Cardio Flashcards
(81 cards)
1
Q
What is acute coronary syndrome?
A
- thrombus from an atherosclerotic plaque blocking a coronary artery
2
Q
What are the main coronary arteries and what do they supply?
A
- RCA - right atrium, right ventricle, inferior aspect of left ventricle, posterior septal area
- LCx - left atrium, posterior aspect of left ventricle
- LAD - anterior aspect of left ventricle, anterior aspect of spetum
3
Q
What are the 3 types of acute coronary syndrome?
A
- unstable angina
- STEMI
- NSTEMI
4
Q
How is acute coronary syndrome diagnosed?
A
- patient presents with symptoms
- perform ECG
- ST elevation or new left bundle branch block = STEMI
- No elevation then perform a troponin blood tes
- raised troponin and/or other ECG changes (ST depression, T wave inversion) = NSTEMI
- normal troponin and normal ECG = unstable angina or another MSK cause
5
Q
Symptoms of acute coronary syndrome
A
- nausea and vomiting
- sweating
- feeling of impending doom
- SOB
- palpitations
- pain radiating to jaw or arms
- if goes away with rest then consider angina
- be aware that diabetics don’t present with normal chest pain
6
Q
What would ECG changes would you expect to see in STEMIs and NSTEMIs?
A
- STEMI: ST elevation or new left bundle branch block
2. NSTEMI: ST depression, T wave inversion, Q waves
7
Q
Match the ECG leads with the corresponding arteries
A
- I, aVL, V3-6 = left coronary
- V1-4 = Left anterior descending
- I, aVL, V5-6 = left circumflex
- II, III, aVF = right coronary
8
Q
What can cause raised troponins?
A
- MI
- chronic renal failure
- myocarditis
- aortic dissection
- PE
9
Q
Investigations for Acute coronary syndrome?
A
- ECG
- troponins
- physical exam
- Bloods
10
Q
How is acute coronary syndrome managed?
A
- Acute STEMI: PCI (if available within 2 hours) if not then thrombolysis (significant risk of bleeding, streptokinase, alteplase, tenecteplase)
- NSTEMI: BATMAN (beta blockers, aspirin 300mg, ticagrelor 180mg, morphine, anticoagulant fondaparinux, nitrates to relieve spasm)
- to prevent ACS: aspirin 75mg, clopidogrel or ticagrelor, atorvostatin 80mg, ACE inhibitor, atenolol, aldosterone (if you have heart failure)
11
Q
What are the 4 different types of MI?
A
- Due to acute coronary event
- Secondary to increased demand/reduced supply of O2
- Sudden cardiac death suggestive of ischaemic event
- MI associated with PCI/stunting/CABG
12
Q
How does heart failure present?
A
- SOB
- looking and feeling unwell
- cough with frothy white/pink sputum)
- orthopnoea
- paroxysmal nocturnal dyspnoea
- peripheral oedema
13
Q
How is heart failure diagnosed?
A
- clinical presentation
- N-terminal pro-B type natriuretic peptide
- echocardiogram
- ECG
- listen to lung bases for crackles
14
Q
What can cause heart failure?
A
- ischaemic heart disease
- valvular heart disease (aortic stenosis)
- hypertension
- arrhythmias (AF)
15
Q
How is heart failure managed?
A
- refer to specialist
- surgical treatment for severe aortic stenosis or mitral regurgitation
- stop smoking
- exercise at tolerated
- treat co-morbidities
- ACE inhibitor
- Beta blocker
- Aldoesterone
- loop diuretics
- if acute then sit patient up, give O2 if sats are low, give furosemide and monitor fluid balance
16
Q
Signs of heart failure on examination
A
Left: tachycardia, tachypnoea, displaced apex beat, bilateral basal crackles
Right: raised JVP, hepatomegaly, ascites, ankle/sacral oedema
17
Q
Signs of heart failure on a CXR
A
- alveolar shadowing
- kerley B lines
- cardiomegaly
- upper lobe diversion
- pleural effusion
18
Q
Causes of atrial fibrillation
A
- thyrotoxicosis
- hypertension
- pneumonia
- alcohol
- hypertension
- mitral valve disease
- ischaemic heart disease
- rheumatic heart disease
- cardiomyopathy
- pericarditis
- sick sinus syndrome
- atrial myxoma
19
Q
Presenting symptoms of atrial fibrillation
A
- often asymptomatic
- palpitations
- SOB
- syncope
- symptoms of cause of AF
20
Q
Signs of atrial fibrillation
A
- irregularly irregular pulse
- difference in apical beat and radial pulse
21
Q
Main differential of AF
A
- ventricular ectopics
- this will disappear when the heart rate goes over a certain threshold
22
Q
AF on an ECG
A
- absent P waves
- narrow QRS complex tachycardia
- irregularly irregular rhythm
23
Q
Valvular vs non-valvular AF
A
- valvular = mitral stenosis
- non-valvular = anything else (incl. mitral regurg)
24
Q
How can AF be treated?
A
- Rate or rhythm control
- Anticoagulation
- Rate control is first-line UNLESS: reversible cause, new onset (within 48 hrs), causing heart failure, symptomatic despite being effectively rate controlled
- Go for beta blocker, calcium channel blocker or digoxin
- Rhythm control if reversible cause, new onset, casing heart failure, symptomatic despite effective rate control
- Cardioversion is used
- Immediate if less than 48 hours or unstable
- Delayed if more than 48 hours and stable
- anticoagulate for 3 weeks before delayed cardioversion
- cardioversion is achieved using flecanide or amiodarone (if structural heart disease)
- or use electrical cardioversion
25
What is the CHADSVASc score?
- risk of stroke
- used for AF patients, to determine best anticoagulation policy
- Congestive heart failure, hypertension, age, diabetes, prior stroke, vascular disease, female
- 1 = consider
- 2 or more = offer anticoagulation
26
What is the HAS-BLED score?
- patients on anticoagulation
- risk of serious bleed each year
- hypertension, abnormal renal and liver function, stroke, bleeding, labile INRs, elderly, drugs or alcohol
27
What is aortic dissection?
tear in the inner layer of the aorta, allowing blood to flow between the layers of the wall of the aorta (between intima and media)
28
Which part of the aorta is usually affected by dissection?
- ascending aorta and arch
| - right lateral area of ascending aorta is under most stress from blood leaving the heart
29
What is the Stanford system of classifying aortic dissection?
- Type A = ascending aorta before brachiocephalic artery
| - Type B = descending aorta, after subclavian artery
30
What is the DeBakey system of classifying aortic dissection?
- Type I begins in the ascending aorta and involves at least the aortic arch
- Type II is isolated to the ascending aorta
- Type IIIa begins in the descending aorta and involves only the section above the diaphragm
- Type IIIb begins in the descending aorta and involves the aorta below the diaphragm
31
Risk factors for developing aortic dissection
- age
- male
- smoking
- hypertension (main one)
- poor diet
- reduced physical activity
- raised cholesterol
- bicuspid aortic valve
- coarction of aorta
- aortic valve replacement
- CABG
- connective tissue disorders
32
Presentation of aortic dissection
- difficult to spot
- sudden onset, severe ripping or tearing chest pain
- anterior chest when ascending is affected
- back is descending is affected
- some don't have chest pain
- hypertension
- differences in BP between arms
- radial pulse deficit
- diastolic murmur
- focal neurological deficit
- chest and abdominal pain
- collapse
33
How is aortic dissection diagnosed?
ECG and CXR to exclude MI
CT angiogram to confirm the diagnosis
MRI angiogram has more detail but takes longer
34
How is aortic dissection treated?
- surgery
- analgesia
- BP and HR control using beta blockers
- type A = midline sternotomy
- type B = thoracic endovascular aortic repair
35
Complications of aortic dissection
- MI
- stroke
- cardiac tamponade
- aortic valve regurgitation
- death
36
Define AAA
- dilation of the abdominal aorta with a diameter of more than 3cm
37
Risk factors for developing an AAA
- male
- age
- smoking
- hypertension
- family history
- existing cardiovascular disease
38
How can we screen for AAA
- US scan for men at age 65
| - if above 3cm then referred to a vascular team
39
How do AAAs present?
- usually asymptomatic
- non-specific abdominal pain
- pulsatile and expansile mass when palpated
- as an incidental finding on xray, US or CT
40
How can we diagnose an AAA?
US is initial investigation
CT angiogram to give a detailed picture of the aneurysm and helps guide elective surgery to repair the aneurysm
41
How can we classify AAAs?
- Normal = less than 3cm
- Small = 3 - 4.4cm
- Medium = 4.5 - 5.4cm
- Large = above 5.5cm
42
How should we manage AAAs?
- treat reversible risk factors
- smoking
- healthy diet and exercise
- optimise management of hypertension, diabetes and hyperlipidaemia
- yearly screens for 3-4.4cm
- 3 monthly for 4.5-5.4cm
- elective repair for patients with any of: symptomatic aneurysm, diameter growing more than 1cm per year, diameter above 5.5cm
- elective repair involves inserting an artificial graft into the section of the aorta affected by the aneurysm
- open repair via a laparotomy
- endovascular aneurysm repair via femoral arteries
- inform DVLA if above 6cm
- stop driving if above 6.5cm
43
What are the most common causes of infective endocarditis?
- streptococci
- staphylococci
- enterococci
44
What are the risk factors for infective endocarditis?
- prior history
- presence of prosthetic heart valve
- abnormal valves
- congenital heart disease
- post-heart transplant
- recent dental work/poor dental hygiene
- IV drug use
45
How does infective endocarditis present?
- fever with sweats/chills/rigors
- malaise
- arthralgia
- myalgia
- confusion
- skin lesions
46
Signs of infective endocarditis on examination
- pyrexia
- tachycardia
- signs of anaemia
- clubbing
- janeway lesions and osler's nodes
- splinter haemorrhages
47
Investigations for infective endocarditis
- Bloods (rheumatoid factor positive is common)
- Urinalysis (microscopic haematuria, proteinuria)
- Blood culture
- Echocardiogram
- Duke's classification
48
Management of infective endocarditis
- Antibiotics, benzylpenicillin or gentamicin
- Strep = flucloxacillin/vancomycin/gentamicin
- Enterococci = ampicillin/gentamicin
- Culture -ve = vancomycin or gentamicin
- Surgery if urgent valve replacement needed
49
Complications of infective endocarditis
- valve incompetence
- fistulae or abscesses
- aneurysm
- heart failure
- renal failure
- glomerulonephritis
50
How should ventricular tachycardia be treated?
- amiodarone infusion
51
What is atrial flutter, what are the associated conditions and how is it treated?
- when electrical signal keeps looping around the atria to keep atrial contractions at 300bpm, enters ventricle every second so 150bpm ventricular contraction
- sawtooth appearance on ECG with p wave after p wave
- hypertension, IHD, cardiomyopathy, thyrotoxicosis
- rate/rhythm control with beta blockers or cardioversion
- treat underlying cause
- anticoagulation based on CHA2DS2VASc score
52
What is supraventricular tachycardia?
- electrical signal re-entering the atria from the ventricles and back through the AV node causing another ventricular contraction
- results in self-perpetuating electrical loop without an end-point
- QRS followed immediately by a T wave and so on
53
What are the 3 different types of SVT?
1. Atrioventricular nodal re-entrant tachycardia - re-entry point is back through the AV node
2. Atrioventricular re-entrant tachycardia (WPWS)
3. Atrial tachycardia - electrical signal originates in the atria somewhere other than the SAN
54
How should stable patients with SVT be managed? How should it be managed in the long-term?
- continuous ECG
- Valsalva manoeuvre (blow hard against resistance)
- Carotid sinus massage
- Adenosine
- Direct current cardioversion if all else fails
- beta blockers, calcium channel blockers or amiodarone
55
Contraindications to adenosine
- asthma
- COPD
- heart failure
- heart block
- severe hypotension
56
Causes of prolonged QT
- long QT syndrome
- medications (antipsychotics, citalopram, flecainide, sotalol, amiodarone, macrolide, antibiotics)
- electrolyte disturbance (hypokalaemia, hypomagnesia, hypocalcaemia)
57
How should torsades de pointes be managed?
correct the cause, magnesium infusion, defibrillation if VT occurs
- avoid medications that cause QT interval prolongation, correct electrolytes, beta blockers (not solatol) and pacemaker/implantable defibrillator
58
Describe the different types of heart block
1. First degree = delayed atrioventricular conduction through the AV node (PR interval longer than normal)
2. Second degree Mobitz 1 = atrial impulses get weaker and then a missed conduction (increasing PR and then absent QRS)
3. Second degree mobitz 2 = intermittent failure or interruption of AV conduction resulting in missing QRS complexes (normal PR interval but regular missing QRS ,2:1, 3:1)
4. Third degree = complete heart block, no relationship between P waves and QRS complexes. Significant risk of asystole
59
How are unstable heart blocks treated?
atropine 500mcg IV
60
Mitral stenosis causes, signs, complications
- rheumatic heart disease or infective endocarditis
- mid-diastolic, low pitched rumbling murmur
- loud s1 then decrescendo-crescendo
- malar flush due to CO2 retention
- AF caused by left atrium strain
61
Mitral regurgitation causes, signs, complications
- idiopathic weakening of the valve, IHD, infective endocarditis, rheumatic heart disease, connective tissue disorders
- pan-systolic, high-pitches whistling murmur, axilla
- results in congestive cardiac failure due to reduced ejection fraction and a backlog of blood that is waiting to be pumped through the left side of the heart
62
Aortic stenosis causes, signs, complications
- most common
- idiopathic age related calcification or rheumatic heart disease
- ejection systolic, high pitched murmur with crescendo-decrescendo character
- radiates to carotids
- slow rising pulse
- light headedness and fainting when exercising
63
Aortic regurgitation causes, signs, complications
- idiopathic age related weakness
- connective tissue disorder
- early diastolic, soft murmur
- decrescendo at s2
64
Risk factors for myocarditis
- usually idiopathic
- Viruses (coxsackie B, EBV, CMV, adenovirus, influenza)
- Bacteria (streptococcal, TB, diphtheria)
- Fungal (candidiasis)
- Protozoal
- Helminths
- SLE, sarcoidosis, polymyositis
- Drugs
65
Presenting symptoms of myocarditis
- fever, malaise, fatigue, lethargy
- breathlessness
- palpitations
- sharp chest pain
66
How should myocarditis be investigated?
- 12 lead ECG
- CXR
- serum CK
- serum CK-MB
67
Risk factors for pericarditis
- males
- 20 to 50
- transmural MI
- cardiac surgery
68
Features of pericarditis
- sharp, severe retrosternal chest pain worse with inspiration and supine
- relived when sitting forward
- pericardial friction rub
- Beck's triad (raised JVP, low BP, muffled heart sounds)
69
Types of peripheral vascular disease
- intermittent claudication
- limb ischaemia
- arterial ulcers
- gangrene
70
Symptoms of PVD
- intermittent claudication = cramping in calf, thigh or buttock after walking for a given distance
- limb ischaemia = pain even on rest, ulcers, gangrene, night pain
71
6 Ps of limb ischaemia
pain, pale, pulseless, paralysis, paraesthesia, perishingly cold
72
Cause of venous ulcers, where do they usually form?
incompetent valves in the lower limbs leading to venous stasis and increased venous pressure
- superior to medial malleoli
73
Risk factors and features of venous ulcers
- large, shallow
- relatively painless
- irregular margin
- varicose veins, DVT, fracture, surgery
74
What is classified as hypertension?
140/90 in clinic or 135/85 during ambulatory
75
Causes of hypertension
1. Essential = 95% of hypertension
2. Secondary = ROPE
- renal disease
- obesity
3. Pregnancy induced / pre-eclampsia
4. Endocrine especially hyperaldosteronism
76
Complications of hypertension
- IHD
- cerebrovascular accident
- hypertensive retinopathy
- hypertensive nephropathy
- heart failure
77
How often does NICE recommend we take blood pressure?
- every 5 years if borderline for diagnosis but every year with T2DM
78
Why might the blood pressure be more than 20/10mmHg higher in the clinic than at home?
white coat hypertension
79
What are the different stages of hypertension?
Stage 1 = over 140/90 or 135/85
Stage 2 = over 160/110 or 150/95
Stage 3 = over 180/120
80
What investigations should patients with a new diagnosis of hypertension have?
- Urine albumin:creatinine ratio for proteinuria and dipstick for haematuria
- Bloods for HbA1c, renal function and lipids
- Fundus examination for hypertensive retinopathy
- ECG for cardiac abnormalities
81
What medications for hypertension? How do we decide which to use?
```
ACEi
Beta blocker
Calcium channel blocker
Thiazide-like diuretic
Angiotensin II receptor blocker
```
Angiotensin receptor blocker used instead of ACEi if not tolerant or black/African or Afro-Caribbean - don't use them together
- Medication for all with stage 2 or stage 1 and under 80 with Q-risk 10% or more, diabetes, renal disease, cardiovascular disease or end-organ damage
1. Aged less than 55 and non-black = ACEi
2. Aged over 55 or black or African or Afro-Caribbean = calcium channel blocker
3. ACEi + Calcium channel blocker or ARB + calcium channel blocker
4. ACEi/ARB + CCB + diuretic
