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Cardiology Flashcards

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1
Q

causes of atrial fibrillation?

A 
cardiomyopathy
valve disease (mitral valve disease) 
thyrotoxicosis 
hypokalaemia 
obesity
alcohol 
caffeine
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2
Q

pathophysiology of atrial fibrillation?

A

chaotic activity in the atria, either due to the presence of multiple foci or a single re-entrant circuit that becomes repeatedly excited within the atria

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3
Q

symptoms of atrial fibrillation?

A

light headedness
palpitations
syncope
dizziness

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4
Q

ECG findings of atrial fibrillation?

A

irregularly irregular
absent p waves
QRS<120

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5
Q

what are the three different types of atrial fibrillation?

A

paroxysmal - self terminating episodes that last less than 7 days
persistent - lasts longer than 7 days
permanent- cannot be cardioverted

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6
Q

what are the two types of VT?

A

monomorphic

polymorphic

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7
Q

pathophysiology of monomorphic VT?

A

impulse is generated from a single point either to the left or the right of the ventricle, most commonly due to scarring of the heart muscle

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8
Q

pathophysiology of polymorphic VT?

A

multiple abnormalities in ventricular muscle repolarization leads to beat to beat variation in morphology

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9
Q

what is an example of polymorphic VT?

A

torsades des pointes

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10
Q

ECG findings of torsades des pointes?

A

long QT and polymorphic VT

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11
Q

what condition can lead to torsades des pointes?

A

long QT syndrome

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12
Q

management of torsades des pointes?

A

IV magnesium sulphate
IV atropine
cardiac pacing

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13
Q

causes of prolonged QT interval?

A 
antiarrhythmic drugs (amiodarone) 
TCA
antipyschotics - haloperidol 
erythromycin 
hypokalaemias
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14
Q

management of shockable rhythms?

A

IF IN ARREST:
cardioversion -
administer shock (unsynchronised if pulseless, synchronised if pulse present)
CPR 30:2 x 5
re-check rhythm - if still in VT or VF-> shock again and administer adrenaline
CPR 30:2 x 5
if still in VT or VF- shock again and consider amiodarone

IF NOT IN ARREST:
IV amiodarone
planned synchronised DC

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15
Q

what is ventricular fibrillation?

A

irregular, uncoordinated rippling contraction of the ventricles with no effective cardiac output

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16
Q

ECG findings of VF?

A

no p waves
no QRS
no rhythm

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17
Q

causes of VF?

A 
IHD
cardiomyopathy
overdose of cardiotoxic drugs
hypoxia
major trauma
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18
Q

management of VF and VT?

A

CPR

defibrillation

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19
Q

management of NSTEMI/unstable angina?

A 
MONA/ROMANCE:
Reassure
Oxygen
Morphine 10mg IV (+antiemetic) 
Aspirin 300mg
Nitrates 
Clopidogrel 300mg
Enoxiparin 2.5mg
ECG- if STEMI then PCI asap.
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20
Q

management of STEMI?

A 
morphine/analgesia 
oxygen 
nitrates 
antiplatelet- ticagrelor + aspirin 
PCI immediately
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21
Q

management of STEMI if diabetic?

A

same as for STEMI but convert to IV insulin infusion

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22
Q

causes of HF?

A 
MI
myocarditis
myopathy 
HTN
valvular disease
severe anaemia 
thyrotoxicosis
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23
Q

causes of isolated RVHF?

A

cor pulmonale

right ventricular MI

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24
Q

name of the classification used to assess severity of heart failure?

A

New York Heart Association

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25
what are the different stages of the new york heart association classification of heart failure?
``` class I: mild (physical activity not impaired) class II: mild (mild symptoms with physical activity) class III: moderate (symptoms with minimal activity) class IV: severe (symptoms at rest) ```
26
investigation of HF?
n-terminal BNP | transthoracic ECHO
27
pathophysiology of pulmonary oedema in CHF?
compensatory increase in blood volume through decrease perfusion of kidneys leading to activation of RAAS system, causing an increase in overall fluid. This causes increased fluid in the RV, which cannot be moved through the heart due to HF and so is backed up into the alveoli.
28
what are the compensatory mechanisms activated during HF?
``` adrenergic sympathetic activity (leading to vasoconstriction) decreased vagal activity tachycardia RAAS frank starling mechanism ```
29
what is the post-MI management?
``` lifestyle modification aspirin and ticagrelor BB ACE-I statin ```
30
ECG changes in STEMI?
ST elevation and new onset LBBB
31
ECG changes in NSTEMI?
ST depression and inverted T waves
32
what are 3 types of primary cardiomyopathy?
genetic mixed acquired
33
what are the 2 main types of genetic primary cardiomyopathy?
hypertrophic obstructive cardiomyopathy | arrhythmogenic right ventricular dysplasia
34
what is the genetic inheritance of hypertrophic obstructive cardiomyopathy?
autosomal dominant
35
what is the pathophysiology of HOCM?
mutation in the gene encoding beta-myosin heavy chain protein leading to diastolic dysfunction, which causes left ventricular hypetrophy, decreased compliance and decreased cardiac output
36
symptoms/features of HOCM?
exertional dyspnoea angina syncope - typically following exercise sudden death
37
signs of HOCM?
ejection systolic murmur that increases with valsalva manoeuvre and decreased on squatting
38
classical ECG finding of HOCM?
large dagger like septal Q waves in the lateral leads
39
management of HOCM?
``` Amiodarone BB Cardioverter defibrillator Dual chamber pacemaker Endocarditis prophylaxis ``` ACE-I/ARB-> INHIBTED IN HOCM
40
what are the 3 types of SVT?
atrio- ventricular nodal re-entry tachycardia atrio-ventricular re-entry tachycardia atrial tachycardia
41
which type of arrythmia is WPW?
atrioventricular re-entry tachycardia (SVT)
42
what is the pathophysiology of WPW syndrome?
anatomical re-entry circuit formed due to the presence of the bundle of kent between the atria and ventricles. This pathway does not have rate limiting properties.
43
ECG findings of WPW?
``` short PR interval (<200) wide QRS (>100) delta wave - slurred upstroke of QRS complex ```
44
management of WPW?
definitive treatment - radiofrequency ablation | acute situation - medical cardioversion - amiodarone, flecinide
45
murmur and signs of aortic stenosis?
ejection systolic murmur radiating to carotids and decreased following the valsalva manoeuvre ejection click narrow pulse pressure
46
symptoms of aortic stenosis?
syncope angina dyspnoea fainting
47
investigations of aortic stenosis?
ECHO
48
management of aortic stenosis?
TAVI (valve replacement) | Transcatheter aortic valve implantation
49
causes of aortic stenosis?
degenerative calcification (most common cause in older patients> 65) bicuspid aortic valve (most common cause in younger patients <65) rheumatic fever HOCM
50
murmur and signs of aortic regurgitation?
``` early diastolic murmur best heard at the left sternal border (over tricuspid valve) de mussets sign quinkes sign wide pulse pressure austin flint murmur ```
51
causes of aortic regurgitation?
``` rheumatic fever infective endocarditis bicuspid aortic valve HTN marfans syphilis ```
52
management of aortic regurgitation?
vasodilators (ARB/ACE-I) if symptomatic | valve replacement
53
murmur and signs of mitral stenosis?
mid-diastolic murmur at apex of heart loud S1 malar flush
54
causes of mitral stenosis?
rheumatic fever!!!!! rheumatic fever rheumatic fever
55
causes of mitral regurgitation?
``` post-mi mitral valve prolapse infective endocarditis rheumatic fever congenital ```
56
murmur and signs of mitral regurgitation?
"blowing"pansystolic murmur quiet S1 split S2
57
investigations of mitral reurgitation?
ECG- broad P wave (indicates atrial enlargement) XRAY- cardiomegaly ECHO
58
management of mitral regurgitation?
medical management- nitrates, diuretics, positive inotropes | valve repair or replacement
59
what heart defect is associated with downs syndrome?
VSD AVSD tetraloy of fallot PDA
60
signs of PDA including murmur?
continuous machinery murmur best heard at the clavicles wide pulse pressure bounding pulse
61
features of tetralogy of fallot?(4)
VSD overriding aorta left ventricular hypertrophy Pulmonary stenosis
62
signs and symptoms of tetralogy of fallot?
``` cyanotic failure to thrive displaced apex beat palpable thrill pansystolic murmur best heard at left sternal border or ejection systolic murmur due to the pulmonary stenosis ```
63
XRAY findings of tetralogy of fallot?
"boot shaped" heart- due to the left ventricular hypertrophy
64
complications of VSD?
pulmonary HTN- leading to eisenmenger syndrome RHF aortic regurgitation
65
which condition is associated with coarctation of the aorta?
Turners syndrome
66
what are the two cyanotic congenital heart conditions ?
tetralogy of fallot | transposition of the aorta
67
what are the features of an innocent murmur?
``` 8S's: soft systolic short sounds s1s2 normal symptomless sensitive to posture sternal depression stills murmur = most common ```
68
presentation of VSD in infancy?
failure to thrive poor feeding hepatomegaly oedema
69
VSD murmur?
Pansystolic murmur best heard at the sternal edge think VSD, VIP= Pansystolic
70
when does the ductus arteriosus normally close?
1 week after birth
71
management of PDA?
``` NSAID treatment (indomethacin) or closure of the duct with a coil (catheter) around 1 year ```
72
signs of ASD?
Systolic ejection murmur in the pulmonary area think ASD, A&E- Ejection systolic
73
what is eisenmenger syndrome?
Irreversible pulmonary hypertension due to L-R shunt. This leads to RV hypertension, which causes the pressure in the RV eventually to become so large that is exceeds the LV and there is reversal of the blood flow.
74
how does eisenmenger syndrome present?
cyanosis, initially during exercise then during rest
75
management of eisenmenger syndrome?
heart and lung transplant
76
what is coarctation of the aorta?
congenital narrowing of the aorta in the area of the ductus arteriosus. Often the PDA is maintained in order to maintain systemic circulation.
77
signs of coarctation of the arota?
radial-radial delay if ascending aorta | radial-femoral delay
78
presentation of tetralogy of fallot?
``` cyanosis - however not usually present at birth tachypnoea restlessness white and floppy collapse cyanosis can get compensatory polycythemia ```
79
management of tetralogy of fallot?
IV prostaglandin E infusion to keep DA open | surgery
80
how does transposition of the great vessels present?
``` severe hypoxia and cyanosis at birth metabolic acidosis hypoglycaemia collapse and death heart failure is not usually a feature ```
81
management of transposition of the great vessels?
maintain PDA with IV prostaglandin E infusion urgent surgery correction of metabolic acidosis and hypoglycaemia
82
acute management of SVT?
vagal manourveres - valsalva manouvere, carotid sinus massage IV adenosine electrical cardioversion
83
long term management of SVT? (to prevent further episodes)
BB | radio-frequency ablation
84
what are some contra-indications for adenosine?
``` asthma COPD HF heart block hypotension ```
85
what is a vagal manouvere?
movement to stimulate the vagus nerve in order to slow the heart rate
86
what are the most common precipitating causes of acute heart failure?
ACS hypertensive crisis - e.g. thyrotoxicosis acute arrhythmias valvular disease
87
what are the signs and symptoms of acute heart failure?
``` breathlessness- cyanosis reduced exercise tolerance- tachycardia oedema- elevated JVP fatigue displaced apex beat S3 heart sound ```
88
what can be heard of ausculation of the lungs in acute heart failure?
classical bibasal crackles - due to pulmonary oedema
89
investigations of suspected acute heart failure?
``` BNP ECG full blood work up CXR ECHO ```
90
what are the features of chronic heart failure?
``` dyspnoea cough- worse at night with pink frothy sputum orthopnea paroxysmal nocturnal dyspnoea wheeze weight loss bibasal crackles on examination signs of right sided heart failure ```
91
name some conditions/factors that may increase BNP?
``` LV hypertrophy ischaemia tachycardia reduced renal function sepsis COPD ```
92
name some conditions/factors that decrease BNP levels?
``` obesity diuretics ACE-inhibitors BB ARB ```
93
what is the management of acute heart failure?
oxygen loop diuretics (furosemide, bumetanide) BB ARB/ACE-I
94
what is the management of chronic heart failure?
first line- ACE-I + BB second line- aldosterone antagonist or ARB third line- digoxin (particularly if also in AF) diuretics if in fluid overload
95
what are the cardiac vessels and their branches?
LC-> LAD + left circumflex | RC-> right marginal + PDA
96
which coronary arteries correspond with which leads of the ECG?
circumflex (lateral leads)- I, aVL, V5, V6 RCA (inferior)- II, III, aVF LAD- V1, V2
97
what is the management of angina?
1) lifestyle factors 2) GTN spray 3) aspirin + statin 4) BB or Ca channel blocker 5) add nicorandil or ivabradine
98
investigations of hypertension?
``` 24 hour ABPM U+E (to check for renal disease) lipids glucose ECG urine dipstick ```
99
what are the stages of HTN and when to treat?
stage 1- 135/85 - treat if >80yrs or end organ damage, or QRISK > 10% stage 2- 150/95- treat anyone
100
management of HTN?
if <55 years or T2DM -> ACE-I or ARB if >55 years or afrocarribean -> CCB stage 2: ACE-I/ARB + CCB stage 3: if K> 4.5 add BB, if K<4.5 add spironolactone
101
management of hypertrophic obstructive cardiomyopathy?
Amiodarone BB or CCB Cardioverter defib Dual chamber blocker
102
classical symptoms of pericarditis?
chest pain worse when lying down, relieved when sitting forwards non-productive cough flu like symptoms
103
signs of pericarditis on auscultation?
pericardial rub
104
signs of pericarditis on examination?
tachypnoea tachycardia raised JVP with inspiration
105
classical findings on ECG of pericarditis?
saddle shaped ST elevation and PR depression
106
management of pericarditis?
NSAIDS | colchicine
107
classical presentation of cardiac tamponade? (triad)
raised JVP hypotension muffled heart sound
108
causes of cardiac tamponade?
pericarditis renal failure malignancy chest trauma
109
management of cardiac tamponade?
urgent pericardiocentesis - aspirate fluid
110
symptoms of myocarditis?
chest pain SOB peripheral oedema fatigue
111
causes of myocarditis?
viral - coxsackie, adenovrius, HIV, parvovirus B19 (most common)
112
management of myocarditis?
ACE-I diuretics carvedilol/BB
113
5 steps causing formation of atherosclerosis?
``` endothelial dysfunction formation of lipid layer or fatty streak in intima leukocyte migration foam cell formation degeneration of extracellular matrix ```
114
how does atherosclerosis lead to formation of an aneurysm?
lesion extends into the medial layer resulting in atrophy and loss of elastic tissue, which causes dilation of the artery to form an aneurysm
115
investigations of atherosclerosis?
CT angiography ECHO ECG
116
what does a pathological Q wave on an ECG represent?
previous cardiac arrest
117
which bacteria causes rheumatic fever?
strep pyogenes
118
which criteria is used to diagnose RF?
Jones criteria
119
what is the jones crtieria?
2 major or 1 major + 1 minor: major: polyarthritis, carditis, erythema marginatum, sydenhams chorea, nodules minor: fever, ESR/CRP raised, arthalgia
120
management of RF?
benzypenicillin aspirin treat HF
121
mode of action of ACE-I?
prevents conversion of angiotensin I to angiotensin II, or production of aldosterone which leads to vasodilation
122
S/E of ACE-I?
dry cough hyperkalaemia angio-oedema/peripheral oedema
123
MOA of CCB?
blocks voltage gated calcium channels which relaxes smooth muscle and reduces the contraction force
124
what are the three groups of CCB?
group 1: dihydropyridines (amlodipine, nifedipine-> act on smooth muscle) group 2: verapamil -> act on cardiac muscle group 3: diltiazem
125
S/E of CCB?
flushing peripheral oedema headache
126
MOA of sodium channel blockers?
reduces phase O slope and peak action potential by blocking fast NA channels responsible for depolarization
127
examples of NA channel blockers and when are they used? (2)
flecinide lidocaine both used in chemical cardioversion of SVT and VT
128
how do BB work?
blocks receptors of adrenaline/noradrenaline to Beta-1 receptors in the kidneys and heart reducing inotropy, chronotropy and dromotropy
129
MOA of K+ channel blockers?
delay of repolarization (phase 3) by blocking K+ and prolonging QT + refractory period
130
example of K+ channel blocker?
amiodarone
131
indications of amiodarone?
VT/SVT/AF
132
S/E of amiodarone?
peripheral neuropathy, pulmonary fibrosis
133
MOA of adenosine?
powerful vasodilator and relaxation of muscle fibre by decreasing phase 4
134
when is adenosine used?
SVT - WPW
135
MOA of loop diuretics and example?
inhibits K+/Na+co-transporter in ascending limb of loop of henle furosemide bumetanide
136
S/E of loop diuretics?
hypokalaemia, metabolic alkalosis, dehydration
137
MOA of thiazide diuretics and example?
inhibits Na+/K+ pump in distal tubule bendroflumothiazide
138
MOA of potassium sparing diuretic?
antagonoist of aldosterone receptor at distal tubule
139
S/E of potassium sparing diuretic?
hyperkalaemia, metabolic acidosis, gynaecomastia
140
S/E of thiazide diuretics?
hypokalaemia, metabolic alkalosis, dehydration
141
ECG shows bradycardia and prolonged PR interval- what is the likely diagnosis?
heart block
142
what are the different types of heart block?
first degree second degree - mobitz type I, mobitz type II third degree
143
what is the pathophysiology of first degree heart block?
all atrial impulses reach the ventricle, but conduction through the atrioventricular tissues takes longer than normal
144
what are the causes of first degree heart block?
myocarditis ischaemia/MI electrolyte disturbances - hypokalaemia, hypomagnesaemia medications - rate control i.e. BB, CCB
145
what is seen on the ECG of a patient with first degree heart block?
prolonged PR intervals > 0.2ms
146
what is the pathoohysiology of mobitz type I heart block?
almost always due to AV node disease, some atrial pulses reach the ventricles however due to disease some do not
147
what is seen on ECG of mobitz type I heart block?
Wenckebach- "walking back" | PR interval increases over three or four beats, after which a QRS complex is dropped completely
148
what is the pathophysiology of mobitz type II heart block?
there is an unexpected non-conducted atrial impulse, most often due to disease of the purkinje fibres or conducting system
149
what is seen on ECG of mobitz type II heart block?
PR interval prolonged but regular, until random QRS complex is dropped
150
what is the pathophysiology of third degree heart block/complete heart block?
the impulse is completely blocked, therefore an accessory pacemaker in the lower chambers will typically activate the ventricles- this is known as an escape rhythm. However, as it is an accessory pathway, it fires independently of the ventricles, and therefore there is no relationship between ventricular and atrial contraction.
151
what is seen on ECG of third degree heart block?
bradycardia - often ventricular rate is very slow | no relationship between P waves and QRS complex
152
what causes bundle branch block?
heart disease MI cardiac surgery
153
what is the main ECG criteria for LBBB? (3)
1) QRS > 120ms 2) Broad monomorphic S wave in V1 (W in 1) 3) Broad monomorphic R wave (I and V6) with no S wave (M in V6) ASK ABOUT THIS
154
what is the management of atrial fibrillation?
stroke prevention- warfarin or NOAC rate control - BB, CCB (verapamil), digoxin rhythm control - amiodarone or flecanide (chemical cardioverson - however patient needs to be antiocoagulated for at least 4 weeks before you can cardiovert UNLESS the episode has lasted less than 24 hours) IF >24hrs however they are haemodynamically unstable then you can cardiovert as risk outweighs benefit
155
what score is used to asses the risk of stroke in AF?
``` CHA2DS2-VASc: Congestive heart failure Hypertension Age > 75 Diabetes Stroke Vascular disease Sex (female) ```
156
what could be seen after an MI on ECG?
pathological Q waves | inverted T waves
157
what cardiac markers are used to assess for MI?
CK-MB | Troponin I + T (T is more reliable)
158
DVLA regulations regarding driving after heart attack?
patient must inform the DVLA | stop driving for 6 weeks
159
Investigations of angina?
``` FBC- anaemia TFT- thyrotoxicosis U+E- if considering ACE-I lipid profile - atherosclerosis glucose - diabetes ```
160
MOA of aspirin?
cox-2 inhibitor -> prevents production of thromboxine from platelet thus preventing platelet aggregation and the formation of thrombosis
161
changes on ECG due to digoxin?
T wave inversion | ST depression in V5-V6
162
S/E of statins?
myositis
163
give some conditions that can cause an increase in troponin T?
cardiac ischaemia cardiac arrhythmia pneumonia PE
164
give some medications that can cause heart block?
BB | CCB
165
management of patient who has collapsed due to heart block?
ABCDE atropine IV adrenaline IM transcutaneous pacing vs defibrillator
166
ECG that shows lead II go from ST elevation to ventricular fibrillation- what is the cause?
R on T phenomenon - during the repolarization period an ectopic beat occurs triggered by the unstable myocardium, initiating VF
167
what pattern of conduction is seen in second degree heart block?
usually 2:1 can be 3:1 or 4:1 or variable such as mobitz type 1
168
causes of second degree heart block?
hypothyroid sarcdoidosis IHD drugs- digoxin and verapamil
169
management of second degree heart block?
admission and observation in first instance dual chamber pacemaker if syncope present then temporary pacing needed until dual chamber pacemaker available
170
what medication is contra-indicated in WPW?
digoxin!!
171
management of acute SVT??
vagal manouvers adenosine, amiodarone, flecinide DC
172
what medication is contraindicated in heart failure?
CCB- further depresses cardiac function

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