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Yr3 - General Medicine > Cardiology > Flashcards

Cardiology Flashcards

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
Q

Atorvastatin effects

A

Statin

  • reduce LDL-C < 1.8mmol/L or 40% reduction in non-HDL-C
  • total cholesterol target < 4.0mmol/L
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26
Q

Control of diabetes in MI

A 
Insulin infusions
HbA1c targets
- type 1 < 7%
- type 2 = 6.5-7.5%
Metformin introduced with caution if LV dysfunction suspected post MI
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27
Q

Complications of STEMI

A

Heart failure - diuretics
Shock - inotropes and balloon pump
Valve damage
Septal defect

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28
Q

Management of NSTEMI/unstable angina

A

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

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29
Q

Symptoms of stable angina

A

Chest discomfort provoked by effort or emotion and relieved by rest
Isolated throat tightness
Arm heaviness
Exertional breathlessness

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30
Q

Features of severe stable angina

A

Fear
Sweating
Nausea

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31
Q

Risk factors for CAD

A 
Cigarette smoking
Hypertension
DM
Hypercholesterolaemia
FH of premature of coronary artery disease
Vascular disease
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32
Q

Coronary risk factor profile

A

Chest discomfort more likely to represent coronary artery disease in an individual with two or more existing risk factors

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33
Q

Causes of angina

A

Coronary artery disease
Aortic stenosis
Hypertensive heart disease
Hypertrophic cardiomyopathy

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34
Q

History for angina should include

A 
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
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35
Q

Features that make angina unlikely

A

Pain continuous or very prolonged
Unrelated to activity
Brought on by breathing
Associated symptoms such as dizziness or dysphagia

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36
Q

Features of examination for angina

A 
Weight and height - calculate BMI
Blood pressure
Presence of murmurs - aortic stenosis
Evidence of hyperlipidaemia
Evidence of peripheral vascular disease and carotid bruits
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37
Q

Investigations for stable angina

A

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

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38
Q

Treatment for CAD

A

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

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39
Q

Drug treatment of CAD

A

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

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40
Q

Non-cardiac causes of chest pain

A 
Costochondritis
Gastro-oesophageal
PE
Pneumonia
Pneumothorax
Psychogenic/psychosomatic
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41
Q

Stages of hypertension

A 
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
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42
Q

ABPM

A

Ambulatory Blood Pressure Monitoring

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43
Q

HBPM

A

Home Blood Pressure Monitoring

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44
Q

Symptoms of hypertension

A

Nil or headache
Sweating, headache, palpitations, anxiety -> phaeochromocytoma
Muscle weakness and tetany -> hyperaldosteronism

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45
Q

CVS risk

A 
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
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46
Q

Physical assessment for hypertension

A

Look for secondary causes

  • Cushing’s syndrome
  • enlarged kidney (PCK)
  • renal bruits
  • radio-femoral delay (coarctation)
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47
Q

Investigations for hypertension

A

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

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48
Q

LVSD

A

Left Ventricular Systolic Dysfunction

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49
Q

Target blood pressure in hypertension

A

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

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50
Q

Non-pharmacological hypertension treatment

A 
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
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51
Q

Pharmacological hypertension treatment

A

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

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52
Q

Define hypertensive crisis

A

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
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53
Q

Treatment for hypertensive crisis

A

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

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54
Q

Define hypertensive urgency

A

Severe blood pressure elevation that will cause damage within days

  • diastolic > 130mmHg
  • retinal changes apparent
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55
Q

Hypertensive urgency treatment

A 
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)
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56
Q

Symptoms of phaeochromocytoma

A

Episodic headache, sweating and tachycardia

Sustained or paroxysmal hypertension most common

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57
Q

Diagnosis of phaeochromocytoma

A

24 hour urine collection
- fractionated metanephrines and catecholamines
CT or MRI abdo and pelvis - detect tumours
MIBG scan

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58
Q

Treatment of phaeochromocytoma

A

Surgery - resection
Whilst waiting surgery
- alpha and beta adrenergic blockade
- phenoxygenzamine 10mg OD/BD - 10-20mg every 2-3 days

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59
Q

Features of Cushing’s syndrome

A 
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
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60
Q

Diagnosis of Cushing’s syndrome

A

Low-dose dexamethasone suppreession test

Adrenal CT

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61
Q

Features of primary aldosteronism

A

Low serum potassium and high/normal sodium
Very low/undetectable plasma renin
High plasma aldosterone
Adrenal CT

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62
Q

Causes of heart failure

A 
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
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63
Q

HFREF

A

Heart Failure with Reduced Ejection Fraction

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64
Q

HFNEF

A

Heart Failure Normal Ejection Fraction

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65
Q

NFNEF patient profile

A

Elderly
Overweight
Hypertension
AF

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66
Q

Features of heart failure which contribute to poor prognosis

A 
Severe fluid overload
Very high NT-proBNP levels
Severe renal impairment
Advanced age
Mulit-morbidity
Frequent admissions
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67
Q

Investigations in heart failure

A

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

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68
Q

NT-proBNP

A

Brain Natriuretic Peptide

- secreted by cardiomyocytes in ventricles in response to stretching caused by increased ventricular blood volume

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69
Q

Features of CXR in heart failure

A 
Cardiomegaly
Perihilar shadowing/consolidations
Alveolar oedema
Air bronchograms
Increased width of vascular pedicle
Could be pleural effusions
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70
Q

Assessment of LV function

A

Echocardiography - confirm diagnosis

Cardiac MRI - echogardiogram may miss right ventricle

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71
Q

Features of heart failure in echocardiogram

A

Dilated poorly contracting left ventricle - systolic dysfunction
Stiff, poorly relaxing, small diameter left ventricle - diastolic dysfucntion
Valvular disease
Atrial myxoma
Pericardial disease

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72
Q

Lifestyle modification in heart failure

A

Smoking cessation
Restriction of alcohol consumption
Salt restriction
Fluid restriction - presence of hyponatraemia

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73
Q

Medication for heart failure

A

Diuretics
ACEi
ARBs
Angiotensin Receptor-Neprilysin Inhibitor (ARNI)
Beta blockers
Vasodilators - hydralazine and isosorbide mononitrate
Ivabradine - those who cannot tolerate beta blockers
Nitrates

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74
Q

How are diuretics used in heart failure?

A

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
Q

Uses of ACEis in heart failure

A

Improve

  • symptoms and signs in all stages
  • exercise tolerance
  • slow disease progression
  • survival
76
Q

Use of ARBs in heart failure

A

Valsartan and Candesartan

77
Q

Use of ARNIs in heart failure

A

Sacubitril with Valsartan

Symptomatic chronic heart failure with reduced ejection fraction with stable dose of ACEis and ARBs

78
Q

Use of beta blockers in heart failure

A

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
Q

Uses of vasodilators in heart failure

A

Hydralazine and isosorbide mononitrate
Beneficial effect on survival
- pts of African or Caribbean origin - cannot take ACEi/ARBs
- pts with resistant CCF

80
Q

Use of Ivadbradine in heart failure

A

Those who cannot tolerate beta-blockers or those who HR>75 despite beta-blockers
In sinus rhythm
No impact on blood pressure

81
Q

Effect of nitrates in heart failure

A

Reduce

  • preload
  • pulmonary oedema
  • ventricular size
82
Q

Uses of nitrates in heart failure

A

Acute heart failure
- underlying ischaemia
- hypertension
- regurgitant aortic and mitral valve disease
Chronic heart failure
- relief of orthopnoea and exertional dyspnoea

83
Q

Contraindications of nitrates in heart failure

A

Aortic and mitral stenosis
HOCM
Pericardial constriction

84
Q

HOCM

A

Hypertrophic Obstructive CardioMyopathy

85
Q

ECG of LBBB

A

Broad QRS duration

- depolarisation is delayed from septum to lateral wall -> mechanical reduction

86
Q

LBBB

A

Left Bundle Branch Block

87
Q

Uses of complex implantable devices in LBBB

A

Cardiac Resynchronisation Pacemaker (CRT)

- double pace spikes before QRS

88
Q

ICD

A

Implantable Cardiac Defibrillators

89
Q

Uses of ICDs

A

Do not improve symptoms
Prevent sudden cardiac death associated with heart failure
- detect and cardiovert VT/VF

90
Q

Symptoms of Aortic Stenosis

A

Decrease in exercise tolerance or dyspnoea on exertion
Angina
Heart failure
Syncope

91
Q

Causes of aortic stenosis

A

Age related
Congenital bicuspid valve
Chronic kidney disease
Previous rheumatic fever

92
Q

Features of aortic stenosis murmur

A

Aortic area - 2nd intercostal space right side

Ejection systolic radiating to carotid/neck

93
Q

Severity of AS

A 
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
Q

Indications for surgery for AS

A 
Symptoms causes by AS
Asymptomatic severe AS with 
- left systolic dysfunction
- abnormal exercise test
- time of other cardiac surgery
95
Q

What should be used in older patients with many co-morbidities in symptomatic AS

A

Transcatheter aortic valve implantation (TAVI)

- implanted by femoral artery

96
Q

Symptoms of AR

A

Asymptomatic - many years

Exertional dyspneoa and reduced exercise tolerance - increased volume load on LV -> LV dilation -> heart failure

97
Q

Causes of AR

A

Idiopathic dilation of aorta - pulling valve leaflets apart
Congenital abnormalities of aortic valve - bicuspid
Calcific degeneration
Rheumatic disease
Infective endocarditis
Marfan syndrome

98
Q

Describe AR murmur

A

Left sternal edge
Early diastolic blowing murmur
- associated with collapsing pulse

99
Q

Treatment for patients with severe AR

A

ACEi - afterload reduction

- slows rate of LV dilation

100
Q

Assessment of AR

A

Echocardiography

  • quantification of severity of disease
  • assessment of rest of heart
101
Q

Indiciations for surgery in AR

A

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
Q

Symptoms of MR

A

Mostly asymptomatic

103
Q

Causes of MR

A 
Mitral valve prolapse
- Marfan's syndrome
- pectus excavatum
Rheumatic heart disease
IHD
Infective endocarditis
Drugs
Collagen vascular disease
104
Q

Describe MR murmur

A

Pan-systolic blowing murmur

  • mitral area - 5th ICS mid-clavicular line
  • radiates to axilla
105
Q

Assessment of MR

A

Echocardiography

  • assess LV function and size
  • severity of blood coming through valve
106
Q

Surgical treatment of MR

A

Replacement
Repair
- reduced operative mortality

107
Q

Indications for surgical intervention in severe MR

A

Symptomatic MR
Asymptomatic with mild-moderate LV dysfunction
- EF 30-60%
- LVESD 4.5-5.5cm

108
Q

LVESD

A

Left Ventricular End-Systolic Diameters

109
Q

Medical treatment of MR

A 
Diuretics
ACEI in functional or ischaemic MR
If LV systolic dysfunction
- ACEi
- beta-blockers
- CRT
110
Q

Predisposing conditions for infective endocarditis

A 
Mitral valve prolapse
Presence of prosthetic material
- valves
- patches
Rheumatic heart disease
Degenerative and bicuspid aortic valve disease
Congenital heart disease
111
Q

Common causative organisms of infective endocarditis

A

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
Q

Causes of mortality in infective endocarditis

A

Heart failure
CNS emboli
Uncontrolled infection

113
Q

Features of IE

A

Unexplained fever
Bacteraemia
Systemic illness
New murmur

114
Q

Routine investigations for IE

A 
FBC
ESR and CRP
U&amp;Es
LFTs
Urine dipstick analysis and MSU for MS&amp;C
CXR
ECG
115
Q

Key diagnostic investigations for IE

A

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
Q

Diagnostic criteria for IE

A

2 major
1 major and 3 minor
5 minor

117
Q

Major diagnostic criteria for IE

A 
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
Q

Minor diagnostic criteria for IE

A 
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
Q

Management of IE

A

Antibiotic therapy
- tunnelled central venous line for prolonged courses
Surgery

120
Q

Antibiotic therapy for management of IE

A

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
Q

How to monitor response to therapy in IE

A 
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&amp;Es
122
Q

Indications for surgery in IE

A

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
Q

How to calculate rate in an ECG

A

Standard 12 lead ECG rhythm strip = 10 seconds

- number of QRS complexes * 6 = HR per min

124
Q

Normal heart rate

A

60-100 bpm

125
Q

Bradycardia

A

< 60 bpm

- absolute < 40bpm or HR inappropriately slow for haemodynamic state of patient

126
Q

Tachycardia

A

> 120 bpm

127
Q

Stages of reading an ECG

A 
Rate
Rhythm
Axis
Intervals
ST/T wave changes
128
Q

How to work out if ECG rhythm is regular?

A

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
Q

Types of heart rhythm

A

Normal
Irregular
- regularly irregular
- irregularly irregular

130
Q

Define cardiac axis

A

Overall direction of electrical spread within the heart

131
Q

Normal cardiac axis

A

11 o’clock to 5 o’clock

  • spread of depolarisation to leads I, II and III - positive deflection
  • most negative deflection in aVR
132
Q

Causes of right axis deviation (RAD)

A 
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
Q

Features of RAD

A

1-7 o’clock depolarisation

  • deflection in lead I becomes negative
  • deflection in lead aVF/III to be more positive
134
Q

Causes of left axis deviation (LAD)

A

Conduction defections

- not increased mass of LV

135
Q

Features of LAD

A

Depolarisation to left

  • deflection in lead III becomes negative
  • only significant if lead II becomes negative
136
Q

P wave features of ECG

A

P-waves present
Each p-wave followed by a QRS complex
Normal shape, duration and direction

137
Q

What to consider if no p waves on ECG

A

Atrial flutter - sawtooth baseline
AF - choatic baseline
No atrial activity - flatline

138
Q

Normal P-R interval

A

120-200 ms

- 3-5 small squares

139
Q

What does a prolonged PR interval indicate

A

AV block

140
Q

Features of first degree heart block

A

Fixed prolonged PR interval (>200ms)

Occurs between SA node and AV node - in atrium

141
Q

Features of second degree heart block Mobitz type 1

A

PR interval slowing increasing then dropped QRS complex

Occurs in the AV node

142
Q

Features of second degree heart block Mobitz type 2

A

Fixed PR interval then dropped QRS complex

Occurs after the AV node in bundle of His or Purkinje fibre

143
Q

Features of third degree heart block

A

P waves and QRS complexes completely unrelated

Occurs anywhere after AV node - complete conduction blockage

144
Q

Causes of shortened PR interval

A

Normal - smaller atria or closer location of SA node
Accessory pathway
- delta wave = Wolff Parkinson White Syndrome

145
Q

Aspects of QRS complex to observe in ECG

A

Width
Height
Morphology

146
Q

Normal width of QRS complex

A

< 0.12 seconds

147
Q

Causes of broad QRS complex

A

Abnormal depolarisation sequence

  • ventricular ectopic
  • bundle branch block
148
Q

Normal height of QRS complex

A

< 5mm in limb leads or < 10mm in the chest leads

149
Q

Causes of tall QRS complex

A

Imply ventricular hypertrophy

- can be due to body habitus - tall slim people

150
Q

Delta waves

A

Slurred upstroke of QRS complex

  • early activation of ventricles
  • featured in Wolff-Parkinson-White syndrome
151
Q

Pathological Q waves

A

> 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
Q

R wave progression

A

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
Q

Causes of poor R wave progression

A

Previous MI

Larger people due to lead position

154
Q

Define J point

A

Where S wave joins ST segment

155
Q

Features of benign early repolarisation

A

Elevated J point - ST segment following raised

  • under 50s
  • widespread ST elevation in multiple territories
  • T waves raised
  • does not change over time
156
Q

QTc

A

Corrected QT interval

157
Q

Normal QTc

A

400-440ms or 2 large squares

158
Q

Features of ST elevation

A

Greater than 1mm (1 small square) in 2 or more contiguous leads or >2mm in 2 or more chest leads

159
Q

Causes of ST elevation

A

Acute full thickness myocardial infarction - STEMI

160
Q

Features of ST depression

A

> 0.5mm in > 2 contiguous leads

161
Q

Causes of ST depression

A

Myocardial ischaemia

162
Q

What do T waves represent

A

Repolarisation of ventricles

163
Q

Features of tall T waves

A

> 5mm in limb leads and > 10mm in chest leads

164
Q

Causes of tall T waves

A

Hyperkalaemia - tall tented T waves

Hyperacute STEMI

165
Q

Features of inverted T waves

A

Normal on V1 and III

166
Q

Causes of inverted T waves

A 
Ischaemia
Bundle branch blocks
- V4-6 in LBBB
- V1-3 in RBBB
PE
Left ventricular hypertrophy - lateral leads
Hypertrophic cardiomyopathy - widespread
General illness
167
Q

Causes of biphasic T waves

A

Ischaemia

Hypokalaemia

168
Q

Causes of flattened T waves

A

Ischaemia

Electrolyte imbalance

169
Q

Featues of U waves

A

> 0.5mm deflection after T wave

- best seen in V2 or V3

170
Q

Causes of U waves

A 
Become larger the slower the bradycardia
Electrolyte imbalance
Hypothermia
Antiarrhythmic therapy
- digoxin
- procainamide
- amiodarone
171
Q

Causes of sinus bradycardia

A 
Medications
Hypothyroidism
Hypothermia
Sleep apnoea
Rheumatic fever
Viral myocarditis
Pericarditis
172
Q

Treatment of second degree AV block Mobitz type II

A

Permanent pacing

173
Q

Causes of third degree AV block

A

Anti-arrhythmic drugs
- digoxin
Following inferior STEMI
Severe hyperkalaemia

174
Q

Treatment of third degree AV block

A

Atropine - 600μg - 3mg
- haemodynamically stable patient
Isoprenaline - 5 μg/min
Urgent pacing

175
Q

Natural history of AF

A

Brief paroxysms of increasing duration

Persistent and permanent AF

176
Q

Associated complications of AF

A

Haemodynamic instability due to tachyarrhythmia or bradyarrhythmia
Acute coronary syndrome
Congestive cardiac failure
Cardioembolic stroke

177
Q

Symptoms of AF

A 
Breathlessness
Palpitations
Syncope/dizziness
Chest discomfort
Stroke/TIA
178
Q

Management of AF

A 
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
179
Q

Types of supraventricular tachycardia

A

AV nodal re-entry tachycardia (AVNRT)

Atrio-ventricular re-entry tachycardia (AVRT)

180
Q

Treatment of supraventricular tachycardia

A 
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
181
Q

Describe Valsalva maneouvre

A

Forceful attempted exhalation against closed airway

- blowing into syringe to move the plunger

182
Q

Describe carotid massage

A

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
183
Q

Treatment of ventricular tachycardia

A

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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