Flashcards in Cardiology Deck (140):
What is the difference between stable and unstable angina?
Stable angina usually by exertion
Unstable can occur at any time, may be more severe, and may not be relived by rest/ GTN
What basic investigations would you want to do for a px with probable angina?
FBC to check for anaemia
U&Es for renal function
Fasting blood glucose if no known diabetes/ HbA1c if known diabetes
LFTs baseline before commencing statins
Serum lipids for hyperlipidaemia
Troponins and cardiac enzymes
12 lead ECG
What ECG changes could show in a px with angina?
T wave inversion
How would you manage a px with angina?
Conservative: reduce IHD risk factors eg weight loss, dietary advice, smoking cessation, exercise, optimise HTN and diabetes
Medical: GTN spray PRN, Aspirin OD, statin (atorvastatin), beta blocker, Ca2+ channel blocker
Surgical: PCI or CABG
Give an example of a Ca2+ channel blocker relatively selective for myocardium
What are some side effects of Ca2+ channel blockers?
Cause vasodilation and reduce HR and FOC so...
What are some modifiable and non modifiable risk factors for an MI?
Non-modifiable: age, male, ethnicity (south Asians), family history, premature menopause
Modifiable: smoking, diabetes Mellitus, hypertension, obesity, hyperlipidaemia
What does ST elevation in leads 1 to 4 indicate?
Anteroseptal STEMI of LAD
Where would ECG changes present for a lateral STEMI?
In V5-6 (Cx/ LAD)
What leads would an inferior MI show ECG changes in and what artery would be affected?
II, III, aVF
Right coronary artery
A high lateral MI would show ECG changes in which leads?
I and aVL
What ECG changes can appear for an MI?
T wave inversion
Pathological Q waves
How do the levels of different cardiac enzymes change in the blood over time?
Troponins: start to rise 3-12 hours post onset of pain, peak at 24-48 hours, return to baseline within 5-14 days
CK-MB: starts to rise 3-12 hours post onset of pain, peaks at 24 hours, returns to baseline after 48-72 hours
What is the initial management of a px suffering from an MI?
= morphine, oxygen, nitrates (GTN spray), Aspirin
Also establish IV access
Do FBC, troponins, CK-MB, lipids, U&Es
12 lead ECG
What medications would a patient be on post MI?
Aspirin (for life)
Clopidogrel (for one year)
Can’t drive for 4 weeks
What is the most common type of AVRT?
Wolf Parkinson White syndrome
What is the accessory pathway called in Wolf Parkinson White syndrome?
Bundle of Kent
Why are P waves not visible in AVNRT?
As the atria and ventricles contract at a similar time so the atrial depolarisation is masked by the ventricular depolarisation
What are the pathways involved in AVNRT?
Slow alpha pathway
Faster beta pathway
What is the definitive treatment of AVRT or AVNRT?
Radio frequency ablation of the accessory pathway/ slow alpha pathway
Can also use vagal manoeuvres (carotid sinus massage or valsalva manoeuvre) to activate the vagus nerve and block the AVN
Medication to slow AVN conduction
If not, cardioversion
What ECG changes are seen in Wolff Parkinson White syndrome?
Shortened PR <120ms
Long QRS (as ventricle contract early)
How long is one small square on an ECG?
How long is one large square on an ECG?
How would you calculate a regular rate on an ECG?
300/ number of squares in RR interval
How would you calculate an irregular rate on an ECG?
The number of QRS complexes in 30 large squares x 10
What should the normal axis on an ECG be?
-30 to +90 degrees
Left axis deviation will cause which leads to become more positive and negative?
1 and aVL will be more positive
2 and 3 more negative
(So leads 1 vs 2 and 3 are ‘leaving’ each other)
Right axis deviation will cause which leads to become more positive and negative?
Leads 3 and aVF will become more positive
Lead 1 more negative
So leads 1 and 3 “reaching” each other
Where would you place the ECG leads v1 to v6?
V1 4th ICS RSE
V2 4th ICS LSE
V3 in between V2 and V4
V4 5th ICS MCL
V5 5th ICS anterior axillary line
V6 5th ICS mid axillary line
How long should the PR interval be?
3 to 5 squares (0.12 to 0.2 seconds)
What does a lengthened PR interval indicate?
1st degree heart block
Delay in conduction between the atria and ventricles
Delay usually in the AVN
How would Mobitz type 1 heart block show on an ECG?
Progressive lengthening of the PR intervals, followed by a missed QRS, which then resets and repeats
What type of heart block in Wenckebachs phenomenon?
How does Mobitz type 2 heart block present on an ECG?
Constant PR but occasionally dropped QRS
(Usually a bundle branch problem)
What is 3rd degree heart block?
When there is no relationship between P waves and QRS complexes so no beats are conducted from the atria to the ventricles
Often due to fibrosis of the bundle of His
Causes the ventricles to contract at their own intrinsic rate (very slow, hence urgent pacing required)
Increased height of the QRS complex indicates what?
Ventricular hypertrophy (R or L depending on lead)
Increased width of the QRS complex indicates what?
Bundle branch block
Why do LBBB show a W shape in lead 1 and an M shape in lead 6?
As the bundle branch block means the depolarisation is reversed so the RBBB is depolarised first and then goes through the septum to the left heart
Tall T waves indicate what?
Prolonged QTc is associated with which ventricular tachycardia?
Torsades des pointes
What do U waves indicated?
Severe hypokalaemia or hypocalcaemia
What arrhythmia will present with loss of the isoelectric baseline and a saw tooth pattern?
What is the first line anti hypertensive drug for for 47 year old Caucasian patient?
(if under 55 and not Afro Caribbean)
What is the first line anti hypertensive drug for a 40 year old Afro Caribbean patient?
Calcium channel blocker
(Either if aged over 55 or if Afro Caribbean)
What is the second line drug treatment for hypertension?
ACEi + CCB
When would a thiazide diuretic by contraindicated?
What are some ADRs of ACEi?
For a hypertensive patient on an ACEi and CCB but still not responding adequately to treatment, what other drug would you add?
Thiazide like diuretic
How do thrombolytic drugs work?
Activate plasminogen to plasmin which degrades fibrin
What are some examples of thrombolytic drugs?
What does the CHADS-VASc score determine?
Whether to anticoagulate a px with AF
If 0, no anticoag
If 1, anticoag if male. If 2, anticoag if female.
What are some causes of systolic heart failure?
What are some symptoms/ signs seen in left sided heart failure?
Pink/ white frothy sputum (due to pulmonary oedema)
What are some symptoms and signs seen in right sided heart failure?
What is usually raised in the blood in heart failure?
What signs could indicated heart failure on a chest x Ray?
Kerley B lines
Dilated prominent upper lobe vessels
What does a third heart sound heard in early diastole indicate?
Normal in young people and athletes
Indicates congestive heart failure in older people
Caused by a sudden deceleration of blood flow into the LV from the LA
How is heart failure managed?
1. Conservative (smoking cessation, exercise, weight loss, diet
ACEi and Beta blocker 1st line
Loop diuretic e.g. furosemide for symptomatic relief (can then add thiazide if needed)
2nd line add spironolcatone (K sparing so monitor U&Es)
Consider digoxin if still symptomatic
What are some side effects of ACEi?
What are some side effects of furosemide?
What does the NYHA scale measure?
New York heart association classifies heart failure 1 to 4, 4 being dyspnoea at rest and 1 being dyspnoea only on exertion
Which murmurs are heard best on expiration?
Left sided murmurs
(Intrathoracic pressure increases, so pulmonary vessels constrict and blood is forced from pulmonary veins into LA)
What are some causes of mitral stenosis?
Old age and calcification
When is mitral stenosis heard?
Mid diastolic murmur
What are some causes of aortic stenosis?
Age related calcification
Congenital bicuspid valve
What are some symptoms of aortic stenosis?
Also: dyspnoea, dizziness
Where does an aortic stenosis murmur radiate to?
What type of murmur is an aortic stenosis murmur?
Where would you hear an aortic stenosis murmur?
2nd ICS, RSE
Which murmur has a characteristic slow rising pulse with narrow pulse pressure?
What may you see on an ECG for a px with aortic stenosis?
T wave inversion
Which murmurs are heard during systole?
When is aortic regurgitation heard?
Early diastolic murmur
What are some causes of aortic regurgitation?
Connective tissue disorders e.g. Marfans, Ehlers Danlos
Which murmur also has a collapsing pulse with a wide pulse pressure?
Which valve incompetency has an early diastolic murmur?
When is aortic regurgitation best heard?
With px sat forwards
Which valve incompetency can be treated with ACEi?
(To reduce systolic HTN)
Why are aortic murmurs heard best with the patient sat forwards?
As this brings the aortic valve closer to the chest wall
Why are mitral murmurs heard loudest with the patient on their left side?
Brings the apex closer to the chest wall
What does S1 represent?
Start of systole
Mitral and tricuspid Valves are closed
Peripheral pulse is felt at the same time as which heart sound?
What does S2 represent?
Start of diastole and end of systole
Closure of aortic and pulmonary valves
What are some causes of carcinogenic shock?
- post MI
- serious arrhythmias
- acute worsening of AF
Cardiac tamponade is an example of which type of shock?
What is Beck’ triad?
Signs of cardiac tamponade
Raised JVP, muffled heart sounds, low BP
What are some signs of distributive shock?
Warm, red extremities (due to widespread vasodilation, where hypovolaemic shock has cold, pale extremities)
Where is mitral stenosis best heard?
With the bell at the apex
Px lay on their side
What are some signs and symptoms associated with mitral valve stenosis?
Pink frothy sputum (pulmonary HTN)
Enlarged LA on CXR
ECG can show AF
How can mitral stenosis be treated?
Diuretics to reduce preload and pulmonary venous congestion
If in AF: anticoagulate and rate control
If still symptomatic: ballon valvuloplasty, open mitral valvotomy, or valve replacement
Which valve defect has a mid diastolic murmur?
What are some causes of mitral regurgitation?
Papillary muscle rupture post-MI
Mitral valve prolapse
CT disorder eg Ehlers Danlos, Marfans
When is a mitral regurgitation murmur?
Pan systolic murmur
Heard at the apex and radiates to the axilla
Patients with a 10 year cardiovascular risk greater than what value should receive a statin?
What are some side effects of statins?
Myopathy (myalgia, myosotis, rhabdomyolysis, asymptomatic raised CK)
Liver impairment (so check LFTs at baseline, 3month and 12 month)
What ECG features are present in hypokalaemia?
Small/ absent T waves
Prolonged PR interval
“You have no Pot and no T, but a long PR and a long QT”
Rheumatic fever can develop 2-4 weeks after an infection by what?
Streptococcal pyogenes throat infection
What features indicate a diagnosis of infective endocarditis until proven otherwise?
Fever and a new murmur
Janeway lesions and Osler’s nodes together are pathognomic for which condition?
What are common causative organisms of infective endocarditis?
What is the difference between janeway lesions and oslers nodes?
Janeway lesions: non tender haemorrhagic legions on palms/ soles of feet, due to septic emboli depositing bacteria in small vessels (microabscesses)
Osler’s nodes: small tender red raised lesions on pulp of the phalanges, due to immune complex deposition
How will AVRT and AVNRT present on ECG?
Narrow complex tachycardia
No P waves
What is the accessory pathway in WPW?
Bundle of Kent
How would you treat a narrow complex tachycardia that has a regular rhythm?
If unsuccessful, IV adenosine
How should atrial fibrillation be managed?
1) rate control: beta blocker or CCB
If unsuccessful/ px still symptomatic: rhythm control
2) cardioversion (if more than 48hrs wait few weeks to anticoag before cardioversion)
If drug tx for long term rhythm control is needed: amiodarone
Anticoagulation based on CHA2DS2-VASc score
What are some examples of broad complex tachycardias?
Torsades de pointes
Wolff Parkinson white
What causes ventricular tachycardia?
Coronary heart disease
How can vebtricular tachycardia show on ECG?
May have capture beats or fusion beats
What are capture beats and fusion beats?
Can be seen with ventricular tachycardia
Capture beat: normal QRS with VT complexes
Fusion beat: when normal sinus rhythm gets through and fuses with VT
What is ventricular fibrillation?
Heart is quivering instead of pumping due to disorganised electrical activity so CO is insufficient and can result in cardiac arrest with LOC and no pulse
How is ventricular fibrillation treated?
Defibrillation and CPR
What are some causes of Torsades de Pointes?
Long QTc due to drugs (amiodarone, erythromycin, citalopram), diarrhoea, low Mg, low K, low Ca
How is Torsades de Pointes treated?
(Also stop any precipitating drugs)
In what syndrome can delta waves be seen on an ECG?
Wolff Parkinson White syndrome
What is sick sinus syndrome?
Malfunction of the SAN often due to age,often causing bradycardia or can cause the heart to alternative between tachy and Brady
How are bradycardias treated?
(Can give atropine too)
When are beta blockers contraindicated?
In asthma: bronchoconstriction
With verapamil: bradycardia, heart block, congestive heart failure
Sick sinus syndrome
How does pericarditis appear on an ECG?
Widespread ST elevation
An inferior MI will show ECG changes in which leads? Which artery is affected?
II, III, aVF
Right coronary artery
What is the GRACE tool?
Used to determine mortality risk for px with NSTEMI or STEMI
For a px with a STEMI, how would manage this?
Morphine, O2 if sats <94%, Nitrates, aspirin, clopidogrel
PCI (angioplasty and stent to reopen the blocked vessel, done via a catheter inserted into the radial or femoral artery)
To prevent further events: Aspirin, clopidogrel, beta blocker, ACEi, statin
What type of drug is indapamide?
A thiazide like diuretic
(Third line for HTN)
What are the typical symptoms for pericarditis?
Sharp pleuritic chest pain (can radiate to L shoulder)
Relieved by sitting forwards!
ST saddle shaped elevation on ECG is indicative of what?
A pericardial friction rub is indicative of what?
What can pericarditis lead to?
Pericardial effusion (which could lead to cardiac tamponade)
What are some causes of pericarditis?
Viral (cocksackie, HIV, Epstein Barr)
Infective (TB, pneumococcal)
MI (Dresslers syndrome)
Autoimmune (SLE, rheumatic fever)
What is cardiac tamponade?
A type of pericardial effusion that leads to reduced ventricular filling (so reduces CO and can lead to shock)
What is Becks triad?
= raised JVP, low BP, muffle heart sounds
Indicates cardiac tamponade
What can cause low voltage QRS complexes on ECG?
Pericardial effusion (& cardiac tamponade)
Also obesity, pleural effusion, pneumothorax
How is cardiac tamponade treated?
Supportive: fluids etc
What is aortic dissection?
When blood accumulates within the tunica intima and media after damage to the tunica intima
How would you manage a suspected aortic dissection?
Beta blocker to keep BP 100-110
Cross match blood
What are common causative organisms for infective endocarditis?
Staph aureus most common
Strep viridans 2nd
Staph epidermis common for prosthetic valves
What criteria is used to diagnose infective endocarditis?
(Diagnosis confirmed if 2 major or 1 major + 3 minor or 5 minor)
What is dukes criteria?
Used to diagnose infective endocarditis (“BE FIVE PM”)
B: Blood culture +ve with typical bacteria on 2 occasions
E: Echo showing new valvular regurgitation/ vegetation
F: fever >38
I: immune phenomena e.g. Roth’s spots, Osler’s nodes
V: vascular phenomenon e.g. janeway lesion
E: echo findings (that don’t meet major criteria)
P: predisposition e.g. IVDU, prosthetic valve, valvular heart disease
M: microbiological evidence (that doesn’t meet major criteria)
Why are delta waves seen in AVRT?
As the conduction of the ventricles via the accessory pathway produces pre excitation of the ventricles (as the accessory pathway conducts more rapidly than the AVN), and this early ventricular activation is manifested as a delta wave (a slurred upstroke at the start of the QRS)
ECG U waves are pathognomonic for what?
(Also small/ absent T, prolonged PR, long QT)
When should surgery be considered for aortic stenosis?
Or if asymptomatic but valvular gradient >40mmHg