Passmedicine - Cardiology Flashcards
(451 cards)
1
Q
Define syncope
A
Transient loss of consciousness due to global cerebral hypoperfusion with rapid onset, short duration and spontaneous recovery
2
Q
What are the three types of syncope?
A
Reflex syncope (neurally mediated)
Orthostatic syncope
Cardiac syncope
3
Q
What are the types of reflex syncope?
A
Vasovagal
Situational
Carotid sinus syncope
4
Q
What triggers vasovagal syncope?
A
Emotion
Pain
Stress
5
Q
What is vasovagal syncope otherwise known as?
A
Fainting
6
Q
What things may cause situational syncope?
A
Cough
Micturition
GI
7
Q
What are the types of orthostatic syncope?
A
Primary automatic failure - PD, LBD
Secondary automatic failure - e.g. diabetic neuropathy, amyloidosis, uraemia
Drug induced - diuretics, alcohol, vasodilators
Volume depletion - haemorrhage, diarrhoea
8
Q
What things may cause a cardiac syncope?
A
Arrhythmias - bradycardias (sinus node dysfunction, AV conduction disorders) or tachycardias (supraventricular, ventricular)
Structural - valvular, MI, hypertrophic obstructive cardiomyopathy
PE
9
Q
How do you examine someone presenting with syncope?
A
CV Ex Postural BP readings - symptomatic fall in systolic BP >20 or diastolic >10 or decrease in systolic BP <90 is diagnostic ECG Carotid sinus massage Tilt table tet 24h ECG
10
Q
What does carotid artery sinus massage involve?
A
Massaging the carotid artery for 5 seconds to stimulate the baroreceptors and parasympathetic nervous system –> increased vaal tone + affects SA and AV node –> decreased BP and HR
If baroreceptor is hypersensitive response is exaggerated
11
Q
What are the two types of exaggerated responses that can occur after a carotid sinus massage?
A
Cardioinhibitory - ventricular pause of >3s
Vasodepressive - fall in SBP >50mmHg
12
Q
What is long QT syndrome?
A
An inherited condition associated with delayed repolarisation of the ventricles
13
Q
What can long QT syndrome lead to?
A
VT/torsade de pointes can lead to collapse/sudden death
14
Q
What are the most common variants of long QT syndrome? What causes them?
A
LQT1 and 2 - caused by defects in alpha subunit of the slow delayed rectifier potassium channel
15
Q
What is a normal correct QT interval?
A
<430ms in males
<450ms in females
16
Q
What are congenital causes of a long QT interval?
A
Jervell-Lange Neilsen syndrome (deafness)
Romano-Ward syndrome (no deafness)
17
Q
What are drug causes of a long QT interval?
A
Amiodarone, sotalol, class 1a antiarrhythmics TCAs, SSRIs (esp citalopram) Methadone Chloroquine Terfenadine Erythromycin Haloperidol Ondansteron
18
Q
What other things can cause a long QT?
A
Electrolytes - hypocalcaemia, hypokalaemia, hypomagnaemia Acute MI Myocarditis Hypothermia SAH
19
Q
What is LQT1 usually associated with?
A
Exertional syncope, often swimming
20
Q
What is LQT2 usually associated with?
A
Syncope often following emotional stress, exercise or auditory stimuli
21
Q
What is LQT3 associated with?
A
Events often occur at night/rest
22
Q
What is the management of long QT syndrome?
A
Avoid drugs that prolong the QT interval + other precipitants, e.g. strenuous exercise
Beta blockers
Implantable cardioverter defibs if high risk
23
Q
What are the characteristic exam features of MI?
A
Heavy, central chest pain, radiates to L arm/neck
N, sweating
RFs for cardiovascular dx
Elderly/DM may experience no pain
24
Q
What are the characteristic exam features of pneumothorax?
A
Hx of asthma, Marfans etc.
Sudden SoB, pleuritic chest pain
25
What are the characteristic exam features of PE?
Sudden SoB, pleuritic chest pain
Calf swelling/pain
Current COC user, malignancy
26
What are the characteristic exam features of pericarditis?
Sharp pain relieved by sitting forwards
| May be pleuritic in nature
27
What are the characteristic exam features of dissecting aortic aneurysm?
Tearing chest pain radiating to back
| Unequal upper limb BP
28
What are the characteristic exam features of GORD?
Burning retrosternal pain
| Regurg/dysphagia
29
What are the characteristic exam features of MSK chest pain
Worse on movement and palpation
| May be precipitated by coughing/trauma
30
What causes aortic dissection?
Flap/filling defect within aortic intima --> blood tracks into medial layer and splits tissues creating a false lumen
31
Where does aortic dissection most commonly occur?
In ascending aorta
32
Who is aortic dissection most common in?
Afrocarribean males 50-70y
33
How does aortic dissection classically present?
Tearing intrascapular pain (similar to MI pain)
34
What is the classification of aortic dissection?
Stanford (A = proximal origin, B = distal to L subclavian)
35
How can aortic dissection be diagnosed?
CXR showing widening mediastinum
| Confirmed usually with CT angiography
36
How can you diagnose perforated peptic ulcer?
Erect CXR - shows small amounts of free intra-abdominal air
37
How is perforated peptic ulcer managed?
Laparotomy (small --> excised and overlaid with omental patch, large --> partial gastrectomy)
38
What is Boerhaaves syndrome?
Spontaneous rupture of the oesophagus that occurs due to repeated vomiting
39
How is Boerhaaves syndrome diagnosed?
CT contrast swallow
40
How is Boerhaaves syndrome managed?
Thoracotomy and lavage
If <12h --> repair
>12h --> insert T tube to create a controlled fistula between oesophagus and skin
41
What are features of complete heart block?
```
syncope
heart failure
regular bradycardia (30-50 bpm)
wide pulse pressure
JVP: cannon waves in neck
variable intensity of S1
```
42
What are the types of heart block?
```
1st degree
2nd degree (Mobitz 1 and 2)
3rd degree (complete)
```
43
What is 1st degree heart block?
PR interval >0.2s
44
What is 2nd degree heart block (Mobitz 1)?
Progressive prolongation of the PR interval until a dropped beat occurs
45
What is 2nd degree heart block (Mobitz 2)?
PR interval is constant but P wave is often not followed by a QRS complex
46
What is 3rd degree heart block?
No associated between P waves and QRS complexes
47
What is coarctation of the aorta?
Congenital narrowing of the descending aorta
48
What are features of coarctation of the aorta?
```
Infancy - heart failure
Adult - HTN
Radio-femoral delay
Midsystolic murmur, maximal over back
Apical click from aortic valve
Notching at inferior border of ribs (due to collateral vessels)
```
49
What things are associated with coarctation of the aorta?
Turner's syndrome
bicuspid aortic valve
berry aneurysms
neurofibromatosis
50
What are SEs of ACEis?
Cough
Andioedema
Hyperkalaemia
First dose hypotension
51
What is thought to cause the cough associated with ACEis?
Increased bradykinin levels
52
What are CIs for ACEis?
```
Pregnancy, breastfeeding
Renovascular disease
Aortic stenosis (leads to hypotension)
Seek specialist advice is K >=5mmol/L
Avoid in those on high dose diuretics (hypotension)
```
53
What parameters should be checked before starting someone on ACEis?
U+E
Acceptable changes are increase in serum Cr up to 30% from baseline + increase in K up to 5.5mmol/L
54
What are complications of MI?
```
Cardiac arrest (usually due to VF)
Cardiogenic shock
Chronic heart failure
Tachyarrhythmias
Bradyarrhythmias
Pericarditis
Left ventricular aneurysm
Left ventricular free wall rupture
VSD
Acute MR
```
55
What causes cardiogenic shock post MI?
If large part of ventricular myocardium is damage --> decreased ejection systolic fracture
56
How is cardiogenic shock post-MI treated?
Inotropic support and/or intra-aortic balloon pump
57
What can cause chronic heart failure post-MI?
Ventricular myocardial damage
58
How is chronic heart failure post-MI treated?
Loop diuretics, e.g. furosemide
| ACEi/Bblockers
59
AV block is more common following which kind of MI?
Inferior MI
60
Pericarditis in the first ____ following a ______ MI is common.
48 hours
| Transmural
61
How does pericarditis post-MI present?
Pain worse on lying flat
Pericardial rub
Pericardial effusion on echo
62
What is Dressler's syndrome?
Syndrome that occurs 2-6w post Mi
Thought to be autoimmune reaction against antigenic proteins formed as the myocardium recovers
Get fever, pleuritic pain, pericardial effusion, raised ESR
63
How is Dressler's syndrome managed?
NSAIDs
64
How can LV aneurysm occur after an MI?
Ischaemic damage weakens myocardium
65
What is LV aneurysm post MI typically associated with?
Persistent ST elevation and LV failure
66
What are patients who get LV aneurysm more at risk of?
Thrombus and therefore stroke
Must anticoagulate them
67
When does LV free wall rupture tend to occur post-MI? How do patients present?
1-2 weeks
| Heart failure secondary to cardiac tamponade (raised JVP, pulsus paradoxus, diminished heart sounds
68
How is LV free wall rupture managed?
Urgent pericardiocentesis
| Thoracotomy
69
When does VSD tend to occur post-MI and how does it present?
1st week
| Acute heart failure + pansystolic murmur
70
How is VSD post-MI diagnosed?
Echocardiogram
71
How is VSD post-MI managed?
Surgery
72
With what kind of MI is MR most common?
Inferio-posterior
73
What causes MR post-MI?
Ischaemia/rupture of papillary muscle
74
What are features of MR post-MI?
Acute hypotension and pulmonary oedema
75
How is MR post-MI managed?
Vasodilator therapy, surgery often req.
76
What is the strongest RF for developing IE?
Prev episode IE
77
What is the most commonly affected valve in those with no RF for IE?
Mitral valve
78
What are RFs for IE?
```
Rheumatic valve disease
Prosthetic valves
Congenital heart defects
IVDU
Recent piercings
```
79
What valve is usually affected in IE in IVDAs?
Tricuspid
80
What is the most common cause of IE?
Staph aureus (was strep viridians)
81
What is the most common cause of IE in IDVAs?
Staph aureus
82
What is the most common cause of IE in those with prosthetic valves?
For first 2 months after surgery - staph epidermis, thereafter staph aureus
83
What is strep viridians IE associated with?
Poor dental hygiene
| Following a dental procedure
84
What are non-infective causes of IE?
SLE (Libman-Sacks)
| Malignancy - marantic endocarditis
85
What are culture negative causes of IE?
```
Prior antibiotics
Coxiella burnetii
Bartonella
Brucella
HACEK - haemophilus, actinobacillus, cardiobacterium, eikenella, kingella
```
86
The vast majority of IE are caused by what three organisms?
Strep viridians
Staph aureus
Staph epidermis
87
What are rare causes of IE?
```
Enterococcus
Strep bovis
Candida
HACEK group
Coxiella burnetii
```
88
Acute endocarditis is most commonly caused by what organism?
Staph
89
What is subacute IE most commonly caused by?
Strep
90
What is the empirical antibiotic therapy for IE?
Native valve - amoxicillian + gentamicin
NVE + severe sepsis, penicillin allergy/suspected MRSA - vancomycin + gentamicin
NVE with sepsis + RF for gram negative infection - vancomycin + meropenem
Prosthetic valve endocarditis - vancomycin, gentamicin, rifampicin
Once blood culture results available - give specific therapy
Treatment usually 4-6w IV
91
What criteria is used for diagnosing IE?
Modified Duke
92
How can IE be diagnosed using Duke's criteria?
Pathological criteria positive or
2 major criteria or
1 major and 3 minor or
5 minor
93
What is the pathological duke criteria?
Positive histology/microbiology of pathological material obtained at autopsy/cardiac surgery
94
What are the major duke criteria?
Positive blood cultures
- 2 +ve showing typical IE organisms, e.g. HACEK or strep viridians
- persistent bacteraemia from 2 blood cultures taken >12h apart/3+ +ve blood cultures where the pathogen is less specific, e.g. staph aureus, staph epidermis...
- Positive serology for coxiella burnetii, bartonella spp or chlamydia psittaci
- Positive molecular assays for specific gene targets
Evidence of endocardial involvement
- +ve echo (oscilating structures, abscess formation, new valvular regurg, dehisence of prosthetic valves) or
- New valvular regurg
95
What are the minor Duke criteria?
predisposing heart condition or intravenous drug use
microbiological evidence does not meet major criteria
fever > 38ºC
vascular phenomena: major emboli, splenomegaly, clubbing, splinter haemorrhages, Janeway lesions, petechiae or purpura
immunological phenomena: glomerulonephritis, Osler's nodes, Roth spots
96
What is the following scoring system used for:
| CHA2DS2VASc?
Determine need for anticoagulation in AF
97
What is the following scoring system used for:
| ABCD2?
Prognostic scoring for risk stratifying patients with suspected TIA
98
What is the following scoring system used for:
| NYHA?
Heart failure severity
99
What is the following scoring system used for:
| DAS28?
Disease activity in RA
100
What is the following scoring system used for:
| Child-Pugh?
Severity of liver cirrhosis
101
What is the following scoring system used for:
| Wells score?
Risk of DVT
102
What is the following scoring system used for:
| MMSE?
Cognitive impairment
103
What is the following scoring system used for:
| HAD?
Hospital anxiety and depression scale
104
What is the following scoring system used for:
| PHQ-9?
Patient health questionnaire - assess severity of depression symptoms
105
What is the following scoring system used for:
| GAD-7?
Screening tool and measure for GAD
106
What is the following scoring system used for:
| SCOFF?
Detect eating disorders and aid treatment
107
What is the following scoring system used for:
AUDIT
CAGE
FAST
Alcohol screening tools
108
What is the following scoring system used for:
| CURB-65?
Prognosis of pt with pneumonia
109
What is the following scoring system used for:
| IPSS?
International prostate symptom score
110
What is the following scoring system used for:
| Gleason score?
Prognosis in prostate cancer
111
What is the following scoring system used for:
| APGAR?
Assess health of newborn immediately after birth
112
What is the following scoring system used for:
| Bishop?
Whether induction of labour will be req.
113
What is the following scoring system used for:
| Waterlow?
Risk of developing a pressure sore
114
What is the following scoring system used for:
| FRAX?
10 year risk of developing osteoporosis related fragility fracture
115
What is the following scoring system used for:
| Ranson criteria?
Pancreatitis
116
What is the following scoring system used for:
| MUST?
Malnutrition
117
What are features of inhaled FB?
Cough
Stridor
SoB
118
Where are inhaled FBs most likely to be found?
R main bronchus
119
What drugs have been proven to improve mortality in HF patients?
ACEi
Spironolactone
Beta blockesr
Hydralazine with nitrates
120
What is the first line management for all patients with HF?
ACEi and beta blocker (start 1 at a time)
121
What is the second line treatment of heart failure?
Aldosterone antagonist, ARB/hyralazine in combination with a nitrate
122
If symptoms of HF persistent despite 1st and 2nd line treatment what should be considered?
Cardiac resynchonisation therapy or digoxin or ivabradine (ivabradine only if pt already on aldosterone antagonist, ACEi, bblocker + HR >75 + LVF <35%)
123
What treatment should be given for fluid overload in HF?
Diuretics
124
What vaccinations should those with HF be offered?
Annual flu
| One off pneumococcal
125
What beta blockers are licensed in the UK to treat HF?
Bisoprolol, carvedilol, nebivolol
126
What other drug can be used in those with HF with reduced ejection fraction who are still symptomatic on ACEi or ARBs?
Sacubitril-valsartan
127
What is p. mitrale?
Bifid P wave due atrial hypertrophy/strain (e.g. in mitral stenosis)
128
In which condition is increased P wave amplitude classically seen?
Cor pulmonale
129
What is the most likely congenital heart defect to be found in adulthood?
ASD
130
What are the two types of ASD?
Ostium secundum
| Ostium primum
131
What are features of ASDs?
Ejection systolic murmur, fixed splitting of S2
| Embolism may pass from venous system to L side of heart --> stroke
132
What syndrome is ostium secundum associated with?
Holt-Oram syndrome (tripharyngeal thumbs)
133
What do you see on ECG with ostium secundum?
RBBB with RAD
134
What is ostium primum associated with?
Abnormal AV valves
135
What do you see on ECG with ostium primum?
RBBB with LAD and prolonged PR interval
136
What is involved in adult life support?
Chest compressions + ventilations (30:2)
Defibrillation
VF/VT cardiac arrest - 1mg adrenaline (then given every 3-5 minutes)
If cardiac arrest witness in monitored patient give up to 3 quick successive shocks rather than 1 shock followed by CPR
Asystole/pulseless electrical activity - 1mg adrenaline followed by 2 min CPR prior to reassessment of rhythm
Successful resus --> O2 to reach sats of 94-98%
137
What are reversible causes of cardiac arrest?
```
The Hs -
Hypoxia
Hypovolaemia
Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia and other metabolic disorders
Hypothermia
```
```
The Ts -
Thrombosis (pulmonary/coronary)
Tension pneumothorax
Tamponade (cardiac)
Toxins
```
138
How is ivabradine work?
Reduces HR by acting on Lf ion current which is highly expressed in the SA node
139
What AEs are associated with ivabradine?
Visual effects, esp. luminous phenomena
Headache
Bradycardia, heart block
140
What does complete heart block following an Mi indicate?
Right coronary artery lesion (as AV node is supplied by branch of right coronary (posterior interventricular artery))
141
What is the investigation of choice in suspected PE in renal impairment?
VQ scan
142
What are adverse signs in bradycardia that indicate haemodynamic compromise and the need for treatment?
Shock - hypotension (SBP <90), pallor sweating, cold, clammy extremities, confusion, impaired consciousness
Syncope
MI
Heart failure
143
What is given for bradycardia if there are adverse signs?
Atropine 500mcg IV
144
If atrophine fails to treat bradycardia what can be given?
Atropine up to max 3mg
Transcutaneous pacing
Isoprenaline/adrenaline infusion titrated to response
145
What are risk factors for asystole (so that even if there is an okay response to atropine, specialist help should be sought to determine need for transvenous pacing)?
Complete heart block with broad QRS complex
Recent asystole
Mobitz type II AV block
Ventricular pause >3s
146
Define stage I HTN
Clinic BP >=140/90 + ABPM daytime average/HBPM average >=135/85
147
Define stage II HTN
Clinic BP >=160/100, ABPM daytime average/HBPM average BP >=150/95
148
Define severe HTN
Clinic systolic BP >=180 or clinic diastolic BP >=110
149
What lifestyle advice should be given to those with HTN?
Low salt diet (<6g/day)
Reduced caffeine intake
Stop smoking, drink less, balanced diet, wt loss
150
When should you treat stage I HTN?
If <80 + any of: target organ damage, established CV disease, renal disease, DM or 10 year CV risk equivalent to 10% or more
151
When should stage II HTN be treated?
Always
152
What age should you consider referring if they develop HTN?
<40
153
What are step 1 treatments for HTN in those who are <55 or have T2DM?
ACEi/ARB
154
What are step 1 treatments for HTN in those who are >55 or afrocaribbean?
CCB
155
What are step 2 treatments for HTN?
Already on ACEi/ARB --> add CCB/thiazide type diuretic
If already on CCB --> add ACEi/ARB (ARB if afrocarribbean)
156
What are step 3 treatments for HTN?
Add other drug they're not on - so on ACEi/ARB + CCB + thiazide type diuretic
157
What are step 4 treatments for HTN?
NB step 4 = resistant HTN
Confirm elevated BP, assess for postural hypotension, discuss adherence
If K <4.5 - add low dose spironoloactone
If K>4.5 - add alpha/beta blocker
if this fails --> refer to specialist
158
What is the BP target for someone with HTN who is <80?
Clinic - 140/90
| ABPM/HBPM - 135/85
159
What is the BP target for someone with HTN who is >80?
Clinic - 150/90
| ABPM/HBPM - 145/85
160
What is paroxysmal SVT?
Sudden onset of narrow complex tachycardia, typically AV nodal re-entry tachycardia
161
What is involved in the acute management of SVT?
Vagal manoeuvres - valsalva, carotid sinus massage
IV adenosine 6mg --> 12mg --> 12mg (CI in asthmatics, alt: verpamil)
Electrical cardioversion
162
What is used to prevent episodes of SVT?
Beta blockers
| Radio-frequency ablation
163
How do statins work?
Inhibit HMG-CoA reductase (the rate limiting step in hepatic cholesterol synthesis)
164
What adverse effects are associated with statins?
Myopathy
| Liver impairment
165
What are CIs for statins?
Macrolides
Pregnancy
Prev ICH
166
Who should recieve statins?
Those with established CV disease
10 year Cv risk >10%
T1 diabetics who were diagnosed >10 years ago or are aged over 40 or have established neprhopathy
167
when should statins be taken?
At night (this is when most of cholesterol synthesis takes place)
168
What is the currently recommended statin for primary prevention?
Atrovastatin 20mg
169
What is the currently recommended statin for secondary prevention?
Atrovastatin 80mg
170
What monitoring should be done for those on amiodarone?
TFT, LFT, UE, CXR prior to treatment
| TFT, LFT every 6 months
171
What is VT?
A broad complex tachycardia originating from a ventricular ectopic focus
172
Why does VT require urgent treatment?
It can cause VF
173
What are the two main types of VT?
Monomorphic - commonly caused by MI
| Polymorphic - subtype of polymorphic is torsade de pointes which is precipitated by prolongation of the QT interval
174
How is VT managed?
Patient has adverse signs (SBP <90, chest pain, heart failure) --> immediate cardioversion)
If none of these --> antiarrhythmic (fail --> electrical cardioversion can be used)
175
What drugs can be used to treat VT?
Amiodarone (through central line)
Lidocaine (caution in LV impairment)
Procainamide
176
What drug must you AVOID in VT?
Verapamil
177
If drug therapy fails in VT what are treatment options?
Electrophysiology study
| Implantable cardioverted defibrillator (particularly in patients with LV impairment)
178
What is the most common important cause of VT clinically?
Hypokalaemia (followed by hypomagnesaemia)
179
What is the DeBakey classification of aortic dissection?
Type 1 - originates in ascending aorta, propagates to at least the arch and possibly beyond it
Type 2 - originates in and is confined to the ascending aorta
Type 3 - originates in descending aorta
180
How is type A aortic dissection managed?
Surgery
| Maintain target SBP 100-120
181
How is type B aortic dissection managed?
Conservative
Bed rest
Reduced BP (IV labetalol)
182
What are complications of a backward tear in aortic dissection?
Aortic incompetence/regurg
| MI - inferior pattern often seen due to R coronary involvement
183
What complications of a forward tear are often seen in aortic dissection?
Unequal arm pulses and BP
Stroke
Renal failure
184
What agents have proven efficiacy in the pharmacological cardioversion of AF?
```
Amiodarone
Flecanide (if no structural heart disease)
```
185
What are less effective agents used in pharmacological cardioversion in AF?
```
Beta blockers
CCB
Digoxin
Disopyramide
Procainamide
```
186
What are common SEs of amiodarone?
```
Bradycardia
Hyper/hypothyroidism
Pulmonary fibrosis/pneumonitis
Liver fibrosis/hepatitis
Jaundice
Taste disturbance
Persistent slate grey appearance
Raised serum transaminases
Nausea
Constipation
```
187
What are the two situations cardioversion should be used in AF?
Electrical cardioversion as an emergency if the patient is haemodynamically unstable
Electrical/pharmacological cardioversion as an elective procedure where rhythm control strategy is preferred
188
What is the approach to AF management?
Rate or rhythm control if onset of arrhythmia less than 48h
| Rate control only if >48h since onset/uncertain
189
How is AF onset <48h managed?
```
Give heparin, if RF for ischaemic stroke - lifelong oral anticoagulation
Otherwise cardiovert (DC/pharmacological - amiodarone if structural heart disease or flecainide/amiodarone if no structural heart disease)
```
Following DC cardioversion if AF is confirmed as being <48h - further anticoagulation unnecessary
190
How is AF onset >48h ago managed?
Anticoagulation required for 3 weeks prior to cardioversion OR TOE to exclude left atrial appendage thrombus (if excluded can heparinise patient and cardiovert immediately)
191
If you are cardioverting after 3 weeks of anticoagulation for AF, is DC or pharmacological cardioversion recommended?
DC
192
If there is a high risk of cardioversion failure in AF (e.g. prev failure/AF recurrence)?
Have at least 4 weeks amiodarone or sotalol prior to DC cardioversion
193
Following DC cardioversion should patients be anticoagulation?
Yes, for at least 4 weeks (unless done <48h of onset)
194
What monitoring should be done for those on statins?
LFTs at baseline, 3 months and 12 months
195
What is the first line test for chronic heart failure?
N-terminal pro-B-type natriuretic peptide (NT-proBNP)
196
How should NT-proBNP be interpreted?
If levels high - arrange specialist assessment (incl. TTE) within 2 weeks
If levels raised arrange specialist assessment (incl. TTE) within 6 weeks
197
What is BNP?
A hormone produced mainly in the left ventricular myocardium in response to strain
198
Very high levels of what hormone are associated with poor prognosis in heart failure?
BNP
199
What factors increase BNP levels?
```
LV hypertrophy
Ischaemia
Tachycardia
RV overload
Hypoaemia
GFR <60
Sepsis
COPD
DM
Age >70
Liver cirrhosis
```
200
What factors lower BNP levels?
```
Obesity
Diuretics
ACEi
Betablockers
ARBs
Aldosterone antagonists
```
201
How is major bleeding in a patient on warfarin managed?
Stop warfarin
Give IV vit K 5mg
Prothrombin complex concentrate (or FFP if not available)
202
How is minor bleeding with INR >8 in a warfarin patient managed?
Stop warfarin
IV vit K 1-3mg
Repeat dose of vit K if INR still too high after 24h
Restart warfarin when INR <5
203
How is INR >8 and no bleeding managed in a warfarin patient?
Stop warfarin
Give vit K 1-5mg by mouth (using IV prep orally)
Repeat if INR still too high after 24h
Restart when INR <5
204
How should INR 5-8 in a warfarin patient who has a minor bleed be managed?
Stop warfarin
Give IV vit K 1-3mg
Restart when INR <5
205
How should INR 5-8 with no bleeding in a warfarin patient be managed?
Withhold 1-2 doses of warfarin
| Reduce subsequent maintenance dose
206
Patients on warfarin have reduced levels of what clotting factors?
X, IX, VII, II
207
What is the management of orthostatic hypotension?
Education + lifestyle changes, e.g. adequate hydration
Discontinuation of vasoactive drugs, e.g. anti-HTNs, nitrates...
If symptoms persist, consider compression garments, fludrocortisone, midodrine, counter pressure manoeuvres and head tilt sleeping
208
What is postural hypotension?
Fall in systolic BP of >20mmHg on standing
209
What are causes of postural hypotension?
Hypovolaemia
Autonomic dysfunction - DM, PD
Drugs - diuretics, antiHTN, Ldopa, phenothiazines, antidepressants, sedatives
Alcohol
210
What is the most important thing in managing AF?
Reducing risk of stroke
211
What are the types of AF?
```
First detected
Recurrent episodes
Paroxysmal
Persistent
Permanent
```
212
What is recurrent AF?
If there are 2 or more episodes of AF
213
What is paroxysmal AF?
AF that self-terminates (episodes tend to last less than 7 days)
214
What is persistent AF?
Arrhythmias that do not self-terminate
215
What is permanent AF?
Continuous AF that cannot be cardioverted or attempts to do are deemed inappropriate - treat with rate control/anticoagulation
216
What are features of AF?
Palpitations
SoB
Chest pain
Irreg irreg pulse
217
What investigation is key to a diagnosis of AF?
ECG
218
What are the two paths of treating AF?
Rate control - reduce rate to avoid negative effects on cardiac function
Rhythm control - try to make normal sinus rhythm return
219
NICE advocate using a rate control strategy to treat AF except in what situations?
Coexistent heart failure
First onset AF
Or an obvious reversible cause
220
What drugs are used first line for rate control in AF?
Beta blocker
| Rate limiting CCB, e.g. diltiazem
221
What is second line rate control for AF?
Combination therapy with 2 of:
- Beta blocker
- Diltiazem
- Digoxin
222
When is the highest risk for embolism leading to a stroke in AF?
When a patient switches from AF to sinus rhythm
223
What is CHA2DS2-VASc score?
```
C = congestive heart failure 1
H = hypertension 1
A2 = age >75 -2, age 65-74 - 1
D = diabetes
S = prior stroke/TIA 2
V = vascular disease, incl IHD/PAD 1
S = sex (female)
```
224
What CHA2DS2VASc score does not require any treatment?
0
225
What CHA2DS2VASc score should prompt consideration of treatment?
1
Males - consider anticoagulation
1 - females - no treatment
226
What CHA2DS2VASc score definitely requires treatment?
2+ - give anticoagulants
227
What anticoagulation should be given for prevention of stroke in AF?
NOACs or warfarin
228
What is bifasicular block?
RBBB + left anterior or posterior hemiblock, e.g. RBBB with left axis deviation
229
What is trifasicular block?
Features of bifasicular heart block + 1st degree heart block
230
What are SEs of betablockers?
```
Bronchospasm
Cold peripheries
Fatigue
Sleep disturbances, incl. nightmares
Erectile dysfunction
Reduced hypoglycaemia awareness
```
231
What are CIs of beta blockers?
Uncontrolled heart failure
Asthma
Sick sinus syndrome
Concurrent verapamil use - may precipitate severe bradycardia
232
What is torsade de pointes?
Form of polymorphic VT associated with a long QT interval
233
How is torsade de pointes managed?
IV Mg Sulphate
234
How does pericarditis present?
Pleuritic chest pain relieved by sitting forward
Non-productive cough, SoB, flu like symptoms
Pericardial rub
Tachypnoea, tachycardia
235
What can cause pericarditis?
```
Viral infections (Coxsackie)
TB
Uraemia (fibrinous pericarditis)
Trauma
Post-MI, Dressler's
Connective tissue dx
Hypothyroidism
Malignancy
```
236
What changes do you see on ECG in pericarditis?
Saddle shaped ST elevation
| PR depression
237
All patients with suspected acute pericarditis should have what investigation?
TTE
238
How is pericarditis managed?
Treat underlying cause
| Combo of NSAIDs and colchicine 1st line for idiopathic/viral pericarditis
239
How do thiazide diuretics work?
Inhibit Na resorption at DCT by blocking thiazide sensitive NaCl symporter
240
What thiazides are recommended for HTN?
Indapamide or chlortalidone
241
What are common AEs of thiazide diuretics?
```
Dehydration
Postural hypotension
Hyponatraemia, hypokalaemia, hypercalcaemia
Gout
Impaired glucose tolerance
Impotence
```
242
What are rare SEs associated with thiazide diuretics?
Thrombocytopenia
Agranulocytosis
Photosensitivity rash
Pancreatitis
243
Peri-arrest tachycardias should be classified as being stable or unstable based on the presence of what signs?
Shock - hypotension (SBP <90), pallor, sweating, cold, clammy extremities, confusion or impaired consciousness
Syncope
MI
Heart failure
244
If adverse signs are present in a tachyarrhythmia how is it managed?
Synchronised DC shocks
Then treatment is based on whether QRS is narrow or broad and whether rhythm is regular or not
245
How is regular broad-complex tachycardia managed?
Assume VT - give loading dose of amiodarone followed by 24h infusion
246
How is irregular broad-complex tachycardia managed?
1. AF with bundle branch block - treat as for narrow complex tachycardia
2. Polymorphic VT - IV magnesium
247
How is regular narrow complex tachycardia managed?
Vagal manoeuvres followed by IV adenosine, if unsuccessful consider diagnosis of atrial flutter and give rate control
248
How is irregular narrow complex tachycardia manaed?
Probably AF
<48h cardiovert
Rate control + anticoagulation
249
What are signs of mild airway obstruction?
Able to respond to 'are you choking'
| Able to breath, cough and speak
250
What are signs of severe airway obstruction?
Unable to respond to 'are you choking'
| Unable to breath, wheezing, attempts at coughing are silent, victim may be unconscious
251
How is mild airway obstruction managed?
Encourage pt to cough
252
How is severe airway obstruction where the patient is conscious managed?
5 back blows
If unsuccessful 5 abdominal thrusts
Repeat
253
How is severe airway obstruction where the patient is unconscious managed?
Call ambulance
| Start CPR
254
What are common things that should prompt you to reconsider putting someone on warfarin?
Hx falls
Old age
Alcohol xs
255
What score can be used to help decide if we should put someone on warfarin based on their bleeding risk?
HASBLED
HTN (uncontrolled SBP >160) - 1
Abnormal renal/liver function - 1 each
S - stroke hx - 1
B - bleeding, hx of bleeding, tendency to bleed
L - liable INR -1
E - elderly (>65) - 1
D - drugs prediposing to bleeding (antiplatelet, NSAID or alcohol use (>8 drinks/week) - 1 each
Score >=3 = high risk of bleeding
256
What ECG changes occur in acute MI?
Hyperacute t waves often first sign (only last a few mins)
ST elevation
T waves invert within first 24h (lasts days - months)
Pathological Q waves develop after several hours/days (persistent indefinitely)
257
What is NYHA class I?
No symptoms
| No limitation: ordinary physical exercise does not cause undue fatigue, SoB or palpitations
258
What is NYHA class II?
Mild symptoms
| Slight limitation of physical activity: comfortable at rest but ordinary activity --> fatigue, palpitations, SoB
259
What is NYHA class III?
Moderate symptoms
| Marked limitation of physical activity - comfortable at rest but less than ordinary activity --> symptoms
260
What is NYHA class IV?
Severe symptoms
| Unable to carry out any physical activity without discomfort, symptoms even at rest
261
What are AEs of adenosine?
Chest pain
Bronchospasm
Transient flushing
Can enhance conduction down accessory pathways --> increased ventricular rate (e.g. WPW syndrome)
262
How is adenosine given?
Ideally infused via a large calibre cannula due to its short halflife
263
How does adenosine work?
Causes transient heart block in AV node
264
In which group of patients should adenosine be avoided?
Asthmatics (bronchospasm)
265
Where are the changes in a posterior MI?
V1-2
Also see tall R waves
266
What artery is affected in a posterior MI?
Usually left circumflex, also right coronary
267
What drug is CI in aortic stenosis?
Nitrates due to risk of profound hypotension
268
What is Eisenmenger's syndrome?
Reversal of a L to R shunt in a congenital heart defect due to pulmonary hypertension
269
What is Eisenmenger's syndrome associated with?
VSD
ASD
PDA
270
What are features of Eisenmenger's syndrome?
```
original murmur may disappear
cyanosis
clubbing
right ventricular failure
haemoptysis, embolism
```
271
How is Eisenmenger's syndrome managed?
Heart lung transplantation is req
272
What can cause constrictive pericarditis?
Any cause of pericarditis
| Esp TB or recent cardiac surgery
273
What are features of constrictive pericarditis?
```
SoB
Right heart failure (elevated JVP, ascites, oedema, hepatomegaly)
JVP shows prominent x and y descent
Pericardial knock (loud S3)
Kussmaul sign is +ve
```
274
What is commonly seen on CXR in constrictive pericarditis?
Pericardial calcification
275
What is kussmauls sign?
A raised JVP that increases with inspiration
276
What is Buerger's disease?
A small and medium vessel vasculitis that is strongly associated with smoking
277
What are features of Buerger's disease?
Extremity ischaemia (intermittent claudication, ischaemic ulcers)
Superficial thrombophlebitis
Raynaud's phenomenon
278
What are possible causes of palpitations?
Arrhythmias
Stress
Increased awareness of normal heart beat/stress
279
What are first line investigations for palpitations?
12 lead ECG
TFTs (thyrotoxicosis can precipitate AF)
UE (e.g. to rule out hypokalaemia)
FBC
280
If all the first line investigations for palpitations are normal what can be done next?
```
Holter monitoring (continuously records ECG from 2-3 leads, usually done for 24h)
Pt keeps sympto diary
```
281
If no symptoms are found on holter monitor and symptoms continue, what investigations can be done for palpitations?
External loop recorder
| Implantable loop recorder
282
What are ECG features of hypokalaemia?
```
U waves
Small/absent T waves
Prolonged PR interval
ST depression
Long QT
```
283
What is hypertrophic obstructive cardiomyopathy?
An AD disorder of muscle tissue caused by defects in genes encoding contracile proteins
284
HOCM is the most common cause of what in young people?
Sudden cardiac death
285
What does the most common defect in HOCM involve?
A mutation in the gene encoding b-myosin heavy chain protein or myosin-binding protein C --> predominantly diastolic dysfunction
286
What is HOCM characterised by on biopsy?
Myofibrillar hypertrophy and chaotic and disorganised myocytes and fibrosis
287
How does HOCM present?
Often asymptomatic
Exertional SoB
Angina
Syncope (typically following exercise - due to hypertrophy of ventricular septum --> AS)
Sudden death (due to ventricular arrhythmias)
Jerky pulse, large 'a' waves, double apex beat
Ejection systolic murmur (increases with valsalva, decreases on squatting)
HOCM --> mitral valve closure impairment --> regurg
288
What is HOCM associated with?
Friedreich's ataxia
| WPW
289
What are common echo findings in HOCM?
MR SAM ASH
Mitral regurg
Systolic anterior motion of the anterior mitral valve leaflet
Asymmetric hypertrophy
290
What do you see on ECG in HOCM?
L ventricular hypertrophy
Non-specific ST segment and T wave abnormalities, progressive T wave inversion
Deep Q waves
AF sometimes seen
291
What are the two types of HTN?
Primary/essential
| Secondary
292
What are secondary causes of HTN?
```
GN
Chronic pyelonephritis
APCK
Renal artery stenosis
Primary hyperaldosteronism
Phaeochromocytoma
Cushing's
Liddles syndrome
Congenital adrenal hyperplasia
Acromegaly
Glucocorticoids
NSAIDs
Pregnancy
Coarctation of the aorta
COC
```
293
What 3 things are essential to check when newly diagnosing someone with HTN?
Fundoscopy - check for hypertensive retinopathy
Urine dipstick - check for renal disease (cause/consequence)
ECG - check for LV hypertrophy/IHD
Others to consider - UE (renal dx), HbA1c, lipids
294
What are SEs of CCBs?
Flushing
Ankle swelling
Headache
295
What do ARBs typically end in?
-sartan
296
What is malignant hypertension?
Very severe hypertension (>=180/120) with evidence of acute organ damage
297
What are signs and symptoms of malignant hypertension?
Papilloedema (must be present before a diagnosis of malignant hypertension can be made)
Retinal bleeding
Increased cranial pressure causing headache and nausea
Chest pain due to increased workload on the heart
Haematuria due to kidney failure
Nosebleeds which are difficult to stop
298
What is the BP target for someone with T1DM?
<140/90
299
What is the BP target for someone with T2DM?
Intervene if BP 135/85 unless they have albuminuria/2+ features of metabolic syndrome - then intervene if 130/80
300
Why are ACEi first line for hypertension in DM?
They have a renoprotective effect in DM
301
What should afrocarribbean diabetic patients have to treat their HTN?
AEi + TZD/CCB
302
Why should beta blockers be avoided in diabetics?
Can cause insulin resistance, impair insulin secretion + alter autonomic response to hypoglycaemia
303
What is acute heart failure?
Sudden onset or worsening symptoms of heart failure
304
What is AHF without pre-existing heart failure called?
De-novo AHF
305
Which of decompensated and de-novo AFH is more common?
Decompensated
306
What causes AHF?
Reduced cardiac output that results from functional/structural abnormality
307
What causes de-novo heart failure?
Increased cardiac filling pressures and myocardial dysfunction usually due to ischaemia --> reduced cardiac output + hypoperfusion
Can cause pulmonary oedema
Less common causes - viral myopathy, toxins, valve dysfunction
308
What are the most common precipitating causes of decompensated AHF?
ACS
Hypertensive crisis
Acute arrhythmia
Valvular disease
309
How are AHF patients generally categorised?
With/without fluid congestion
| With/without hypoperfusion
310
What are symptoms of AHF?
Breathlessness
Reduced exercise tolerance
Oedema
Fatigue
311
What are signs of AHF?
```
Cyanosis
Tachycardia
Elevated JVP
Displaced apex beat
Chest signs - classically bibasal crackles, wheeze
S3 heart sound
```
312
How is BP affected in AHF?
Normal/elevatd usually
313
What is involved in the diagnostic workup of AHF?
Blood tests - check for underlying abnormality, e.g. anaemia, abnormal electrolytes, infection
CXR - findings incl. pulmonary venous congestion, interstitial oedema, cardiomegaly
Echo - pericardial effusion/cardiac tamponade
BNP - raised levels indicate myocardial damage and support diagnosis
314
What ECG changes are associated with hypothermia?
```
bradycardia
'J' wave - small hump at the end of the QRS complex
first degree heart block
long QT interval
atrial and ventricular arrhythmias
```
315
When digoxin first line for rate control in AF?
If the patient has co-existing heart failure
316
What favours rate control in AF?
Older than 5
| Hx IHD
317
What factors favour rhythm control in AF?
```
<65
Symptomatic
First presentation
Lone AF or AF secondary to a corrected precipitant (e.g. alcohol)
Congestive heart failure
```
318
When is catheter ablation used in AF?
For those who have not responded to or wish to avoid antiarrhythmic medication
319
What is the aim of catheter ablation in the treatment of AF?
To ablate the faulty electrical pathways causing the AF (usually due to aberrant electrical activity between the pulmonary veins and left atrium)
320
How is catheter ablation performed?
Percutaneously usually via the groin
Can be done via radiofrequency/cryotherapy
321
What are the guidelines re anticoagulation for catheter ablation?
Use 4 weeks before and during the procedure
Does not reduce stroke risk even if patients remain in rhythm so if CHA2DS2VASc >1 still req. long term anticoagulation
(if score 0 - 2 months anticoagulation)
322
What are complications of catheter ablation?
Cardiac tamponade
Stroke
Pulmonary valve stenosis
323
What is the pulmonary artery occlusion pressure an indirect measure of?
Left atrial pressure + thus the filling pressure of the heart
324
What are key points to remember about arrhythmogenic right ventricular dysplasia?
Genetic AD condition
RV myocardium replaced by fatty + fibrofatty tissue
50% pts have mutation of one of the several genes which encodes the components of the desmosome
ECG abnormalities in V1-3, typically T wave inversion
Epilson wave found in 50%
325
What are classic causes of dilated cardiomyopathy?
Alcohol
Coxsackie B virus
Wet beri beri
Doxorubicin
326
What are classic causes of restrictive cardiomyopathy?
Amyloidosis
Post-radiotherapy
Loefflers endocarditis
327
When does peripartum cardiomyopathy typically develop?
Last month of pregnancy - 5months post-partum
328
Who is peripartum cardiomyopathy more common in?
Older women
Greater parity
Multiple gestations
329
What is takotsubo cardiomyopathy?
Stress induced cardiomyopathy, e.g. pt just found out family member died and develops chest pain and feature of heart failure
Transient, apical ballooning of myocardium
330
What infections can cause a cardiomyopathy?
Coxsackie B
| Chagas
331
What are infiltrative causes of cardiomyopathy?
Amyloidosis
332
What are storage causes of cardiomyopathy?
Haemachromatosis
333
What are toxic causes of cardiomyopathy?
Doxorubicin
| Alcoholic cardiomyopathy
334
What are inflammatory causes of cardiomyopathy?
Sarcoidosis
335
What are endocrine causes of cardiomyopathy?
DM
Thyrotoxicosis
Acromegaly
336
What are neuromuscular causes of cardiomyopathy?
Friedreich's ataxia
Duchenne-Becker muscular dystrophy
Myotonic dystrophy
337
What nutritional deficiency can cause cardiomyopathy?
Thiamine
338
What is an autoimmune cause of cardiomyopathy?
SLE
339
What are features of a dilated cardiomyopathy?
Four chamber dilatation and systolic dysfunction
340
What is Wolff-Parkinson White syndrome?
A condition caused by a congenital accessory conducting pathway between the atria and ventricles --> AVRT
As accessory pathway does not slow conduction AF can degenerate into VF
341
What are ECG features of WPW?
Short PR interval
Wide QRS with slurred upstroke (delta wave)
Left axis deviation if R sided accessory pathway
Right axis deviation if left sided accessory pathway
342
How can you differentiate between WPW type A and B?
Type A - left sided - dominant R wave in V1
| Type B - right sided - no dominant R wave in V1
343
What is WPW associated with?
```
HOCM
Mitral valve prolapse
Ebstein's anomaly
Thyrotoxicosis
Secundum ASD
```
344
What is the definitive management of WPW?
Radiofrequency ablation of accessory pathway
345
What medical therapies can be used for WPW?
Sotalol (only if no AF), amiodarone, flecanide
346
What every day activities may contribute to orthostatic hypotension?
After meals
Venous pooling during exercise
Prolonged bed rest (deconditioning)
347
What are the three main SEs of GTN spray?
Hypotension
Headache
Tachycardia
348
What is the most important risk factor for aortic dissection?
HTN
349
What are associations with aortic dissection?
```
Trauma
Bicuspid aortic valve
Marfans, EDS
Turners, Noonans
Pregnancy
Syphillis
```
350
What are the clinical features of aortic dissection?
Tearing chest pain, radiates to back
AR
Hypertension
If coronary arteries involved --> angina
Spinal artery involvement --> paraplegia
Distal aorta involvement --> limb ischaemia
351
Patients with heart failure and a reduced LVEF should be given what as first line treatment?
A beta blocker and an ACE inhibitor
352
What is normal LVEF?
45-60%
353
What are the two types of chronic heart failure?
Impaired left ventricular contraction (systolic heart failure)
Impaired left ventricular relaxation (diastolic heart failure)
354
What does left ventricular failure lead to?
Back up of blood into the lungs
355
What are key features of chronic heart failure?
```
Breathlessness (worse on exertion)
Cough (frothy white/pink sputum)
Orthopnoea
PND
Peripheral oedema
```
356
What is PND?
Suddenly wakening up at night with acute SoB and cough
357
What are causes of chronic heart failure?
IHD
Valvular heart disease (e.g. aortic stenosis)
HTN
Arrhythmias, AF
358
How is chronic heart failure managed?
```
Check BNP (urgent referral if BNP >2000)
Medical and surgical treatment
```
359
What is key to remember about treating someone with heart failure who has valvular disease?
Avoid ACEi use until a specialist can see the patient
360
What should be offered to any patient with BP >=140/90mmHg?
ABPM or HBPM to confirm diagnosis
361
In which hypertensive patients is one reading of HTN enough for immediate treatment?
If BP >=180/110mmHg
| If signs of papilloedema/retinal haemorrhages --> same day assessment by specialist
362
What are common clinic signs in PE?
Tachypnoea
Crackles
Tachycardia
Fever
363
What should all patients presenting with PE have done?
Hx, Ex, CXR (to exclude other pathologies)
364
What scoring system is used to determine likelihood of a PE?
Clinical signs and symptoms of DVT - 3
Alternative diagnosis is less likely than PE - 3
HR >100
Immobilisation >3 days/surgery in last 4 weeks - 1.5
Prev DVT/PE - 1.5
Haemopytsis - 1
Malignancy (on treatment or treated in last 6 months or palliative) - 1
365
If well's score is ___ or more, PE is likely.
4
366
If PE is likely what is your management?
Arrange urgent CTPA (if delay give therapeutic anticoagulation (DOAC) in interim
367
If PE is unlikely what is your management?
D-dimer
If +ve --> CTPA
-ve --> consider alt diagnosis
368
What are the classic ECG signs seen in PE?
Large S wave in lead I, large Q wave in lead III and inverted T wave in lead III
Most common finding is sinus tachycardia
RBBB and R axis deviation also associated with PE
369
What must you consider in cardiac arrest before calling time of death?
The 8 reversible causes of cardiac arrest (hypothermia, hypoxia, hypovolaemia, hypokalaemia, hyperkalaemia, hypoglycaemia, tension pneumothorax, toxins, tamponade, thrombosis)
370
What should all patients be offered post-MI?
Dual antiplatelet therapy (aspirin + second antiplatelet)
ACEi
Beta blocker
Statin
371
When can sexual activity resume after an MI?
4 weeks
| Only use PDE5 inhibitor 6 months after an MI
372
What are the second antiplatelets of choice in secondary prevention fo MI?
Ticagrelor + prasugrel
Post-ACS medically managed - ticagrelor (stop after 12m) + aspirin
Post-PCI: prasugrel/ticagrelor (stop after 12m) + aspirin
373
When might aldosterone antagonists be used after an MI?
In those who had an acute MI and who have symptoms/signs of heart failure and LV systolic dysfunction
374
When are nitrates contraindiated in ACS management?
In hypotension (<90mmHg)
Bradycardia (<50bpm)
Recent PDE5 inhibitors
375
When should type 1 diabetics be offered statins?
Age >40
DM for >10 years
Established neprhopathy
Other CV risk factors, e.g. HTN, obesity
Give atrovastatin 20mg
376
How can you distinguish between unstable angina and NSTEMI?
Serial troponin tests (rises in NSTEMI, does not rise in unstable angina)
377
In which situations are patients with long QT given implantable cardioverted defibrillators?
High risk situations only, e.g. if QTc >500ms or prev. episodes of cardiac arrest
378
How do you measure the QT interval?
From start of Q to end of T wave
379
What does a long QT interval mean?
QRS = ventricular depol
T wave = ventricular repol
Long QT = some of heart cells taking longer to repolarise
380
What kindof channels do class 1A antiarrythmics block?
Na and K
381
What kind of channels do class II antiarrythmics block?
K
382
In what % of cases do VSDs spontaneously close?
50%
383
What are congenital VSDs associated with?
Downs
Edwards
Patau syndrome
384
What is the classic murmur heard in VSD?
Pan systolic murmur which is louder in smaller defects
| Louder P2
385
What are complications of VSD?
```
Aortic regurg
IE
Eisenmenger's complex
R heart failure
Pulmonary hypertension
```
386
The majority of VSDs are caused by a defect in the muscular region/membranous region of the ventricular septum?
Membranous
387
What is NT-proBNP?
Inactive prohormone of BNP that is released from left ventricle in response to strain and acts to increase renal excretion of water and sodium, and relax smooth muscle --> vasodilation
388
What may a diagnosis of new LBBB point toward?
Diagnosis of ACS
389
Define postural hypotension?
Fall in SBP >20mmHg on standing (or DBP >10mmHg or drop in SBP below 90mmHg)
390
What are causes of postural hypotension?
Hypovolaemia
Autonomic dysfunction - PD, DM (HR does not respond appropriately)
Drugs - antidepressants, antihypertensives, Ldopa, phenothiazines, sedatives
Alcohol
391
What is the mechanism of action of warfarin?
Inhibits epoxide reductase preventing reduction of vit K to its active hydroquinone form prevents formation of factors II, VII, IX, X) and protien C
392
What is the target INR for someone who has had a VTE?
2.5
| If recurrent 3.5
393
What is the target INR for someone on warfarin for AF?
2.5
394
What factors may potentiate warfarin?
Liver disease
P450 enzyme inhibitors, e.g. amiodarone, ciprofloxacin
Cranberry juice
Drugs which displace warfarin from plasma albumin, e.g. NSAIDs
Drugs which inhibit platelet function, e.g. NSAIDs
395
What SEs are associated with warfarin?
Haemorrhage
Teratogenic
Skin necrosis
Purple toes
396
What is the mechanism of action of dipyridamole?
Inhibits phosphodiesterase and decreases cellular uptake of adenosine
397
What is preload?
Amount of blood entering ventricles at end of diastole (increased pre-load increases contraction = frank startling mechanism)
398
What is afterload?
Force cardiomyocytes must overcome to pump blood out of the ventricle
399
What does the heart look with in hypertrophic cardiomyopathy?
Left ventricular hypertrophy with no chamber dilation
400
What is the most common mutation in hypertrophic cardiomyopathy?
Myosin heavy chain
401
What are causes of hypertrophic cardiomyopathy?
Chronic hypertension --> increased afterload --> LV hypertrophy
Aortic stenosis
Inherited
402
What are the two types of hypertrophic cardiomyopathy?
Obstructive - LV hypertrophy + interventricular septal hypertrophy (blocks outflow through aorta)
Non-obstructive type - LV hypertrophy (reduced EDV ---> reduced SV --> reduced CO)
403
How does LV ejection fraction differ between obstructive and non-obstructive hypertrophic cardiomyopathy?
In obstructive the interventricular septum thickening blocks outflow --> reduced ejection systolic fraction
Normal in non-obstructive as outflow is not blocked
404
What kind of pulse is sometimes associated with HOCM?
Bisferiens pulse
405
An inferior MI and AR murmur points towards what?
Ascending aortic dissection
406
Following a TIA or stroke, what should be given to AF patients?
Warfarin/direct thrombin/factor Xa inhibitor
| Start after 2 weeks in absence of haemorrhage
407
In general, how long is warfarin stopped before surgery?
5 days and once the INR is <1.5
408
When may warfarin be resumed after surgery?
On evening/next day after surgery
409
How is acute heart failure managed?
```
Oxygen
IV loop diuretics
Opiates
Vasodilators
Inotropic agents
CPAP
Ultrafiltration
Mechanical circulatory assistance, e.g. intra-aortic balloon counterpulsation/ventricular assist devices
Consider stopping beta blockers
```
410
What is Takotsubo cardiomyopathy?
Non-ischaemic cardiomyopathy associated with transient, apical ballooning of the myocardium
Can be triggered by stress
411
What are features of Takotsubo cardiomyopathy?
Chest pain
Features of heart failure
ST elevation
412
What are considered acceptable changes in UE and creatinine after starting an ACEi?
Increase in serum Cr up to 30% from baseline
| Increase in K up to 5.5mmol/l
413
Do NICE recommend routine antibiotic prophylaxis for those at risk of infective endocarditis undergoing dental and other procedures?
No
414
After starting an ACE inhibitor, significant renal impairment may occur in the the patient has what?
Undiagnosed bilateral renal artery stenosis
415
How is systolic hypertension managed?
In same way as essential hypertension
416
What is the advice re VTE related to travel?
No major risk factors - no prophylaxis req
Major risk factors - compression stockings
If risk very high - consider delaying flight or LMWH
417
When should CPAP be considered in those who have acute heart failure?
Considered for those not responding to treatment
418
What are features of chronic heart failure?
```
SoB
Cough
Orthopnoea
PND
Cardiac wheeze
Anorexia
Bibasal crackles on Ex
```
419
What are signs of R heart failure?
Raised JVP
Ankle oedema
Hepatomegaly
420
Is atropine recommended for asystole/pulseless electrical activity?
no
421
What is the mechanism of action of loop diuretics?
Inhibit Na-K-Cl cotransporter on thick ascending limb of loop of henle
422
What are SEs of loop duretics?
```
hypotension
hyponatraemia
hypokalaemia, hypomagnesaemia
hypochloraemic alkalosis
ototoxicity
hypocalcaemia
renal impairment (from dehydration + direct toxic effect)
hyperglycaemia (less common than with thiazides)
gout
```
423
What are features of Takayasu's arteritis?
```
Systemic features, malaise, headache
Unequal BP in upper limbs
Carotid bruit
Intermittent claudication
AR
Seen in young Asian females classically
```
424
When should treatment with statins be discontinued?
If serum transaminases rise to and persist 3x upper limit of reference range
425
How are pulseless electrical activity and asystole managed?
These are non-shockable rhythms and are therefore unresponsive to defib
give 1mg IV adrenaline and CPR
Can give adrenaline 1mg every 3-5m during alternate 2-min loops of CPR
426
What are the criteira for urgent valvular replacement in IE?
Severe congestive cardiac failure
Overwhelming sepsis
Recurrent embolic episodes despite antibiotics
Pregnancy
427
What clotting test does warfarin affect?
PT
428
What is teh most common ECG finding in hypercalcaemia?
Shorted QT interval
429
How long should you not drive for after an MI?
4 weeks
430
Do patients who have had catheter ablation for AF still require long-term anticoagulation?
Yes, as per their CHADSVASC
431
What signs do you see on ECG in digoxin toxicity?
Down sloping ST depression
Flattened/inverted T waves
Short QT interval
Arrhythmias, e.g. AV blocl, bradycardia
432
What is the most common cause of secondary hypertension?
Primary aldosteronism
433
What is atrial flutter?
A form of SVT characterised by succession of rapid atrial depolarisation waves
434
What are the ECG findings in atrial flutter?
Sawtooth appearance
Underlying atrial rate often about 300/min
Flutter waves may be visible following carotid sinus massage/adenosine
435
How is atrial flutter managed?
Similar to AF
436
What is curative in most patients with atrial flutter?
Radiofrequency ablation of tricuspid valve isthmus
437
What is the most common form of cardiomyopathy?
Dilated (DCM)
438
What are causes of DCM?
idiopathic: the most common cause
myocarditis: e.g. Coxsackie B, HIV, diphtheria, Chagas disease
ischaemic heart disease
peripartum
hypertension
iatrogenic: e.g. doxorubicin
substance abuse: e.g. alcohol, cocaine
inherited: either a familial genetic predisposition to DCM or a specific syndrome e.g. Duchenne muscular dystrophy
around a third of patients with DCM are thought to have a genetic predisposition
a large number of heterogeneous defects have been identified
the majority of defects are inherited in an autosomal dominant fashion although other patterns of inheritance are seen
infiltrative e.g. haemochromatosis, sarcoidosis
439
What is the pathophysiology of DCM?
Dilated heart leading to predominantly systolic dysfunction
| Eccentric hypertrophy seen (sarcomeres added in series)
440
What are features of DCM?
Heart failure
Systolic murmur
S3
Balloon appearance of heart on CXR
441
What is the grading of murmurs?
Grade 1 - very faint, frequently overlooked
Grade 2 - slight murmur
Grade 3 - moderate murmur, without palpable thrill
Grade 4 - loud murmur with palpable thrill
Grade 5 - very loud murmur with extremely palpable thrill
Grade 6 - extremely loud murmur, can be heard wo stethoscope touching chest wall
442
What is the half life of adenosine?
10 seconds
443
Can warfarin be used when breast feeding?
Yes
444
What should be given to patients on warfarin who are going for emergency surgery?
If surgery can wait 6-8h: 5mg vit K IV
| If surgery cant wait - 25-50 units/kg four factor prothrombin complex
445
When is thrombolysis given first line for PE?
Massive PE with circulatory failure
446
Define mild hypothermia
32-35C
447
Define moderate/severe hypothermia
<32C
448
What are general RFs for hypothermia?
```
GA
Substance abuse
Hypothyroidism
Impaired mental status
Homelessness
extremes of age
```
449
What are signs of hypothermia?
Shivering
Cold pale skin
Slurred speech
Tachycardia, tachypnoea, hypertension if mild
Resp depression, bradycardia and hypothermia if moderate
450
What are investigations for hypothermia?
```
Temperature
12 lead ECG
FBC, serum electrolytes
BG
ABG
Coagulation factors
CXR
```
451
How should hypothermia causing cardiac arrest be managed?
Chest compressions but withhold shocks until patients temp >30
