Cardiology Flashcards
(164 cards)
1
Q
What is essential hypertension?
A
Hypertension with no identifiable cause
2
Q
What are risk factors for essential hypertension?
A
Increased age, family history, male sex, african-americans
3
Q
What can essential hypertension lead to (broadly)?
A
Cardiac, renal and cerebral events
4
Q
In primary care, if a patient has an initial blood pressure reading of >140/90, what should you do?
A
Repeat their blood pressure
5
Q
In primary care, if a patients second blood pressure reading is again >140/90, what should you do?
A
Offer ambulatory or home blood pressure monitoring
6
Q
How is ambulatory blood pressure monitoring done?
A
2 blood pressure measurements are taken per hour during usual waking hours (around 14 readings a day). An average blood pressure is then calculated from these
7
Q
How is home blood pressure monitoring done?
A
2 consecutive blood pressure measurements are taken 1 minute apart, twice daily for 4-7 days. Measurements on day 1 are discarded and then an average of the other readings calculates the blood pressure.
8
Q
How is end organ damage assessed in essential hypertension?
A
Test urine for proteinuria
Take bloods for glucose, electrolytes, creatinine, eGFR, cholesterol
Examine fundi for hypertensive retinopathy
Arrange a 12-lead ECG
9
Q
What is stage 1 hypertension defined as (clinic & ABPM readings)?
A
Clinic ≥ 140/90
ABPM ≥135/85
10
Q
What is stage 2 hypertension defined as (clinic & ABPM readings)?
A
Clinic ≥ 160/100
ABPM ≥ 150/95
11
Q
What is severe hypertension defined as (clinic readings)?
A
Clinic ≥ 180 systolic or diastolic ≥ 110
12
Q
What lifestyle interventions can be done for hypertension?
A
Healthy diet, low salt diet
Aerobic exercise
Stop smoking
Decrease alcohol intake
13
Q
What is the first line treatment for patients under 55 with essential hypertension?
A
ACE inhibitor or ARB (e.g. rampipril or losartan)
14
Q
What is the first line treatment for patients ≥55 or afro-carribean with essential hypertension?
A
Calcium channel blocker (e.g. amlodipine)
15
Q
What is the second line treatment for essential hypertension?
A
ACEi/ARB + Calcium channel blocker
16
Q
What is the third line treatment for essential hypertension?
A
ACEi/ARB + Calcium channel blocker + thiazide diuretic
17
Q
Which kind of thiazide diuretics should patients be started on for 3rd line essential hypertension treatment?
A
Indapamide or chlortalidone
18
Q
What drug is added 4th line in essential hypertension if the patients potassium is less than 4.5mmol?
A
Spironolactone
19
Q
What is the 4th line treatment of essential hypertension if the patients potassium is more than 4.5mmol?
A
Higher dose of thiazide diuretic
20
Q
How do ACE inhibitors work?
A
Prevent conversion of angiotensin I to angiotensin II leading to vasodilation and decreased BP
21
Q
What are side effects of ACE inhibitors?
A
Dry cough, hyperkalaemia, fatigues, dizziness, headache
22
Q
How do ARBs work?
A
Block angiotensin II receptors resulting in vasodilation and decreased BP
23
Q
What are side effects of ARBs?
A
Dizziness, headache
24
Q
What type of calcium channel blockers are used in hypertension treatment?
A
Dihydropiridines
25
What are side effects of dihydropiridines?
Flushing, headache, ankle swelling
26
How do calcium channel blockers work?
Block voltage gated calcium channels
27
How do thiazide diuretics work?
Inhibit sodium resorption at the distal convoluted tubule
28
What are side effects of thiazide diuretics?
Postural hypotension, gout, dehydration, electrolyte imbalance
29
What kind of drug is spironolactone?
Aldosterone agonist
30
What are some side effects of spironolactone?
Nausea, vomiting, hyperkalaemia, rashes, gynaecomastia
31
What does the umbrella term acute coronary syndrome cover?
Unstable angina, STEMI, NSTEMI
32
What are risk factors for acute coronary syndrome?
Obesity, smoking, family history, high cholesterol, alcohol
33
What are the two consequences of atherosclerotic plaque build up in the arteries?
Narrowing of the arteries (causing less blood any oxygen)
| Sudden plaque rupture causing arterial occlusion
34
What are symptoms of acute coronary syndrome?
Pain - left sided, radiating to jaw and down arm
Breathlessness
Sweating
Nausea & vomiting
35
What causes STEMI?
Complete occlusion of a coronary artery due to plaque rupture, leading to myocardial ischaemia
36
What ECG changes do you see in STEMI?
ST elevation, T wave inversion, Q waves
37
What are the 3 criteria on an ECG that would be suggestive of STEMI?
≥1mm elevation in 2 adjacent limb leads OR
≥2mm elevation in 2 contiguous chest leads OR
New LBBB
38
Is troponin elevated in STEMI?
Yes
39
What leads will you see ST elevation in an inferior MI?
II, III, aVF
40
What artery is occluded in an inferior MI?
Right coronary artery
41
Why is an inferior MI likely to cause arrythmias?
As the RCA supplies the AV node and sometimes the SA node
42
What leads will you see ST elevation in an anterior MI?
V1-V6
43
What leads will you see ST elevation in an anteroseptal MI?
V1-V4
44
What leads will you see ST elevation in an anterolateral MI?
I, aVL, V5. V6
45
What artery is occluded in an anterior MI?
Left anterior descending (LAD)
46
What artery is occluded in a lateral MI?
Left circumflex
47
What leads will you see ECG changes in a posterior STEMI?
V1-V3 - ST DEPRESSION
48
What is an NSTEMI?
ACS where there is plaque rupture but transient/non-complete arterial occlusion
49
What are the ECG changes in NSTEMI?
Normal or ST depression and T wave inversion
50
Is troponin elevated in NSTEMI?
YES
51
What is unstable angina?
An ACS with no evidence of cardiac damage
52
What are the ECG changes in unstable angina?
Normal or ST depression and T wave inversion
53
Is troponin elevated in unstable angina?
NO
54
What drugs should all patients presenting with ACS be given ASAP?
Aspirin 300mg
Ticagrelor 180mg
Metoprolol 50-100mg/5-15mg IV
55
If a patient has ST elevation, how long is the window for doing PCI from diagnosis?
<120 minutes
56
If a patient with ST elevation is not able to get PCI within 120 minutes from diagnosis, how should you manage them?
Thrombolysis IV (Alteplase) and fondaparinux
57
After thrombolysis, when should you perform an ECG?
90 minutes later to check for resolution of ST elevation
58
How should patients with no ST elevation be managed first (following aspirin, ticagrelor & metoprolol)?
Fondaparinux or LMWH SC
| Nitrates IV
59
After initial management of no ST elevation ACS, what should be calculated?
GRACE Score - estimates risk of death/MI
60
If the GRACE score is medium to high what should be done?
Coronary angiography
61
Following ACS, what antiplatelet therapy should all patients be on and for how long?
6 months dual antiplatelet therapy - aspirin 75mg and ticagrelor 90mg BD
Then aspirin 75mg lifelong
62
What other maintenance medications should all patients with ACS be put on?
ACE inhibitor - lifelong
Statin - lifelong
Beta-blocker - at least 12 months/lifelong
63
What is heart failure?
When cardiac output is inadequate for the bodies requirements
64
What is the pathophysiology of the systolic nature of heart failure?
Inability of the ventricle to contract normally, leading to a decreased ejection fraction and therefore decrease CO
65
What is the pathophysiology of the diastolic nature of heart failure?
Inability of the ventricle to relax and fill normally causing increased filling pressures (note that systolic and
66
What are the main causes of left heart failure?
MI, hypertension, CHD
67
What are the symptoms of left heart failure?
Dyspnoea, fatigue, orthopnoea, PND, nocutrnal cough with pink frothy sputum
68
What are the signs of left heart failure?
Displaced apex, gallop rhythm, murmurs (aortic stenosis/mitral regurgitation)
69
What are the causes of right sided heart failure?
Left heart failure, pulmonary stenosis, cor pulmonale
70
What are the symptoms of right sided heart failure?
Peripheral oedema, ascites, nausea, anorexia, facial engorgement
71
What are the signs of right sided heart failure?
Pulsation in face and neck
| Tricuspid regurgitation
72
What is congestive cardiac failure?
Both right and left sided heart failure
73
How is congestive cardiac failure classified?
Framingham criteria
74
If you are suspicious of a diagnosis of heart failure, what is the first line investigation for a patient who has had an MI?
Echocardiogram within 2 weeks
75
If you are suspicious of a diagnosis of heart failure, what is the first line investigation for a patient who has NOT had an MI?
Measure serum brain natruretic peptide (BNP)
76
What is BNP?
A hormone produced by the left ventricle in response to stress/strain
77
What do high levels of BNP correlate with in heart failure?
A poor prognosis
78
If the BNP levels are high, what should you do?
Echocardiogram within 2 weeks
79
If BNP levels are raised but not very high, what should you do?
Echocardiogram within 6 weeks
80
What other investigations are important in heart failure?
FBC, U&Es, CXR, ECG
81
What does CXR show in left ventricular failure?
```
Alveolar shadowing
Kerly B lines
Cardiomegaly
Dilated vessels
Effusion (pleural)
```
82
How should you treat acute heart failure?
Oxygen
Diuretics, vasodilators, ionotropes
CPAP
Mechanical circulatory interventions
83
What is the first line drug treatment for heart failure?
ACE inhibitor + betablocker
84
What are the second line add on treatments for heart failure?
Addition of either
Aldosterone agonist (spironolactone)
ARB
Hydralazine and nitrate
85
If heart failure persists after first and second line treatment, what should be considered?
Cardiac resynchronization OR
Digoxin OR
Ivabradine
86
When should diuretics be used in heart failure?
Only if evidence of fluid overload
87
What is stable angina?
Syndrome caused by plaques in the coronary arteries restricting blood flow and causing symptoms
88
What are symptoms of stable angina?
Chest pain lasting minutes provoked by exercise or emotion, relived by rest/GTN
89
What medication should all patients with stable angina be put on for cardioprotection?
Long term aspirin and statin
90
What is the first line therapy for stable angina?
Betablocker
91
What is the first line therapy for stable angina if the patient cannot tolerate a beta-blocker?
Rate limiting CCB - Verapamil or Diltiazem
92
What is the second line treatment option for stable angina?
Betablocker + dihydropiridine CCB (Amlodipine, nifedipine)
93
What treatment should be given to patients with stable angina for symptomatic relief?
GTN spray for prevention and relief
94
What other therapies are available for stable angina?
Isosorbide mononitrate
Ivabradine
Nicorandil
95
What causes murmurs?
Audible turbulent blood flow as a consequence of valve disease
96
What is the diagnostic investigation for murmurs?
Echocardiogram
97
'Ejection systolic murmur best heard at the aortic region that radiates to the carotids'
Aortic stenosis
98
'Slow rising pulse'
Aortic stenosis
99
What are causes of aortic stenosis?
Congenital bicuspid valve, rheumatic heart disease, age related calcification
100
What sort of murmur does pulmonary stenosis cause?
Ejection systolic
101
'Pansystolic murmur best heart at the apex, radiating to the axilla'
Mitral regurgitation
102
'Displaced apex beat'
Mitral regurgitation
103
'Harsh pansystolic murmur'
Ventricular septal defect
104
What are causes of a late systolic murmur?
Mitral valve prolapse
| Coarctation of aorta
105
'Early diastolic murmur best heard when patient is sitting forward on expiration'
Aortic regurgitation
106
'Wide pulse pressure, collapsing pulse'
Aortic regurgitation
107
'High pitched blowing murmur'
Aortic regurgitation
108
What are some causes of aortic regurgitation?
Endocarditis, aortic dissection, marfans, vasculitis
109
'Rumbling mid-diastolic murmur, best heard on expiration with patient lying on their side'
Mitral stenosis
110
'Opening snap, malar flush, tapping apex'
Mitral stenosis
111
What are the causes of mitral stenosis?
Rheumatic fever, congenital
112
'Continuous machine like murmur'
Patent ductus arteriosis
113
What are the features of innocent murmurs?
Soft, early systolic and vary with position
114
Where do supraventricular arrhythmias originate from?
Above the ventricle (e.g. SA node, AV node, bundle of His)
115
What are some examples of supraventricular tachycardias?
Atrial fibrillation
Atrial flutter
Ectopic atrial tachycardia
116
What are examples of supraventricular bradycardias?
Sinus bradycardia
| Sinus pauses
117
Where do ventricular arrhythmias originate from?
The ventricle
118
What are examples of ventricular arrythmias?
Ventricular ectopics
Premature ventricular complexes
Ventricular tachycardia
Ventricular fibrillation
119
What are causes of arrhythmias?
Abnormal anatomy (e.g. LVH, accessory pathways)
Autonomic nervous system (e.g. increased vagal tone)
Metabolic (hypoxia, electrolyte imbalance)
Inflammation (myocarditis)
Drugs
Genetic
120
What are ectopic beats?
Beats originating from somewhere other than the SA node
121
What is re-entry tachycardia?
More than 1 conduction pathway in the heart results in different depolarisation speeds and a paroxysmal tachycardia as the depolarisation travels back up the accessory pathway reactivating the atria
122
What is a congenital cause of re-entry tachycardia?
Wolff-Parkinson White syndrome
123
What two classes of antiarrhythmic drugs are rhythm control?
Class I and II
124
What two classes of antiarrhythmic drugs are rate control?
Class II and class IV
125
What are some class I anti-arrhythmics?
Lignocaine, flecainide, quinidine
126
What are some class II anti-arrythmic drugs?
Beta-blockers (bisoprolol)
127
What are some class III anti-arrhytmic drugs?
Amiodarone, sotalol, dronedarone
128
What is a class IV anti-arrhythmic drug?
Verapamil
129
What is radiofrequency ablation?
Selective cautery of tissue to prevent tachycardia
130
What is implantable cardioversion defibrillation?
Terminates arrhythmia by dose of electrical current
131
What are the 3 types of atrial fibrillation?
Permanent Paroxysal Persistent
132
What are the two main treatment areas for permanent atrial fibrillation?
Rate control
| Anti-coagulation
133
What are options for rate control in AF?
Beta-blocker (bisoprolol)
Rate limiting CCB (diltiazem, verapamil)
Digoxin
134
What score is used to assess whether anti-coagulation is necessary?
CHA2DS2VASc
135
What are the two ways of cardioverting patients?
Chemical
| DC
136
What time period do you have after the onset of symptoms of persistent AF to cardiovert the patient?
48 hours
137
What is it important to carry out before cardioversion?
Anticoagulation
138
What are drug options for chemical cardioversion?
Amiodarone
| Flecainide
139
How is tachycardia with adverse features treated?
DC Cardioversion
140
How is regular broad complex tachycardia treated?
Amiodarone 300mg IV over 20-60min then 900mg over 24hrs
141
How is regular narrow complex tachycardia treated?
Vagal manouevres
| Adenosine (6mg->12mg->12mg)
142
What is an irregular narrow complex tachycardia likely to be and how is it treated?
Probably AF
| Betablocker or diltiazem
143
How is bradycardia with adverse features managed?
Atropine 500mcg (repeat up to 3mg)
144
What is the normal PR interval on an ECG?
0.12-0.2s
145
What is the normal QRS complex length?
<0.12 s
146
'Tall tented T waves'
Hyperkalaemia
147
Flattened T waves
Hypokalaemia
148
S wave slurring
Digoxin toxicity
149
Delta waves
Wolff-Parkinson White
150
Shortened QT interval
Hypercalcaemia
151
Lengthened QT interval
Hypocalcaemia
152
Saddle shaped ST elevation
Pericarditis
153
Absent P waves
Atrial fibrillation
154
Irregularly irregular pulse
Atrial fibrillation
155
J Waves on ECG
Hypothermia
156
U waves on ECG
Hypocalcaemia
157
S1 Q3 T3 Pattern
Pulmonary embolus
158
Saw tooth baseline
Atrial flutter
159
Prominent P waves in leads II and III
COPD
160
Rightwards shift of QRS axis and poor progression of R wave
COPD
161
Fibrinoid necrosis and BP of 200/140
Malignant hypertension
162
What is Dresslers syndrome?
Post MI pericarditis
163
What CHA2DS2VASC score do you anticoagulate?
2 and above
164
How do you investigate pericarditis?
Echocardiogram
