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Cardiology Flashcards

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1
Q

Unstable angina vs NSTEMI

A

UA- no ST elevation and troponin normal

NSTEMI - no ST elevation , troponin raised

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2
Q

What is acute coronary syndrome?

A

STEMI NSTEMI UA

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3
Q

RFs for ischemic heart disease - unmodifiable (3)

A

Age
Male gender
Family history

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4
Q

RFs for ischemic heart disease - modifiable (5)

A

Smoking

Diabetes, HTN , high cholesterol, obesity

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5
Q

Likely occluded artery in an inferior MI

What leads would you see ST elevation

A

Right coronary

2,3, AVF

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6
Q

ST elevation leads I, avL,V5 ,V6
Likely occluded artery ?
Are of infarct ?

A

Left circumflex

Lateral MI

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7
Q

Anterior/anteroseptal MI
ST elevation in what leads
Likely occluded artery

A

V1-V4

LAD

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8
Q

Anterolateral MI
ST elevation in what leads
Likely occluded artery

A

1, avL, V4 V5 V6

LAD or left circumflex

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9
Q

Features of left main coronary artery (LMCA) occlusion on ECG
What should be done?

A

Widespread ST depression
ST elevation in aVR

Emergency coronary angio

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10
Q

STEMI - management acute

A 
MONA - IV morphine, O2, Nitrates, Aspirin 300 mg
Presentation :
Within 12 hr of sx onset:
- 1ry PCI = gold standard 
If unavailable or 12 hrs
- thrombolkysis ( Alteplase preferred)
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11
Q

Long term management of MI

A
  1. Aspirin , ACEi , statins - lifelong
  2. Ticragrelor or Prasugrel - 12 months OR clopidogrel
  3. B-blockers 12 months (atenolol, bisoprolol)

Statin 80 mg OD PO

AABC+S

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12
Q

NSTEMI / UA management

A

Give ASAP :
300mg Aspirin +
LMWH (enoxaparin, dalteparin) or Fondaparinux = SC
- no high risk of bleeding and no angio in next 24 hrs
- if angio likely in next 24 or creatinine >265 give
=unfractionated heparin - IV

Intermediate/high risk of=adverse cardio event ( predicted 6 month mortality > 3% :
angio w/in 96 hrs of admission
Intravenous glycoprotein receptor antagonist
= eptifibatide or tirofiban

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13
Q

Becks triad

A

Hypotension
Muffle heart sounds
Raised JVP

= cardiac tamponade

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14
Q

Cardiac tamponade

  • causes
  • features
A

Becks triad
Can develop as MI complication
Most important cause is trauma

CXR - enlarged globular heart
Dx - echo

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15
Q

Complications of MI

A 
Arrest - VFIB - mcc of death after MI 
CHF 
Acute pericarditis 
Dressler syndrome 
Left ventricular aneurysm 
Acute mitral regurgitation 
VSD, MR
Pericardial effusion
Cardiac tamponade
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16
Q

What is diagnostic of cardiac tamponade

Treatment

A

Dx - Echocardiogram

Treatments -
Oxygen + ventilation
1-2 L IV fluids
urgent pericardiocentesis

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17
Q

Atrial myxoma

Features

A

Left atrium 75%
Benign tumour , groves on inter-atrium septum wall
10% inherited

  • obstruct mitral valve = mid diastolic murmur , syncope, dyspnoea
  • PE stroke clubbing and blue fingers
  • AF
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18
Q

Echo : pedunculated heterogenous mass attached to fossa ovalis
Dx?

A

Atrial myxoma

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19
Q

Axis deviation

A 
Check lead 1 and AVF 
 1 & AVF - both pointing up = normal 
1 up , AVF down - left axis deviation
1 down, AVF up - right axis deviation 
Both down - right superior axis deviation
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20
Q

Causes of left axis deviation (5)

A 
Inferior MI  
LVH 
Left anterior fascicular block or hemi-block
Obese 
WPW
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21
Q

Right axis deviation causes (6)

A 
Lateral MI 
RVH 
Left posterior fascicular block or hemiblock 
Thin tall children 
Chronic lung disease 
Pulmonary embolism
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22
Q

Causes of extreme right axis deviation

A

Congenital heart disease

Left ventricular aneurysm

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23
Q

1st degree heart block + management

A

PR > .2s only

No treatment as long as pt is asymptomatic

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24
Q

2nd degree heart block + management

A
  1. Mobitz 1 = wenkebach
    Progressive prolongation of PR until a beat drops
  2. Mobitz 2
    Constant PR interval, but P wave often not followed by QRS

Permanent pacemaker

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25
3rd degree heart block + management
No association between P and QRS Pacemaker
26
Rate control in AF
B blockers - 1st line , CI in asthma CCB - (non dihydropyridine )= diltiazem, verapamil - used in asthma Digoxin - preferred choice if coexistent with heart failure Unstable - cardio version
27
Aflutter management
Cardioversion - shock
28
VTach management
Conscious/ semiconscious hemodynamically stabl e - Amiodarone Unstable - DC cardioversion
29
Vfib management
- defibrillation - asynchronised shock
30
Symptomatic sinus bradycardia | Treatment
O2 , ABCD Atropine .5mg IV push , can repeat until 3mg given If no response - temporary transcutaneous pacemaker Normal in young athletes
31
Sinus tachy causes
Excercise, stress, anger Hx of infection Treat the cause
32
CHF management
Symptomatic relief and reduce vol overload - diuretics = furosemide, lascivious or bumetanide Start w/ ACEi or BB one at a time, If sx persist and the next one - start with ACEi if diabetic If sx still persist - add Spironolactone
33
CHF on treatment , still has LL oedema | Next step
Up dose of fursemide Or switch to bumetanide to torsemide Consider admission for IV loop diuretics
34
HF + a fib management
Digoxin
35
Patent foramen ovale Features Most accurate investigation
R—>L atrium blood flow Most individuals - not problematic , undetected Paradoxical embolism - emb from venous to arterial side = stroke or TIA Transoesophageal echo with bubble contrast = gold
36
Pericarditis Features ECG
Within 48 hrs of MI Pleuritic chest pain , worse lying flat and during inspiration +_ fever, pericardial rub Confirm via echo ECG - widespread saddle shaped ST elevation + upward con cavity + PR depression
37
Treatment pericarditis
Full dose NSAID - =ibuprofen 100-1800mg/d; indomethacin 75-150mg/d Aspirin 2-4g/d =7-14 days
38
Dressler syndrome | Features , ECG
Pericarditis in 2-6 weeks following MI Autoimmune reaction against antigenic proteins as myocardium recovers Same features as pericarditis + raised ESR Saddle shaped ST elevation +- PR depression
39
Treatment of Dressler’s syndrome
NSAIDs
40
Left ventricular aneurysm Features XR ECHO ECG
4-6 weeks post MI Weakened myocardium - thin muscular layer - aneurysm formation Left ventricle failure + persistent ST elevation Can increase risk of stroke ECG - persistent ST elevation + LVF Bulge at left heart border XR Echo - paradoxical movement of ventricular wall
41
VSD Features Treatment
1st week after MI in 1-2% patients Pan systolic murmur + acute heart failure Echo- diagnostic - excludes MR Urgent surgical correction
42
Mitral regurgitation
Pan systolic murmur (early-mid diastolic) 2-15 days after MI Ischemia or rupture of papillary muscles of mitral valve Hypotension tachycardia pulmonary oedema Echo- dx Treatment - vasodilator therapy and surgical repair
43
New murmur + fever + malaise and rigours Dx? Initial step?
Infective endocarditis | Blood culture —> echo
44
RF of infective endocarditis
Previous episode of endocarditis = strongest RF Rheumatic valve disease Prosthetic valve Congenital heart defects IV drug users - typically tricuspid lesion
45
Causative organism of IE
Staph aureus - general Epidermis is - after prosthetic valve surgery Viridans (mitris and sanguidis) - poor dental hygiene or after dental procedure
46
Modified duke criteria - major
``` IE 2 major or 1 major 3 minor or 5 minor Major - 1. + blood culture 2, showing HÁČEK or known organism) or persistent bacteremia in 2 cultures >12 hrs apart or 3 or + with staph aureus or epidermidis ``` 2.evidence of endocarditis involvement = echo +ve for IE
47
Modified duke criteria - minor
1. Predisposing heart condition or IVDU 2. Microbiological evidence that doesn’t meet major criteria 3. Fever >38 4. Vascular phenomena = Jane way , petechia, purpura, splinter hgx, major emboli, splenomegaly 5. Immunological phenomena - oiler node, Roth spots, glomerulonephritis
48
Oiler node vs janeway lesion
O - painful red nodules on hand and feet J- non tender, small erythematous or hemorhhagic macular or nodular lesions on soles /palms = septic microemboli
49
Endocarditis - initial empirical blind therapy
National valve endocarditis - Amoxicillin + low dose gentamicin or Vancomycin + low dose gentamicin - ig peicillin allergic or MRSA suspect or sever sepsis Hx of prosthetic valve Vancomycin + low dose gentamicin+ rifampin
50
CHA2DS2VASc score
``` CHF HTN Age =/>75 = 2pts DM S- prior stroke , TIA, thromboembolism = 2pts Vascular disease Age 65-74 Sex category - female ``` Score =/> 2 - warfarin or DOAC , men >/=1 - the same
51
Score to estimate risk of major bleeding inpatients on anti coagulation for atrial fibrillation
HAS BLED score
52
What score predicts 3 month outcome in ischaemic stroke patients receiving tPA (alteplase)
DRAGON score
53
What is the QRISK2 score
Determines risk of cardiovascular event in next 10 years
54
Pulmonary oedema | Features
``` Desaturation Dyspnoea Orthopnoea Auscultation = crackles /rales Tachycardia Kerley lines on CXR ```
55
Most appropriate investigation for pulmonary oedema
CXR
56
Investigation needed to identify cause of pulmonary oedema
Echo
57
Management of pulmonary oedema
``` MONF Morphine O2 Nitrates Furosemide O2 sat >92% or 90 in COPD 2 puffs GTN 40 mg IV furosemide - slow Diamorphine 2/5-5mg IV slowly or morphine 5-10mg IV slow ``` If heart failure also present : + ACEi or BB one at a time on discharge
58
Dissecting aortic aneurysm | Clinchers
``` Unequal pulses upper limb Hx of Marfan Tall long slender limbs and fingers Ehler danlos/ Turner Severe chest pain radiating to back HTN - most important RF ```
59
Dissecting aneurysm presentation
Presentation: hypotension, SOF , tachycardia, sweating
60
Most important risk factor dissecting aneurysm
HTN
61
Pathophysiology of dissecting aneurysm
Tear in tunica intima wall of aorta | - blood floes between layers of aorta - forces layers apart
62
Investigations for dissecting aortic aneurysm
Emergency - US or CT TEE - 98% sensitive, 97% specific - preferred imaging modality CT scan w/ contrast or MRI
63
Stanford classification of aortic dissection
Type A - ascending aorta -2/3 of cases | B - descending aorta, distal to left subclavian , 1/3 of cases
64
Management of aortic dissection
Type A - surgical , control BP to 100-120 mmHg SBP in the meantime Type B - conservative - bed rest , reduce BP , IV labetalol to prevent progression
65
LBBB | ECG features
Broad QRS - notched M = I avL V6(not always) Deep inverted negative QRS - V1 usually LAD - not always New onset LBBB - characteristic for MI “William” = W in V1 , M in V6
66
Rule turned abdominal aortic aneurysm | Most appropriate initial investigation
US | If not in options pick CT abdomen
67
AAA screening in the UK | Criteria
Men @ 65 years old via ultrasound | Once only
68
Coronary artery dominance
Artery that supplies the posterior descending artery - determines dominance 85% - Right coronary artery 15% left circumflex Artery dominance = RCA =gives off PDA in 85% of people
69
ECG changes hypokalemia
U wave - an additional wave after T
70
Management hypokalemia
Oral or IV kcl based on severity <2.5 - IV Treat the cause
71
Paroxysmal supraventricular tachycardia | Features
Narrow complex SVT Usually in young patients Palpitations light headed ness, Recurrent young
72
management of PSVT
``` Initial : Valsalva , carotid massage No improvement —> IV adenosine = 6mg rapid IV bolus if fails —> Additional 12 mg - no improvement —>Further 12 mg — no improvement —> DC cardioversion ``` Verapamil CCB - in asthmatics
73
Prevention of future PSVT episodes
B blockers | Radio-frequency ablation
74
Torsades de pointes | Features
Polymorphic Broad complex ventricular tachy - beat 2 beat variations Broad QRS, long QT, fainting episodes Young athlete, recurrent
75
Treatment of torsades de pointes
IV MgSo4
76
HTN classification - stage 1
Clinic BP >/= 140/90 +Ambulatory BP monitor >/= 135/85 mmHg Or Home BP monitor - BP >/= 135/85
77
Stage 2 - HTN
Clinic BP >/= 160/100 mmHg + | ABPM or HBPM >/= 150/95 mmHg
78
Stage 3 HTN
Clinic SBP >180 mmHg | Clinic DBP >/= 110 mmHg
79
When you should you treat stage 1 HTN
``` Patient <80 yrs + any : target organ damage Established CVD Renal disease Diabetes 10 year cardiovascular risk >/= 20% ```
80
Stage 1 HTN management
Lifestyle + diet modification and follow up Unless criteria to be treated present
81
What should be done for a stage 2 HTN at clinic before starting antihypertensives
Check ABPM or HBPM
82
Stage 2 HTN or higher + <40 YO | What should you consider
2ry causes of HTN - refer to specialist to exclude
83
Medical management HTN
Step 1 <55 yo + white - ACEi ARBs >55 yo + white - CCB Afrocarribean + any age - CCB Step 2 - still hypertensive after step 1 ACEi + CCB ``` Step 3 Add diuretic = thiazides - chlorthalidone 12-25 mg OD Or indapamide 1.5mg OD modified release, or daily 2.5mg OD Bendroflumethazide NOT recommended ``` Step 4 - resistant HTN <4.5 mmol/l - spironolactone 25mg OD >4.5mmol/l - add higher dose thiazides like diuretic If further diuretic not tolerated or CI = consider alpha or beta blocker Refer to specialist - if they fail to respond to step 4
84
BP targets - diabetics - hypertensive w/o DM
DM - <130/80 mmHg if end organ damage otherwise <140/80 mmHg HTN - <80 - clinic 140/90 mmhg , A/HBPM 135/85 - 150/90 clinic , 145/85 mmhg
85
Treatment of HTN in a diabetic patient
Always ACEi regardless of age If DM + afrocarribean - ACEi + CCB as 1st step Check eGFR before you start ACEi <30 = advanced kidney disease - avoid ACEi & ARBs
86
Why use ACEi in hypertensive DM
Reno-protective Protection against diabetic retinopathy +ve effect on glucose metabolism
87
Postural hypotension Def Dx
Drop in SBP at least 20 mmHg within 3 mins of standing Drop in DBP at least 10 mmhg within 3 minutes of standing Dx - monitor BP
88
Postural hypotension common in
``` Elderly people (baroreceptors decline with age) Esp in poly pharmacy and those with HTN ``` Antihypertensives can cause postural hypotension
89
1st line in AFIB
Beta blockers If asthmatic - CCB If associate HF - give digoxin Also calculate chadvasc score and anticoagulants accordingly - warfarin or DOAC
90
Ventricular ectopic | Features
Ventricular trigeminal - 3 beat patterns Missed skipped beat, unsustained palpitations +- SOB Early/ broad QRS complex
91
Causes ventricular ectopic
IHD - MI Cardiomyopathy Stress Alcohol Caffeine cocaine or natural Can be benign if there’s no underlying hearts disease If there is may ppt vfib
92
What medications should NEVER be given to CKD CHD IHD patients
NSAIDS Selective COX-2 inhibitors - celecoxib They can worse heart failure and renal function NSAIDs inhibit prostaglandin synthesis = decreased gfr = salt + water retention
93
Silent MI in diabetics is due to
Autonomic neuropathy
94
Pt w/. Hx of syncope + SOB + pulmonary embolism and early-mid diastolic murmur Suspect
Think atrial myxoma
95
Alcohol recommendations UK
Not more than 14 units - week Not > 3 units a day + 2 alcohol free days a week
96
Most important cause of ventricular tachycardia clinically
Hypokalemia
97
Aortic stenosis murmur | Features
Ejection systolic Rt 2nd ICS - radiates to carotid SOB on activity, angina chest pain, syncope
98
Pulmonary stenosis murmur | Features
Ejection systolic Lt 2nd ICS lateral to sternum , radiates to left shoulder and infraclavicular area Systemic cyanosis
99
Aortic regurgitation | Features
Early diastolic Rt 2nd ICS lateral to sternum Heart failure sx
100
Pulmonary regurgitation | Features
Early diastolic Left 2nd ICS , lat to sternum Rt sided HF sx
101
Mitral stenosis
``` Mid-late diastolic + opening click (loud S1) - best heard on expiration Apex 5th ICS midclavicular line Sx of HF Low volume pulse , malar flush AFIB ```
102
Tricuspid stenosis | Features
Diastolic rumble 4-5th ICS over LSB Fluttering discomfort in neck
103
Mitral regurgitation | Features
Pan- systolic murmur Apex, left 5th ICS MCL radiates to axilla CHF sx, oedema ascites
104
Tricuspid regurgitation | Features
Pan systolic 4-5th ICS LSB Sx of Rt sided CHF
105
What murmurs have sx of rt sided heart failure
Pulmonary regurgitation - early diastolic | Tricuspid regurgitation - pan systolic
106
Murmurs with HF sx
Aortic regurgitation - early diastolic Pulmonary regurgitation - early diastolic (rt sided HF) Mitral stenosis - mid-late diastolic w/ opening click Mitral regurgitation - pan systolic (CHF) Tricuspid regurgitation- pan systolic (RHF)
107
Pan systolic murmur
Mitral regurgitation Tricuspid regurgitation VSD
108
Diastolic murmurs
Aortic regurgitation - early Pulmonary regurgitation - early Mitral stenosis - mid to late + opening click Tricuspid stenosis - rumble
109
Common causes of mitral stenosis
Rheumatic fever!!!!!!!!
110
CXR mitral stenosis
Straight left side heart border MS - impeded LV filling - increased LA pressure - LA hypertrophy = straight left heart border Blood goes back to lungs - pulmonary congestion , RVF
111
Mitral aortic murmurs best heard
Expiration | Left heart = expirations
112
Tricuspid + pulmonary murmurs best heard
Inspiration | Rt - insp
113
ECG in mitral stenosis
Signs of RVH P mitrale AFIB
114
Decreased Ejection fraction + decreased septal wall thickness
Dilated cardiomyopathy
115
Increased ejection fraction + increased septal wall thickness
Hypertrophic cardiomyopathy
116
Causes of dilated cardiomyopathy
Alcohol Pospartum HTN Inherited - autosomal dominant Infection - coxsackie B , HIV , parasitic, diphtheria Hyperthyroidism DMD Kwashiorkor, pellagra, thiamine/selenium def Doxorubicin
117
Causes of falls
Cardiac - arrhythmia Postural hypotension Hypoglycemia Seizure
118
Cyanotic baby with ejection systolic murmur
TOF - pulmonary stenosis
119
Preterm baby with continuous or machinery murmur
PDA
120
Progressive severe cyanosis + poor feeding + pan systolic murmur
Tricuspid atresia
121
Acyanotic + pan systolic murmur
VSD
122
Diagnosis of patent ductus arteriosus | Management
Echo Mgmt - indomethacin/ibuprofen - closes the duct If assoc with anther congenital heart defect - prostaglandin E1 - keep open until surgically repaired
123
TOF features
VSD RVH RV outflow tract obstricipn - pulmonary stenosis - ejection systolic murmur Overriding aorta
124
Management of TOF
Surgical repair | B blockers to reduce infundibular spasm = help cyanotic episodes
125
Familial hypercholesterolemia Inheritance pattern When should suspect it?
AD 1. Cholesterol >7.5 (N= < 5 mmol/l) 2. Family hx of MI - 1st degree relative before 60 or 2nd degree below 50
126
Most common valvular disease that causes syncopal attacks
Aortic stenosis
127
Causes of AFIB
Endocardium - endocarditis , mitral valve disease Myocardium - cardiomyopathy Pericardium - constructive pericarditis HF HTN MI Hyperthyroidism, excessive alcohol and chronic lung disease
128
Before prescribing amiodarone - what should be done
Amidarone = class 3 antiarrythmic - block K+ channels - inhibits depolarisation - prolongs action potential TFT LFT UE CXR ECG
129
Monitoring patients taking amiodarone
TFT LFT UE CXR ECG - prior to tx TFT LFT every 6 mo. ECG every 12 mo
130
Adverse effects. Amiodarone
``` Hypothyroidism , hyperthyroidism Corneal deposits Pulmonary fibrosis (**most serious) / pneumonitis Liver fibrosis/ hepatitis Peripheral neuropathy, myopathy Photosensitivity Grey skin Thrombophlebitis ( so usually given via central veins) Bradycardia Prolonged qt ```
131
Corrected pulmonary stenosis in TOF can later become
Pulmonary regurgitation
132
Commonest valvular disease in elderly >65
Aortic stenosis Usually asymptomatic apart from excercise intolerance Can cause syncopal fainting
133
Digoxin toxicity
GT - commonest - nausea, vomiting , anorexia Neuro - hallucination, confusion Visual - yellow haloes , yellow - green vision, blurred vision Arrhythmia - Bradycardia , vtach , premature contractions
134
Management of digoxin toxicity
Digoxin level Digibind / digifab = digoxin immune FAB Correct arrhythmia Monitor K+
135
Sx of aspirin toxicity
Tinnitus , impaired hearing | Hyperventilation , vomiting , dehydration, fever , double vision and feeling faint
136
How do thiazides like diuretics work | Adverse effects
Inhibit Na absorption from beginning of proximal DCT - block Na-Cl symporter Postural hypotension, gout, hypokalemia and HypOnatremia Hypercalcemia and hypocalciuria
137
Loop diuretic moA
Inhibit Na-K-cl cotransporter in thick ascending limb of loop of henle
138
Hypotension tachycardia and pulmonary post MI
Mitral regurgitation
139
Osborne wave in
Hypothermia
140
``` Antiplatelet guideline Acute MI PCI TIA Ischemic stroke Ischaemic stroke + AF PAD ```
MI - aspirin life-long , ticragrelor or clopidogrel 12 mo PCI- aspirin life-long, prasugrel or ticragrelor 12 mo TIA/ischemic stroke - aspirin 300mg 2 weeks then clopidogrel 75mg lifelong Ischemic stroke + AF - aspirin 300mg 2 weeks then start anticoagulation warfarin/DOAC PAD - Clopidogrel lifelong
141
Who should receive statin - 1ry prevention
Anyone with 10 year CVD risk >/=10% T1DM diagnosed >10 years ago or over 40 or established neuropathy CKD if eGFR <60 Atorvastatin 20 mg OD If LDL does not fall by >/= 40% - up dose to 80
142
2ry prevention - start statins in cases of
Known IHD , cerebrovascular disease, PAD Atorvastatin 80 mg OD
143
Important side effects of CCBs
Ankle swelling | Gingival hyperplasia
144
Most common arrhythmia in alcoholic cardiomyopathy
AFIB
145
Holiday heart syndrome
Acute alcohol intake causing AF or clutter
146
Widespread ST depression + ST elevation in aVR
Left main coronary artery occlusion | - emergency coronary angio
147
AFib +unstable patient | Presents >48 hrs after sx onset
No cardioversion Give BB + LMWH Assess chad score for long term DOAC
148
QRISK3 score
Risk of cardiovascular event in next 10 years | >10% + age = 84 —> start stain
149
Complications of mitral stenosis
Atrial fibrillation Venous thromboembolism Cerebral infarction
150
Common complication of aortic stenosis
LVH
151
Most common arrythmia associated with congenital long QT syndrome
Ventricular tachyarrythmia | There is also risk of vfib - some patients use long term beta blocker treatment
152
Investigations of Heart failure
NT-proBNP | If raised - do Echo
153
Management of chest pain according onset
<3 hrs of chest pain onset Troponin - <12 - repeat after 3 hrs of chest pain onset >30 - correlate with ecg and hx - treat as ACS > 3hrs <12 - ACS unlikely >30 -ECG and history - treat as ACS

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