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FOCP > Cardiology > Flashcards

Cardiology Flashcards

1
Q

Management for quitting smoking

A

Nicotine gum
Varinicline - oral selective nicotine receptor antagonist
Bupropion - shown to reduce smoking

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2
Q

When a patient describes chest pain, you’re worried about

A

Pulmonary embolism
MI
Dissecting aortic aneurysm
Pericarditis

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3
Q

Constricting chest pain

A

Angina, oesophageal spasm or anxiety

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4
Q

Sharp chest pain

A

From pleura or pericardium

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5
Q

Prolonged, dull, crushing chest pain

A

MI

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6
Q

Cardiac ischemia can radiate

A

To shoulders, either arms, neck and jaw

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7
Q

Dissecting aneurysm can radiate to

A

Infra scapular or retro sternal

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8
Q

Epigastric pain

A

Can also be cardiac

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9
Q

Pain caused by exercise, mood, cold

A

Either cardiac or anxiety

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10
Q

Pain caused by meals, lying flat or hot drinks

A

Gastric

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11
Q

If glycerol trinitrite resolves pain quickly

A

It’s angina,

If slowly, it’s oesophageal spasm

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12
Q

If antacids relieve pain

A

It’s gastric

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13
Q

If pain improves on leaning forward

A

Suspect pericardiac causes

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14
Q

Causes of dyspnoea

A 
Pulmonary embolism
Respiratory cause
Anxiety
LVF
Pericardiac causes
Pleursy
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15
Q

Symptoms of MI

A

Vomiting
Nausea
Sweating

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16
Q

Causes of Angina

A

Coronary heart disease
Aortic stenosis
Hypertrophic cardiac myopathy
Paroxysmal supra ventricular tachycardia

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17
Q

Patient presents with Dyspnoea

Ask about:

A

Shortness of breath at rest, on exertion, on exercise
Is it episodic
Triggered by lying flat

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18
Q

Dyspnoea is associated with

A

Cardiac failure
Pillows at night (orthopnoea)
Gasping for breathing, waking up at night (paroxysmal dyspnoea)
Peripheral oedema

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19
Q

What to do with an acutely Ill patient

A 
Admit to hospital
Check BP, JVP, heart sounds, DVT
O2 mask, IV line
Relieve pain
Cardiac monitor
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20
Q

Causes of palpitations

A 
Ectopics
AF
SVT
VT
Thyroid toxicity
Anxiety
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21
Q

Syncope can be caused by

A

Cardiac or CNS reasons

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22
Q

Symptoms for cardiac syncope

A

Chest pain, palpitations, dyspnoea,

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23
Q

What to ask patients with syncope

A

Pulse?
Limb jerking, urinary discharge, tongue biting
Recovery time
Rapid or prolonged

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24
Q

slight but regular lengthening and then shorten- ing (with respiration)

A

Sinus Arrhythmia, common in children

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25
Q

P wave (upright in II, III, & aVF; inverted in aVR) followed by a QRS complex.

A

Sinus rhythm

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26
Q

Sawtooth ECG

A

Atrial flutter

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27
Q

no discernible P waves and QRS complexes are irregularly irregular

A

Atrial fibrillation

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28
Q

normal QRS complex but P waves are absent or occur just before or within QRS complexes

A

Nodal rhythm

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29
Q

QRS complexes >0.12s
with P waves following them

A

Ventricular rhythm

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30
Q

Left axis deviation of the mean frontal axis of an ECG is caused by

A

LVH, left anterior hemiblock, inferior MI, VT from LV focus, Wolff–Parkinson–White (WPW) syndrome (some types).

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31
Q

Right axis deviation of the mean frontal axis of an ECG is caused by

A

RVH, PE, anterolateral MI, left posterior hemiblock (rare), WPW syndrome (some types)

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32
Q

Causes of absent p wave

A

AF, sinoatrial block, junctional (AV nodal) rhythm.

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33
Q

Dissociation between p wave and qrs

A

Heart block

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34
Q

What is p mitrale and a likely cause

A

bifid P wave, indicates left atrial hypertrophy

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35
Q

What is p pulmonale and a likely cause?

A

peaked P wave, indicates right atrial hypertrophy.

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36
Q

What is a PR interval and what is it’s normal range?

A

Measure from start of P wave to start of QRS. Normal range: 0.12–0.2s (3–5 small squares).

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37
Q

What does a long PR interval indicate

A

1st degree heart block

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38
Q

What does a short PR interval indicate

A

unusually fast AV conduction down an accessory pathway, eg WP

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39
Q

What can a qrs complex of >0.12s suggest?

A

ventricular conduc- tion defects, eg a bundle branch block

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40
Q

What does a large qrs complex suggest?

A

Ventricular hypertrophy

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41
Q

Pathological q waves occur

A

After MI

Normal Q wave

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42
Q

What is a qt interval and it’s normal range?

A

Measure from start of QRS to end of T wave

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43
Q

Prolonged QT interval can be caused

A

acute myocardial ischaemia, myocarditis, bradycardia (eg AV block), head injury, hypothermia, U&E imbalance (reduced K+, Ca2+, Mg2+), congenital (Romano–Ward and Jervell–Lange–Nielson syndromes, p724); sotalol, quinidine, antihistamines, macrolides (eg erythromycin), amiodarone, phenothiazines, tricyclics.

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44
Q

ST segment is usually

A

Isoelectric. Raised or depressed st segment indicates ischemia or infarct

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45
Q

Peaked t wave indicates

A

Hyperkalaemia

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46
Q

Depressed t wave indicates

A

Hypokalaemia

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47
Q

J wave I seen only in

A

Hypothermia, hypercalemia and subarachnoid haemorrhage

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48
Q

Define sinus tachycardia and it’s causes

A

Anaemia, anxiety, exercise, pain, T°, sepsis, hypovolaemia, heart failure, pulmonary embolism, pregnancy, thyrotoxicosis, beri beri, CO2 retention, autonomic neuropathy, sympathomimetics, eg caffeine, adrenal- ine, and nicotine (may produce abrupt changes in sinus rate, or other arrhythmia).

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49
Q

In the obese, an AAA

A

Can be impalpable

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50
Q

Groups of patients that tend to present with atypical chest pain

A

Women and diabetics

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51
Q

In patients with MI the apex beat is

A

Lower and more lateral because of dead and floppy cardiac muscle

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52
Q

Name 3 common causes of atrial fib

A

IHD, thyrotoxicosis, hypertension.

53
Q

What’s the sign of 3rd degree heart block and the common causes?

A

Absent p wave
IHD, idiopathic (fibrosis), congenital, aortic valve calcification, cardiac surgery/trauma, digoxin toxicity, infiltration (ab- scesses, granulomas, tumours, parasites).

54
Q

What’s a pathological q wave and what can cause it?

A

Pathological Q waves are usually >0.04s wide and >2mm deep. Usually as sign of infarction, and may occur within a few hours of an acute MI. Non-pathological Q waves may occur in V5 and V6, aVL and I.

55
Q

What can cause a raised st interval?

A

Normal variant (high take-off), acute MI, Prinzmetal’s angina (p722), acute pericarditis (saddle-shaped), left ventricular aneurysm.

56
Q

What can cause a depressed st interval?

A

Normal variant (upward sloping), digoxin (downward sloping), ischaemic (horizontal): angina, acute posterior MI.

57
Q

What can cause a t wave inversion?

A

T inversion: In V1–V3: normal (black patients and children), right bundle branch block (RBBB), pulmonary embolism. In V2–V5: subendocardial MI, HCM, subarachnoid haem- orrhage, lithium. In V4–V6 and aVL: ischaemia, LVH, associated with left bundle branch block (LBBB).

58
Q

What’s seen in an ECG after an MI

A

Within hours, the T wave may become peaked and ST segments may begin to rise.
• Within 24h, the T wave inverts, as ST segment elevation begins to resolve. ST eleva-
tion rarely persists, unless a left ventricular aneurysm develops. T wave inversion
may or may not persist.
• Within a few days, pathological Q waves begin to form. Q waves usually persist, but
may resolve in 10% of patients.
• The leads affected reflect the site of the infarct: inferior (II, III, aVF), anteroseptal
(V1–4), anterolateral (V4–6, I, aVL), posterior (tall R and ST in V1–2), and thus the oc- cluded vessel: left anterior descending (anteroseptal), right coronary (inferior or right ventricular), circumflex (posterior, and, in 20%, inferior termed ‘left domi- nance’) .

59
Q

What’s seen in an ECG on a pulmonary embolism?

A

Sinus tachycardia is commonest. There may be RAD, RBBB (p91), right ventricular strain pattern (R-axis deviation. Dominant R wave and T wave inversion/ST depression in V1 and V2. Leads II, III and aVF may show similar changes). Rarely, the ‘SIQIIITIII’ pattern occurs: deep S waves in I, pathological Q waves in III, inverted T waves in III.

60
Q

What’s the digoxin effect?

A

Digoxin effect: ST depression and inverted T wave in V5–6 (‘reversed tick’). In digoxin toxicity, any arrhythmia may occur (ventricular ectopics and nodal bradycardia are common). Hyperkalaemia: tall, tented T wave, widened QRS, absent P waves, ‘sine wave’ appearance

61
Q

Where do you place the chest leads?

A

V1: right sternal edge, 4th intercostal space
V2: left sternal edge, 4th intercostal space
V3: half-way between V2 and V4
V4: 5th intercostal space, mid-clavicular line;
all subsequent leads are in the same horizontal plane as V4
V5: anterior axillary line
V6: mid-axillary line (V7: posterior axillary line)

62
Q

What’s a cardiac catheterization

A

This involves the insertion of a catheter into the heart via the femoral or radial artery or venous system, and manipulating it within the heart and great vessels to

63
Q

Purpose of catheterization

A

• Sample blood to assess oxygen saturation and measure pressures (see BOX).
• Inject radiopaque contrast medium to image cardiac anatomy and blood flow.
• Perform angioplasty (± stenting), valvuloplasty, and cardiac biopsies, or to do pro- cedures, eg transcatheter ASD closure.
• Perform intravascular ultrasound or echocardiography.

64
Q

What are the complications associated with cardiac catheterization

A

Complications:
• Haemorrhage: Apply firm pressure over puncture site. If you suspect a false aneu-
rysm, ultrasound the swelling and consider surgical repair.
• Contrast reaction: This is usually mild with modern contrast agents.
• Loss of peripheral pulse: May be due to dissection, thrombosis, or arterial spasm.
Occurs in 24h, take blood cultures before giving antibiotics.

65
Q

What is intra-cardiac electrophysiology

A

This catheter technique can determine types and origins of arrhythmias, and locate (and ablate) aberrant pathways (eg causing atrial flutter or ventricular tachycardia). Arrhythmias may be induced, and the ef- fectiveness of control by drugs assessed. Radiofrequency ablation may be used to destroy aberrant pathways or to prevent AF.

66
Q

What is CT angiography and what is it used for

A

CT angiogram permits contrast-enhanced imaging of coronary arteries during a single breath hold. It can diagnose significant (>50%) stenosis in CAD with an accuracy of 89%. Its negative predictive value is >99%, which makes it an effective non-invasive alternative to routine coronary angiography to rule out CAD

67
Q

Chief risk factor for IHD

A

Smoking

68
Q

What is Aspirin, how does it work and who’s it for?

A

Anti platelet drug,
Aspirin irreversibly acetylates cyclo-oxygenase, preventing pro- duction of thromboxane A2, thereby inhibiting platelet aggregation. Used in low dose (eg 75mg/24h PO) for secondary prevention following MI, TIA/stroke, and for patients with angina or peripheral vascular disease. May have a role in primary prevention.15 ADP receptor antagonists (eg clopidogrel, prasugrel) also block platelet aggregation, but may cause less gastric irritation.

69
Q

What is Warfarin, how does it work and who’s it for?

A

Anticoagulant,

Warfarin (p344) is mainly used in AF, and with mechanical valves.

70
Q

What are beta blockers, how does it work and who’s it for?

A

Block -adrenoceptors, thus antagonizing the sympathetic nervous system. Blocking 1-receptors is negatively inotropic and chronotropic (pulse by firing of sinoatrial node), and 2-receptors induce peripheral vasoconstriction and bronchoconstriction. Drugs vary in their 1/2 selectivity (eg propranolol is non-se- lective, and bisoprolol relatively 1 selective), but this does not seem to alter their clinical efficacy. Uses: Angina, hypertension, antidysrhythmic, post MI (mortality), heart failure (with caution). CI: Asthma/COPD, heart block. Caution: Heart failure (but see carvedilol, p130). SE: Lethargy, erectile dysfunction, joie de vivre, nightmares, headache.

71
Q

Expiration increases blood flow to which side of the heart

A

Left, because thoracic cavity reduces in size

72
Q

How do loop diuretics work and what are they used to treat?

A

Loop diuretics (eg furosemide) are used in heart failure, and inhibit the Na/2Cl/K co-transporter. Thiazides are used in hypertension and inhibit Na/Cl co- transporter. SE: Loop: dehydration, K+, Ca2+, ototoxic; thiazides: K+, Ca2+, Mg2+, urate (±gout), impotence (NB: small doses, eg chlortalidone 25mg/24h rarely cause significant SEs); Amiloride: K+, GI upset.

73
Q

How do vasodilators work and what are they used to treat?

A

Used in heart failure, IHD, and hypertension. Nitrates preferentially dilate veins and the large arteries,  filling pressure (pre-load), while hydralazine (often used with nitrates) primarily dilates the resistance vessels, thus  BP (after- load). Prazosin (an -blocker) dilates arteries and veins.

74
Q

What is mitral stenosis and what are it’s causes

A

Mitral stenosis is narrowing of the mitral valves
Rheumatic, congenital, mucopolysaccharidoses, endo- cardial fibroelastosis, malignant carcinoid (p278; rare), prosthetic valve.

75
Q

What are other signs of mitral stenosis?

A

Malar flush on cheeks (due to  cardiac output); low-volume pulse; AF common; tapping, non-displaced, apex beat (palpable S1). On auscultation: loud S1; opening snap (pliable valve); rumbling mid-diastolic murmur (heard best in expiration, with patient on left side). Graham Steell murmur (p44) may occur. Severity: The more severe the stenosis, the longer the diastolic murmur, and the closer the open- ing snap is to S2.

76
Q

What investigations should be done after auscultation a murmur?

A

ECG

Echocardiogram

77
Q

What is mitral regurgitation?

A

Turbulent flow of blood due to back flow because of failure of closure of mitral valve

78
Q

What are the causes of mitral regurgitation?

A

Functional (LV dilatation); annular calcification (elderly); rheumatic fever, infective endocarditis, mitral valve prolapse, ruptured chordae tendinae; papillary muscle dysfunction/rupture; connective tissue disorders (Ehlers–Danlos, Marfan’s); cardiomyopathy; congenital (may be associated with oth- er defects, eg ASD, AV canal); appetite suppressants (eg fenfluramine, phentermine

79
Q

What are the symptoms and signs of mitral regurgitation?

A

Symptoms: dyspnoea, palpitations, fatigue, infective endocarditis
Signs: AF
Pan systolic murmur that radiates to axilla

80
Q

What are common causes of mitral valve prolapse?

A

ASD, patent ductus arteriosus, cardiomyopathy, Turner’s syndrome, Marfan’s syndrome, osteogenesis imperfecta, pseudoxanthoma elasticum, WPW

81
Q

What are the signs and symptoms of mitral valve prolapse?

A

Symptoms: asymp, chest pain, palpitations, autonomic dysfunction
Signs: mid systolic clic or late systolic murmur

82
Q

What are the complications of mitral valve prolapse?

A

Mitral regurgitation, cerebral emboli, arrhythmias, sudden death.

83
Q

What is aortic stenosis, and name some common causes

A

Aortic stenosis is narrowing of the aorta, and it’s caused by Senile calcification is the commonest.96 Others: con- genital (bicuspid valve, William’s syndrome, p143), rheumatic heart disease.

84
Q

What are the common signs and symptoms?

A

Symptoms: angina, chest pain, breathlessness, syncope, dizziness, sudden death, emboli,
Signs:Slow rising pulse with narrow pulse pressure (feel for diminished and delayed carotid upstroke—parvus et tardus); heaving, non-displaced apex beat; LV heave; aortic thrill; ejection systolic murmur (heard at the base, left sternal edge and the aortic area, radiates to the carotids).

85
Q

What is Aortic sclerosis?

A

senile degeneration of the valve. There is an ejection systolic murmur, no carotid radiation, and normal pulse (character and volume) and S2

86
Q

What are the common causes of aortic regurgitation

A

Acute: Infective endocarditis, ascending aortic dis- section, chest trauma. Chronic: Congenital, connective tissue disorders (Marfan’s syndrome, Ehlers–Danlos), rheumatic fever, Takayasu arteritis, rheumatoid arthritis, SLE; pseudoxanthoma elasticum, appetite suppressants (eg fenfluramine, phenter- mine), seronegative arthritides (ankylosing spondylitis, Reiter’s syndrome, psoriatic arthropathy), hypertension, osteogenesis imperfecta, syphilitic aortitis

87
Q

What are the symptoms of aortic regurgitation?

A

Symptoms: Exertional dyspnoea, orthopnoea, and paroxysmal nocturnal dyspnoea. Also: palpitations, angina, syncope, CCF. Signs: Collapsing (water-hammer) pulse (p40); wide pulse pressure; displaced, hyperdynamic apex beat; high-pitched early diastolic murmur (heard best in expiration, with patient sitting forward). Eponyms: Corrigan’s sign: carotid pulsation; de Musset’s sign: head nodding with each heart beat; Quincke’s sign: capillary pulsations in nail beds; Duroziez’s sign: in the groin, a finger compressing the femoral artery 2cm proximal to the stethoscope gives a systolic murmur; if 2cm distal, it gives a diastolic murmur as blood flows backwards; Traube’s sign: ‘pistol shot’ sound: over femoral arteries; an Austin Flint murmur (p44) denotes severe AR.

88
Q

What is the definition of heart failure?

A

Cardiac output of heart is insufficient for the body’s needs. Typically poor prognosis.

89
Q

What is systolic heart failure and what are the possible causes?

A

inability of the ventricle to con- tract normally, resulting in cardiac output. Ejection fraction (EF) is

90
Q

What is diastolic failure and it’s causes?

A

Failure of ventricles to relax normally, causing lower filling pressure.
Causes: constrictive pericarditis, tamponade, restrictive cardiomyopathy, hypertension. NB: systolic and diastolic fail- ure usually coexist.

91
Q

Left sided heart failure causes

A

Pulmonary oedema, breathlessness, poor exercise tolerance, pink frothy sputum, weight loss, muscle wasting

92
Q

What are some of Right sided heart failure’s causes and symptoms?

A

Causes: LVF, pulmonary stenosis, lung disease
Symptoms: Ascites, peripheral oedema, tricuspid regurgitation, nausea, anorexia

93
Q

What is WPW caused by?

A

Abnormal accessory conduction pathways between the atria and ventricles which can stimulate the ventricles prematurely

94
Q

What can be seen in the ECG of a patient with WPW

A

A special type of supra ventricular tachycardia, called atrioventricular reentrant tachycardia

95
Q

What are the symptoms of WPW?

A

Usually asymptomatic, but palpitations, dizziness, SOB and syncope can occur during an SVT

96
Q

What is a bundle branch block?

A

A defect in the bundle branches in the electrical conduction system of the heart

97
Q

What can a bundle branch block cause?

A

Loss of ventricular synchronization

98
Q

What can be seen in the ECG of a right bundle branch block?

A

Axis of ECG shifts to the right

Qrs complex is >120s. (Last part is elongated)

99
Q

What can be seen in the ECG of a left bundle branch block?

A

Axis of ECG shifts to the left

Qrs complex is >120s. (Entire qrs wave is elongated)

100
Q

What is WPW caused by?

A

Abnormal accessory conduction pathways between the atria and ventricles which can stimulate the ventricles prematurely

101
Q

What’s associated with aortic stenosis?

A

Syncope
Exertional dyspnoea
Angina

102
Q

What is valvuloplasty and what is it used for?

A

A balloon catheter is inserted into the valve and inflated

Used in mitral pulmonary regurgitation

103
Q

What is the clinical presentation of infective endocarditis?

A

Fever, rigors, sweating, finger clubbing, murmurs, janeway lesions, Roth spots, oslers nodes, malaise, weight loss, anaemia

104
Q

What are the common causes of infective endocarditis?

A

Strep veridans, Staph aureus, diphtheroids

105
Q

What is acute myocarditis?

A

Inflammation of myocardium

106
Q

What are the causes of acute myocarditis?

A

Viral infection (polio, flu, hepatitis, coxsackie, HIV, mumps) bacterial infection(diphtheria, clostridium, TB, meningococcus), drugs (sulphonamide, penicillin, cyclosphamide, herceptin)

107
Q

What are the signs and symptoms of acute myocarditis?

A

Dyspnoea, chest pain, soft S1, galloping S4, fatigue, fever, palpitations, tachycardia

108
Q

What can be seen in the ECG of someone with acute myocarditis?

A

St elevation or depression, t wave inversion, arial arrhythmia, transient AV block

109
Q

What is dilated cardiomyopathy?

A

A dilated, flabby heart of unknown causes

110
Q

What is dilated cardiomyopathy associated with?

A

Alcohol, thyrotoxicosis, pre or post partum, haemochromatosis, congenital, autoimmune, hypertension

111
Q

What is the clinical presentation of cardiomyopathy?

A

Raised JVP, RHF, VT, AF, hypotension, S3 gallop, pulmonary oedema, oedema, fatigue, dyspnoea, mitral or tricuspid regurgitation, jaundice, Hepatomegaly

112
Q

A cause of sudden cardia c death in the young could be:

A

Cardiac hypertrophy

113
Q

What are the causes of restrictive cardiomyopathy?

A

Idiopathic, amyloidosis, haemochromatosis, sarcoidosis, scleroderma, Löeffer’s eosinophilia endocarditis, endomyocardial fibrosis

114
Q

What is the presentation of restrictive cardiomyopathy?

A

Like RVF: raised JVP, Ascites, oedema

115
Q

What are the clinical features of acute pericarditis?

A

Central chest pain worse on inspiration or lying flat ± relief by sitting forward. A pericardial friction rub may be heard. Look for evidence of a pericardial effusion or cardiac tamponade (see below). Fever may occur.

116
Q

What is a pericardial effusion?

A

Accumulation of fluid in the pericardial space

117
Q

What are the clinical features of a pericardial effusion?

A

Central chest pain worse on inspiration or lying flat ± relief by
sitting forward. A pericardial friction rub (p44) may be heard. Look for evidence of a pericardial effusion or cardiac tamponade (see below). Fever may occur.

118
Q

What is constrictive pericarditis?

A

The heart in encased in a stiff pericardium

119
Q

What are the clinical features of constrictive pericarditis?

A

These are mainly of right heart failure with JVP (with prominent x and y descents, p41); Kussmaul’s sign (JVP rising paradoxically with inspiration); soft, diffuse apex beat; quiet heart sounds; S3; diastolic pericardial knock, hepato- splenomegaly, ascites, and oedema.

120
Q

What is cardiac tamponade?

A

Accumulation of pericardial fluid raises intrapericardial pres- sure, hence poor ventricular filling and fall in cardiac output.

121
Q

What are the clinal features of cardiac tamponade?

A

Pulse, BP, pulsus paradoxus, JVP, Kussmaul’s sign, muffled S1 and S2. Diagnosis: Beck’s triad: falling BP; rising JVP; muffled heart sounds.

122
Q

What are the causes of raised JVP?

A 
HF
Constrictive pericarditis
Cardiac tamponade
SVC obstruction
Fluid overload
123
Q

A narrow complex tachycardia that reverts to sinus rhythm after the valsalva manoeuvre is

A

AV nodal re entry tachycardia

124
Q

A young man with central chest pain and breathlessness with a history of sore throat likely has

A

Acute pericarditis

125
Q

What it’s the most likely cause of an ejection systolic murmur?

A

Aortic stenosis

126
Q

If a tachycardia is resolved by adenosine it is caused by

A

The AV node, as adenosine blocks the AV node allowing sinus rhythm to return

127
Q

What MI causes Bradycardia and why?

A

Inferior MI

As the r. Coronary artery supplies the SA node in most people

128
Q

What is the treatment of broad complex tachycardia?

A

Amiodarone

FOCP (12 decks)

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