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Phase 3B > Cardiology 1 > Flashcards

Cardiology 1 Flashcards

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1
Q

What is a channelopathy?

A

A genetic disorder in which the electrical activity of the heart is abnormal, but the heart is structurally normal.

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2
Q

When do symptoms first appear in channelopathies?

A

30-40 years

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3
Q

What is the cause of Brugada syndrome, a type of channelopathy?

A

Cardiac sodium channelopathy (SCN5A gene)

Autosomal dominant inheritance but can be a new mutation.

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4
Q

How does Brugada syndrome cause arrhythmias?

A

Abnormally slow conduction in the heart - decreased flow of Na+ ions changes the AP, slowing conduction.
“Short circuits” form, causing wavebreak and causing re-entry (U-turns).

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5
Q

What are the symptoms of channelopathies?

A 
May be asymptomatic
Syncope
Sudden cardiac death
Palpitations
Chest pain
Breathlessness or dizziness
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6
Q

How is syncope caused by a channelopathy?

A

Brief arrhythmias revert to a normal rhythm spontaneously OR vasovagal syncope.

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7
Q

In Brugada syndrome, when do arrhythmias occur?

A

At rest
Following a heavy meal
Fever/alcohol
When vagus nerve is activated

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8
Q

How is Brugada syndrome diagnosed?

A

Genetic testing
ECG with or without flecainide (provocation test):
Brugada sign: coved ST segment elevation >2mm in >1 of V1-V3 followed by a negative T wave

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9
Q

What must Brugada sign be associated with to diagnose channelopathies?

A

One of:

  • Documented VF or polymorphic VT
  • FH of SCD<45 years
  • FH of similar ECG
  • Syncope
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10
Q

Which arrhythmias may be caused by a Brugada syndrome?

A

Ventricular fibrillation
Polymorphic ventricular tachycardia
AV nodal re-entrant tachycardia
Sinus node dysfunction

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11
Q

As part of the treatment of Brugada syndrome, what triggers must be avoided?

A 
Fever
Alcohol and drugs
Dehydration
Tricyclics, anaesthetics, sodium channel blockers (flecainide)
CCBs
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12
Q

What is the main treatment of Brugada Syndrome?

A

Implantable cardiac defibrillator

If not appropriate - quinidine

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13
Q

What is a normal QT interval?

A

<440ms (two large squares)

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14
Q

What are the risks of prolonged QT syndrome?

A

Delayed repolarization of the heart following a heart beat increases the risk of toursades des pointes episodes

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15
Q

What are the congenital causes of LQTS?

A

Cardiac ion channel mutation:
Jervell and Lange Nielson syndrome
Romano-Ward syndrome

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16
Q

What are the acquired causes of LQTS?

A 
Low Ca/K/Mg
Drugs: amiodarone, TCAs, SSRIs
MI
3rd degree heart block
Fasting and bradycardia
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17
Q

What are the subtypes of LQTS?

A

Potassium channel: risk of SCD when patient is startled or awoken suddenly
Sodium channel: risk of SCD when patient is sleeping

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18
Q

What are the symptoms of LQTS?

A

Syncope and palpitations as a result of polymorphic VT

Nausea, pallor, dyspnoea, chest pain

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19
Q

What is seen on the ECG in LQTS?

A

QTc>440m/s
Toursades des points
Degeneration into sustained VT or VF

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20
Q

What is the treatment of congenital LQTS?

A

Propanolol (unless bradycardic)
Pacing
ICD

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21
Q

Why is propranolol contra-indicated in acquired LQTS?

A

Bradycardia can precipitate toursades.

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22
Q

What is the treatment of toursades des pointes?

A

IV magnesium sulphate
Temporary atrial pacing to increase HR and reduce QT
Correct predisposing factor e.g. QT prolonging drug
IV isoprenaline

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23
Q

Define cardiomyopathy.

A

Myocardial disorder in which the heart muscle in structurally and functionally abnormal without coronary artery disease, hypertension, valvular, or congenital heart diseases.

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24
Q

How can cardiomyopathies present?

A

Heart failure
Arrhythmias
SCD
Thromboembolism

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25
What is the most common form of cardiomyopathy?
Dilated cardiomyopathy
26
What is the hallmark of dilated cardiomyopathy?
Left or both ventricles are dilated with impaired systolic function
27
What are the causes of dilated cardiomyopathy?
Idiopathic Familial Alcoholic
28
What is hypertrophic cardiomyopathy?
Left or right sided hypertrophy leading to LV outflow obstruction
29
What is affected in restrictive cardiomyopathy?
Diastolic filling
30
What is the pathophysiology of arrhythmogenic right ventricular cardiomyopathy?
Fatty and fibrous replacement of ventricular myocardium
31
Prolonged isometric training may result in athlete's heart which may have features of...
Hypertrophic cardiomyopathy
32
What is seen on CXR in cardiomyopathy?
Cardiomegaly
33
What is seen on ECG in cardiomyopathy?
T wave inversion ST changes LVHT
34
What investigation differentiates between the different types of cardiomyopathy?
Transthoracic echo
35
What are the aims of treatment in cardiomyopathy?
Symptomatic Treat heart failure Prevent thromboembolism
36
What is the treatment of cardiomyopathies?
BB Verapamil ICD Cardiac Tx
37
What are the indications for amiodarone in cardiomyopathy?
Massive LVHT Family history SCD Unexplained syncope VT
38
What is infective endocarditis?
Infection of the endocardium, cardiac valves, intrathoracic vessels and prostheses.
39
What are the effects of infective endocarditis?
Valvular insufficiency | Systemic emboli
40
What are the two factors required for development of infective endocarditis?
Bacteraemia | Abnormal cardiac endothelium
41
Name three risk factors that cause bacteraemia and therefore infective endocarditis.
Poor dental hygiene - s.viridans IV drug use - s.aureus Cardiac surgery - s.epidermis
42
Name some causes of abnormal cardiac endothelium.
Valvular disease including replacement Structural heart disease Hypertrophic CMY
43
What are the most common organisms in infective endocarditis?
S.aureus | S.viridans
44
What are the symptoms of infective endocarditis?
Fever New/changing murmur CCF Pleuritic or back pain
45
Name some immunological phenomena of infective endocarditis.
Splinter haemorrhages Roth's spots Glomerulonephritis Embolic stroke
46
Name 6 signs of infective endocarditis.
``` Petechiae Splinter and subungal haemorrhages Osler's nodes Roth's spots Janeway lesions Splenomegaly ```
47
What are the appropriate investigations for infective endocarditis?
3 sets of blood cultures prior to starting treatment | ECG, CXR, TTE
48
What is the diagnostic criteria for infective endocarditis?
Modified Duke criteria Major: +ve culture, evidence of endocardial involvement Minor: predisposition, fever, vascular/immunological phenomena, echo findings
49
What is the choice empirical antibiotic for infective endocarditis whilst awaiting blood culture results?
Amoxicillin and gentamycin
50
What is the typical cause of pericarditis?
80% postviral or idiopathic
51
What is the function of the pericardium?
Protects cardiac efficiency by limiting dilation, maintaining ventricular compliance. Aids atrial filling and is a barrier against infection Reduces external friction
52
Name three other causes of pericarditis.
SLE Sarcoidosis Primary/metastatic neoplasms
53
Describe the pain of pericarditis.
Sharp pain in the substernal/precordial region, which can radiate to the neck or shoulders. Inspiration, swallowing, coughing, and lying flat exacerbates pain; sitting up or leaning forward relieves pain.
54
What are the other symptoms of pericarditis?
Fever Chills Non-productive cough Signs include tachycardia, tachypnoea.
55
What is the pathognomonic sign of pericarditis?
Pericardial friction rub heard best in the midline and lower left parasternal edge, louder in inspiration
56
Why does dyspnoea develop in pericarditis?
Cardiac tamponade
57
What are the main ECG changes seen in pericarditis?
Saddle shaped ST elevation T wave elevation which flattens and inverts as time goes by PR segment depression
58
What is seen on CXR in pericarditis?
Enlarged flask shaped cardiac silhouette
59
What other investigations should be done in suspected pericarditis?
Echo Blood cultures Bloods for WCC, ESR, CRP, urea, cardiac enzymes, RF etc
60
What is the treatment of pericarditis?
Rest and avoid physical activity Naproxen 250mg 6-8hourly Colchicine
61
What is Beck's triad of cardiac tamponade?
Hypotension, elevated systemic venous pressure, muffled heart sounds.
62
Define hyperkalaemia.
Plasma potassium >5.5mmol/L | Severe>6.5mmol/L
63
Give four causes of hyperkalaemia.
AKI/CKD Tumour lysis syndrome DKA Spironalactone
64
The symptoms of hyperkalaemia are non specific; what are the signs?
Bradycardia from heart block Tachypnoea from respiratory muscle weakness Flaccid paralysis Depressed or absent tendon reflexes
65
What is seen on ECG in hyperkalaemia?
Peaked T waves, wide QRS complex, prolonged PR interval, reduced P wave
66
What is the cardiac protection aspect of hyperkalaemia treatment?
10ml 10% calcium gluconate
67
How is hyperkalaemia managed after cardiac protection?
Insulin-glucose infusion, then nebulised salbutamol if necessary Calcium resonium
68
Define hypokalaemia.
Serum K<3.5mmol/L | Severe<2.5mmol/L
69
Give four causes of hypokalaemia.
Persistent vomiting Burns Respiratory or metabolic alkalosis Diuretic use
70
what are the symptoms of hypokalaemia?
Generalised weakness and then paralysis Constipation Respiratory failure and ileus Paraesthesiae and tetany
71
What is seen on ECG in hypokalaemia?
Flat T waves, ST depression, prominent U waves
72
What other investigations are important in hypokalaemia?
U&Es, ABG, urinalysis for K, Na, and osmolality
73
What is the oral ambulatory treatment of mild hypokalaemia in primary care?
Perform an ECG Treat any underlying cause Dietary supplementation 40-120mmol/day
74
What is the treatment of severe hypokalaemia?
PO potassium bicarbonate in lower risk patients | IV KCL in normal saline 10mmol/hour or less, until ECG abnormalities resolve
75
Define hypocalcaemia.
Serum corrected calcium<2.1mmol/L
76
What are the causes of hypocalcaemia?
``` Hypoparathyroidism Secondary hypoparathyroidism Tumour lysis syndrome Osteoblastic metastases Acute pancreatitis ```
77
How does hypocalcaemia present?
Paraesthesia of the fingers, toes, and mouth | Tetany, muscle cramps, and carpopedal spasm
78
What are the main signs of hypocalcaemia?
Chvostek's sign Trousseau's sign Laryngospasm Seizures
79
What is seen on ECG in hypocalcaemia?
Arrhythmias and prolonged QT interval
80
What blood tests are important in hypocalcaemia?
U&Es: exclude CKD Amylase: exclude pancreatitis CK: exclude rhabdomyolysis Serum PTH, Mg, PO4, vit D
81
What is the treatment of acute hypocalcaemia (symptomatic, or calcium <1.9mmol/L)?
Slow 10ml IV 10% calcium gluconate Correct Mg prior if low
82
Define hypercalcaemia?
Serum calcium>2.5mmol/L
83
What are the most common causes of hypercalcaemia?
Primary hyperparathyroidism Ectopic PTH Granulomatous conditions e.g. TB or sarcoid
84
What are the main symptoms of hypercalcaemia?
``` Polyuria and polydipsia Dyspepsia Depression Constipation Muscle weakness Nausea and anorexia Abdo pain and pancreatitis Coma Cardiac arrhythmias and shortened QT interval ```
85
Which investigations are required in hypercalcaemia?
PTH X-Ray USS parathyroid U&Es, LFTs for ALP
86
What is the treatment of acute hypercalcaemia?
0.9% saline IV pamidronate or IV zolendronic acid Furosemide if fluid overload
87
What is the treatment of symptomatic PTH-mediated hypercalcaemia?
Reduce dietary calcium | Partial parathyroidectomy
88
What are the types of PE?
Thrombosis Fat following long bone fracture Amniotic fluid Air
89
What is Virchow's triad?
Hypercoagulability Reduced mobility Blood vessel abnormalities
90
Other than surgery, thrombotic disorders, and heart disease, give fourother risk factors for a PE.
Malignancy Late pregnancy/puerperium Myeloproliferative disorders COCP/HRT
91
How does a PE present?
Dyspnoea Pleuritic/retrosternal chest pain Cough and haemoptysis Collapse/sudden death
92
What are the signs of PE?
Tachypnoea, tachycardia, pyrexia, hypotension Hypoxia Raised JVP Gallop rhythm, split S2, TR murmur
93
How is PE diagnosed?
CTPA and raised D-Dimer | Two level PE Well's score
94
What is Hampton's hump?
Wedge shaped area of pulmonary infarction seen on CXR
95
What is seen on ABG in PE?
Reduced PaO2 | Reduced PaCO2 due to hyperventilation or acidosis
96
What is the management of PE?
ABCDE approach 100% oxygen, IV access If haemodynamically unstable: IV alteplase If not, then LMWH or fondaparinux
97
What is the further management of patients who have had PE?
Warfarin or rivaroxaban 3 months and then assess risks and benefits of continuing
98
What is the management of recurrent PE on anticoagulation?
Inferior vena cava filter
99
What are the contraindications to LMWH or fondaparinux and what is the alternative?
eGFR<30ml Bleeding risk Unfractionated heparin
100
What is aortic dissection?
Disruption of the medial layer of the wall of the aorta provoked by intramural bleeding, resulting in separation of the aortic wall layers and subsequent formation of a true lumen and a false lumen
101
Give five causes of aortic dissection.
``` Hypertension Marfan's syndrome or EDS Direct blunt chest trauma Cocaine and amphetamines Familial thoracic aortic aneurysm type 1 and 2 ```
102
What are the two classification systems for aortic dissection?
Stanford and Debakey
103
What is the main symptom of aortic dissection?
Migratory tearing/sharp chest pain
104
What can aortic dissection lead to?
``` Cardiac tamponade Haemothorax Sudden death Multiorgan failure Cardiac failure from gross AR ```
105
How is suspected aortic dissection investigated?
Distinguish from MI as thrombolysis will worsen the dissection ECG normal or non specific ST changes Echo
106
How is aortic dissection managed?
IV access, analgesia, ICU IV BB to reduce the force of ventricular contraction Blood products Stents or grafts
107
What is seen on ECG in pulmonary embolism?
Sinus tachycardia
108
What is seen on ECG in hypothermia?
J waves
109
What is the treatment of acquired LQTS?
Correct predisposing factor IV MgSO4 IV isoprenaline accelerates AV conduction and decreases QT interval
110
How is streptococcal infection diagnosed?
High anti-streptolysin O titre

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