Cardio Flashcards
(144 cards)
1
Q
What is Heart Failure
A
Inability of CO to meet body’s metabolic demands despite normal venous pressures
2
Q
what causes sudden death in HOCM
A
ventricular arrhythmia
3
Q
How do you classify HF
A
LOW OUTPUT (low EF: EF<40) or HIGH OUTPUT (normal EF)
4
Q
What are causes of low output HF
A
LHF:
- ischaemic heart disease (most common)
- hypertension
- dilated cardiomyopathy
- aortic valve disease, mitral regurg
RHF:
- secondary to LHF (congestive cardiac failure)
- restrictive cardimyopathy
- MI
- tricuspid regurg
5
Q
what are causes of high output HF
A
anaemia, beri beri, pregnancy
6
Q
What are symptoms of chronic LHF
A
dyspnoea
orthopnoea
PND
fatigue
7
Q
what are sx of acute LHF
A
dyspnoea
wheeze
cough
pink frothy sputum
8
Q
what are sx of RHF
A
swollen ankles fatigue increased weight (due to oedema) reduced exercise tolerance anorexia, nausea
9
Q
what are signs of LHF
A
tachycardia, tachypnoea, displaced apex beat (LV dilatation)
bibasal crackles, S3 gallop (rapid ventricular filling
if acute: cyanosis, pulsus alternans (alternating strong and weak peripheral pulses - reduced EF and SV –> more blood remains in ventricles )
10
Q
what are signs of RHF
A
raised JVP (>3)
hepatomegaly
ascites
pitting oedema
11
Q
How can you classify LHF?
A
New York Heart Association Classificationo
1- no limit on activity
2- comfortable at rest, dyspnoea on ordinary activity
3- dyspnoea on less than ordiinary activity
4- dyspnoea at rest
12
Q
What ix for acute HF?
A
Bloods: FBC U&EE LFT CRP Gluc LIpids TFT ABG, trop, BNP CXR ECG Echo (assess ventricular dysfunction)
13
Q
vaccinations to offer HF people,
A
annual influenza vaccine
pneumococcal
14
Q
How d you manage chronic HF (haemodynamically stable)?
A
BASHeD heart
- BB (HFREF, if HFPEF = loop diuretiic) + ACEi
- BB + ACEi + aldosterone antagonist (spironolactone and eplerenone)
+ SGLT-2 inhibitor (dapagliflozin)
- Specialist
- Hydralazine + isosorbide dinitrate (vasodilators - use in AfroCarib people)
- DIgoxin (inotrope - inc contractility)
- Ivabradine (If Channel blocker)
- sacubitri-valsartan (ARNI)
15
Q
What is AF?
A
irregularly irregular pulse
16
Q
What are sx of AF
A
dyspnoea chest pain fatigue dizziness syncope
17
Q
What are AF findings on ECG
A
irreg irreg
absent P wave
– atrial flutter = sawtooth
18
Q
How can you split causes of AF, and what are they
A
CARDIAC
- IHD
- rheumatic heart disease
- cardiomyopathy
- sick sinus
- pericarditis
SYSTEMIC
- hyperthyroid
- infection
- alcohol
RESP
- PE
- bronchial cancer
19
Q
what is the first key split in AF management pathway, and what are conditions for each
A
RHYTHM vs RATE control
RHYTHM CONTROL if:
- AF is reversible
- coexistent HF (caused by AF)
- new onset AF
RATE CONTROL if:
permanent AF
20
Q
How do you RHYTHM control someone?
A
<48h: DC cardiovert (3 synchronous shocks) > pharm cardiovert (fleicanide or amiodarone)
> 48h from onset of AF: anticoag for 4 weeeks before cardioverting
THEN LONG TERM BETA BLOCKER
21
Q
How do you rate control someone
A
Beta blocker or CCB
Second line: digoxin
Third line: amiodarone
22
Q
When do you give fleicanide or amiodarone for DC cardioversion
A
Fleicanide: young, no structural heart disease
Amiodarone: old, structural heart disease
23
Q
What else must you do in someone with AF
A
CHADS VASC SCORE vs HAS-BLED risk
to determine stroke risk compared to risk of bleeding
if low: aspitrin
if high: warfarin
24
Q
what are symptoms of infectious endocarditis
A
- Fever with sweats/chills/rigors
- Malaise, fatigue
- Weight loss
- Arthralgia
- Myalgia
- Confusion
- Skin lesions
- Ask about recent dental surgery or IV drug use
25
what are signs of infectious endocarditis
FROM MS JANE
Fever
Roth spots on retina
Osler's nodes (tender nodules on finger/toe pads)
Murmur (new, regurgitant)
```
Microscopic haematuria (due to damage to kidneys)
Splenomegaly (due to emboli damage to spleen )
```
Janeway lesions (painless macules on the palms which blanch on pressure)
Anaemia
Nail clubbind and haemorrhage (splinter)
Emboli
26
What ix do you do for IE
```
• Bloods
o FBC - high neutrophils, normocytic anaemia
o High ESR/CRP
o U&Es
o rheumatoid factor positive
```
• Urinalysis
o Microscopic haematuria
o Proteinuria
* Blood Culture - with microscopy and sensitivities as well
* Echocardiography - Transthoracic or transoesophageal (produces better image)
27
What classifications do you use for IE
DUKES classification - 2 majors OR 1 major + 3 minor OR 5 minors
28
What mx do you give for IE
Abx 6 weeks (initially IV > PICC line)
| start broad spec (amox + gent), then guided by culture results
29
What is pericarditis
inflammation of pericardium
30
What are causes of pericarditis
```
Vascular: post-MI, Dressler
Infection - viral (cocksackie, HIV), TB, mumps
Trauma
AI (, SLE,)
Metabolic (Uraemia)
Inflamm (sarcoid, scleroderma)
```
31
What are sx of periicarditis
| -- explain the type of pain
Pleuritic chest pain (sharp, central., radiatimg to shoulders, relieved by sitting forward)
Non productive cough
Dyspnoea
Flu like sx
32
What is audible on ascultation in pericarditis
pericardial RUB
33
What is finding on ECG in periicarditis
widespread saddle shaped ST elevation
34
MANAGEMET OF periciarditis
NSAID + colcichine
35
How do you assess for cardiac arrest?
Shout for help. Does this patient have a DNACPR?
Call 2222
A- Head tilt chin life, ask someone to hold jaw thrust
B- Look, listen and feel for signs of life, Breathing, chest movement
C- check central pulse
36
what are shockable rhythms
VF, pulseless VT
37
What are non-shockable rhythms
pulseless electrical activity, asystole
38
What do you do once you have ascertained no breathing and no central pulse
COMMENCE CPR 30 chest compressions : 2 rescue breaths via bag valve mask
Call 2222 for cardiac arrest
Continue CPR until crash team arrive with resus trolley
39
What do you do once crash team arrive
Place defib pads on chest, look at rhythm
40
What do you do for shockable rhythm
Stand clear - Defib max 1x (150J)
Reassess - if no change, Continue CPR for 2 minutes
repeat shock
You can repeat this cycle (CPR-shock) max 3 times
then continue CPR + give adrenaline 1mg IV + amiodarone 300mg IV
Restart CPR 2mins > rhythm check > shock -- with adrenaline after alternate shock
41
What do you do for PEA/Asystole
continue CPR
Give 1mg Adrenaline IV
Secure airway with LMA /igel -- otherwise hold jaw thrust
CPR for 2 mins > reassess > give adrenaline at alternate reassesses
42
What do you do if patient has spontaneous return of circulation
Send to ITU
Document
Debrief
Datix
43
what symptoms do you get with stable angina
chest pain on exertion relieved by rest
44
what is the pathophysiology of stable angina
mismatch in oxygen supply and demand to myocardium
| due to constricted coronary
45
what is the first line ix for stable angina
CT coronary angiography CTCA
(but check renal function first as it requires contrast)
using this look at CALCIUM SCORE
46
what is management for stable angina
CONSERVATIVE: lifestyle changes
MEDICAL:
1. BB/CCB + GTN spray
- ---- use nonDHP CCB e.g. verapamil / diltaziem
2. BB + CCB + GTN spray
- ---- use DHP CCB with BB e'g nifedipine (otherwise risk of heart block)
3. AA (Aspirin and Atorvastatin)
47
what is definition of HTN
SBP > 140 and / or DBP >90 on three separate occasions
48
How can you divide causes of HTN
```
Primary (essential/idiopathic)
Secondary
- renal (RAS, PKD, CKD)
- endocriine (hyperthyroid, cushing's, Conn's, phaeo)
- cardiovascular (aortic coarct)
```
49
what is aortic coarctation
congenital narrowing of the aorta
50
where does aortic coarctation usually occur, and how does this result in different signs?
- usually AFTER left subclavian artery > radiofemoral delay
| - rarely BEFORE left subclavian > radioradial delay
51
what are complications of aortic coarctation
upper extremity HTN
LV hypertrophy
malperfusion of abdomen and LL
52
how do you diagnose and tx aortic coarct
echo
CT / MR angio
Tx: angioplasty or surgery
53
when do you need to admit someone with hypertension?
when BP >180/110
will usually present with signs of deterioration e.g. retinal haemorrghage, papilloedema, confusion, AKI, chest pain etc
54
what do we define as severe HTN
BP > 180/110
55
what medication do you need to give first line for HTN
if <55 and not afrocarribean: ACEi or ARB
| if >55 or afrocarrib: CCB
56
what med do you give second line for HTN
add the one you weree not giving before or thiazide-like diuretic
SO:
if <55 and not afrocarribean: (ACEi or ARB) + (CCB or thiazide-like diuretic)
if >55 or afrocarrib: CCB + (ACEi or ARB or TLD)
57
what med do you give third line for HTN
ACEi or ARM + CCB + TLD
58
what med do you give first line for HTN if pt had T2DM, regardless of demographiocs
ACEi or ARB
if black, give ARB only
59
what investigations do you do for HTN
exclude secondary causes
| ambulatory BP monitoring > if declined / white coat syndrome, monitor at home
60
What is rheumatic fever
inflammatory multisystem disorder occuring 2-4 weeks after **group A beta haemolytic strep** e.g. S Pyogenes >> SCARLET FEVER
antibodies against GAS cross react normal cells
61
What are signs and symptoms of ACUTE rheumatic fever + typical pt
in children 5-15yo
* 2-4 weeks after pharyngeal GAS infection (SORE THROAT)
* general: malaise, fever, anorexia -> WL
* joints: painful and swollen (arthralgia), red ROM
* cardiac: breathless, chest pain, palpitations
* later (up to 6 months later) sydenam's chorea
62
What is sydenham's chorea
rapid, involuntary, irregular movements with dancing quality
63
what criteria do you use for rheymatic fever dx
JONES CRITERIA
64
Explain Jones criteria
Evidence of GAS infection + 2 major or 1 major + 2 minors
65
what provides evidence of GAS infection
* Positive throat culture – but usually negative by the time symptoms occur
* Rapid streptococcal antigen test +ve
* Elevated/rising streptococcal antibody titre (anti-streptolysin aso titire)
* Recent scarlet fever
66
what are major Jones criteria for rheumatic fever
CASES
```
Carditis
Arthiris
Subcut nodules
Erythema marginatum
Sydenams chorea
```
67
What are minor crit for Jones
PRAPP
* Pyrexia
* Raised ESR or CRP
* Arthralgia (if arthritis not in major)
* Prolonged PR
* Previous RF
68
investigations for rheumatic fever
* **Bloods**: FBC (inc WCC), inc ESR/CRP, rising antistreptolysin O titre
* **Throat swab**: culture for GAS, rapid streptococcal antigen test
* **ECG**: saddle-shaped ST elevation and PR segment depression (pericarditis), arrhythmias, prolonged PR interval
* **Echocardiogram**: pericardial effusion, myocardial thickening or dysfunction, valvular dysfunction
69
How do you manage Rh F
Acutely (attack lasts 3 months)
- bed rest
- analgesia (NSAID, aspirin)
- oral penicillin V QDS 10/7
70
what is Rh F prophylaxis
Once monthly IM benzathine penicillin
71
What is a AAA
localised enlargement of the abdominal aorta
| - diameter > 3cm or >50% normal
72
WHat are RF for AAA
- male
- FH
- smoking, HTN, hypercholesteraemia
- connective tissue disease
73
What are symptoms for unruptured AAA
often asymptomatic, may cause abdo or non-specific abdo pain
74
What are signs for unruptured AAA
pulsatile lateral expansile abdominal mass
| abdominal bruits
75
what are sx of ruptured AAAA
sudden and severe abdo/flank/back pain radiates to back, iliac fossae, groins
syncope
drowsy
nausea and vomiting
76
what additional sign may be visible on the abdomen in ruptured triole A
Grey turner = flank bruising (retroperitoneal bleeding ~ as aorta is retroperitoneal)
77
ruptured AAA classic triad of signs
flank/back pain + hypotension + pulsatile abdminal mass
78
what investigation must you get in suspected AAA q
Bloods: FBC, clotting, LFT, UE, X match
| Imaging (only if stable): USS (if unruptured), CT with contrast (if ruptured)
79
uk screening programme for AAA
Single Abdominal US scan for all men at age 65:
< 3cm --> discharge
3.1 – 4.4 cm --> annual ultrasound
4.5 – 5.4 cm --> 3 monthly ultrasound
> 5.5 cm --> treat (refer w/in 2 weeks to vascular surgery)
80
indications for surgical management of AAA
1. AAA > 5.5cm in diameter
2. AAA expanding at > 1cm/year
3. Symptomatic AAA in an otherwise fit patient
81
how do you manage unruptured AAA
regular duplex USS
| reduced CVS ris factors: stop smoking, lose weight, antihypertensives, statins and antiplatelets
82
How do you manage a ruptured AAA
SURGICAL EMERGENCY
1. BLEEP for senior help, vasuclar surgeon and anaesthetist
2. Activate major haemorrhage protocol
* 15L O2 via non-rebreather
* Gain rapid IV access
* analgesia
* Urgent bloods: FBC, U&Es, clotting, X-match, G&S
* X-match for minimum 6U
3. treat shock careully: senior help --> STAT crystalloid/blood (O-ve if not x matched)
4. catherise
5. transfer patient to local vascular unit
6. VTE prophylaxis
7. Surgical repair (EVAR if stable, open if unstable
83
complications of AAA
* rupture (--> AKI, multiorgan failure)
* Retroperitoneal leak
* Embolization -> acute limb ischaemia
84
what is the genetic inheritance of HOCM
Autosomal DOMINANT
| 1 in 500
85
How does HOCM happen?
defect in gene for contractile protein > diastolic dysfunction> LV hypertrophy > ventricles stiffen > decreased compliance > decreased SV and CO
86
What shows up on HOCM biopsy
myofibrillar hypertrophy with chaotic and disorganised fashion myocytes
87
sx of hocm
often asymptomatic
fh of suden death
exertional: dyspnoea, angina, syncope
palpitations
88
signs of hocm
jerky carotid pulse, large A waves, double apex beat, ejection systolic murmur
89
what two ix must you get for HOCM
Echo
| ECG
90
What are HOCM findings on Echo
MR SAM ASH
Mitral Regurgitation (MR)
Systolic Anterior Motion of anterior miitral valve leaflet (SAM)
Asymmetrical Septal hypertrophy (ASH)
91
Management of HOCM
```
ABCDE
Amiodaroe
beta blocker / verapamil for sx
cardioverter defib
dual chamber pacemaker
endocarditis prophylaxis
```
92
what is cor pulmonale
pulmonary heart disease
| presenting as RV HYPERTROPHY and RV DILATION
93
why does cor pulmonale occur?
due to:
| - pumonary HTN (either primary or COPD, interstitial lung disease)
94
what are signs of cor pulmonale
due to backup of blood into systemic venous system:
- ascites
- jaundice
- hepatomeg
- raised JVP
due to difficulty in allowing blood to reach lungs:
- SOB
- wheeze
95
how do calcium channel blockers work
reduce calcium uptake into cell > vascular smooth muscle relaxaton> decreases systemic vascular resistance > lowers HTN
96
give an example of a CCB
Amlodipine
97
give an example of an ARB
losartan
| candesartan
98
give an example of an ACEi
ramipril
| enalapril
99
what are DVLA rules for driving after MI
Stop driving for:
- 1 week if angioplasty was successful, no further procedures
- 4 weeks if angioplasty was unsuccessful, if they had an MI with no angioplasty, CABG surgery
100
How do you identify orthostatic hypotension
3-2-1 drop:
3 minutes of standing, then a drop of 20/10 in BP
101
what can cause long QT syndrome
Congenital
Drugs
Endocrine (hypocalcaemia, hypokalaemia, hypomagnaesaemia)
Vascular (MI, myocarditis
102
what congenital conditions can cause long QT
jervell-Lange Nielsen syndrome (deafness)
| Romano-Ward syndrome (no deafness)
103
What drugs can cause Long QT
METH CATS
```
Methadone
Erythromycin
Terfenadine
Haloperidol
Clarythromycin
Amiodarone
TCA
SSRI
```
104
what is the danger of long QT
leads to VT > death
105
What is torsade de pointes and how do you manage it
a type of VT
Manage with IV magnesium sulphate
106
what type of drug should you start in HF if EF is <30%
SGLT2 inhibitor
107
what is cardiac tamponade
Buildup of fluid in pericardial sac > compression of heart
108
What are causes of cardiac tamponade
```
vascular (MI, rupture, aortic dissection)
infection
trauma (incl cardiac surgery)
Malignancy
Inflamm (pericarditisi)
```
109
what is Becks triad
Triad that identifies cardiac tamponade (cardiac tamponade generally occurs with pericarditis)
- low BP
- high JVP
- muffled heart sounds
110
what is special feature of Cardiac Tamponade?
PULSUS PARADOXUS (BP drops by 10mmHg with every inspiration)
111
how do you manage cardiac tamponade
pericardiocentesis
112
which beta blocker offers prognostic benefit in heart fsailure
CARVEDILOL
113
what condition does JVP have an absent A wave=
AF
114
whayt condition has a heaving apical pulse
aortic stenosis
115
what murmur has a WATERHAMMER PULSE
Aortic regurg (also called Corrigan's opulse)
116
What murmur has a TAPPING APEX BEAT?
Mitral stenosis (sound is made as the valve shuts - because it is so stiff)
117
what are pacemakers for?
PACING OUT THE HEART
- SA node pathology
- AF
- HF
118
What are Implantable Cardioverter Defibrillators for
Shocking the heart into feasible rhythm
| used for tachyarrhythmias
119
What causes CANNON A WAVES?
Complete heart bloc (due to synchronous contractions of atria and ventricles)
120
what is pulmonary HTN
RAISED pulmonary artery pressure
so an umbrella term for conditions which cause increased pressure in the pulmonary artery
121
causes of pulmonary HTN - categories
- Pulmonary artery obstruction (PE, or rarely an intravascular tumour)
- lung disease (COPD, interstitial lung disease> cause backflow)
- Left heart disease (LVD, valve disease, cardiomyopathy)
- Pulmonary arterial HTN in absence of other causes (iaatrogemic, RF connective tissue diseases)
122
What bacterium causes ACUTE IE, and who is this common in ?
S aureus -- IVDU
123
what valve does S aureus affect and why
tricuspid valve - as is the first reached from systemic circulation
124
What bacterium causes chronic IE, and from where does it come
Strep viridans
from brushing your teeth
125
what valve does S viridans affect and why
Mitral valve - because it is a much weaker and less quantity of bacterium, so it only affects already damaged valve !!
126
what is the chadsVASC score component
```
CHF
HTN
Age >= 75
Diabetes
Stroke
Age >=65
Sex Category (female)
```
Age and Stroke are worth 2 points
127
how do you treat pericarditis / dressler's post MI?
NSAIDs
128
what is dresslers and how does it occur
post MI -- 6 weeks
because myocardium has been damaged > you have made autoantibodies to it
129
what condition for a long time after an MI causes prolonged ST elevation?
left ventricular aneurysm
130
what is QRISK used for
Scoring system
| for 10 year risk of developing cardiovasc disease
131
What are the parameters of QRisk for which different treeatments are employed?
QRISK >10% = high risk of CVD = high dose statin
| QRISK <10% = lifestyle modification
132
when do you need to treat HTN
>140/90 if >80 + end organ damage, CVD, CKD, diabetes, QRisk >10
in everyone else treat if >160/100
133
give an example of a thiazide like diuretic
indapamide
134
what are major and minor criteria for Duke's (IE)
Major: BE
Bacteraemia, Echo findings
Minor: FEVEER
Feever
Echo findings other
Vascular phenomena (emboli, splinter haemorrhages, janeway lesions)
Evidence of immune involvcement (Osler nodes, Roth spots, RF)
Evidence of microbio envolvement (+ve culture)
RF: IVDU, heart condition
135
vaccinations to offer HF people,
annual influenza vaccine
| Offer vaccination against pneumococcal disease
136
immediate management for both stemi and nstemi
MONA
IV **morphine** 5-10mg (diamorphine better)
* IV **metoclopramide** 10mg (antiemetic)
Sit up and If** SaO2 < 94%: oxygen **at 15L using non-rebreather mask
**GTN** spray
* Ensure patient does not have aortic stenosis)
* useful for hypertensive or acute LVF
* associated with hypotension and headaches
PO **aspirin 300 mg **STAT
137
stemi management
138
nstemi management
139
unstable angina therapy
**Dual Antiplatelet therapy**
* Aspirin 300mg oral STAT --> Then 75-100mg daily
* And clopidogrel 300-600mg loading then 75mg daily
**Low-molecular weight heparin (LMWH) (antithrombin) **
* SC Enoxaparin twice daily
* Measure anticoagulation effect with APTT at 6h
140
Driving advice for MI
* No driving for 1 week post MI
* No driving for 4 weeks if complications
141
long term management of ACS
6 A's
* **Aspirin 75mg OD for life** (+ gastro-protection)
* Another antiplatelet --> **Clopidogrel 75mg OD for 1 year **
*** Atorvastatin 80mg OD for life**
* ACE inhibitor --> **ramipril 1.25-2.5mg OD **increasing up to 10mg
* Atenolol (Beta-blocker e.g. **bisoprolol 2.5mg OD** increasing up to 10mg )
* Aldosterone antagolnist (**eplerenone**)
142
Early Complications of MI (within 24-72 hrs)
**d**eath
ventricular **a**rrythmias (VF) and aneurysms
myocardial **r**upture
**h**eart failure
143
Late Complications of MI
tamponade
ventricular septal defect
thromboembolism
valvular regurigtation
144
how does papillary muscle ruptre present
acute heart failure, hypotension, early-mid systolic murmur (MR)
