Cardiology Flashcards
(117 cards)
1
Q
Name the structures that cause chest pain
A
Heart, pericardium, pleura, diaphragm, abdominal structures, aorta, chest wall, skin, spine, oesophagus
2
Q
Mechanisms of chest pain: cardiac muscle ischaemia- what nerves are involved?
A
Sympathetic afferent nerves: T1-T5
Vagal afferent nerves- medulla
3
Q
Mechanisms of chest pain: pericardial inflammation- what nerves are involved?
A
Branch of phrenic nerve
4
Q
Mechanisms of chest pain: pleural inflammation- what nerves are involved?
A
Thoracic nerves - there are no lung pain fibres.
5
Q
Cardiac causes of chest pain:
A
AMI, unstable angina, pericarditis
6
Q
Vascular causes of chest pain:
A
Aortic dissection
7
Q
What occurs in NSTEMI/ UA/ NSTEACS?
A
There is stenosis of coronary arteries but the vessel is not occluded so it may resolve.
8
Q
What differentiates stable and unstable angina?
A
Onset of stable angina is always with exertion, never with rest, and offset is with rest.
9
Q
Why is troponin not very important?
A
Because it can be raised in both STEMI and NSTEMI, and it takes around 6 hours to become elevated in the blood which is often too late.
10
Q
How do we treat STEMI?
A
Coronary angioplasty: it is ~99% successful,
people are less likely to bleed than with thrombolysis,
less likely to have another MI.
11
Q
How long do we have to do a coronary angioplasty after the onset of symptoms of STEMI?
A
90 minutes
12
Q
What is the intervention for NSTEMI?
A
GTN, morphine but need to treat depending on pathology/pathophysiology
13
Q
What are respiratory causes of chest pain?
A
Pulmonary embolus
Pneumonia
Pleurisy
Pneumothorax
14
Q
What are oesophageal causes of chest pain?
A
GORD
Oesophageal spasm
15
Q
What are musculoskeletal causes of chest pain?
A
Muscle injury
Costochondral joint inflammation
16
Q
How can the skin cause chest pain?
A
Shingles: the pain can show up before the rash
17
Q
What are the symptoms of AMI?
A
Tightness in chest, chest pain that can radiate to both arms, left jaw, shoulders, neck.
Worse with exertion,
May be relieved by rest or GTN
Associated sweating, nausea and dyspnoea.
18
Q
What is a common presentation of angina?
A
Older man goes for a walk after dinner in the cold, gets chest pain that can be walked off.
19
Q
What is takotsubo cardiomyopathy?
A
‘Broken heart syndrome’.
The ventricle dilates with acute stress, balloons out and infarction can occur due to sheer forces induced by stress which erode or rupture a plaque.
20
Q
What is more common for women, plaque erosion or rupture?
A
Plaque erosion
21
Q
What level of stenosis occurs in stable angina?
A
70%
But it can be less for smaller arteries and it also depends on the length of the plaque.
22
Q
Why do people with stable angina get chest pain?
A
There is pain when oxygen demand is greater than the supply
23
Q
What is the process that occurs in UA and AMI?
A
Ruptured atherosclerotic plaque and thrombus,
Acute narrowing or occlusion of coronary artery,
Pain due to acute decrease in myocardial oxygen supply
24
Q
What occurs when a plaque ruptures?
A
Fat, lipid and macrophages are exposed to blood,
Clotting cascade is activated,
Thrombus forms on top of plaque.
25
Name 6 drugs used in the anti coagulation therapy used for STEMI/ NSTEMI.
Aspirin: a COX 2 inhibitor involved in pain relief but mainly used as an anti platelet.
Thienopyradine: anti platelet: aimed at clot.
Enoxaparin/ unfractionated heparin/ clexane: anti coagulation drug which prevents propagation of the clot to become occlusive.
Statins: acutely makes a difference by stabilizing plaque and having off target anti inflam properties.
GTN: vasodilation
Morphine: pain medication.
26
What is decubitus angina?
Angina on lying flat
27
Who is likely to have atypical pain with AMI?
Women, diabetics
28
Important past medical history for chest pain?
Angina, infarction, bypass surgery, coronary intervention.
29
What are risk factors for coronary disease?
```
High cholesterol
Smoking
Hypertension
Diabetes
Past family history
```
30
If STE occurs in the chest leads: V1 to V6 where is the infarction?
Anterior of heart
31
If STE occurs in inferior limb leads, where is the infarction?
Inferior wall
32
Which artery is not represented in a 12 lead ECG?
Circumflex artery
33
What do you see on an ECG for a posterior infarct?
Deep ST depression anteriorly
34
What do you see on ECG for pericarditis?
STE everywhere, PR depression
35
What is a common presentation of pericarditis?
More common in winter months post viral infection (gastro or URTI), in younger people.
It is relieved by sitting up, worse on lying down.
Sharp, stabbing pain, worse on movement or breathing, central or left sided.
May hear rub on examination.
May see neutrophilia and elevated CRP.
36
What is pericarditis with troponin elevation?
Myopericarditis: inflam in both pericardium and muscle.
37
Which conditions are not to be missed with chest pain?
PE
Aortic dissection
STEMI
38
What are the risk factors of PE?
```
FHx
PHx
Post op
Travel
Sick in bed
Cancer
```
39
True or false: oesophageal spasm may be relieved by GTN
True
40
When is oesophageal pain worse?
After meals and on lying down.
41
What does an irregularly irregular heart beat indicate?
Atrial fibrillation.
| It could be a sinus rhythm with a lot of extort but that would eventually have some regular beats.
42
What does a regularly irregular heart beat indicate?
Sinus rhythm with ectopic beats - ventricular ectopy.
43
What does a narrow QRS complex indicate?
Sinus, atrial or junctional origin.
44
What does a wide QRS complex indicate?
Ventricular origin OR supraventricular with aberrant conduction
45
What does an absent p wave represent?
Sinus arrest, atrial fibrillation
46
What is a high arched palate a sign of?
Marfan syndrome.
47
If you detect AF, what should you look out for?
Mitral valve disease.
48
If you feel an apical thrill, what could be the reason?
Prior infarction.
49
What is the bell used for and therefore what murmur could it detect?
Low pitched sounds; it can detect the low rumbling murmur of mitral stenosis.
50
What is the diaphragm of the steth used for and therefore, name a murmur it can detect.
High pitched sounds like a decrescendo murmur.
51
What murmur are you listening for when you ask a patient to breathe out and stop breathing whilst sitting up?
Aortic regurgitation- quieter murmur.
52
What manoeuvre do you do if there is a systolic murmur?
Val salva.
53
What does a pulsatile liver indicate?
Tricuspid regurgitation.
54
What artery do you palate if the patient has had coronary bypass surgery?
Ulnar artery at wrist or brachial artery.
55
What does a carotid bruit represent?
Carotid narrowing
56
What is the S3 heart sound and what does it indicate?
It is turbulence during early filling of the ventricle. It may be normal, may be dilated left ventricle:
Dilated cardiomyopathy, volume overload; MR or AR.
57
What is the S4 heart sound and what does it indicate?
Turbulence during atrial contraction: In stiff ventricle; hypertension, aortic stenosis, hypertrophic cardiomyopathy.
58
What type of murmur is aortic stenosis?
Systolic murmur
Crescendo-decrescendo.
"Ejection systolic"
59
What type of murmur is mitral regurgitation?
Pansystolic murmur.
60
Physiological murmurs can be non pathological and occur in high flow states, or not be pathological themselves but indicate an underlying disease process. Name 4 states which may present with a physiological murmur.
Pregnancy, childhood, anaemia, thyrotoxicosis
61
Name 2 peripheral signs of endocarditis
Splinter haemorrhages and Janeway lesions.
62
What percentage of patients with heart failure have preserved ejection fraction?
40%
63
What is the commonest cause of HEFREF?
Ischaemic heart disease
64
What is HEFREF?
Heart failure with reduced ejection fraction: Systolic/LV heart failure.
65
For which type of heart failure is there a plethora of effective therapy and which is there no proven effective therapy for mortality?
HEFREF: plethora of effective therapy.
HEFPEF: pretty much a death sentence within the next 5 years.
66
When does HEFPEF occur?
More commonly in diabetic, hypertensive patients. Usually overweight, diabetic , older women.
67
Describe a typical HEFPEF heart
Stiff
68
Name 4 symptoms common with heart failure
Fatigue, PND, orthopnoea, pneumonia.
69
How do you test ejection fraction?
Via echocardiogram
70
What is cardiac output determined by?
Input (preload/venous return)
Rate
Strength (contractility)
Resistance (afterload)
71
What is the commonest cause of RHF?
LHF
72
How does pulmonary oedema occur?
Increased pressure on the left heart causes fluid to be translocated into the alveoli
73
What are the causes of oedema
- Increased venous pressure: heart failure
- Decreased osmotic pressure: plasma loss due to renal or liver failure
- Blocked lymphatics: cancer
- Increased capillary permeability: infection.
74
After assessing fluid levels, when is it safe to I've beta blockers?
In the absence of orthopnoea. Orthopnoea is the symptom that best correlates with a wedge pressure.
75
Name 4 causes of shortness of breath
Cardiac
Respiratory
Anaemia
Poor fitness
76
What is orthopnoea specific for?
Heart failure
77
Name 7 causes of heart failure
```
Ischaemic heart disease
Valvular heart disease
Hypertensive heart disease
Congenital heart disease
Cardiomyopathy
Cor Pulmonale (RH)
Pericardial disease
```
78
What is Cor Pulmonale?
Heart failure due to lung disease which causes pulmonary hypertension.
Eg. COPD, CF, pulmonary fibrosis
79
What are 4 principles of treating heart failure?
Reduce venous pressure
Block the renin angiotensin system
Block the sympathetic nervous system (beta blockers)
Treat the underlying and precipitating causes
80
Name 5 drugs used to treat heart failure:
Diuretics: eg. Frusemide
Aldosterone antagonists eg. Spironolactone
ACE inhibitors eg. Irbesartan
Beta blockers eg. Carvedilol
81
Name 4 systemic pathology that can cause ECG changes?
Sepsis, PE, intracranial pathology, electrolyte disturbance.
82
What does a saw tooth characteristic on an ECG indicate?
Atrial flutter
83
What 6 things should you analyse when reading an ECG?
```
Rate and rhythm
Cardiac axis
PR interval
QRS complexes
ST segments and T waves
QT interval
```
84
What should you earn patients about when giving adenosine?
Immediate but temporary sensation of impending doom.
85
How do you treat SVT
Vagal manoeuvres, adenosine, AV nodal blockers, IV amiodarone, DCR (shock)
86
What should you give for ventricular tachycardia?
Give magnesium
87
What does VT look like on ECG?
Fast rate, irregular rhythm, broader QRS.
88
What condition mimics a normal ECG and what is it?
Wolff-Parkinson-White syndrome. Can be differentiated by a delta wave.
Referred to as a pre-excitation syndrome, it is caused by an abnormal accessory electrical conduction pathway between the atria and the ventricles. In addition to the AV node, they have an accessory pathway- the bundle of Kent.
89
What is the normal pathway of electrical conduction through the heart?
Arises at SA node
Transmitted via intermodal pathways to AV node.
Brief delay
Through bundle of His
To left and right bundle branches
Then to Purkinje fibres and endocardium.
Finally to the ventricular myocardium.
90
What's is Torsades syndrome?
'Twisting of the points'
An abnormal heart rhythm that can lead to sudden cardiac death.
It is a polymorphic VT.
Prolongation of the QT interval can increase a person's risk of developing this.
91
Where does the sinus node most commonly get blood supply from? What is a complication of blockage of this supply?
Sinus branch of RCA.
| Blockage of the artery can lead to complete heart block.
92
What does a narrow QRS indicate and what could it indicate?
Supraventricular tachycardia.
| Could be AF, atrial flutter, true SVT.
93
What does the p wave indicate?
Atrial depolarisation
94
What is left axis deviation?
A condition where the mean electrical axis of ventricular contraction lies in a frontal plane direction of -30 to -90 degrees
95
How do you detect left axis deviation in an ECG?
A QRS complex that's positive in lead I and negative in aVF and II.
96
What are 3 common causes of left axis deviation?
Left ventricular hypertrophy, inferior infarct, left anterior fascicular block (or hemiblock)
97
When would Left axis deviation be normal?
When patient is obese, stocky, or has Wolff-Parkinson-White syndrome.
98
What is right axis deviation
Deviation of QRS axis between +90 and +180 degrees
99
How do you recognise right axis deviation on an ECG?
QRS is positive in leads III and aVF, QRS is negative in leads I and aVL.
100
When is RAD normal?
In children and thin adults with a horizontally positioned heart.
101
What is the Wenckebach phenomenon?
Progressive lengthening of the PR interval.
102
How do you define 2:1 AV conduction block and what treatment should be recommended?
Every 2nd p wave is non-conducted. Px usually requires a pacemaker.
103
How do you treat acute infective bronchitis in an otherwise we'll person?
Self limiting.
104
How do you treat acute infective bronchitis in someone with chronic lung disease?
Needs antibiotics to prevent progression of the infection, inhaled bronchodilators and steroids, potentially oral steroids, sputum clearance measures and follow up.
105
How do you treat severe pneumonia?
Empiric antibiotics to cover typical and atypical organisms + supportive treatment: oxygen, fluids, pain relief, sputum clearance, observation, reassurance.
106
Describe the murmur of aortic stenosis and the manoeuvre used to exaggerate it.
Ejection systolic murmur. Crescendo-decrescendo.
Loudest when sitting up and leaning forward.
Can radiate to carotids.
107
Describe the murmur of mitral regurgitation and the manoeuvre used to exaggerate it.
Pansystolic murmur.
| Loudest when patient is rolled onto left side. Can radiate to axilla.
108
What causes S3 and what condition is it associated with?
Caused by blood from LA colliding with left over blood in LV. Associated with heart failure.
109
What is S4 caused by and what condition is it associated with?
Caused during atrial systole when blood is squeezed into non-compliant LV.
It is associated with hypertension.
110
How are extra heart sounds best heard?
With the bell of the steth, laid over LV, with patient lying on left side.
111
What does radio-radial delay indicate?
Aortic coarctation
112
What is a narrow pulse pressure associated with?
Aortic stenosis
113
What is widened pulse pressure associated with?
Aortic regurgitation
114
What are xanthelasma? And what are they associated with?
Yellow raised lesions around the eyes associated with hypercholesterolaemia.
115
What would angular stomatitis indicate in a cardiovascular exam?
Iron deficiency.
116
In a cardiovascular exam, what does a high arched palate indicate?
And what does that condition increase the risk of?
Marfan syndrome,
| Increased risk of aortic aneurysm or dissection.
117
What are the accentuation manoeuvres in a cardiovascular exam?
Auscultate carotid arteries with patient holding their breath for radiation of an AS murmur.
Auscultate the aortic area with the patient sitting up and leaning forwards for AR.
