Cardiology Flashcards
(30 cards)
- Name 4 coronary arteries
- What part of the heart do they supply
- where does right coronary artery originate from + left + where do they drain into
- Which ECG leads
Right coronary artery arises from right coronary sinus
Left coronary artery arises from left aortic sinus
Both drain into right atrium coronary sinus
LAD - anterior - V1-V4
Circumflex - lateral - I, AVL, V5-6
LCA - anterolateral - I, AVL, V3-6
RCA - inferior - II, III, AVF
Acute coronary syndrome:
- Risk factors - modifiable and non modifiable
- Symptoms
- Signs
- Investigations
- Other conditions where troponin is raised
- Management
- secondary prevention
- Poor prognostic factors
- Complications
- Symptoms: central crushing chest pain at rest >15 mins rad to jaw/shoulder, syncope, n+v, sweating
- signs: tachyc/pnoea, silent diabetic
- ix: ecg, fbc/u+es/lfts/hba1c/lipids/troponin, echo
- mx stemi:
initial: MONA (no nitrates if hypotensive)
1. if <12 hours onset or <2 hours pci then pci - give pragusrel (if high bleed risk or already on anticoag then clopidogrel), unfractionated heparin then pci. if can’t do pci then thrombolysis + tricagrelor and check ecg 90 mins after
Mx: nstemi:
2. fondaparinux and calc GRACE score
3. if grace <4 then ticagrelor
4. if grace 4 or more or if unstable pci within 72 hours + pragusrel + unfractionated heparin. If stable ct coronary angiogram within 72 hours
- secondary mx: stay on aspirin 75 mg, and also pragusrel for 12 months, acei, b blocker, atorvastatin
- poor factors: age, hf, peripheral vascular disease, reduced systolic bp, cardiac arrest
- complications: cardiogenic shock, cardiac arrest, chronic hf, tachyarryth, bradyarryth, pericarditis, dresslers, left ventricular aneurysm, left ventricular free wall rupture, vsd, acute mitral regurg
Stable angina:
- Definition
- Symptoms
- DD
- Investigations
- Management
- definition: narrowing of coronary arteries means when increased oxy demand insufficient blood supply
- symptoms: chest pain <15 mins relieved when resting, sob
- dd: aortic stenosis, htn, hypertrophic cardiomyopathy
- ix: fbc/hba1c/lipids, ecg, ct calcium (ct angiography), stress echo, mr perfusion, invasive coronary angiography
mx: gtn spray, aspirin 75mg, if monotherapy ccb then non dihyd verapamil, b blocker + ccb dihydropyridine amplodipine, if can’t have this then 3rd line nicorandil, statin, acei
Pericarditis:
- Definition
- Causes
- Symptoms
- Investigations
- Management
Pericarditis:
- Definition: inflammation of pericardium
- Causes: viral infection (hiv, tb), autoimmune (ra/sle), idiopathic, methotrexate, MI post, radiotherapy
- Symptoms: sharp central chest pain worse on inspiration + better leaning forward, fever, pericardial rub when auscultating
- Investigations: ecg (wide saddle st seg elevation, pr depression most specific marker), fbc/crp/troponin (may be inc), echo
- Management: nsaids + colchicine (improves response, reduces recurrence), treat cause
Hypertension:
- Stages
- Pathophysiology
- Causes
- Risk factors
- Symptoms (8)
- Signs (5)
- Complications
- Investigations
- Management
Hypertensive emergencies:
- Definition
- Complications (5)
- Symptoms
- Management
- HTN urgency management
- List 3 causes
Hypertensive emergencies:
- Definition: increase in bp which will lead to irrev organ damage
- Complications (5): encephalopathy, lvf, aortic dissection, renal failure, unstable angina
- Symptoms: encephalopathy, pul oedema, AKI, MI
- Management: need to reduce diastolic bp to 110 in 3-12 hours if emergency and 24 hours if urgency. Sodium nitroprusside, labetalol, gtn, esmolol
- HTN urgency management: high bp without critical illness - amlodipine, diltiazem, lisinopril
- List 3 causes: phaeochromocytoma (headache/sweating/tachycardia), cushings, primary aldosteronism
Heart failure:
- Pathophysiology
- Causes (8)
- Causes of acute
- Symptoms (5)
- Investigations
- Other conditions where BNP is raised
- Management
- Classification of chronic HF
- path: L HF = pul oedema, R HF = peripheral oedema
- causes: acute: sepsis, ACS, arrhythmias, fluid overload iv, chronic: valve disease, htn, copd, isch HD, hiv, cardiomyopathy
- symptoms: exert dyspnoa, frothy white sputum, parox nocturnal dysp, orthopnoea, syncope
- signs: peripheral oed R, bibasal crackles L, hepatomeg R, inc jvp R, cyanosis
- ix: ecg, probnp, fbc, u+es, lfts, echo, cxr (cardiomeg, pleural eff, air bronchog, alv oedema, perihilar shadowing)
- mx: abal (if b blocker contraind then ivabradone), vaccines, cardiac resynchronisation if lbbb
new york heart association:
1. no symptoms
2. mild, slight limitation on physical activities
3. moderate
4. severe, no physical activity without discomfort, symptoms at rest
- poor prognosis: high bnp, high fluid overload, severe renal impairment, frequent admissions, inc age
Ejection fraction - definition
- HFrEF: Causes
- HFpEF: Causes
Ejection fraction - definition
- HFrEF: Causes: <40%, thin fibrosed chambers struggle to eject during systole
ACS, dilated cardiomyopathy, myocarditis, arrhythmia
- HFpEF: Causes: stiff thickened walls struggle to fill
Restrictive cardiomyopathy, cardiac tamponade, constrictive pericarditis
Cor pulmonale:
- Definition (how is this different to LV failure)
- Causes (4)
- Symptoms (4)
- Signs (5)
- Management
-
Infective endocarditis:
- Definition
- Pathophysiology
- Risk factors (7)
- Causes (6)
- Complications (3)
- Symptoms (2)
- Signs (9)
- DD (5)
- Investigations
- Management
- Indications for surgery
Infective endocarditis:
- Definition: infection of the endocardium - most commonly mitral valve, tricuspid if iv drug user
- Pathophysiology: damage to valves causes platelet + fibrin aggregation causing vegetations
- Risk factors (7): previous, rheumatic valve disease, prosthetic valves, congenital heart defects, IVDU
- Causes (6): strep viridans (>1 yr valve), staph (most common, <1 year valve, IV drug use), candida/aspergillus (immunosupp), enterococcus (GI), HACEK are culture neg causes (haemoph, actinobacillus, cardiobacterium, eikenella, kingella)
- Complications (3): hf, stroke, sepsis
- Symptoms (2): unexplained fever/sweating, sepsis signss
- Signs (9): ejection systolic murmur, janeway lesions, oslers nodes, splinter haemorrhages, roth spots, splenomegaly, haematuria
- DD (5): vasculitis, RA, SLE
- Investigations: ecg (AV block), urine dip, fbc/crp/u+es/lfts, cxr (hf), blood cultures from 3 diff sites over several hours, transoseophageal echo
- Management: strep viridans (benzylpenicillin + gentamicin), staph (flucoloxacillin + gentamicin), enterococcus (amoxicillin + gentamicin) - 2 weeks central line IV then 4 weeks oral
Also monitor via echo 1x, ecg 2x week, esr/crp/fbc 2x
- Surgery: severe valve, aortic abscess, resistant to abx
Rheumatic fever: 2-4 weeks after pyogenes infection - activates the immune system and igm/g ab t2 sensitivity reaction reacts with myosin and sm of myocardial tissue valves
Erythema marginatum, polyarthritis, raised crp, pyrexa, prolonged PR
Needs oral penicillin V, nsaids
Aortic stenosis:
- Causes (4)
- Pathophysiology:
- Symptoms (4)
- Signs (3)
- Investigations
- Management and indications for surgery
- INR for aortic valve replacements
Aortic stenosis:
- Causes (4): congen biscuspid valves <65yrs, age calcification >65yrs, rheumatic fever, ckd
- Pathophysiology: LVH causes HF + pul oedema
- Symptoms (4): syncope, angina, exertional dyspnoea, HF symptoms
- Signs (3): crescendo decrescendo systolic murmur radiating to carotids, narrow pp, slow rising pulse
- Investigations: ecg, fbc/prontbnp/lfts/lipids, cxr, echo
- Management and indications for surgery
>1.2 mild, 1-1.2 mod, <1 severe. Surgery valve replacement (transcatheter aortic valve implantation TAVI/balloon valvuloplasty) if high risk) if symptoms, severe LV dysfunction, exercise intolerance, having other cardiac surgery, aortic valve gradient >40
- INR: 3
In young patients mechanical HV are better bc last longer but requires lifelong anticoags. Otherwise is usually bovine
Aortic regurgitation:
- Pathophysiology
- Causes (6)
- Symptoms
- Signs (4)
- Management
Aortic regurgitation:
- Pathophysiology: LVH causes dilatation hence HF
- Causes (6): ehlers, marfans, rheumatic HD, IE, calcification
- Symptoms: mostly assymp until bad, exertional dyspnoea
- Signs (4): early diastolic blowing murmur, collapsing pulse, wide pp, demussets sign, nailbed pulsation (quinckes sign)
- Management: acei and other hf mx, surgery if symptomatic, LV systolic dysfunction or aortic root dilatation >5.5cm
Mitral regurgitation:
- Pathophysiology
- Causes (5)
- Symptoms
- Signs (1)
- Management
Mitral regurgitation:
- Pathophysiology: LA dilatation = LVH = HF
- Causes (5): marfans, ehlers, rheumatic, IE, age, mitral valve prolapse
- Symptoms: mostly asymptomatic, HF symptoms
- Signs (1): pansystolic murmur radiating to axilla
- Management: acei + other hf meds, surgery
Mitral stenosis:
- Pathophysiology
- Causes
- Symptoms
- Signs
- mx
- INR for mitral valve replacements
Mitral stenosis:
- Pathophysiology: LAH = oesophageal compression, AF, HF
- Causes: rheumatic fever
- Symptoms: malar rash, dyspnoea, haemoptysiis
- Signs: mid diastolic rumbling murmur, AF, loud s1 with opening snap
- Mx: warfarin if AF, if symptomatic percut mitral balloon valvuloplasty
- INR: 3.5
DD for systolic murmur
aortic stenosis
mitral regurgitation
aortic coarctation
hypertrophic cardiomyopathy
Cardiac tamponade:
- Definition
- Causes
- Symptoms
- Management
Cardiac tamponade:
- Definition: mechanical shock of the heart as it can’t fill properly due to fluid in the pericardial cavity
- Causes: trauma, cancer, iatrogenic
- Symptoms: becks triad (hypotension, distended neck veins (raised jvp, absent Y descent), muffled HS), sob, chest pain, tachycardia, pulsus paradoxus (large bp drop during inspiration)
- Ix: ECG (electrical alternans), echo definitive
- Management: percardiocentesis 14/16G needle into 5th intercostal space close to sternal angle
SAN bradycardia:
- Definition
- Symptoms
- Types (4)
- Causes (9)
- What happens when SAN not working
- Mx
SAN bradycardia:
- Definition: HR <60 (absolute = <40)
- Symptoms: hf, syncope, wide pp
- Types (4): sinus bradycardia, 1st degree AV block, mobitz type 1, mobitz type 2, complete HB
- Causes (9): meds, hypothyroidism, hypothermia, rheumatic fever, sleep apnoea, pericarditis
- What happens when SAN not working: AVN takes over causing narrow qrs + no p wave (junctional rhythm)
- Mx: atropine, permanent pacemaker
AF:
- Definition
- Symptoms (5)
- Causes (5)
- Risk factors (4)
- Complications (3)
- Investigations
- Management
- Irreg irreg DD
AF:
- Definition: supraventricular tachycardia
- Symptoms (5): intermittent -> paroxysms -> persistent palpitations, chest pain, sob, syncope
- Causes (5): sepsis, mitral valve disease, isch HD, thyrotoxicosis, htn
- Risk factors (4): OSA, age, mechanical hv, hospital, obese
- Complications (3): stroke, tachy/bradycardia, chf
- Investigations: ecg (irreg irreg tachycardia, absent p waves, narrow qrs), echo, then calculate cha2dvasc score (chf, htn, age>75/65-74, diabetes, stroke, vasc disease, sex f) (if >1 consider anticoag in M and if >2 in F) + orbit score (hb<130/120, age >74, bleeding hx, renal <60, antiplatelets)
- Management: doac and rate control for life (b blocker or ccb diltiazem). For rhythm control If <48 hours then cardiovert electrically if haem unstable or pharmacologically (amiodarone/ flecainide). If >48 hours wait for 3 weeks bc highest risk for stroke is when sinus rhythm is restored so want to break it down first
If <48 hours and cardioverted no longer need anticoag. If >48 hours + cardioversion then anticoag for at least 4 weeks after
- Irreg irreg DD
Supraventricular tachycardia:
- Definition
- Types (3)
- Causes (6)
- ecg
- Symptoms
- Management
Supraventricular tachycardia:
- Definition: arrythmia arising from atrial, san, avn
- Types (3): avn reentrant, av reentrant (accessory pathway), atrial
- Causes (6): smoking, alc, rheumatic fever, hyperthyroid
- ecg: regular, narrow qrs, no p wave
- Symptoms: syncope, palpitations, sob
- Management:
If unstable (pul oedema, hypotensive, chest pain) then cardiovert
If stable then valsalvre manoeuvre, carotid sinus massage, iv adenosine (not in asthmatics!!)
Prevention: radiofreq ablation, b blockers
blowing against resistance , inc intrathoracic pressure, inc venous and right atrial pressure reducing venous return, reduced preload reduces CO
Wolf Parkinson white syndrome:
- Pathophysiology
- ECG changes (3)
- Management
Wolf Parkinson white syndrome:
- Pathophysiology: accessory pathway connecting atria and ventricles leading to AV reentrant tachycardia leading to VF
- ECG changes (3): short pr <0.12, wide qrs, slurred upstroke qrs (delta waves)
- Management: radiofreq ablation definitive. Medical: sotalol, amiodarone, flecainide
Atrial flutter:
- Pathophysiology
- Risk factors (4)
- ECG change
- Management
Atrial flutter:
- Pathophysiology: electrical signal recirculates in loop due to extra electrical pathway so constant atrial contractions and then to ventricles every 2nd lap (due to long refractory period) causing ventricle contraction
- Risk factors (4): htn, isch hd, cardiomyopathy, thyrotoxicosis
- ECG change: sawtooth pattern
- Management: rate control (b blocker), rhythm (flecainide), radiofreq ablation, anticoag based on chad
Ventricular tachycardia
- Pathophysiology
- causes
- mx
Ventricular fibrillation:
- Pathophysiology
- Complications
Ventricular tachycardia
- Pathophysiology: 3 consecutive premature ventricular ectopic beats
- Causes: post MI, prolonged qt
- mx: if unstable (bp <90, chest pain, hf, mi) then cardioversion with synchronised DC shocks
Or drugs: amiodarone, lidocaine
If fails implantable cardioverter defibrillator (ICD)
Ventricular fibrillation:
- Pathophysiology: abnormal choatic fast ventricular depolarisations where impulses from numerous ectopic sites in ventricles hence no coordinated contraction
- Complications: no CO so cardiac arrest
Bifasicular block:
- Definition
- ECG (2)
Trifasicular block:
- Definition
- ECG (3)
Aortic dissection:
- Definition
- Risk factors
- Symptoms
- Signs
- Complications
- Ix
- Mx
Aortic dissection:
- Definition: tear in tunica intima of aorta creates false lumen for blood. type a ascending aorta, type b descending (stanford)
- Risk factors: htn, marfans, cocaine, trauma
- Symptoms: 50yr old man sudden onset tearing chest pain radiating to back
- Signs: radial radial / radial femoral delay, diff bp on both arms, weak pulses
- Complications: bowel/limb ischaemia, renal failure, cardiac tamponade, mi, aortic regurg
- Ix: ct angiogram (transoesoph echo if unstable), cxr (widened mediastinum), troponin inc
- Mx: resus, iv metoprolol strict bp control 100-120 if type b, surgical aortic root replacement if type A
