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Phase 3B > Cardiology 2 > Flashcards

Cardiology 2 Flashcards

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1
Q

What is atrial fibrillation?

A

The most common sustained cardiac arrhythmia
Characterised by irregularly irregular ventricular pulse and loss of association between the cardiac apex beat and radial pulsation

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2
Q

What are the adverse effects of the loss of active ventricular filling in AF?

A

Stagnation of blood in the atria –> thrombus formation

Reduced cardiac output may lead to heart failure

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3
Q

What are the types of AF?

A 
Acute: onset within 48h
Paroxysmal: spontaneous termination
Recurrent: 2+ episodes
Persistent: not self terminating but successful cardioversion
Permanent: resistant to cardioversion
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4
Q

What is the aetiology of AF?

A 
11% idiopathic
Coronary/valvular heart disease
Hyperthyroidism
Diabetes
Lung cancer
Excess caffeine and alcohol
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5
Q

How does symptomatic AF present?

A 
Dyspnoea
Palpitations
Syncope/dizziness
Chest pain
Stroke or TIA
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6
Q

What are the signs of AF?

A

S3 heart sound

Irregularly irregular pulse

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7
Q

What is seen on ECG in AF?

A

Variability in R-R intervals

No P waves

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8
Q

What other investigations are important in AF?

A

24h ambulatory ECG
Bloods: TFTs, FBC, biochem, electrolytes esp K, coagulation screen (pre warfarin)
CXR for structural causes
Baseline TTE

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9
Q

What are the indications for urgent admission in AF?

A

Pulse >150BPM or systolic BP<90mmHg

Loss of consciousness, severe dizziness, ongoing chest pain, progressive dyspnoea

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10
Q

What is the treatment of acute AF with and without haemodynamic instability?

A

With: emergency electrical cardioversion

Without: Electrical cardioversion or pharmacological cardioversion (flecainide or amiodarone)

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11
Q

In which patients is rhythm control preferred to rate control in AF?

A

AF has a reversible cause
HF is present and caused by AF
New onset AF

Rate control= >65 years, history of ischaemic HD

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12
Q

What is the first line monotherapy rate control in AF, and the contraindications?

A

Atenolol/bisoprolol (CI: COPD, asthma, bradycardia, heart block)

Diltiazem/verapamil (CI: heart failure)

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13
Q

What is the second line rate control treatment of AF?

A

Combine two medications: a beta blocker, diltiazem, digoxin)

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14
Q

Why should sotalol be avoided in AF?

A

Long QT Syndrome and toursades des pointes risk

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15
Q

Detail rhythm control of AF.

A

Electrical cardioversion with amiodarone before and after
OR
Drug treatment: amiodarone (if structural heart disease) or flecainide/amiodarone (if no structural heart disease)

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16
Q

What is the treatment of AF if drug treatment has failed to control symptoms?

A

Left atrial/AVN ablation and/or pacing

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17
Q

Which score assesses stroke risk in AF patients?

A

CHA2DS2VASc

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18
Q

Which score assesses risk of bleeding in patients on anticoagulation?

A

HAS-BLED

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19
Q

What is the thromboprophylaxis treatment of AF?

A

Warfarin or a NOAC.

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20
Q

What are the main subtypes of heart block?

A

AV block: block in the AV node or bundle of His

Bundle branch block: block lower down.

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21
Q

What does the Bundle of His split into?

A

Left bundle branch (which has anterior and posterior divisions) and right bundle branch

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22
Q

What is shown on an ECG in complete bundle branch blocks (left or right)?

A

Wide QRS (>0.12s), normal axis

RBBB: RSR in V1 (M) and W in V6 (marrow)

LBBB: septal depolarization is reversed so change in initial direction of QRS (William).

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23
Q

What are the pathological effects of complete bundle branch blocks?

A

LBBB: late activation of the left ventricle

RBBB: late activation of the right ventricle

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24
Q

What is a hemiblock?

A

Block in the separate divisions of the left bundle produces a swing of depolarization (electrical axis)

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25
What is seen in left anterior hemiblock, and left posterior hemiblock?
LA: left axis deviation, Q waves in I and aVL, small R in III LP: right axis deviation, small R in I, small Q in III
26
What is first degree AV block?
Prolongation of PR interval >0.2s | Every atrial depolarization conducts to ventricles but it is delayed
27
What are the types of 2nd degree AV block?
Mobitz type I | Mobitz type II (2:1 or 3:1)
28
What is Mobitz type I heart block?
Progressive lengthening of the PR interval with eventual dropped ventricular contraction
29
How long is the QRS complex in Mobitz type II block?
>0.12s
30
Where is the blockage in Mobitz type II block?
Bundle of His
31
What has occurred when there is complete dissociation between the atria and ventricles?
3rd degree AV block
32
What are five causes of heart block?
``` Acute MI SLE Endocarditis Cardiomyopathy Hypokalaemia/hypomagnesaemia ```
33
How is heart block treated?
Pacemaker | Acute bradycardia: atropine, isoprenaline/adrenaline, temporary pacing
34
What occurs in preserved ejection fraction heart failure?
Impaired LV relaxation - diastolic, normal LV ejection fraction
35
Define reduced ejection fraction heart failure, and what it leads to.
Ejection fraction below 40% | Impaired contraction --> reduced cardiac output
36
Give three causes of high output heart failure?
Anaemia Paget's disease Hyperthyroidism
37
Low output heart failure is where output is decreased and fails to increase with exertion. Give the three types and an example.
Chronic excessive afterload: AS/HTN Excessive preload: MR/fluid overload Pump failure: systolic/diastolic failure, anti-arrhythmics are negatively ionotropic
38
How does acute heart failure present?
Pulmonary or peripheral oedema without peripheral hypoperfusion
39
Give five signs and symptoms of left ventricular failure.
``` Dyspnoea/PND/orthopnoea Poor exercise tolerance Fatigue Wheeze Nocturnal cough with pink frothy sputum ```
40
Give five signs and symptoms of right ventricular failure.
``` Peripheral oedema Ascites Pulsation in neck and face from tricuspid regurgitation Nausea and anorexia RV heave from PHTN ```
41
How is heart failure initially investigated?
ECG and BNP | If any abnormalities, then echo and/or CXR
42
What is seen on CXR in heart failure?
``` Alveolar oedema Kerley B lines (interstitial oedema) Cardiomegaly Dilated prominent upper lobe vessels Pleural Effusion ```
43
What criteria is used to diagnose congestive heart failure?
Framingham criteria
44
What is the New York classification of heart failure?
1. No dyspnoea but heart disease present 2. Comfortable at rest, dyspnoea on ordinary activities 3. Less than ordinary activity causes dyspnoea, which is limiting 4. Dyspnoea present at rest
45
Why should alcohol be reduced in managing heart failure?
Can act as a negative inotrope, increases BP and risk of arrhythmias
46
What is the treatment of preserved ejection fraction heart failure?
Loop diuretic | Any other treatment of CV disease
47
What is the three step treatment of reduced ejection fraction heart failure?
1) ACEI and BB 2) Aldosterone antagonist/ARB/hydralazine AND nitrate 3) Digoxin/Ivabradine Loop diuretic for fluid overload
48
Which drugs should be avoided in heart failure?
Verapamil, diltiazem, short acting dihydropyridine agents
49
Which additional drug can be used in heart failure and when?
Sacubitril valsartan | For patients who are symptomatic on ACEIs or ARBs
50
What is included in the acute coronary syndrome?
Unstable angina NSTEMI STEMI
51
Name some non-modifiable risk factors for ACS.
``` Male FH of premature CHD Premature menopause Ethnicity: S.Asian Increasing age ```
52
What symptoms is ACS chest pain associated with?
Sweating Nausea Dyspnoea Palpitations
53
How might atypical ACS present?
Women and elderly | Abdo discomfort or jaw pain
54
What are three signs of ACS?
Low grade fever Hypo or hypertension S3 and S4 Signs of CCF
55
What is seen on ECG in ACS?
New ST segment elevation Initially peaked T waves then T wave inversion New Q waves
56
What is seen on ECG in myocardial ischaemia?
ST depression
57
What other investigations are important in ACS?
``` FBC, potassium, magnesium, eGFR, lipid profile, CRP Cardiac troponins T and I Myocardial creatine kinase CXR and Echo Pulse oximetry and blood gases Cardiac angiography ```
58
What is the pre-hospital or initial management of ACS?
Oxygen SL glycerol trinitrate IV morphine 300mg Aspirin
59
How is reperfusion achieved in STEMIs or NSTEMIs?
Primary PCI is superior to fibrinolysis Before, give aspirin, ticagrelor, and unfractionated/LMW heparin If not suitable, then fibrinolysis
60
What is the treatment of patients post-MI?
``` Clopidogrel and aspirin Beta blocker ACEI Statin Eplerenone if signs of HF ```
61
What is the gold standard diagnosis of Prinzmetal's angina?
Coronary angiography with provocative tests (ergonovine/acetylcholine/dopamine)
62
Define postural hypotension.
Drop in BP>20/10mmHg within three minutes of standing
63
Why does postural hypotension occur?
Normal pooling of the blood in the lower limbs is not correctly regulated by the CV system when moving to a vertical position
64
Give five causes of postural hypotension
``` Multi-system atrophy Pregnancy Diuretics/vasodilators Aortic stenosis/AF Heart failure ```
65
When do you refer to cardiology in postural hypotension?
If the ECG is abnormal, or heart disease is suspected
66
What self measures can be taken to improve postural hypotension?
Stand up slowly and dorsiflex the feet first Cross legs whilst upright Raise head of the bed Morning caffeine
67
What is the first line management of postural hypotension?
Increase intravascular fluid volume with large daily salt intake until weight has increased by 1.3-2.3kg
68
What is second line management of postural hypotension?
Fludrocortisone 0.1-0.2mg/day | Still requires high salt diet and adequate fluid intake
69
What is the main consequence of renal artery stenosis?
Renal hypoperfusion leads to hyperactivation of the renin-angiotensin-aldosterone axis, causing hypertension
70
Give three causes of renal artery stenosis.
Atherosclerosis Takayasu's arteritis Fibromuscular dysplasia of the renal artery - string of beads appearance on MR angiography
71
Describe the hypertension of renal artery stenosis.
Abrupt onset and severe Resistant to standard medical therapy With hypokalaemia
72
How else may renal artery stenosis present?
Decompensatoin of CCF in an already hypertensive patients e.g. flash pulmonary oedema
73
What is the main finding of renal artery stenosis on examination?
Systolic-diastolic bruit heard over the flank
74
How is RAS diagnosed?
U&Es, glucose, lipids 24h urinary protein excretion, presence of RBC Duplex renal USS and Doppler CT/MR angiography
75
How is RAS managed?
Avoid ACEIs, ARBs, and other nephrotoxic drugs | Angioplasty with stenting
76
Where are the most common locations for peripheral vascular disease?
Subclavian artery | Brachiocephalic trunk
77
Give five possible symptoms of PVD.
``` Intermittent claudication Critical limb ischaemia Skin ulceration Paraesthesiae and coldness Hair loss ```
78
How is PVD diagnosed?
BP both arms difference>15mmHg Duplex USS Palpation of pulses ABPI
79
What are the different scores of the Ankle-brachial pressure index?
Normal=1 Claudication=0.6-0.9 Rest pain=0.3-0.6 Impending gangrene=0.3 or less
80
How is PVD treated?
Antiplatelets Peripheral vasodilators such as naftidrofuryl oxalate Endovascular surgery
81
What is ventricular tachycardia?
A broad complex tachycardia originating from a ventricular ectopic focus Defined as 3+ ventricular extrasystoles in succession at a rate of more than 120BPM
82
What are the types of VT?
Fascicular Right ventricular outflow tract Toursades des pointes Polymorphic ventricular tachycardia
83
What is the cause of VT?
Coronary and structural disease Low K, Mg, Ca Caffeine or cocaine
84
How does VT present?
Symptoms of ischaemic heart disease, or haemodynamic compromise from poor perfusion
85
What is seen on ECG in VT?
Rate 150-200BPM Wide QRS complexes>120ms AV dissociation Fusion beats
86
What is the treatment of pulseless VT?
Treated as for VF (CPR, assessment of rhythm, unsynchronised defibrillation) ``` Post cardiac arrest treatment: ABCDE approach SpO2 94-98% 12-lead ECG Treat cause and control temp ```
87
What is the treatment of unstable VT with reduced cardiac output?
Synchronised cardioversion | Advanced cardiac life support
88
What is the treatment of haemodynamically stable VT?
IV 300mg Amiodarone/IV Lidocaine 2nd line cardioversion If poor left ventricular dysfunction, then amiodarone
89
How is VT prevented against in patients with a history?
Implantable cardioverter defibrillator
90
What are the types of SVTs?
AV nodal re-entry tachycardia AV re-entry tachycardia Atrial tachycardia
91
What are some causes of SVTs?
Accessory bypass pathways e.g. WPW is most well known type of AVRT Fast conducting and slow conducting pathways Abnormalities of impulse conduction
92
What is seen on ECG during an attack of SVT?
P waves may not be visible | Short PR<0.12s and delta wave - WPW pattern, evidence of pre-excitation
93
What is the treatment of haemodynamically unstable SVT?
DC cardioversion
94
What is the treatment of haemodynamically stable SVT?
Vagal manoeuvres e.g. carotid massage or Valsalva IV adenosine Cardioversion 3rd line
95
What is the function of adenosine and are there any contraindications?
Blocks conduction through the AV node | CI: severe asthma
96
What is the ongoing management of SVT?
Radiofrequency ablation of the slow/accessory pathway | Rate limiting CCB, flecainide
97
What are the symptoms of aortic stenosis?
Asymptomatic even if moderate (but still susceptible to SCD) | Dyspnoea on exertion, angina, syncope
98
What are the signs of AS?
Pulsus parvus et tardus Narrow pulse pressure Crescendo-decrescendo systolic ejection murmur loudest at apex, 2nd IC space, radiation to carotids
99
What is the gold standard diagnosis of valvular disease?
Echo with Doppler
100
What is the treatment of AS?
Treat any HF | Aortic valve replacement
101
What are the complications of calcific cardiac valves?
Infective endocarditis | Small systemic emboli
102
What are the causes of aortic regurgitation?
Rheumatic heart disease Bicuspid aortic valve SLE
103
What is the AR murmur?
Early diastolic murmur heard best in the aortic area, with the patient sitting forward and in expiration
104
What is the treatment of AR?
Vasodilators and inotropic agents prior to aortic valve replacement
105
What are the effects of mitral stenosis?
Increased left atrial and pulmonary arterial pressure, which leads to RV dilation and tricuspid regurgitation
106
What are three causes of mitral stenosis?
Rheumatic fever Degenerative calcification Lutembacher's syndrome
107
How does mitral stenosis present?
AF, progressive dyspnoea, palpitations, haemoptysis Malar flush, raised JVP, signs of RV failure Mid-late diastolic murmur, best heard in left lateral position with bell
108
What is the treatment of mitral stenosis?
Percutaneous mitral commissurotomy (balloon valvuloplasty)
109
What is the murmur of mitral regurgitation?
Pansystolic murmur at the apex
110
Which patients are at risk of having a silent MI?
Elderly | Diabetic
111
When are Q waves pathological?
>40ms (1mm) wide >2mm deep Seen in leads V1-V3
112
What are the symptoms of neutrally mediated (reflex) syncope?
Prodrome of sweating, pallor, nausea and vomiting | Transient loss of consciousness
113
What is seen on ECG in hypothermia?
J waves - notch in the downward portion of the R wave in QRS complex
114
Which beta blockers can be used in heart failure?
Bisoprolol Carvedilol Nebivolol
115
What is stage 1 hypertension?
Clinic reading of 140/90 AND home reading of 135/85
116
What is stage 2 hypertension?
Clinic reading of 160/100 AND home reading of 150/95
117
When should stage 1 hypertension be treated?
Age under 80 and: - Q risk over 10% - diabetes/renal/CV disease - Target end organ damage
118
Outline the management of hypertension for patients aged under 55 or type 2 diabetics.
1) ACEI/ARB 2) ACEI/ARB + CCB/thiazide like diuretic 3) ACEI/ARB + CCB + thiazide like diuretic 4) If K+ <=4.5, low dose spironolactone; if K+ >4.5, alpha or beta blocker
119
What is the difference in management in Afro Caribbean patients or patients aged over 55 at presentation?
First step is a CCB

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