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Yr3 - General Medicine > Cardiology > Flashcards

Cardiology Flashcards

(183 cards)

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1
Q

Define hs-Tnl

A

High sensitivity Troponin I

- released from cardiac myocytes due to necrosis

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2
Q

Features of STEMI

A

ST elevation > 1mm in limb leads and 2mm in chest leads
hs-Tnl > 100ng/L
CK > 400

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3
Q

Features of NSTEMI

A 
ECG may show
- ST segment depression 
- T wave inversion
- may be normal
hs-Tnl > 100ng/L
Previously established ECG changes may be present
- old MI
- LV hypertrophy
- AF
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4
Q

Features of unstable angina

A 
ECG may show
- ST segment depression 
- T wave inversion
- may be normal
hs-Tnl in normal range
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5
Q

Change in troponin levels in ACS

A

Rise 3-4 hours after myocardial damage and stay elevated for up to 2 weeks
- males > 34ng/L = high likelihood of myocardial necrosis
- females > 16ng/L
Elevations 5 fold have very high predictive value for type 1 MI
Rising and falling levels differentiate acute from chronic cardiomyocyte damage
- ACS = more pronounced change - > 5ng/L

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6
Q

When are hs-Tnl levels taken

A

On admission and 1 hour later

- only 1 if onset of symptoms 3+ hours previously

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7
Q

False positive elevation of hs-Tnl

A 
Renal failure
Large PE
Severe congestive cardiac failure
Myocarditis
Prolonged tachyarrhythmias
Aortic dissection
Aortic stenosis
Hypertrophic cardiomyopathy
Takotsubo cardiomyopathy
Malignancy
Stroke 
Severe sepsis
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8
Q

ECG changes in STEMI

A

ST elevation in 2 or more leads from the same zone or presence of LBBB (left bundle branch block)
ST depression confined to leads V1-V4 may have true posterior MI

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9
Q

Leads giving inferior views

A

II, III and aVF

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10
Q

Leads giving right ventricle and septum view

A

V1 and V2

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11
Q

Leads giving anterior views

A

V3 and V4

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12
Q

Leads giving IVS and anterior surface views

A

V1-V4

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13
Q

Leads giving lateral view

A

I, aVL, V5, V6

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14
Q

Which extra leads should be used in supspected MI

A

Posterior - V7-V9
Right ventricular leads
- ST elevation in RV4 highly sensitive for right ventricular infarction

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15
Q

ECG changes in unstable angina and NSTEMI

A

Transient ST segment depression or elevation
T wave inversion or flattening
T wave pseudo-normalisation

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16
Q

Conditions that can mimic STEMI on ECG

A 
Early repolarisation
- up-sloping ST elevation - leads V1 and V2
- commonly younger, athletic pts and Afro-Caribbeans
Pericarditis
- concave ST elevation
- widespread ST changes
Brugada syndrome
- similar to anterior STEMI
Takotsubo cardiomyopathy 
- can mimic STEMI and NSTEMI
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17
Q

Management of STEMI

A

Transfer to catheter lab
IV access
Pain relief - morphine and anti-emetic
Oxygenation - if hypoxic aim for sats > 94%
Aspirin - 300mg loading followed by 75mg od for life
Prasugrel - 60mg loading and 10mg daily for 12 months
Primary Percutaneous Coronary Intervention
Full biochemical screen - incl. lipid profile, random glucose and Hb1Ac
Bisoprolol - 1.25mg od
Ramipril - 2.5mg od or Losartan 25mg od
Atorvastain 80mg od
Control diabetes, hypertension and smoking cessation

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18
Q

MOA of prasugrel

A

Thienopyridine inhibits ADP receptors

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19
Q

Uses of prasugrel

A

Patients undergoing PPCI for STEMI

  • under 75
  • weigh more than 60kg
  • no prior TIA or stroke
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20
Q

Alternatives to prasugrel

A

Clopidogrel
- loading 600mg followed by 75mg od for 12 months
- for those who do not fulfil criteria for prasugrel
Ticagrelor
- 180mg loading dose followed by 90mg bd for 12 months
- used for those who cannot have prasugrel or NSTEMI

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21
Q

What is PPCI

A

Primary Percutaneous Coronary Intervention

  • primary therapeutic measure in pts presenting with MI - without thrombolysis
  • restoration of normal flow in culprit artery achieved in over 95%
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22
Q

Effects of bisoprolol

A

Beta-blocker

  • reduces HR
  • avoid shock or hypotension
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23
Q

Effects of ramipril

A

ACE inhibitor

- prevents muscle over-damage

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24
Q

Effects of losartan

A

ARB

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25
Atorvastatin effects
Statin - reduce LDL-C < 1.8mmol/L or 40% reduction in non-HDL-C - total cholesterol target < 4.0mmol/L
26
Control of diabetes in MI
``` Insulin infusions HbA1c targets - type 1 < 7% - type 2 = 6.5-7.5% Metformin introduced with caution if LV dysfunction suspected post MI ```
27
Complications of STEMI
Heart failure - diuretics Shock - inotropes and balloon pump Valve damage Septal defect
28
Management of NSTEMI/unstable angina
Pain relief - morphine and anti-emetic Aspirin - 300mg loading and 75mg od LMWH (Enoxaparin) - 48hrs based on weight and creatinine Repeat ECG Risk assessment of patient with elevated hs-Tnl - grace score Ticagrelor if risk > 3% (medium) - 180mg loading and 90mg BD Whilst waiting for inpatient angiography consider anti-anginals - nitrates, ranolazine, CCB
29
Symptoms of stable angina
Chest discomfort provoked by effort or emotion and relieved by rest Isolated throat tightness Arm heaviness Exertional breathlessness
30
Features of severe stable angina
Fear Sweating Nausea
31
Risk factors for CAD
``` Cigarette smoking Hypertension DM Hypercholesterolaemia FH of premature of coronary artery disease Vascular disease ```
32
Coronary risk factor profile
Chest discomfort more likely to represent coronary artery disease in an individual with two or more existing risk factors
33
Causes of angina
Coronary artery disease Aortic stenosis Hypertensive heart disease Hypertrophic cardiomyopathy
34
History for angina should include
``` Precipitants of anginal attacks Relieving factors Stability of symptoms Risk factors Occupation Assessment of intensity, length and regularity of exercise Basic dietary assessment Alcohol intake Drug history Family history ```
35
Features that make angina unlikely
Pain continuous or very prolonged Unrelated to activity Brought on by breathing Associated symptoms such as dizziness or dysphagia
36
Features of examination for angina
``` Weight and height - calculate BMI Blood pressure Presence of murmurs - aortic stenosis Evidence of hyperlipidaemia Evidence of peripheral vascular disease and carotid bruits ```
37
Investigations for stable angina
Full blood count and biochemical screen - inclucing glucose/HbA1c Full lipid profile Resting 12-lead ECG - rhythm, heart block, previous MI, myocardial hypertrophy and ischaemia
38
Treatment for CAD
Estimated likelihood of CAD 61-90% - Invasive coronary angiography 30-60% - Functional imaging as 1st line diagnostic intervention - stress MRI, echo, myoview 10-29% - CT calcium scoring
39
Drug treatment of CAD
75mg aspirin OD - clopidogrel 75mg OD for those allergic or intolerant Sublingual GTN Beta-blockers for symptomatic relief - Ivabradine 5-7.5mg alternate if HR > 70bpm Non-dihydropyridine CCB for rate limitation - diltiazem or verapamil Long-acting nitrates - isosorbide mononitrate Potassium channel opening drugs - nicorandil Ranolazine 375mg-750mg - add on Statin
40
Non-cardiac causes of chest pain
``` Costochondritis Gastro-oesophageal PE Pneumonia Pneumothorax Psychogenic/psychosomatic ```
41
Stages of hypertension
``` Stage 1 - clinical BP > 140/90 - ABPM or HBPM average > 135/85 Stage 2 - clinical BP > 160/100 - ABPM or HBPM average > 150/95 Severe hypertension - clincial BP > 180/110 ```
42
ABPM
Ambulatory Blood Pressure Monitoring
43
HBPM
Home Blood Pressure Monitoring
44
Symptoms of hypertension
Nil or headache Sweating, headache, palpitations, anxiety -> phaeochromocytoma Muscle weakness and tetany -> hyperaldosteronism
45
CVS risk
``` TIA Stroke Diabetes Previous renal disease Smoking Cholesterol NSAID excess Angina CCF Palpitations Syncope Valvular heart disease FH of hypertension, premature coronary disease and polycystic kidney disease ```
46
Physical assessment for hypertension
Look for secondary causes - Cushing's syndrome - enlarged kidney (PCK) - renal bruits - radio-femoral delay (coarctation)
47
Investigations for hypertension
Urine albumin:creatinine ratio and haematuria Blood sample - glucose, electrolytes, creatinine, eGFR, serum total cholesterol and HDL cholesterol - may suggest secondary cause - low K+, high Na+, hyperaldosteronism Examine fundi - hypertensive retinopathy 12-lead ECG Echocardiography - suggestion of LVH, valve disease or LVSD
48
LVSD
Left Ventricular Systolic Dysfunction
49
Target blood pressure in hypertension
Low risk = < 140 High risk = < 130/80 Elderly <80 = 140-150 but <140 if tolerated Elderly >80 = 140-150 Diastolic = <90 except in diabetes where target <85
50
Non-pharmacological hypertension treatment
``` Weight reduction if BMI > 25 - each kg lost yields BP reduction of 3/2 mmHg Moderate salt intake - can reduce BP by 8/5 mmHg Minimise alcohol intake Aerobic exercise Smoking cessation - reduce CVS risk ```
51
Pharmacological hypertension treatment
1st line - under 55 - ACEi or ARB - over 55 or black person or African/Caribbean family - CCB 2nd line - ACEi/ARB + CCB 3rd line - ACEi/ARB + CCB + thiazide-like diuretic Resistant hypertension - ACEi/ARB + CCB + thiazide-like diuretic + further diuretic or alpha/beta blocker
52
Define hypertensive crisis
Increase in blood pressure which if sustained over next few hours will lead to irreversible end-organ damage - encephalopathy - LV failure - aortic dissection - unstable angina - renal failure
53
Treatment for hypertensive crisis
Reduce diastolic BP to 110mmHg in 3-12 hours IV - sodium nitroprusside - labetalol - GTN - 1-10mg/hr - esmolol - acts in 60 secs with duration of 10-20 mins - 0.5-1mg/kg loading dose followed by infusion of 50μ/kg/min-300μ/kg/min
54
Define hypertensive urgency
Severe blood pressure elevation that will cause damage within days - diastolic > 130mmHg - retinal changes apparent
55
Hypertensive urgency treatment
``` Reduce BP gradually to diastolic of 100mmHg over 48-72hrs Oral - amlodipine 5-10mg OD (CCB) - diltiazem 120-300mg OD (CCB) - lisinopril 5mg OD (ACEi) ```
56
Symptoms of phaeochromocytoma
Episodic headache, sweating and tachycardia | Sustained or paroxysmal hypertension most common
57
Diagnosis of phaeochromocytoma
24 hour urine collection - fractionated metanephrines and catecholamines CT or MRI abdo and pelvis - detect tumours MIBG scan
58
Treatment of phaeochromocytoma
Surgery - resection Whilst waiting surgery - alpha and beta adrenergic blockade - phenoxygenzamine 10mg OD/BD - 10-20mg every 2-3 days
59
Features of Cushing's syndrome
``` Increased weight Mood change - depression, lethargy, irritability, psychosis Proximal weakness Gonadal dysfunction - irregular menses, hirsutism, erectile dysfunction Central obesity Moon face Buffalo hump Skin and muscle atrophy Purple abdominal striae Increased BP Increased blood glucose Elevated 24hr urine cortisol - 3x ```
60
Diagnosis of Cushing's syndrome
Low-dose dexamethasone suppreession test | Adrenal CT
61
Features of primary aldosteronism
Low serum potassium and high/normal sodium Very low/undetectable plasma renin High plasma aldosterone Adrenal CT
62
Causes of heart failure
``` Ischaemic heart disease Hypertension Valvular heart disease - rheumatic fever in elderly Atrial fibrilation Chronic lung disease Cardiomyopathy - hypertrophic, dilated right ventricle, post-viral, post-partum Previous cancer chemotherapy drugs HIV ```
63
HFREF
Heart Failure with Reduced Ejection Fraction
64
HFNEF
Heart Failure Normal Ejection Fraction
65
NFNEF patient profile
Elderly Overweight Hypertension AF
66
Features of heart failure which contribute to poor prognosis
``` Severe fluid overload Very high NT-proBNP levels Severe renal impairment Advanced age Mulit-morbidity Frequent admissions ```
67
Investigations in heart failure
Renal function - baseline and for diuretic effect FBC - anaemia as consequence of bone marrow issue LFT's - hepatic congestion TFT's - thyroid disease Ferritin and transferrin - possible haemochromatosis in younger patients NT-proBNP - < 100ng/L rules out acute heart failure
68
NT-proBNP
Brain Natriuretic Peptide | - secreted by cardiomyocytes in ventricles in response to stretching caused by increased ventricular blood volume
69
Features of CXR in heart failure
``` Cardiomegaly Perihilar shadowing/consolidations Alveolar oedema Air bronchograms Increased width of vascular pedicle Could be pleural effusions ```
70
Assessment of LV function
Echocardiography - confirm diagnosis | Cardiac MRI - echogardiogram may miss right ventricle
71
Features of heart failure in echocardiogram
Dilated poorly contracting left ventricle - systolic dysfunction Stiff, poorly relaxing, small diameter left ventricle - diastolic dysfucntion Valvular disease Atrial myxoma Pericardial disease
72
Lifestyle modification in heart failure
Smoking cessation Restriction of alcohol consumption Salt restriction Fluid restriction - presence of hyponatraemia
73
Medication for heart failure
Diuretics ACEi ARBs Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Beta blockers Vasodilators - hydralazine and isosorbide mononitrate Ivabradine - those who cannot tolerate beta blockers Nitrates
74
How are diuretics used in heart failure?
Loop diuretics most effective for symptomatic treatment Furosemide 40-500mg OD - IV when severe fluid overload - large doses in renal impairment - prolonged infusions give better effects - 250mg over 7 hrs Bumetanide - better oral absorption Thiazides added on - bendroflumethiazide 2.5mg OD - metolazone 2.5-5mg OD If hypokalaemia persists spironolactone 25mg OD
75
Uses of ACEis in heart failure
Improve - symptoms and signs in all stages - exercise tolerance - slow disease progression - survival
76
Use of ARBs in heart failure
Valsartan and Candesartan
77
Use of ARNIs in heart failure
Sacubitril with Valsartan | Symptomatic chronic heart failure with reduced ejection fraction with stable dose of ACEis and ARBs
78
Use of beta blockers in heart failure
Safe if systolic BP > 100mmHg with resting HR > 60bpm and no postural drop Carvedilol - 3.125mg BD - 25mg BD Bisoprolol - 1.25mg OD - 10 mg OD
79
Uses of vasodilators in heart failure
Hydralazine and isosorbide mononitrate Beneficial effect on survival - pts of African or Caribbean origin - cannot take ACEi/ARBs - pts with resistant CCF
80
Use of Ivadbradine in heart failure
Those who cannot tolerate beta-blockers or those who HR>75 despite beta-blockers In sinus rhythm No impact on blood pressure
81
Effect of nitrates in heart failure
Reduce - preload - pulmonary oedema - ventricular size
82
Uses of nitrates in heart failure
Acute heart failure - underlying ischaemia - hypertension - regurgitant aortic and mitral valve disease Chronic heart failure - relief of orthopnoea and exertional dyspnoea
83
Contraindications of nitrates in heart failure
Aortic and mitral stenosis HOCM Pericardial constriction
84
HOCM
Hypertrophic Obstructive CardioMyopathy
85
ECG of LBBB
Broad QRS duration | - depolarisation is delayed from septum to lateral wall -> mechanical reduction
86
LBBB
Left Bundle Branch Block
87
Uses of complex implantable devices in LBBB
Cardiac Resynchronisation Pacemaker (CRT) | - double pace spikes before QRS
88
ICD
Implantable Cardiac Defibrillators
89
Uses of ICDs
Do not improve symptoms Prevent sudden cardiac death associated with heart failure - detect and cardiovert VT/VF
90
Symptoms of Aortic Stenosis
Decrease in exercise tolerance or dyspnoea on exertion Angina Heart failure Syncope
91
Causes of aortic stenosis
Age related Congenital bicuspid valve Chronic kidney disease Previous rheumatic fever
92
Features of aortic stenosis murmur
Aortic area - 2nd intercostal space right side | Ejection systolic radiating to carotid/neck
93
Severity of AS
``` Mild - mean gradient <25mmHg - peak gradient <36mmHg - AoV area > 1.2cm2 Moderate - mean gradient 25-39mmHg - peak gradient 36-64mmHg - AoV area 1.0-1.2cm2 Severe - mean gradient >40mmHg - peak gradient >65mmHg - AoV area < 1.0cm2 ```
94
Indications for surgery for AS
``` Symptoms causes by AS Asymptomatic severe AS with - left systolic dysfunction - abnormal exercise test - time of other cardiac surgery ```
95
What should be used in older patients with many co-morbidities in symptomatic AS
Transcatheter aortic valve implantation (TAVI) | - implanted by femoral artery
96
Symptoms of AR
Asymptomatic - many years | Exertional dyspneoa and reduced exercise tolerance - increased volume load on LV -> LV dilation -> heart failure
97
Causes of AR
Idiopathic dilation of aorta - pulling valve leaflets apart Congenital abnormalities of aortic valve - bicuspid Calcific degeneration Rheumatic disease Infective endocarditis Marfan syndrome
98
Describe AR murmur
Left sternal edge Early diastolic blowing murmur - associated with collapsing pulse
99
Treatment for patients with severe AR
ACEi - afterload reduction | - slows rate of LV dilation
100
Assessment of AR
Echocardiography - quantification of severity of disease - assessment of rest of heart
101
Indiciations for surgery in AR
Symptomatic severe AR Asymptomatic severe AR with evidence of early LV dysfunction - EF <50% - LV end-systolic diameter > 5cm - LV end-diastolic diameter > 7cm Asymptomatic AR of any severity with aortic root dilation > 5.5cm
102
Symptoms of MR
Mostly asymptomatic
103
Causes of MR
``` Mitral valve prolapse - Marfan's syndrome - pectus excavatum Rheumatic heart disease IHD Infective endocarditis Drugs Collagen vascular disease ```
104
Describe MR murmur
Pan-systolic blowing murmur - mitral area - 5th ICS mid-clavicular line - radiates to axilla
105
Assessment of MR
Echocardiography - assess LV function and size - severity of blood coming through valve
106
Surgical treatment of MR
Replacement Repair - reduced operative mortality
107
Indications for surgical intervention in severe MR
Symptomatic MR Asymptomatic with mild-moderate LV dysfunction - EF 30-60% - LVESD 4.5-5.5cm
108
LVESD
Left Ventricular End-Systolic Diameters
109
Medical treatment of MR
``` Diuretics ACEI in functional or ischaemic MR If LV systolic dysfunction - ACEi - beta-blockers - CRT ```
110
Predisposing conditions for infective endocarditis
``` Mitral valve prolapse Presence of prosthetic material - valves - patches Rheumatic heart disease Degenerative and bicuspid aortic valve disease Congenital heart disease ```
111
Common causative organisms of infective endocarditis
Streptococci viridans Staphylococcus aures - IV drug users Coagulase-negative staphylococci (S.epidermis) - 1 yr post prosthetic heart vavlue implantion Enterococcal endocarditis - GU or lower GI tract
112
Causes of mortality in infective endocarditis
Heart failure CNS emboli Uncontrolled infection
113
Features of IE
Unexplained fever Bacteraemia Systemic illness New murmur
114
Routine investigations for IE
``` FBC ESR and CRP U&Es LFTs Urine dipstick analysis and MSU for MS&C CXR ECG ```
115
Key diagnostic investigations for IE
Blood cultures - min 3 from different sites over several hours - if pt stable delay antibiotics to allow for comprehensive sampling Echocardiogram - transoesophageal echocardiography (TOE)
116
Diagnostic criteria for IE
2 major 1 major and 3 minor 5 minor
117
Major diagnostic criteria for IE
``` Positive blood cultures - typical organism from 2 - persistent positive blood cultures taken > 12 hrs apart - > 3 positive blood cultures taken over more than one hour Endocardial involvement Positive echo findings - vegetation - abscess New valvular regurgitation Dehiscence of prosthesis ```
118
Minor diagnostic criteria for IE
``` Predisposing valvular or cardiac abnormality IV drug user Pyrexia > 38 Embolic phenomenon Vasculitic phenomenon Blood cultures suggestive - organism grown but not achieving major criteria Suggestive echo findings ```
119
Management of IE
Antibiotic therapy - tunnelled central venous line for prolonged courses Surgery
120
Antibiotic therapy for management of IE
Streptococci - benzylpenicillin IV plus low-dose gentamicin (80mg BD) - vancomycin if penicillin-allergic Enterococci - amoxicillin IV plus low-dose gentamicin (80mg BD) - vancomycin if penicillin-allergic Staphylococci - flucloxacillin plus gentamicin - benzylpenicillin if penicillin-sensitive - vancomycin if penicillin-allergic
121
How to monitor response to therapy in IE
``` Echocardiogram weekly - assess vegetation size - look for complications - valve destruction, intracardiac abscesses ECG twice weekly - detect conduction disturbances - indicate development of aortic root abscess in aortic valve infection Blood tests twice weekly - ESR - CRP - FBC - U&Es ```
122
Indications for surgery in IE
Moderate to severe cardiac failure due to valve compromise Valve dehiscence Uncontrolled infection despite appropriate antimicrobial therapy Relapse after optimal medical therapy Threatened or actual systemic emboli Coxiella burnetii or fungal infections Paravalvar infection - aortic root abscess Sinus of valsalva aneurysm Valve obstruction
123
How to calculate rate in an ECG
Standard 12 lead ECG rhythm strip = 10 seconds | - number of QRS complexes * 6 = HR per min
124
Normal heart rate
60-100 bpm
125
Bradycardia
< 60 bpm | - absolute < 40bpm or HR inappropriately slow for haemodynamic state of patient
126
Tachycardia
> 120 bpm
127
Stages of reading an ECG
``` Rate Rhythm Axis Intervals ST/T wave changes ```
128
How to work out if ECG rhythm is regular?
Mark out several consecutive R-R intervals on piece of paper and move along rhythm strip to check is subsequent intervals are the same
129
Types of heart rhythm
Normal Irregular - regularly irregular - irregularly irregular
130
Define cardiac axis
Overall direction of electrical spread within the heart
131
Normal cardiac axis
11 o'clock to 5 o'clock - spread of depolarisation to leads I, II and III - positive deflection - most negative deflection in aVR
132
Causes of right axis deviation (RAD)
``` Right ventricular hypertrophy - extra heart muscle causes stronger signal to be generated by the RHS of the heart Pulmonary conditions - strain the heart Normal finding in very tall individuals ```
133
Features of RAD
1-7 o'clock depolarisation - deflection in lead I becomes negative - deflection in lead aVF/III to be more positive
134
Causes of left axis deviation (LAD)
Conduction defections | - not increased mass of LV
135
Features of LAD
Depolarisation to left - deflection in lead III becomes negative - only significant if lead II becomes negative
136
P wave features of ECG
P-waves present Each p-wave followed by a QRS complex Normal shape, duration and direction
137
What to consider if no p waves on ECG
Atrial flutter - sawtooth baseline AF - choatic baseline No atrial activity - flatline
138
Normal P-R interval
120-200 ms | - 3-5 small squares
139
What does a prolonged PR interval indicate
AV block
140
Features of first degree heart block
Fixed prolonged PR interval (>200ms) | Occurs between SA node and AV node - in atrium
141
Features of second degree heart block Mobitz type 1
PR interval slowing increasing then dropped QRS complex | Occurs in the AV node
142
Features of second degree heart block Mobitz type 2
Fixed PR interval then dropped QRS complex | Occurs after the AV node in bundle of His or Purkinje fibre
143
Features of third degree heart block
P waves and QRS complexes completely unrelated | Occurs anywhere after AV node - complete conduction blockage
144
Causes of shortened PR interval
Normal - smaller atria or closer location of SA node Accessory pathway - delta wave = Wolff Parkinson White Syndrome
145
Aspects of QRS complex to observe in ECG
Width Height Morphology
146
Normal width of QRS complex
< 0.12 seconds
147
Causes of broad QRS complex
Abnormal depolarisation sequence - ventricular ectopic - bundle branch block
148
Normal height of QRS complex
< 5mm in limb leads or < 10mm in the chest leads
149
Causes of tall QRS complex
Imply ventricular hypertrophy | - can be due to body habitus - tall slim people
150
Delta waves
Slurred upstroke of QRS complex - early activation of ventricles - featured in Wolff-Parkinson-White syndrome
151
Pathological Q waves
> 25% of the size of the R wave that follows it or > 2mm in height and > 40ms in width Single not cause for concern - in entire territory for evidence of previous MI
152
R wave progression
In lead V1 R wave should be small - becomes larger throughout precordial leads - R wave larger than S wave in lead V3 or V4 - S wave gets smaller
153
Causes of poor R wave progression
Previous MI | Larger people due to lead position
154
Define J point
Where S wave joins ST segment
155
Features of benign early repolarisation
Elevated J point - ST segment following raised - under 50s - widespread ST elevation in multiple territories - T waves raised - does not change over time
156
QTc
Corrected QT interval
157
Normal QTc
400-440ms or 2 large squares
158
Features of ST elevation
Greater than 1mm (1 small square) in 2 or more contiguous leads or >2mm in 2 or more chest leads
159
Causes of ST elevation
Acute full thickness myocardial infarction - STEMI
160
Features of ST depression
> 0.5mm in > 2 contiguous leads
161
Causes of ST depression
Myocardial ischaemia
162
What do T waves represent
Repolarisation of ventricles
163
Features of tall T waves
> 5mm in limb leads and > 10mm in chest leads
164
Causes of tall T waves
Hyperkalaemia - tall tented T waves | Hyperacute STEMI
165
Features of inverted T waves
Normal on V1 and III
166
Causes of inverted T waves
``` Ischaemia Bundle branch blocks - V4-6 in LBBB - V1-3 in RBBB PE Left ventricular hypertrophy - lateral leads Hypertrophic cardiomyopathy - widespread General illness ```
167
Causes of biphasic T waves
Ischaemia | Hypokalaemia
168
Causes of flattened T waves
Ischaemia | Electrolyte imbalance
169
Featues of U waves
> 0.5mm deflection after T wave | - best seen in V2 or V3
170
Causes of U waves
``` Become larger the slower the bradycardia Electrolyte imbalance Hypothermia Antiarrhythmic therapy - digoxin - procainamide - amiodarone ```
171
Causes of sinus bradycardia
``` Medications Hypothyroidism Hypothermia Sleep apnoea Rheumatic fever Viral myocarditis Pericarditis ```
172
Treatment of second degree AV block Mobitz type II
Permanent pacing
173
Causes of third degree AV block
Anti-arrhythmic drugs - digoxin Following inferior STEMI Severe hyperkalaemia
174
Treatment of third degree AV block
Atropine - 600μg - 3mg - haemodynamically stable patient Isoprenaline - 5 μg/min Urgent pacing
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Natural history of AF
Brief paroxysms of increasing duration | Persistent and permanent AF
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Associated complications of AF
Haemodynamic instability due to tachyarrhythmia or bradyarrhythmia Acute coronary syndrome Congestive cardiac failure Cardioembolic stroke
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Symptoms of AF
``` Breathlessness Palpitations Syncope/dizziness Chest discomfort Stroke/TIA ```
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Management of AF
``` Anticoagulation - prevent stroke - apixiban, rivaroxaban and edoxaban - inhibit factor Xa - dabigatran - inhibit thrombin Rate control - beta-blocker - rate-limiting calcium-channel blocker - diltiazem or verapamil - digoxin Rhythm control - amiodarone - electrical cardioversion ```
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Types of supraventricular tachycardia
AV nodal re-entry tachycardia (AVNRT) | Atrio-ventricular re-entry tachycardia (AVRT)
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Treatment of supraventricular tachycardia
``` Transient blocking AV nodal conduction Vagal manoeuvres - haemodynamically stable patients - Valsalva manoeuvre - carotid massage IV adenosine - 6 mg stat followed by 12mg if unsuccessful then further 12mg Verapamil - 5-10mg stat - contraindicated beta-blockers or LV dysfunction Synchronised cardioversion - following sedation - starting at 150J - pts who are hypotensive, pulmonary oedema, chest pain with ischaemia IV flecainide - avoided in pts with MI - past or present ```
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Describe Valsalva maneouvre
Forceful attempted exhalation against closed airway | - blowing into syringe to move the plunger
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Describe carotid massage
Massage carotid sinus for several seconds on non-dominant cerebral hemisphere side - auscultate for bruits before attempting manoeuvre - wait 10 seconds before trying other side
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Treatment of ventricular tachycardia
Cardioversion - haemodynamically compromised - synchronised 150-200 J shock with a biphasic defibrillator Beta-blockers Amiodarone - 300mg IV stat then 900 mg over 24 hrs Lidocaine - 50-100mg over 3-5 mins - alternative

Yr3 - General Medicine (9 decks)

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