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medicine can be fun > Cardio > Flashcards

Cardio Flashcards

1
Q

what percentage of strokes are ischaemic

A

85%

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2
Q

acronym for stroke symptoms

A

FAST
- facial drooping
- arm weakness
- slurred speech

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3
Q

what arteries does an anterior circulation infarct involve in a stroke

A

anterior and middle cerebral arteries

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4
Q

features of a stroke of the anterior cerebral artery

A
  • contralateral lower limb weakness
  • behavioural changes
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5
Q

features of a stroke of the middle cerebral artery

A
  • contralateral upper limb weakness
  • contralateral sensory loss
  • aphasia
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6
Q

what are the 2 types of aphasia

A
  1. Wernicke’s: can speak but not comprehend
  2. Broca’s: can comprehend but not speak
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7
Q

features of a stroke of the posterior cerebral artery

A
  • contralateral homonymous hemianopia with macular sparing
  • visual agnosia
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8
Q

features of a stroke affecting the cerebellum

A

ipsilateral DANISH
- dysdiadochokinesia
- ataxia
- nystagmus
- intention tremor
- slurred speech
- hypotonia

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9
Q

first line investigation for a stroke

A

non-contrast CT to exclude haemorrhage

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10
Q

how to manage acute ischaemic stroke once bleeding excluded

A

< 4.5 hours since symptoms:
- thrombolysis (alteplase) + aspirin 300mg
- add thrombectomy if anterior circulation confirmed by CT angio

> 4.5 hours
- oral aspirin

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11
Q

secondary prevention of ischaemic stroke

A
  • aspirin 75mg for 2 weeks then lifelong clopidogrel
  • warfarin in AF patients
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12
Q

how to manage a haemorrhagic stroke

A

reverse anticoagulation and refer to neurosurgery

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13
Q

QRISK indication for a statin

A

> 10%

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14
Q

what is the difference between syncope and loss of consciousness

A
  • loss of consciousness can either be syncopal or non-syncopal
  • syncope is loss of consciousness due to cerebral hypoperfusion
  • non syncopal causes include epilepsy, hypoglycaemia, head trauma, alcohol
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15
Q

how do you classify syncope

A
  • based on its causes
    1. reflex
    2. cardiac
    3. orthostatic
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16
Q

what are two causes of reflex syncope

A
  • vasovagal syncope: fear
  • situational syncope: when straining
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17
Q

what are two causes of cardiac syncope

A
  • arrhythmias: heart block
  • outflow obstruction: AS, HOCM
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18
Q

what are two causes of orthostatic syncope

A
  • drugs: ACEi, beta blockers, CCB
  • autonomic instabilty: Parkinson’s
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19
Q

what are 3 triggers for vasovagal syncope

A
  • fear
  • pain
  • standing too long
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20
Q

what is the pathophysiology of vasovagal syncope

A

excessive vagal discharge causes bradycardia and hypotension

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21
Q

how does loss of consciousness in vasovagal syncope present

A
  • Before: lightheaded, sweating, nausea
  • During: lasts seconds
  • After: fast recovery
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22
Q

What investigations would you do for loss of consciousness

A

Bedside:
- ECG for arrhythmias
- BM for hypoglycaemia
Bloods:
- FBC for anaemia
- U&Es for electrolyte abnormalities
Imaging:
- consider echo for cardiac causes
- consider CT head for trauma

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23
Q

3 ways to manage a patient with vasovagal syncope

A
  • advice to avoid triggers
  • advise physical techniques
  • advise electrolyte rich sports drinks
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24
Q

how to manage a patient with syncope due to HOCM, Brugada

A

implant a cardioverter-defebrillator

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25
Q

sign of HOCM on auscultation

A

ejection systolic murmur

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26
Q

three steps to managing orthostatic syncope

A

i) educate and advice salt and hydration
ii) discontinue drugs
iii) fludrocortisone

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27
Q

how to manage syncope due to complete heart block

A

i) atropine
ii) transvenous pacing

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28
Q

triad of causes for VTE

A

Virchow’s triad:
1. stasis
2. injury
3. coagulability

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29
Q

acronym to remember risk factors for PE

A

CT sil vous plait:
- C: cancer, chemo
- T: trauma, travelling
- S: surgery, smoking, stasis
- V: virchow’s, varicose veins
- P: pill, pregnancy, previous DVT, polycythaemia

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30
Q

four symptoms for PE

A
  1. pleuritic chest pain
  2. SOB
  3. haemoptysis
  4. collapse
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31
Q

three signs of PE

A
  1. tachycardia
  2. tachypnoea
  3. hypoxia
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32
Q

what are the PERC criteria

A
  • used when very low probability of PE just to be sure
  • PE excluded when they’re all negative
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33
Q

what are two initial investigations for PE

A
  • CXR
  • ECG
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34
Q

CXR findings for PE

A
  • most commonly normal
  • Westermark’s sign
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35
Q

ECG findings for PE

A
  • usually sinus tachycardia
  • RBBB, RAD
  • rarely S1Q3T3
    - S wave in lead I
    - Q wave & inverted T wave in lead III
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36
Q

how do you score PE to decide how to investigate it

A

Well’s score
- more than 4 do a CTPA
- 4 or less do a D-dimer

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37
Q

when is a CTPA unsuitable and what is the alternative

A
  • renal impairment (CKD)
  • do a V/Q scan
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38
Q

what do you do if a CTPA is negative in PE

A

do a leg US for DVT

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39
Q

what do you do if the D-dimer is elevated in PE and what if it’s normal

A
  • elevated: CTPA
  • normal: alternative diagnosis
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40
Q

what do you do if there is a delay in CTPA in PE

A

give them apixaban in the meantime

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41
Q

how do you treat PE

A
  • unstable: thrombolysis with alteplase
  • stable: DOAC aka apixaban unless severe renal impairment then LMWH
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42
Q

how long do you treat a PE for

A
  • provoked PE: 3 months
  • unprovoked PE: 6 months
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43
Q

how do you manage recurrent PEs

A

IVC filter

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44
Q

what is VTE prophylaxis in hospital patients

A
  • TED stockings
  • LMWH
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45
Q

which breast cancer drug increases the risk of VTE

A

tamoxifen

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46
Q

what will an ABG in PE show

A

respiratory alkalosis

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47
Q

what is aortic dissection

A

tear in the tunica intima forms a false lumen

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48
Q

what is the epidemiology and risk factors for aortic dissection

A
  • men over 50
  • hypertension
  • smoking
  • connective tissue disorders (Marfan’s)
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49
Q

how do you classify aortic dissection and which type is the most common

A
  • Type A: involves ascending aorta
    - IA: both
    - IIA: ascending only
  • Type B: does not involve ascending
    - IIIa: above diaphragm
    - IIIb: above and below
  • most common is type A
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50
Q

typical symptom of aortic dissection

A

sudden severe tearing chest pain that radiates to the back

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51
Q

three signs of aortic dissection

A
  1. weak/absent pulses
  2. blood pressure difference between arms
  3. aortic regurgitation murmur (Type A)
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52
Q

three artery-specific symptoms of aortic dissection

A
  • angina (coronary arteries)
  • hemiparesis (spinal arteries)
  • syncope (subclavian artery)
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53
Q

how to investigate suspected aortic dissection

A
  • CXR: widened mediastinum
  • stable: CT angio false lumen (diagnostic)
  • unstable: TOE
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54
Q

how to manage aortic dissection and what is the target blood pressure

A
  • Type A: surgery (aortic root replacement) + morphine + labetalol
  • Type B: bed rest + morphine + IV labetalol
  • labetalol controls blood pressure to a target of 100-120
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55
Q

what are the three types of peripheral arterial disease

A
  1. intermittent claudication
  2. critical limb ischaemia
  3. acute limb ischaemia
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56
Q

what are 5 risk factors for peripheral arterial disease

A
  • age >40
  • smoking
  • diabetes
  • hypertension
  • hyperlipidaemia
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57
Q

what is the presentation of acute limb ischaemia

A

6 Ps
- pale
- pain
- paraesthesia
- perishingly cold
- pulseless
- paralysis

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58
Q

what are the symptoms of intermittent claudication

A
  • calf pain on exertion
  • worse going up the hill
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59
Q

what are the symptoms of critical limb ischaemia

A
  • calf pain at rest
  • relieved by hanging legs off the bed
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60
Q

what are two signs of peripheral vascular disease

A
  • hair loss
  • absent pulses
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61
Q

how do you test for peripheral vascular disease on examination

A
  • Buerger’s test
  • angle less than 20 degrees is severe ischaemia
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62
Q

what is leriche syndrome

A
  • erectile dysfunction
  • buttock claudication
  • absent pulses
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63
Q

what is an investigation specific for peripheral vascular disease and how to interpret it

A
  • ABPI
  • normal is around 1
  • vascular disease is less than 0.9
  • critical limb ischaemia is less than 0.5
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64
Q

when is ABPI not a reliable test for peripheral vascular disease

A
  • diabetes
  • more than 1.3
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65
Q

which US is for acute limb ischaemia and which for intermittent claudication

A

o is before u so acute
- acute: Doppler
- intermittent: Duplex

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66
Q

what is the first line and diagnostic imaging for peripheral vascular disease

A
  • first line: duplex US
  • diagnostic: MR angiogram
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67
Q

how to manage acute limb ischaemia

A

i) heparin + paracetamol + morphine
ii) revascularisation
iii) amputation

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68
Q

how to manage peripheral vascular disease

A
  • quite smoking + statin + clopidogrel + exercise
  • revascularisation in critical limb ischaemia
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69
Q

what are the types of ischaemic heart disease

A
  • stable angina
  • ACS (unstable angina, NSTEMI, STEMI)
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70
Q

five risk factors for ischaemic heart disease

A
  • male
  • HTN
  • diabetes
  • smoking
  • hyperlipidaemia
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71
Q

what is stable angina

A

chest pain on exertion relieved by rest

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72
Q

how would you investigate stable angina

A
  • ECG: normal
  • troponin: normal
  • bloods: lipid profile, FBC, HbA1c
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73
Q

what is the management for stable angina

A
  • aspirin 75mg
  • statin
  • GTN
  • beta blocker or verapamil
  • 2nd line: beta blocker + amlodipine
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74
Q

what is unstable angina

A

chest pain at rest

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75
Q

what is the management for unstable angina/NSTEMI

A

i) MONA
ii) if unstable then PCI
iii) LMWH + GRACE score
iv) long term prevention

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76
Q

what is the long term management in all patients with ACS

A
  • aspirin 75mg
  • tricagrelor/clopidogrel
  • ACEi
  • statin
  • beta blocker
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77
Q

how do you interpret the GRACE score

A
  • > 3% take them for PCI
  • <3% give aspirin + tricagrelor
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78
Q

what do you give before and during a PCI

A
  • before: prasugrel + aspirin
  • during: unfractionated heparin
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79
Q

what are the symptoms of ACS

A
  • chest pain radiates to left arm and jaw
  • sweating, nausea, SOB
  • diabetics can have an atypical presentation (no chest pain)
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80
Q

what investigations would you do in ACS

A
  • ECG
  • troponin: elevated
  • bloods for clotting, FBC, lipid profile
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81
Q

2 ECG features of an NSTEMI

A
  • ST depression
  • T wave inversion
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82
Q

2 ECG features of a STEMI

A
  • ST elevation
  • LBBB
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83
Q

what are the 4 areas of myocardial infarction and arteries supplying them

A
  • anterior MI: V1 - V4 (LAD)
  • lateral MI: I, aVL, V5 - V6 (left circumflex)
  • inferior MI: II, III, aVF (right coronary)
  • posterior MI: ST depression in V1 - V3
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84
Q

how to manage an ACS

A

i) MONA
ii) determine whether it’s STEMI or NSTEMI
iii) if STEMI then PCI within 2 hours within 12 hours of symptoms
iv) if more than 2 hours then give alteplase + antithrombin

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85
Q

3 contraindications for fibrinolysis in a STEMI

A
  • blood thinners
  • head trauma
  • more than 12 hours since symptoms
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86
Q

what do you do if fibrinolysis is unsuccessful in a STEMI

A

coronary angio with PCI

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87
Q

what are the complications of an MI

A

DARTH VADER
- death
- arrhythmias (V-fib, V-tach, heart block)
- rupture (tamponade)
- tamponade
- heart failure
- valve problems (MR)
- aneurysm (persistent ST elevation)
- dressler’s (pericarditis fever)
- embolism
- recurrence

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88
Q

how do you investigate a DVT

A
  • if Wells >2:
    doppler US then D dimer if negative US
  • if Wells <2:
    D-dimer then doppler US if high D-dimer
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89
Q

what causes arterial ulcers

A
  • peripheral arterial disease
  • atherosclerosis
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90
Q

what causes venous ulcers

A
  • valve incompetence
  • varicose veins, DVT
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91
Q

compare the appearance of venous vs arterial ulcer

A
  • venous: shallow, dark, not well defined
  • arterial: pale, deep, well defined
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92
Q

compare the location of venous vs arterial ulcer

A
  • venous are on medial malleolus
  • arterial are on toes, lateral feet
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93
Q

what two investigations do you want to do for all leg ulcers

A
  • ABPI
  • duplex US
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94
Q

what are four signs of peripheral venous disease (venous ulcers)

A
  • stasis eczema
  • atrophie blanche (shiny skin)
  • hemosiderin deposition (pigmentation)
  • lipodermatosclerosis (champagne bottle hardening)
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95
Q

how do you manage venous ulcers

A
  • compression stockings
  • moisturise eczema
96
Q

what are 2 important considerations before giving compression stockings in venous ulcers

A
  • exclude PVD (contraindicated if ABPI <0.8)
  • exclude diabetic neuropathy
97
Q

what is the epidemiology of acute pericarditis

A

young/middle aged males

98
Q

what are 3 causes of acute pericarditis

A
  • viral: Coxsackie B, TB
  • Dressler’s syndrome: weeks post MI
  • idiopathic
99
Q

what are the symptoms of acute pericarditis

A
  • pleuritic chest pain relieved by leaning forwards
100
Q

what is a sign of acute pericarditis

A
  • pericardial friction rub on the left sternal edge on expiration
101
Q

what does the ECG show in acute pericarditis

A
  • global saddle-shaped ST elevation
  • PR depression
102
Q

what is the diagnostic investigation for all patients with acute pericarditis

A

TTE

103
Q

how do you manage acute pericarditis

A
  • NSAIDs + colchicine
  • restrict exercise
  • pericardiectomy if recurrent
104
Q

what is cardiac tamponade

A
  • fluid in the pericardium increases pressure and restricts heart pumping
105
Q

what are 3 causes of cardiac tamponade

A
  • trauma
  • heart surgery
  • complication of acute pericarditis
106
Q

what are the features of cardiac tamponade

A
  • Beck’s triad: hypotension, raised JVP, distant heart sounds
  • pulsus paradoxus
  • SOB
107
Q

what do you see on an ECG in cardiac tamponade

A

electrical alternans (tall followed by short QRS)

108
Q

what do you see in a chest x-ray for cardiac tamponade

A

globular heart

109
Q

what is the diagnostic investigation for cardiac tamponade

A

TTE

110
Q

how do you manage cardiac tamponade

A

urgent pericardiocentesis

111
Q

what is constrictive pericarditis

A

thickened pericardium restricts heart pumping

112
Q

what causes constrictive pericarditis

A

acute pericarditis complication (TB)

113
Q

what are features of constrictive pericarditis

A
  • RHF: ascites, oedema, raised JVP
  • Kussmaul’s sign: raised JVP on inspiration
  • S3
114
Q

what do you see on a CXR for constrictive pericarditis

A

calcification of the pericardium

115
Q

what is the diagnostic investigation for constrictive pericarditis

A

echo: pericardial thickness distinguishes from restrictive cardiomyopathy

116
Q

how do you manage constrictive pericarditis

A

pericardiectomy

117
Q

what is the epidemiology of myocarditis

A

younger patients (acute chest pain in younger patients)

118
Q

what are 4 causes of myocarditis

A
  • viral: Coxsackie B
  • bacterial
  • autoimmune
  • Chagas disease
119
Q

what are the symptoms of myocarditis

A
  • young patient with acute chest pain
  • SOB
  • palpitations
  • flu like (fever)
120
Q

what investigations would you do for myocarditis

A
  • ECG: ST elevation, T inversion
  • high CK, high troponin
  • high CRP
  • high BNP
  • CXR & echo
121
Q

how do you manage myocarditis

A
  • supportive treatment
  • treat complications
122
Q

what drug would you give in a case of myocarditis if they are unstable (acutely hypertensive)

A

nitroprusside (vasodilator)

123
Q

what are three symptoms of HOCM

A
  • syncope
  • sudden death in young athletes
  • exertional dyspnoea
124
Q

what murmur, heart sound and ECG feature is seen in HOCM

A
  • ejection systolic louder on Valsava, quite on squatting, no radiation
  • S4
  • LVH
125
Q

what are 3 causes of dilated cardiomyopathy

A
  • alcohol
  • Coxsackie B myocarditis
  • pregnancy
126
Q

what heart sound and CXR feature is seen in dilated cardiomyopathy

A
  • S3
  • balloon heart
127
Q

what is the presentation of Takotsubo cardiomyopathy

A
  • stress induced chest pain (broken heart syndrome)
128
Q

what are causes of infective endocarditis

A
  • Staph (most common, IVDUs, prosthetic valve)
  • Strep viridans (dental procedures)
129
Q

what are signs of infective endocarditis

A
  • FROM JANE
  • fever (rigours), Roth spots, Osler nodes, murmur, Janeway lesions, anaemia, nail haemorrhage, emboli
  • clubbing
130
Q

what valve is affected in infective endocarditis

A
  • usually mitral regurgitation
  • tricuspid in IVDUs
131
Q

what are Duke’s criteria for infective endocarditis and how many do you need for diagnosis

A
  • 2 major or 1 major + 3 minor or 5 minor
    Major:
  • positive blood cultures 12hrs apart
  • positive echo valve vegetation
  • new murmur (regurgitation)
  • Coxiella
    Minor:
  • risk factors (IVDU)
  • fever
  • emboli
  • Osler/Roth
  • positive culture once
132
Q

how do you manage a patient with infective endocarditis

A

i) A-E sepsis six
ii) broad spectrum antibiotics after cultures
- native: amoxicillin
- prosthetic: vancomycin + rifampicin
iii) antibiotics
- strep: amoxicillin + gentamicin
- staph: flucloxacillin
- MRSA/allergy: vancomycin
iv) consider valve surgery
v) anticoagulate prosthetic valves

133
Q

what are two causes of aortic stenosis

A
  • older: calcification (most common)
  • younger: bicuspid valve
134
Q

what are the symptoms of aortic stenosis

A

SAD
- syncope
- angina
- dyspnoea

135
Q

describe the murmur heard in aortic stenosis

A
  • ejection systolic
  • radiates to the carotids
  • louder on expiration
136
Q

what is the pulse like in aortic stenosis

A
  • slow-rising
  • narrow pulse pressure
137
Q

what heart sounds can be heard in aortic stenosis

A
  • soft S2
  • S4
138
Q

what can be seen on the ECG in aortic stenosis

A
  • wide QRS with LBBB
  • LVH with left axis deviation
139
Q

what is the diagnostic investigation for aortic stenosis

A

echo

140
Q

how do you manage aortic stenosis

A
  • asymptomatic: observe
  • low risk patients: aortic valve replacement
  • high risk patients: TAVI
  • percutaneous valvuloplasty if unsuitable for replacement
141
Q

what are causes of aortic regurgitation

A
  • valve problems (IE acutely, rheumatic fever chronic most common)
  • aorta problems (aortic dissection acutely, Marfan’s & ankylosing spondylitis chronic)
142
Q

what are 4 signs of aortic regurgitation

A
  • collapsing pulse
  • wide pulse pressure
  • early diastolic murmur
  • displaced apex beat
143
Q

what is an Austin Flint murmur

A

severe aortic regurgitation

144
Q

how do you investigate aortic regurgitation

A
  • ECG: LVH, LAD
  • CXR: cardiomegaly
  • Echo: diagnostic
145
Q

how do you manage aortic regurgitation

A

i) inotropes (increase contractility)
ii) aortic valve replacement
iii) anticoagulate prosthetic valve

146
Q

what causes mitral stenosis

A

rheumatic fever in females

147
Q

what are the signs and symptoms of mitral stenosis

A

Symptoms:
- fatigue, dyspnoea
- palpitations
Signs:
- mid diastolic murmur
- loud S1
- opening snap

148
Q

how do you investigate mitral stenosis

A
  • ECG: AF, p-mitrale (bifid), RVH, RAD
  • CXR: pulmonary congestion
  • echo: diagnostic
149
Q

how do you manage mitral stenosis

A

i) manage AF with beta blocker
ii) manage congestion with furosemide
iii) penicillin for rheumatic fever
iv) percutaneous balloon valvotomy

150
Q

what are causes of mitral regurgitation

A

primary issues with the valve:
- IE, rheumatic fever
- Marfan’s (chordae rupture)
secondary functional issues:
- left ventricle dilatation

151
Q

what are the signs and symptoms of mitral regurgitation

A

Symptoms:
- asymptomatic, SOB, palpitations
Signs:
- pansystolic murmur
- displaced apex beat if LV dilatation

152
Q

how do you investigate mitral regurgitation

A
  • ECG: AF, p-mitrale
  • CXR: cardiomegaly & pulmonary oedema (LHF LV dilatation)
  • echo: diagnostic
153
Q

how do you manage mitral regurgitation

A
  • medical support (nitrates, inotropes, diuretics)
  • manage heart failure, AF
  • surgery to repair if severe
154
Q

what do you hear in mitral valve prolapse

A

mid-systolic click

155
Q

what is mitral valve prolapse and its associations

A

floppy mitral valve associated with connective tissue disorders (Marfan’s)

156
Q

what are two causes of tricuspid regurgitation

A
  • valve vegetations due to IE in IVDUs
  • RV dilatation due to pulmonary congestion in LHF
157
Q

what are signs of tricuspid regurgitation

A
  • raised JVP
  • ascites, hepatomegaly, oedema
  • pansystolic murmur on inspiration
158
Q

how to investigate tricuspid regurgitation

A
  • ECG for AF
  • CXR for cardiomegaly, pulmonary oedema
  • echo for diagnosis
159
Q

how to manage tricuspid regurgitation

A
  • treat the cause
  • treat heart failure and AF
  • valve replacement
160
Q

what murmur do you hear in tricuspid stenosis

A

diastolic

161
Q

what do you see on the ECG for right heart valve disease

A
  • p-pulmonale (tall p waves)
  • RVH, RAD, RBBB
162
Q

what murmur do you hear in pulmonary stenosis

A

ejection systolic

163
Q

what murmur do you hear in pulmonary regurgitation

A
  • diastolic
  • Graham Steel if associated with mitral stenosis
164
Q

where is the most common site for AAAs

A

below the renal arteries

165
Q

what is the epidemiology and risk factors for a AAA

A
  • men >65 years
  • smoking
  • HTN
  • Marfan’s
166
Q

what are the symptoms of a ruptured AAA

A
  • sudden severe back/abdo pain
  • syncope
  • shock
167
Q

what are three signs of a AAA

A
  • Grey Turner’s sign
  • pulsatile non expansile mass
  • bruit
168
Q

what is the screening protocol for AAAs

A
  • single US for all males at 65
  • rescan in 3 months if 4.5-5.4cm
  • rescan in 12 months if 3-4.4cm
169
Q

how do you investigate a AAA

A
  • abdominal US detects the aneurysm
  • contrast CT detects the rupture but only if stable
  • in unstable patients diagnosis is clinical
170
Q

how do you manage a AAA

A

i) give blood, antibiotics, LMWH
- keep systolic <100
ii) emergency surgery
- EVAR if stable but risks endo-leak
- open surgery if unstable

171
Q

what are the criteria for operating an asymptomatic AAA

A
  • > 5.5cm
  • expanding at >1cm/year
172
Q

what is characteristic about a TIA

A
  • resolves within 24hrs
  • no structural ischaemic changes
173
Q

how long does a TIA attack usually last

A

few minutes, resolves within the hour

174
Q

how do you investigate a TIA

A
  • BM to exclude hypoglycaemia
  • same day specialist assessment + MRI
  • CT only if on anticoagulants to exclude bleeding (not recommended as it doesn’t show ischaemic changes)
175
Q

how do you manage a TIA

A
  • aspirin 300mg STAT
  • lifelong clopidogrel + statin
176
Q

what are features of an SVT on an ECG

A
  • narrow QRS < 3 squares
  • regular
  • no p waves
177
Q

what are 3 causes of an SVT

A
  • heart surgery
  • alcohol
  • digoxin toxicity
178
Q

how do you manage an SVT

A
  • unstable: DC cardioversion
  • stable:
    i) valsalva manoeuvre, carotid massage
    ii) 6mg adenosine followed by 12, 12mg
  • verapamil if asthmatic
179
Q

what is WPW syndrome

A
  • accessory conduction pathway so the ventricles get excited quicker
  • younger patients
180
Q

what do you see on an ECG for WPW syndrome

A
  • delta waves (slurred upstroke QRS)
  • shorter PR
  • axis deviation
181
Q

how to manage WPW syndrome

A
  • SVT so Valsalva, adenosine
  • radiofrequency ablation of accessory pathway
182
Q

what do you give in WPW patients with AF

A

flecainide

183
Q

what are the features of atrial fibrillation on an ECG

A
  • narrow QRS
  • irregular tachycardia
  • absent P-waves
  • squigly
184
Q

what are 5 causes of atrial fibrillation

A
  • IHD
  • heart failure
  • alcohol
  • hyperthyroidism
  • mitral stenosis
185
Q

how do you manage a stable patient with AF

A
  • beta blocker
  • if contraindicated then rhythm control:
  • <48 hours: LMWH + DC cardioversion
  • > 48 hours: DOAC for 3 weeks then cardioversion OR exclude thrombus with TOE + cardioversion
186
Q

when should you choose rhythm control instead of rate control in AF

A
  • first episode of AF
  • reversible cause
  • heart failure
187
Q

how do you decide whether an AF patient requires anticoagulation

A
  • CHA2 DS2 VASc score
  • males anticoagulation if 1
  • females anticoagulation if 2
  • if score = 0 do a TTE to check
  • assess bleeding risk using ORBIT
188
Q

what is the CHA2 DS2 VASc score

A
  • congestive heart failure
  • hypertension
  • age > 75 = 2
  • diabetes
  • previous stroke = 2
  • vascular disease
  • age > 65
  • sex female
189
Q

how do you manage any unstable patient with tachycardia

A
  • DC cardioversion
190
Q

what do you see on an ECG for atrial flutter

A
  • regular
  • saw tooth pattern
  • narrow QRS
191
Q

what are features of ventricular tachycardia on an ECG

A
  • broad QRS > 3 squares
  • regular
  • fusion beats (normal beat between)
  • capture beats (normal QRS between abnormal)
192
Q

how do you manage a stable patient with V-tach

A

i) amiodarone
ii) DC cardioversion if it fails

193
Q

what is torsades de pointes

A

polymorphic irregular V-tach with long QT (twisty)

194
Q

what are causes of torsades de pointes

A

TIIMMES
- toxin (clarithromycin)
- inherited
- ischaemia
- myocarditis
- mitral valve
- electrolytes (hypokalaemia, low Mg)
- SAH

195
Q

how do you manage torsades de pointes

A

magnesium sulfate

196
Q

what do you see on an ECG for ventricular fibrillation

A
  • irregular
  • broad QRS
  • very messy
197
Q

what is first degree heart block

A
  • prolonged PR > 5 squares
  • sinus rhythm
  • no treatment required
198
Q

what is Weckenbach heart block

A
  • gradual PR prolongation until a beat drops
  • regular
199
Q

what is Mobitz II heart block

A
  • no PR prolongation
  • only some P waves are followed by QRS
  • regular ratio
200
Q

what is complete heart block

A
  • no association between Ps and QRS
  • irregular
201
Q

how do you manage bradycardia

A
  • do not treat if asymptomatic >40
    i) IV atropine
    ii) temporary pacing
202
Q

what causes cardiac arrest

A
  • 4 Hs: hypoxia, hypovolaemia, hypokalaemia, hypothermia
  • 4 Ts: thromboembolism, tension pneumothorax, tamponade, toxins
203
Q

what are shockable and non-shockable rhythms in cardiac arrest

A

Shockable:
- V-fib
- pulseless V-tach
Non-shockable:
- asystole
- pulseless electrical activity

204
Q

how do you manage a shockable rhythm in cardiac arrest

A
  • CPR 30:2 STAT
  • cardioversion every 2 minutes
  • 1mg adrenaline after 2nd shock every 3-5 minutes
  • 300mg amiodarone after 3rd shock
205
Q

how do you manage a non-shockable rhythm in cardiac arrest

A
  • CPR 30:2 STAT
  • 1mg adrenaline every 3-5 minutes
206
Q

what are causes of high output heart failure

A

NAP MEALS
- nutrition (thiamine deficiency)
- anaemia
- pregnancy
- malignancy
- endo (thyrotoxicosis)
- AV malformations
- liver cirrhosis
- sepsis

207
Q

how do you classify low output heart failure

A
  • left and right heart failure
  • left can be reduced (<40%) or preserved (>50%) ejection fraction
208
Q

what are causes of heart failure with reduced ejection fraction

A
  • systolic dysfunction
  • dilated cardiomyopathy
  • IHD
  • arrhythmias
  • myocarditis
209
Q

what are causes of heart failure with preserved ejection fraction

A
  • diastolic dysfunction
  • tamponade
  • restrictive cardiomyopathy
  • HOCM
210
Q

what are causes of right heart failure

A
  • LHF, TR
  • lung: COPD, pulmonary HTN
211
Q

how do you classify heart failure

A

NYHA classification using SOB
- I: heart failure with no SOB
- II: SOB during any activity
- III: SOB limits small ADLs
- IV: SOB at rest

212
Q

what are signs and symptoms of left heart failure

A
  • orthopnoea
  • SOB
  • PND
  • nocturnal cough with pink frothy sputum
    Signs:
  • fine bibasal crackles
  • S3 gallop (dilated LV)
  • displaced apex beat
213
Q

what are signs and symptoms of right heart failure

A
  • weight gain
  • anorexia
  • hepatomegaly & ascites
  • raised JVP
  • peripheral oedema
  • pansystolic murmur
214
Q

how do you investigate heart failure

A
  • bloods: high BNP, dilutional hyponatraemia, anaemia
  • CXR: A-E (alveolar oedema, B-lines, cardiomegaly, diverted upper lobe, effusion)
  • TTE: diagnostic calculates EF
215
Q

how do you manage acute heart failure

A
  • position them upright
  • oxygen if <94%
  • morphine with antiemetic if in a lot of pain
  • furosemide
  • GTN
  • if not responding put on CPAP
216
Q

how do you manage chronic heart failure

A

i) ACEi + beta blocker
ii) add spironolactone, SGLT2 inhibitor (gliflozins)
iii) digoxin for symptoms, hydralazine if black
iv) ICD
v) LVAD, transplant, palliative

217
Q

what is pulmonary hypertension

A

vasoconstriction of pulmonary vasculature increases pulmonary arterial pressure and can result in RHF

218
Q

what are causes of pulmonary HTN

A
  • LHF
  • lung pathology (COPD)
  • mitral stenosis
  • PE
219
Q

what are 3 features of pulmonary HTN

A
  • progressive SOB
  • Graham Steel murmur of pulmonary regurgitation with mitral stenosis
  • signs of RHF
220
Q

how do you investigate pulmonary HTN

A
  • ECG: RBBB, p-pulmonale
  • CXR: pulmonary artery dilatation
  • TTE, right heart catheterisation
221
Q

how do you manage pulmonary HTN

A

amlodipine + anticoagulate + exercise

222
Q

what are the stages of hypertension

A
  • I: >140/90
  • II: >160/100
  • III: >180/110
  • malignant: >200/120
223
Q

what are symptoms of malignant hypertension based on systems

A
  • renal: haematuria, proteinuria
  • cardio: palpitations, SOB, S4, angina
  • neuro: headache, blurred vision, retinopathy
224
Q

what are the stages of hypertensive retinopathy

A
  • I: silver wiring
  • II: AV nipping
  • III: flame haemorrhage
  • IV: papilloedema
225
Q

how do you investigate hypertension

A
  • average of 3 clinic readings
  • ABPM > 135/85
  • calculate QRISK
  • exclude secondary causes
226
Q

what are secondary causes of hypertension

A

Endo
- Cushings, Conns, phaeo, acromegaly
Renal
- GN, RAS, CKD, PCKD (young, LVH)
Other
- pre-eclampsia, OCP, aorta coarctation

227
Q

how do you manage acute malignant hypertension

A

IV labetalol

228
Q

how do you manage essential hypertension

A

i) monotherapy with:
- ACEi if <55 or diabetic (ARB if black)
- CCB if >55 or black
ii) combination therapy up to three (add thiazide)
iii) assess potassium
- if >4.5 then beta/alpha blocker
- if <4.5 then spironolactone

229
Q

what are side effects and contraindications of ACEi and what is an alternative

A
  • cough, hyperkalaemia
  • give ARB if cough
  • both contraindicated in pregnancy, RAS
230
Q

what are side effects of calcium channel blockers

A
  • bradycardia, flushing
  • ankle oedema in amlodipine (peripheral vessels)
231
Q

what are side effects of thiazides

A
  • postural hypotension
  • gout
  • hypercalcaemia, hyperglycaemia
  • hyponatraemia, hypokalaemia
  • erectile dysfunction
232
Q

what are electrolyte abnormalities of loop diuretics

A
  • hypokalaemia
  • hyponatraemia
  • hypocalcaemia
233
Q

what are side effects and contraindications for statins

A
  • myopathy
  • liver disease
  • contraindicated in erythromycin, pregnancy
234
Q

what are contraindications for beta blockers

A
  • asthma (bronchospasm)
  • verapamil
235
Q

what is a side effect of adenosine

A
  • chest pain
  • bronchospasm so not in asthmatics (verapamil instead)
236
Q

what are side effects of amiodarone

A
  • lung fibrosis
  • hepatitis
  • thyroid issues
  • potentiates warfarin
237
Q

when do you use different antiplatelets

A
  • ACS: aspirin + tricagrelor
  • PCI: aspirin + tricagrelor/presugrel
  • stroke/TIA: clopidogrel
  • PVD: clopidogrel

medicine can be fun (12 decks)

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