PASS MEDICINE: CARDIOLOGY

ABCD2

Prognostic score for risk stratifying patients who've had a suspected TIA

SCOFF

Questionnaire used to detect eating disorders and aid treatment

FRAX

Risk assessment tool developed by WHO which calculates a patients 10-year risk of developing an osteoporosis related fracture

ARB losartan

what should be used when ACE inhibitors are not tolerated (e.g. dry cough)? give an example __

new LBBB STEMI ST depression T-wave inversion

what should prompt investigation for an ACS?

third

which additional heart sound is likely to be present in acute HF?

SOB on exertion orthopnoea PND

3 signs of L-sided heart failure?

raised JVP ankle oedema hepatomegaly

3 signs of R-sided heart failure?

50% (autosomal dominant)

A 15-year-old boy collapses and dies whilst playing football at school. He had no past medical history of note. Post-mortem examination reveals asymmetric hypertrophy of the interventricular septum. Given the likely underlying diagnosis, what is the individual risk his sister will also have the same underlying disorder?

hypertrophic obstructive cardiomyopathy

A 15-year-old boy collapses and dies whilst playing football at school. He had no past medical history of note. Post-mortem examination reveals asymmetric hypertrophy of the interventricular septum. What is the likely underlying disorder?

implatable cardioverter-defibrillator

A 21-year-old man collapses whilst playing football with unexplained syncope. He is sent for an echocardiogram which shows an increase in the thickness of the interventricular septum. Which of the following is the best next step in the management of this patient?

ECG to assess for long QT (risk of sudden death)

A 21-year-old man was brought in by police to the psychiatry unit due to reports of him behaving strangely in public place. On arrival, the clerking doctor gets a full history which shows evidence of paranoid ideation, thought insertion, withdrawal and broadcasting. He has no previous medical history and he is not on any regular medication. He denies illegal substance use and urine drug screen results were negative. The consultant psychiatrist feels the top differential diagnosis is first episode psychosis and recommends initiation of a daily anti-psychotic. Before prescribing this class of drugs, an initial assessment must include?

ostium secundum

A 25-year-old female is found to have a left hemiparesis following a deep vein thrombosis. An ECG shows RBBB with right axis deviation. What is the most likely underlying diagnosis?

infective endocarditis

In someone with fever and heart murmur, consider ___

50%

A 28-year-old man is a new patient at your surgery and attends for an initial visit. He has been in good health and has not had any hospitalisations. With regards to his family history. he reports that his father died of sudden cardiac death at age 38. A post-mortem examination revealed that his cause of death was hypertrophic cardiomyopathy. What is the probability that your patient inherited the same condition?

blood cultures

A 34-year-old man presented to the emergency department. He looked unwell and has a temperature of 38.2ºC. He is normally fit and well without any past medical condition. He is an iv drug user. He drinks 10 units of alcohol per week and smokes 1 pack a day.Examination of the cardiovascular and respiratory system revealed a pansystolic murmur in the left lower sternal edge and enlarged cervical lymph nodes. Which of the following will be most helpful to make the diagnosis?

widespread ST elevation

A 41-year-old man is admitted with left-sided pleuritic chest pain. He has a dry cough and reports that the pain is relieved by sitting forward. For the past three days he has been experiencing flu-like symptoms. Given the likely diagnosis of acute pericarditis, what is the most likely finding on ECG?

takotsubo cardiomyopathy

A 45-year-old woman suffered from sudden onset central crushing chest pain. Her electrocardiogram showed ST-segment elevation. Troponin is slightly raised. She was rushed for an emergency invasive angiogram but this revealed slight wall irregularities with no luminal obstruction. Subsequently, cardiovascular MR (CMR) showed an apical ballooning of the myocardium resembling an octopus pot. She did not have any significant past medical history. There is a family history of premature coronary artery disease. Her partner recently passed away of prostate cancer.What is the most likely cause of the ST-segment elevation?

immediate administration of prostaglandin (maintain a patent ductus arteriosus- allow adequate circulation until it's possible to attempt corrective surgery)

A 5-day old infant presents to the paediatric assessment unit with poor feeding, tachypnoea and drowsiness.He was born at 38 weeks via normal vaginal delivery and was discharged within 24 hours after a newborn check was normal. On examination, he was also tachycardic with weak femoral pulses bilaterally. The lungs were clear and the liver was enlarged by 2cm.An echocardiogram was performed which confirmed a diagnosis of coarctation of the aorta.What is the most appropriate next step in management after resuscitation?

no oxygen therapy

A 50-year-old man is admitted to Resus with a suspected anterior myocardial infarction. An ECG on arrival confirms the diagnosis and thrombolysis is prepared. The patient is stable and his pain is well controlled with intravenous morphine. Clinical examination shows a blood pressure of 140/84 mmHg, pulse 90 bpm and oxygen saturations on room air of 97%. What is the most appropriate management with regards to oxygen therapy?

synchronised DC cardioversion

A 54-year-old male was admitted with a 12-hour history of palpitations. On admission his observations are: Heart rate incalcuable, blood pressure 80/50mmHg, respiratory rate 20/min, temperature 36.9º, saturations 97% on air. The patient reports he has not experienced any previous similar episodes. He has no past medical history and takes no regular medications. On examination: Pulse is irregular with good volume, heart sounds are normal and fine-bibasal crackles are heard extending to the mid-zones of the lungs. A 12-lead ECG is performed and shows a irregular narrow complex tachycardia with a sawtooth baseline at rate 150-180 beats per minute.. What is the most appropriate management strategy of this patient?

mitral regurgitation

A 55-year-old woman presents to the emergency department with a sudden onset of central chest pain while she was at rest. The pain was not relieved by her glyceryl trinitrate spray. She has a past history of angina and hypertension. ECG and cardiac biomarkers were positive for an ST-elevation myocardial infarction (STEMI).A few minutes later, she complained of worsening shortness of breath. On examination, her pulse was weak and thready. Her jugular venous pressure is increased. On chest auscultation, there was a new systolic murmur. Her pulse rate was 130 beats per minute and blood pressure was 80/55 mmHg. There were no new acute changes to the ECG.Which of the following is the most likely diagnosis?

aortic dissection

A 60-year-old man arrives into the emergency department shocked with sudden onset, severe chest pain at rest. He complains that the pain is radiating into his back and down his arms. He has a past medical history of hypertension, angina and had a deep vein thrombosis (DVT) 4 years ago. His regular medications include ramipril, glyceryl trinitrate (GTN) spray and simvastatin. He has never smoked, doesn't drink alcohol and has not had any recent travel abroad. A chest x-ray reveals a widened mediastinum and ECG shows sinus tachycardia. He thinks he found some relief from the pain 20 minutes after using his GTN spray. What is the most likely diagnosis?

complete occlusion of the left anterior descending artery

A 60-year-old man is admitted with severe central chest pain to the resus department. The admission ECG shows ST elevation in leads V1-V4 with reciprocal changes in the inferior leads. Which one of the following is most likely to account for these findings?

Constrictive pericarditis

A 60-year-old man presents with a 2-week history of dyspnoea and leg swelling. On examination, he has a raised JVP that doesn't fall with inspiration. His lung bases are clear and a pericardial knock is heard on auscultation. His only past medical history is angina for which he was recently investigated with a coronary angiogram. Given this presentation, which of the following is the most likely cause of his presentation?

risk of stroke is the same = remain on apixaban (Patients who've had a catheter ablation for atrial fibrillation still require long-term anticoagulation as per their CHA2DS2-VASc score)

A 64-year-old-man is admitted to the cardiology ward for routine catheter ablation to treat his atrial fibrillation. His wife asks whether he needs to continue his longterm apixaban. What is the correct advice to give her and the patient?

aspirin emergency admission

A 67-year-old woman is reviewed in the afternoon GP surgery. She describes a 20 minute episode heavy central chest pain shortly after getting up from bed this morning, about 7 hours ago. This has not happened before and she has been pain free since the morning. Clinical examination is normal but the ECG shows T wave inversion in the inferior leads. What is the most appropriate action?

unstable angina

A 70-year-old man presents with a sudden onset of central chest pain, radiating to his jaw and left shoulder. The chest pain occurred an hour ago when he was sitting on a chair after his dinner. He has a past history of hypertension.On examination, he is alert but appears to be sweaty, nauseous and short of breath. His pulse rate is 120 bpm and his blood pressure is 150/100 mmHg. ECG shows a T-wave inversion and an ST-segment depression in the anterior leads. Troponin levels, which were taken at 3 hours and at 6 hours after the symptom onset were not elevated.Which of the following is the most likely diagnosis?

RCA lesion

A 72-year-old man is admitted to the Emergency Department with chest pain. On initial assessment he is noted to be pale, have a heart rate of 40/min and a blood pressure of 90/60 mmHg. An ECG shows that he is in complete heart block. Which one of the coronary arteries is most likely to be affected? (complete heart block following a MI)

start amlodipine

A 74-year-old woman is reviewed. She recently had ambulatory blood pressure monitoring that showed an average reading of 142/90 mmHg. There is no significant past medical history of note other than hypothyroidism. Her 10-year cardiovascular risk score is 23%. What is the most appropriate management?

posterior MI

A 78-year-old man presents to the emergency department with severe, crushing chest pain and shortness of breath. He is seen immediately and, among other investigations, an ECG is performed. You are the F1 in the department, and your registrar says that the ECG shows tall R waves in the V1 and V2 leads. What is this man suffering from?

posterior STMI

A patient is admitted to the emergency department with new-onset chest pain that is radiating to their left arm. It came on shortly after performing a 5km run. The patient has a past history of angina. You perform an ECG and note the following: -ST depression in leads V1-V3 - Tall R waves in leads V1-V3 - Inverted T-wave in lead aVR - All other T-waves are normally oriented What is the most likely diagnosis?

Child-Pugh classification

A scoring system used to assess the severity of liver cirrhosis

posterior interventricular artery

AV node is supplied by which artery?

Gleason score

Indicates prognosis in prostate cancer

BNP

All patients with suspected chronic heart failure should have an ____ test first-line

pericarditis

complications of MI: common in 10% in the first 48 hrs post MI. pleuritic chest pain, worse on lying flat. pericardial rub may be heard.

APGAR

Assesses the health of a newborn immediately after birth

Waterlow score

Assesses the risk of a patient developing a pressure sore

DCT

Bendroflumethiazide - inhibits sodium reabsorption by blocking the Na+-Cl− symporter at the beginning of the ___

tricuspid

Infective endocarditis in intravenous drug users most commonly affects the ____ valve

20 80

Cardiovascular disease: atorvastatin __mg for primary prevention, __mg for secondary prevention

3 sets of blood culture echocardiogram

Duke criteria for infective endocarditis

bradycardia J wave (small hump at the end of QRS) first degree heart block long QT atrial and ventricular arrythmias

ECG changes: hypothermia

valsalva manœuvre

ESM of aortic stenosis can be decreased following ___

NYHA

Heart failure severity scale

Wells score

Helps estimate the risk of a patient having a deep vein thrombosis

HAD

Hospital Anxiety and Depression (HAD) scale - assesses severity of anxiety and depression symptoms

ventricular arrhythmia

Hypertrophic obstructive cardiomyopathy - is associated with sudden death in young athletes due to____

DAS28

Measure of disease activity in rheumatoid arthritis

MMSE

Mini-mental state examination - used to assess cognitive impairmen

pulmonary oedema secondary to MI

Mr Smith has been admitted to hospital with chest pain and is being treated for a suspected myocardial infarction. While he is being reviewed by the admitting team, he suddenly gets very short of breath. On examination, he had bilateral crackles throughout the entire lung fields, his oxygen saturations have dropped to 92% and his blood pressure is low at 90/50 mmHg. What is the most likely cause of Mr Smith's deterioration?

class II

NYHA classification: mild symptoms slight limitation of physical activity: comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea

class III

NYHA classification: moderate symptoms marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms

class I

NYHA classification: no symptoms no limitation: ordinary physical exercise does not cause undue fatigue, dyspnoea or palpitations

class IV

NYHA classification: severe symptoms unable to carry out any physical activity without discomfort: symptoms of heart failure are present even at rest with increased discomfort with any physical activity

PHQ-9

Patient Health Questionnaire - assesses severity of depression symptoms

hypokalaemia

T-wave flattening and the appearance of U-waves suggests ___

GAD-7

Used as a screening tool and severity measure for generalised anxiety disorder

Epworth Sleepiness Scale

Used in the assessment of suspected obstructive sleep apnoea

CURB-65

Used to assess the prognosis of a patient with pneumonia

CHA2DS2-VASc

Used to determine the need to anticoagulate a patient in atrial fibrillation

Bishop score

Used to help assess the whether induction of labour will be required

Edinburgh Postnatal Depression Score

Used to screen for postnatal depression

cardiogenic shock

complications of MI: if a large part of the myocardium is damaged- ejection fraction of the heart may decrease- patient will develop ____

(peri arrest tachycardia) immediate DC cardioversion

You are called to see a 74-year-old patient who is complaining that her heart is racing. On examination, her heart rate is 209bpm and she appears breathless. Cardiac monitoring confirms a rapid narrow complex tachycardia. She states that she is now experiencing chest pain.What is the most appropriate management step?

dual antiplatelet therapy beta-blocker ACE inhibitor statin

You are doing the discharge summary for a 56-year-old man who is being discharged following a ST-elevation myocardial infarction (MI) for which he was treated with a percutaneous coronary intervention. He has no past medical history of note. Following NICE guidance, which of the following best describes the medications which he should be taking?

AUDIT CAGE FAST

alcohol screening tool

yes

are inverted T-waves normal in aVR?

V1-V3 ST depression tall, broad R-waves upright T-waves

characteristic posterior STEMI on ECG:

Dressler's syndrome

complications of MI: 2-6 wks post-MI. autoimmune reaction against antigenic proteins formed as the myocardium recovers. fever, pleuritic pain, pericardial effusion, raised ESR. treated with NSAIDs.

pericarditis

complications of MI: A 50-year-old man complains of central, pleuritic chest pain 24 hours after being admitted with an anterior myocardial infarction. The pain is eased when he sits upright.

left ventricular free wall rupture (catastrophic event- immediate surgery)

complications of MI: A 66-year-old woman suddenly develops dyspnoea 10 days after having an anterior myocardial infarction. Her blood pressure is 78/50 mmHg, JVP is elevated and the heart sounds are muffled. There are widespread crackles on her chest and the oxygen saturations are 84% on room air.

ventricular tachycardia

complications of MI: After being admitted to the coronary care unit a middle aged man develops a regular, broad complex tachycardia. His blood pressure drops to 88/50 mmHg. He was admitted 6 hours previously following an anterolateral myocardial infarction

acute mitral regurgitation

complications of MI: More common with infero-posterior infarction and may be due to ischaemia or rupture of the papillary muscle. Acute hypotension and pulmonary oedema may occur. An early-to-mid systolic murmur is typically heard. Patients are treated with vasodilator therapy but often require emergency surgical repair.

ventricular fibrillation

complications of MI: cardiac arrest most commonly occurs due to patients developing ____

LV aneurysm

complications of MI: ischaemic damage may weaken the myocardium resulting in _______ formation. associated with persistent ST elevation and LV failure. thrombus may form = increasing risk of stroke. patients therefore need to be anticoagulated.

LV free wall rupture

complications of MI: seen in around 3% of MI and occurs 1-2 wks afterwards. presentation: acute HF secondary to cardiac tamponade. urgent pericardiocentesis and thoracotomy required.

ventricular septal defect

complications of MI: usually occurs in the first week and is seen in around 1-2% of patients. Features: acute heart failure associated with a pan-systolic murmur. An echocardiogram is diagnostic and will exclude acute mitral regurgitation which presents in a similar fashion. Urgent surgical correction is needed.

tall waves V1-2 LCx, RCa

how does a posterior MI present on ECG? typically which artery will be affected?

macrolides

important common interaction statins + ____

Duke criteria

infective endocarditis criteria

IPSS

international prostate symptom score

Pulmonary hypertension

name a cause of a loud S2?

Ranson criteria

scoring system: acute pancreatitis

pleuritic chest pain dyspnoea haemoptysis

triad for PE

NSAIDs

what are used to close a patent ductus arteriosus?

prostaglandins

what are used to keep the ductus arteriosus patent?

positive Kussmaul's sign (raised JVP which doesn't fall with inspiration = constrictive pericarditis)

what can be used to differentiate cardiac tamponade and constrictive pericarditis?

flash pulmonary oedema

what can happen following acute mitral valve regurgitation secondary to MI?

STEMI

what is shown here?

atrial flutter

what is shown on this ECG?

CTPA

what is the main investigation of choice in a patient with a PE (no renal impairment?)

V/Q scan

what is the main investigation of choice in a patient with a PE + renal impairment?

3.5

what is the target INR for someone suffering from recurrent PEs?