Before exam Flashcards
(61 cards)
1
Q
name the drugs for heart failure
A
- beta blockers
- ACE/ARBs
- spironolactone/ furosemide
2
Q
Describe the macroscopic appearance of the MI - 0-12 hours
- 12-24 hours
- 24-72 hours
- 3-10 days
- weeks - months
A
- 0-12 hours = no changes
- 12-24 hours = pale with blotchy discolouration
- 24-72 hours = soft, pale and yellow
- 3-10 days = soft, yellow-brown with hyperaemic border
- weeks - months = white fibrous scar
3
Q
Describe the histology appearance of the MI
- 0-12 hours
- 12-24 hours
- 24-72 hours
- 3-10 days
- weeks - months
A
- 0-12 hours = No changes
- 12-24 hours = bright eosinophilia of muscle fibres reflecting onset of coagulation necrosis; intracellular oedema
- 24-72 hours = coagulative necrosis with loss of nuclei and striations, beginning of acute inflammatory response with heavy interstitial neutrophil infiltrate
- 3-10 days = replacement of infarcted area by granulation tissue
- weeks - months = collagenous scar tissue
4
Q
What are the symptoms of right sided heart failure
A
Liver
- pure liver congested - nutmeg
- centrilobular necrossi and firbosis
- portal vein pressure increase - splenomegaly, ascities, kidneys and brain hypoxia, peripheral oedema
- biventricular - plus LVF
5
Q
what are the causes of secondary hypertension
A
Renal
- Chronic renal disease
- glomerulonephritis
- renal artery stenosis
Neurological
- stress including surgery
- psychogenic
- raised intracranial pressure
Cardiovascular
- coarctation of the aorta
- systemic vasculitis
- increased intravascular volume
Endocrine
- cushings
- conns
- exogenous hormones
- pheochromocytoma
- acromegaly
- thyroid disease
- pregnancy
6
Q
What can cause pulmonary hypertension
A
- diseases of the lung parenchyma such as COPD, cystic fibrosis, diffuse interstitial fibrosis
- diseases of the pulmonary vessels such as recurrent, PEs, primary PH, severe vasculiits
- Disorders affecting chest movement such as kyphoscoliosis, neuromuscular disease
- disorders causing arterial constriction such as hypoxaemia, chronic altitude sickness
7
Q
How do you work out the QTc
A
QT/ square root of RR
8
Q
what is the axis in left axis deviation and right axis deviation
A
Left axis deviation is when the axis is greater than -30
right axis deviation is when the axis is greater than +120
9
Q
What can cause right axis deviation
A
– children and tall thin adults
– RVH
– chronic lung disease/ pulmonary embolus
– left posterior hemiblock
– atrial septal defect/ ventricular septal defect
– Wolff-Parkinson-White syndrome - left sided accessory pathway
10
Q
What can cause left axis deviation
A
– LVH
– LBBB and left anterior hemiblock
– Q waves of inferior myocardial infarction
– Wolff-Parkinson-White syndrome - right sided accessory pathway
11
Q
What causes P pulmonale
A
- peaked P wave
- Right atrial hypertrophy (tall and thin)
12
Q
What causes P mitrale
A
- Bifid P wave
- Left atrial hypertrophy (M shape)
13
Q
what is wolf parkinson white syndrome associated with
A
- pre excitation through an accessory pathway
14
Q
What does an ECG of wolf parkinsons white syndrome look like
A
- Short P-R interval
- delta wave
- Wide QRS complex
15
Q
what leads look at which part of the wall
- inferior
- anterior
- lateral
A
- inferior - II/III/aVF
- anterior - V2-4
- lateral - V5-6/I/aVL
16
Q
Wellens syndrome
A
Antero-lateral T wave inversion
- anterior NSTEMI pending troponin
- LAD syndrome - LAD can involve the lateral wall as well as the anterior wall
- this patient should be treated as an MI
- Sign of an LAD lesion
17
Q
What ECG changes happen in hypokalaemia
A
- small T waves
- Prominent U waves
- Peaked P waves
18
Q
What ECG changes happen in hyperkalemia
A
- Tall Tented T waves
- wide QRS complex
- Absent P waves
- Sine wave appearance
19
Q
What ECG changes happen in hypercalcaemia
A
- short QT interval
20
Q
What ECG changes happen in hypocalcaemia
A
- long QT interval
- small T waves
21
Q
What can cause a prolonged QT interval
A
- Congenital – Romano-Ward syndrome, Jervell and Lange-Nielsen syndrome
- Cardiac – MI, ischaemia, mitral valve prolapse
- HIV – direct effect of virus or protease inhibitors
- Metabolic – hypokalaemia, hypomagnesaemia, hypocalcaemia, starvation, hypothyroidism, hypothermia
- Toxic – organophosphates
- Anti-arrhythmic drugs – quinidine, amiodarone, procainamide, sotalol
- Antimicrobials – erythromycin, levofloxacin, pentamide, halofantrine
- Antihistamines – terfenadine, astimazole
- Motility drugs – domperidone
- Psychoactive drugs – haloperidol, risperidone, TCAs, SSRIs
- Connective disease disorders – Anto-RO/SSA Abs
- Herbalism – Chinese folk remedies (arsenic), cocaine, quinine, artemisinins (antimalarials)
22
Q
What can cause AF
A
- IHD
- thyrotoxicosis
- hypertension
- obesity
- CCF
- alcohol
23
Q
What is bifasciular block
A
LBBB+RBBB: manifests as an axis deviation
24
Q
What is trifascicular block
A
bifasciular block + 1st degree Heart block
25
What does left ventricular hypertrophy look like
R-wave in V6 >25mm OR sum of S-wave in V1 and R-wave in V6 >35mm
26
What does right ventricular hypertrophy look like
Dominant R-wave in V1, T-wave inversion in V1-V3 or V4, deep S-wave in V6, RAD
27
How do you assess the patient with tachycardia and what do you do in unstable tachycardia
- Monitor SpO2 and give oxygen if they are hypoxic
- monitor ECG and BP and record 12 lead ECG
- obtain IV access
- identify and treat reversible causes
adverse features
- shock
- MI
- heart failure
- Syncope
- if you have these adverse features then this means that the tachycardia is unstable
- if the tachycardia is unstable you should administer a synchronised DC shock up to 3 times
28
What are the adverse features of tachycardia
- shock
- MI
- heart failure
- Syncope
29
What are the risk factors for stroke (CHADSVASC score) in AF
- Congestive heart failure - 1 point
- hypertension - 1 point
- age 65-74 - 1 point, age 75 years of older - 2 points
- diabetes mellitius - 1 point
- previous stroke, transient ischaemic attack/thromboembolism - 2 points
- vascular disease - 1 point
- female - 1 point
30
What is the difference between orthodromic and antidromic AVRT
Orthodromic AVRT
- the ventricle is activated down the pukinje his pathway and then goes up the accessory pathway
- Narrow QRS complex
Antidromic AVRT
- the ventricles are activated by the accessory pathway therefore the right side of the ventricle is activated first, the pathway then goes back up the bundle of His
- Broad QRS complex
31
What happens if you have a narrow QRS complex and the rhythm is regular
Narrow QRS complex
- rhythm is regular
- vagal manoeuvres
- adenosine 6mg rapid IV bolus - if no effect give 12mg if no effect give further 12 mg
- monitor/record ECG continuously
- check to see if sinus rhythm is achieved
- if no seek expert help - could be a possible atrial flutter - control rate with something like a beta blocker
- if yes
probably re-entry paroxysmal SVT
- record 12 lead ECG in sinus rhythm
- if SVT recurs treat again and consider anti-arrhythmic prophylaxis
32
What happens if you have a narrow QRS complex and the rhythm is irregular
- have a narrow QRS complex
- If the rhythm is irregular it is probable AF
- control rate with a beta blocker or dilitiazem
- if in heart failure consider digoxin or amiodarone
- assess thromboembolic risk and consider anticoagulation
33
What do you do if the broad QRS complex is regular
It is VT until proven otherwise
- amiodarone 300mg IV over 20-60 minutes then 900mg over 24 hours
If known to be SVT with bundle branch block
- treat as for regular narrow-complex tachycardia
34
What do you do if the broad QRS complex is irregular
= seek expert help
- AF with bundle branch block treat as for narrow complex
- Pre-excited AF consider amiodarone
35
If the bradycardia has no adverse features how do you treat
calculate if there is a risk of asystole
- recent asystole
- Mobitz II AV block
- complete heart block with broad QRS complex
- ventricular pause greater than 3 seconds
if no
- continue to observe
```
if yes
Consider interim measures
- Atropine 500mcg IV repeat to maximum of 3mg
or
- transcutaneous pacing
or
- isoprenaline 5mcgmin-1 IV
- adrenaline 2-10mcgmin-1 IV
- alternative drugs
```
- Seek expert help - arrange transvenous pacing
36
What happens if you have adverse features of bradycardia
adverse features
- shock
- syncope
- myocardial ischaemia
- heart failure
Yes
- atropine 500 mcg IV
- satisfactory response
Yes
calculate if there is a risk of asystole
- recent asystole
- Mobitz II AV block
- complete heart block with broad QRS complex
- ventricular pause greater than 3 seconds
no
- continue observation
```
if no satisfactory response to atropine
Consider interim measures
- Atropine 500mcg IV repeat to maximum of 3mg
or
- transcutaneous pacing
or
- isoprenaline 5mcgmin-1 IV
- adrenaline 2-10mcgmin-1 IV
- alternative drugs
```
- Seek expert help - arrange transvenous pacing
37
How do you treat a STEMI
- Aspirin and ticagrelor (P2Y12 receptor antagonists)
- GpIIb/IIIa inhibitor
- unfractionated/LMWH
- PPCI
38
What is the criteria for reperfusion therapy
1. Typical clinical symptoms of MI
2. ECG criteria - either of the following
- ST elevation>1mm in 2 or more adjacent limb leads or >2mm in 2 or more adjacent chest leads
- LBBB
- posterior changes: deep ST depression and tall R-waves in V1-V3
39
When do you not thrombolyse
- ST depression alone
- T wave inversion alone
- Normal ECG
40
Name the absolute contraindications to thrombolysis
- previous intracranial haemorrhage
- ischameic stroke < 6 months
- c cerebral malignancy or arteriovenous malformations
- recent major trauma/surgery/head injury less than 3 weeks ago
- GI bleeding less than 1 month ago
- known bleeding disorder
- aortic dissection
- non-compressible punctures < 24 hours e.g. liver biopsy, lumbar puncture
41
How does heart failure keep getting worse
Heart failure
- this causes decreased stroke volume and cardiac output
- this causes a neurohormonal response
- this leads activation of sympathetic system and renin angiotensin aldosterone system is activated
- this causes vasoconstriction, increased sympathetic tone, angiotensin II, endothelins, impaired nitric oxide release, sodium and fluid retention, increased vasopressin and aldosterone
- this causes further stress on the ventricular wall and dilatation leading to worsening of ventricular function
- this leads to further heart failure
42
Name the classes for the New York Heart association classification (NYHA) for heart failure
Class One
- no symptoms
Class II
- symptoms on exertion e.g. cant walk very far
Class III
- symptoms of minimal exertion e.g. cant walk around the house without getting breathless
Class IV
- symptoms at rest
43
What are the causes of high output heart failure
- anaemia
- pregnancy
- hyperthyroidism
- pagers disease
- beriberi
44
what are the signs of mitral regurgitation
- AF
- displaced hyperdyanmic apex
- pan systolic murmur at apex radiating to axilla
- soft s1, split s2, loud p2
the larger the left ventricle the more severe
45
What would an ECG finding find in aortic stenosis
- Left ventricular strain pattern due to pressure overload = depressed ST segments, T wave inversion in leads orientated to the left ventricle (I, AVL, V5 and V6)
- usually sinus rhythm is present but ventricular arrhythmias may be recorded
46
What are the signs of aortic regurgitation
- Collapsing pulse
- wide pulse pressure
- hydrodynamic apex beat
- high pitched early diastolic murmur
- quick carotid filling up
47
What type of murmur is tricuspid regurgitation
- pan systolic murmur
48
What type of murmur is pulmonary stenosis
ejection click systolic murmur
49
What type is murmur is tricuspid stenosis
rumbling mid-diastolic murmur
50
What are the signs of infective endocarditis
- Septic signs = fever, riggers, night sweats, malaise, weight loss, anaemia, splenomegaly, clubbing
- any new murmur
- vegetation on valves
- vasculitis
- glomerulonephritis
- splinter haemorrhages
51
What causes an pan systolic murmur
Tricuspid regurgitation
Mitral regurgitation
Ventricular septal defect
52
What causes an systolic ejection
Pregnancy- turblence
Pulmonary stenosis
Aortic stenosis
Aortic coarction
53
What are the three stages of hypertension
Stage 1
- 140/90 and ABPM 135/85
Stage 2
- 160/100 and ABPM 150/95
Stage 3
- Systolic> 180 or diastolic >110
54
What is the definition of malignant hypertension
- BP > 180/110 AND signs of papilloedema or retinal haemorrages
55
What blood pressure drugs can be used in pregnancy
- Labetolol
- Methyl Dopa
- Nifedipine
56
What can cause diffuse alveolar damage (ARDS; Shock lung)
- shock
- trauma
- sepsis
- viral infection
- noxious gases
- radiation
57
What are the types of emphysema
- centriacinar
- panacinar
- paraseptal
- irregular
58
define centriacinar emphysema
- central/proximal parts of respiratory bronchioles are affected
- distal spared
- seen in smokers
59
Define panacinar emphysema
- uniform dilatation of acini from respiratory bronchiole to alveoli, seen in alpha-1-anti trypsin deficiency
60
Define paraseptal emphysema
- peripheral along lung margins
- occurs adjacent to scarring, collapse or fibrosis
- predisposes to spontaneous pneumothorax in young adults
61
define irregular emphysema
- irregular involvement of acini seen with scarring
