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Passing FRACP Flashcards

(103 cards)

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1
Q

What is the primary mechanism through which beta-blockers exert beneficial effects in stable angina?

A

Reduction in myocardial oxygen demand

Myocardial oxygen demand is influenced by heart rate, contractility, and left ventricular wall stress, all of which are decreased by beta-blockers.

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2
Q

What are the adverse side effects of beta-blockers?

A
  • Bradycardia
  • AV node conduction problems
  • Reduced contractility
  • Bronchoconstriction
  • Worsening of peripheral vascular disease
  • Raynaud phenomenon
  • Fatigue
  • Nightmares
  • Erectile dysfunction

Adverse effects can vary based on patient condition and concurrent medications.

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3
Q

What compensatory mechanisms are activated in heart failure?

A
  • Increased ventricular preload with dilatation
  • Peripheral vasoconstriction
  • Myocardial hypertrophy
  • Renal sodium and water retention
  • Activation of the adrenergic nervous system

These mechanisms contribute to the symptoms and progression of heart failure.

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4
Q

What is idiopathic ventricular tachycardia?

A

Ventricular tachycardia without structural heart disease

It often originates from the right ventricular outflow tract.

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5
Q

What is the primary cause of myocarditis in developed countries?

A

Viral infection

Enteroviruses, particularly the Coxsackie virus, are the most commonly associated viral species.

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6
Q

What is the sequence of electrical propagation of the cardiac impulse?

A
  • Sino-atrial node
  • Anterior, middle, and posterior internodal tracts
  • AV node
  • Bundle of His
  • Right and left bundle branches
  • Purkinje fibres

This sequence is crucial for coordinated heart contractions.

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7
Q

What is the role of calcium in cardiac muscle contraction?

A

Calcium release triggers muscle contraction by altering the binding of troponin and tropomyosin to actin

This leads to ATP-driven myosin–actin interactions that generate contraction.

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8
Q

What is perhexiline used for?

A

Treatment of congestive heart failure and refractory angina

It modifies myocardial substrate utilization to reduce oxygen consumption.

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9
Q

What are the major side effects of perhexiline?

A
  • Hepatotoxicity
  • Peripheral neuropathy
  • Hypoglycemia

Monitoring is essential to prevent these toxicities.

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10
Q

What distinguishes beta-blockers with partial agonist activity?

A

They cause little or no depression of resting heart rate while blocking increases in heart rate during exercise

An example is pindolol, which also produces mild vasodilation.

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11
Q

What are the characteristic findings in acute pericarditis?

A
  • Chest pain
  • Pericardial friction rub
  • ECG changes

The pain worsens with inspiration, distinguishing it from myocardial infarction.

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12
Q

What is the drug of choice for treating streptococcal pharyngitis in acute rheumatic fever?

A

Oral penicillin V

Twice-daily dosing is as effective as four times a day dosing.

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13
Q

What is the significance of the ST segment elevation in acute pericarditis?

A

It indicates inflammation in the superficial layer of myocardium

This elevation is typically seen in multiple leads.

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14
Q

What is the recommended target resting heart rate for patients on beta-blockers for angina?

A

55–60 beats/min

The dose of beta-blocker should be titrated to achieve this target.

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15
Q

What is the typical success rate of catheter ablation for symptomatic idiopathic ventricular tachycardias?

A

80–90% in experienced centres

Success rates may vary based on the location of the tachycardia origin.

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16
Q

What does the P wave in an electrocardiogram represent?

A

Depolarization of the atria

This is part of the cardiac cycle and crucial for understanding ECG readings.

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17
Q

What percentage of people of all ages have rheumatic heart disease?

A

2%

Similar rates are seen throughout the Western Pacific region, including in Maori and Pacific Islander populations in New Zealand.

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18
Q

What is the drug of choice for treating streptococcal pharyngitis?

A

Oral penicillin V

Twice-daily dosing is as effective as four times a day dosing and may improve compliance.

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19
Q

What are the most commonly-used tests for confirming the diagnosis of rheumatic fever?

A
  • Plasma anti-streptolysin O (ASO)
  • Anti-DNase B titres

A rise in ASO titre occurs in 75–80% of untreated Group A streptococci pharyngeal infections.

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20
Q

How soon should treatment be started after the onset of symptoms to prevent rheumatic fever?

A

Within 9 days

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21
Q

What is the recommended first-line treatment for arthritis or arthralgia in acute rheumatic fever?

A

Aspirin

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22
Q

Is Sydenham chorea self-limiting?

A

True

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23
Q

What percentage of pharyngitis cases in adults is caused by Group A streptococci?

A

5%

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24
Q

What is indicated if a patient presents with sudden onset chest pain radiating to the interscapular area?

A

Acute aortic dissection

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25
What imaging techniques are recommended for diagnosing acute aortic dissection?
* Echocardiography * CT angiography ## Footnote MRI is favoured for assessing chronic dissection.
26
What is the mean sensitivity and specificity for transoesophageal echocardiography, CT angiography, and MRI in diagnosing aortic dissection?
More than 95%
27
What are important findings to assess in imaging for aortic dissection?
* Extent of the dissection * Size of the true and false lumen * Localisation of the intimal tear * Involvement of aortic branches * Presence of aortic regurgitation * Presence and extent of periaortic haematoma, mediastinal haematoma, or effusion
28
What does Brain natriuretic peptide (BNP) levels reflect in congestive heart failure (CHF)?
* Severity of CHF * Risk of hospitalisation * Survival
29
What is the cut-off value of BNP for diagnostic accuracy in CHF?
100 pg/mL
30
What is the first-line therapy for patients with systolic heart failure?
ACE inhibitors
31
What is the effect of beta-blockers in heart failure treatment?
* Improves systolic function * Increases ejection fraction by 5–10% * Reduces symptoms
32
What is recommended for patients receiving high cumulative doses of anthracyclines?
Dexrazoxane
33
What should be performed for all patients treated with anthracyclines?
Baseline echocardiogram and serial monitoring of myocardial function
34
What is the primary risk factor for chronic anthracycline cardiotoxicity?
Cumulative dose
35
What are the criteria for recommending coronary artery bypass graft (CABG)?
* Significant left main coronary artery disease * Three-vessel disease * Two-vessel disease with significant left anterior descending artery involvement or abnormal LV function
36
What imaging test has excellent sensitivity and specificity for significant coronary artery disease?
Computed tomography coronary angiography (CTCA)
37
What is a major drawback of dabigatran?
Lack of an effective antidote
38
What ECG findings indicate the need for temporary transvenous pacing?
* Severe and symptomatic bradyarrhythmias * High (second or third)-degree AV block associated with AMI
39
What is Mobitz type II 2:1 heart block?
A type of second-degree heart block characterized by intermittent failure of conduction through the AV node.
40
When is temporary transvenous pacing necessary?
For severe symptomatic bradyarrhythmias or high risk of complete heart block due to acute myocardial infarction.
41
What is the association between high-degree AV block and acute myocardial infarction?
High-degree AV block is associated with increased mortality in patients with inferior or anterior AMI.
42
What should be considered for pacing following an AMI?
* Complete (third-degree) heart block * New bifascicular block with PR prolongation * Symptomatic bradycardia with hypotension * Mobitz type II second-degree AV block * Bradycardia-induced tachyarrhythmias
43
What is the incidence of AV block in acute myocardial infarction cases?
AV block occurs in almost 7% of AMI cases.
44
What is Eisenmenger syndrome?
Pulmonary hypertension due to a left-to-right shunt caused by congenital heart defects.
45
What is the estimated maternal mortality rate associated with Eisenmenger syndrome during pregnancy?
Between 30% and 56%.
46
What is a contraindication for pregnancy in patients with Eisenmenger syndrome?
High maternal mortality risk and fetal death risk.
47
What is the risk associated with hypertrophic cardiomyopathy?
Sudden cardiac death, with annual rates of 1% or less.
48
What is a significant risk factor for sudden cardiac death in hypertrophic cardiomyopathy?
Left ventricular wall thickness greater than 3 cm.
49
What are the six major risk factors for sudden cardiac death in hypertrophic cardiomyopathy?
* Previous cardiac arrest or sustained ventricular tachycardia * Non-sustained ventricular tachycardia * Extreme left ventricular hypertrophy * Unexplained syncope * Abnormal blood pressure response to exercise * Family history of sudden death
50
What is the most common cause of prosthetic valve endocarditis?
Staphylococcus aureus.
51
What proportion of infective endocarditis cases does prosthetic valve endocarditis account for?
20%.
52
What is the typical timeframe for pathogens seen in prosthetic valve endocarditis after valve implantation?
* Within 2 months: S. aureus (36%), coagulase-negative staphylococci (17%) * After 2 months: coagulase-negative staphylococci and S. aureus (18–20% each)
53
What is the treatment mainstay for congenital long-QT syndrome?
Beta-blockade.
54
What are the two common hereditary variants of congenital long-QT syndrome?
* Jervell and Lange–Nielsen syndrome * Romano–Ward syndrome
55
What are common causes of acquired long-QT syndrome?
* Hypocalcaemia * Hypokalemia * Hypomagnesaemia * Hypothyroidism * Certain medications
56
What is the key indication for percutaneous balloon mitral valvuloplasty (PBMV)?
Progressive exertional dyspnoea associated with moderate or severe mitral stenosis.
57
What is a contraindication for PBMV?
A large left atrial thrombus.
58
What is peri-infarction pericarditis?
Pericarditis that occurs 1–2 days after an acute myocardial infarction.
59
What is the typical presentation of post-myocardial infarction syndrome?
Fever, pleuritic chest pain, and pericardial rub.
60
What is the first-line treatment for supraventricular tachycardia?
Vagal manoeuvres.
61
What is the role of adenosine in treating supraventricular tachycardia?
Blocks atrioventricular nodal conduction and terminates re-entrant tachycardias.
62
What is the classic pattern of pre-excitation in Wolff–Parkinson–White syndrome?
A symptomatic pre-excited atrial fibrillation.
63
What is the recommended acute drug therapy for pre-excited atrial fibrillation?
Class IC anti-arrhythmic drugs like flecainide.
64
What effect does verapamil have on the AV node?
Lengthens AV node refractoriness, decreases concealed conduction into the accessory pathway ## Footnote Has no direct effect on the accessory pathway
65
What are the potential effects of intravenous adenosine?
Causes similar effects to verapamil and can precipitate ventricular fibrillation ## Footnote Contraindicated in certain situations
66
What is the role of intravenous amiodarone in atrial fibrillation?
May be effective for reverted AF in WPW or may slow the ventricular rate ## Footnote Affects accessory pathway refractoriness and conduction
67
What percentage of adults have Streptococcus bovis in their gastrointestinal tract?
5–16% ## Footnote Found among the normal flora
68
What serious conditions can S. bovis cause if it enters the bloodstream?
Bacteraemia and endocarditis ## Footnote Approximately 12% of infective endocarditis is caused by S. bovis
69
What is the association between S. bovis endocarditis and colorectal cancer?
Increased risk of prevalent colorectal neoplasia ## Footnote Nearly all patients are older than 50 years
70
What defines high-output heart failure?
Elevated resting cardiac index beyond 2.5–4.0 L/min/m2 ## Footnote Most patients with heart failure have a low or normal cardiac output
71
What can cause an increased cardiac output in patients with Paget disease?
Multiple arteriovenous fistulas ## Footnote Extensive Paget disease can lead to high-output heart failure
72
List some causes of high-output heart failure.
* Severe anaemia * Vitamin B1 deficiency * Psoriasis * Severe septicaemia * Congenital fistulas * Acromegaly * Pregnancy * Polycythemia vera ## Footnote High-output states can contribute to heart failure
73
What are high-risk features for infective endocarditis?
* Heart failure * Stroke * Recurrent embolic events * Septic shock * Fever >7–10 days * Large vegetation * New heart block * Severe left-sided regurgitation * Pathogens other than viridans streptococci ## Footnote Particularly Staphylococcus aureus, fungi, and Gram-negative bacilli
74
What characterizes cholesterol embolisation syndrome?
Embolisation of cholesterol crystals from atherosclerotic plaque ## Footnote Causes end-organ damage by mechanical plugging and inflammatory response
75
What are common clinical manifestations of cholesterol embolisation syndrome?
* Renal failure * Bowel ischaemia * Dermatological manifestations * Constitutional signs (fever, weight loss) ## Footnote Hypereosinophilia is frequent but not pathognomonic
76
What is the first-line therapy for ongoing ventricular fibrillation?
Amiodarone ## Footnote According to AHA guidelines, it is preferred over other anti-arrhythmic drugs
77
What is the most important risk factor for cardiac death or complications?
Uncontrolled heart failure ## Footnote History of functional limitation is crucial for assessment
78
What is the gold standard for diagnosing transplant coronary artery disease (TCAD)?
Coronary angiography ## Footnote Useful for focal lesions but less sensitive for diffuse disease
79
What is the significance of intimal thickness in TCAD?
Intimal thickness >0.5 mm correlates with increased risk of complications ## Footnote Severe increases within the first year are particularly concerning
80
What are current treatments for TCAD?
* Pharmacotherapy * Percutaneous coronary intervention * Repeat transplantation ## Footnote Drug-eluting stents reduce in-stent restenosis
81
What is myocardial contrast echocardiography used for?
Detecting the presence of TCAD ## Footnote It cannot identify the extent of disease compared with angiography.
82
What are current treatments for TCAD?
* Pharmacotherapy * Percutaneous coronary intervention * Repeat transplantation * Emerging novel therapies ## Footnote Repeat transplantation is the only definitive treatment.
83
What is a major complication of percutaneous coronary intervention?
High incidence of in-stent restenosis
84
What do drug-eluting stents reduce compared to bare metal stents?
In-stent restenosis
85
What are the key features of restrictive cardiomyopathy?
* Increased stiffness of the ventricles * Compromised diastolic filling * Preserved systolic function ## Footnote Changes may develop in association with inflammatory, infiltrative, or storage diseases.
86
Which diseases can cause restrictive cardiomyopathy?
* Sarcoidosis * Amyloidosis * Post-irradiation therapy * Myeloma * Lymphoma * Connective tissue disease * Endomyocardial fibrosis * Löffler cardiomyopathy * Haemochromatosis * Glycogen storage disease * Fabry disease
87
What is the importance of differentiating restrictive cardiomyopathy from constrictive pericarditis?
Patients with constrictive pericarditis may recover completely following surgical removal of the fibrotic pericardium.
88
How do patients with fulminant myocarditis typically present?
Acute heart failure up to 2 weeks after a viral prodrome
89
What are common causes of myocarditis in the developed world?
* Viral infections (Coxsackie is the commonest) * Bacteria * Protozoa * Spirochaetes * Rickettsia * Cardiotoxic agents * Hypersensitivity reactions * Systemic disorders ## Footnote Examples include sarcoidosis and inflammatory bowel disease.
90
What symptoms may accompany myocarditis?
* Chest pain (if pericarditis is present) * Arrhythmias * Palpitations * Hypotension
91
What is the effect of weight reduction on blood pressure in hypertensive patients?
Can achieve important reductions in blood pressure
92
What dietary pattern is established for managing hypertension?
DASH diet and variations of the Mediterranean diet
93
What was the average blood pressure reduction from the DASH diet in the ENCORE study?
* Control group: 3.4/3.8 mmHg * DASH diet alone: 11.2/7.5 mmHg * DASH diet plus weight management: 16.1/9.9 mmHg
94
What is a common physical finding in ventricular septal defects (VSDs)?
Harsh, pan-systolic murmur best heard at the left lower sternal border
95
What is Eisenmenger syndrome?
A serious complication of long-standing left-to-right cardiac shunts leading to severe, irreversible pulmonary hypertension
96
What are the three main locations for atrial septal defects (ASDs)?
* Ostium secundum (75%) * Ostium primum (15%) * Sinus venosus (10%)
97
What is the hallmark of physical examination in ASD?
Wide and fixed splitting of the second heart sound
98
What is the recommended treatment for ASDs with a ratio of pulmonary-to-systemic flow of 1.5 or more?
Surgical closure
99
What are the main features of coarctation of the aorta?
* Differences in pulses and blood pressures above and below the coarctation * Possible lower-extremity claudication * Asymptomatic in many cases
100
What does ECG typically show in coarctation of the aorta?
Left ventricular hypertrophy
101
What is a characteristic radiological finding in coarctation of the aorta?
Dilatation of the aorta proximal and distal to the coarctation site leading to a '3 sign' on chest X-ray
102
What is the treatment for severe pulmonary stenosis?
Percutaneous balloon valvuloplasty or valvular replacement if necessary
103
What is the clinical significance of right ventricular outflow obstruction?
May lead to dyspnoea on exertion, fatigability, and right ventricular failure

Cardiology (2 decks)

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