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PM Finals > Cardio > Flashcards

Cardio Flashcards

1
Q

ACS mx

A

Morphine - if severe pain
Oxygen - If So2 <92%
Nitrates - useful if chest pain or HTN. Careful if hypotensive
Aspirin - 300mg

STEMI
- 2nd anti platelet: prasugral (clopidogrel if high bleeding risk)
- PCI - w/in 12hrs of onset and w/in 120 of potential fibrinolysis.
— Radial access preferred: give unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor (GPI)
- OR Fibrinolysis: w/in 12hrs
— give an antithrombin drug (heparin/ LMWH/ fondaparinux/ bivalirudin)
— repeat ECG after 60-90mins , if persistent STEMI-consider PCI

NSTEMI
- immediate coronary angiography (+/- PCI) if: GRACE score >3% OR clinically unstable. Give
- antithrombin treatment - fondaparinux if not immediate PCI. Heparin if PCI
- 2nd anti platelet: prasugral or ticagrelor if PCI/ ticagrelor if conservative (clopidogrel if high bleeding risk)

DAPT summary: aspirin &…
- prasugrel if primary PCI
- ticagrelor if medically managed
- Clopidogrel - if high bleed risk (e.g. oral anticoagulant)
———–

Secondary prevention
- ACEi
- Beta clocker
- Statin
- DAPT (aspirin lifelong, 2nd for 12 months)

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2
Q

STEMI criteria

A

clinical symptoms & ECG changes in >=2 or more contiguous leads:

V2-3 ST elevation:
>= 2.5mm in men under 40
>= 2mm in men over 40
>= 1.5mm in women

All other leads ST elevation:
>= 1mm

new LBBB

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3
Q

Pericarditis mx

A

(ECG: saddle shaped widespread STelevation, PR depression)

tx underlying cause
- idiopathic or viral: 1st-
- NSAIDS & colchicine combination
- avoid strenuous activity

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4
Q

ALS algorithm for cardiac arrest

A

chest compression - 30:2

Defib - a single shock for shockable rhythm (VF/pulseless VT) , then 2 mins CPR
- if cardiac arrest happens in cardiac monitored pt-> up to 3 successive shocks

Adrenaline 1mg
- ASAP for non-shockable
- shockable - start after 3rd shock, repeat every 3-5mins

Amiodernone (/ lidocaine)
- NOT in non-shockable
- shockable - 300mg after 3rd shock, repeat 150mg after 5 shocks

Thrombolytic drugs
- If PE suspected
- CPR should be continued for another 60-90mins if given

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5
Q

Reversible causes of cardiac arrest:

A

H
- hypoxia
- hyper/hypo-kalaemia , hypoglycaemia, hypocalcaemia, acidaaemia
- hypothermia

T
- Thrombosis
- tension pneumothorax
- Tamponade
- Toxins

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6
Q

Angina pectoris mx

A

(stable angina)

aspirin
statin
sublingual GTN
1st: B blocker OR CCB (rate-limiting: verapamil/ diltiazam)
2nd: increase to maximum tolerated dose
3rd: B blocker AND CCB (dihydropyridine - amlodipine)

If 3rd is contraindicated: a long-acting nitrate, ivabradine, nicorandil, ranolazine

4rth: only add 3rd drug whilst a patient is awaiting assessment for PCI or CABG

( Nitrate - isosorbide mononitrate - stop nitrate tolerance: asymmetric dosing interval w nitrate-free time of 10-14 hours)

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7
Q

Antiplatelet secondary prevention: MI, TIA, stroke, PAD

A

Acute coronary syndrome (medically treated) 1st: Aspirin (lifelong) & ticagrelor (12 months)
2nd: clopidogrel (lifelong)

Percutaneous coronary intervention
1st: Aspirin (lifelong) & prasurgrel or ticagrelor (12 months)
2nd: clopidogrel (lifelong)

TIA/ ischemic stroke
1st: Clopidogrel (lifelong)
2nd: Aspirin (lifelong) & dipyridamole (lifelong)

Peripheral arterial disease
1st:Clopidogrel (lifelong)
2nd: Asprin (lifelong)

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8
Q

Features of Aortic stenosis

A

Clinical
- chest pain
- dyspnoea
- syncope / presyncope (e.g. exertional dizziness)
- ESM - radiates to carotids, decreased following valsalva

Features of severe aortic stenosis
- narrow pulse pressure
- slow rising pulse
- delayed ESM
- soft/absent S2
- S4
- thrill
- left ventricular hypertrophy or failure

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9
Q

Aortic stenosis mx

A

symptomatic or valvular gradient > 40 mmHg - valve repair

otherwise - observe

Choice of aortic valve replacement (AVR)
- surgical AVR - young, low/medium operative risk patients
- transcatheter AVR (TAVR) - high risk

Baloon valvuloplasty
- children with no aortic valve calcification
- adults w critical aortic stenosis not fit for AVR

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10
Q

Features of aortic regurgitation

A

early diastolic murmur: intensity of the murmur is increased by the handgrip manoeuvre
collapsing pulse
wide pulse pressure
Quincke’s sign (nailbed pulsation)
De Musset’s sign (head bobbing)

mid-diastolic Austin-Flint murmur in severe AR - due to partial closure of the anterior mitral valve cusps caused by the regurgitation streams

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11
Q

Arrhythmogenic right ventricular cardiomyopathy ECG

A

ECG abnormalities in V1-3, typically T wave inversion.

An epsilon wave is found in about 50% of those with ARV - this is best described as a terminal notch in the QRS complex

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12
Q

AF mx

A

haemodynamically unstable -> electrical cardioversion

rate control unless: coexistent heart failure / first onset AF / obvious reversible cause.

Rate
1st: beta blocker or rate-limiting calcium channel blocker (e.g. diltiazem)
2nd: combination of 2- betablocker/ diltiazem/ digoxin

Rhythm
- either symptom onset <48hrs or anti coagulated for 3weeks/ TOA to exclude a left atrial appendage thrombus
- electrical DC synchronised cardioversion/ flecainide or amiodarone

Anticoagulation if indicated by CHADSVasc
If not - Transthorasic echo to exclude valvular disease -> indication for anticoagulation

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13
Q

Orbit score

A

Anaemia
Age > 74
Bleeding hx
Renal impairment (GFR < 60)
anti platelet tx

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14
Q

cardiac enzymes to look for in MI?

A

troponin T and I

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)

(myoglobin is the first to rise)

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15
Q

Hypertrophic obstructive cardiomyopathy echo

A

Echo findings include MR, systolic anterior motion (SAM) of the anterior mitral valve and asymmetric septal hypertrophy

MR SAM ASH

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16
Q

chronic Heart failure dx

A

N-terminal pro-B-type natriuretic peptide (NT‑proBNP)

if high (>2000) -> specialist assessment (including transthoracic echocardiography) within 2 weeks
if raised (400-2000) -> “ “ within 6 weeks

17
Q

chronic Heart failure mx

A

1st: ACE-inhibitor AND beta-blocker (bisoprolol, carvedilol, and nebivolol)

2nd: ++ aldosterone antagonist (spironolactone and eplerenone), heart failure with a reduced ejection fraction ++ SGLT-2 inhibitors

3rd (specialist) :
- ivabradine - sinus rhythm > 75/min and a left ventricular fraction < 35%
- sacubitril-valsartan - should be initiated following ACEi or ARB wash-out period
- digoxin
- hydralazine in combination with nitrate - esp in Afro-Caribbean patients
- cardiac resynchronisation therapy - widened QRS (e.g. left bundle branch block) complex on ECG

Other treatments
- annual influenza
- one off pneumococcal vaccine

18
Q

DVLA & ACS

A

acute coronary syndrome- 4 weeks off driving, 1 week if successful PCI

19
Q

Bifascicular block & trifasicular block

A

Bifascicular block
the combination of RBBB with
- … left axis deviation - left anterior hemiblock
- … right axis deviation - left posterior hemiblock

Trifascicular block
- features of bifascicular block as above + 1st-degree heart block

20
Q

Acute Heart failure mx

A

Sit pts up

IV loop diuretics- e.g. furosemide or bumetanide

O2 - target sats: 94-98%

Vasodilators- not for everyone, if concomitant myocardial ischaemia, severe hypertension or regurgitant aortic or mitral valve disease (CI in hypotension)

Patients with respiratory failure- CPAP

Hypotension/ cariogenic shock
- ionotropic agents - severe left ventricular dysfunction who have potentially reversible cardiogenic shock
- vasopressor agents - norepinephrine
- mechanical circulatory assistance - intra-aortic balloon counterpulsation or ventricular assist devices

continue regular CHF meds: beta-blockers should only be stopped if the patient has HR< 50 beats per minute, second or third degree atrioventricular block, or shock

21
Q

S3 (third heart sound) in

A

caused by diastolic filling of the ventricle

considered normal if < 30 years old (may persist in women up to 50 years old)

heard in left ventricular failure (e.g. dilated cardiomyopathy), constrictive pericarditis (called a pericardial knock) and mitral regurgitation

22
Q

S4 (fourth heart sound)

A

may be heard in aortic stenosis, HOCM, hypertension

caused by atrial contraction against a stiff ventricle

therefore coincides with the P wave on ECG

in HOCM a double apical impulse may be felt as a result of a palpable S4

23
Q

loud & quiet S1 sound causes

A

Causes of a loud S1
mitral stenosis
left-to-right shunts
short PR interval, atrial premature beats
hyperdynamic states

Causes of a quiet S1
mitral regurgitation

24
Q

causes of loud, soft, split S2 sound

A

Causes of a loud S2
hypertension: systemic (loud A2) or pulmonary (loud P2)
hyperdynamic states
atrial septal defect without pulmonary hypertension

Causes of a soft S2
aortic stenosis

Causes of fixed split S2
atrial septal defect

Causes of a widely split S2
deep inspiration
RBBB
pulmonary stenosis
severe mitral regurgitation

25
Q

stages of HTN

A

1
Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg

2
Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg

3
Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 120 mmHg

26
Q

HTN tx criteria

A

ABPM/HBPM >= 135/85 mmHg (i.e. stage 1 hypertension)
- treat if < 80 years of age AND any of the following apply; target organ damage, established cardiovascular disease, renal disease, diabetes or a 10-year cardiovascular risk equivalent to 10% or greater
- under 60 and an estimated 10-year risk below 10%

ABPM/HBPM >= 150/95 mmHg (i.e. stage 2 hypertension)
offer drug treatment regardless of age

27
Q

HTN lifestyle advice

A

Lifestyle
- a low salt diet is recommended, aiming for less than 6g/day, ideally 3g/day.
- caffeine intake should be reduced
- stop smoking, drink less alcohol, eat a balanced diet rich in fruit and vegetables, exercise more, lose weight

28
Q

Modified duke criteria

A

Infective endocarditis diagnosed if
pathological criteria positive, or
2 major criteria, or
1 major and 3 minor criteria, or
5 minor criteria

pathological
- Positive histology or microbiology of pathological material obtained at autopsy or cardiac surgery

Major
- Positive blood cultures (2 +ve typical organisms: viridian/ HACEK // two blood cultures taken > 12 hours or >3 +ve Staph aureus or Staph epidermidis // +ve serology for Coxiella burnetii, Bartonella species or Chlamydia psittaci // molecular assays)
- Endocardial involvement (new valvular regurgitation // positive echocardiogram: oscillating structures, abscess formation, new valvular regurgitation or dehiscence of prosthetic valves)

Minor
- 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

29
Q

Native valve infective endocarditis emperical tx

A

native valve:
- Amoxicillin (+/- low-dose gentamicin)
(Flucloxacillin when staph identified. Benzylpenicillin when strep identified)

Pen allergic:
- vancomycin + low-dose gent

prosthetic valve
- vancomycin + rifampicin + low-dose gentamicin

30
Q

Infective endocarditis indications for surgery

A

valvular incompetence

aortic access (lengthening PR interval)

resistant to antibiotic/ fungal infection

congestive cardiac failure

recurent emboli

31
Q

JVP wave forms

A

a’ wave = atrial contraction
large if atrial pressure e.g. tricuspid stenosis, pulmonary stenosis, pulmonary hypertension
absent if in atrial fibrillation

Cannon ‘a’ waves
caused by atrial contractions against a closed tricuspid valve
(complete heart block, ventricular tachycardia/ectopics, nodal rhythm, single chamber ventricular pacing)

‘c’ wave
closure of tricuspid valve
not normally visible

‘v’ wave
due to passive filling of blood into the atrium against a closed tricuspid valve
giant v waves in tricuspid regurgitation

‘x’ descent = fall in atrial pressure during ventricular systole

‘y’ descent = opening of tricuspid valve

32
Q

risk factors for asystole in Bradycardia

A

complete heart block with broad complex QRS

recent asystole

Mobitz type II AV block

ventricular pause > 3 seconds

33
Q

Rheumatic fever dx criteria

A

2 major criteria
1 major with 2 minor criteria

Major
- J - polyarthritis
- O - carditis and valvulitis (eg, pancarditis)
- N - subcutaneous nodules
- E- erythema marginatum
- S- sydenham’s chorea (late)

Minor criteria
raised ESR or CRP
pyrexia
arthralgia (not if arthritis a major criteria)
prolonged PR interval

34
Q

Rheumatic fever mx

A

antibiotics: oral penicillin V
anti-inflammatories: NSAIDs are first-line
treatment of any complications that develop e.g. heart failure

35
Q

Contraindications for statin

A

macrolides (e.g. erythromycin, clarithromycin) - stop stain till you finish course

pregnancy

PM Finals (21 decks)

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