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Cardio Flashcards

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1
Q

ECG timings

A

PR - 0.12-0,2 secs
QRS - 0.1s
QT interval - 0.4 secs
QTc - <450ms

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2
Q

Causes of PR interval shortening and lengthening

A

• Shortening - WPW syndrome

Lengthening - beta blockers, type 1 heart block, fit pt

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3
Q

What is the timing of the ECG squares?

A

• Small square = 0.04 seconds

Large square = 0.2 seconds

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4
Q

State the arteries of the leads on ECG

A

I, aVL, V5, V6 - LCx or diagonal branch of LAD (lateral)
V1-V4 - LAD (anterior)
II, III, aVF - RCA or LCx (inferior)

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5
Q

Sequence of evolving MIs on ECG?

A
  1. In minutes - ST elevation and T wave bigger
    1. Hours - R wave begins to decrease and Q wave begins to deepen
    2. 1-2 days - T wave inverts and Q wave deeper.
    3. Days later - ST normalises
    4. Weeks later - normal except for Q wave persistence
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6
Q

How would posterior MI present on ECG?

A

Reciprocal changes - ST depression

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7
Q

ECG changes for NSTEMI?

A

• ST segment depression
• T wave flattening or depression
NSTEMI is more persistant than UA

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8
Q

How can you clinically differentiate between unstable angina and NSTEMI?

A

NSTEMI - ELEVATED BIOMARKERS. UA NO ELEVATION

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9
Q

ECG changes for pericarditis?

A

Widespread ST elevation with saddle back shape

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10
Q

ECG changes for pace makers?

A

paceing spikes before QRS.

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11
Q

ECG changes for wandering pacemeker? Patho of wandering pacemaker? Pts who get it?

A

• Atrial arrhythmia where cardiac pacemaker switches between SAN, atria, and AVN
• Pts with resp failure eg exacerbation of COPD
Varying PP and PR intervals. 3 distinct P wave morphologies in the same lead

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12
Q

Causes of long QT

A

• Antiarrhythmics - amiodarone, sotalol
• TCAs
• Erythromycin and azithromycin
Electrolyte - hypocalcemia, hypokalaemia, hypomagnesaemia

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13
Q

Patho of WPW

A

• Congenital accessory conducting pathway leading to atrioventricular re-entry tachycardia (AVRT)
Can degenerate rapidly to VF

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14
Q

ECG changes for WPW

A

• Short PR

Wide QRS complex with delta wave - slurred upstroke

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15
Q

Tx of WPW?

A

• Ablation of accessory pathway - definitive

Medical management - sotalol (avoid if AF), amiodarone, flecainide

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16
Q

Hypokalaemia on ECG?

A
  • U waves
    • Small or absent T waves
    • Prolonged PR interval
    • ST depression
    • Long QT

“In hypokalaemia, U have no Pot and no T, but a long PR and a long QT”

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17
Q

Hyperkalaemia on ECG?

A
  • Flattened P waves
    • Widened QRS
    • Tall tented T waves
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18
Q

ECG changes for hypothermia?

A
  • Bradycardia

* J wave - size of wave is proportional to hypothermia

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19
Q

ECG changes for digoxin?

A
  • Downsloping ST depression
    • Flattened, inverted or biphasic T waves
    • Shortened QT
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20
Q

Acute tx for STEMI?

A

Acute Treatment (MONA):
• M - Morphine + metoclopramide
• O - Oxygen (if O2 <94%)
• N - Nitrates (if hemocompromised DO NOT USE)
• A - Antiplatelets (aspirin + prasugrel)

Is PCI available within 120 mins?
a. Yes - pci
No- Fibrinolysis (tPA) with rescue PCI if not successful

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21
Q

ECG indications for PCI for STEMI

A

• ST elevation of >2mm in V1-V6 OR
• ST elevation of >1mm in inferior leads OR
New left bundle branch block

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22
Q

Post MI tx?

A 
• Lifelong therapy of:
		○ Aspirin
		○ Antiplatelet eg clopidogrel
		○ Beta blocker
		○ ACEi
		○ Statin
	• Lifestyle advice:
		○ Mediterranean diet
		○ Exercise - until slight breathlessness
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23
Q

PCI contraindications?

A 
• Due to antiplatelets
	• High risk of bleeding
	• Allergy 
	• Uncontrolled HT
	• Stroke 
Bleeding disorders
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24
Q

Acute tx of NSTEMI?

A
  1. Morphine +anti emetic (metoclopromide) + GTN (don’t use if hemocompromised)
    1. Antiplatelets - aspirin (300mg PO) + clopidogrel
    2. Beta blockers to limit ischemia (metoprolol) or verapamil if contra
    3. Fondaparindux to disrupt thrombus
    4. IV nitrate if pain continues
    5. Record ECG and stratify risk using GRACE + TIMI
      a. High risk - infusion of GPIIb/IIIa antagonist + angiography referral
      b. Low risk - Treat medically and arrange further investigation eg stress test
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25
Pathology of STEMI/atheroma?
1. Initial endothelial damage caused by smoking, HT, or hyperglycemia etc 2. Results in inflammation and oxidative damage 3. LDL particles infiltrate subendothelial space 4. Macrophages infiltrate and phagocytose LDL and turn into foam cells. Macrophages die and propagate inflammation Smooth muscle proliferation and migration into tunica intima results in formation of fibrous capsule covering fatty plaque
26
IHD RFs modifiable and non modifiable
``` HOPEFULS H - HTN O - Obesity P - PVD E - Elevated LDL F - FHx U - Up glucose (DM) L - Low HDL S - Smoking, Sex (male), Sedentary ```
27
S&S of ACS
``` Chest pain: • Typically central or left sided • May Radiate to jaw or left arm • Described as heavy or constricting Certain pts eg elderly or diabetics may experience no CP ``` Other symptoms: • Dyspnoea • Sweating N&V Examination: • Cold and Clammy All life signs may be normal
28
Diagnostic criteria for ACS?
2 of 3 needed: • Clinical history • ECG changes Blood results
29
Ix for ACS?
ECG | Bloods - troponin
30
S&S of stable angina
• Chest pain on exertion | Relieved by rest or GTN spray
31
What must you remember about CCBs and why?
NEVER EVER MIX 2 TYPES OF CCB - causes complete heartblock
32
Ix for stable angina?
• ECG Exercise tolerance test shows: | ST depression
33
Tx for stable angina?
1st line - bisoprolol + aspirin + statin + glyceryl nitrate 2nd line - + CCB (nifedipine, amlodopine) 3rd line - + long acting nitrate or ivabradine 4th line - ? PCI or CABG
34
S&S of unstable angina
• Pain on exertion NOT relieved by rest | NO elevated serum biomarkers
35
Complications of MI?
1. Cardiac arrest following V fib 2. Cardiogenic shock 3. Chronic heart failure Arrhythmias
36
Qs to ask for cardiac history
• Chest pain - Does it hurt to touch? MSK likely. • SOB • Dizziness and syncope? • Palpitations - abnormality in heartbeat causes conscious awareness • Orthopnoea or PND? Peripheral oedema
37
S&S of pericarditis pain
Sharp pain relieved by sitting forwards.
38
S&S of dissecting aortic aneurysm pain
Tearing chest pain radiating to back | Unequal upper limb blood pressure
39
Angina S&S and features of typical + atypical angina
Angina symptoms: • Constricting Discomfort in front of chest, neck, shoulders, jaw or arms • Precipitated by exercise • Relived with rest or GTN in about 5 mins All 3 features is typical angina. 2 features is atypical. 1 or less is non angina.
40
Chest pain referral criteria
• Current CP in past 12 hrs with abnormal ECG - Emergency admission • CP 12-72 hrs ago - Refer to hospital for same day assessment CP >72 hrs ago - ECG and troponin then assess
41
Signs of CVS instability?
• Pulmonary oedema • Angina Decrease BP
42
Investigation to be done for all possible cardiac problems?
TFT
43
Patho of S3 and S4?
S3 - • Caused by stiff or dilated ventricle which reaches sudden elastic limit and decelerates rush of blood, S4 - • Atrial contraction into a non-compliant or hypertrophied ventricle
44
Where do the 4 common left murmurs radiate to?
• Aortic stenosis - to carotids • Aortic regurg - 3rd ICS on left on expiration with pt leaning forward • Mitral regurg - Left axilla Mitral stenosis - little radiation
45
Classification of HF
Class I - no limitations Class II - slight limitations Class III - Marked limitations Class IV - Symptoms at rest
46
S&S of HF
Pulmonary oedema, ankle swelling, exercise intolerance, raised JVP, PND, cardiomegaly
47
LT pharm tx of HF
1st line - ACEi + BB 2nd line - + Aldost antag OR +ARB +Hydralazine with nitrate 3rd line - +digoxin OR + ivabradine Fluid overload - furosemide
48
Which drugs improve mortality and which only improve symptoms in HF?
Drugs which improve symptoms ONLY: • Loop diuretics eg furosemide Digoxin ``` Drugs which improve mortality in HF: • ACEi • Spironolactone • Beta blockers Hydralazine with nitrates ```
49
Non pharm tx of HF
``` Non drug management: • Cardiac resynchronisation therapy: ○ If HF and wide QRS ○ Biventricular pacing • Exercise training improves symptoms • Annual flu vaccine One off pneumococcal vaccine - if asplenic or CKD need booster every 5 yrs ```
50
S&S of acute HF
Symptoms: • Dyspnoea • Orthopnoea Pink frothy sputum
51
Ix for acute HF
``` • CXR - ABCDE BNP • ECG - Signs of MI, arrhythmias • U&E, troponin, ABG Echo ```
52
Tx of acute HF
1. Sit pt upright 2. 100% oxygen non rebreath mask 3. IV access and ECG. Treat arrhythmias 4. Investigations whilst continuing treatment 5. Diamorphine IV 1.25-5mg 6. Furosemide 40-80mg IV 7. GTN spray 2 puffs. DON’T GIVE IF HEMOCOMPROMISED 8. If systolic >100mmHg, nitrate infusion eg isosorbide dinitrate 9. If pt worsening, consider CPAP Consider discontinuation of beta blockers in short term.
53
Ix for HF
Echo Bloods - BNP, U&E, FBC to find underlying cause CXR LOOK FOR CAUSE OF HF.
54
Causes of HF cardiac and extra cardiac
Causes of HF: 1. Cardiac - IHD, congenital, valvular disease, cardiomyopathies Extra Cardiac - HTN, pulmonary, iatrogenic
55
AF Tx
Rate control for older than 65 or history of IHD Everything else rhythm control. Rate control - atenolol, diltiazem or verapamil, or digoxin (if HF coexistant) Rhythm control - if pt hemo stable: • Flecainide - Flecainide if no structural heart disease • Amiodarone - AMIODARONE ONLY THROUGH CENTRAL LINE Sotalol If pt not hemostable: • Electrical cardioversion. Give midazolam for sedation before shocking.
56
What is CHADSVASC?
``` Risk factor Points C Congestive heart failure 1 H Hypertension (or treated hypertension) 1 A2 Age >= 75 years 2 Age 65-74 years 1 D Diabetes 1 S2 Prior Stroke or TIA 2 V Vascular disease (including ischaemic heart disease and peripheral arterial disease) 1 S Sex (female) 1 ```
57
What is HAS-BLED
``` Risk factor Points H Hypertension, uncontrolled 1 A Abnormal renal function 1 Or Abnormal liver function 1 S Stroke, history of 1 B Bleeding, history of bleeding 1 L Labile INRs 1 E Elderly (> 65 years) 1 D Drugs Predisposing to Bleeding (Antiplatelet agents, NSAIDs) 1 for drugs Or Alcohol Use (>8 drinks/week) 1 for alcohol ``` 3+ = high risk
58
Diagnosing HTN?
If a clinic reading is >140/90mmHg, repeat. If still above: | • Offer ABPM - ambulatory blood pressure monitoring, or HBPM
59
When to treat HTN
``` ○ If >135/85 mmHg - treat if <80 yo AND: § Organ damage § Established CVD § Renal disease § Diabetic § 10 yr CV risk of 20+% ○ If >150/95 mmHg - treat regardless ```
60
Tx of HTN?
If below 55: 1st line - ramipril 2nd line - ramipril + diltiazem 3rd line - + thiazide diuretic (indapamide) 4th line - K less 4.5 mmol add spiro if more increase dose thiazide diuretic If above 55 or black: 1st line - diltiazem and then continue as usual
61
Consequences of HTN
``` • Increased risk of MI + Stroke • Aneurysms • HF • Retinopathy Nephropathy ```
62
Lifestyle advice for HTn
• Low salt diet - <6g/day • Caffeine intake reduce Stop smoking, less alcohol, balanced diet, exercise, lose weight
63
S&S of malignant HTN
• Headache • +/- visual disturbance Underlying causes may be present eg pain
64
Tx of malignant HTN
• Use oral therapy with short half life so you can monitor the drop in BP without taking ages Reduce BP by not more than 25% to avoid stroke risk
65
Signs of hypertensive retinopathy?
Graded: 1. Tortuous arteries with thick shiny walls - copper wiring 2. A-V nipping (narrowing where arteries cross veins) 3. Flame haemorrhages and cotton wool spots 4. Papilloedema
66
After how many weeks gestation is pre eclampsia seen
20
67
Tx of pre-eclampsia
• Treat if above 160/110 mmHg • Oral labetalol first line. Nifedipine and hydralazine may also be used Delivery of baby is definitive step if gestation allows.
68
RFs for pre-eclampsia
``` • >40 yrs old • Multiple pregnancy • Fat • T2DM • FHx Pre-existing vascular disease eg htn ```
69
S&S of severe pre-eclampsia
``` • Hypertension above 170 systolic • Headache • Visual disturbance • Papilloedema • RUQ pain • Hyperreflexia Low platelet count ```
70
How many korotkov sounds are there
5
71
RFs for infective endocarditis
``` • Previous episode of endocarditis (strongest) • Rheumatic valve disease • IVDU • Immunocompromised • Congenital heart defects Prosthetic valve ```
72
S&S of IE
• Fever + New murmur = Endocarditis until proven otherwise • Sepsis - fever, rigors, night sweats, malaise, weight loss • Look at hands - janeway lesions (painless), oslers node (painful), splinter hemorrhages, clubbing IE can cause emboli to occur anywhere in body. Janeway lesions and oslers nodes are emboli in the skin
73
MOs causing IE. What are they each associated with?
* Strep viridans - 50% cause - Usually following dental procedure or poor dental hygiene * Staph epidermis - especially prosthetic * Staph aureus - IVDUs, acute presentation * Strep bovis - associated with colorectal cancer. MUST UNDERGO COLONOSCOPY FOR MALIGNANCY
74
S&S of aortic stenosis
• Exertional Syncope - Most severe symptom. • Chest pain/Angina SOB ESM radiating to neck
75
Causes of aortic stenosis
* Degenerative calcification - most common if pt >65 | * Bicuspid aortic valve - most common if pt <65
76
Tx of aortic stenosis
• If asymptomatic + valvular gradient <50mmHg - observe • Asymptomatic but valvular gradient >50mmHg AND features eg LV systolic dysfunction consider surgery If symptomatic - valve replacement
77
Pros/cons of mechanical or biological valve replacement?
• Biological - LT Anticoag not needed. Deteriorates faster | Mechanical - Need LT anticoag. Lasts longer
78
signs of severe aortic stenosis?
``` Signs of severe stenosis: • Narrow pulse pressure - small difference in pressures • Delayed ESM • Delayed radial pulse • Soft or absent S2 LVH or failure ```
79
Mitral regurg features
• Pan systolic murmur • Soft S1, split S2 Mitral area/apex heard. Radiation to L axilla
80
Causes of mitral regurg
• Calcification | Endocarditis
81
Mitral stenosis causes
Rheumatic fever
82
Ix for mitral stenosis
echo | CXR - atrial enlargement
83
Symptoms of mitral stenosis
• SOBOE progressing to SOB at rest | PND with severe MS
84
Features of mitral stenosis
``` • Mid-late diastolic murmur louder expiration. Roll pt to their left and use the bell of the steth • Loud S1 • Low volume pulse • Malar flush AF ```
85
features of aortic regurge
• Early diastolic murmur - 'blowing murmur'. Heard best when pt upright on expiration. • Collapsing pulse • Wide pulse pressure - big difference in pressures. Results in multiple signs: ○ Double impulse pulse ○ De Musset sign - head bobbing with each systole ○ Quicke sign - capillary pulsation visible at proximal nail beds
86
Aortic regurg causes
``` Valve disease causes: • Rheumatic fever • Infective endocarditis • Connective tissue disease eg RA/SLE Bicuspid aortic valve ``` Aortic root causes: • Aortic dissection • HTN Marfans
87
S&S of cardiac tamponade
• Beck's triad: ○ Low arterial BP ○ Distended neck veins - raised JVP with an abscent Y descent ○ Distant muffled heart sounds • Tachycardia • Pulsus Paradoxus (large fall in systolic BP on inspiration, due to additional pressure on heart)
88
Tx of cardiac tamponade
Pericardiocentesis under USS. Subxiphoid approach
89
Causes of pericardial effusion
``` • Infectious pericarditis • Uraemia • Post MI • Malignancy HF ```
90
S&S of pericarditis
* Chest pain may be pleuritic. Relieved by sitting forwards * Dyspnoea * Pericardial rub * Non productive cough * Tachypnoea and tachycardia
91
Causes of pericarditis
``` • Viral infections (coxsackie) • TB • Uraemia • Trauma Post MI ```
92
RFs for aortic dissection
* Hypertension * Trauma * Bicuspid aortic valve * Collagen deficiency - marfans, ehlers danlos
93
Classify aortic dissection
* Type A - Ascending aorta, 2/3rd of cases | * Type B - descending aorta
94
Tx of aortic dissection
• Type A - Surgery (aortic root replacement), reduce BP | Type B - Conservative, bed rest, reduce BP
95
Ix for aortic dissection
• CXR - widened mediastinum, abnormal aortic knob, tracheal and oesophageal deviation • CT angiography of thoracic aorta MRI angiography
96
MO for rheumatic fever?
group a strep
97
What are the 2 types of CCB and give egs
Non-dihydropyridines - verapamil, diltiazem. Selective for myocardium Dihydropyridines - nifedipine, amlodopine, felodopine. Non selective
98
How to treat non hemo compromised broad complex tachy peri-arrests
• Loading dose amiodarone followed by 24 hr infusion | IF torsades de pointes - magnesium IV
99
How to treat non hemocompromised narrow complex tachy peri arrests
• Use vagal maneouvre. Eg valsalva maneouvre • If doesn’t work use IV adenosine (contra in asthmatics, use verapamil instead) Electrical cardioversion
100
How to treat hemocompromised peri arrests if tachy or brady
Tachy - immediate synced DC cardioversion and thromboprophylaxis Brady - atropine first line. Transvenous pacing second line.
101
Asystole Tx?
Transvenous pacing. If there is a delay of transvenous pacing, administer: • Atropine up to 3mg • Transcutaneous pacing Adrenaline titrated to response
102
Tx of TCA overdose
• IV bicarb | IV lipid emulsion
103
Describe JVP waveform
``` A - Atrial contraction C - RV Contraction. Tricuspid bulges into atria X - atrial relaXation and filling V - Venous filling Y - passive emptYing of atria into RV. ```
104
Define broad QRS. Patho of broad QRS?
QRS more than 160ms • Re-entry caused by a blocked/slowed pathway resulting in a loop. Commonly after MI. Abnormal conduction caused by medication eg digoxin or abnormalities eg torsades and Mg.
105
Causes of VF
• MI • Electrolyte abnormalities • Cardiomyopathy Long QT --> TdP --> VF
106
Tx of VF
IMMEDIATE DC SHOCK UNSYNCHRONISED (synchronised wont work as there isnt a rhythm to sync to so the machine will waste time trying to find a rhythm before delivering a shock).
107
S&S of AVNRT
* Sudden onset rapid regular palpitations | * Well tolerated and rarely life threatening
108
Tx of AVNRT
1. Valsalva maneouvre | Adenosine
109
ECG changes of AVNRT
• P waves present BUT buried in QRS complex. | REGULAR RHYTHM
110
Tx of AVN block
Atropine A1 agonist
111
Give cyanotic congenital heart disease
TTT Tricuspid atresia Transposition of great arteries Tetralogy of Fallot
112
Pattern of inheritance for HOCM?
Auto dom
113
Patho of HOCM?
* Common defect is gene encoding beta-myosin or myosin binding protein C * 1 in 500
114
ECG changes of HOCM
• LVH • Progressive T wave inversion Deep Q waves
115
Echo changes of HOCM?
Echocardiogram - MR SAM ASH: • Mitral Regurg • Systolic Anterior Motion of anterior mitral valve leaflet • Asymmetric Hypertrophy
116
S&S of HOCM?
• Young person presenting with unusual collapse or sudden death • Often asymptomatic • Dyspnoea, angina, syncope • Double apex beat, jerky pulse, large 'a' waves • Ejection systolic murmur which increases with Valsalva manoeuvre Associated with WPW and friedrichs ataxia
117
Patho of aneurysm
• Dilatation of all layers of arterial wall • Caused by degenerative disease Dilatation of 50+% is aneurysm
118
S&S of aneurysm
• Silent. MAY cause abdo/back pain | Can burst leading to shock - hypovolemic
119
Ix of anuerysm
Investigations: • USS - first line CT with contrast
120
Common sites of anuerysms
• Aorta • Iliac • Femoral Popliteal

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