1
Q
Causes of Myocarditis
A
viral: coxsackie B, HIV
bacteria:diphtheria, clostridia
spirochaetes: Lyme disease
protozoa: Chagas’ disease, toxoplasmosis
autoimmune
drugs: doxorubicin
2
Q
Which Coronary artery
I , V5-6
A
Lt circumflex
3
Q
Which Coronary artery
II, III, aVF
A
RCA
4
Q
Which Coronary artery
V1-V4
A
LAD
5
Q
In STEMI
antiplatelet prior to PCI
A
‘dual antiplatelet therapy’, i.e. aspirin + another drug
- if the patient is not taking an oral anticoagulant: prasugrel
- if taking an oral anticoagulant: clopidogrel
6
Q
Antiplatelets during PCI
A
- patients undergoing PCI with radial access:
unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor (GPI)
- patients undergoing PCI with femoral access:
bivalirudin with bailout GPI
7
Q
In stable angina
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
a long-acting nitrate
ivabradine
nicorandil
ranolazine
8
Q
rise in the creatinine and potassium may be expected after starting ACEi
acceptable changes
- increase in serum creatinine, up to ……
- increase in potassium up to …….
- decrease in eGFR of up to…….
A
- increase in serum creatinine, up to 30% from baselineand an
- increase in potassium up to 5.5 mmol/l.
- decrease in eGFR of up to 25%
9
Q
Atropine is anantagonist of ……
A
Atropine is anantagonist of the muscarinic acetylcholine receptor.
10
Q
atropine may trigger…….
A
acute angle-closure glaucomain susceptible patients
11
Q
Effects of BNP
A
- vasodilator
- diuretic and natriuretic
- suppresses both sympathetic tone and the renin-angiotensin-aldosterone system
12
Q
Factors which reduce BNP levels include treatment with
A
ACEi,
ARBs
diuretics.
13
Q
Beck’s triad
A
- hypotension
- raised JVP
- muffled heart sounds
- Classical features of Cardiac tamponade
14
Q
pulsus paradoxus
A
an abnormally large drop in BP during inspiration
15
Q
eosinophilia
purpura
renal failure
livedo reticularis
Features of……?
A
Cholesterol embolisation
16
Q
Conditions associated with Coarctation of the aorta
A
Turner’s syndrome
bicuspid aortic valve
berry aneurysms
neurofibromatosis
17
Q
The coronary arteries fill during ………
A
diastole
18
Q
RCA supplies SA node in ………..%, AV node in ……..%
A
RCA supplies SA node in 60%, AV node in 90%
19
Q
The following ECG changes are considered normal variants in an athlete:
(4)
A
- sinus bradycardia
- junctional rhythm
- first degree heart block
- Mobitz type 1 (Wenckebach phenomenon)
20
Q
Which condition is associated with Patent foramen ovale (PFO)
A
Migraine
21
Q
4 ECG changes in PE
A
- S1Q3T3 ( this change is seen in no more than 20% of patients)
- RBBB
- RT axis deviation
- Sinus tachycardia
22
Q
In treatment of PE
if neither apixaban or rivaroxaban are suitable then
A
if neither apixaban or rivaroxaban are suitable then either LMWH followed by dabigatran or edoxaban OR LMWH followed by a vitamin K antagonist (VKA, i.e. warfarin)
23
Q
Treatment of PE in renal Impairment
A
if renal impairment is severe (e.g. < 15/min) then LMWH, unfractionated heparin or LMWH followed by a VKA
24
Q
Comparing CTPA to V/Q scanning in pregnancy
A
CTPA slightly increases the lifetime risk of maternal breast cancer, Pregnancy makes breast tissue particularly sensitive to the effects of radiation
V/Q scanning carries a slightly increased risk ofchildhood cancer
25
Pathophysiology of Aortic dissection
tear in .......
tear in the tunica intima of the wall of the aorta
26
Aortic dissection is associated with
HTN
Trauma
Bicuspid aortic valve
Pregnancy
Syphilis
collagens: Marfan's syndrome, Ehlers-Danlos syndrome
Turner's and Noonan's syndrome
27
ECG changes maybe seen in Aortic dissection
ST-segment elevation may be seen in the inferior leads
28
Stanford classification
type A - ascending aorta, 2/3 of cases
type B - descending aorta, distal to left subclavian origin, 1/3 of cases
29
DeBakey classification of Aortic dissection
30
Aortic dissection: investigation
1. Chest x-ray
widened mediastinum
2. CT angiography of the chest, abdomen and pelvis is the investigation of choice
suitable for stable patients and for planning surgery
3. Transoesophageal echocardiography (TOE)
more suitable for unstable patients who are too risky to take to CT scanner
31
Management of Aortic dissection
Type A
surgical management, but blood pressure should be controlled to a target systolic of 100-120 mmHg whilst awaiting intervention
Type B*
conservative management
bed rest
reduce blood pressure IV labetalol to prevent progression
32
Aortic dissection Complications of backward tear
aortic incompetence/regurgitation
MI: inferior pattern is often seen due to right coronary involvement
33
Aortic dissection Complications of a forward tear
unequal arm pulses and BP
stroke
renal failure
34
5 Associations of WPW
Secundum ASD
HOCM
thyrotoxicosis
Ebstein's anomaly
mitral valve prolapse
35
Management of WPW
definitive treatment: radiofrequency ablation of the accessory pathway
medical therapy: sotalol***, amiodarone, flecainide
sotalol should be avoided if there is coexistent atrial fibrillation
36
Mechanism of action of WARFARIN
inhibits epoxide reductase preventing the reduction of vitamin K to its active hydroquinone form
this in turn acts as a cofactor in the carboxylation of clotting factor II, VII, IX and X (mnemonic = 1972) and protein C.
37
What are the risk factors for asystole. Even if there is a satisfactory response to atropine
complete heart block with broad complex QRS
recent asystole
Mobitz type II AV block
ventricular pause > 3 seconds
38
- Dose of adenosine in SVT
- Contraindication ?
rapid IV bolus of 6 mg → if unsuccessful give 12 mg → if unsuccessful
contraindicated in asthmatics - verapamil is a preferable option
39
Causes of long QT interval
congenital
Jervell-Lange-Nielsen syndrome
Romano-Ward syndrome
antiarrhythmics: amiodarone, sotalol, class 1a antiarrhythmic drugs
tricyclic antidepressants
antipsychotics
chloroquine
terfenadine
erythromycin
electrolyte: hypocalcaemia, hypokalaemia, hypomagnesaemia
myocarditis
hypothermia
subarachnoid haemorrhage
40
A normal corrected QT interval is ......
A normal corrected QT interval is
< 430 ms in males and
< 450 ms in females.
41
the usual mechanism by which drugs prolong the QT interval is .......?
blockage of potassium channels
42
The most common variants of Long QT Syndrome (LQT1 & LQT2) are caused by defects in ........?
defects in the alpha subunit of the slow delayed rectifier potassium channel.
43
Features of
1. Long QT type 1
2. Long QT TYPE 2
3. LONG QT TYPE 3
1. Long QT1 - usually associated with exertional syncope, often swimming
2. Long QT2 - often associated with syncope occurring following emotional stress, exercise or auditory stimuli
3. Long QT3 - events often occur at night or at rest
44
Causes of a prolonged QT interval:
1. Congenial
2. Drugs
3. Electrolytes
4. Others
1. Congenial
- Jervell-Lange-Nielsen syndrome (includes deafness and is due to an abnormal potassium channel)
- Romano-Ward syndrome (no deafness)
2. Drugs
- amiodarone, sotalol, class 1a antiarrhythmic drugs
- SSRI & tricyclic antidepressants
- methadone
- chloroquine
- terfenadine**
- erythromycin
- haloperidol
- ondanestron
3. Electrolytes : hypo Ca, k , mg
4. Others
- MI
- myocarditis
- hypothermia
- SAH
45
Mechanism of loop diuretics that act by inhibiting ............
the Na-K-Cl cotransporter (NKCC) in the thick ascending limb of the loop of Henle,
- reducing the absorption of NaCl.
46
Adverse effects of loop diuretics
- Hypotension
- Hypo Na , K, Mg, Ca
- hypo chloraemic alkalosis
- ototoxicity
- hyperglycaemia
- gout
- renal impairment (from dehydration + direct toxic effect)
47
Signs of MR
1. pansystolic murmur described as “blowing”
2. S1 may be quiet as a result of incomplete closure of the valve.
3. Severe MR may cause a widely split S2
48
Signs of Mitral stenosis
1. mid-late diastolic murmur (best heard in expiration)
2. loud S1
3. opening snap : indicates mitral valve leaflets are still mobile
4. low volume pulse
5. malar flush
49
Signs of severe MS
1. length of murmur increases
2. opening snap becomes closer to S2
50
the normal cross-sectional area of the mitral valve is ........?..... sq cm.
A 'tight' mitral stenosis implies a cross-sectional area of ......?..... sq cm
the normal cross-sectional area of the mitral valve is ( 4-6 sq cm) .
A 'tight' mitral stenosis implies a cross-sectional area of ( < 1 sq cm)
51
Which anticoagulant can be used in mitral stenosis
DOACs for mild MS
WARFARIN for moderate / severe ms
52
Management of Mitral stenosis in asymptomatic patients
monitored with regular echocardiograms
percutaneous/surgical management is generally not recommended
53
Management of Mitral stenosis in symptomatic patients
percutaneous mitral balloon valvotomy
mitral valve surgery (commissurotomy, or valve replacement)
54
Mitral valve prolapse maybe associated with
1. congenital heart disease: PDA, ASD
2. cardiomyopathy
3. WPW syndrome
4. Long QT Syndrome
5. Turner's syndrome
6. Marfan's syndrome, Fragile X
7. Ehlers-Danlos Syndrome
8. polycystic kidney disease
9. osteogenesis imperfecta
10. pseudoxanthoma elasticum
55
Features of severe aortic stenosis ( 8 )
1. narrow pulse pressure
2. slow rising pulse
3. delayed ESM
4. soft/absent S2
5. S4
6. thrill
7. duration of murmur
8. LVH or failure
56
Causes of aortic stenosis
degenerative calcification (most common cause in older patients > 65 years)
bicuspid aortic valve (most common cause in younger patients < 65 years)
William's syndrome (supravalvular aortic stenosis)
post-rheumatic disease
subvalvular: HOCM
57
Management of AS
if asymptomatic >>> observe the patient is a general rule
if symptomatic >>> valve replacement
if asymptomatic but valvular gradient > 40 mmHg and with features such as left ventricular systolic dysfunction then consider surgery
58
balloon valvuloplasty in AS
may be used in children with no aortic valve calcification
in adults limited to patients with critical aortic stenosis who are not fit for valve replacement
59
options for aortic valve replacement (AVR) include
1. surgical AVR is the treatment of choice for young, low/medium operative risk patients. Cardiovascular disease may coexist. For this reason, an angiogram is often done prior to surgery so that the procedures can be combined
2. transcatheter AVR (TAVR) is used for patients with a high operative risk
60
Signs of AR
collapsing pulse
wide pulse pressure
Quincke's sign (nailbed pulsation)
De Musset's sign (head bobbing)
early diastolic murmur: intensity of the murmur is increased by the handgrip manoeuvre
mid-diastolic Austin-Flint murmur in severe AR - due to partial closure of the anterior mitral valve cusps caused by the regurgitation streams
61
In AR, aortic valve surgery indications include
symptomatic patients with severe AR
asymptomatic patients with severe AR who have LV systolic dysfunction
62
What is the most common type of ASD
Ostium secundum (70% of ASDs)
63
Signs of ASD
ejection systolic murmur, fixed splitting of S2
64
1. Ostium secundum is associated with ......
2. Ostium primum is associated with ......
1. associated with Down syndrome and Holt-Oram syndrome (tri-phalangeal thumbs)
2. associated with abnormal AV valves
65
ECG in ASD
Ostium secundum >>> ECG: RBBB with RAD
Ostium primum >>> ECG: RBBB with LAD, 1st degree AVB
66
1. Ostium secundum is located in .......
2. Ostium primum is located in ......
1. In the mid of portion of atrial septum
2. In the lowest portion of atrial septum
67
Complications of Bicuspid aortic valve
aortic stenosis/regurgitation
higher risk for aortic dissection and aneurysm formation of the ascending aorta
68
Bicuspid aortic valve is associated with
1. left dominant coronary circulation (the posterior descending artery arises from the circumflex instead of the right coronary artery).
2. Turner's syndrome
69
Factors decrease the BNP level:
1. Obesity
2. Diuretics
3. ACEi
4. ARBs
5. B blocker
6. Aldosterone antagonists
70
1. If BNP High, arrange ECHO within ..........
2. If BNP raised, arrange ECHO within ..........
1. Within 2 weeks
2. Within 6 weeks
71
ACE-inhibitors and beta-blockers have no effect on mortality in heart failure with .........
preserved ejection fraction
72
In HF, hydralazine in combination with nitrate indicated in
Afro-Caribbean patients
73
In HF, cardiac resynchronisation therapy is indicated in
widened QRS (e.g. LBBB)
74
criteria of ivabradine
sinus rhythm > 75/min and a left ventricular fraction < 35%
75
Causes of left axis deviation (LAD)
1. Lt anterior hemiblock
2. LBBB
3. Inferior MI
4. WPW syndrome ( rt sided accessory pathway)
5. HYPER K
6. CONGENITAL: OSTIUM PRIMUM ASD , TRICUSPID ATRESIA
7. MINOR LAD IN OBESE PEPOPLE
76
Causes of right axis deviation (RAD)
1. Lt posterior hemiblock
2. RBBB
3. LATERAL MI
4. Chronic lung disease
5. PE
6. Ostium secundum ASD
7. WPW SYNDROME ( LT SIDED ACCESSORY PATHWAY)
8. Normal in infant < 1 years old
9. Minor RAD IN TALL PEOPLE
77
ECG: digoxin (4)
down-sloping ST depression ('reverse tick', 'scooped out')
flattened/inverted T waves
short QT interval
arrhythmias e.g. AV block, bradycardia
78
ECG features of hypokalaemia
1. U waves
2. small or absent T waves (occasionally inversion)
3. ST depression
4. prolong PR interval
5. long QT
79
5 ECG changes : hypothermia
1. Bradycardia
2. atrial and ventricular arrhythmias
3. Long QT
4. First degree AVB
5. Osborne wave
80
Causes of LBBB
1. MI
2. HTN
3. Aortic stenosis
4. Cardiomyopathy
5. rare: idiopathic fibrosis, digoxin toxicity, hyperkalaemia
81
Causes of a prolonged PR interval
idiopathic
ischaemic heart disease
digoxin toxicity
hypokalaemia*
rheumatic fever
aortic root pathology e.g. abscess secondary to endocarditis
Lyme disease
sarcoidosis
myotonic dystrophy
82
Causes of RBBB
normal variant - more common with increasing age
right ventricular hypertrophy
chronically increased right ventricular pressure - e.g. cor pulmonale
pulmonary embolism
myocardial infarction
atrial septal defect (ostium secundum)
cardiomyopathy or myocarditis
83
Causes of ST depression
secondary to abnormal QRS (LVH, LBBB, RBBB)
ischaemia
digoxin
hypokalaemia
syndrome X
84
Causes of ST elevation
myocardial infarction
pericarditis/myocarditis
normal variant - 'high take-off'
left ventricular aneurysm
Prinzmetal's angina (coronary artery spasm)
Takotsubo cardiomyopathy
rare: subarachnoid haemorrhage
85
Causes of Peaked T waves
Hyper K
MI
86
Causes of Inverted T waves
myocardial ischaemia
digoxin toxicity
subarachnoid haemorrhage
arrhythmogenic right ventricular cardiomyopathy
pulmonary embolism ('S1Q3T3')
Brugada syndrome
87
During treatment with Mg So4 , you should monitor .....
1. urine output
2. RR
3. SPO2
4. reflexes
88
What is the first-line treatment for magnesium sulphate induced respiratory depression
calcium gluconate
89
Causes of High-output heart failure
anaemia
arteriovenous malformation
Paget's disease
Pregnancy
thyrotoxicosis
thiamine deficiency (wet Beri-Beri)
90
Drug can cause HTN
steroids
monoamine oxidase inhibitors
the combined oral contraceptive pill
NSAIDs
leflunomide
91
Causes of TR
right ventricular infarction
pulmonary hypertension e.g. COPD
rheumatic heart disease
infective endocarditis (especially intravenous drug users)
Ebstein's anomaly
carcinoid syndrome
92
Features of Takotsubo cardiomyopathy
chest pain
features of heart failure
ECG: ST-elevation
normal coronary angiogram
93
7 Causes of Restrictive cardiomyopathy
1. Amyloidosis
2. Haemochromatosis
3. Sarcoidosis
4. Scleroderma
5. post-radiation fibrosis
6. endocardial fibroelastosis
7. Loffler's syndrome
94
Features suggesting restrictive cardiomyopathy rather than constrictive pericarditis
prominent apical pulse
absence of pericardial calcification on CXR
the heart may be enlarged
ECG abnormalities e.g. bundle branch block, Q waves
95
What is Pulsus paradoxus ?
2 Causes
greater than the normal (10 mmHg) fall in systolic blood pressure during inspiration → faint or absent pulse in inspiration
Casuses
- severe asthma,
- cardiac tamponade
96
Causes of Slow-rising/plateau
(1)
AS
97
3 Causes of Collapsing pluse
1. AR
2. PDA
3. hyperkinetic states (anaemia, thyrotoxic, fever, exercise/pregnancy)
98
Causes of Pulsus alternans
Severe LVF
99
What is Bisferiens pulse ?
Causes?
double pulse' - two systolic peaks
1. mixed aortic valve disease
2. HOCM may occasionally be associated with a bisferiens pulse
100
Causes of 'Jerky' pulse
- HOCM
101
Pulmonary arterial hypertension (PAH) may be defined as a resting mean pulmonary artery pressure of >= ...... mmHg.
a resting mean pulmonary artery pressure of >= 25 mmHg.
102
In pulmonary HTN, which test can help in deciding on the appropriate management strategy.
acute vasodilator testing
103
Treatment of pulmonary HTN, If there is a positive response to acute vasodilator testing
Oral CCB
104
Treatment of pulmonary HTN, If there is a negative response to acute vasodilator testing
1. phosphodiesterase inhibitors: sildenafil
2. prostacyclin analogues: treprostinil, iloprost
3. endothelin receptor antagonists
- non-selective: bosentan
- selective antagonist of endothelin receptor A: ambrisentan
105
In pulmonary HTN, Patients with progressive symptoms should be considered for
heart-lung transplant.
106
Target INR in mechanical valves
- Aortic :
- mitral :
- Aortic : 3.0
- mitral : 3.5
107
Features of severe pre-eclampsia
hypertension: typically > 160/110 mmHg and proteinuria as above
proteinuria: dipstick ++/+++
headache
visual disturbance
papilloedema
RUQ/epigastric pain
hyperreflexia
platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome
108
connection between the pulmonary trunk and descending aorta
Which condition?
PDA
109
Management of PDA
indomethacin or ibuprofen
- inhibits prostaglandin synthesis
if associated with another congenital heart defect amenable to surgery then prostaglandin E1 is useful to keep the duct open until after surgical repair
110
angina-like chest pain on exertion
ST depression on exercise stress test
but normal coronary arteries on angiography
Which condition?
Syndrome X
111
Which drug is used as a first-line to control the rate in AF.
BB or CCB ( diltiazem )
112
What to do, If one drug does not control the rate in patients with AF
combination therapy with any 2 of the following:
a betablocker
diltiazem
digoxin
113
In AF, anticoagulation is indicated if CHA2DS2-VASc score
Score 1 in male
Score 2 in female
114
Agents with proven efficacy in the pharmacological cardioversion of atrial fibrillation
amiodarone
flecainide (if no structural heart disease)
others (less commonly used in UK): quinidine, dofetilide, ibutilide, propafenone
115
If the patient has been in AF for more than 48 hours then anticoagulation should be given for.......
At least 3 weeks prior to CARDIOVERSION
116
In AF, Following electrical cardioversion patients should be anticoagulated for
at least 4 weeks
117
Rate control should be offered as the first‑line treatment strategy for atrial fibrillation except in people:
1. New onset AF < 48 hrs
2. Reversible cause of AF
3. who have heart failure thought to be primarily caused by atrial fibrillation
4. with atrial flutter whose condition is considered suitable for an ablation strategy to restore sinus rhythm
5. for whom a rhythm‑control strategy would be more suitable based on clinical judgement
118
complications of catheter ablation
cardiac tamponade
stroke
pulmonary vein stenosis
119
Features suggesting VT rather than SVT with aberrant conduction
1. AV dissociation
2. fusion or capture beats
3. positive QRS concordance in chest leads
4. marked left axis deviation
5. history of IHD
6. lack of response to adenosine or carotid sinus massage
7. QRS > 160 ms
120
Brugada syndrome
- What type of inheritance?
- Brugada syndrome is more common in .......
- autosomal dominant
- in Asians
121
Brugada syndrome is caused by a mutation in .....
by a mutation in the SCN5A gene which encodes the myocardial sodium ion channel protein
122
ECG changes in Brugada syndrome
convex ST segment elevation > 2mm in > 1 of V1-V3 followed by a negative T wave
partial RBBB
123
What is the investigation of choice in suspected cases of Brugada syndrome
the ECG changes may be more apparent following the administration of flecainide or ajmaline
124
Burger disease
- It affects....... sized blood vessels.
- strongly associated with ....
- Small and medium vessel vasculitis.
- strongly associated with smoking.
125
Features of Buerger's disease (also known as thromboangiitis obliterans)
1. Raynaud's phenomenon
2. superficial thrombophlebitis
3. extremity ischaemia
- intermittent claudication
- ischaemic ulcers
126
1. Which cardiac marker is the first to rise ?
2. which one is useful to look for reinfarcation?
1. Myoglobin
2. CK-MB is useful to look for reinfarction as it returns to normal after 2-3 days (troponin T remains elevated for up to 10 days)
127
What are the acyanotic congenital heart diseases ?
1. PDA
2. ASD
3. VSD
4. COARCTATION OF AORTA
5. AORTIC STENOSIS
128
Who are at an high risk of Transposition of the great arteries (TGA)?
Children of diabetic mothers
129
Transposition of the great arteries (TGA) is a form of cyanotic congenital heart disease. It is caused by the failure of ............?
caused by the failure of the aorticopulmonary septum to spiral during septation.
130
cyanosis
tachypnoea
loud single S2
prominent right ventricular impulse
'egg-on-side' appearance on chest x-ray
Picture of which disease ?
Transposition of the great arteries
131
Features of Tetralogy of Fallot
1. VSD
2. RVH
3. Rt ventricular outflow tract obstruction, pulmonary stenosis
4. Overriding aorta
132
What is the most common cause of congenital heart disease
VSD
133
Aetiology of VSD
1. often association with chromosomal disorders
- Down's syndrome
- Edward's syndrome
- Patau syndrome
cri-du-chat syndrome
2. congenital infections
3. acquired causes
- post-myocardial infarction
134
VSDs may be detected in utero during ......?
the routine 20 week scan.
135
Investigations of Takayasu's arteritis
MRA or CTA
136
Treatment of Takayasu's arteritis
Steroids
137
Which drug is used as first-line in patients with peripheral arterial disease
clopidogrel should be used first-line in patients with peripheral arterial disease in preference to aspirin.
138
Dressler's syndrome tends to occur ...... weeks following a MI.
occurs around 2-6 weeks
139
Dressler's syndrome is treated with ......?
treated with NSAIDs.
140
persistent ST elevation and left ventricular failure
Associated with Which of MI complications ?
Lt ventricular aneurysm
141
Acute mitral regurgitation treated with....
treated with vasodilator therapy but often require emergency surgical repair.
142
Treatment of Multifocal atrial tachycardia (MAT)
correction of hypoxia and electrolyte disturbances
rate-limiting calcium channel blockers are often used first-line
143
Treatment of Kawasaki disease
1. high-dose aspirin
2. Iv Ig
144
What is the initial screening test for coronary artery aneurysms in Kawasaki disease?
ECHO (rather than angiography)
145
Cannon waves is Caused by .....?
Caused by the right atrium contracting against a closed tricuspid valve
146
1- Causes of regular cannon waves
2- Causes of irregular cannon waves
1. VT & atrio-ventricular nodal re-entry tachycardia (AVNRT)
2. Complete heart block
147
Causes of eruptive xanthoma
familial hypertriglyceridaemia
lipoprotein lipase deficiency
148
Causes of Tendon xanthoma, tuberous xanthoma, xanthelasma
familial hypercholesterolaemia
remnant hyperlipidaemia
149
Causes of Palmar xanthoma
remnant hyperlipidaemia
may less commonly be seen in familial hypercholesterolaemia
150
Hypertension in pregnancy in usually defined as:
systolic > 140 mmHg or diastolic > 90 mmHg
151
What is the next step, if the patient on antihypertensive (A+ C + D) and still BP uncontrolled?
Check potassium level
if potassium < 4.5 mmol/l add low-dose spironolactone
if potassium > 4.5 mmol/l add an alpha- or beta-blocker
152
Blood pressure targets
If age < 80
Clinical BP : 140/90
ABPM/ HBPM : 135/ 85
* Minus 5
153
Blood pressure targets
If age > 80
Clinical BP : 150/90
ABPM/ HBPM : 145/ 85
* Minus 5
154
HOCM IS ASSOCIATED WITH
Friedreich's ataxia
Wolff-Parkinson White
155
Echo finding in HOCM
mnemonic - MR SAM ASH
mitral regurgitation (MR)
systolic anterior motion (SAM) of the anterior mitral valve leaflet
asymmetric hypertrophy (ASH)
156
ECG findings in HOCM
1. AF
2. LVH
3. Deep Q waves
4. non-specific ST segment and T-wave abnormalities, progressive T wave inversion may be seen
157
HOCM
defects involve a mutation in .......
the gene encoding β-myosin heavy chain protein or myosin-binding protein C
158
Drugs to avoid in HOCM
nitrates
ACE-inhibitors
inotropes
159
Management of HOCM
Amiodarone
Beta-blockers or verapamil for symptoms
Cardioverter defibrillator
Dual chamber pacemaker
Endocarditis prophylaxis*
160
Poor prognostic factors of HOCM
1. syncope
2. family history of sudden death
3. young age at presentation
4. non-sustained ventricular tachycardia on 24 or 48-hour Holter monitoring
5. abnormal blood pressure changes on exercise
6. increased septal wall thickness
161
Eisenmenger's syndrome
1. PDA
2. ASD
3. VSD
162
Exercise: physiological changes
Blood pressure
systolic increases, diastolic decreases
leads to increased pulse pressure
163
Exercise: physiological changes
Cardiac output
stroke volume up to 1.5-fold increase
HR up to 3-fold increase
increase in cardiac output may be 3-5 fold
164
Systemic vascular resistance falls in exercise due to
due to vasodilatation in active skeletal muscles.
165
Ebstein's anomaly may be caused by exposure to ........ in utero.
lithium
166
Ebstein's anomaly
Associated with
1. PFO
2. ASD
3. WPW SYNDROME
167
JVP in
1. Cardiac tamponade
Vs
2. Constrictive pericarditis
1. Absent Y descent
2. X + Y present
168
Arrhythmogenic right ventricular cardiomyopathy is inherited in an autosomal ....... pattern
autosomal dominant pattern
169
In Arrhythmogenic right ventricular cardiomyopathy is the right ventricular myocardium is replaced by .......?
By fatty and fibrofatty tissue
170
Management of Arrhythmogenic right ventricular cardiomyopathy
drugs: sotalol is the most widely used antiarrhythmic
catheter ablation to prevent ventricular tachycardia
implantable cardioverter-defibrillator
171
triad of ARVC, palmoplantar keratosis, and woolly hair
Naxos disease
172
Naxos disease is an autosomal .............. variant of ARVC
autosomal recessive
173
What are the ECG abnormalities in Arrhythmogenic right ventricular cardiomyopathy
ECG abnormalities in V1-3, typically T wave inversion
174
Classic causes of Restrictive cardiomyopathy include
amyloidosis
post-radiotherapy
Loeffler's endocarditis
175
When can develop Peripartum cardiomyopathy ?
Typical develops between last month of pregnancy and 5 months post-partum
176
Treatment of Takotsubo cardiomyopathy ( Stress'-induced cardiomyopathy)
Treatment is supportive
177
Catecholaminergic polymorphic ventricular tachycardia (CPVT) is inherited in an ........ fashion
autosomal dominant
178
In Catecholaminergic polymorphic ventricular tachycardia,
the most common cause is a defect in ......
the most common cause is a defect in the ryanodine receptor (RYR2) which is found in the myocardial sarcoplasmic reticulum
179
Treatment of Catecholaminergic polymorphic ventricular tachycardia
1. B blocker
2. ICD
180
Aschoff bodies describes the granulomatous nodules found in
in rheumatic heart fever
181
The strongest risk factor for developing infective endocarditis is a ........?
previous episode of endocarditis
182
Culture negative causes of IE
1. prior antibiotic therapy
2. Coxiella burnetii
3. Bartonella
4. Brucella
5. HACEK: Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella)
183
now the most common cause of infective endocarditis
Staphylococcus aureus
184
endocarditis caused by organisms is linked with poor dental hygiene or following a dental procedure
Streptococcus viridans
Streptococcus mitis and
Streptococcus sanguinis
185
the most cause of endocarditis in patients following prosthetic valve surgery
coagulase-negative Staphylococci such as Staphylococcus epidermidis
186
Streptococcus bovis is associated with ................. cancer
colorectal cancer
187
non-infective causes of IE
SLE (Libman-Sacks)
malignancy: marantic endocarditis
188
4 Poor prognostic factors of IE
1. Staphylococcus aureus infection
2. prosthetic valve (especially 'early', acquired during surgery)
3. culture negative endocarditis
4. low complement levels
189
Mortality according to organism
staphylococci - ...............%
bowel organisms - .........%
streptococci - .............. %
Mortality according to organism
staphylococci - 30%
bowel organisms - 15%
streptococci - 5%
190
5 Indications for surgery in IE
1. severe valvular incompetence
2. aortic abscess (often indicated by a lengthening PR interval)
3. infections resistant to antibiotics/fungal infections
4. cardiac failure refractory to standard medical treatment
5. recurrent emboli after antibiotic therapy
191
prophylaxis of Infective endocarditis
In dental procedures
do not require
192
prophylaxis of Infective endocarditis
In upper and lower GIT procedures
Not require
193
prophylaxis of Infective endocarditis
genitourinary tract; this includes urological, gynaecological and obstetric procedures and childbirth
Not require
194
prophylaxis of Infective endocarditis
upper and lower respiratory tract; this includes ear, nose and throat procedures and bronchoscopy
Not require
195
Mechanism of action of WARFARIN
inhibits epoxide reductase preventing the reduction of vitamin K to ........?
its active hydroquinone form
196
Factors that may potentiate warfarin
1. liver disease
2. P450 enzyme inhibitors, e.g.: amiodarone, ciprofloxacin
3. cranberry juice
4. drugs which displace warfarin from plasma albumin, e.g. NSAIDs
5. inhibit platelet function: NSAIDs
197
WARFARIN and breastfeeding
can be used
198
INR 5.0-8.0
No bleeding
Withhold 1 or 2 doses of warfarin
199
INR > 8
NO BLEEDING
1. Stop warfarin
2. Give oral vitamin K 1-5mg , Repeat dose of vitamin K if INR still too high after 24 hours
Restart when INR < 5.0
200
INR 5.0-8.0
Minor bleeding
1. Stop warfarin
2. Give iv vitamin K 1-3mg
Restart when INR < 5.0
201
INR > 8.0
Minor bleeding
1. Stop warfarin
2. Iv vitamin K 1-3mg
Repeat dose of vitamin K if INR still too high after 24 hours
Restart warfarin when INR < 5.0
202
Treatment of High INR
Major bleeding (e.g. variceal haemorrhage, intracranial haemorrhage)
1. Stop warfarin
2. Iv vitamin K 5mg
3. Prothrombin complex concentrate - if not available then FFP
203
Thiazide diuretics work by inhibiting ........? 1......... reabsorption at the beginning of the .........2?........ by blocking the thiazide-sensitive Na+-Cl− symporter.
Thiazide diuretics work by inhibiting (1. sodium ) reabsorption at the beginning of the (2. distal convoluted tubule (DCT)) by blocking the thiazide-sensitive Na+-Cl− symporter.
204
7 common Side effects of thiazides
1. Dehydration
2. Postural Hypotension
3. Hypo K , Na
4. Hyper Ca
5. Gout
6. impaired glucose tolerance
7. impotence
205
4 Rare Side effects of thiazide
1. thrombocytopaenia
2. agranulocytosis
3. photosensitivity rash
4. pancreatitis
206
Thiazide induced hypo K due to .....
increased delivery of sodium to the distal part of the DCT.
207
Which antibiotics are contraindicated with statins ?
macrolides (e.g. erythromycin, clarithromycin)
Statins should be stopped until patients complete the course
208
Statins inhibit the action of .......
HMG-CoA reductase, the rate-limiting enzyme in hepatic cholesterol synthesis.
209
When prescribed Statins , recommend checking LFTs at .........?
at baseline, 3 months and 12 months.
210
When to DC statin in liver impairment
discontinued if serum transaminase concentrations rise to and persist at 3 times the upper limit of the reference range
211
Risks factors for myopathy due to statins
1. advanced age,
2. female sex,
3. low body mass index
4. presence of multisystem disease such as DM.
212
Myopathy due to statins is more common in which preparations ?
1. simvastatin
2. atorvastatin
213
Mechanism of action of hydralazine increases ......... leading to smooth muscle relaxation
cGMP
214
6 Side effects of hydralazine
1. Tachycardia
2. Palpitations
3. Headache
4. Flushing
5. Fluid retention
6. Drug induced lupus
215
Which drug can reduce the risk of developing pre eclampsia
Low dose aspirin
216
What is the first line for pregnancy induced HTN
I. Labetalol
If asthmatic >> nifedipine and hydralazine may also be used
217
The specific cut-off value for defining a positive acute vasodilator test
decrease in mean pulmonary arterial pressure by at least 10 mmHg to a level below 40 mmHg
218
What is the first line treatment of isolated systolic HTN
CCB
219
SCN5A gene seen in …?
Brugada syndrome
220
SCN5A gene seen in …?
Brugada syndrome
MRCP Part 1
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