infective endocarditis?
12 hours
131
What is the most likely pathogen to cause rheumatic fever?
GAS (strep pyogenes)
132
What is the broad pathophysiology of rheumatic fever?
AB cross reactivity with myosin, muscle glycogen and VSMC
133
What is the latent period between pharyngeal infection and onset of rheumatic fever?
2-6 weeks
134
Recall some of the key symptoms of rheumatic fever
Pericarditis
Polyarthritis
Erythema marginatum
135
What are sydenham's chorea?
Unwanted jerky movements that appear 2-6 months following rheumatic fever
136
Recall the Duckett-Jones diagnostic criteria
For diagnosing rheumatic fever:
CASES (major) FRAPP (minor)
Carditis
Arthritis
Sydenham's chorea
Erythema marginatum
Subcutaneous nodules
137
What is the antibiotic treatment recommended in rheumatic fever?
Phenoxymethylpenicillin QDS 10/7
138
What drugs can be used to treat sydenham's chorea?
Haloperidol
Diazepam
139
How long does penicillin treatment need to continue following an episode of rheumatic fever to prevent rheumatic heart disease?
If carditis + residual heart disease: 10y or until age 40 (whichever is longer), possibly lifetime
If carditis but NO residual heart disease: 10y or until age 21 (whichever is longer)
If NO carditis: 5y or until age 21 (whichever is longer)
140
What is 'fibrinous' pericarditis?
Pericarditis caused by uraemia
141
Recall some signs and symptoms of pericarditis
Pleuritic chest pain
Non-productive cough
Dyspnoea
Flu-like symptoms
Pericardial rub
Tachypnoea + tachycardia
142
What are the typical ECG findings in pericarditis?
Widespread PR depression or saddle-shaped ST elevation
143
How should pericarditis be broadly managed?
Treat cause
NSAIDs + colchicine
144
Recall some cardiac causes of clubbing
Atrial myxoma
Cyanotic heart disease
Infective endocarditis
145
What can cause a collapsing pulse other than aortic regurgitation?
Pregnancy
Thyrotoxicosis
Anaemia
146
What do the S1 and S2 heart sounds represent?
```
S1 = mitral valve closure
S2 = aortic valve closure
```
147
What would cause a split S1?
Mitral + tricuspid valve closing at different times - normal in some
148
What are the 2 types of purely genetic primary cardiomyopathy?
HOCM
Arrhythmogenic right ventricular dysplasia
149
What are the 2 types of purely acquired primary cardiomyopathy?
Peripartum cardiomyopathy
Takotsubo cardiomyopathy
150
Recall 2 types of primary cardiomyopathy that have mixed genetic/ acquired causes?
Dilated cardiomyopathy
Restrictive cardiomyopathy
151
Recall 4 possible causes of dilated cardiomyopathy
Alcohol
Cocksackie B
Wet beri beri
Doxorubicin
152
Recall 3 possible causes of restrictive cardiomyopathy
Amyloidosis
Post-radiotherapy
Loeffler's endocarditis (due to eosinophillic infiltration)
153
What is the most common gene mutation causing HOCM?
Beta-myosin heavy chain protein mutation
154
What would the following echo findings be suggestive of:
Mitral regurgitation
Systolic anterior motion of the anterior mitral valve
Asymmetrical septal hypertrophy
HOCM
155
What is arrhythmogenic right ventricular dysplasia?
Replacement of RV myocardium with fatty + fibrofatty tissue
156
What is the following description of an abnormal ECG most suggestive of:
Abnormalities in V1-3, typically T wave inversion. Possible epsilon wave.
Arrhythmogenic right ventricular dysplasia
157
What would the following echo findings be suggestive of:
All 4 heart chambers dilated
Tricuspid and mitral regurgitation
Dilated cardiomyopathy
158
What condition does the following describe: "transient, apical ballooning of the myocardium"?
Takotsubo cardiomyopathy
159
Recall some causes of secondary cardiomyopathy
Infiltration (eg amyloidosis )
Inflammation (eg sarcoidosis)
Storage (eg haemochromatosis)
Deficiencies (eg beri beri)
Neuromuscular (eg Friedereich's ataxia, duchenne-becker musculdystrophy)
Infective (cocksackie B, chagas)
Endocrine (thyrotoxicus, diabetes mellitis, acromegaly)
160
Why is long QT syndrome dangerous?
Can cause VT --\> death
161
Recall 2 causes of congenital long QT syndrome, and how they can be differetiated?
Jervell-Lange-Nielsen syndrome (deafness)
Romano-Ward syndrome (no deafness)
162
Recall some drugs that can cause long QT syndrome
METH CATS
Methadone
Erythromycin
Terfenadine
Haloperidol
Clarithromycin
Amiodarone/ arythromycin
TCAs
SSRIs (esp. citalopram)
163
What is the 1st line management of torsades de pointes?
IV magnesium sulphate
164
What is torsades de pointes?
A type of polymorphic VT that is a/w QT prolongation
165
How much does BP have to drop on standing to classify as 'orthostatic hypertension'?
Over 3 mins, BP needs to fall by 20/10
166
What is pulsus paradoxus, and in which conditions would it be seen?
\>10mmHg fall in SBP during inspiration
Seen in severe asthma and cardiac tamponade - why?:
Inspiration --\> reduced intrathoracic pressure --\> blood pulled into right side of heart
Interventricular septum bulges into the left side of the heart --\> reduced CO --\> transient BP drop
You will feel varying strength of the pulse with inspiration and expiration
167
What is pulsus alternans and in which condition is it seen?
Regular alternation of the force of the arterial pulse
Seen in severe LVF
168
In which disease might a 'jerky' pulse be felt?
HOCM
169
What is the inheritance pattern of HOCM?
Autosomal dominant
170
How can HOCM cause sudden death?
Can cause spontaneous VF/VT
171
How might the JVP be abnormal in a patient with HOCM?
Large a waves
172
What are the 3 key features of HOCM on echo?
Mitral regurgitation
Systolic anterior motion (SAM)
Asymmetric hypertrophy
173
Recall some general principles of HOCM management
A to E
Amiodarone
B-blockers
Cardioverter defibrillator
Dual chamber pace maker
Endocarditis prophylaxis
174
What are the classical clinical signs of pulmonary oedema?
Reduced exercise tolerance
Raised jugular venous pressure
Audible 3rd heart sound
175
Which electrolyte abnormalities may cause torsades de pointes?
Hypokalaemia
Hypomagnesaemia
Hypocalcaemia
176
Name 2 drugs that can increase the effect of warfarin
Metronidazole
Sertralline
177
Name one drug that can decrease the effect of warfarin
Phenobarbital
178
When should DC cardioversion be attempted before chemical cardioversion for a tachyarrhythmia?
If SBP \<90
179
What should an inferior MI + aortic regurgitation raise suspicion of?
Ascending aortic dissection
180
When would thrombolysis be the first line for treating PE, rather than anticoagulative medicines?
If circulatory collapse - eg hypotension
181
What is the antibiotic of choice in native valve infective endocarditis?
IV amoxicillin
182
What should the initial management be for patients with bradycardia and signs of shock?
500micrograms of atropine (repeated up to max 3mg)
183
What ECG abnormality is most likely in hypercalcaemia?
Shortened QT interval
184
What are prominent V waves in the JVP indicative of?
Tricuspid regurgitation
185
What are cannon A waves in the JVP indicative of?
Complete heart block
186
What is a prominent x descent in the JVP indicative of?
Can be caused by:
Acute cardiac tamponade
Constrictive pericarditis
187
Which 2 beta blockers have been proven to be effective in stable heart failure?
Carvedilol and bisoprolol
188
What are the 3 most-commonly used drugs for treating NSTEMI medically?
Aspirin, ticagrelor, and fondaparinux
| (Take special care to avoid GTN in hypotensive patients)
189
When would you NOT use flecainide for rate control?
In structurally abnormal hearts (which includes those with a PMH of ischaemic heart disease)
190
What is Beurger's disease also known as?
Thromboangiitis obliterans
191
What are the symptoms of Beurger's disease?
Raynaud's syndrome
Intermittent claudication
Finger ulcerations
192
What is the biggest risk factor for Beurger's disease?
Smoking
193
What is the medical management of choice for conservative management of an NSTEMI?
Dual antiplatelet therapy:
Aspirin + clopidogrel/ ticagrelor
Clopidogrel if high bleeding risk, ticagrelor if low bleeding risk
194
What is the biggest risk factor for renal impairment following prescription of an ACE inhibitor?
If the patient already has bilateral renal artery stenosis it can cause significant renal impairment
195
What is radiofemoral delay a sign of?
Aortic coarctation
196
Which congenital condition is strongly associated with aortic coarctation?
Turner's
197
In which arrhythmia is verapamil contraindicated and why?
Ventricular tachycardia
Verapamil is a CCB - may reduce cardiac contractility
198
Recall the location on the praecordium where each valve is best auscultated
Aortic: Right 2nd ICS
Pulmonary: Left 2nd ICS
Tricuspid: left 4th ICS at sternal border
Mitral: left 5th ICS, MCL
199
Where is aortic regurgitation best auscultated
Tricuspid area: left 3rd ICS parasternally (Erb's point)
200
At what point in the breathing cycle is aortic regurgitation best auscultated, and in which position?
End expiration
Sat up and forward
Put stethoscope at Erb's point
201
Why are right-sided murmurs louder on inspiration?
Increased venous return to the RHS
202
Recall 2 types of murmur that are louder when there is LESS blood flow across the affected area
HOCM murmurs
Mitral valve prolapse
203
Which murmur is best auscultated when the patient is in the left lateral decubitus position?
Mitral stenosis
204
Which murmurs can radiate? Where do they radiate to?
Aortic stenosis --\> carotids
Mitral regurgitation --\> axilla
205
Describe the meaning of each of the 6 grades of heart murmur
Grade 1 - Difficut to hear
Grade 2 - Quiet
Grade 3 - Easy to hear
Grade 4 - Easy to hear with a palpable thrill
Grade 5 - Easy to hear with stethoscope barely touching chest
Grade 6 - Easy to hear with stethoscope away from patient
206
How does mitral stenosis vs regurgitation affect the heart structurally and why?
Stenosis --\> atria have to work really hard to push blood through valve --\> hypertrophic left artium
Regurgitation --\> backflow of blood into atria stretches chamber --\> left atrial dilatation
207
What are the 2 main possible causes of mitral stenosis?
Rheumatic heart disease is the most common
Infective endocarditis
208
Why do you get a loud S1 in mitral stenosis?
Thickened valve needs a large systolic force to shut - once this systolic threshold is met the valve will shut very suddenly
209
What is the cause of malar flush in patients with mitral stenosis?
Backflow of blood into the pulmonary system --\> rise in CO2 and vasodilation
210
Why does mitral stenosis sometimes present with haemoptysis?
Increased pressures cause rupture of pulmonary vessels
211
What is the link between mitral regurgitation and congestive heart failure?
Backflow of blood --\> reduced ejection fraction
--\> backlog of blood waiting to pass through left side of heart
212
What are the possible causes of mitral regurgitation and which of them is most common?
Age-related weakening is most common
Also associated with:
- IHD
- Infective endocarditis
- Rheumatic heart disease
- Connective tissue disease (EDS/ Marfan's)
213
Which type of valve disease is associated with exertional syncope and why?
Aortic stenosis
Difficulty perfusing brain
214
What is the most common cause of aortic stenosis?
Idiopathic age-related calcification
215
What is Corrigan's pulse?
Also known as collapsing pulse
Pulse rapidly appears and then disappears
216
Recall 2 causes of aortic regurgitation
Age-related calcification
Connective tissue disease
217
What is paroxysmal nocturnal dyspnoea?
Waking up suddenly in the night feeling acutely SOB with a really bad cough/ wheeze
They have to get up + gasp for air
Sx typically improve after a few minutes
218
What is the mechanism of PND (3 aspects)?
1. Lying flat --\> fluid settling across large surface area of lungs
2. Respiratory centre in the brain is less responsive during sleep - so lungs can become much more congested that they would normaly do before they wake up
3. Adrenaline levels are much lower at night so myocardium is more relaxed --\> reduced CO
219
Recall the immediate management of rheumatic fever
Aspirin prn
Benzylpenicillin IM stat
10 day course of benzylpenicillin PO
220
When in the course of rheumatic fever/heart disease is valve imcompetence most likely?
Acutely
221
Which murmur is best heard at the apex with the bell of the stethoscope?
Mitral stenosis
222
Is pericarditis more commonly viral or bacterial?
Viral
223
ST elevation in which leads would represent an anteroseptal STEMI?
V1-V4
224
In the setting of acute pulmonary oedema post MI, how can severe hypotension be managed?
CPAP - it effectively pushes fluid out of your lungs
225
Which artery is occluded in an anterior MI?
Left anterior descending
226
Which artery is occluded in an anterolateral MI?
Left anterior descending
227
Which artery is occluded in inferior MI?
Right coronary artery (RV branch included)
228
Which artery is occluded in a posterior MI?
Circumflex
229
In which leads would you see ST elevation in an inferior STEMI?
II, III, aVF
230
In which leads would you see ST elevation in an anterior STEMI?
V3, V4
231
In which leads would you see ST elevation in a lateral STEMI?
I, aVL, V5, V6
232
What is always the first thing to do in an acute exacerbation of heart failure?
Sit up and give 60-100% O2
233
Which valve is most commonly affected by strep viridians infective endocarditis, and why?
Mitral
Strep viridians usually a/w teeth (commensal there)
Affects mitral valve as this valve is under higher pressures than in right side of heart and so is under higher pressure
234
What is the most likely pathogen in infective endocarditis in IVDUs?
Staphylococcus
235
Recall some causes of atrial fibrillation
PIRATES:
Pulmonary cancer
Ischaemic heart disease
Rheumatic heart disease
Atrial myxoma/ alcohol binge
Thyrotoxicosis
Embolus
Sepsis
236
If you see a Q wave as well as ST elevation on an ECG, what does that mean?
Tissue death
237
What may appear to be an anterior STEMI on an ECG post-MI, that is not actually an anterior STEMI?
Left ventricular aneurysm
238
What class of drug is ticagrelor?
P2 Y12 inhibitor
239
When would heparin be used in MI management?
In cath lab prior to PCI to prevent thrombosis
240
Why does ticagrelor work more quickly than clopidogrel?
Clopidogrel is a pro-drug so takes longer to work
241
Recall one diuretic that improves prognosis post-MI and one that isn't proven to
Improves prognosis: eplerenone
Does not improve prognosis: furosemide
242
How long can someone not drive for post-MI?
If completeley revascularised with okay LVEF = 1w
If severely reduced LVEF = 4w
243
Recall 3 uses of SGLT2 inhibitors
Diabetes mellitus
Chronic kidney disease
Symptomatic chronic heart failure with reduced ejection fraction
244
What is sacubitril with valsartan used for?
Improves LVF in patients who are already on other heart failure therapy
245
How long after an MI might an ICD (implantable cardioverter defibrillator) be indicated?
40 days
246
Which drug should be held 48 hours before and after angiogram?
Metformin
247
How do you manage atrial flutter?
1. Treat underlying cause
2. Anticoagulate as you would for atrial fibrillation
If haemodynamically unstable: rate control or cardioversion
248
How would you manage SVT in an asthmatic patient in whom vagal manoevres have failed?
IV verapamil
249
How do you differentiate between aortic stenosis and sclerosis?
Aortic sclerosis is:
- normal in the elderly
- has a normal pulse (not narrow pulse pressure)
- No radiation
250
Recall 5 causes of raised JVP other than right-sided heart disease
Tricuspid regurgitation
Complete heart block
CCF
Pericardial effusion
SVC obstruction
251
Recall 5 complications of a prosthetic valve
Failure
Infection
Bleeding
Anaemia
Thromboembolic
252
Recall 3 causes of an irregularly irregular pulse that aren't AF
Ventricular etopics
Atrial flutter
Sinus arrhythmias
253
If in a suspected DVT the D-dimer is positive but the the USS is negative, what should you do?
Stop anticoagulation + repeat scan in 1w
254
What is the most appropriate anti-anginal treatment in a pateint with known heart failure?
Bisoprolol (verapamil CI in the case of CF)
255
In ALS, when would 3 shocks be given instead of 1?
If arrest witnessed in the cath lab/ CCU/ critical care and rhythmn is VF/pVT
256
What should be the initial drug treatment for patients with low EF heart failure?
Bisoprolol + ramipril
257
Which class of abx can cause torsades de pointes?
Macrolides eg azithromycin
258
Why is a pericardial friction rub heard in pericarditis?
The inflammed visceral + parietal pericardium rub against each other
259
What is the basic pathophysiology of Sydenham's chorea?
Autoimmune reaction against the basal ganglia
260
What drug should be added to CPR for a patient in cardiac arrest if pulomnary emboli are suspected?
Alteplase
261
When would you *not* use IV beta blockers to treat fast AF, and hwat would you do instead?
In fast AF not a/w shock, syncope, myocardial ischaemia or heart failure - do up to 3 synchronised DC shocks instead
262
How can nitrate tolerance be prevented when prescribing isosorbide mononitrate?
Asymmetric dosing regimen
263
What complication of MI does the following describe: sudden heart failure, raised JVP, pulsus parodoxus
Left ventricular free wall rupture
264
What is the most useful blood test for detecting re-infarction post-MI?
CK-MB
265
What ECG findings are highly specific for critical stenosis of LAD? What is this indicative of?
Deep T wave inversion or biphasic T waves in V2-3
Wellens Syndrome: v high risk for extensive anterior wall MI within days-weeks
