PassMed Learning Points Flashcards

Question

Which valvular pathology is an acute complication of MI? [1] How long after an MI does this occur? [1]

Answer 1

**Acute mitral regurgitation** is a complication of myocardial infarction (MI): - which most commonly occurs **2 to 7 days after**

Answer 2

Internal iliac artery

Answer 3

External iliac artery

Answer 4

**Prodromal symptoms:** - sweating or feeling warm/hot before TLoC **Posture** - prolonged standing, or similar episodes that have been prevented by lying down **Provoking factors** - such as pain or a medical procedure

Answer 5

Which of the following is most likely to be the cause of a large JVP v-wave (giant v-wave)? Atrial fibrillation Cardiac tamponade Obstruction of the superior vena cava **Tricuspid regurgitation** Ventricular tachycardia

Answer 6

Which of the following is most likely to be the cause of a loss of a JVP a wave? **Atrial fibrillation** Cardiac tamponade Obstruction of the superior vena cava Tricuspid regurgitation Ventricular tachycardia

Answer 7

The characteristic murmur of mitral stenosis is a **mid-diastolic rumbling murmur** following an opening **snap** after the **second heart sound**

Answer 8

What is an absolute contraindication to thrombolysis? **Brain neoplasm** The rest are all relative contraindications

Answer 9

If the initial scan shows an AAA of **< 3 cm**, they are **discharged**. If it is between **3 and 4.4 cm**, they are invited back for **yearly screening.** If it is between **4.5 and 5.4 cm**, they receive an **ultrasound scan every 3 months** **Above 5.5 cm**, they are referred to a **vascular** **surgeon** for consideration for **repair**.

Answer 10

An 80-year-old man develops a bundle branch block during an acute myocardial infarction. Which of the following arteries is most likely to be involved? **Left anterior descending artery**

Answer 11

**Circumflex artery**

Answer 12

**LFTs at baseline, 3 months and 12 months**

Answer 13

**Percutaneous mitral commissurotomy** is the intervention of choice for severe mitral stenosis

Answer 14

**Left renal artery** Dissection of the descending aorta tends to propagate proximally and distally along the left lateral side of aorta. The renal arteries are lateral branches of the abdominal aorta. Therefore, the ostium of the left renal artery may be involved in aortic dissection.

Answer 15

**Under the age of 70:** - **bicuspid valve**. **Over the age of 70:** - **Calcific aortic stenosis**

Answer 16

**Cardiac tamponade**

Answer 17

A 68-year-old male is started on amiodarone for atrial fibrillation. What investigations should be performed before starting treatment? **Liver function tests (LFTs), urea and electrolytes (U&Es), thyroid function tests (TFTs) and chest X-ray**

Answer 18

**Pericarditis**

Answer 19

What are the limits of the normal cardiac axis? 0 to 90 degrees 0 to -90 degrees -30 to 60 degrees **-30 to 90 degrees** 30 to -60 degrees

Answer 20

The patient undergoes primary percutaneous coronary intervention (PCI), during which an occlusion is found within a vessel lying within the coronary sulcus. Which of the following structures is most likely to be the site of occlusion? Anterior interventricular (left anterior descending) artery **Coronary sinus** Right coronary artery Right (acute) marginal artery Left coronary artery

Answer 21

Patients with symptoms for over 48 hours or duration of onset is uncertain: * Rate control is the preferred mode of management: * **beta-blockers** (except sotalol) or **diltiazem/verapamil** are **first-line** for rate control (2021 NICE updates) * **digoxin** may be used if the patient is sedentary or if other rate‑limiting drug options unsuitable due to comorbidities or the person's preferences (2021 NICE update). * If symptoms are not controlled with monotherapy, a **combination of two drugs** may be used. * If AF has been present for more than 48 hours and cardioversion is required, **electrical cardioversion is preferred:** it should not be attempted until the patient has been **fully anticoagulated for at least three weeks.**

Answer 22

Standard EVAR techniques cannot be used to treat aneurysms that occur **above the level of the renal arteries**, and, in these cases, **open repair is the only available option** Above the renal arteries, there is **not an adequate length of the normal aorta to attach the graft**, increasing the risk of blood leaking around the graft **(an endoleak).**

Answer 23

**Acute pericarditis**

Answer 24

**Atypical symptoms**: - shortness of breath - weakness - fatigue (rather than the typical substernal chest pain)

Answer 25

**Coarctation of the aorta** is an important differential to keep in the back of the mind for younger adults with poorly controlled hypertension

Answer 26

- **hypertension** - **weak or absent femoral pulses** - **heart failure** - **left ventricular hypertrophy**

Answer 27

- **Prominent right ventricular cardiac impulse** - A **systolic ejection murmur** heard best in the **pulmonic** **area** and along the **left sternal border** - **Fixed splitting of the second heart sound.** These findings are due to an **abnormal left-to-right shunt through the defect**, which creates a **volume overload on the right side**. This increase in volume on the right side creates a **flow murmur, dilatation of the right-sided chambers, and delayed closure of the pulmonic valve**, all of which are seen in this presentation. Small atrial septal defects are usually asymptomatic.

Answer 28

Wenckebach’s phenomenon is typically benign, particularly in patients with normal haemodynamics. If Wenckebach’s phenomenon is accompanied by **acute myocardial infarction, complete heart block or symptomatic Mobitz type II block, temporary pacing is indicated**

Answer 29

**Cardiac tamponade** - muffled or distant heart sounds - low systolic blood pressure - distended JVP

Answer 30

**constrictive pericarditis** or **restrictive cardiomyopathy**.

Answer 31

Kussmaul’s sign is a paradoxical **rise in jugular venous pressure (JVP)** on **inspiration** due to **impaired filling of the right ventricle.**

Answer 32

**cardiac tamponade:** - jugular veins have a **prominent x descent** and an **absent y descent** **Constrictive pericarditis**: - there will be a **prominent x** and **y descent.**

Answer 33

**a wave**: Atrial contraction **X1 descent**: relaXation of the atrium and closure of the tricuspid valve **c wave**: ventricular Contraction and bulging of the tricuspid valve **X2 descent**: due to eXtra space within the pericardium to allow atrial filling **v wave:** increase in Volume of the right atrium due to filling **y descent**: emptYing of the right atrium with tricuspid valve opening

Answer 34

This waveform relates to Cardiac tamponade Constrictive pericarditis **Atrial fibrillation** Atrial septal defect Tricuspid regurgitation

Answer 35

This waveform relates to Cardiac tamponade **Constrictive pericarditis** Atrial fibrillation Atrial septal defect Tricuspid regurgitation

Answer 36

This waveform relates to Cardiac tamponade **Constrictive pericarditis** Atrial fibrillation Atrial septal defect Tricuspid regurgitation

Answer 37

This waveform relates to **Cardiac tamponade** Constrictive pericarditis Atrial fibrillation Atrial septal defect Tricuspid regurgitation

Answer 38

**A 'cannon', 'giant' or 'large' A wave** is seen when there is **simultaneous atrial and ventricular activation leading to contraction of the right atrium against a closed tricuspid valve** - This leads to a sharp, and pronounced, elevation in the JVP pressure. They occur due to rhythmic dissociation between atria and ventricle: e.g. **complete heart block, ventricular tachycardia**.

Answer 39

Giant ‘cv’ waves or tall ‘v’ waves are due to **tricuspid regurgitation**. **Blood regurgitates through the tricuspid valve during ventricular systole** (i.e. when the right ventricle contacts). If severe, the c wave obliterates the v wave leading to the term ‘cv’ wave.

Answer 40

The a wave represents atrial contraction. Therefore, in conditions such as atrial fibrillation when there is rapid, chaotic, atrial firing these waves are absent.

Answer 41

When **filling of the right ventricle is impaired** following the **opening of the tricuspid valve**, this may lead to a **slow or absent y descent**. Examples include **tricuspid stenosis or pericardial tamponade** because there is **equalisation of pressure across all chambers.**

Answer 42

A patient with idiopathic pericarditis becomes increasingly unwell, with hypotension, jugular venous distension and muffled heart sound on auscultation. Echocardiogram confirms a pericardial effusion. At which of the following sites does this effusion occur? Between the visceral pericardium and the myocardium **Between the visceral pericardium and the parietal pericardium** Between the parietal pericardium and the fibrous pericardium Between the fibrous pericardium and the mediastinal pleura Between the fibrous pericardium and the central tendon of the diaphragm

Answer 43

Computed tomography (CT) thorax with intravenous (IV) contrast

Answer 44

A low sodium diet contains < **2** g of sodium daily.

Answer 45

**Rare, benign tumour** that arises from connective tissue, found in most commonly in **left atrium** Often grow from a stalk and **swing freely with the flow of blood**, as a tetherball does. As they swing, they **may move in and out of the nearby mitral valve** This swinging motion **may plug and unplug the valve over** and over again, so that blood flow stops and starts intermittently.

Answer 46

Blockage of the flow through the mitral valve can also lead to: - **Syncopal episodes** - **Dyspnea** - **Pulmonary oedema** - **JVP distension** - **Afib** - due to electrical disruption - **Clubbing** - **TIAs** - CXR: **unusual intra-cardiac calcification within the left atrium**

Answer 47

**Loud first heart sound** and a **plopping sound in early diastole are heard.** **Precordial findings may mimic mitral stenosis**. The first heart sound (S1) may be loud and widely split because of the delay in the closure of the mitral valve due to the prolapse of the tumour into the mitral valve orifice.

Answer 48

Infective endocarditis Cyanotic congential heart disease Atrial myxoma

Answer 49

A 74-year-old female presents to her General Practitioner (GP) for a routine check-up. On examination, she appears slight breathless at rest. Her pulse is 74 bpm and irregularly irregular, and her blood pressure is 124/76 mmHg. Systems examination reveals nothing of concern. There is no significant medical history, and the patient is not on any regular medication. What is the most likely cause of this lady’s atrial fibrillation (AF)? Thyrotoxicosis Ischaemic heart disease Hypertension **Alcohol excess** Lone AF

Answer 50

**Pansystolic murmur that gets louder with inspiration** Indicates **tricuspid regurgitation**

Answer 51

Right heart failure can lead to **hepatomegaly** due to increased **back pressure** Detectable due to **pulstatile hepatomegaly**

Answer 52

The most common cause of a pulsatile liver is **tricuspid incompetence.**

Answer 53

The descending thoracic aorta lies in which of the following compartments of the mediastinum? Superior only **Posterior only** Middle only Middle and superior Superior and posterior

Answer 54

Impaired LV relaxation – increased LV end-diastolic pressure – normal LV end-systolic volume

Answer 55

**Impaired LV contraction – increased LV end-diastolic pressure – increased LV end-systolic volume** Impaired LV contraction results in LV dilation (increased end-systolic and end-diastolic volumes) and increased LV end-diastolic pressure.

Answer 56

* Because the pericardial sac isn't very compliant, when it becomes full of liquid it doesn't expand much * Therefore the **pressures inside the heart chambers equalise** as the ventricles have **less room to fill during diastole** * Therefore **EDV, SV & BP decrease**

Answer 57

**Pulsus paradoxus:** * Auscultation of heart sounds in the inspiration associated with a drop in systolic blood pressure of > 10 mmHg **Pathophysiology**: * During inspiration, get **decrease in intrathoracic pressure** * However, in cardiac tamponade you have an **increased return to RA** (due to equalised chamber pressures) * This means that increase in **RV filling** * Causes **expansion** into **septal** **side** & into the **LV** * Thereby reducing **stroke volume and blood pressure**.

Answer 58

Usually, **65 years is the upper limit for consideration of single, double lung or heart transplants**, and **55 years for both heart and lung transplants.**

Answer 59

- **>65** - **end-stage liver or kidney disease** - **bone marrow failure** - **active** **smoking** - **debilitating psychiatric disease**

Answer 60

* irreversible renal dysfunction (estimated glomerular filtration rate < 30 ml/min/1.73 m2), * clinically severe symptomatic cerebrovascular disease * tobacco and substance misuse * active malignancy * severe irreversible pulmonary hypertension.

Answer 61

**Hereditary hemorrhagic telangiectasia**: - Telangiectasias are a type of **arteriovenous malformation (AVM)**. They are small, dilated blood vessels that occur close to the surface of skin or mucous membranes. - AVMs in the lungs can lead to **low blood oxygen levels** and AVMs in the brain can cause seizures or headaches. - The most common clinical features are **nosebleeds and telangiectases on the lip, oral mucosa and hands.** - **High-output cardiac failure** is a rare complication of HHT usually caused by shunting of blood through **AVMs in the liver**

Answer 62

**Buerger's disease (thromboangiitis obliterans):** - a distinct vascular disorder characterised by **segmental thrombosing inflammation in medium-sized and small arteries** - **Long term smoking** big RF

Answer 63

**Acute pericarditis**

Answer 64

**Acute pericarditis** * Widespread concave ST elevation and PR depression is present throughout the precordial (V2-6) and limb leads (I, II, aVL, aVF). * There is reciprocal ST depression and PR elevation in aVR.

Answer 65

**Subendocardial infarction:** - setting of **shock** - affects **most ECG leads**. **Transmural infarction:** * limitation of ST elevation to a few leads

Answer 66

**Lower limb angiography** *Angiography is **not performed** when the clinical picture suggests complete occlusion, as it introduces a delay in revascularisation. In an incomplete occlusion, angiography uses stent placement to open the vessels.*

Answer 67

The patient’s presentation of a long-term history of hypertension and complaints of a painful, burning sensation in both legs suggest **coarctation of the aorta.** **Pathophysiology**: * In this condition, patients typically **present with hypertension in the upper extremities and hypotension in the lower extremities**, as the **aortic lumen narrows just distal to the branches of the aortic arch.** * Therefore, **blood shunts preferentially through the arch vessels**, and **little flow passes through the descending aorta** * Furthermore, these patients can suffer from symptoms of **lower extremity claudication** due to low oxygen delivery to those regions

Answer 68

A 65-year-old female with no significant medical history develops a paradoxical embolic stroke following a deep vein thrombosis. What embryological problem is most likely to explain this? **Patent foramen ovale** Paradoxical emboli occur when venous thromboses avoid clot capture by the lungs and enter the systemic circulation by way of a shunt by a septal defect. Patent foramen ovale occurs in up to 30% of adults and results in failure of the septum primum and secundum to fuse, preventing the normal creation of the inter-atrial septum.

Answer 69

**ACE inhibitor**: - Angiotensin-converting enzyme (ACE) inhibitors such as Ramipril have been shown to reduce proteinuria in diabetic nephropathy

Answer 70

**Spironolactone**

Answer 71

Intermittent claudification: - **ABPI** CLI: - **Duplex US** ALI: - **Doppler US**

Answer 72

Duplex ultrasound

Answer 73

This imaging would be given by **Duplex**

Answer 74

**Paroxysmal SVT**: - Most common type is **AVNRT**

Answer 75

The most common cause of death within the first hour after the onset of symptoms is a lethal arrhythmia such as **ventricular fibrillation**

Answer 76

A 73-year-old female attends her General Practitioner post discharge from hospital. She was admitted three weeks ago with chest pain and diagnosed with a non-ST elevation myocardial infarction. While admitted, she was started on several new medications to prevent further cardiac events and would now like some more advice. What is the most appropriate advice to give on her dose of statin? Simvastatin 40 mg od Simvastatin 80 mg od Atorvastatin 20 mg od Atorvastatin 40 mg od **Atorvastatin 80 mg od**

Answer 77

**Pulmonary oedema**

Answer 78

- Aortic dissections - atherosclerosis - PAD

Answer 79

**Balloon shaped**

Answer 80

Aortic dissection

Answer 81

Haemophilus influenzae pneumonia

Answer 82

Enlarged intercostal arteries produce **notching of the inferior margins of the ribs**, which can be detected by radiography and is diagnostic of this condition. The adult form of aortic coarctation is caused by stenosis in the aortic arch, just distal to the left subclavian artery. This leads to hypertension proximal to, and hypotension distal to, the stenotic segment. Hypertension in the upper part of the body manifests with headache, dizziness and other neurologic symptoms. Hypotension in the lower part of the body results in signs and symptoms of ischaemia, most often claudication, i.e. recurrent pain due to ischaemia of leg muscles. In addition, collateral arteries between the pre-coarctation and post-coarctation aorta (e.g. the intercostal and internal mammary arteries) enlarge and establish communication between aortic segments proximal and distal to the stenosis. Enlarged intercostal arteries produce notching of the inferior margins of the ribs, which can be detected by radiography and is diagnostic of this condition. Remember that the infantile form of aortic coarctation is associated with patent ductus arteriosus, whereas the adult form is not.

Answer 83

**Pericardial effusion** hypotension, distended neck veins and muffled heart sounds: **Beck's triad**

Answer 84

**cardiogenic shock secondary to an acute myocardial infarction**

Answer 85

**intra-aortic balloon pump** - provides ventricular support without compromising the blood pressure. It is inserted by a cardiac surgeon and increases blood pressure via a ball–valve effect in the proximal aorta. This is a temporising measure to allow recovery or as a bridge to transplant.

Answer 86

A 76-year-old female presents to the General Practitioner complaining of ‘bulging blue veins’ on her legs. While examining the patient’s legs, you note the presence of tortuous, dilated veins, accompanied by brown patches of pigmentation and dry, scaly plaques of skin. A diagnosis of varicose veins is made. Which vein is most likely to be affected? **Long saphenous vein**

Answer 87

**Lipodermatosclerosis**

Answer 88

Which investigation should be performed prior to compression bandaging for varicose veins? **Ankle-brachial pressure index** Prior to compression bandaging being applied, the patient needs to have their ABPI to ensure there will be no compromise to the arterial supply to the limb

Answer 89

A saphena varix is a dilatation of the **saphenous vein** at the **saphenofemoral junction in the groin.** It typically presents as a **lump around 2-4cm inferior-lateral to the pubic tubercle**. It often has a **bluish tinge, is soft to palpate and will vanish when the patient lies down** which can help differentiate it from an inguinal hernia.

Answer 90

Femoral hernia

Answer 91

**Ruptured AAA**causes **acidosis with a raised anion gap** - Reduced tissue perfusion leads to inadequate oxygenation, despite normal PaO2 - Widespread and **significant anaerobic metabolism** of glucose to **lactic** **acid** and **possible impairment of hepatic metabolism** (that would convert lactate back to glucose) - If renal perfusion is compromised (i.e. due to hypotension), the ability of the kidney to excrete excess H+ may also be impaired.

Answer 92

**VVI** (Ventricular pacing)

Answer 93

* **Anterior ST elevation myocardial infarction (STEMI)** * **Pericarditis** ST elevation in both **Pericarditis**: - chest pain relieved by **leaning** **forwards** - commonly follows a **viral** **illness** - **PR depression and saddle shaped ST**

Answer 94

Which jugular vein is commonly the best measure of central venous pressure (CVP)? Right anterior **Right internal** Right external Left internal Left external

Answer 95

A 25-year-old **intravenous drug user** is found to have a systolic murmur best heard at the left sternal edge at the fifth costal cartilage. Disease at which one of the following anatomical sites is the most likely cause of the murmur? **Tricuspid valve** - This regurgitation is likely caused by **infective** **endocarditis**, resulting in the formation of vegetations and destruction of the valve leaflets, leading to valve leakage. The patient's history as an intravenous drug user increases the likelihood of right-sided heart involvement, as microbes can be introduced through injection into veins.

Answer 96

**Ejection systolic murmur decreased by squatting** - This obstruction causes a reduction in the amount of blood the heart can pump out to the body, leading to decreased cardiac output

Answer 97

Ejection systolic murmur decreased by squatting

Answer 98

**HOCM**: - **Systolic function is preserved**, whilst **diastolic** **function** is impaired by the **increased septal growth** - The abnormal diastolic function is responsible for most symptoms.

Answer 99

In posterior myocardial infarction, **distinct ECG changes are observed in leads V1 through V3**, which are opposite in pattern compared to an anterior/anteroseptal myocardial infarction. Consequently, **ST depression is commonly seen in these leads**, reflecting the ischemic **involvement of the posterior wall of the heart.**

Answer 100

Aortic stenosis

Answer 101

Aortic stenosis can lead to which of the following **VWD** Turbulent flow across the stenotic aortic valve can lead to an acquired von Willebrand deficiency High shear forces inducing structural changes in the shape of the protein leading to clotting abnormalities.

Answer 102

This is most likely associated with Aortic regurg **Aortic stenosis** Mitral regurg Mitral stenosis **Angiodysplasia**

Answer 103

A patient has low-gradient AS. Which is the most appropriate next imaging technqiue to use? MCST **Dobutamine stress echocardiogram** CXR Exercise stress test

Answer 104

How do you determine if an asymptomatic patient has AS? [1] MCST Dobutamine stress echocardiogram CXR **Exercise stress test**

Answer 105

Heyde's syndrome is a combination of angiodysplasia causing anaemia, acquired coagulapathy and which valvular pathology? **Aortic stenosis**

Answer 106

**Acquired Type II VWD**

Answer 107

Combination of: - **RBBB** - **left anterior fascicular block (LAFB)**: which shows **LAD**; **prolonged PR waves**

Answer 108

**In LAFB:** - Impulses are conducted to the **left ventricle (LV)** via the **posterior fascicle**, which inserts into the **inferoseptal wall of the LV along its endocardial surface**

Answer 109

(aka collapsing pulse) **Aortic regurgitation**

Answer 110

LBBB is most asscociated with **Aortic stenosis**

Answer 111

Afib is most asscociated with - Aortic regurgitation - **Mitral regurgitation** - Aortic stenosis - Mitral stenosis

Answer 112

double-density sign is most asscociated with - Aortic regurgitation **- Mitral regurgitation** - Aortic stenosis - Mitral stenosis

Answer 113

**- Acute mitral regurgitation**

Answer 114

Gasless abdomen:**acute mesenteric ischaemia**

Answer 115

**Normally due to RH failure**: - constrictive pericarditis - restrictive cardiomyopathy - tricuspid stenosis - pulmonary hypertension (PH)

Answer 116

In ALS, if IV access cannot be achieved then drugs should be given **via the intraosseous route (IO)** - the tracheal route is no longer recommended

Answer 117

Is the most appropriate first-line anti-anginal for stable angina in a patient with known heart failure, if there are no contraindications? A. Verapamil B. Amlodipine C. Nifedipine **D. Bisoprolol** E. Nicorandil F. Isosorbide mononitrate

Answer 118

Patients may develop tolerance to this medication necessitating a change in dosing regime A. Verapamil B. Amlodipine C. Nifedipine D. Bisoprolol E. Nicorandil **F. Isosorbide mononitrate**

Answer 119

It is an inflammatory condition that causes **thrombus formation** in the **small and medium-sized blood vessels** in the **distal arterial system** (affecting the hands and feet).

Answer 120

**Younger than 50 years** **Not having risk factors for atherosclerosis**, other than **smoking** Usually men **25-35** who have **smoked heavily**

Answer 121

**Corkscrew collaterals**

Answer 122

**extremity ischaemia** * intermittent claudication * ischaemic ulcers **superficial thrombophlebitis** **Raynaud's phenomenon**

Answer 123

* **Complete cessation of smoking** * **Intravenous iloprost** (a prostacyclin analogue that dilates blood vessels).

Answer 124

TOM TIP: The key presentation to remember for your exams is a **young male smoker with painful blue fingertips**. The exam question may ask the diagnosis (Buerger disease or thromboangiitis obliterans) or ask the most important aspect of management **(completely stopping smoking).**

Answer 125

The **Duke** **criteria** are used for definitive diagnosis of infective endocarditis

Answer 126

The Duke criteria are used for definitive diagnosis of **infective endocarditis**

Answer 127

**Acute endocarditis** is most commonly caused by **Staphylococcus** **Subacute** cases are most commonly caused by **Streptococcus species.**

Answer 128

Native valve endocarditis (NVE): amoxicillin + gentamicin NVE with severe sepsis, penicillin allergy or suspected methicillin-resistent staphylococcus aureus (MRSA): vancomycin + gentamicin NVE with severe sepsis and risk factors gram negative infection: vancomycin + meropenem Prosthetic valve endocarditis: vancomycin, gentamicin + rifampacin

Answer 129

**Native valve endocarditis**

Answer 130

**vancomycin + meropenem** is the treatment for: native valve endocarditis with severe sepsis, penicillin allergy or suspected methicillin-resistent staphylococcus aureus (MRSA) Native valve endocarditis Prosthetic valve endocarditis **NVE with severe sepsis and risk factors gram negative infection**

Answer 131

**Prosthetic valve endocarditis**

Answer 132

vancomycin + gentamicin is the treatment for **native valve endocarditis with severe sepsis, penicillin allergy or suspected methicillin-resistent staphylococcus aureus (MRSA)** Native valve endocarditis Prosthetic valve endocarditis NVE with severe sepsis and risk factors gram negative infection

Answer 133

Which of the following would you use to treat native valve endocarditis? vancomycin + gentamicin vancomycin + meropenem vancomycin, gentamicin + rifampacin **amoxicillin + gentamicin**

Answer 134

Which of the following would you use to treat MRSA +ve endocarditis? **vancomycin + gentamicin** vancomycin + meropenem vancomycin, gentamicin + rifampacin amoxicillin + gentamicin

Answer 135

Which of the following would you use to treat **NVE with severe sepsis and risk factors gram negative infection**? vancomycin + gentamicin **vancomycin + meropenem** vancomycin, gentamicin + rifampacin amoxicillin + gentamicin

Answer 136

Which of the following would you use to treat **prosethetic valve endocarditis**? vancomycin + gentamicin vancomycin + meropenem **vancomycin, gentamicin + rifampacin** amoxicillin + gentamicin

Answer 137

**Stop diabetes treatment** **Start a Sliding Scale regimen** which in hospital is most easily done with **IV insulin and an infusion pump.**

Answer 138

**ACE-inhibitors**

Answer 139

What medication should be avoided in this patient? Amiodarone Atenolol Disopyramide **Ramipril** Verapamil **ACE-inhibitors** should be avoided in patients with HOCM

Answer 140

**HOCM** + **left ventricular outflow tract**

Answer 141

Most common ECG change in PE: **44% sinus tachycardia** **34% right ventricular strain pattern** **18% complete or incomplete RBBB** **S1Q3T3** does occur, but v rarely

Answer 142

**Electrical alternans** - Alternating loud and soft QRS complexes during to variation in fluid around the heart in each beat - is suggestive of **cardiac tamponade**

Answer 143

**Inducers**: cause **decrease** in **INR** **“SCARS”** * **S** → Smoking * **C** → Chronic alcohol intake * **A** → Antiepileptics: Phenytoin, Carbamazepine, Phenobarbitone (all barbiturates) * **R** → Rifampicin * **S** → St John's Wort **Inhibitors**: cause **increase** in **INR** **“ASS-ZOLES”** * **A** → Antibiotics: Ciprofloxacin, Erythromycin, Isoniazid, Clarithromycin * **S** → SSRIs: Fluoxetine, Sertraline * **S** → Sodium Valproate * - **Zoles** → Omeprazole, Ketoconazole, Fluconazole

Answer 144

**Diltiazem** **Beta-blockers** are contraindicated in patients with **asthma** when managing atrial fibrillation

Answer 145

According to the British National Formulary (BNF) and Resuscitation Council UK guidelines, **IV amiodarone** is recommended as the **first-line pharmacological treatment in cases of broad-complex tachycardia, particularly when the arrhythmia is suspected to be ventricular tachycardia (VT).**

Answer 146

* **Bradycardia** (< 60bpm) and not tachycardia * **J waves** * **Prolonged PR, QT and QRS intervals** * **Shivering artefacts** * **VT, VF or asystole**

Answer 147

A patient presents with a mid-diastolic murmur. She also has flushed cheeks. What other sign or symptom could she potentially have? A difference in blood pressure between the two arms Fine tremor in her hands **Haemoptysis** Involuntary head nodding Janeway lesions **Haemoptysis can be a symptom of mitral stenosis**

Answer 148

A **potassium above 6mmol/L** should prompt **cessation of ACE inhibitors** in a patient with **CKD** (once other agents that promote hyperkalemia have been stopped)

Answer 149

**IV magnesium sulphate**

Answer 150

**IV magnesium sulphate** (ECG showing torsades de pointes)

Answer 151

Adenosine may cause **chest pain** - This drug is used to terminate **supraventricular tachycardias after vagal manoeuvers have failed**. It can cause a brief sensation of flushing and intense chest pain, but the side-effects should resolve fastly. This medication should not be administered to asthmatics as it can cause bronchospasm.

Answer 152

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

Answer 153

Adenosine should ideally be infused via a **large-calibre** **cannula** due to it's short half-life,

Answer 154

It should be avoided in **asthmatics** due to possible **bronchospasm**.

Answer 155

DVLA advice post MI - cannot drive for **4 weeks**

Answer 156

What treatment is first-line in the management of acute pericarditis? Aspirin Ibuprofen **Ibuprofen + colchicine** Prednisolone Prednisolone + ibuprofen

Answer 157

* **sinus bradycardia** * **junctional rhythm** * **first degree heart block** * **Mobitz type 1 (Wenckebach phenomenon)**

Answer 158

**Tall, broad R waves (>30ms)** - **ST DEPRESSION in V1, V2, V3** - most important **Upright T waves.** **Dominant R wave (R/S ratio > 1) in V2.**

Answer 159

A **double** **pulse** felt in **systole** is called a **bisferiens pulse or pulsus bisferiens.** **Bisferiens pulse**

Answer 160

**Pulsus biferiens**

Answer 161

* **Aortic regurgitation** * **Concomittant aortic stenosis and regurgitation**

Answer 162

**Ivabradine** **sacubitril-valsartan** **digoxin** **hydralazine in combination with nitrate** **cardiac resynchronisation therapy**

Answer 163

**Hydralazine and nitrate**

Answer 164

**Ivabradine** - sinus rhythm > 75/min and a left ventricular fraction < 35% **sacubitril-valsartan**: - criteria: left ventricular fraction < 35% - is considered in heart failure with reduced ejection fraction who are symptomatic on ACE inhibitors or ARBs **digoxin** **hydralazine in combination with nitrate** - this may be particularly indicated in Afro-Caribbean patients **cardiac resynchronisation therapy** - indications include a widened QRS (e.g. left bundle branch block) complex on ECG

Answer 165

* **hydralazine in combination with nitrate**

Answer 166

A patient has chronic heart failure. You iniate an ACEin and a BB as first line treatment. This does not resolve their EF. You next trial and aldosterone antagonist. This does also not help. They have a widened QRS on their ECG. What is the appropriate third line treatment? * Ivabradine * sacubitril-valsartan * digoxin * hydralazine in combination with nitrate * **cardiac resynchronisation therapy**

Answer 167

A patient has chronic heart failure. You iniate an ACEin and a BB as first line treatment. This does not resolve their EF. You next trial and aldosterone antagonist. This does also not help. They have LVEF < 35% and symptomatic What is the appropriate third line treatment? **sacubitril-valsartan**

Answer 168

A patient has chronic heart failure. You iniate an ACEin and a BB as first line treatment. This does not resolve their EF. You next trial and aldosterone antagonist. This does also not help. They have LVEF < 35% and a sinus rhythm of 90bpm What is the appropriate third line treatment? **Ivabradine**

Answer 169

**BB AND ACEin** generally, one drug should be started at a time. NICE advise that clinical judgement is used when determining which one to start first

Answer 170

What is the mechanism of action of fondaparinux? Reversible direct thrombin inhibitor Glycoprotein IIb/IIIa receptor antagonist Inhibits antithrombin III Inhibits ADP binding to its platelet receptor **Activates antithrombin III**

Answer 171

Flattening of T waves - due to hypokalaemia

Answer 172

Citalopram is an anti-depressant that may **cause QT-prolongation.**

Answer 173

Tall tented T waves (from hyperkalaemia)

Answer 174

**Beta blockers**

Answer 175

* bronchospasm * cold peripheries * fatigue * sleep disturbances, including nightmares * erectile dysfunction

Answer 176

**Amiodarone** is used in the treatment of monomorphic ventricular tachycardia.

Answer 177

**METHCATS** - **M**ethadone - **E**rythromycin - **T**erfenadine (antihistamine) - **H**aloperidol (antipsychotic) - **C**hloroquine - **A**miodarone - **T**CAs (tricyclic antridepresants) - **S**otalol (beta blocer) & SSRIs (citalopram)

Answer 178

**Escalating dose of loop diuretic**: to ensure a sufficient concentration is achieved within the tubules.

Answer 179

**Cardiac output drops** sufficiently to result in **renal dysfunction** The reduced cardiac function causes **hypotension, tachycardia, reduced peripheral perfusion, and hepatic congestion** **Hyponatraemia** occurs because of dilutional effect of heart failure. **Increased doses of diuretics** are required to **improve cardiac contractility,** improve cardiac output, and thus increase renal perfusion.

Answer 180

**Atrial fibrillation with bundle branch block** is the most likely cause of an irregular broad complex tachycardia in a stable patient

Answer 181

U waves are visible in leads V2 and V3, and QT interval prolongation

Answer 182

Arrangements are made to start PCI and you are asked to prepare the site of insertion. What is the best site for insertion? Brachial artery **Femoral artery** Femoral vein Jugular vein Radial artery

Answer 183

New LBBB is always **pathological.**

Answer 184

* **myocardial infarction** diagnosing a myocardial infarction for patients with existing LBBB is difficult rhe Sgarbossa criteria can help with this * **hypertension** * **aortic stenosis** * **cardiomyopathy** | New LBBB is always pathological

Answer 185

Remember that if a CHA2DS2-VASc score suggests no need for anticoagulation it is important to ensure a **transthoracic echocardiogram** has been done to **exclude valvular heart disease,** which in combination with AF is an absolute indication for anticoagulation.

Answer 186

An increase in serum creatinine up to **30%** from baseline is acceptable when initiating ACE inhibitor treatment

Answer 187

Synchronised DC cardioversion takes place as per the tachyarrhythmia advanced life support algorithm. Which part of the QRS complex is used for synchronisation? P wave Q wave **R wave** S wave T wave

Answer 188

Which one of the following would be strongest indication for thrombolysis in PE? Extensive deep venous thrombosis **Hypotension** Patient choice following informed consent Hypoxaemia despite high flow oxygen ECG showing right ventricular strain

Answer 189

**Kussmaul's sign** is typical of **constrictive pericarditis**, and is a **raised JVP with inspiration** **Pulsus paradoxus**, which is an **abnormally large drop in blood pressure** (and stroke volume) caused by inspiration, and is typical of **cardiac tamponade.**

Answer 190

If the beta-blocker is contraindicated - e.g. if they have **asthma** if a patient is on monotherapy and cannot tolerate the addition of a calcium channel blocker or a beta-blocker then consider one of the following drugs: * **a long-acting nitrate** * **ivabradine** * **nicorandil** * **ranolazine**

Answer 191

An 87-year-old woman presents to the emergency department with confusion and generalised malaise following a syncope. On examination, she looks pale and clammy, her pulse is regular and slow. Her vital signs show the following: heart rate 45/min, respiratory rate 7/min, blood pressure 87/55 mmHg and temperature 35.9 ºC. She has a past medical history of amyloidosis and types two diabetes mellitus, usually well controlled. Which one of the following management options is the most appropriate for this patient? DC cardioversion Transcutaneous pacing IV adrenaline IV adenosine **IV atropine**

Answer 192

A 14-year-old boy presents to the Emergency Department as he is unable to control his facial muscles and arm movements. For the last 5 weeks, following a throat infection, he has been experiencing ongoing fever, worsening shortness of breath and joint pains, mainly in his legs which have not been effectively managed. What is the most likely cause of the patient's recent symptoms? Huntington's chorea Chorea gravidarum Wilson's disease Drug-induced chorea **Sydenham's chorea**

Answer 193

Cardiovascular disease: atorvastatin **20mg** for primary prevention, **80mg** for secondary prevention

Answer 194

**ventricular fibrillation/pulseless ventricular tachycardia** (VF/pulseless VT)

Answer 195

1. **CPR 30:2** 2. Attach defibrillator 3. Assess rhythm: - If shockable (VF / Pulseless VT): **one shock, then resume CPR for 2 min then assess rhythm again and repeat** - If non-shockable: **immediately resume CPR for 2 mins and assess rhythm again** **Adrenaline**: - **1 mg** as soon as possible for **non-shockable rhythms** - **during a VF/VT cardiac arrest, adrenaline 1 mg** is given once **chest** **compressions** have **restarted** after the **third shock** - repeat adrenaline **1mg every 3-5** minutes whilst ALS continues **amiodarone**: * **300 mg** should be given to patients who are in **VF/pulseless VT after 3 shocks have been administered.** * a further dose of amiodarone **150 mg** should be given to patients who are in **VF/pulseless VT after 5 shocks** have been administered **thrombolytic drugs**: * should be considered if a **pulmonary embolus** is **suspected** * if given, **CPR** should be continued for an **extended period of 60-90 minutes**

Answer 196

**Adrenaline**: - **1 mg** as soon as possible for **non-shockable rhythms** - **during a VF/VT cardiac arrest, adrenaline 1 mg** is given once **chest** **compressions** have **restarted** after the **third shock** - repeat adrenaline **1mg every 3-5** minutes whilst ALS continues **amiodarone**: * **300 mg** should be given to patients who are in **VF/pulseless VT after 3 shocks have been administered.** * a further dose of amiodarone **150 mg** should be given to patients who are in **VF/pulseless VT after 5 shocks** have been administered **thrombolytic drugs**: * should be considered if a **pulmonary embolus** is **suspected** * if given, **CPR** should be continued for an **extended period of 60-90 minutes**

Answer 197

**Adrenaline**: - **1 mg** as soon as possible for **non-shockable rhythms** - **during a VF/VT cardiac arrest, adrenaline 1 mg** is given once **chest** **compressions** have **restarted** after the **third shock** - repeat adrenaline **1mg every 3-5** minutes whilst ALS continues

Answer 198

**amiodarone**: * **300 mg** should be given to patients who are in **VF/pulseless VT after 3 shocks have been administered.** * a further dose of amiodarone **150 mg** should be given to patients who are in **VF/pulseless VT after 5 shocks** have been administered

Answer 199

**thrombolytic drugs**: * should be considered if a **pulmonary embolus** is **suspected** * if given, **CPR** should be continued for an **extended period of 60-90 minutes**

Answer 200

**94-98%** - is to address the potential harm caused by hyperoxaemia

Answer 201

Risk factors for asystole in bradycardia (? needs transvenous pacing) * **complete heart block with broad complex QRS** * **recent asystole** * **Mobitz type II AV block** * **ventricular pause > 3 seconds**

Answer 202

Form of inherited cardiovascular disease with may present with **sudden cardiac death** - **autosomal dominant** - mutation in gene that encodes the **myocardial sodium ion channel protein** - more common in **males**

Answer 203

* convex ST segment elevation > 2mm in > 1 of V1-V3 followed by a negative T wave * partial right bundle branch block

Answer 204

**Investigation**: * the **ECG changes** may be more **apparent** following the administration of **flecainide** or **ajmaline** **Management** * **implantable cardioverter-defibrillator**

Answer 205

**Up the dose of warfarin** - As the patient suffers from recurrent pulmonary embolisms, her **target INR is 3.5**. Therefore the patients warfarin dose should be increased to 5.5mg.

Answer 206

**target INR is 3.5**

Answer 207

organised or semi-organised electrical activity of the heart persists but the product of systemic vascular resistance and the increase in systemic arterial flow generated by the ejection of the **left ventricular stroke volume is not sufficient to produce a clinically detectable pulse**

Answer 208

**Tension pneumothorax**

Answer 209

**systemic lupus erythematosus**

Answer 210

ACS management: **nitrates** should be used with caution if the patient is **hypotensive**

Answer 211

Type A dissection is defined as a dissection proximal to the **brachiocephalic artery.**

Answer 212

**IV BB and surgery** The patient's blood pressure must be controlled **within 100 -120 mmHg (systolic)** whilst awaiting surgical intervention, therefore IV labetalol must be given.

Answer 213

**control BP(IV labetalol)**

Answer 214

The most common congenital cardiac abnormality which does not cause cyanosis is a **ventricular septal defect** Ventricular septal defects are associated with a **pansystolic murmur**

Answer 215

VSDs are associated with **Aortic regurgitation** Aortic stenosis Mitral stenosis Mitral regurgitation

Answer 216

poorly supported right coronary cusp resulting in cusp prolapse

Answer 217

**IV furosemide or bumetanide** **Nitrates** are generally **contraindicated**

Answer 218

Acute HF + - **concomitant myocardial ischaemia** - **severe hypertension** - **regurgitant aortic or mitral valve disease**

Answer 219

Acute HF + - **patients with severe left ventricular dysfunction who have potentially reversible cardiogenic shock**

Answer 220

Add an inotropic agent (such as **dobutamine**)

Answer 221

heart rate less than 50 beats per minute, second or third degree atrioventricular block, or shock

Answer 222

If hypotensive / in cardiogenic shock and have an insufficient response to inotropes and there is evidence of end-organ hypoperfusion

Answer 223

**Anterior MI** - **ST-segment elevation** in the precordial leads **V1-V4** **Posterior MI** - **tall R waves V1-3** *PosteRioR contains 2 tall Rs* - **Horizontal ST depression** in **V1-3**

Answer 224

**Left circumflex**; **RCA**

Answer 225

Posterior infarction is confirmed by **ST elevation and Q waves in posterior leads (V7-9)**

Answer 226

**GTN** are CI in AS due to the fact that they are **potent vasodilators**, meaning that they would **reduce BP**, and the heart would have to **work even harder** (and likely cause blood back into the Pulmonary Circulation and Right Ventricle)

Answer 227

**BASHeD** They all reduce mortality except digoxin **B**eta blocker **A**CEi **S**pironolactone **H**ydralazine + nitrates **D**igoxin - symptomatic relief only

Answer 228

SVT: **Narrow QRS** VT:**Wide QRS**

Answer 229

Wellens Syndrome is a clinical syndrome characterised by **biphasic or deeply inverted T waves in V2-3**, plus a history of **recent chest pain now resolved**. It is highly specific for **critical stenosis of the left anterior descending artery (LAD)** **ECG pattern present in pain-free state** is part of the diagnostic criteria

Answer 230

Wellen's syndrome suggests stenosis of which coronary artery RCA LCA Circumflex artery **LAD**

Answer 231

**Wellen's syndrome** - suggests stenosis in LAD

Answer 232

**Kartagener's syndrome** - linked to **dextrocardia** Dextrocardia is associated with an **inverted P wave in lead I, right axis deviation, and loss of R wave progression**

Answer 233

**In third degree HB:** Since the P and QRS waves are completely unrelated this means the atria and ventricles each pace themselves: * **the p-p interval will always be the same** * **the R-R interval will always be the same** i think complete AV block is most easily confused with Mobitz Type II - however Mobitz II: * **R-R interval will not be the same since there will be a dropped QRS complex somewhere!**

Answer 234

**Takayasu's arteritis**: - **large vessel vasculitis**. - It mainly causes causes occlusion of the **aorta** and its branches. It can also affect the **pulmonary arteries.**

Answer 235

* systemic features of a vasculitis e.g. malaise, headache * questions commonly refer to an **absent limb pulse** * **unequal blood pressure** in the **upper limbs** * **carotid** **bruit** and tenderness * **absent or weak peripheral pulses** * upper and lower limb **claudication** on exertion * **aortic** **regurgitation** (around 20%)

Answer 236

Diagnosis involves **CT angiography** or **MRI** **angiography**. *vascular imaging of the arterial tree is required to make a diagnosis of Takayasu's arteritis*

Answer 237

**steroids**

Answer 238

**aspirin** and a P2Y12 receptor antagonist such as **clopidogrel, prasugrel, or ticagrelor**

Answer 239

Which of the following causes GI ulceration? Bisoprolol Diltiazem Isosorbide mononitrate **Nicorandil** Ranolazine

Answer 240

**Left ventricular heart failure**

Answer 241

Which of the following medications are known to cause QTc prolongation? Bisoprolol Diazepam Salbutamol **Sotalol** Carvedilol

Answer 242

Which class of anti-arrhythmics cause prolonged QT intervals? **Class I** Class II Class III Class IV

Answer 243

Hypocalcaemia Hypomagnesium Hypokalaemia

Answer 244

* **acute myocardial infarction** * **myocarditis** * **hypothermia** * **subarachnoid haemorrhage**

Answer 245

the usual mechanism by which drugs prolong the QT interval is blockage of **potassium channels**. See the link for more details

Answer 246

Prolonged QT intervals from drug treatment usually occurs due to blockage of which channels Ca2+ Na+ **K+** Cl-

Answer 247

**Class I:** - **Na** **blockers** **Class II:** - **Beta blockers** **Class III:** - **K blockers** **Class IV** - **Ca blockers**

Answer 248

**Arrhythmias** are **disorders** of **rate and rhythm** of the heart, which arise due to either **abnormal generation or conduction of electrical impulses.**

Answer 249

**Arrhythmogenesis** may be due to **increased automaticity, re-entry or triggered activity.**

Answer 250

**Increased automaticity**: tissue other than the SA node develops spontaneous depolarization that supersedes the SA node itself. Due to: - **Conduction pathway** - i.e. specialised autorhythmic cells. - **Contractile tissue** - contractile cells may gain autorhythmic function for various reasons, e.g. ischaemia. **Re-entry**: - Begins when an electrical impulse reaches a branch in which one pathway is refractory **Triggered activity** - Damage to the myocardium may lead to oscillations of membrane potentials at the end of the action potential, termed afterdepolarisations.

Answer 251

**triggered activity**

Answer 252

**Positive inotropic** (contractility) **Negative chronotropic** (heart rate)

Answer 253

Digoxin inhibits sodium-potassium ATPase in the ventricular myocardium: leads to an increase in intracellular concentration of Na, affecting Na Ca exchange, and ultimately more Ca for contracton in the myocardium

Answer 254

**Increased vagus nerve activity**

Answer 255

**Curved ST segment depression**

Answer 256

**Hypokalaemis**

Answer 257

**Bidirectional ventricular tachycardia:** - electrical axis shifting from L to R from one beat to the next

Answer 258

**1A** - Phase 0: **Depress** **1B** - Phase 0: **Depress** 1C - Phase 0: **Markedly depress**

Answer 259

Which stage of the cardiac action potential do Class I anti-arrythmics work on? **Phase 0** Phase 1 Phase 2 Phase 3 Phase 4

Answer 260

Which stage of the cardiac action potential do Class II anti-arrythmics work on? Phase 0 Phase 1 Phase 2 Phase 3 **Phase 4**

Answer 261

Which stage of the cardiac action potential do Class III anti-arrythmics work on? Phase 0 Phase 1 Phase 2 **Phase 3** Phase 4

Answer 262

Phase 0 Phase 1 **Phase 2** Phase 3 Phase 4

Answer 263

A: **Class 1** - Na channel blocker B. **Class 4** - Ca 2+ channel blocker C. **Class 3** - K+ channel blocker D: **Class 2** - Beta blocker

Answer 264

Flecainide works at which of the following **A** - **Class 1** B C D

Answer 265

Propanalol works at which of the following A B C **D**

Answer 266

Amiodarone works at which of the following A B **C** D

Answer 267

Verapamil and Diltiazem work at which of the following A **B** C D

Answer 268

Which of the following anti-arrythmic causes gum hyperplasia as an adverse effect? Digoxin Amiodarone **Verapamil / Diltiazem** Adenosine Atropine

Answer 269

Which of the following anti-arrythmic causes changes in colour perception / yellow halos? **Digoxin** Amiodarone Verapamil / Diltiazem Adenosine Atropine

Answer 270

Which of the following anti-arrythmic causes a sense of impending doom? Digoxin Amiodarone Verapamil / Diltiazem **Adenosine** Atropine

Answer 271

**Class I** (Na blocker) - **Lidocaine**, **Phenytoin** (Class Ib) - **Flecainide** (Class 1c) **Class II:** (B blocker) - **Propranolol, Bisoprolol** **Class III:** (K blocker) - **Amiodarone, Sotalol** **Class IV**: (Ca2+ blocker) - **Verapamil, Diltiazem**

Answer 272

**Class III**

Answer 273

Which class of antiarrhythmic drugs primarily acts by blocking sodium channels in cardiac myocytes? **A) Class I** B) Class II C) Class III D) Class IV

Answer 274

Which antiarrhythmic drug class primarily prolongs the action potential duration and refractory period by blocking potassium channels? A) Class I B) Class II **C) Class III** D) Class IV

Answer 275

Which antiarrhythmic drug is associated with the side effect of torsades de pointes and may prolong the QT interval? **A) Amiodarone** B) Metoprolol C) Verapamil D) Digoxin

Answer 276

Which antiarrhythmic drug class is least likely to cause negative inotropic effects and exacerbate heart failure? A) Class I B) Class II C) Class III **D) Class IV**

Answer 277

Which antiarrhythmic drug is known for its potential to cause pulmonary toxicity and thyroid dysfunction? **A) Amiodarone** B) Sotalol C) Lidocaine D) Diltiazem

Answer 278

What is a common side effect of Class I antiarrhythmic drugs, such as flecainide and propafenone? A) Bradycardia B) Hypotension **C) Proarrhythmia** D) Hyperkalemia

Answer 279

**Shockable rhythms:** - Amiodarone should be given to patients in **ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT)** AFTER they've recieved **three shocks** - a further dose of **amiodarone 150 mg** should be given to patients who are in VF/pulseless VT **after 5 shocks have been administered**

Answer 280

**if the cardiac arrested is witnessed in a monitored patient** (e.g. in a coronary care unit) then the 2015 guidelines recommend 'up to three quick successive (stacked) shocks', rather than 1 shock followed by CPR & if in **ventricular fibrillation or pulseless VT**

Answer 281

**Non-shockable rhythms:** - adrenaline 1 mg **as soon as possible** **Shockable rhythms:** - adrenaline 1 mg is given once chest compressions have **restarted** after the **third shock** **repeat** adrenaline 1mg **every 3-5 minutes whilst ALS continues**

Answer 282

A patient with AF + an acute stroke (not haemorrhagic) should have anticoagulation therapy started **two weeks after the event**

Answer 283

The criteria for urgent valvular replacement are as follows: * **Severe congestive cardiac failure** * **Overwhelming sepsis despite antibiotic therapy** (+/- perivalvular abscess, fistulae, perforation) * **Recurrent embolic episodes despite antibiotic therapy** * **Pregnancy**

Answer 284

Which of the following medications are known to cause QTc prolongation? Bisoprolol Diazepam Salbutamol **Sotalol** Carvedilol **METHCATS prolong QTi** M - Methadone E - Erythromycin T - Terfenadine H - Haloperidol C - Chloroquine / Citalopram A - Amiodarone T - Tricyclics S - Sotalol

Answer 285

HOCM may present with ejection systolic murmur, **louder on performing Valsalva** and **quieter on squatting**

Answer 286

Cardiovascular disease: atorvastatin **20mg** for primary prevention, **80mg** for secondary prevention

Answer 287

**Ascending**

Answer 288

Which one of the following ECG changes is associated with Wolff-Parkinson White syndrome? Long QT P wave inversion 'J' waves Hyperacute T waves **Short PR interval**

Answer 289

Aortic valve: - **3.0** Mitral valve: - **3.5** Mechanical heart valves have a high propensity for clot formation, particularly mitral valves.The only drugs licensed for anticoagulation in mechanical heart valves are warfarin and low molecular weight heparin (LWMH).

Answer 290

**Atypical chest pain:** - chest pain - pleuritic pain - epigastric pain - upper back pain - dizziness - generalised fatigue

Answer 291

Pregnancy is a contraindication to **statin therapy**

Answer 292

Small: **< 1cm** Moderate: **1-2cm** Large: **> 2cm**

Answer 293

**Aspirin & Clopidogrel**

Answer 294

**Aspirin & prasugrel**

Answer 295

**Calcium and glucose raised** **Mg, K, Na decreased** *Thiazides cause a lot of trouble can make glucose and calcium double and yet they deal another blow with pot, mag and sodium low*

Answer 296

**Pregnant** **Renal impairment**

Answer 297

Which one of the following ECG changes is associated with Wolff-Parkinson White syndrome? Long QT P wave inversion 'J' waves Hyperacute T waves **Short PR interval**

Answer 298

***hereditary long QT syndrome (LQTS):*** * *Long QT syndrome (LQTS) is an inherited condition associated with delayed repolarization of the ventricles* * *The most common variants of LQTS (LQT1 & LQT2) are caused by defects in the alpha subunit of the slow elayed rectifier potassium channel.* * **Long QT1** - usually associated with exertional syncope, often swimming * **Long QT2** - often associated with syncope occurring following emotional stress, exercise or auditory stimuli * **Long QT3** - events often occur at night or at rest * sudden cardiac death

Answer 299

**hereditary long QT syndrome (LQTS):** * Long QT syndrome (LQTS) is an inherited condition associated with delayed repolarization of the ventricles * The most common variants of LQTS (LQT1 & LQT2) are caused by defects in the alpha subunit of the slow **delayed rectifier** **potassium channel.**

Answer 300

Long QT syndrome arises from a defect in the alpha subunit in which channel * Gain-of-function of K+ channels * Gain-of-function of Na+ channels * Loss-of-function of Ca2+ channels * **Loss-of-function of K+ channels** * Loss-of-function of Na+ channels **K+ leaves during repolarisation hence loss of function would prolong the QT segment**

Answer 301

ORBIT: - **bleeding risk from AF** CHAD2S2VASc: - **Risk of stroke from aF**

Answer 302

**Hypocalcaemia**: prolongs QT **Hypercalcaemia**: shortens QT - QT is start of depol. to repol (systole) - platau phase in cardiac cycle is controlled by Ca2+ movement into cytoplasm - More Ca2+ means more movement and more systole = shorter QT

Answer 303

Which of the following describes the murmur found in tricuspid regurgitation **Holosystolic murmur louder on inpsiration** Ejection systolic murmur louder on inpsiration Ejection systolic murmour louder on expiration

Answer 304

Aortic stenosis

Answer 305

**Pulmonary stenosis**

Answer 306

**Clarithromycin**

Answer 307

Bifid p waves (atrial enlargement) Extreme QRS (LVH)

Answer 308

**ASAP** If shockabale (pulseless VT/VF - give after 3rd shock)

Answer 309

**Type II**

Answer 310

Left sided HF presents with S1 S2 **S3** S4

Answer 311

Prolonged PT Normal APTT

Answer 312

**Stenosis of proximal subclavian artery** - When use arm with stenosis of proximal subclavian artery, theres insufficient blood flow - To compensate, get retrograde flow from vertebral artery, which supplies posterior brain - As a result cerebellum etc is underperfused and get dizziness

Answer 313

**Surgical**: if low / medium risk from surgery **Transcatheter**: high risk from srugery

Answer 314

PE = **resp alkalosis**

Answer 315

**Global T wave changes** (not indicative to one artery) **Prolonged QT**

Answer 316

Thrombolytic drug (e.g. **alteplase**) and **fondaparinoux**

Answer 317

Rheumatic fever

Answer 318

Anticoagulate for 3 weeks Perform TOE and exclude left atrial appendage

Answer 319

**Dabigatran**: - **Idacrucizumab** **Apixaban**: - **Andexanet alfa**

Answer 320

Hepatomegaly Raised JVP Ankle oedema

Answer 321

**arrhythmogenic right ventricular dysplasia (ARVD)**

Answer 322

The CT shows a large saddle embolus where the pulmonary trunk splits to form the right and left pulmonary arteries. - **big grey line in the pulmonary vessels**

Answer 323

External pacing

Answer 324

Bio: **aspirin only** Mech: **Warfarin and aspirin**

Answer 325

Over 80 and stage 1 HTN? **Don't treat** - Calcfication of arteries is so common that would need to treat everyone

Answer 326

**Lidocaine**

Answer 327

Most common: **mitral valve** IVDU: **tricuspid valve**

Answer 328

**Coarctation of the aorta**

Answer 329

If patient has renovascular disease - e.g. renal artery stenosis

Answer 330

Start asymmetrical dosing times

Answer 331

Which of the following does not cause a diastolic murmur? **A Tricuspid regurgitation** B Mitral stenosis C Tricuspid stenosis D Aortic regurgitation E Austin-Flint murmur

Answer 332

Which of the following best describes chronic pericarditis? A Pericardial inflammation lasting > 14 days B Pericardial inflammation lasting > 4-6 weeks **C Pericardial inflammation lasting > 3 months** D Pericardial inflammation lasting > 6 months E Pericardial inflammation lasting > 1 year

Answer 333

**Pericardiectomy** is generally considered for patients with chronic constrictive pericarditis and severe symptoms of heart failure.

Answer 334

If suffering from **paroxysmal atrial fibrillation**: In the absence of other cardiovascular co-morbidities, this patient can be managed with **flecainide**.

Answer 335

Which of the following pulse characteristics is associated with aortic stenosis? Pulsus alternans **Slow-rising pulse** Waterhammer pulse Jerky pulse Thready pulse

Answer 336

Which of the following pulse characteristics is associated with HOCM? Pulsus alternans Slow-rising pulse Waterhammer pulse **Jerky pulse** Thready pulse

Answer 337

A sinus pause describes the failure of the SAN to initiate electrical activity and can be seen as an absent P wave on the ECG. Transient absence of P waves that lasts ≥ 2 seconds

Answer 338

Which of the following pulse characteristics is associated with aortic regurgitation? A Pulsus alternans B Slow-rising pulse **C Waterhammer pulse** D Jerky pulse E Thready pulse

Answer 339

A 38 year old intravenous drug use is admitted to hospital with high fevers and palpitations. He is a known intravenous drug use and was recently treated for cellulitis at an injection site. On this admission his MRSA swab was positive The working diagnosis is infective endocarditis and a transthoracic echocardiogram is organised for the next day. Initial blood cultures show gram positive cocci in clusters. Which of the following is the most appropriate antibiotic? A Clindamycin B Gentamicin C Rifampicin D Flucloxacillin E **Vancomycin**

Answer 340

The treatment of choice for a methicillin sensitive staphylococcus aureus (MSSA) would be **flucloxacillin**.

Answer 341

- Large cv wave in JVP

Answer 342

JVP rises on inspiration: = **Constrictive pericarditis** Kussmaul's sign *Constrictive pericarditis occurs when the pericardium is recovering from pericarditis and forms scar tissue. This scar tissue makes the pericardium stiff, hard and non-compliant, resulting in difficulty filling the heart.*

Answer 343

Exaggerated fall in BP during inspiration by over 10mmHg: **Cardiac tamponade** Pulsus paradoxus

Answer 344

**Pulsus paradoxus:** - Decrease in BP by 10mmHG during inspiration - Associated with cardiac tamponade **Kussmauls sign:** - Rise in JVP with inspiration - Constrictive pericarditis

Answer 345

The 6As of secondary prevention: - aspirin - antiplatlet (clopidogrel or ticagrelor) - atorvastatin - ACEi - Atenolol (or other beta blocker) - & Aldosterone antagonist if in heart failure

Answer 346

Form of inherited cardiovascular disease which may present with syncope or sudden cardiac death: * inherited in an **autosomal** **dominant** pattern with variable expression * the **right ventricular myocardium** is **replaced** by **fatty and fibrofatty tissue** * around 50% of patients have a mutation of one of the several genes which encode components of desmosome

Answer 347

**Arrhythmogenic right ventricular cardiomyopathy**

Answer 348

* **ECG** abnormalities in **V1-3, typically T wave inversion**. An epsilon wave is found in about 50% of those with ARV - this is best described as a **terminal notch in the QRS complex** * **echo** changes are often subtle in the early stages but may show an **enlarged, hypokinetic right ventricle with a thin free wall** * **magnetic resonance imaging** is useful to show **fibrofatty** **tissue**

Answer 349

Management * drugs: **sotalol** is the most widely used antiarrhythmic * **catheter** **ablation** to prevent ventricular tachycardia * **implantable cardioverter-defibrillator**

Answer 350

**VF/pulseless VT should be treated with 1 shock as soon as identified**

Answer 351

**arrange transfer to a PCI centre** because if ST elevation occurring post fibronolysis suggests a failed attempt at reperfusion by fibrinolysis, indicating the need for a rescue percutaneous coronary intervention (PCI).

Answer 352

- Perform **thrombolysis** - **Repeat ECG** should be performed **60-90 minutes** after fibrinolysis. - If it continues to **show residual ST elevation**, **immediate coronary angiography** with possible follow-on PCI should be offered.

Answer 353

* right ventricular infarction * pulmonary hypertension e.g. COPD * rheumatic heart disease * infective endocarditis (especially intravenous drug users) * Ebstein's anomaly * carcinoid syndrome

Answer 354

* pan-systolic murmur * prominent/giant V waves in JVP * pulsatile hepatomegaly * left parasternal heave

Answer 355

What is the most specific ECG finding related to acute pericarditis Concave ST elevation - Although this finding is more sensitive to acute pericarditis compared to PR depression, it is a less specific finding **PR depression**

Answer 356

Most common cause of endocarditis: * Staphylococcus aureus * Staphylococcus epidermidis if < 2 months post valve surgery

Answer 357

For a patient with symptomatic stable angina on a calcium channel blocker but with a contraindication to a beta-blocker, the next line treatment should be **long-acting nitrate, ivabradine, nicorandil or ranolazine**