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Cardiology Flashcards

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1
Q

Define heart failure

A

The inability of the heart to pump adequate amounts of blood to meet the body’s metabolic demands

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2
Q

What are the signs and symptoms of heart failure?

A

SOB (esp lying flat and on exertion)
Fatigue
Ankle oedema
Cough - frothy pink sputum

Hepatomegaly
Tachycardia
Tachypnoea
Raised JVP

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3
Q

What are the two main types of heart failure?

A

HF-PEF (preserved ejection fraction)

HF-REF (reduced ejection fraction)

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4
Q

What blood test is used to diagnose HF?

A

NT-proBNP (>2000 requires urgent referral)

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5
Q

What investigations are needed in patients with HF?

A

ECHO
ECG
CXR
NT-proBNP

(FBCs, U&Es, LFTs, TFTs, HbA1c)

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6
Q

What are the signs of heart failure that are seen on CXR?

A

Cardiomegaly
Kerly B lines
Upper lobe diversion
Pleural effusions

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7
Q

How can heart failure be classified?

A

New York Heart Association (NYHA) Classification of Heart Failure

Grade 1: No limitation of function
Grade 2: Slight limitation - moderate exertion causes symptoms
Grade 3: Marked limitation - mild exertion causes symptoms
Grade 4: Severe limitation - any exertion causes symptoms (may have symptoms at rest)

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8
Q

What are the complications of heart failure?

A

Muscle undwrperfusion - muscle weakness and atrophy –> fatigue, exercise intolerance and dyspnoea

Increased risk of thromboembolism and stroke

Arrhythmias - AF is most common, VT can occur in advanced HF

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9
Q

Describe the management of heart failure

A

Exercise, smoking cessation, salt and fluid restrict

ACEi and B-blocker
Aldosterone antagonist (spironolactone)
Loop diuretics - furosemide improves symptoms

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10
Q

For patients with HF, what needs to be routinely checked and why?

A

U&Es

Diuretics, ACEi and aldosterone antagonists can cause electrolyte disturbances

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11
Q

What treatments in HF improve prognosis?

A

ACEi

Beta-blocker

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12
Q

What can be used to treat AF in patients with HF?

A

Digoxin

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13
Q

Although Ca channel blockers are no longer routinely used in the management of HF, what Ca channel blocker can be used?

A

Amlodopine

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14
Q

What is the step-wise approach in the management of HF?

A 
ACEi/ARB 
\+ Diuretic
\+ Beta-blocker
\+ Aldosterone antagonist
\+ Digoxin
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15
Q

Describe the management of acute heart failure

A 
Sit up 
100% O2 flow
2 puff GTN 
IV opiates - reduce anxiety, reduce preload
IV furosemide - reduce fluid retention
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16
Q

What implantable devices can be used in the management of HF?

A

Pacemaker
ICD
Left ventricular assist devices

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17
Q

What are the effects of AF?

A

Irregularly irregular ventricular contraction
Tachycardia
Heart failure due to poor filling of the ventricles during diastole
Risk of stroke

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18
Q

How can AF present?

A 
Asymptomatic 
Palpitations
SOB
Syncope
Symptoms of associated conditions (stroke, sepsis, thyrotoxicosis)
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19
Q

What two differential diagnoses are there for an irregularly irregular pulse?

A

AF

Ventricular ectopics

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20
Q

How can AF and ventricular ectopics be differentiated between?

A

Ventricular ectopics will disappear when the HR goes above a certain threshold

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21
Q

What are the signs associated with AF seen on an ECG?

A

Absent T waves
Narrow QRS complex tachycardia
Irregularly irregular ventricular rhythm

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22
Q

What is valvular AF?

A

Patients with AF who also have moderate/severe mitral stenosis or a mechanical heart valve

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23
Q

What are the most common causes of AF?

A 
Sepsis
Mitral valve pathology (stenosis/regurgitation)
Ischaemic heart disease
Thyrotoxicosis
Hypertension
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24
Q

What are the two principles of treating AF?

A

Rate/rhythm control

Anticoagulation to prevent stroke

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25
Why is rate control important in the management of treating AF?
Atria normally pump blood into ventricles In AF, atrial contractions are uncoordinated therefore ventricles have to fill up by suction and gravity The higher the heart rate, the less time available for the ventricles to fill with blood and the lower the cardiac output Reducing the heart rate below 100 increases the time in diastole which increases the time available for the ventricles to fill with blood
26
What group of patients should not have rate control as first line management of their AF?
Reversible cause of their AF Their AF is new onset (within last 48 hours) Their AF is causing heart failure They remain symptomatic despite being effectively rate controlled
27
What are the options for rate control?
``` Beta blocker (atenolol) Calcium channel blocker (diltiazem) Digoxin ```
28
What is the aim of rhythm control?
Return patient to normal sinus rhythm
29
When can immediate cardioversion be considered?
AF has been present for less than 48 hours or severely haemodynamically compromised
30
When is delayed cardioversion required?
AF has been present for >48 hours and they are stable
31
Prior to delayed cardioversion, how long should a patient be anti coagulated for?
3 weeks
32
What are the pharmacological options of cardioversion?
Flecanide | Amiodarone
33
What are the possible longterm medical rhythm control options?
Beta blockers Dronedarone Amiodarone
34
Define paroxysmal AF
AF comes and goes in episodes, usually last <48 hours
35
Describe the 'pill in the pocket' approach to managing paroxysmal AF
Take flecanide when they feel the symptoms of AF starting | must have no underlying structural heart disease
36
Why must flecanide be avoided in atrial flutter?
Can cause 1:1 AV conduction | Results in significant tachycardia
37
Why is anticoagulation important in AF?
Uncontrolled and uncoordinated movement of atria causes blood to stagnate in the left atrium - particularly atrial appendage Stagnant blood --> thrombus Thrombus --> embolus Embolus: atria --> ventricles --> aorta --> carotid arteries --> ischaemic stroke
38
What measure of the clotting cascade is extended by warfarin?
PT
39
What has to be measured routinely in patients taking warfarin?
INR
40
What is the targeted INR in patients taking warfarin for AF?
2-3
41
What are the potential benefits of DOACs compared to Warfarin?
No monitoring required No major interaction problems Equal/slightly better at prevent strokes in AF Equal/slightly less risk of bleeding
42
What score is used to assess whether a patient with AF requires anticoagulation?
CHA2DS2-VASc
43
What are the components of the CHA2DS2-VASc score?
``` Congestive heart failure Hypertension Age > 75 (score 2) Diabetes Stroke/TIA previously (score 2) Vascular disease Age 65-74 Sex (female) ```
44
What CHA2DS2-VASc score recommends coagulation?
>1
45
What assessment tool can be used to assess the risk of a patient bleeding whilst taking anticoagulation?
HAS-BLED
46
What are the components of the HAS-BLED score?
``` Hypertension Abnormal renal/liver function Stroke Bleeding Labile INRs Elderly Drugs or alcohol ```
47
What does the left coronary artery become?
Circumflex artery | Left anterior descending artery
48
What areas of the heart are supplied by the right coronary artery?
Right atrium Right ventricle Inferior aspect of left ventricle Posterior septal area
49
What areas of the heart are supplied by the circumflex artery?
Left atrium | Posterior aspect of left ventricle
50
What areas of the heart are supplied by the left anterior descending artery?
Anterior aspect of left ventricle | Anterior aspect of septum
51
What are the ECG changes associated with a STEMI
ST segment elevation | New LBBB
52
What ECG changes are associated with a NSTEMI
ST segment depression Deep T wave inversion Pathological Q waves
53
What area of the heart is supplied by the Left Coronary Artery?
Anterolateral
54
What ECG leads depict the left coronary artery?
I, aVL, V3-6
55
What area of the heart is supplied by the LAD?
Anterior
56
What ECG leads depict the LAD?
V1-4
57
What area of the heart is supplied the circumflex artery?
Lateral
58
What ECG leads depict the circumflex artery?
I, aVL, V5-6
59
What area of the heart is supplied by the right coronary artery
Inferior
60
What ECG leads depict the right coronary artery?
II, III, aVF
61
What is a rise of troponin consistent with?
myocardial ischaemia
62
What are potential causes of raised troponins?
``` ACS Chronic renal failure Sepsis Myocarditis Aortic dissection Pulmonary embolism ```
63
In a patient with suspected ACS, what investigations should you organise?
``` Bloods: FBCs, U&Es, LFTs, lipids, TFTs, HbA1c ECG CXR ECHO CT angiogram ```
64
What are the two options for treating an acute STEMI?
Primary PCI | Thrombolysis
65
What is the premise for the treatment of an acute STEMI
``` Morphine Oxygen (if O2 sats <95%) Nitrates (GTN) Aspirin 300mg Tricagrelor (180mg) ```
66
What score can be used to assess the 6-month risk of a patient dying or having a repeated MI after having a NSTEMI?
GRACE score | medium to high risk consider early PCI
67
What are complications of MI?
``` Death Rupture of heart septum/papillary muscles Oedema Arrhythmia and aneurysm Dressler's syndrome ```
68
What is Dressler's syndrome?
Post-myocardial infarction syndrome Occurs 2-3 weeks post MI Localised immune response --> pericarditis
69
How may a patient present with Dressler syndrome?
Pleuritic chest pain Low grade fever Pericardial rub
70
What can Dressler syndrome cause?
Pericardial effusion | Pericardial tamponade
71
How can a diagnosis of Dressler syndrome be made?
ECG (global ST elevation an T wave inversion) ECHO (pericardial effusion) Raised CRP and ESR
72
How can Dressler syndrome be managed?
NSAIDs Steroids May require pericardiocentess
73
What are the secondary prevention methods of MIs?
``` Aspirin (75mg) Another antiplatelet Atorvastatin ACE inhibitors Atenolol Aldosterone antagonist (clinical heart failure) ```
74
What is a type 1 MI?
Acute coronary event
75
What is a type 2 MI?
Ischaemia secondary to increased demand or reduced supply of oxygen
76
What is a type 3 MI?
Sudden cardiac death
77
What is a type 4 MI?
Associated with PCI, coronary stenting, CABG
78
What is the most common cause of left axis deviation?
Defects of the conduction system
79
The duration of the PR interval is noted to become increasingly prolonged. In addition, the QRS complexes appeared to be dropped at regular intervals. What diagnosis does this suggest?
Second degree Mobitz type 1
80
What is the normal duration of a PR interval?
0.12-0.2 seconds (3-5 small squares)
81
What can a shortened PR interval suggest?
Accessory pathway between the atria and the ventricles (Wolff Parkinson White Syndrome)
82
What is the normal duration of the QRS complex?
0.12 seconds (3 small squares)
83
What is a common cause of right axis deviation?
Right ventricular hypertrophy
84
What is the often the earliest sign seen in an ECG during a myocardial infarction?
Tall peaked T waves
85
Give some risk factors for the development of infective endocarditis
Valvular damage: Previous rheumatic heart disease Age related valvular degeneration Prosthetic valve IV drug user
86
In what circumstances is a diagnosis of endocarditis given until proven otherwise?
New murmur and fever
87
Describe the acute presentation of endocarditis
``` Fever and new heart murmur Petechiae Haematuria Rigors Night sweats Splinter haemorrhages Nail fold infarcts Roth spots Embolic incidents Malaise ```
88
What type of people are likely to present with a subacute presentation of infective endocarditis?
Known congenital or valvular disease
89
What type of organism can cause a subacute presentation of endocarditis along with hepatosplenomegaly?
Coxiella
90
What are the potential causative agents of infective endocarditis?
``` S. vidians - most common S.aureus S.bovis - need colonoscopy ?tumour Q fever HACEK (haemophilus, actinobacillus, Cardiobacterium, kingella, eikenella) Brucella Yeasts ```
91
How can infective endocarditis be diagnosed?
Duke Criteria
92
What are the Major Duke Criteria?
Positive blood culture for infective organism (on 2 separate tests) Evidence of IR from other tests (Echo - strictures, unusual blood flow, implanted/unusual material) New valve regurgitation
93
What are the minor Duke criteria?
``` Fever >38 Predisposed to IE Unusual ECHO Immunological factors present (Roth spots, Osler nodes, GN, RF) Blood cultures positive Vascular abnormalities ```
94
What type of ECHO should be used if a patient has prosthetic valves?
TOE
95
What antibiotics can be given in an acute presentation of IE?
Flucloxacillin | Gentamicin
96
What antibiotics an be given in a sub-acute presentation of IE?
Benzylpenicillin | Gentamicin
97
What antibiotics can be given If a patient has a prosthetic valve or resistant organism in IE?
Vancomycin Gentamicin Rifampicin
98
What are indications for surgery in patients with IE?
``` IE resistant to antibiotic treatment Fungal disease resistant to treatment IE causing embolic events IE causing CHF Severe structural damage on echo ```
99
What is the aetiology of IE?
Damaged endocardium --> platelet and fibrin deposition --> organism adhere and grow --> infective vegetation
100
What valves are most commonly affected in IE?
Aortic and mitral valves
101
In IVDU, what side of the heart is most commonly affected in IE/
Right
102
What are the 4 cardiac arrest rhythms and which are shockable?
VT and VF - shockable | Pulseless electrical activity and asystole
103
How should an unstable patient with a tachycardia be treated?
Up to 3 synchronised shocks | Consider amiodarone infusion
104
What are the three narrow QRS complex tachycardias?
Atrial fibrillation Atrial flutter SVT
105
How should a stable patient with tachycardia due to atrial fibrillation be treated
Rate control with beta-blocker or diltiazem
106
How is atrial flutter treated?
Rate control with beta blocker or cardioversion Treat underlying cause Radiofrequency ablation of the re-entry rhythm Anticoagulation depending on CHA2DS2VASc score
107
How should a ventricular tachycardia causing a broad QRS complex tachycardia be treated?
Amiodarone infusion
108
What is the atrial contraction rate in atrial flutter?
300bpm
109
What is the ventricular contraction rate in atrial flutter?
150bpm
110
What is the classical appearance of atrial flutter on ECG?
Saw tooth
111
What conditions are associated with atrial flutter?
HTN Ischaemic heart disease Cardiomyopathy Thyrotoxicosis
112
What is the process behind SVT?
Electrical signal re-enters the atria from the ventricles | Signal travels back through the AV node into ventricles
113
What is paroxysmal SVT?
SVT reoccurs and remits in the same patient over time
114
What are the three main types of SVT?
1. Atrioventricular nodal re-entrant tachycardia - re-entry point is through the AV node 2. Atrioventricular re-entrant tachycardia - re-entry is through an accessory pathway 3. Atrial tachycardia - electrical signal originates in the atria but somewhere other to the SA node
115
How should a stable patient with SVT be managed?
Continuous heart monitoring 1. Valsalva manoeuvre 2. Carotid sinus massage 3. Adenosine (or verapamil if contraindicated) 4. Direct current cardioversion
116
In what patients should adenosine be avoided?
``` Asthma COPD Heart failure Heart block Severe hypotension ```
117
What doses of adenosine can be used in the management of SVT';
6mg --> 12mg --> 12mg
118
How can patients with paroxysmal SVT be managed on a LT basis?
Medication - beta-blocker, ca channel blockers, amiodarone | Radiofrequency ablation
119
What is the accessory pathway in Wolff-Parkinson-White commonly known as?
Bundle of Kent
120
What is the definitive treatment of Wolff-Parkinson-White syndrome?
Radiofrequency ablation of the accessory pathway
121
What ECG changes are associated with Wolff-Parkinson-White Syndrome?
Short PR interval (<0.12s) Wide QRS complex (>0.12s) Delta wave
122
When can radio frequency ablation be curative?
AF Atrial flutter SVT WPW syndrome
123
What type of tachycardia is Torsades des pointes?
Polymorphic ventricular tachycardia
124
What happens to the height of the QRS complex in Torsades des Pointes?
Progressively get shorter then longer
125
In what patients can Torsades des Pointes occur?
Prolonged QT
126
What can Torsades des Pointes revert into?
VT
127
What are causes of a prolonged QT?
Long QT syndrome Drugs Electrolyte disturbances - hypokalaemia, hypomagnesaemia, hypocalcaemia
128
What drugs can cause prolonged QT?
``` Anti psychotics Citalopram Flecainide Sotalol Amiodarone Macrolide antibiotics ```
129
What is the acute management of Torsades des Pointes?
Correct the cause Magnesium infusion Defib if VT occurs
130
What is the long term management of Torsades des Pointes?
Avoid medications that prolong QT interval Correct electrolyte disturbance Beta blockers Pacemaker or implantable defibrillator
131
What is the appearance of a ventricular ectopic on ECG?
Individual random, abnormal, broad QRS complexes on a background of a normal ECG
132
Describe first degree heart block
Delayed atrioventricular conduction through AV node Every atrial impulse leads to a ventricular contraction PR interval >0.2s
133
Describe second degree heart block
Some of the atria impulses do not make it through the AV node There are instances where p waves do not lead to QRS complex
134
Describe Mobitz type I heart block
Atrial impulses get weaker until it doesn't pass through the AV node The cycle then repeats
135
Describe Moritz type 2 heart block
Intermittent failure or interruption of AV condition Missing QRS complexes Usually a set ratio of p waves to QRS complexes Risk of asystole
136
What is 3rd degree heart block
Complete heart block No observable relationship between p waves and QRS complexes Significant risk of asystole
137
What is the treatment of bradycardia/AV node blocks if the patient is stable?
Observe
138
What is the treatment of bradycardia/AV node blocks if the patient is unstable or at risk of asystole?
Atropine IV | Atropine up to 6 doses, other inotropes, transcutaneous cardiac pacing
139
What are some side effects of atropine?
(Antimuscarinic - inhibits PNS) Constipation Urinary retention Pupil dilatation Dry eyes

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