Cardiology Flashcards
What is the difference between stable and unstable angina?
Stable angina usually by exertion
Unstable can occur at any time, may be more severe, and may not be relived by rest/ GTN
What basic investigations would you want to do for a px with probable angina?
FBC to check for anaemia U&Es for renal function Fasting blood glucose if no known diabetes/ HbA1c if known diabetes LFTs baseline before commencing statins Serum lipids for hyperlipidaemia TFT Troponins and cardiac enzymes 12 lead ECG
What ECG changes could show in a px with angina?
ST depression
T wave inversion
LBBB
How would you manage a px with angina?
Conservative: reduce IHD risk factors eg weight loss, dietary advice, smoking cessation, exercise, optimise HTN and diabetes
Medical: GTN spray PRN, Aspirin OD, statin (atorvastatin), beta blocker, Ca2+ channel blocker
Surgical: PCI or CABG
Give an example of a Ca2+ channel blocker relatively selective for myocardium
Verapamil
What are some side effects of Ca2+ channel blockers?
Cause vasodilation and reduce HR and FOC so…
Headaches Constipation Flushing Bradycardia Reflex tachycardia Ankle oedema
What are some modifiable and non modifiable risk factors for an MI?
Non-modifiable: age, male, ethnicity (south Asians), family history, premature menopause
Modifiable: smoking, diabetes Mellitus, hypertension, obesity, hyperlipidaemia
What does ST elevation in leads 1 to 4 indicate?
Anteroseptal STEMI of LAD
Where would ECG changes present for a lateral STEMI?
In V5-6 (Cx/ LAD)
What leads would an inferior MI show ECG changes in and what artery would be affected?
II, III, aVF
Right coronary artery
A high lateral MI would show ECG changes in which leads?
I and aVL
What ECG changes can appear for an MI?
ST elevation
T wave inversion
New LBBB
Pathological Q waves
How do the levels of different cardiac enzymes change in the blood over time?
Troponins: start to rise 3-12 hours post onset of pain, peak at 24-48 hours, return to baseline within 5-14 days
CK-MB: starts to rise 3-12 hours post onset of pain, peaks at 24 hours, returns to baseline after 48-72 hours
What is the initial management of a px suffering from an MI?
MONA
= morphine, oxygen, nitrates (GTN spray), Aspirin
Also establish IV access
Do FBC, troponins, CK-MB, lipids, U&Es
12 lead ECG
What medications would a patient be on post MI?
Aspirin (for life) Clopidogrel (for one year) Statin ACEi Beta blocker
Can’t drive for 4 weeks
What is the most common type of AVRT?
Wolf Parkinson White syndrome
What is the accessory pathway called in Wolf Parkinson White syndrome?
Bundle of Kent
Why are P waves not visible in AVNRT?
As the atria and ventricles contract at a similar time so the atrial depolarisation is masked by the ventricular depolarisation
What are the pathways involved in AVNRT?
Slow alpha pathway
Faster beta pathway
What is the definitive treatment of AVRT or AVNRT?
Radio frequency ablation of the accessory pathway/ slow alpha pathway
Can also use vagal manoeuvres (carotid sinus massage or valsalva manoeuvre) to activate the vagus nerve and block the AVN
Medication to slow AVN conduction
If not, cardioversion
What ECG changes are seen in Wolff Parkinson White syndrome?
Shortened PR <120ms
Delta waves
Long QRS (as ventricle contract early)
How long is one small square on an ECG?
0.04 seconds
How long is one large square on an ECG?
0.2 seconds
How would you calculate a regular rate on an ECG?
300/ number of squares in RR interval
How would you calculate an irregular rate on an ECG?
The number of QRS complexes in 30 large squares x 10
What should the normal axis on an ECG be?
-30 to +90 degrees
Left axis deviation will cause which leads to become more positive and negative?
1 and aVL will be more positive
2 and 3 more negative
(So leads 1 vs 2 and 3 are ‘leaving’ each other)
Right axis deviation will cause which leads to become more positive and negative?
Leads 3 and aVF will become more positive
Lead 1 more negative
So leads 1 and 3 “reaching” each other
Where would you place the ECG leads v1 to v6?
V1 4th ICS RSE V2 4th ICS LSE V3 in between V2 and V4 V4 5th ICS MCL V5 5th ICS anterior axillary line V6 5th ICS mid axillary line
How long should the PR interval be?
3 to 5 squares (0.12 to 0.2 seconds)
What does a lengthened PR interval indicate?
1st degree heart block
Delay in conduction between the atria and ventricles
Delay usually in the AVN
How would Mobitz type 1 heart block show on an ECG?
Progressive lengthening of the PR intervals, followed by a missed QRS, which then resets and repeats
What type of heart block in Wenckebachs phenomenon?
Type 2.1
How does Mobitz type 2 heart block present on an ECG?
Constant PR but occasionally dropped QRS
Usually a bundle branch problem
What is 3rd degree heart block?
When there is no relationship between P waves and QRS complexes so no beats are conducted from the atria to the ventricles
Often due to fibrosis of the bundle of His
Causes the ventricles to contract at their own intrinsic rate (very slow, hence urgent pacing required)
Increased height of the QRS complex indicates what?
Ventricular hypertrophy (R or L depending on lead)
Increased width of the QRS complex indicates what?
Bundle branch block
Why do LBBB show a W shape in lead 1 and an M shape in lead 6?
As the bundle branch block means the depolarisation is reversed so the RBBB is depolarised first and then goes through the septum to the left heart
Tall T waves indicate what?
Hyperkalaemia
Prolonged QTc is associated with which ventricular tachycardia?
Torsades des pointes
What do U waves indicated?
Severe hypokalaemia or hypocalcaemia
What arrhythmia will present with loss of the isoelectric baseline and a saw tooth pattern?
Atrial flutter
What is the first line anti hypertensive drug for for 47 year old Caucasian patient?
ACEi
if under 55 and not Afro Caribbean
What is the first line anti hypertensive drug for a 40 year old Afro Caribbean patient?
Calcium channel blocker
Either if aged over 55 or if Afro Caribbean
What is the second line drug treatment for hypertension?
ACEi + CCB
When would a thiazide diuretic by contraindicated?
Gout
Hypokalaemia
Hyponatraemia
What are some ADRs of ACEi?
Dry cough
Angio-oedema
Renal failure
Hyperkalaemia
For a hypertensive patient on an ACEi and CCB but still not responding adequately to treatment, what other drug would you add?
Thiazide like diuretic
How do thrombolytic drugs work?
Activate plasminogen to plasmin which degrades fibrin
What are some examples of thrombolytic drugs?
Alteplase
Streptokinase
What does the CHADS-VASc score determine?
Whether to anticoagulate a px with AF
If 0, no anticoag
If 1, anticoag if male. If 2, anticoag if female.
What are some causes of systolic heart failure?
IHD
MI
Cardiomyopathy
What are some symptoms/ signs seen in left sided heart failure?
Dyspnoea Dizziness Pink/ white frothy sputum (due to pulmonary oedema) Fatigue Orthopnoea Cold peripheries PND
What are some symptoms and signs seen in right sided heart failure?
Dyspnoea
Oedema
Ascites
Raised JVP
What is usually raised in the blood in heart failure?
BNP
What signs could indicated heart failure on a chest x Ray?
Cardiomegaly Kerley B lines Pleural effusion Batwing shadowing Dilated prominent upper lobe vessels