Cardio Flashcards
(70 cards)
1
Q
JVP: Location & features
A
Location: - JVP is assessed by looking at the internal jugular vein. - IJV is located deep to the sternomastoid muscle. Features/Differences from carotid pulse: - Complex wave form: beats twice in one cardiac cycle. - Visible but not palpable - Occludable and fills from above. - Decreases with deep inspiration. - Changes with head position.
2
Q
JVP Wave form
A
A wave
- Atrial contraction, coincides with first
heart sound.
- Large/canon A waves = Tricuspid
stenosis, pulmonary stenosis, complete
heart block
C Wave
- Tricuspid valve closure
- Not visible.
X decent
- Atrial relaxation
- Absent = AF
- Exaggerated = tamponade, constrictive
pericarditis.
V wave
- Atrial filling
- Large = tricuspid regurgitation
Y Descent
- Rapid ventricular filling
- Sharp = TR
- Slow = TS
3
Q
Inferior MI
A
Leads II, III, aVF
4
Q
Anteroseptal MI
A
Leads V1-4
5
Q
Anterolateral MI
A
Leads V4-6, I, aVL
6
Q
Posterior MI
A
Tall R waves
ST depression in V1-2
7
Q
ECG findings in pulmonary embolism
A
Sinus tachycardia RAD RBBB Right ventricular strain pattern = dominant R waves, T wave inversion/ST depression in V1 and V2 Classic pattern (rare) = S1Q3T3
8
Q
Definition of ACS
A
Includes: unstable angina, STEMI, NSTEMI
9
Q
Management of ACS with ST elevation
A
- ABC’s
- Quick history and physical exam
- 12 lead ECG
- Bloods: U&E, troponin, glucose,
cholesterol, FBC, CXR. - Aspirin 300mg PO; consider clopidogrel
300mg. - Morphine 5-10mg IV + Metoclopramide
10mg IV. - GTN 1-2 tabs SL or spray.
- BB Atenolol 5mg IV
- O2 mask or nasal prongs.
- Restore coronary perfusion: PCI
(< 30min from admission,
within 24hrs of onset of chest pain).. - Consider DVT prophylaxis.
10
Q
Treatment of hypertension
A
Monotheray:
- If > 55 yrs or black of any age - CCB or thiazide.
- If < 55 yrs - ACEI is first choice; ARB if ACE CI,
- BB: not first line but consider in patient who can’t take ARB/ACEI, younger patients, women of child bearing potential.
Combination therapy:
1. ACEI + CCB
2. ACEI + diuretic
3. ACEI + CCB + diuretic
If still uncontrolled consider 4th drug = spironolactone, higher dose of thiazide, BB.
4. If patient only on BB and not well controlled - add CCB not thiazide to decrease risk of diabetes.
11
Q
Doses of anti-hypertensive drugs
A
Thiazide: Chlortalidone 25-50mg
CCB: Nifedipine 30-60mg/24hrs
ACEI: Lisinopril 5-20mg/24 hr (max 40mg)
BB: Bisoprolol 2.5-5mg/24hrs
12
Q
ECG Leads: Anteroseptal infarct
A
LAD
V1+V2
13
Q
ECG Leads: Anterior infarct
A
LAD
V3+V4
14
Q
ECG Leads: Anteriolateral
A
LAD artery involved
I, aVL, V3-V6
15
Q
ECG Leads: Inferior infarct
A
RCA involved
II, III, aVF
16
Q
Right ventricle
A
RCA involved
V3R, V4R (right sided chest leads)
17
Q
ECG Leads: Posterior MI
A
RCA involved
V1, V2, prominent R waves
18
Q
ECG Leads: Lateral MI
A
Circumflex artery
I, aVL, V5-V6
19
Q
ECG changes: HyperK+
A
Mild hyperK+ (5-7mmol/L): tall peaked T waves
Severe hyperK+: P wave flattening, QRS widens.
20
Q
ECG changes: HypoK+
A
ST segment depression
Prolonged QT interval
Prominent U waves
21
Q
ECG changes: HyperCa++
A
Shortened QT interval
22
Q
ECG changes: HypoCa++
A
Prolonged QT interval
23
Q
Digitalis: Side effects
A
Palpitations Fatigue Vision changes - yellow vision Decreased appetite Hallucinations Confusion Depression
24
Q
Digitalis: ECG changes
A
Therapeutic levels: Dig effect ST downsloping/scooping = reversed tick T wave depression/inversion QT shortening First degree heart block
Toxic levels: Paroxysmal atrial tachycardia with conduction block Complete heart block Bradycardia PVC VT
25
Cardiac biomarkers
```
Troponin I&T
- Peaks 1-2 days, stays elevated up to 2
weeks.
- Check at presentation and 8hr later.
CK-MB
- Peaks 1 day, returns to BL 3 days later
- Can diagnose re-infarction.
AST and LDH
- Increased in MI
- Low specificity
BNP
- Secreted in response to stretch.
- Increased in MI, CHF, AF, PE, COPD
```
26
SVT: Types & management
Types:
- Sinus tachycardia
- AFib
- A-flutter
- Multifocal atrial tachycardia
- AVNRT
- AVRT (seen in WPW)
- Paroxysmal atrial tachy
Management:
- ABC's
- High flow oxygen
- Determine if rhythm is regular
- Irregular - treat as AFib - RACE
- Regular
1. Vagal manoeuvers - carotid massage,
valsalva.
2. Adenosine - 6mg bolus IV - followed
by 12mg bolus IV - another 12mg if
nec.
3. If adenosine doesn't work - assess if
patient is stable.
4. Unstable - sedate - synchronized DC
CV 100J - 200J, 360J. Or Amiodarone
300mg IV over 20-60min.
5. Stable - try metoprolol, verapamil, etc.
6. If all above fails - DC cardioversion.
27
Ventricular tachycardia: Types & management
```
Types:
- VT
- Torsades
- SVT with abberant conduction.
- AV conduction through bypass tract
(WPW).
```
```
Management:
1. Unstable:
- Synchronized DC shock = 100J -
360J- 360J.
- Amiodarone 300mg IV over 20 to
60min - followed by 900mg over 24hrs.
```
2. Stable:
- Reg rhythm: Amiodarone (as above)
- Irreg: Synchronized DC shock
28
A-Fib: Management
```
RACE
1. Rate control
- BB, diltiazem, verapamil.
- In patients with HF give digoxin,
amiodarone.
```
2. Anticoagulate
- Assess stroke risk with CHADS2.
- No risk = Aspirin 81-325mg
- 1 RF = aspirin or warfarin
- >1 RF = warfarin
3. Cardiovert
- AF < 48hrs CV without anticoag.
- AF > 48hrs anticoag for 3wk before
and 4wk after.
- If patient unstable cardiovert after ruling
out atrial clot with TEE
4. Etiology
- HTN, CAD, valvular disease,
pericarditis, cardiomyopathy, PE,
COPD, thyrotoxicosis, SSS, alcohol,
lone AFib.
Newly discovered AF
1. Rate control + anticoagulate
2. Cardiovert
```
Recurrent/Permanent AF
1. Rate control + anticoag.
2. If symptoms are bothersome or
episodes prolonged use anti-arrythmic
- No heart diseae = flecainide
- Heart disease = amiodarone, BB.
```
29
Ventricular fibrillation: management
ACLS
| Defibrillation
30
WPW: management
Electrocardioversion
IV procainamide
IV amiodarone
Avoid BB, CCB, digitalis
31
Torsades: management
Mg++
Temporary pacing
Electrical cardioversion if unstable
32
Pulmonary edema: Treatment
LMNOPP
Lasix - Furosemide 40-500mg IV
Morphine - 2-5mg IV (decreases anxiety and venodilation = decreases preload)
Nitroglyceran - IV/SL
Oxygen
Posture -sit patient upright
Positive pressure ventilation - CPAP, BiPap = decreases preload and need for ventilation.
33
Acute coronary syndrome: Risk factors
Non-modifiable risk factors:
- Age, male gender, family hx.
Modifiable risk factors (6):
- Smoking
- HTN
- Hyperlipedemia
- Obesity
- DM
- Sedentary lifestyle
Controversial risk factors:
- Stress
- Type A personality
- Apoprotein A increase
- Increased fibrinogen levels
- Hyperinsulinemia
- Elevated homocysteine levels
- Cocaine use
34
Criteria for diagnosing STEMI
ECG changes plus symptoms or elevated cardiac markers.
ECG changes:
- ST elevation > 2mm in 2 or more chest
leads.
- ST elevation > 1mm in 2 more more limb
leads.
- Posterior infarction = dominant R waves +
ST depression in V1-3.
- New onset LBBB.
35
Reperfusion in STEMI
1. PCI
- Treatment of choice in STEMI.
- If within 90min of patient arriving to
hospital.
- Most beneficial if carried out within
24hrs from onset of symptoms.
2. Thrombolytic therapy
- Administered if symptom onset is
within 12 hours.
- Door to needle time < 30min.
- Do rescue PCI in patients who do not
respond.
- Example: Streptokinase, Alteplase.
36
Management of STEMI
Goal is to reperfus artery: thrombolysis
within 30 minutes or primary PCI within
90 minutes.
```
Acute management:
- ABC's
- Attache ECG record 12 leads
- High flow oxygen (caution in COPD)
- IV access
- Bloods for FBC, U&E, cardiac marker,
glucose, lipids.
```
MONA:
- Morphine 5-10mg IV
- Oxygen
- Nitrate GTN SL 2 puffs or 1 tablet prn
- Aspirin 300mg
Thrombolysis:
- Streptokinase: 1.5million units in 100mL
0.9% saline IV over 1 hour.
- Alteplase: given as 2 IV boluses 2hrs
apart followed by heparin.
PCI:
- First choice if can be done within 90 mins
from admission.
- Start ASA, heparin.
- Start Gp IIb/IIIa (abciximab).
- Following stent placement give ASA and
clopidogrel for 12mo.
Additional medication to start:
- Atenolol 5mg IV (unless asthma, COPD,
LVF, bradycardia).
- Start ACEI in normotensive patient
(systolic > 120mmHG) within 24 hours =
Lisinopril 2.5mg
37
Contraindications to thrombolysis
Absolute CI
- Internal or heavy vaginal bleeding
- Acute pancreatitis
- Active lung disease with cavitation
- Recent trauma or surgery < 2 wks
- Severe HNT > 200/120mmHg
- Suspected aortic dissection
- Recent hemorrhagic stroke
- Esophageal varices
- Cerebral neoplasms
Relative CI:
- HTN
- Peptic ulcer
- History of CVA
- Bleeding
- Recent delivery
- Anticoagulants
- SBE
- Prolonged CPR
38
PCI; Explain procedure and risks
- Percutaneous coronary intervention also
known as coronary angioplasty is a non
surgical procedure to treat
stenotic/narrowed blood vessels in the
heart.
- The procedure involves feeding a deflated
balloon via a catheter through the femoral
or radial artery all the way up to your
heart.
- XRY imaging is used to see the
balloon.
- At the blockage site the balloon is
inflated and a stent is put in place.
- The patient is awake for the procedure.
Risks:
- Chest discomfort during procedure.
- Bleeding from the site of insertion.
- Bruising
- Hematoma
- Pseudoaneurysm
- Infection at puncture site
- Allergic reaction to dye.
- Kidney failure
Serious complications:
- Emergency CABG < 3%
- Death < 0.5%
- Stroke 1/1000
- VF
- MI 0.3%
- Restenosis 20-30% in 6 months
39
Definition: Unstable angina vs. NSTEMI
Unstable angina
- Chest pain that is new, accelerating or
occurs at rest.
- It signifies plaque instability and possible
impending infarction.
NSTEMI:
- Indicates myocardial necrosis with
elevation in cardiac markers.
- Defined clinically by 2/3 below
1. Symptoms of angina/ischemia
2. Rise/fall of markers of myocardial
necrosis
3. Evolution of ischemic ECG changes
without ST elevation or new LBBB.
40
Management of NSTEMI / Unstable Angina
Basic principals
- ABC's
- Admit to CCU for close monitoring.
- Identify and modify risk factors
```
BEMOAN: Acute management
- BB: Metoprolol 50-100mg/8hr po
Atenolol 5-100mg/24hrs po
- If BB CI give CCB:
Verapamil 80-120mg/8hr po
Diltiazem 6-120mg/8hr po
```
- Enoxaparin (LMWH) 1mg/kg/12hr sc
- LMWH preferred except in renal failure or
if CABG planned within 24hrs.
- Alternative: UFH 5000U IV bolus
- Morphine 5-10mg IV
- Oxygen high flow by face mask
- Aspirin 300 mg po
- Nitrates
GTN spray or sL tablets prn
Titrate to pain
Maintain systolic BP > 100
High risk patients:
- Persistent or recurrent ischemia despite
therapy.
- Give clopidogrel 300mg loading dose,
then 75mg QD.
- Arrange urgent angiogram with intention
of performing angioplasty or CABG.
```
Low risk patients:
- Pain resolving, normal ECG, neg
troponin.
- May be DC if repeat troponin is neg at
12hrs
- Treat medically.
- Predischarge exercise test. No signs of
ischemia = DC; signs of ischemia =
angiogram.
```
41
CABG versus PCI
CABG:
- Performed in left main stem disease,
triple-vessel disease, patients unsuitable
for angioplasty, failed angioplasty,
refractory angina.
- When CABG and PCI are both valid,
NICE guidelines recommends PCI.
- Patients with single vessel disease +
normal LV function undergo PCI.
- Patients with triple vessel disease +
abnormal LV function = CABG.
- Studies have shown same outcomes with
both procedures.
- CABG probably gives better long term
relief of stenosis but is associated with
increased risk of stroke & longer hospital
stays.
42
Thrombolysis complications
- Bleeding 10%
- Hypotension
- Allergic reaction
- Intracranial hemorrhage 0.3% with SK,
0. 6% with rt-PA.
- Reperfusion arrythmia.
- Systemic embolization.
43
Pericardial effusion: Causes, Sign & symptoms
```
Types:
1. Transudate/Serous - CHF,
hypoalbuminemia, hypothyroidism.
2. Exudate/Bloody/Serosanguinous -
trauma, post-MI, myocardial rupture, AD.
```
Signs & symptoms:
- Symptoms similar to acute pericarditis.
- Dyspnea, cough
- Recurrent laryngeal nerve irritation.
- Raised JVP
- Decreased PP
- Distant heart sounds +/- rub.
44
Classic 4 signs of cardiac tamponade
1. Hypotension
2. Increased JVP
3. Tachy
4. Pulsus paradoxus.
45
Beck's triad
Cardiac tamponade
1. Hypotension
2. Increased JVP
3. Muffled heart sounds
46
DDx of Pulsus paradoxus
Inspiratory fall in systolic BP > 10mmHg during quite breathing.
Occurs in:
- Constrictive pericarditis/tamponade
- Obstructive lung disease = asthma
- Tension pneumo
- PE
- Cardiogenic shock
47
Causes of Mitral Regurgitation
- Post MI due to papillary muscle rupture.
- HOCM
- Marfans
- Ehler Danlos
- Osteogenesis imperfecta
- Dilated cardiomyopathy caused by
alcohol
- Rheumatic fever.
48
Mitral stenosis: Cause, signs & symptoms, treatment
Causes:
- RF #1
- Calcification of mitral leaflets
- Rheumatoid arthritis
- SLE
- Malignant carcinoid
- Congenital stenosis.
```
Signs:
- SOB, orthopnea, palpitations.
- Malar flush
- Tapping apex beat
- Loud first heart sound
- Left parasternal heave = RVH
- Murmur: low pitched mid diastolic
murmur heard best in left lateral position
on expiration with bell.
```
```
Symptoms:
- Dyspnea
- Fatigue / weakness = due to decreased
CO.
- Malar fush
- Dysphagia = if LA gets large enough.
```
Treatment:
- Asymptomatic - just prophylaxis against
endocarditis.
- Mild symp: diuretics
- A-fib = rate control + anticoag.
- Balloon valvotomy/valvuoplasty.
- Complete valve replacement in patients
who are not good candidates for valve
repair or with severe MR + PHTN.
49
Types of pulses and the associated conditions
Collapsing pulse:
- Aortic regurgitation
- PDA
- AV fistula
Paradoxical pulse:
- Cardiac tamponade
- Left ventricular compression
- Pericarditis
- Severe asthma
Pulsus alterans: alternating strong & weak
- Severe heart failure
Slow rising pulse
- Mild to moderate aortic stenosis
50
Causes of wide pulse pressure
- Aortic regurgitation
- PDA
- AVF
- Thyrotoxicosis
- Fever
- Anemia
- Pregnancy
- Anxiety
- Heart block
- Aortic dissection
- Endocarditis
- Raised intracranial pressure
51
Constrictive pericarditis: SIGNS
- Raised JVP
- Kussmaul sign = increased JVP on
inspiration.
- Paradoxical pulse in 1/3 of patients
- Pericardial knock = 3rd heart sound
- Signs of right heart failure =
hepatosplenomegaly, ascites.
- Pericardial calcification
52
Third heart sound: Causes
Definition:
- Low pitched diastolic sound - heart at the
left sternal edge.
- Usually associated with abnormal filling in
a dilated heart.
Causes:
- Normal in children, anemia, pregnancy.
- LVF
- MR, AR = due to ventricular dilation.
- Constrictive pericarditis but not heard in
uncomplicated pericarditis.
53
A-Fib: Recognized causes
- Ischemia
- Hypertension
- Rheumatic heart disease
- Mitral valve disease
- Heart muscle disorders = alcoholic,
idiopathic cardiomyopathy.
- Diabetes
NOTE:
Aortic stenosis is not a direct cause of A-Fib.
54
Benzafibrate
Used to lower triglycerides
55
Ezetimibe
Second line agent for hyperlipidemia
56
ECG diagnostic features of acute MI
1. ST segment elevation of at least 1mm in
two adjacent limb leads.
2. ST segment elevation of at least 2mm in
two adjacent precordial leads.
3. New LBBB
57
Conditions known to be associated with aortic regurgitation
- Ulcerative colitis
- Ankylosing spondylitis
- Rheumatoid arthritis
- VSD
58
Causes of load first heart sound
- Thin person
- Hyperdynamic circulation = anemia,
thyrotoxicosis.
- Mitral stenosis
- Short PR interval
59
Canon waves
```
Cause:
- Occurs when right atrium contracts
against a closed tricuspid valve.
- Same timing as A-wave
Seen in:
- Complete heart block; not 2nd degree HB
```
60
Mid-diastolic murmur
- Mitral stenosis
- Tricuspid stenosis
- Austin flint murmur
61
Early diastolic murmur
- Aortic regurgitation
- Pulmonary regurgitation
- Graham steel = due to pulm reg in PHTN.
62
Ejection systolic murmur
- Aortic stenosis
- Pulmonary stenosis
- ASD
- HCM
- Fallot of tetralogy
- Flow murmurs from AR or PR
63
Pansystolic murmur
- Mitral regurgitation
- Tricuspid regurgitation
- VSD
64
Late systolic murmur
- HOCM = loudest on standing
- Mitral valve prolapse
- CoA
65
Down syndrome is associated with what heart defect?
- ASD
- TofF
- PDA
66
Marfans is associated with what heart defect?
- Aortic regurgitation
- VSD
- ASD
67
Features of tetralogy of fallot
1. Overriding aorta
2. RVH
3. Pulmonary stenosis
4. VSD
68
Placement of ECG leads
Yellow - Left arm
Green - Left leg
Red - right arm
Black - right leg = earth
```
V1 - 4th ICS right sternal boarder
V2 - 4th ICS left sternal boarder
V3 - 1/2 way between V3 and V4
V4 - Apex beat
V5 - Same plane as V4; AAL
V6 - Same plane as V4; MAL
```
69
Collapsing pulse
Definition:
- Large volume pulse with brisk rise and
fall.
Associated with:
- High cardiac output states.
- Anemia, thyrotoxicosis, aortic
regurgitation, PDA.
70
Complications of coronary angiography
- Mortality rate of 0.2%
- Complications increase with severity of
symptoms.
- 0.1% risk of stroke.
- 0.2% risk of MI
- Femoral access injury > radial
