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Cardiology Flashcards

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1
Q

SVT

A

Sudden onset of a regular narrow complex tachycardia, ^AVNRT than AVRT

-> 1) valsalva (empty syringe, carotid sinus massage), 2) IV adenosine (6-12-18) or verapamil if asthma, DC cardioversion if unstable

Prevent - b-blockers, RF ablation

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2
Q

Digoxin Toxicity

A

Causes - v K/ Mg, ^Ca/ Na, v PH, v temp, age, renal failure, MI, v thyroid, v albumin, amiodarone, verapamil, ciclosporin, thiazides, loops

= lethargy, nausea, anorexia, confusion, arrythmia, gynaecomastia, yellow-green vision

Inv - ECG (sloping ST depression, short QT, flat/ inverted T, AV block, brady)

-> digibind, only routinely monitor in toxicity, measure 8-12hrs from last dose, monitor K

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3
Q

Complications of MI

A

Death
Arrhythmia - VF -> arrest, AV block after inf.
Rupture - free wall, IV septum, papillary muscle
Tamponade
Heart failure

Valvular - acute VSD, MR (pansystolic)
Aneurysm of ventricle - persistent ST elevation
Dressler’s - AI pericarditis 2-6wks (vs normal 2 days)
Embolus - stroke
Recurrence

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4
Q

ECG Calcium

A

High - shortened QT

Low - prolonged Qt

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5
Q

ECG: Potassium

A

High

= tall tented T, short QT, no p, broad QRS, sine waves, VF

Mild 5.5-6, Mod 6.0-6.5, Severe >6.5

= all with severe/ ECG changes need calcium gluconate (stabilises myocardium), insulin/ dextrose infusion (drives K into cells), neb salbutamol, calcium resonoum (enema, removes it)

*If in AKI and and persistent high K+ consider dialysis

Low

= U waves (upward deflection after T) , small T waves, long PR, ST depression

U have no Pot and no T but a long PR and QT

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6
Q

Pericarditis

A

Inflammation of pericardial sac, <6wks (normally 2wk)

Causes - virus (cox), TB, post-MI, radiotherapy, uraemia, SLE/ RA, v thyroid, lung/ breast cancer, trauma

= pleuritic pain, better leaning forward, tachycardia, SOB, pericardial rub, flu-liek, fever

Inv - ^ESR, ^trop, ECG (widespread saddle ST elevation, PR depression), all get TT ECHO

-> NSAIDs, Colchicine

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7
Q

Pathway for STEMI Management

A

All get aspirin 300mg

Symptoms <12hrs + PCI possible <120 min

Yes - Angiography + follow-on PCI, Prasugrel + aspirin, UFH + bailout gp25/3ai

No - Fibrinolysis, Antithrombin, ECG 60-90min after, Ticagrelor + aspirin

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8
Q

NSTEMI pathway

A

All get Aspirin 300mg.

Fondaparinux if PCI not immediately planned (i., not unstable)

GRACE mortality score (6m)

> 3% - immediate PCI if unstable, or angiography <72hrs, prasugrel/ ticagrelor + aspirin, UFH

<3% - ticagrelor + aspirin

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9
Q

Aortic Dissection

A

Tear in the intima

RF- HTN, trauma, bicuspid aortic valve, Marfan, EDS, syphilis, Turner’s, Noonan’s, preg

= sudden severe sharp chest pain, upper back if desc, pulse deficit, AR, HTN, angina (coronary), paraplegia (spinal), limb ischaemia (distal aorta)

Inv - CXR (wide mediastinum), CT angiography (CAP, false lumen), TO ECHO (if not fit for CT)

Type A - ascending aorta
Type B - distal to left subclavian

-> BP control, surgery for type A, IV labetalol and bed rest for type B

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10
Q

DVLA issues

A

Angioplasty/ pacemaker - 1 week
ACS - 4 weeks if no angioplasty
Angina - stop if happens at rest
Aneurysm - DVLA review >6cm, no driving >6.5

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11
Q

Loop Diuretics

A

Inhibit the Na/K/cl transporter in thick ascending limb

SE: v BP, v Na, v Mg, v Na, v K, v Cl alkalosis, ototoxic, gout, ^glucose, renal impairment

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12
Q

Aspirin

A

All patients with IHD should be on if no contra-indication

Potentiates steroids, warfarin and oral hypoglycaemics

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13
Q

Aortic Regurg

A

Causes - rhematic fever, calcification, RA, SLE, dissection, IE, bicuspid aortic valve, syphilis, marfans, EDS, ank spond

= early diastolic, collapsing pulse, wide pulse pressure and head bobbing (de mussets) and nailbed pulsation (quinckes)

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14
Q

Aortic Stenosis

A

Cause - calcified, bicuspid, William, HOCM, RF

= chest pain, SOB, syncope, ejection systolic murmur, radiates to carotids, v with valsalva

^Severity = narrow pulse pressure, slow rising pulse, soft S2, S4, thrill, duration

-> treat symptomatic or gradient >40mmHg, surgical or transcatheter AVR

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15
Q

Mitral Stenosis

A

Cause - RF, carcinoid

= SOB, haemoptysis, mid-late diastolic murmur, loud S1, low volume pulse, opening snap, malar flush, AF

^Severe = duration, snap close to S2

-> observe and regular ECHO if no symptoms, balloon valvotomy

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16
Q

Mitral Regurg

A

RF - F, v BMI, age, renal dysfunction, CTD

Cause - post-MI, IE, RF

= blowing pansystolic murmur, to axilla, quiet S1, split S2 if severe

Inv - ECG (broad P), CXR (cardiomegaly)

-> repair > replacement

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17
Q

Heart Failure: Management

A
  1. ACEi and B-blocker
  2. Aldosterone Antagonist - monitor potassium

SGLT2 inhibitor

  1. specialist - ivabradine , sacubitril-valsartan, digoxin or hydralazine (^black), cardiac resynch (wide QRS)

+ annual Influenza and one-off pneumo

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18
Q

BiFasicular Block

Trifasicular

A

RBBB + LAD

+/- 1st degree heart block

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19
Q

Infective Endocarditis: Organisms

A

Staph Aureus - most common

Strep Viridans - developing countries, poor dental hygiene

Staph epidermidis - valve surgery <2m ago, lines

Strep bovis - CRC

Non-infective - SLE (libman-sacks)

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20
Q

PAD Management

A

-> stop smoking, statin 80mg, clopidogrel, exercise training

Severe PAD / critical ischaemia
-> endovascular revascularisation (<10cm or aortoiliac disease) or surgical (>10cm, multifocal, common fem, infrapop alone)

E.g., angioplasty, bypass, amputation

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21
Q

Methods of Action of AC

A

Dabigatran - direct thrombin inhibitor, reverse with Idarucuzumab

Rivaroxaban/ apixaban - direct Xa inhibitor, reverse with Andexanet alpha

Edoxaban - Xa inhibitor, no reversal

Heparin - activates antithrombin 3

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22
Q

Warfarin Potentiation

A

Metabolised by CYP450

^INR with;
liver disease
P450 inhibitors
cranberry juice
brocolli, spinach, kale, sprouts (high Vit K)
NSAIDs (displace warfarin from plasma albumin/ inhibit platelet function)

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23
Q

Atherosclerosis

A
  1. Endothelial dysfunction
  2. Changes to the endothelium including pro-inflmmatory, pro-oxidant and reduced NO
  3. LDL infiltrate subendothelial space
  4. Monocytes turn to macrophages and phagoctyose LDL coming foam cells.
    5 Smooth muscle proliferation causes fibrous capsule over fatty plaque
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24
Q

ECG territories

A

Anterior - V1-V4 - LAD
Inferior - 2,3 and AvF - right coronary
Lateral - 1, V5 and 6 - left circumflex

PAILS - ST elevation changes in these leads cause depression in the next. ie elevation in posterior causes depression in anterior.

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25
Secondary Prevention of MI
Aspirin + Clopidogrel Beta-blocker ACEi Statin
26
Criteria for a STEMI
Clinical features + persistent ECG features in 2 contiguous leads: 2.5mm St elevation in V2-3 in men under 40 or over 2.0 in over 40 year olds 1.5mm elevation in these leads for women 1mm other leads New LBBB
27
ACS: 30 Day Mortality
KIllip class system 1. no signs of HF - 6% mort 2. lung crackles or S3 - 17% 3. Frank pulmonary oedema - 38% 4. Cardiogenic Shock - 81%
28
ALS algorithms
30:2 compressions to ventilation breaths Non-shockable - PEA/ asystole -> 1mg adrenaline Shockable - VF/ pulseless VT -> 1 shock (3 if witness + monitored), up to 3, 1mg adrenaline every 3-5mins, amiodarone (300mg after 3 shocks, 150mg after 5) Extend CPR by 60-90min if given thromolytic drug IV> IO, tracheal not recommended
29
Reversible Causes of Arrest
H's - Hypoxia, Hypovolaemia, Hyperkalemia, hypothermia The T's - Thrombosis, tension, tamponade and toxins Other met disorders e.g., hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia
30
Angina Management
All get GTN, aspirin and statin 1. BB or CCB (rate-limiting e.g., v/d) 2. Combine the two (a/n) 3. Assess for PCR/ CABG, long-acting nitrates, ivabradine, nicorandil or ranolazine Nitrates - need asymmetrical dosing, free time of 10-14hrs
31
Genetic Cardiomyopathies
HOCM AD, ^sudden cardiac death, beta mysoin heavy chain gene mutation, diastolic dysfunction Link - Friedreich's ataxia, WPW = functional AS (^ Valsalva, v squat), exertional SOB, syncope, ventricular arrhythmias, Bisferiens (double) pulse Inv - ECHO (MR SAM ASH), biopsy (myofibrillar hypertrophy, myocytes 'disarray' and fibrosis) -> amiodarone, BB, ICD, dual pacemaker and endocarditis prophylaxis (NO ACEI) RA Arrhythmogenic AD, 2nd common, RV myocardium replaced by fibrous fatty tissue = T wave inversion in V1-3 or terminal notch in QRS (epsilon)
32
Mixed + Acquired Cardiomyopathies
Dilated (90%) Causes - alcohol, baby (pregnancy), wet beri beri (v thiamine), Coxsackie B, Chaga's, cocaine, Duchenne's, doxorubicin = systolic dysfunction and murmur, S3 Inv - CXR (balloon) Restrictive Causes - amyloid, TB, post-radiotherapy Acquired Takotsubo = apical ballooning of myocardium after stress, chest pain, HF Inv - ST elevation, normal angio Secondary; haemochromatosis, sarcoidosis, DM, thyrotoxicosis, acromegaly, myotonic dystrophy, SLE
33
Anticoagulation in AF
Assess using CHA2DS2- VASc (+/- ORBIT) Treat if 1 in M if 2 in F Do TTE to excl. valve disease if suggests no treatment
34
AF: Rate Control
1st line unless; reversible cause, causing HF, new onset (<48hrs) -> BB, CCB (d/v), digoxin + heparin
35
AF: Rhythm Control
Immediate CV if <48hrs or unstable -> electrical (no AC after), flecanide, amiodarone (SHD) Delayed CV if >48hrs and stable -> 3wks AC before electrical (+/- amiodarone), rate-control while waiting Long-term rhythm control -> B-blocker (not sotolol), dronedarone, amiodarone (if HF) No response/ don't want drugs -> RF ablation (AC 4wks before and during, 2m after then reassess)
36
ASD
Most common CHD in adults (^secundum) = ejection systolic murmur, louder on insp, fixed split s2, stroke Primum = RBBB +LAD Secundum = RBBB + RAD
37
AV block
1st - PR > 0.2secs, no need to treat 2nd - T1 (Wenckebach): progressive prolongation until dropped beat - T2: constant PR but often p wave not followed by QRS 3rd - no association between atria and ventricles
38
BNP
Hormone produced by the left myocardium once strained Causes - MI, valvular heart disease, CKD Reduced by ACEi, ARB, diuretics
39
Brugada Syndrome
AD, inherited CVD, SCN5A gene (sodium channel), ^Asian = sudden cardiac death Inv - ECG (convex st elevation in V1-3, inverted T, may have partial RBBB), more obvious with flecainide -> ICD
40
Buerger's disease
Thromboangitis obliterans, small and medium vessel vasculitis, ^smokers = extremity ischaemia, superficial thrombophlebitis, Raynaud's
41
Cardiac Enzymes
Myoglobin - first to rise CK-MB - useful for re-infarction, normal after 2-3d Trop T stays high
42
Cardiac Tamponade
Accumulation of pericardial fluid under pressure = v BP, ^JVP, muffled heart sounds, SOB, tachycardia, absent Y descent, Pulsus paradoxus (v BP on inspiration), electrical alternans -> pericardiocentesis., PC balloon pericardiotomy if cancer
43
NYHA classification
1 - no symptoms and no limitation 2 - mild symptoms and slight limitation (comfy at rest). 3 - moderate symptoms and marked limitation (still comfy at rest) 4 - severe symptoms and even at rest
44
Hypothermia ECG
= bradycardia, J waves (small hump end QRS), first degree HB, ^QT
45
Ischaemic ECG changes
Hyperacute T waves T invert in first 24 hours (lasts day to months) Q waves after days (permanent)
46
Wellen's Syndrome
High grade stenosis in LAD = biphasic or deep T wave inversion in V2 - 3, minimal ST elevation
47
Acute HF: Management
-> IV loop diuretic, oxygen, vasodilators (if associated MI or severe HTN), CPAP if resp failure, Severe v BP - inotropes i.e, dobutamine. Continue regular HF meds, stop BB if HR <50
48
Heart Sounds
S1 - closure of M and T (soft in MR, loud in MS) S2 - closure of A and P (soft in AS, loud in pulm HTN, normal to split on insp) Pulmonary HTN - valves closing with more force due to higher pressure S3 - diastolic filling of LV (normal <30, or MR, LVF, constrictive pericarditis) S4 - atrial contraction against stiff LV (AS, HOCM, HTN)
49
Diagnosis of HTN
-> treat all stage 2, stage 1 if <80yrs + CVD/ DM/ kidney/ 10% Qrisk Stage 1 > 140/90 (ABPM 135/85) Stage 2 >160/100 (ABPM 150/95) Stage 3 >180 systolic or >120 diastolic -> admit for assessment if retinal bleed, papilloedema, confusion, chest pain, AKI (if none then urgent inv. for organ damage)
50
HTN: Management
Low salt diet. Reduce caffeine. Other general advice 1. ACEi (< 55 or T2DM), CCB (55+, black) 2. +thiazide or the alternative (ARB > ACE if black) 3. ACEi/ ARB + CCB + TD ? adherence, expert, postural 4 - K < 4.5 add spironolactone, K > 4.5 alpha or beta blocker
51
Blood pressure targets
<80 - 140/90 or 135/85 in ABPM >80 - 150/90 or 145/85 ABPM
52
Infective Endocarditis
RF - 50% normal valves (^m), prev. IE, IVDU (t), prosthetic valves, RHD, CHD, recent piercings Modified Dukes (2 major, 1 major + 3 minor, 5 minor) Major - two typical cultures (3+ atypical), ECHO (oscillation, abscess, dehiscence of prosthetic), or new regurg Minor - RF, don't meeting major, >38, vascular (emboli, clubbing, splenomegaly, splinter, janeway) or immunological issues (GN, roth spots, osler nodes) -> Abx (amox +/- gent empirical), surgery if aortic abscess (^PR), not responding, cardiac failure and recurrent emboli
53
Long QT
Causes Jervell-Lange-Nielsen (deaf), Romano-Ward (not) Drugs - amiodarone, sotalol, TCA, SSRIs (^citalopram), methadone, erythromycin, haloperidol, ondansetron Electrolytes - v Ca/ K/ Mg Other - acute MI, myocarditis, hypothermia, SAH Long QT1 - exertional syncope (swimming) Long Qt2 - following stress or auditory stimuli Long QT3 - at night or at rest -> b-blockers (NOT sotolol)
54
MV prolapse
CHD Turners, Fragile X Marfan's Osteogenesis imperfectica WPW Long QT EDS PCKD Cardiomyopathy = chest pain, palp, mid systolic click, late systolic murmur
55
Myocarditis
Cause - viral, autoimmune, doxorubicin = young, acute onset chest pain, SOB, arrhythmia Inv - ^inflam, trop, BNP, ECG (tachy, arrhythmia, ^ST, T inversion)
56
Orthostatic Hypotension
A drop in BP (20/10) within 3min of standing RF - old, neurogenic (Parkinson's), autonomic (DM), alcohol, a-blockers, L-dopa, diuretics, anti-depressants -> midodrine, fludrocortisone
57
Rheumatic Fever
Cause - group A strep pyogenes infection 2-6wks ago (molecular mimicry of the M protein) Revised Jones criteria - 2 major or 1 major and 2 minor, + evidence of recent group A strep) Major Joint polyarthritis Organ inflammation (carditis, valvulitis) Nodules (SC) Erythema marginatum Sydenham's chorea Minor ^ESR / CRP, ^temp, ^PR, arthralgia -> PO penicillin V, NSAIDs
58
Takayasus Arteritis
Large vessel vasculitis, causes occlusion of the aorta Link - renal artery stenosis = young asian F, absent peripheral pulses, unequal BP in arms, limb claudication on exertion, AR, carotid bruit, vasculitis features Inv - CTA or MRA -> steroids
59
Torsades
Polymorphic ventricular tachycardia Cause - ^QT -> IV magnesium sulphate
60
Management of a High INR
Major Bleed: -> Stop warfarin, IV Vit K 5mg, prothrombin complex concentrate Minor Bleed: -> stop warfarin, IV vit K 1-3mg (INR >8 repeat if still high at 24hrs), restart when INR <5 No Bleeding: -> INR >8 - stop warfarin, PO vit K (repeat if still high at 24hrs), restart when INR <5 -> INR 5-8 - withhold 1-2 doses and reduce maintenance dose
61
Grading Murmurs
Levine Scale 1 - very faint 2 - slight murmur 3 - moderate murmur no thrill 4 - loud and palpable thrill 5 - very loud and heard with edge of stethoscope 6 - extremely loud - stethoscope not touching chest
62
VT
Broad-complex tachycardia, from ventricular ectopic focus Causes - MI (mono), ^QT (poly) -> amiodarone via central line, cardiovert unstable If irregular - seek expert help (AF with BBB is most likely cause)
63
Constrictive Pericarditis
Cause - TB pericarditis = SOB, right HF (^JVP, ascites, oedema, hepatomegaly), pericardial knock (loud S3), +ve Kussmaul's (paradoxical JVP rise on inspiration) Inv - JVP (prominent x and y descent), CXR (pericardial calcification)
64
Bradycardia ALS
Treat if; Shock Syncope MI HF -> Atropine 500mcg IV up to 6 times TC pacing, isoprenaline infusion, adrenaline IV if fails TV pacing (expert, if risk of asystole) - consider all with complete heart block + wide QRS, recent asystole, ventricular pause >3 seconds and Mobitz type 2 (even if good atropine response)
65
Coarctation of the Aorta
Congenital arrowing of descending aorta RF - ^men, Turner's, bicuspid aortic v, NF, berry aneurisms = infant HF, HTN, radio-femoral delay, apical click, mid systolic murmur (heard on back), notching of inferior border of ribs
66
Components of the ORBIT Score
Hb / haematocrit low Age over 74 Hx GI/ IC bleed or stroke GFR <60 Antiplatelets = low 0-2, med 3, high 4-7
67
QT interval
Time between the start of the Q wave and the end of the T wave
68
PR segment
End of P wave to start of R
69
PR interval
Start of P to start of R
70
AAA
Routine screening occur in men at 65 with abdo US <3 cm - normal - no action 3-4.5 - small - scan every year 4.5 - 5.5 - medium - every 3 months 5.5+ - large - 2WW referral Also 2WW; increase in 0.5cm in 6m or 1cm in year, symptoms (^risk of rupture)
71
Familial Hypercholesterolaemia
AD, mutation encoding LDL receptor, high LDL and total cholesterol, 1 in 500 Simon Broome criteria TC >7.5 + LDL >4.9 in adults + Definitive - FHx, tendon xanthoma Possible - FHx MI <50 or high cholesterol -> high dose statins, refer to lipid clinic
72
Arteries and their supply
RCA - RA, RV and posterior septum Circumflex - Left atrium and Posterior LV LAD - Anterior aspect of LV and septum
73
Types of MI
1 - spontaneous (plaque rupture) 2 - Ischaemia 3 - death without biomarkers 4 - a) PCI, b) stent thrombosis 5 - CABG
74
Acute HF
Sudden onset or worsening of HF symptoms 25% de-novo, 75% decompensation = SOB, v exercise tolerance, oedema, fatigue, cyanosis, ^JVP, displaced apex, bibasal crackles, wheeze, S3
75
HF: CXR
Alveolar oedema (bat wing) kerley B lines (interstitial oedema) Cardiomegaly - cardiothoracic ratio > 0.5 Dilated upper lobe vessels pleural Effusion
76
Cor Pulmonale
Right-sided HF 2nd to resp disease, ^pressure and resistance in pulmonary arteries, backpressure = cyanosis, oedema, JVP, S3, TR, hepatosplenomegaly, tall p waves
77
MOA of Alteplase
Activates plasminogen to form plasmin Use - thrombolysis
78
Pacemakers
Deliver controlled electrical impulses to heart areas Pulse generator and pacing leads, placed under axilla or left anterior chest wall Single Chamber = RA if SAN issue, RV if AVN Dual Chamber = lead in the right atrium and right ventricle. Triple chamber = RA, RV and LV, normally for HF (cardiac resynchronization) ICD - monitor the heart and apply defib shock to cardiovert back
79
ECG changes in pacemakers
Line before the QRS indicates a lead in the ventricle Line before the P wave indicates a lead in atria.
80
AC and AP therapy
Stable CVD (mono AP) + AF (mono AC) = AC Post ACS / PCI (2AP) + AF (mono AC) = 2AP and 1AC for <6 months, then 1AP and 1AC until 12 months total CVD (AP) + VTE (3-6m AC) = stop AP if high risk of bleeding with both
81
CHA2DS2VASC
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, TIA or thromboembolism 2 V Vascular disease (incl. IHD/ PAD) 1 S Sex (female) 1

ALS (22 decks)

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